Safety-net Primary Care Setting Research Articles

Urinary Incontinence Care in the Academic and Safety-Net Primary Care Settings: Opportunities to Improve Quality of Care

OBJECTIVETo compare the quality of urinary incontinence care for women in the safety-net and non-safety-net settings prior to referral to a specialist. METHODSWe performed a retrospective review of 200 women from two non-safety-net hospitals and 188 women from two safety-net hospitals who were referred to Urogynecology and Reconstructive Surgery specialists for bothersome UI between March 2017 and March 2020. We evaluated the care that women received 12-months prior to referral, by measuring adherence to a set of previously developed quality indicators (QIs), for example the performance of a urinalysis or pelvic exam. RESULTSWomen seen in safety-net hospitals were more likely to receive QI-compliant care than women in the non-safety-net hospitals prior to referral, with 55.53% of appropriate care given in the safety-net vs. 40.3% in the non-safety-net setting (p<0.01). Clinicians in the safety-net hospitals were more likely to adhere to QIs in patients with general, stress, and urgency incontinence. CONCLUSIONSWomen were more likely to receive timely, quality-based UI care in the safety net compared to the non-safety-net setting. This may be in part due to aspects unique to the safety-net system, including an eConsult referral system, which guides referring clinicians in appropriate management steps that should be taken prior to the specialist visit, as well as women’s health focused primary care clinics.

Abstract C117: Implementing on overdue colorectal cancer (CRC) screening in the Federally Qualified Health Center (FQHC) primary care setting: 12-month post intervention results

Abstract PURPOSE: We partnered with the largest FQHC in New Haven, CT to address overdue colorectal cancer screening with evidence-based interventions (EBI). We report on the 12-month follow up of a cohort of 3,127 patients overdue for CRC screening who received 1 or more evidence based interventions (EBIs) in October, 2021. BACKGROUND: Sociocultural and medical concerns are barriers to colonoscopy uptake contributing to disparities in CRC screening. An additional barrier is system level capacity. COVID-19 associated delays exacerbated the existing backlog of individuals overdue for CRC screening, underscoring the need to expand Fecal Immunochemical Testing (FIT) screening capacity. At the time of the study, colonoscopy was the front-line cancer screening strategy in this and other primary care settings in this region. METHODS: We tested the unique and additive value of multiple EBIs for increasing CRC screening in this low-income urban population. The EBIs included: medical reminder to all recipients (Arms 1-4), supplemented with information to address social determinants of health [SDOH]) barriers (Arm 2), offer of assistance from trained community health workers (CHW) to address SDOH barriers (Arm 3), and offer of educational intervention (video and pre- and post- survey) (Arm 4). Twelve-month outcomes include: 1) CRC screening test ordered; 2) CRC screening completed. RESULTS: Of the 3,127 randomized patients, ages 50-75, 77% were Hispanic (33%) or Black (44%). At 12 months post-intervention, 1,692 (54.1%) of the cohort received an order for CRC screening, and 541 (17.3%) of the cohort completed screening. With no path to CRC screening other than a provider order, among patients for whom CRC screening was ordered, nearly one-third (32%) completed screening within 12 months of the intervention. There were no differences in either outcome based on intervention Arm. DISCUSSION: Among the 3,127 individuals who were due or overdue for screening at the time of intervention, only 9 had documented CRC cancer screening in the 5 years before randomization. The promotion of stool-based testing may have brought individuals into CRC screening. There were no differences in CRC screening (colonoscopy or FIT) orders or completed tests across the 4 arms of the study, suggesting that the provider endorsed mailed screening reminder with information on in-home, stool-based testing option (FIT), and notice that CRC screening is now recommended beginning at age 45 was key to behavior change. Provider engagement and post-pandemic care-seeking on part of patients, as well as increased awareness of CRC screening following the death of high-profile actor at age 43 likely contributed to increased uptake of CRC screening. SUMMARY: A mailed reminder is a cost effective, scalable intervention that may be effective in safety net primary care settings that serve high-risk individuals. Closing the screening gap in CRC screening should include educating patients about their CRC screening options as well as the change in recommended age to begin CRC screening. Citation Format: Beth A. Jones, Sakinah C. Suttiratana, Sarah A. DeGiovanni, Levita Robinson, Michael Couturie, Steven J. Parra, Louie M. Gangcuangco, Laney Zhang, Denise Stevens, Margarita Vargas-Torres. Implementing on overdue colorectal cancer (CRC) screening in the Federally Qualified Health Center (FQHC) primary care setting: 12-month post intervention results [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr C117.

