Improving Access to Care for Vulnerable Missourians: The Hotspot Project.

Context: Many rural areas across the country are considered "health and technology desserts." They lack access to healthcare facilities and broadband connectivity for telehealth services. With the emergence of the COVID-19 pandemic and social distancing requirements, rural residents have become even more vulnerable. Purpose: To evaluate the utility of distribution of internet hotspots to rural and underserved Missourians for telehealth access. Methods: Mobile wi-fi devices (hotspots) were distributed to Federally Qualified Healthcare Centers and Community Mental Health Centers to be used by clinics and patients for telemedicine visits through the Missouri Telehealth Network project. We analyzed six sets of surveys from clinic administrators, collected between January and June 2021, to assess usage, technical utility of hotspots, and satisfaction with the project. Findings: A total of 163 (71.5%) survey responses were received. Seventy-seven percent (7,981) of the 10,345 ordered hotspots were distributed. Hotspots were used for video visits, with an average of 5,915.66 monthly visits (range: 3,449 - 8,420). Seven facilities reported technical issues. Open-ended survey responses reported overall satisfaction with the project. The project allowed convenient access to telehealth services for both routine and specialty care, while decreasing patient and staff exposure to COVID-19. Hot-spot service enabled patient access to educational opportunities and providers noticed a decrease in no-shows. Conclusion: The importance of internet connectivity in enabling access and means to care for rural, underserved communities cannot be overemphasized. The hotspot distribution project helped the most vulnerable Missourians access needed care during the public health emergency.

Embracing the Power of Show-Me ECHO Learning Communities to Transform Clinical Practice in Missouri.

Show-Me ECHO, a state-funded project, provides access to education within a community of learners in order to optimize healthcare for the citizens of Missouri. Through videoconferencing and case-based review, ECHO shifts professional development from learning about medical problems in isolation to experiential learning as part of a multidisciplinary team. The establishment of a statewide COVID-19 ECHO is allowing a rapid response to this novel, unprecedented, and unanticipated health care crisis. There are many ongoing opportunities for clinicians from across the state to join a Show-Me ECHO learning community as a means to elevate their practice and improve ability to respond amidst a constantly evolving health care environment.

Integrating the Lived Experience Conditions and Care in the ECHO Model.

Show Me ECHO has introduced a 'lived experience' role by including patients and caregivers into some of its ECHO Hub Teams. Grounded in the patient-centered care model, this role provides insights into the lived experience of patients and caregivers experiencing chronic conditions. The goals are to improve patient outcomes, strengthen authentic communication and partnership between providers, patients, and patients' support systems, and to enhance local communities' ability to support its members dealing with chronic conditions.

Building Regional Expertise: Perspectives from Show-Me ECHO Participants.

This article highlights four primary care providers that practice in underserved areas in Missouri. Show-Me ECHO (Extension for Community Healthcare Outcomes) provides colleagues opportunities for consultation and Continuing Medical Education (CME) around particular conditions. Through their participation, these providers have 1) enhanced their comfort and skill in diagnosis and treatment, 2) become important regional resources for patients and other providers, and 3) improved access to specialty services in their community.

Assessing Impact of Show-Me ECHO on the Health of Missourians: Two Examples.

Show Me ECHO is a model for interprofessional collaboration that utilizes telehealth technologies to share evidence-based medical knowledge to improve patient outcomes and minimize variation in care for underserved populations. To measure ECHO outcomes, Show Me ECHO develops both an evaluation of clinical outcomes for patients as well as assessing learner outcomes on the Kirkpatrick Typology of Evaluation. This paper describes evaluation models for Dermatology and Childhood Asthma ECHOs.

Listening to Patients' Voices: Workarounds Patients Use to Construct Pain Intensity Ratings.

This study analyzed patients' perspectives about a measure of current, usual, and extreme pain and a measure of activity-related pain. Thirty-one patients with osteoarthritis participated in focus groups. Researchers completed thematic analysis of transcripts using coding software and an inductive approach. Three emerging themes were that many factors affected patients' perceptions and ratings of pain intensity, patients used different approaches to construct pain ratings, and patients interpreted maximal response anchors differently. Particularly, novel findings were that patients evaluated pain fluctuation, location, duration, and quality when constructing pain intensity ratings. Also, activity items helped patients to remember pain and provided a valued context for communicating pain experiences. However, the activities needed to be sufficiently described and personally relevant. These findings further clarify the challenges patients face and the workarounds they use when rating pain intensity. The patients' suggestions for improved administration methods and items warrant future investigation.

