Accelerating Use of Self-measured Blood Pressure Monitoring (SMBP) Through Clinical-Community Care Models.

Self-measured blood pressure monitoring (SMBP), the regular measurement of blood pressure by a patient outside the clinical setting, plus additional support, is a proven, cost-effective but underutilized strategy to improve hypertension outcomes. To accelerate SMBP use, the Centers for Disease Control and Prevention (CDC) funded the National Association of Community Health Centers, the YMCA of the USA, and Association of State and Territorial Health Officials to develop cross-sector care models to offer SMBP to patients with hypertension. The project aimed to increase the use of SMBP through the coordinated action of health department leaders, community organizations and clinical providers. From 1/31/2017 to 6/30/2018, nine health centers in Kentucky, Missouri, and New York partnered with seven local Y associations (local Y) and their local health departments to design and implement care models that adapted existing primary care SMBP practices by leveraging capacities and resources in community and public health organizations. Nine collaborative care models emerged, shaped by available community assets, strategic priorities, and organizational culture. Overall, 1421 patients were recommended for SMBP; of those, 795 completed at least one cycle of SMBP (BP measurements morning and evening for at least three consecutive days). Of those recommended for SMBP, 308 patients were referred to a local Y to receive additional SMBP and healthy lifestyle support. Community and public health organizations can be brought into the health care delivery process and can play valuable roles in supporting patients in SMBP.

Vaccination Capability Inventory of Community, Migrant, and Homeless Health Centers: A Survey Report.

CONTEXT: Federally funded Community, Migrant, and Homeless Health Centers provide health services to the most vulnerable communities in the United States. However, little is known about their capabilities and processes for providing vaccinations to adults. PROGRAM: We conducted the first national survey of health centers assessing their inventory, workflow, capacity for, and barriers to provision of routinely recommended adult vaccines. In addition, we asked health center leaders' perceptions regarding best practices and policy recommendations for adult vaccinations. IMPLEMENTATION: A survey was developed on the basis of domains elicited from advisory panels and focus groups and was sent electronically to leaders of 762 health centers throughout the United States and its territories; data were collected and analyzed in 2018. EVALUATION: A total of 319 survey responses (42%) were obtained. Health centers reported stocking most routinely recommended vaccines for adults; zoster vaccines were not stocked regularly due to supply and storage issues. Respondents most commonly reported adequate reimbursement for vaccination services from private insurance and Medicaid. Most vaccinations were provided during primary care encounters; less than half of health centers reported providing vaccines during specialist visits. Vaccines administered at the health center were most commonly documented in an open field of the electronic health record (96%) or in an immunization information system (72%). Recommendations for best practices related to better documentation of vaccinations and communication with immunization information systems were provided. DISCUSSION: Health centers provide most adult vaccines to their patients despite financial and technological barriers to optimal provisioning. Further studies at point of care could help identify mechanisms for system improvements.

Community health center provider ability to identify, treat and account for the social determinants of health: a card study.

BACKGROUND: The social determinants of health (SDH) are conditions that shape the overall health of an individual on a continuous basis. As momentum for addressing social factors in primary care settings grows, provider ability to identify, treat and assess these factors remains unknown. Community health centers care for over 20-million of America's highest risk populations. This study at three centers evaluates provider ability to identify, treat and code for the SDH. METHODS: Investigators utilized a pre-study survey and a card study design to obtain evidence from the point of care. The survey assessed providers' perceptions of the SDH and their ability to address them. Then providers filled out one anonymous card per patient on four assigned days over a 4-week period, documenting social factors observed during encounters. The cards allowed providers to indicate if they were able to: provide counseling or other interventions, enter a diagnosis code and enter a billing code for identified factors. RESULTS: The results of the survey indicate providers were familiar with the SDH and were comfortable identifying social factors at the point of care. A total of 747 cards were completed. 1584 factors were identified and 31 % were reported as having a service provided. However, only 1.2 % of factors were associated with a billing code and 6.8 % received a diagnosis code. CONCLUSIONS: An obvious discrepancy exists between the number of identifiable social factors, provider ability to address them and documentation with billing and diagnosis codes. This disparity could be related to provider inability to code for social factors and bill for related time and services. Health care organizations should seek to implement procedures to document and monitor social factors and actions taken to address them. Results of this study suggest simple methods of identification may be sufficient. The addition of searchable codes and reimbursements may improve the way social factors are addressed for individuals and populations.

Patient and Staff Satisfaction and Experience While Transforming Health Center Systems.