Abstract C116: Provider input following implementation trial to address overdue colorectal cancer screening

Abstract Implementing Fit Kit Colorectal Cancer (CRC) Screening in At-Risk Populations Study was a trial of 4 evidence-based strategies to increase colorectal cancer (CRC) screening in the primary care setting. The focus of this report is the factors that impacted implementation of these interventions in a safety net setting. Using the RE-AIM (Reach Effectiveness Adoption Implementation Maintenance) framework, we evaluated providers’ assessments of the impact of the intervention on the 2 main outcomes: 1) CRC screening ordered; 2) CRC screening completed in a diverse population with more than 3,000 individuals overdue for screening. Methods: We conducted a Qualtrics evaluation survey among 51 staff members identified as individuals involved in cancer screening in a safety net primary care setting that serves over 38,000 individuals in New Haven, CT. The staff surveys are part of the evaluation of the program at one-year post-intervention. Invited staff were provided links through group emails from the provider partners requesting participation in a 2–5-minute Qualtrics survey. Questions on job title, role in CRC screening, and whether and how the interventions (referred to as “the study”) impacted CRC screening in this facility, understanding of the procedures in place to facilitate scheduling and completion of CRC screening, and the barriers and facilitators that impact CRC screening completion were queried. Descriptive results will be mapped to relevant aspects of the RE-AIM framework. Results: Twenty (39%) staff members completed the survey including 9 (45.0%) registered nurses/advanced practice registered nurses, 6 (30.0%) physicians, 2 (10.0%) physician assistants, and 3 (15.0%) individuals in other roles, e.g., schedulers. 87.5% (n=14) were authorized to order colorectal cancer (CRC) screening tests, either colonoscopy or stool-based testing, for their patients. By self-report, effectiveness of the intervention on provider behavior was limited with only 22.2% reporting that the study impacted decisions to order CRC screening. Yet 41% of providers in the study placed a “blanket order” for all individuals who were due for CRC screening even if they were not seen for an appointment during the study period. Barriers to completion of CRC screening were “patient factors” (37%) and insufficient consultation time during appointments (27.3%). Most health care providers cited COVID-19 as a significant factor in delivering an effective CRC screening program. Provider suggestions to improve CRC screening uptake included posted information in exam rooms, use of clinical decision-making tools in the electronic medical record to determine if colonoscopy or FIT (stool-based) testing is the best option, nurse visits to teach use of stool-based testing and making in-home test kits available over the counter in pharmacies. Discussion: Although the results from this small sample of providers has limited generalizability, the findings will be useful in designing scalable interventions in similar high volume primary care settings. Citation Format: Beth A. Jones, Denise L. Stevens, Sakinah Suttiratana, Sarah A. DeGiovanni, Laney Zhang, Margarita Vargas-Torres, Michael Couturie, Levita Robinson. Provider input following implementation trial to address overdue colorectal cancer screening [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr C116.

Using Electronic Health Record Data to Measure the Latent Tuberculosis Infection Care Cascade in Safety-Net Primary Care Clinics

Prevention of tuberculosis disease through diagnosis and treatment of latent tuberculosis infection is critical for achieving tuberculosis elimination in the U.S. Diagnosis and treatment of latent tuberculosis infection in safety-net primary care settings that serve patients at risk for tuberculosis may increase uptake of this prevention effort and accelerate progress toward elimination. Optimizing tuberculosis prevention in these settings requires measuring the latent tuberculosis infection care cascade (testing, diagnosis, and treatment) and identifying gaps to develop solutions to overcome barriers. We used electronic health record data to describe the latent tuberculosis infection care cascade and identify gaps among a network of safety-net primary care clinics. Electronic health record data for patients seen in the OCHIN Clinical Network, the largest network of safety-net clinics in the U.S., between 2012 and 2019 were extracted. electronic health record data were used to measure the latent tuberculosis infection care cascade: patients who met tuberculosis screening criteria on the basis of current recommendations were tested for tuberculosis infection, diagnosed with latent tuberculosis infection, and prescribed treatment for latent tuberculosis infection. Outcomes were stratified by diagnostic test and treatment regimen. Among 1.9 million patients in the analytic cohort, 43.5% met tuberculosis screening criteria, but only 21.4% were tested for latent tuberculosis infection; less than half (40.4%) were tested using an interferon-gamma release assay. Among those with a valid result, 10.5% were diagnosed with latent tuberculosis infection, 29.1% of those were prescribed latent tuberculosis infection treatment, and only 33.6% were prescribed a recommended rifamycin-based regimen. Electronic health record data can be used to measure the latent tuberculosis infection care cascade. A large proportion of patients in this safety-net clinical network are at high risk for tuberculosis infection. Addressing identified gaps in latent tuberculosis infection testing and treatment may have a direct impact on improving tuberculosis prevention in primary care clinics and accelerate progress toward elimination.

