"What We're Doing Now Is More Than Water Cooler": Perspectives of Primary Care Leaders on Leading Through (and Beyond) COVID-19.

BACKGROUND: COVID-19 presented numerous challenges to primary care, but little formal research has explored the experience of practice leaders and their strategies for managing teams as the crisis unfolded. OBJECTIVE: Describe the experience of leaders in US primary care delivery organizations, and their strategies for leading teams during COVID-19 and beyond. DESIGN: Qualitative study using semi-structured interviews performed between 9/15/2020 and 8/31/2021. PARTICIPANTS: Purposive sample of 17 clinical leaders in a range of US primary care organizations. APPROACH: An iterative grounded review of interview transcripts was performed, followed by immersion/crystallization analysis. KEY RESULTS: Early in the pandemic, practice leaders reported facing rapid change and the need for constant decision-making, amidst an environment of stress, fear, and uncertainty, but this was buffered by a strong sense of purpose. Later, leaders noted the emergence of layered crises, and evolving challenges including fatigue, burnout, and strained relationships within their organizations and with the communities they serve. Leaders described four interrelated strategies for supporting their teams: (1) Being intentionally present, physically and emotionally; (2) Frequent and transparent communication; (3) Deepening and broadening relationships; (4) Increasing adaptive decision-making, alternating between formal hierarchical and flexible participatory processes. These strategies were influenced by individual leaders' perceived autonomy, which was impacted by the leader's specific role, and organizational size, complexity, and funding model. CONCLUSIONS: As the burnout and workforce crises have accelerated, the identified strategies can be useful to leaders to support teams and build organizational resilience in primary care moving forward.

Trajectories of care and outcomes of Veterans receiving home-based primary care.

BACKGROUND: Veterans Affairs (VA) home-based primary care (HBPC) provides comprehensive longitudinal care to patients with complex, chronic disabling disease. While enrollment is associated with lower hospitalization rates and costs, detailed trajectories have not been well described. METHODS: We performed a longitudinal descriptive study of patients newly enrolled in VA HBPC in fiscal year (FY) 2015. We extracted demographics, comorbidities, functional status, and social supports from VA and Medicare data and examined patterns of care and clinical outcomes, including hospital, nursing home (NH), hospice use and mortality from FY2015-2017. We present results using descriptive statistics, alluvial plots, and heat maps. RESULTS: We identified 10,571 HBPC enrollees in FY2015; mean age was 77.7. HBPC patients commonly had chronic medical conditions with high self-management burden (e.g., diabetes 48.2%) and disabling conditions such as dementia (39.3%). Over half had ≥2 deficits in activities of daily living, 46% had caregivers with functional limitations or no caregiver, and 25% resided in a socially deprived area. Patients experienced variable care trajectories. Mean time enrolled in HBPC was 331 days, 8.3% of patients were discharged after 3 months, and 22.8% stayed enrolled for over 2 years. Institutional health care use declined in the 6 months after initial enrollment: (e.g., hospital: 41%-25%, NH: 34%-11%). At 2 years, 36% of patients had died; among decedents, 58% received hospice and 72% died in a non-institutional setting. In the last 180 days of life, 84% of time was spent at home, and once enrolled in hospice, 97% of time was spent outside of institutional care. CONCLUSIONS: HBPC patients experience highly variable care trajectories but on average have reductions in acute care use and spend a majority of time in non-institutional settings. These data allow for a nuanced understanding of HBPC, providing a platform for monitoring, evaluating, and improving program function.

Ambulatory Intensive Care for Medically Complex Patients at a Health Care Clinic for Individuals Experiencing Homelessness: The SUMMIT Randomized Clinical Trial.