Introduction: Patient satisfaction and experience are important measures of overall quality of care. In 2017, the National Association of Community Health Centers (NACHC) launched an initiative to facilitate changes across organizational systems within Federally Qualified Health Centers (FQHCs) with the goal of improving value-driven care. Methods: NACHC worked with eight health centers, four in Georgia and four in Iowa, along with their state Primary Care Associations, to apply the Value Transformation Framework (VTF). This framework distills evidence-based practices into practical knowledge for goal-driven systems change. It provides actionable steps to help health centers reach value-driven goals of improved health outcomes, improved patient and staff experience, reduced costs, and improved equity (referred to as the Quintuple Aim goals). This paper reports on the patient and staff experience when applying VTF systems changes to improve colorectal cancer screening rates. Results: Patient and staff satisfaction and experience remained highly rated even after extensive organizational changes were implemented as part of this project. Implementation of a systems-approach to organizational change, through application of the VTF, did not negatively impact patient or staff experiences. Conclusion: Patient and staff satisfaction and experience were positive despite the application of the VTF and systems-wide organizational changes. These experience results were alongside improved cancer screening rates, as observed from full project results. Investigators are encouraged that the application of systems change using the VTF may result in the achievement of Quintuple Aim goals without disrupting the experience of patients and staff. Investigators recommend continued exploration of this transformation approach.

Are Community Health Center Patients Interested in Self-Measured Blood Pressure Monitoring (SMBP) - And Can They Do It?

INTRODUCTION: Self-measured blood pressure monitoring (SMBP) helps diagnose and manage hypertension from outside the clinic, which has implications for patient empowerment and outcomes, continuity of care, and resilience in care communities catering to vulnerable populations. METHODS: We instituted a protocol for SMBP among hypertensive patients at 9 community health centers in 3 states and administered questionnaires to patients before and after the protocol was instituted to assess knowledge and engagement with disease management, beliefs and attitudes towards, and experience doing SMBP. Questionnaires included 16 items designed to evaluate patient perceptions and beliefs about SMBP. These included a series of questions using a 5-point Likert scale, binary questions related to their perceived ability to comply with specific SMBP guidelines and open-ended questions to obtain descriptions of experiences with SMBP. RESULTS: The pre-questionnaire was completed by 478 patients and the post-questionnaire was completed by 372. Seventy-seven percent of respondents knew their ideal blood pressure and their engagement with blood pressure management increased significantly (p=0.0024) after completing the protocol. Additionally, 85% of respondents said that they had a positive experience doing SMBP. Open-ended responses revealed insight regarding why patients chose to do SMBP and factors patients appreciated about SMBP. DISCUSSION: When trained properly and supported, community health center patients are capable of and motivated to perform accurate SMBP. Our study provides evidence that health center patients can follow detailed SMBP protocols and monitor their own blood pressure from the safety of their homes, which is critical to their care continuum, particularly in days of a pandemic.

Teaching students to identify and document social determinants of health.

PURPOSE: Social determinants of health (SDH) are responsible for significant health disparities, morbidity and mortality. It is important to acculturate trainees to identify and document SDH. This can elevate their perceptions related to the importance and relevance of SDH. Documentation can encourage trainees to see SDH as factors which medical providers should address. PATIENTS AND METHODS: Researchers devised a novel approach to demonstrate the value of SDH to undergraduate medical students. Proprietary diagnostic codes for SDH and procedure codes for action taken to address them, were developed. Students were encouraged to log these into electronic records for clinical encounters. Students' voluntary use of these codes was evaluated. Additionally, students were surveyed on their familiarity with the concept of SDH, their perceptions of the importance of SDH, as well as documenting SDH, twice in the study period, and results were compared. In their second year of use, proprietary codes were compared to newly available SDH related ICD-10 codes. RESULTS: Students utilized proprietary codes more often than SDH related ICD-10 codes. Over 20,000 codes were logged. Comparison of survey items showed modest increases in students' positive perception about the role of SDH in patient health. CONCLUSION: Students' voluntary logging of SDH codes demonstrates they perceived these factors to be important and relevant to patient encounters. Future analyses will examine students' knowledge, attitudes, beliefs and practice patterns related to SDH.

Faculty perspectives on student attendance in undergraduate medical education.