Understanding Clinic and Community Member Experiences with Implementation of Evidence-Based Strategies for HPV Vaccination in Safety-Net Primary Care Settings

HPV vaccination rates remain below target levels among adolescents in the United States, which is particularly concerning in safety-net populations with persistent disparities in HPV-associated cancer burden. Perspectives on evidence-based strategies (EBS) for HPV vaccination among key implementation participants, internal and external to clinics, can provide a better understanding of why these disparities persist. We conducted virtual interviews and focus groups, guided by the Practice Change Model, with clinic members (providers, clinic leaders, and clinic staff) and community members (advocates, parents, policy-level, and payers) in Los Angeles and New Jersey to understand common and divergent perspectives on and experiences with HPV vaccination in safety-net primary care settings. Fifty-eight interviews and seven focus groups were conducted (n = 65 total). Clinic members (clinic leaders n = 7, providers n = 12, and clinic staff n = 6) revealed conflicting HPV vaccine messaging, lack of shared motivation to reduce missed opportunities and improve workflows, and non-operability between clinic electronic health records and state immunization registries created barriers for implementing effective strategies. Community members (advocates n = 8, policy n = 11, payers n = 8, and parents n = 13) described lack of HPV vaccine prioritization among payers, a reliance on advocates to lead national agenda setting and facilitate local implementation, and opportunities to support and engage schools in HPV vaccine messaging and adolescents in HPV vaccine decision-making. Participants indicated the COVID-19 pandemic complicated prioritization of HPV vaccination but also created opportunities for change. These findings highlight design and selection criteria for identifying and implementing EBS (changing the intervention itself, or practice-level resources versus external motivators) that bring internal and external clinic partners together for targeted approaches that account for local needs in improving HPV vaccine uptake within safety-net settings.

Use of Telehealth for Opioid Use Disorder Treatment in Safety Net Primary Care Settings: A Mixed-Methods Study

Background: The COVID-19 pandemic resulted in a marked increase in telehealth for the provision of primary care-based opioid use disorder (OUD) treatment. This mixed methods study examines characteristics associated with having the majority of OUD-related visits via telehealth versus in-person, and changes in mode of delivery (in-person, telephone, video) over time. Methods: Logistic regression was performed using electronic health record data from patients with ≥1 visit with an OUD diagnosis to ≥1 of the two study clinics (Rural Health Clinic; urban Federally Qualified Health Center) and ≥1 OUD medication ordered from 3/8/2020-9/1/2021, with >50% of OUD visits via telehealth (vs. >50% in-person) as the dependent variable and patient characteristics as independent variables. Changes in visit type over time were also examined. Inductive coding was used to analyze data from interviews with clinical team members (n = 10) who provide OUD care to understand decision-making around visit type. Results: New patients (vs. returning; OR = 0.47;95%CI:0.27-0.83), those with ≥1 psychiatric diagnosis (vs. none; OR = 0.49,95%CI:0.29-0.82), and rural clinic patients (vs. urban; OR = 0.05; 95%CI:0.03-0.08) had lower odds of having the majority of visits via telehealth than in-person. Patterns of visit type varied over time by clinic, with the majority of telehealth visits delivered via telephone. Team members described flexibility for patients as a key telehealth benefit, but described in-person visits as more conducive to building rapport with new patients and those with increased psychological burden. Conclusion: Understanding how and why telehealth is used for OUD treatment is critical for ensuring access to care and informing OUD-related policy decisions.

