Exemplary Practices in Cardiovascular Care: Results on Clinical Quality Measures from the EvidenceNOW Southwest Cooperative.

BACKGROUND: Identifying characteristics of primary care practices that perform well on cardiovascular clinical quality measures (CQMs) may point to important practice improvement strategies. OBJECTIVE: To identify practice characteristics associated with high performance on four cardiovascular disease CQMs. DESIGN: Longitudinal cohort study among 211 primary care practices in Colorado and New Mexico. Quarterly CQM reports were obtained from 178 (84.4%) practices. There was 100% response rate for baseline practice characteristics and implementation tracking surveys. Follow-up implementation tracking surveys were completed for 80.6% of practices. PARTICIPANTS: Adult patients, staff, and clinicians in family medicine, general internal medicine, and mixed-specialty practices. INTERVENTION: Practices received 9 months of practice facilitation and health information technology support, plus biannual collaborative learning sessions. MAIN MEASURES: This study identified practice characteristics associated with overall highest performance using area under the curve (AUC) analysis on aspirin therapy, blood pressure management, and smoking cessation CQMs. RESULTS: Among 178 practices, 39 were exemplars. Exemplars were more likely to be a Federally Qualified Health Center (69.2% vs 35.3%, p = 0.0006), have an underserved designation (69.2% vs 45.3%, p = 0.0083), and have higher percentage of patients with Medicaid (p < 0.0001). Exemplars reported greater use of cardiovascular disease registries (61.5% vs 29.5%,), standing orders (38.5 vs 22.3%) or electronic health record prompts (84.6% vs 49.6%) (all p < 0.05), were more likely to have medical home recognition (74.4% vs 43.2%, p = 0.0006), and reported greater implementation of building blocks of high-performing primary care: regular quality improvement team meetings (3.0 vs 2.2), patient experience survey (3.1 vs 2.2), and resources for patients to manage their health (3.0 vs 2.3). High improvers (n = 45) showed greater improvement implementing team-based care (32.8 vs 11.7, p = 0.0004) and population management (37.4 vs 20.5, p = 0.0057). CONCLUSIONS: Multiple strategies-registries, prompts and protocols, patient self-management support, and patient-team partnership activities-were associated with delivering high-quality cardiovascular care over time, measured by CQMs. TRIAL REGISTRATION: ClinicalTrials.gov registration: NCT02515578.

The Role of Health Extension in Practice Transformation and Community Health Improvement: Lessons From 5 Case Studies.

Passage of the Patient Protection and Affordable Care Act triggered 2 successive grant initiatives from the Agency for Healthcare Research and Quality, allowing for the evolution of health extension models among 20 states, not limited to support for in-clinic primary care practice transformation, but also including a broader concept incorporating technical assistance for practices and their communities to address social determinants of health. Five states stand out in stretching the boundaries of health extension: New Mexico, Oklahoma, Oregon, Colorado, and Washington. Their stories reveal lessons learned regarding the successes and challenges, including the importance of building sustained relationships with practices and community coalitions; of documenting success in broad terms as well as achieving diverse outcomes of meaning to different stakeholders; of understanding that health extension is a function that can be carried out by an individual or group depending on resources; and of being prepared for political struggles over "turf" and ownership of extension. All states saw the need for long-term, sustained fundraising beyond grants in an environment expecting a short-term return on investment, and they were challenged operating in a shifting health system landscape where the creativity and personal relationships built with small primary care practices was hindered when these practices were purchased by larger health delivery systems.

Self-management support for chronic disease in primary care: frequency of patient self-management problems and patient reported priorities, and alignment with ultimate behavior goal selection.