Online lecture capturing system: Expected and actual effects of implementation in a problem-based learning medical curriculum.

CONTEXT: An online lecture capturing system (OLCS) was implemented in a medical school integrating problem-based learning curriculum. An academic investigation examining how medical students used OLCS and what were its educational effects were required. AIMS: This study examined medical students' perceptions of OLCS, actual usage of OLCS, and the effects on learning. METHODS: An online questionnaire asking about the perceptions of OLCS was distributed to first and second year medical students. Individual student's OLCS usage was analyzed descriptively. Cluster analysis was conducted based on the OLCS usage and students' prior academic performance to reveal the academic effects of OLCS. RESULTS: Most students (82 out of 106) perceived OLCS as an effective educational tool. Their actual use of OLCS, however, was low and quite variable depending on their needs and preferences. Reviewing the captured lectures did not affect students' performance on exams of knowledge. CONCLUSIONS: This study calls for follow-up studies investigating personalized use of OLCS and student attributes in PBL.

Through patient eyes: Can third-year medical students deliver the care patients expect?

INTRODUCTION: Patient-centered approaches have a positive impact on adherence to treatment, self-management of chronic disease, and patient satisfaction. We seek to graduate physicians who provide effective Patient-Centered Care (PCC). The aims of this research were to (a) include the patients' perspectives in describing behaviors essential to effective PCC, (b) create an authentic, credible tool to assess these behaviors in third-year medical students, and (c) validate the assessment tool through the eyes of our patients. METHODS: To develop and validate PCC behaviors we (a) developed PCC descriptors that included patient perspectives, (b) developed scenarios for students to demonstrate PCC, (c) administered the PCC-Objective Structured Clinical Exam, and (d) used the patient perspective to validate results. RESULTS: Faculty and students found the PCC-OSCE to be an authentic experience. Students received abundant individualized feedback and demonstrated strong performance in communicating effectively, avoiding medical jargon, listening actively, demonstrating empathy, and leading critical conversations. Patient critiques of exemplary performances confirmed that the PCC-OSCE assesses elements the patients viewed as essential to PCC. CONCLUSION: Incorporating the patients' perspective aids in better understanding professional competencies and legitimizes the assessment.

Reimagining the university's role in the health and well-being of the people it serves.

Academic medical centers and university extension programs remain underdeveloped collaborators, despite the complementary objectives between translational science and extension. This case study details the creation of a nationally unique interprofessional organizational structure between the University of Missouri (MU) Office of Extension and Engagement (MU Extension) and the MU School of Medicine to accelerate statewide reach of research and education discoveries using high-touch community health approaches. This article describes specific strategies used to systematically plan for: 1) creation and operation of the new structure, 2) routinization and institutionalizing the work, and 3) sustainability. We further outline challenges and next steps. The development of the backbone organization office of Health Outreach Policy and Education (HOPE) brings together the interprofessional expertise of five units with a common agenda to advance mutually reinforcing activities. HOPE is poised to make significant contributions to amplify MU's land grant mission, garner additional grant funding, and advance the health of Missourians.

Engaging Patients and Caregivers to Develop a Patient-Centered Agenda for Comparative Effectiveness Research Focused on the Treatment of Complex Knee Problems.

Complex articular cartilage loss in the knee is being diagnosed more frequently and earlier in life, and patients are faced with major decisions regarding invasive surgical interventions at increasingly younger ages. There is a critical unmet need to provide patient-centered comparative effectiveness research for the hundreds of thousands of patients faced with these treatment decisions each year. Toward filling the need, we developed the Patient AdvisoR Team iN Orthopaedic ReSearch (PARTNORS) program. We recruited a diverse group of patients and caregivers with lived experiences in dealing with complex knee problems to define patient-centered research priorities for comparative biological and artificial knee surgery research for middle-aged adults. Adapting the Stakeholder Engagement in Question Development and Prioritization Method, PARTNORS defined a 20-question list of patient-centered research questions of factors influencing a patients' choice between biological and artificial knee surgeries. The highest prioritized research question related to functional level postsurgery as it relates to daily activities and recreational activities. The second highest prioritized research questions related to insurance coverage and financial costs. Other prioritized research areas included caregiving needs, implant longevity, recovery and rehabilitation time, patient satisfaction and success rates, individual characteristics, and risks. By engaging a group of patients and caregivers and including them as members of a multidisciplinary research team, comparative effectiveness research that includes patient-centered factors that go beyond typical clinical success indicators for knee surgery can be designed to allow physicians and patients to work together toward evidence-based shared decisions. This shared decision-making process helps to align patients' and health care team's goals and expectations to improve outcomes.