Abstract A104: Partnering with primary care to implement evidence based interventions (EBI) to address overdue colorectal cancer (CRC) screening in Connecticut (CT)

Abstract PURPOSE: Partnering with the largest Federally Qualified Health Center (FQHC) in New Haven, CT, the goal is to implement and test 4 evidence-based interventions (EBI) to increase CRC screening, while evaluating real-world implementation. Here, we report on the six-month (approximate) follow up of a cohort of 3,127 patients overdue for CRC screening who received 1 or more EBIs in October 2021. BACKGROUND: Sociocultural and medical concerns are barriers to colonoscopy uptake contributing to disparities in CRC screening. An additional barrier is system level capacity. COVID-19 associated delays exacerbated the existing backlog of individuals overdue for CRC screening, underscoring the need to expand Fecal Immunochemical Testing (FIT) capacity. This was particularly evident in the safety-net primary care setting that serves lower socio-economic status individuals living in urban New Haven, CT. METHODS: We are testing the unique and additive value of multiple evidence-based interventions (EBIs) for increasing CRC screening. The EBIs include the use of medical reminders, addressing the structural barriers (social determinants of health [SDOH]), and providing assistance from community health workers (CHW). We randomized 3,127 patients overdue for CRC screening to one of 4 arms of the study. All individuals received a reminder from their providers that they were due/overdue for CRC screening with instructions to contact the FQHC. Arm 2 also included information on SDOH barriers, Arm 3 included this same information with offer of navigation from CHW/navigator; and Arm 4 included the offer of CHW educational video and support if needed. Six-month (approximate) outcomes include: 1) Engagement with FQHC resulting in ordered test; 2) completed test. Results by intervention will be assessed at 12 months. RESULTS: Of the 3,127 randomized patients, ages 50-75, 77% were Hispanic (33%) or Black (44%). At 6+ months, a preliminary look at EMR data show that a minimum of 1,275 (40.8%) patients “engaged” with providers resulting in an ordered FIT Kit (n= 1174) or COMPLETED screening colonoscopy that was not associated with a positive FIT result (n = 102). 217 (18.5%) individuals completed the FIT testing with 13 requiring confirmatory colonoscopy (31% completed at this time). Thus, a minimum of 319 (10%) of 3,127 individuals in the cohort completed CRC screening at approximately 6 months post intervention. DISCUSSION: Despite investments in community engagement, stakeholder input, and FIT kit capacity building, the pandemic presented unforeseen challenges. Flexibility and steadfast commitment from FQHC providers and staff were critical to successful implementation during multiple waves of COVID-19, resulting in CRC screening ordered for 41% of cohort within 6 months of intervention. SUMMARY: At 6 months follow up of 3,127 individual who were overdue for CRC screening, one or more of 4 EBIs, in addition to system level efforts to address CRC screening, resulted CRC screening tests ordered for 41% of cohort with at least 10% completed screening. Citation Format: Beth A. Jones, Sakinah C. Suttiratana, Sarah A. DeGiovanni, Steven J. Parra, Levita Robinson, Michael Couturie, Louie Mar Gangcuangco, Denise Stevens. Partnering with primary care to implement evidence based interventions (EBI) to address overdue colorectal cancer (CRC) screening in Connecticut (CT) [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A104.

Practice-Based Evidence of Lifestyle Redesign® for Hypertension and Diabetes in a Safety-Net Primary Care Setting

Abstract Date Presented 04/01/2022 This study used medical chart reviews to evaluate Lifestyle Redesign® OT services for hypertension and diabetes to improve health and well-being in a safety-net primary care setting. Patients showed significant improvements in clinical outcomes (systolic and diastolic blood pressure, HbA1c), as well as in patient activation and occupational performance. Findings support the promising role of OT as part of routine primary care for patients with chronic disease. Primary Author and Speaker: Stacey L Schepens Niemiec Additional Authors and Speakers: Daniel Padilla Vega Contributing Authors: Gabrielle Granados, Jesus Diaz, Jeanine Blanchard, Elizabeth Pyatak

Rectal specimen self-collection for chlamydia and gonorrhea screening: a cross-sectional feasibility study at a community health center