BACKGROUND: To enable delivery of high quality patient-centered care, as well as to allow primary care health systems to allocate appropriate resources that align with patients' identified self-management problems (SM-Problems) and priorities (SM-Priorities), a practical, systematic method for assessing self-management needs and priorities is needed. In the current report, we present patient reported data generated from Connection to Health (CTH), to identify the frequency of patients' reported SM-Problems and SM-Priorities; and examine the degree of alignment between patient SM-Priorities and the ultimate Patient-Healthcare team member selected Behavioral Goal. METHODS: CTH, an electronic self-management support system, was embedded into the flow of existing primary care visits in 25 primary care clinics and was used to assess patient-reported SM-Problems across 12 areas, patient identified SM-Priorities, and guide the selection of a Patient-Healthcare team member selected Behavioral Goal. SM-Problems included: BMI, diet (fruits and vegetables, salt, fat, sugar sweetened beverages), physical activity, missed medications, tobacco and alcohol use, health-related distress, general life stress, and depression symptoms. Descriptive analyses documented SM-Problems and SM-Priorities, and alignment between SM-Priorities and Goal Selection, followed by mixed models adjusting for clinic. RESULTS: 446 participants with ≥ one chronic diseases (mean age 55.4 ± 12.6; 58.5% female) participated. On average, participants reported experiencing challenges in 7 out of the 12 SM-Problems areas; with the most frequent problems including: BMI, aspects of diet, and physical activity. Patient SM-Priorities were variable across the self-management areas. Patient- Healthcare team member Goal selection aligned well with patient SM-Priorities when patients prioritized weight loss or physical activity, but not in other self-management areas. CONCLUSION: Participants reported experiencing multiple SM-Problems. While patients show great variability in their SM-Priorities, the resulting action plan goals that patients create with their healthcare team member show a lack of diversity, with a disproportionate focus on weight loss and physical activity with missed opportunities for using goal setting to create targeted patient-centered plans focused in other SM-Priority areas. Aggregated results can assist with the identification of high frequency patient SM-Problems and SM-Priority areas, and in turn inform resource allocation to meet patient needs. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT01945918 .

A Community Engagement Method to Design Patient Engagement Materials for Cardiovascular Health.

PURPOSE: EvidenceNOW Southwest is a cluster-randomized trial evaluating the differential impact on cardiovascular disease (CVD) care of engaging patients and communities in practice transformation in addition to standard practice facilitation support. The trial included development of locally tailored CVD patient engagement materials through Boot Camp Translation (BCT), a community engagement process that occurred before practice recruitment but after cluster randomization. METHODS: We introduce a cluster randomization method performed before recruitment of small to medium-size primary care practices in Colorado and New Mexico, which allowed for balanced study arms while minimizing contamination. Engagement materials for the enhanced study arm were developed by means of BCT, which included community members, practice members, and public health professionals from (1) metropolitan Denver, (2) rural northeast Colorado, (3) Albuquerque, and (4) rural southeast New Mexico. Outcome measures were messages and materials from BCTs and population characteristics of study arms after using geographic-based covariate constrained randomization. RESULTS: The 4 BCTs' messages and materials developed by the BCT groups uniquely reflected each community and ranged from family or spiritual values to early prevention or adding relevance to CVD risk. The geographic-based covariate of a cluster randomization method constrained randomization-assigned regions to study arms, allowing BCTs to precede practice recruitment, reduce contamination, and balance populations. CONCLUSIONS: Cluster-randomized trials with community-based interventions present study design and implementation challenges. The BCTs elicited unique contextual messages and materials, suggesting that interventions designed to help primary care practices decrease CVD risk may not be one size fits all.

A protocol for a cluster randomized trial comparing strategies for translating self-management support into primary care practices.