Community Case Study: The Role of Live-Interactive Learning Network in Addressing Community Wide Information Needs Through Show-Me COVID-19 ECHO.

After the COVID-19 pandemic reached Missouri, the Show-Me ECHO (Extension for Community Healthcare Outcomes) project initiated COVID-19 ECHO virtual knowledge-sharing networking sessions. These live-interactive weekly sessions inform participants about up-to-date evidence-based recommendations and guidelines through expert didactic lectures followed by real-life case discussions. We conducted a qualitative analysis of pre-session surveys and questions asked during sessions to learn about information needs of community members during first months of public health emergency. This was a pilot project using qualitative analysis of registration questions regarding anticipated COVID-19 community information needs, and participants' questions asked during sessions collected from March 23 until May 4, 2020. We also analyzed participants' satisfaction surveys collected in December 2020. A total of 761 unique participants attended COVID-19 ECHO during the study period. Survey was completed by 692 respondents. Participants asked 315 questions resulting in 797 identified community information needs. Five thematic categories were recognized: patient care, information seeking, minimizing exposure, financial themes, and general comments. Most attendees rated content quality, logistics, and technical operations as good or excellent on a five-point Likert scale. The COVID-19 ECHO model was responsive to the needs of participants by sharing and discussing up-to-date recommendations and guidelines regarding COVID-19. Sessions were well-attended, and the didactic presenters were invited to deliver same or similar presentations at Boone County Medical Society (BCMS) weekly seminars, suggesting the value of the project to healthcare providers and other community members caring for or working with the most vulnerable populations.

ECHO Autism: Evaluation of Participants' Perceptions of Collaborative Telementoring Network.

Introduction: Primary care clinicians report inadequate training and lack of support regarding identification of early signs of Autism Spectrum Disorder (ASD), resulting in later diagnosis and poor outcomes. The objective of this study was to evaluate the perception of participants in ECHO Autism project regarding the value of the virtual collaborative as a mentoring tool. Methods: We completed a retrospective cross-sectional study of post-virtual clinic surveys of all participants who attended Autism ECHO from September 2, 2015 to June 5, 2019. Results: There were 87 Autism ECHO sessions held, with 83 didactic presentations. A total of 92 de-identified patient cases were discussed with 490 unique learners in attendance. Participants reported increase in self-efficacy in identifying ASD symptoms in children, assessing medical comorbidities, and learning new information. Discussion: Continuing education platforms in healthcare professions are increasingly embracing virtual live-interactive conferences. They provide opportunities to connect with experts, but also hear from peers regarding real-life case examples. During COVID-19 pandemic ECHO Autism was a lifeline for rural providers and will likely continue to increase in participation.

A peek behind the curtain: exploring coaching styles within the implementation and sustainment facilitation (ISF) strategy in the substance abuse treatment to HIV care study.

BACKGROUND: The Grasha-Riechmann teaching styles, which includes three didactic and two prescriptive styles, have been shown to help enhance learning within educational settings. Although an adaption of the Grasha-Riechmann style classification has enabled coaching styles to be identified for use as part of quality improvement (QI) initiatives, research has not examined the styles actually utilized by coaches within a QI initiative or how the styles change overtime when the coach is guiding an organization through change implementation. Interactions between coaches and HIV service organization (HSO) staff participating in a large implementation research experiment called the Substance Abuse Treatment to HIV care (SAT2HIV) Project were evaluated to begin building an evidence base to address this gap in implementation research. METHODS: Implementation & Sustainment Facilitation (ISF) Strategy meetings (n = 137) between coaches and HSO staff were recorded and professionally transcribed. Thematic coding classifications were developed from the Grasha-Riechmann framework and applied to a purposively selected sample of transcripts (n = 66). Four coders independently coded transcripts using NVivo to facilitate text identification, organization, and retrieval for analysis. Coaching style use and changes across the three ISF phases were explored. RESULTS: Facilitator and formal authority were the two coaching styles predominately used. Facilitator sub-themes shifted from asking questions and providing support to supporting independent action over time. Coaches' use of formal authority sub-styles shifted notably across time from setting expectations or ensuring preparation to offering affirmation or feedback about changes that the HSO's were implementing. The use of the delegator or personal model coaching styles occurred infrequently. CONCLUSIONS: The current research extends implementation research's understanding of coaching. More specifically, findings indicate it is feasible to use the Grasha-Riechmann framework to qualitatively identify coaching styles utilized in a facilitation-based implementation strategy. More importantly, results provide insights into how different coaching styles were utilized to implement an evidence-based practice. Further research is needed to examine how coaching styles differ by organization, impact implementation fidelity, and influence both implementation outcomes and client outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT02495402 . Registered on July 6, 2015.