BackgroundMen who have sex with men (MSM) are at increased risk for extra-genital sexually transmitted infections (STIs). Without extra-genital screening, many chlamydia and gonorrhea infections would be missed among MSM. Yet, many barriers exist to extra-genital testing, and, in particular, to rectal collection. Self-collection increases screening and detection of asymptomatic chlamydia and gonorrhea among at-risk MSM and transgender women. This feasibility study assessed use of rectal self-collection and its acceptance among patients and primary care providers (PCPs) at a large, general practice community health center. The primary objective of this project was to assess the feasibility of including rectal self-collection as part of an implementation study looking to embed an STI care program in a safety-net primary care setting that would shift routine screening tasks to non-provider clinical team members such as medical assistants and nurses.MethodsThree PCPs identified and offered rectal self-collection to their MSM and transgender female patients who were due for routine or risk-based STI screening. For those patients who elected to participate in the study, the PCP’s medical assistant (MA) reviewed the self-collection instructions with them as part of their routine preventive care duties, and patients collected their own sample. Patients and PCPs completed brief cross-sectional surveys assessing the self-collection process.ResultsOf 1191 patients with sexual orientation and gender identity (SOGI) data on file who were seen for a medical visit by one of the three PCPs, 87 (7.3%) identified as MSM or transgender female. Seventy-five were due for rectal screening, of whom 33 (44%) were offered and completed rectal self-collection. Survey results indicated that self-collection was acceptable to and preferred over clinician-collection by both PCPs and patients.ConclusionsThis study demonstrated that rectal self-collection is feasible as part of STI screening in a high-volume primary care setting, and can be administered as part of the clinical tasks that MAs routinely conduct. The overall acceptance by both PCPs and patients will allow the inclusion of rectal self-collection in an implementation study looking to increase STI screening at a large community health center by facilitating MA-led collection during medical provider visits and by establishing standalone nurse-led STI visits.

Bridging the evidence-to-practice gap: a stepped-wedge cluster randomized controlled trial evaluating practice facilitation as a strategy to accelerate translation of a multi-level adherence intervention into safety net practices

BackgroundPoor adherence to antihypertensive medications is a significant contributor to the racial gap in rates of blood pressure (BP) control among Latino adults, as compared to Black and White adults. While multi-level interventions (e.g., those aiming to influence practice, providers, and patients) have been efficacious in improving medication adherence in underserved patients with uncontrolled hypertension, the translation of these interventions into routine practice within “real world” safety-net primary care settings has been inadequate and slow. This study will fill this evidence-to-practice gap by evaluating the effectiveness of practice facilitation (PF) as a practical and tailored strategy for implementing Advancing Medication Adherence for Latinos with Hypertension through a Team-based Care Approach (ALTA), a multi-level approach to improving medication adherence and BP control in 10 safety-net practices in New York that serve Latino patients.Methods and designWe will conduct this study in two phases: (1) a pre-implementation phase where we will refine the PF strategy, informed by the Consolidated Framework for Implementation Research, to facilitate the implementation of ALTA into routine care at the practices; and (2) an implementation phase during which we will evaluate, in a stepped-wedge cluster randomized controlled trial, the effect of the PF strategy on ALTA implementation fidelity (primary outcome), as well as on clinical outcomes (secondary outcomes) at 12 months. Implementation fidelity will be assessed using a mixed methods approach based on the five core dimensions outlined by Proctor’s Implementation Outcomes Framework. Clinical outcome measures include BP control (defined as BP< 140/80 mmHg) and medication adherence (assessed using the proportion of days covered via pharmacy records).DiscussionThe study protocol applies rigorous research methods to identify how implementation strategies such as PF may work to expedite the translation process for implementing evidence-based approaches into routine care at safety-net practices to improve health outcomes in Latino patients with hypertension, who suffer disproportionately from poor BP control. By examining the barriers and facilitators that affect implementation, this study will contribute knowledge that will increase the generalizability of its findings to other safety-net practices and guide effective scale-up across primary care practices nationally.Trial registrationClinicalTrials.gov NCT03713515, date of registration: October 19, 2018.