BACKGROUND: Lecture capture technology is widely available in undergraduate medical education and seems to impact class attendance. Further, there is limited understanding about faculty perceptions related to lecture capture and student attendance and how faculty advise students on issues of attendance in an environment where lecture capture is available and attendance is not required. OBJECTIVE: The purpose of the current study was to characterize faculty perceptions and preferences about student attendance, investigate faculty advising practices about attendance, and evaluate the potential impacts of low student attendance on faculty job satisfaction and teaching. METHOD: A 15-min electronic survey was created and emailed to all on-campus teaching faculty at a medical school. The survey included demographic, close-ended (with Likert and Likert-like scales), and open-ended questions. RESULTS: All 35 faculty members were invited to participate in the survey, and 26 (77%) responded. Faculty advising practices on student attendance varied, but most faculty indicated they advised students to attend class if the student expressed loneliness. A majority (15/26, 58%) disagreed or strongly disagreed that student attendance indicated level of professionalism, and many (12/26, 46%) believed that lecture capture was an effective alternative to attending class. Most faculty (19/26, 73%) agreed or strongly agreed they felt more job satisfaction with higher student attendance. A majority (15/26, 58%) also agreed or strongly agreed they would prefer to incorporate active learning in large-group sessions when student attendance was mandatory. CONCLUSION: Faculty member willingness to incorporate active-learning sessions and job satisfaction were influenced by student classroom attendance in the current study. Given the varied options for content delivery, these factors should be taken into account when institutions create attendance policies. These policies should balance the satisfaction of the faculty with the need to encourage autonomy and flexibility for the adult student learners.

Exodus From the Classroom: Student Perceptions, Lecture Capture Technology, and the Inception of On-Demand Preclinical Medical Education.

CONTEXT: Some medical educators have noted a decline in classroom attendance. Understanding student preferences for content delivery and the relationship between student attendance and learning outcomes may enhance curricular design and best practices for technology-supported learning. OBJECTIVE: To measure the attendance of first-year osteopathic medical students, evaluate the relationship between classroom attendance and aggregate mean course grades, and characterize factors that influence attendance decisions when recorded lectures are available. METHODS: In nonmandatory class sessions during the 2015-2016 academic year, student attendance data were collected using audience response technology and were linked to course grades. Pearson product moment and partial correlations, controlling for Medical College Admissions Test scores, were calculated to quantify the relationship between classroom attendance and aggregate mean course grades. Students were surveyed to characterize factors influencing attendance decisions and compare the perceived convenience, efficiency, and effectiveness of classroom attendance vs lecture capture technology. The preferred modality for receiving didactic content was assessed, and open-ended questions were included about the advantages or disadvantages of lecture capture, classroom attendance, and podcasts. Responses were analyzed using open and axial coding. RESULTS: A 78% reduction in first-year student classroom attendance was measured from the beginning to the end of the academic year (P<.001). The correlation between classroom attendance and aggregate mean course grades (r=0.17; P=.29) and the partial correlation between them after controlling for admission test scores (r=0.18; P=.08) were not significant, except in the Neuromusculoskeletal A course (r=0.22; P=.027). Students regarded lecture capture recordings as more convenient, efficient, and effective than classroom attendance, and podcasting was the preferred method of content delivery. Major themes associated with the open-ended questions were effective or ineffective time management, enhanced interaction, learning advantages or challenges, and positive or negative content characteristics. CONCLUSION: First-year classroom attendance decreased significantly during the academic year, but the authors found no significant relationship between attendance and aggregate mean course grades. Students regarded lecture capture recordings as a practical alternative to attending class; however, podcasts were the preferred modality for receiving didactic content. These findings may help in developing learning-centered curricula at colleges of osteopathic medicine.

Rest and Return to Activity After Sport-Related Concussion: A Systematic Review of the Literature.

OBJECTIVE: To systematically review the literature regarding rest and return to activity after sport-related concussion. DATA SOURCES: The search was conducted in the Cochrane Central Register of Controlled Trials, CINAHL, SPORTDiscus, Educational Resources Information Center, Ovid MEDLINE, and PubMed using terms related to concussion, mild traumatic brain injury, physical and cognitive rest, and return to activity. STUDY SELECTION: Studies were included if they were published in English; were original research; and evaluated the use of, compliance with, or effectiveness of physical or cognitive rest or provided empirical evidence supporting the graded return-to-activity progression. DATA EXTRACTION: The study design, patient or participant sample, interventions used, outcome measures, main results, and conclusions were extracted, as appropriate, from each article. DATA SYNTHESIS: Articles were categorized into groups based on their ability to address one of the primary clinical questions of interest: use of rest, rest effectiveness, compliance with recommendations, or outcome after graded return-to-activity progression. A qualitative synthesis of the results was provided, along with summary tables. CONCLUSIONS: Our main findings suggest that rest is underused by health care providers, recommendations for rest are broad and not specific to individual patients, an initial period of moderate physical and cognitive rest (eg, limited physical activity and light mental activity) may improve outcomes during the acute postinjury phase, significant variability in the use of assessment tools and compliance with recommended return-to-activity guidelines exists, and additional research is needed to empirically evaluate the effectiveness of graded return-to-activity progressions. Furthermore, there is a significant need to translate knowledge of best practices in concussion management to primary care providers.