BACKGROUND: Advanced primary care models emphasize patient-centered care, including self-management support (SMS), but the effective use of SMS for patients with type 2 diabetes (T2DM) remains a challenge. Interactive behavior-change technology (IBCT) can facilitate the adoption of SMS interventions. To meet the need for effective SMS intervention, we have developed Connection to Health (CTH), a comprehensive, evidence-based SMS program that enhances interactions between primary care clinicians and patients to resolve self-management problems and improve outcomes. Uptake and maintenance of programs such as CTH in primary care have been limited by the inability of practices to adapt and implement program components into their culture, patient flow, and work processes. Practice facilitation has been shown to be effective in helping practices make the changes required for optimal program implementation. The proposed research is designed to promote the translation of SMS into primary care practices for patients with T2DM by combining two promising lines of research, specifically, (a) testing the effectiveness of CTH in diverse primary-care practices, and (b) evaluating the impact of practice facilitation to enhance implementation of the intervention. METHODS: A three-arm, cluster-randomized trial will evaluate three discrete strategies for implementing SMS for patients with T2DM in diverse primary care practices. Practices will be randomly assigned to receive and implement the CTH program, the CTH program plus practice facilitation, or a SMS academic detailing educational intervention. Through this design, we will compare the effectiveness, adoption and implementation of these three SMS practice implementation strategies. Primary effectiveness outcomes including lab values and evidence of SMS will be abstracted from medical records covering baseline through 18 months post-baseline. Data from CTH assessments and action plans completed by patients enrolled in CTH will be used to evaluate practice implementation of CTH and the impact of CTH participation. Qualitative data including field notes from encounters with the practices and interviews of practice personnel will be analyzed to assess practice implementation of SMS. DISCUSSION: This study will provide important information on the implementation of SMS in primary care, the effectiveness of an IBCT tool such as CTH, and the use of practice facilitation to assist implementation. TRIAL REGISTRATION: Registered with ClinicalTrials.gov - ClinicalTrials.gov ID: NCT01945918 , date 08/27/2013. Modifications have been updated.

Practice context affects efforts to improve diabetes care for primary care patients: a pragmatic cluster randomized trial.

BACKGROUND: Efforts to improve primary care diabetes management have assessed strategies across heterogeneous groups of patients and practices. However, there is substantial variability in how well practices implement interventions and achieve desired outcomes. OBJECTIVE: To examine practice contextual features that moderate intervention effectiveness. DESIGN: Secondary analysis of data from a cluster randomized trial of three approaches for implementing the Chronic Care Model to improve diabetes care. PARTICIPANTS: Forty small to mid-sized primary care practices participated, with 522 clinician and staff member surveys. Outcomes were assessed for 822 established patients with a diagnosis of type 2 diabetes who had at least one visit to the practice in the 18 months following enrollment. MAIN MEASURES: The primary outcome was a composite measure of diabetes process of care, ascertained by chart audit, regarding nine quality measures from the American Diabetes Association Physician Recognition Program: HgA1c, foot exam, blood pressure, dilated eye exam, cholesterol, nephropathy screen, flu shot, nutrition counseling, and self-management support. Data from practices included structural and demographic characteristics and Practice Culture Assessment survey subscales (Change Culture, Work Culture, Chaos). KEY RESULTS: Across the three implementation approaches, demographic/structural characteristics (rural vs. urban + .70(p = .006), +2.44(p < .001), -.75(p = .004)); Medicaid: < 20 % vs. ≥ 20 % (-.20(p = .48), +.75 (p = .08), +.60(p = .02)); practice size: < 4 clinicians vs. ≥ 4 clinicians (+.56(p = .02), +1.96(p < .001), +.02(p = .91)); practice Change Culture (high vs. low: -.86(p = .048), +1.71(p = .005), +.34(p = .22)), Work Culture (high vs. low: -.67(p = .18), +2.41(p < .001), +.67(p = .005)) and variability in practice Change Culture (high vs. low: -.24(p = .006), -.20(p = .0771), -.44(p = .0019) and Work Culture (high vs. low: +.56(p = .3160), -1.0(p = .008), -.25 (p = .0216) were associated with trajectories of change in diabetes process of care, either directly or differentially by study arm. CONCLUSIONS: This study supports the need for broader use of methodological approaches to better examine contextual effects on implementation and effectiveness of quality improvement interventions in primary care settings.

Practice facilitation to improve diabetes care in primary care: a report from the EPIC randomized clinical trial.