Bipolar disorder and PTSD screening and telepsychiatry diagnoses in primary care

ObjectiveTo describe clinical diagnoses from telepsychiatrist consultation in safety net primary care settings for adult patients screening positive for bipolar disorder, PTSD, or both. MethodsPatients were administered the PTSD Checklist (PCL-6) and the Composite International Diagnostic Interview 3.0 (CIDI) for bipolar disorder. Positive screening result definitions were PCL-6 score of ≥14 and CIDI positive stem question responses and score of ≥8. Patient characteristics were assessed by survey. Psychiatrists consulted in primary care via telehealth and recorded clinical diagnoses. ResultsAmong 767 patients attending consultation with a telepsychiatrist, 495 (65%) screened PCL-6 positive only, 249 (32%) screened both PCL-6 and CIDI positive, and 23 (3%) screened CIDI positive. Approximately two-thirds screening PCL-6 positive were diagnosed with PTSD, and most had comorbid mood disorder diagnoses, with bipolar disorder diagnosis occurring more often in those screening CIDI positive compared to negative (42% vs. 15%). Positive predictive values were 64.9% for PCL-6 and 43.8% for CIDI. ConclusionMost individuals screening positive for PTSD and/or bipolar disorder had two or more psychiatric diagnoses; misclassification exists for both instruments but was greater for CIDI. Psychiatrist consultation early in treatment for individuals screening positive on the PCL-6 and/or CIDI could help clarify diagnoses and improve treatment planning.

Knowledge and self-efficacy for caring for breast and colon cancer survivors among safety net primary care providers.

Primary care providers (PCPs) are critical to the provision of comprehensive care for cancer survivors, yet there is very little data on the practices and quality of survivorship care occurring in safety net primary care settings. This study aimed to assess the knowledge and attitudes of PCPs and preferences for care models for breast and colon cancer survivors in a safety net health network. A modified National Cancer Institute Survey of Physician Attitudes Regarding the Care of Cancer Survivors was sent electronically to 220 PCPs in 12 primary care clinics in the San Francisco Health Network affiliated with Zuckerberg San Francisco General Hospital and Trauma Center. The response rate was 50% (110/220). About half of PCPs strongly/somewhat agreed (vs. strongly/somewhat disagreed) that PCPs have the knowledge needed to provide follow-up care related to breast (50%) and colon cancer (54%). Most providers (93%) correctly reported recommended frequency of mammography, however, frequency of blood tests and other imaging surveillance were not as well recognized for breast or colon cancer. Recognition of long-term side effects of chemotherapy drugs ranged from 12% for oxaliplatin to 44% for doxorubicin. Only 33% of providers reported receiving any survivorship training. The most preferred model for survivorship care was shared care model (40%). Safety net PCPs prefer a shared care model for care of cancer survivors but are limited by lack of training, poor communication, and poor delineation of roles. Patient-centered survivorship care can be improved through effective oncologist-PCP-patient partnerships and coordination.

Racism, Mental Health, Healthcare Provider Trust, and Medication Adherence Among Black Patients in Safety-Net Primary Care.

There has been a growing research focus on social determinants to health disparities in general and medication adherence more specifically in low-income Black populations. The purpose of this study was to examine whether prior experiences of racism amongBlack patients in safety-net primary care indirectly predicts poor medication adherence through increased mental health symptoms and low healthcare provider trust. Two competing models were run whereby mental health leads to provider trust or provider trust leads to mental health in this multiple mediational chain. A group of 134 Black patients (76 men, average age 45.39years) in a safety-net primary care clinic completed measures of these constructs. Results revealed that in the first model, mental health mediated the relationship between racism and provider trust, and provider trust mediated the relationship between mental health and medication adherence. All paths within this model were statistically significant, except the path between provider trust and medication adherence which approached significance. In the second model, provider trust and mental health significantly mediated the relationship between racism and medication adherence, and all direct and indirect paths were statistically significant, though the path between provider trust and medication adherence was omitted. These results may serve as catalysts to assess and attempt to mitigate specific minority-based stressors and associated outcomes within safety-net primary care settings.