Melanoma Extension for Community Healthcare Outcomes: A Feasibility Study of Melanoma Screening Implementation in Primary Care Settings.

Introduction Melanoma incidence rates are rising faster than the rates of any other malignancy. As a major global public health concern, melanoma can be identified by a visual exam not requiring expensive invasive procedures. However, non-dermatologists lack specialized training and skills to identify high-risk patients and implement melanoma skin screenings during regular exams. Most patients from rural and underserved areas have inadequate access to specialty dermatologic care, which can potentially lead to later-stage melanomas and poor patient outcomes. The objective of this study was to identify facilitators and barriers to the implementation of risk surveys and melanoma skin screenings in primary care settings through live interactive education and the telementoring project - Melanoma ECHO (Extension for Community Healthcare Outcomes).  Methods This cross-sectional study was designed with theoretical concepts from dissemination and implementation research. Monthly Melanoma ECHO sessions were integrated into an ongoing Dermatology ECHO at the University of Missouri, Columbia, Missouri, USA, from April 2018 to February 2019. Ten primary care providers, medical doctors/doctors of osteopathic medicine (MDs/DOs), nurse practitioners (NPs), and physician assistants (PAs), from across Missouri participated. Eleven virtual monthly melanoma-related didactics and case-based discussions were provided to participants. Information regarding risk factors, risk surveys, and screening techniques was provided. Ongoing telementoring and guidance were also provided for de-identified real-life patient cases. The main outcomes and measures of the study were to identify the facilitators and barriers of risk survey and melanoma skin screenings in primary care settings and to quantify the number of high-risk patients identified by participating providers and the number of new melanomas detected by visual exams during the study period. Results The primary reason why six out of 10 providers reported participation in Melanoma ECHO was that implementing melanoma skin screenings in their practice was made easier as it increased their confidence. Nine providers reported increased knowledge, and eight cited professional networking as other facilitators. The main perceived barrier to melanoma skin screening was lack of administrative and nursing support, and six providers indicated that lack of time to incorporate skin exams was also a barrier. Combined, ten participants reported identifying 976 high-risk patients during the study period and detecting 36 new melanomas. Discussion and conclusion Our findings indicate that primary care providers may benefit from attending regularly scheduled and focused specialized telementoring sessions, such as Melanoma ECHO. Ongoing support from specialists may help providers practicing in rural and isolated areas with the successful integration of risk surveys and melanoma skin screenings in primary care settings. Further Melanoma ECHO sessions with a more diverse group of primary care providers are needed to better understand the generalizability of the results.

Using a Sociogram to Characterize Communication During an Interprofessional Team Huddle.

PURPOSE: The complexity of modern medicine requires high-performance teamwork to ensure quality care. Teams rely on communication patterns that are replicable and efficient. The purpose of this observational study was to characterize communication dynamics among interprofessional team members during a team huddle. The study aimed to (a) characterize communication within structured huddles on an inpatient medicine unit by evaluating who talked and to whom and what types of communication took place during each interaction and (b) explore participants' perceptions of the huddles. MATERIALS AND METHODS: We used a sociogram to diagram direct observations of the structure and patterns of group interaction. Through the sociogram, we documented the flow and frequency of team members information exchange, questions, and requests. We conducted two follow-up focus groups-one with residents and one with nurses. RESULTS: The most frequent type of interaction observed was information exchange: nurse to resident (28.3%) and resident to nurse (47%). Both residents and nurses asked questions: nurse to resident (7.4%) and resident to nurse (14.2%). Nurses made more requests of residents (2.8%) than vice versa (0.3%). Four themes emerged from focus group analysis, including the huddle promotes (1) a better-informed team, (2) relationship building, (3) communication process efficiencies, and (4) logistical challenges. CONCLUSION: Sociograms can serve as a novel tool to characterize what actually happens during information exchange at the point of care and identify the nature of communication among team members. Daily huddles among team members involved in the frontline of patient care provides an opportunity to share information, requests, and questions and update shared mental models to meet team objectives.