PURPOSE: We investigated 3 approaches for implementing the Chronic Care Model to improve diabetes care: (1) practice facilitation over 6 months using a reflective adaptive process (RAP) approach; (2) practice facilitation for up to 18 months using a continuous quality improvement (CQI) approach; and (3) providing self-directed (SD) practices with model information and resources, without facilitation. METHODS: We conducted a cluster-randomized trial, called Enhancing Practice, Improving Care (EPIC), that compared these approaches among 40 small to midsized primary care practices. At baseline and 9 months and 18 months after enrollment, we assessed practice diabetes quality measures from chart audits and Practice Culture Assessment scores from clinician and staff surveys. RESULTS: Although measures of the quality of diabetes care improved in all 3 groups (all P <.05), improvement was greater in CQI practices compared with both SD practices (P <.0001) and RAP practices (P <.0001); additionally, improvement was greater in SD practices compared with RAP practices (P <.05). In RAP practices, Change Culture scores showed a trend toward improvement at 9 months (P = .07) but decreased below baseline at 18 months (P <.05), while Work Culture scores decreased from 9 to 18 months (P <.05). Both scores were stable over time in SD and CQI practices. CONCLUSIONS: Traditional CQI interventions are effective at improving measures of the quality of diabetes care, but may not improve practice change and work culture. Short-term practice facilitation based on RAP principles produced less improvement in quality measures than CQI or SD interventions and also did not produce sustained improvements in practice culture.

Postresidency Practice Setting and Clinical Care Features According to 3 Versus 4 Years of Training in Family Medicine: A Length of Training Pilot Study.

BACKGROUND AND OBJECTIVES: Factors associated with physician practice choice include residency location, training experiences, and financial incentives. How length of training affects practice setting and clinical care features postgraduation is unknown. METHODS: In this Length of Training Pilot (LoTP) study, we surveyed 366 graduates of 3-year (3YR) and 434 graduates of 4-year (4YR) programs 1 year after completion of training between 2013 and 2021. Variables assessed included reasons for practice setting choice, practice type, location, practice and community size, specialty mix, and clinical care delivery features (eg, integrated behavioral health, risk stratified care management). We compared different length of training models using χ2 or Fisher's exact tests for categorical variables and independent samples, and t test (unequal variances) for continuous variables. RESULTS: Response rates ranged from 50% to 88% for 3YR graduates and 68% to 95% for 4YR graduates. Scope of practice was a predominant reason for graduates choosing their eventual practice, and salary was a less likely reason for those completing 4 years versus 3 years of training (scope, 72% vs 55%, P=.001; salary, 15% vs 22%, P=.028). Community size, practice size, practice type, specialty mix, and practice in a federally designated underserved site did not differ between the two groups. We found no differences in patient-centered medical home features when comparing the practices of 3YR to 4YR graduates. CONCLUSIONS: Training length did not affect practice setting or practice features for graduates of LoTP programs. Future LoTP analyses will examine how length of training affects scope of practice and clinical preparedness, which may elucidate other elements associated with practice choice.

Does engagement matter? The impact of patient and community engagement on implementation of cardiovascular health materials in primary care settings.

BACKGROUND: Engaging patients and community members in healthcare implementation, research and evaluation has become more popular over the past two decades. Despite the growing interest in patient engagement, there is scant evidence of its impact and importance. Boot Camp Translation (BCT) is one evidence-based method of engaging communities in research. The purpose of this report is to describe the uptake by primary care practices of cardiovascular disease prevention materials produced through four different local community engagement efforts using BCT. METHODS: EvidenceNOW Southwest (ENSW) was a randomized trial to increase cardiovascular disease (CVD) prevention in primary care practices. Because of its study design, Four BCTs were conducted, and the materials created were made available to participating practices in the "enhanced" study arm. As a result, ENSW offered one of the first opportunities to explore the impact of the BCT method by describing the uptake by primary care practices of health messages and materials created locally using the BCT process. Analysis compared uptake of locally translated BCT products vs. all other products among practices based on geography, type of practice, and local BCT. RESULTS: Within the enhanced arm of the study that included BCT, 69 urban and 13 rural practices participated with 9 being federally qualified community health centers, 14 hospital owned and 59 clinician owned. Sixty-three practices had 5 or fewer clinicians. Two hundred and ten separate orders for materials were placed by 43 of the 82 practices. While practices ordered a wide variety of BCT products, they were more likely to order materials developed by their local BCT. CONCLUSIONS: In this study, patients and community members generated common and unique messages and materials for cardiovascular disease prevention relevant to their regional and community culture. Primary care practices preferred the materials created in their region. The greater uptake of locally created materials over non-local materials supports the use of patient engagement methods such as BCT to increase the implementation and delivery of guideline-based care. Yes, patient and community engagement matters. TRIAL REGISTRATION AND IRB: Trial registration was prospectively registered on July 31, 2015 at ClinicalTrials.gov (NCT02515578, protocol identifier 15-0403). The project was approved by the Colorado Multiple Institutional Review Board and the University of New Mexico Human Research Protections Office.