Social determinants of sleep disturbance in safety-net primary care: unmet needs, classist discrimination, and anxiety

The 3P model proposes that predisposing, precipitating, and perpetuating factors all play a role in sleep disturbance. The purpose of the current study is to investigate social determinants of sleep disturbance by applying the 3P model to a safety-net primary care setting, specifically by evaluating the role of classism and unmet needs as precipitating factors for sleep disturbance, and anxiety as a perpetuating factor for sleep disturbance. Participants (N = 210) were a convenience sample of racially/ethnically diverse adults over the age of 18 (age M = 44.7 years) recruited from a safety-net primary care clinic in an urban area. The study employed a cross-sectional design. Participants completed a survey assessing sleep disturbances, anxiety, unmet needs, classism, social support, and a researcher-generated demographic form. The unmet need for affordable long-term housing and greater experiences of classism were associated with more sleep disturbance, suggesting that both acted as precipitating factors. In a structural equation model with adequate fit indices, anxiety mediated the relationships with sleep disturbance for both the unmet need for affordable long-term housing and classism, suggesting that it serves as a perpetuating factor. Medical providers are recommended to explore these potential needs in safety-net primary care when patients present with sleep disturbance or anxiety. Assisting with connections to long-term housing and helping patients counteract and cope with classist discrimination may be effective in improving sleep in safety-net primary care.

Using Lean Performance Improvement for Patient-Centered Medical Home Transformation at an Academic Public Hospital.

Although Lean performance improvement (PI) has been used in health care for more than 15 years, little is known about how Lean has been used in Patient-Centered Medical Home (PCMH) transformation. We describe our experience implementing Lean in our safety-net, primary care teaching clinic. To advance high value care, a culture of systematic, sustainable PI methods needed to be integrated into primary care and taught to resident physicians. Clinic leadership were trained in Lean methods, protected time was dedicated to PI for a stable, interdisciplinary team, then visual management was introduced, and resident physicians were integrated into the clinic's PI initiatives. Self-assessment using the PCMH Assessment tool demonstrated improvement in core features of the PCMH model. Process outcomes also revealed successful, sustainable integration of Lean into our primary care clinic and resident training, and early findings show improvements in clinical quality outcomes. Patient survey outcomes demonstrate improvement in patient experience. Lean can be used successfully to promote PCMH transformation and create a culture of continuous PI in an academic, safety-net primary care setting.

Addressing Diabetes in Primary Care: Hybrid Effectiveness-Implementation Study of Lifestyle Redesign® Occupational Therapy.

Primary health care is rapidly developing as an occupational therapy practice area. Yet, to date, little evidence supports occupational therapy's feasibility and efficacy in primary care settings. To report on the implementation and preliminary clinical outcomes of a Lifestyle Redesign® (LR)-occupational therapy (LR-OT) diabetes management intervention in a primary care clinic. Patients were randomized to be offered LR-OT or to a no-contact comparison group (data not reported). We assessed implementation outcomes using mixed methods. Safety-net primary care clinic. Clinic providers and staff; English- or Spanish-speaking clinic patients ages 18-75 yr with diabetes and a current hemoglobin A1c (HbA1c) ≥ 9.0%. Eight 1-hr individual sessions of LR-OT focused on diabetes management. Clinical and health behavior outcomes were assessed via electronic medical record (EMR) review and self-report surveys of patients receiving LR-OT at initial evaluation and discharge. We assessed implementation outcomes (acceptability, appropriateness, feasibility, fidelity, efficiency, and timeliness) using patient and staff surveys, interviews, focus groups, and observations. Seventy-three patients were offered LR-OT: 51 completed one or more sessions, and 38 completed the program. Clinical outcomes among program completers indicate beneficial changes in HbA1c, diabetes self-care, and health status. Implementation challenges included a need for patient and staff education, securing adequate workspace, and establishing a referral process. Factors contributing to implementation success included strong buy-in from clinic leadership, colocation, and shared EMR documentation. LR-OT is a feasible approach to enhancing service delivery and clinical outcomes in primary care. This study provides insight into factors that may create challenges or contribute to the success of implementing occupational therapy services within primary health care settings. In addition, this study provides preliminary evidence of occupational therapy's effectiveness in improving clinical outcomes among ethnically diverse, low-income patients with diabetes in a safety-net primary care setting.

Sources and Impact of Time Pressure on Opioid Management in the Safety-Net.