What criteria do faculty use when rating students as potential house officers?

Third-year medical students' grades are a combination of faculty observations, National Board of Medical Examiners examinations, and other departmental specific course requirements. Faculty evaluations include assessment of students' clinical skills, and a global rating for potential as house officer. We wished to better understand the 'potential as house officer' and to understand if these competencies were shared across the third year or unique to a given discipline. We then examined the relationship between house officer potential and performance on traditional measures of success. We analyzed the narrative comments from faculty evaluations of third-year students who faculty rated as 'Outstanding' in the house officer potential category. The low correlations found between house officer potential and traditional measures of academic success indicate that items beyond the stated learning objectives are influencing faculty evaluation of clinical students. Our data suggest that the awarding of 'potential for house officer' reflects the student's ability to work as part of a health care team. Although there appear to be common elements among the house officer comments, we also observed discipline specific differences. Given the importance placed on house officer potential, more conversation is needed to develop a common language across the third-year courses.

Incorporating telehealth into primary care resident outpatient training.

Research is yet to fully examine the utility and effectiveness of telehealth in primary care resident ambulatory training. This study examined the attitudes of preceptors, residents, and nurses on (1) the impact of telehealth on healthcare; (2) the impact of telehealth on the work activity of resident clinics; (3) the impact of telehealth on resident training in the outpatient setting; and (4) the impact of telehealth on relationships. There were three focus groups, one each of preceptors (N = 5), residents (N = 10), nurses (N = 7). Eight focus group themes evolved regarding the use of telehealth in the resident clinic: (1) impact on patient/provider relationships; (2) consistent with the values of those using telehealth; (3) logistics; (4) reduces patient transfers; (5) appropriate level of care; (6) reimbursement concerns; (7) psychological risk; and (8) impact on resident/attending relationships. Though as yet not generalizable, results of this pilot study suggest that there is general acceptability of telehealth in ambulatory resident training settings, but there is concern about the impact that telehealth may have on relationships, logistics, finances, and the need to see patients face-to-face when there is greater complexity.

A comparison of acceptance- and control-based strategies for coping with food cravings: an analog study.

The present study utilized an analog paradigm to investigate the effectiveness of two strategies for coping with food cravings, which was theorized to be critical to the maintenance of weight loss. Ninety-eight undergraduate students were given transparent boxes of chocolate Hershey's Kisses and instructed to keep the chocolates with them, but not to eat them, for 48 h. Before receiving the Kisses, participants were randomized to receive either (a) no intervention, (b) instruction in control-based coping strategies such as distraction and cognitive restructuring, or (c) instruction in acceptance-based strategies such as experiential acceptance and defusion techniques. Measures included the Power of Food Scale (PFS; a measure of psychological sensitivity to the food environment), self-report ratings of chocolate cravings and surreptitiously recorded chocolate consumption. Results suggested that the effect of the intervention depended on baseline PFS levels, such that acceptance-based strategies were associated with better outcomes (cravings, consumption) among those reporting the highest susceptibility to the presence of food, but greater cravings among those who scored lowest on the PFS. It was observed that craving self-report measures predicted chocolate consumption, and baseline PFS levels predicted both cravings and consumption. Results are discussed in terms of the implications for weight loss maintenance strategies.

Journeying to the White Coat Ceremony: A description of the people, situations and experiences that inform student visions of the physician they hope to become.

Little is known about the experiences that influence entering medical students' internal concepts of themselves as future physicians. During orientation to medical school, students were asked to write stories in response to the cue, "Tell a story about a person or experience that inspired you to consider a career of service in medicine." Qualitative methodology was employed to analyze 190 student stories. Thematic analysis identified descriptive details about content and allowed comparison between the students' and School's expectations. Inspirational settings, contexts, and individuals were identified. Nine different inspirational events were described. Student and School expectations for the kinds of physicians they hoped to become were generally consistent. The study demonstrates that students do indeed bring to medical school visions of the kinds of physicians they hope to become. Linking that vision with medical school activities including the White Coat Ceremony provides a bridge between medical school and students' earlier lives, thus explicitly linking orientation to professional formation.