Behavioral health integration and specialty medical care: Opportunities for applying knowledge from primary care integration.

While education and advocacy regarding behavioral health (BH) integration in primary care have been in full force at the state and national level for many years, specialty care BH integration has not received the same attention in terms of practice transformation, workforce development, and payment reform. Models of BH care have been tested in primary care and can be easily adapted to improve specialty patient care. There are many opportunities for using the knowledge base gained from integrated primary care to help move integration forward in the specialty medical setting. The timing for this is rife, as the benefits of integrated BH for patient health outcomes are well established. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Resident Visit Productivity and Attitudes About Continuity According to 3 Versus 4 Years of Training in Family Medicine: A Length of Training Study.

BACKGROUND AND OBJECTIVES: Training models in the Length of Training Pilot (LOTP) vary. How innovations in training length affect patient visits and resident perceptions of continuity is unknown. METHODS: We analyzed resident in-person patient encounters (2013-2014 through 2018-2019) for each postgraduate year (PGY) and total visits at graduation derived from the Accreditation Council for Graduate Medical Education reports for each LOTP program. We collected data on residents' perceptions of continuity from annual surveys (2015-2019). We analyzed continuous variables using independent samples t tests with unequal variance and categorical variables using χ2 tests in comparing 3-year (3YR) versus 4-year (4YR) programs. RESULTS: PGY-1 and PGY-2 residents in 4YR programs saw statistically more patients than their counterparts in 3YR programs. In PGY3, 3YR program residents had statistically higher visit volume compared to 4YR program residents. Visits conducted in PGY4 ranged from 832 to 884. The additional year of training resulted in approximately 1,000 more total patient visits. Most residents in 3YR and 4YR programs rated their continuity clinic experience as somewhat or very adequate (range 86.3% to 93.7%), which did not statistically differ according to length of training. CONCLUSIONS: Resident visits were significantly different at each PGY level when comparing 3YR and 4YR programs in the LOTP and the additional year of training resulted in about 1,000 more total visits. Resident perspectives on the adequacy of their continuity clinic experience appeared to not be affected by length of training. Future research should explore how the volume of patient visits performed in residency affects scope of practice and clinical preparedness.

Patient-centered medical home: how it affects psychosocial outcomes for diabetes.

Fragmentation of the current U.S. health care system and the increased prevalence of chronic diseases in the U.S. have led to the recognition that new models of care are needed. Chronic disease management, including diabetes, is often accompanied by a myriad of associated psychosocial issues that need to be addressed as part of a comprehensive treatment plan. Diabetes care should be aligned with comprehensive whole-person health care. The patient-centered medical home (PCMH) has emerged as a model for enhanced primary care that focuses on comprehensive integrated care. PCMH demonstration projects have shown improvements in quality of care, patient experience, care coordination, access to care, and quality measures for diabetes. Key PCMH transformative features associated with psychosocial issues related to diabetes reviewed in this article include integration of mental and behavioral health, care management/coordination, payment reform, advanced access, and putting the patient at the center of health care. This article also reviews the evidence supporting comprehensive and integrated care for addressing psychosocial issues associated with diabetes in the medical home.

Something Republicans and Democrats can agree on: Support for integrated behavioral health.

Barriers to the spread of integrated behavioral health and primary care continue to limit progress on meeting critical needs for mental health and substance use disorder services. The recent Bipartisan Policy Center Report (2021) provides key policy recommendations to address these barriers and accelerate the adoption of integrated behavioral health in Medicaid and Medicare. Having bipartisan support presents a policy window of opportunity to advance integrated behavioral health through advocacy for implementation of these recommendations, parallel changes to occur in employer-based and other commercial insurance plans, and development of operationalized standards for core service delivery elements. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

An Exploratory Mixed Methods Study of Experiences of Interprofessional Teams Who Received Coaching to Simultaneously Redesign Primary Care Education and Clinical Practice.