This study sought to understand clinicians' and patients' experience managing chronic noncancer pain (CNCP) and opioids in safety-net primary care settings. This article explores the time requirements of safer opioid prescribing for medically and socially complex patients in the context of safety-net primary care. We qualitatively interviewed 23 primary care clinicians and 46 of their patients with concurrent CNCP and substance use disorder (past or current). We also conducted observations of clinical interactions between the clinicians and patients. We transcribed, coded, and analyzed interview and clinical observation recordings using grounded theory methodology. Clinicians reported not having enough time to assess patients' CNCP, functional status, and risks for opioid misuse. Inadequate assessment of CNCP contributed to tension and conflicts during visits. Clinicians described pain conversations consuming a substantial portion of primary care visits despite patients' other serious health concerns. System-level constraints (eg, changing insurance policies, limited access to specialty and integrative care) added to the perceived time burden of CNCP management. Clinicians described repeated visits with little progress in patients' pain or functional status due to these barriers. Patients acknowledged clinical time constraints and reported devoting significant time to following new opioid management protocols for CNCP. Time pressure was identified as a major barrier to safer opioid prescribing. Efforts, including changes to reimbursement structures, are needed to relieve time stress on primary care clinicians treating medically and socially complex patients with CNCP in safety-net settings.

PHS132 - Sociodemographic Disparities in Health-Related Quality of Life Within a Safety Net Primary Care Setting and the Clinical Implications of Symptom Management

PHS132 - Sociodemographic Disparities in Health-Related Quality of Life Within a Safety Net Primary Care Setting and the Clinical Implications of Symptom Management

Impact of a Primary Care CKD Registry in a US Public Safety-Net Health Care Delivery System: A Pragmatic Randomized Trial

Many individuals with chronic kidney disease (CKD) do not receive guideline-concordant care. We examined the impact of a team-based primary care CKD registry on clinical measures and processes of care among patients with CKD cared for in a public safety-net health care delivery system. Pragmatic trial of a CKD registry versus a usual-care registry for 1 year. Primary care providers (PCPs) and their patients with CKD in a safety-net primary care setting in San Francisco. The CKD registry identified at point of care all patients with CKD, those with blood pressure (BP)>140/90mmHg, those without angiotensin-converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB) prescription, and those without albuminuria quantification in the past year. It also provided quarterly feedback pertinent to these metrics to promote "outreach" to patients with CKD. The usual-care registry provided point-of-care cancer screening and immunization data. Changes in systolic BP at 12 months (primary outcome), proportion of patients with BP control, prescription of ACE inhibitors/ARBs, quantification of albuminuria, severity of albuminuria, and estimated glomerular filtration rate. The patient population (n=746) had a mean age of 56.7±12.1 (standard deviation) years, was 53% women, and was diverse (8% non-Hispanic white, 35.7% black, 24.5% Hispanic, and 24.4% Asian). Randomization to the CKD registry (30 PCPs, 285 patients) versus the usual-care registry (49 PCPs, 461 patients) was associated with 2-fold greater odds of ACE inhibitor/ARB prescription (adjusted OR, 2.25; 95% CI, 1.45-3.49) and albuminuria quantification (adjusted OR, 2.44; 95% CI, 1.38-4.29) during the 1-year study period. Randomization to the CKD registry was not associated with changes in systolic BP, proportion of patients with uncontrolled BP, or degree of albuminuria or estimated glomerular filtration rate. Potential misclassification of CKD; missing baseline medication data; limited to study of a public safety-net health care system. A team-based safety-net primary care CKD registry did not improve BP parameters, but led to greater albuminuria quantification and more ACE inhibitor/ARB prescriptions after 1 year. Adoption of team-based CKD registries may represent an important step in translating evidence into practice for CKD management.

Patient Experiences in a Linguistically Diverse Safety Net Primary Care Setting: Qualitative Study.

BackgroundThe patient-centered medical home model intends to improve patient experience and primary care quality. Within an urban safety net setting in Northern California, United States, these desired outcomes are complicated by both the diversity of the patient community and the care continuity implications of a residency program.ObjectiveThe objective of our study was to understand the patient experience beyond standardized satisfaction measures.MethodsWe conducted a qualitative study, interviewing 19 patients from the clinic (English-, Spanish-, or Mien-speaking patients).ResultsSome themes, such as the desire to feel confident in their doctor, emerged across language groups, pointing to institutional challenges. Other themes, such as distrust in care being provided, were tied distinctly to speaking a language different from one’s provider. Still other themes, such as a sense of powerlessness, were related to cultural differences and to speaking a language (Mien) not spoken by staff.ConclusionsFindings illuminate the need to understand cultural behaviors and interactional styles in a diverse patient population to create a high-quality medical home.