INTRODUCTION/OBJECTIVES: Coaching is emerging as a form of facilitation in health professions education. Most studies focus on one-on-one coaching rather than team coaching. We assessed the experiences of interprofessional teams coached to simultaneously improve primary care residency training and interprofessional practice. METHODS: This three-year exploratory mixed methods study included transformational assistance from 9 interprofessional coaches, one assigned to each of 9 interprofessional primary care teams that included family medicine, internal medicine, pediatrics, nursing, pharmacy and behavioral health. Coaches interacted with teams during 2 in-person training sessions, an in-person site visit, and then as requested by their teams. Surveys administered at 1 year and end study assessed the coaching relationship and process. RESULTS: The majority of participants (82% at end of Year 1 and 76.6% at end study) agreed or strongly agreed that their coach developed a positive working relationship with their team. Participants indicated coaches helped them: (1) develop as teams, (2) stay on task, and (3) respond to local context issues, with between 54.3% and 69.2% agreeing or strongly agreeing that their coaches were helpful in these areas. Cronbach's alpha for the 15 coaching survey items was 0.965. Challenges included aligning the coach's expertise with the team's needs. CONCLUSIONS: While team coaching was well received by interprofessional teams of primary care professionals undertaking educational and clinical redesign, the 3 primary care disciplines have much to learn from each other regarding how to improve inter- and intra-professional collaborative practice among clinicians and staff as well as with interprofessional learners rotating through their outpatient clinics.

A Taxonomy for External Support for Practice Transformation.

BACKGROUND: There is no commonly accepted comprehensive framework for describing the practical specifics of external support for practice change. Our goal was to develop such a taxonomy that could be used by both external groups or researchers and health care leaders. METHODS: The leaders of 8 grants from Agency for Research and Quality for the EvidenceNOW study of improving cardiovascular preventive services in over 1500 primary care practices nationwide worked collaboratively over 18 months to develop descriptions of key domains that might comprehensively characterize any external support intervention. Combining literature reviews with our practical experiences in this initiative and past work, we aimed to define these domains and recommend measures for them. RESULTS: The taxonomy includes 1 domain to specify the conceptual model(s) on which an intervention is built and another to specify the types of support strategies used. Another 5 domains provide specifics about the dose/mode of that support, the types of change process and care process changes that are encouraged, and the degree to which the strategies are prescriptive and standardized. A model was created to illustrate how the domains fit together and how they would respond to practice needs and reactions. CONCLUSIONS: This taxonomy and its use in more consistently documenting and characterizing external support interventions should facilitate communication and synergies between 3 areas (quality improvement, practice change research, and implementation science) that have historically tended to work independently. The taxonomy was designed to be as useful for practices or health systems managing change as it is for research.

Comprehensiveness and continuity of care and the inseparability of mental and behavioral health from the patient-centered medical home.

Comprehensiveness and continuity of care are key elements of primary care system redesign. Comprehensiveness encompasses evaluating the whole person and dealing with the full range of physical, mental, and behavioral healthcare issues; and continuity is based on building healing relationships over time. This article suggests that a focus on comprehensiveness and continuity implies that responding to mental health, behavioral health, and substance use must be core elements of the patient-centered medical home. A list of necessary next steps toward achieving comprehensive and integrated care is recommended.

Practice Transformation Support and Patient Engagement to Improve Cardiovascular Care: From EvidenceNOW Southwest (ENSW).

PURPOSE: To improve cardiovascular care through supporting primary care practices' adoption of evidence-based guidelines. STUDY DESIGN: A cluster randomized trial compared two approaches: (1) standard practice support (practice facilitation, practice assessment with feedback, health information technology assistance, and collaborative learning sessions) and (2) standard support plus patient engagement support. METHODS: Primary outcomes were cardiovascular clinical quality measures (CQMs) collected at baseline, 9 months, and 15 months. Implementation of the first 6 "Building Blocks of High-Performing Primary Care" was assessed by practice facilitators at baseline and 3, 6, and 9 months. CQMs from practices not involved in the study served as an external comparison. RESULTS: A total of 211 practices completed baseline surveys. There were no differences by study arm (odds ratio [95% confidence interval]) for aspirin use (1.03 [0.99, 1.06]), blood pressure (0.98 [0.95, 1.01]), cholesterol (0.96 [0.92, 1.00]), and smoking (1.01 [0.96, 1.07]); however, there were significant improvements over time in aspirin use (1.04 [1.01, 1.07]), cholesterol (1.05 [1.03, 1.08]), and smoking (1.03 [1.01, 1.06]), but not blood pressure (1.01 [0.998, 1.03]). Improvement in enrolled practices was greater than external comparison practices across all 4 measures (all P < .05). Implementation improved in both arms for Team-Based Care, Patient-Team Partnership, and Population Management, and improvement was greater in enhanced intervention practices (all P < .05). Leadership and Data-Driven Improvement (P < .05) improved significantly, with no difference by arm. A greater improvement in Building Block implementation was associated with a greater improvement in blood pressure measures (P < .05). CONCLUSIONS: Practice transformation support can assist practices with improving quality of care. Patient engagement in practice transformation can further enhance practices' implementation of aspects of new models of care.

A patient outreach program between visits improves diabetes care: a pilot study.

OBJECTIVE: Barriers to guideline-based diabetes care include poor patient activation, haphazard clinic appointments, poorly organized medical records and a lack of automated physician decision support. We developed a patient recall intervention to mitigate these barriers and improve diabetes care coordination. We evaluated this intervention in terms of operational feasibility, provider and patient acceptance and effects on process of care measures. METHODS: On the basis of the American Diabetes Association criteria, we identified patients with diabetes in a large internal medicine practice who were due for provider visits; hemoglobin A1c, lipid, microalbumin and serum creatinine laboratories; and retinal examinations. An outreach coordinator contacted patients to summarize this information and schedule recommended services. We assessed patient responsiveness to outreach and used medical chart review to compare diabetes care rendered before and after the intervention. Providers gave feedback about their satisfaction with the program. RESULTS: Over 3 months, 709 patients were overdue for diabetes-related services. Of 415 overdue for provider visits, a total of 125 (30.1%) completed such visits arranged by an outreach coordinator and, of these, 101 (80.8%) completed laboratories at least a day ahead of time. An additional 52 out of 415 patients (12.5%) bypassed the outreach coordinator to self-schedule diabetes visits within a 6-week period after the outreach letter was mailed. Among overdue patients, completion of recommended services and intensity of diabetes care were significantly greater through the outreach program compared with traditional care. Provider attitudes were favorable. CONCLUSIONS: An outreach intervention was associated with improved timeliness and intensity of diabetes care in an outpatient setting. The success of this pilot program in terms of process measures warrants additional evaluation focused on clinical outcomes.

Integrating practices' change processes into improving quality of depression care.

BACKGROUND: Primary care practices would benefit from improved understanding of how to make and sustain fundamental changes in their delivery systems. An improvement collaborative project was conducted in 2005 to not only improve the quality of depression care but help participating practices adopt and adapt more effective change processes to implement improved depression care. In a follow-up to an article on the project's impact in terms of measurable, sustained improvements in depression care, an exploratory qualitative study was conducted to examine primary care practices' adoption of effective change processes. METHODS: Qualitative data were collected from 16 primary care practices participating in the National Depression Management Leadership Initiative's Improving Depression Care project. A multistep process of qualitative analysis was used to identify exemplar practices, and a constant comparative method was applied to identify salient features that influenced adoption of change processes associated with improvements in depression care during the course of the 18-month project. RESULTS: The participating practices showed considerable variability in terms of the improvements they made in depression care and corresponding adoption of change processes to help make these and other improvements. Nearly all practices that showed the greatest improvements in depression care also adopted more effective processes for change, with several features associated with exemplar practices able to improve depression care and change processes. DISCUSSION: These findings support the thesis that successful quality improvement efforts should address both clinical content and change processes. They also add to the literature on the impact of improvement collaborative projects, which to date have demonstrated mixed effects in a variety of chronic diseases, including depression.