Importance: Intensive primary care interventions have been promoted to reduce hospitalization rates and improve health outcomes for medically complex patients, but evidence of their efficacy is limited. Objective: To assess the efficacy of a multidisciplinary ambulatory intensive care unit (A-ICU) intervention on health care utilization and patient-reported outcomes. Design, Setting, and Participants: The Streamlined Unified Meaningfully Managed Interdisciplinary Team (SUMMIT) randomized clinical trial used a wait-list control design and was conducted at a health care clinic for patients experiencing homelessness in Portland, Oregon. The first patient was enrolled in August 2016, and the last patient was enrolled in November 2019. Included patients had 1 or more hospitalizations in the prior 6 months and 2 or more chronic medical conditions, substance use disorder, or mental illness. Data analysis was performed between March and May 2021. Intervention: The A-ICU included a team manager, a pharmacist, a nurse, care coordinators, social workers, and physicians. Activities included comprehensive 90-minute intake, transitional care coordination, and flexible appointments, with reduced panel size. Enhanced usual care (EUC), consisting of team-based primary care with access to community health workers and mental health, addiction treatment, and pharmacy services, served as the comparator. Participants who received EUC joined the A-ICU intervention after 6 months. Main Outcomes and Measures: The main outcome was the difference in rates of hospitalization (primary outcome), emergency department (ED) visits, and primary care physician (PCP) visits per person over 6 months (vs the prior 6 months). Patient-reported outcomes included changes in patient activation, experience, health-related quality of life, and self-rated health at 6 months (vs baseline). We performed an intention-to-treat analysis using a linear mixed-effects model with a random intercept for each patient to examine the association between study group and outcomes. Results: This study randomized 159 participants (mean [SD] age, 54.9 [9.8] years) to the A-ICU SUMMIT intervention (n = 80) or to EUC (n = 79). The majority of participants were men (102 [65.8%]) and most were White (121 [76.1%]). A total of 64 participants (41.0%) reported having unstable housing at baseline. Six-month hospitalizations decreased in both the A-ICU and EUC groups, with no difference between them (mean [SE], -0.6 [0.5] vs -0.9 [0.5]; difference, 0.3 [95% CI, -1.0 to 1.5]). Emergency department use did not differ between groups (mean [SE], -2.0 [1.0] vs 0.9 [1.0] visits per person; difference, -1.1 [95% CI, -3.7 to 1.6]). Primary care physician visits increased in the A-ICU group (mean [SE], 4.2 [1.6] vs -2.0 [1.6] per person; difference, 6.1 [95% CI, 1.8 to 10.4]). Patients in the A-ICU group reported improved social functioning (mean [SE], 4.7 [2.0] vs -1.1 [2.0]; difference, 5.8 [95% CI, 0.3 to 11.2]) and self-rated health (mean [SE], 0.7 [0.3] vs -0.2 [0.3]; difference, 1.0 [95% CI, 0.1 to 1.8]) compared with patients in the EUC group. No differences in patient activation or experience were observed. Conclusions and Relevance: The A-ICU intervention did not change hospital or ED utilization at 6 months but increased PCP visits and improved patient well-being. Longer-term studies are needed to evaluate whether these observed improvements lead to eventual changes in acute care utilization. Trial Registration: ClinicalTrials.gov Identifier: NCT03224858.

Estimating the Cardiovascular Disease Risk Reduction of a Quality Improvement Initiative in Primary Care: Findings from EvidenceNOW.

BACKGROUND: This study estimates reductions in 10-year atherosclerotic cardiovascular disease (ASCVD) risk associated with EvidenceNOW, a multi-state initiative that sought to improve cardiovascular preventive care in the form of (A)spirin prescribing for high-risk patients, (B)lood pressure control for people with hypertension, (C)holesterol management, and (S)moking screening and cessation counseling (ABCS) among small primary care practices by providing supportive interventions such as practice facilitation. DESIGN: We conducted an analytic modeling study that combined (1) data from 1,278 EvidenceNOW practices collected 2015 to 2017; (2) patient-level information of individuals ages 40 to 79 years who participated in the 2015 to 2016 National Health and Nutrition Examination Survey (n = 1,295); and (3) 10-year ASCVD risk prediction equations. MEASURES: The primary outcome measure was 10-year ASCVD risk. RESULTS: EvidenceNOW practices cared for an estimated 4 million patients ages 40 to 79 who might benefit from ABCS interventions. The average 10-year ASCVD risk of these patients before intervention was 10.11%. Improvements in ABCS due to EvidenceNOW reduced their 10-year ASCVD risk to 10.03% (absolute risk reduction: -0.08, P ≤ .001). This risk reduction would prevent 3,169 ASCVD events over 10 years and avoid $150 million in 90-day direct medical costs. CONCLUSION: Small preventive care improvements and associated reductions in absolute ASCVD risk levels can lead to meaningful life-saving benefits at the population level.

Vaccines for all: A formative evaluation of a multistakeholder community-engaged COVID-19 vaccine outreach clinic for migrant communities.

Background: Racialized, low-income, and migrant populations experience persistent barriers to vaccines against COVID-19. These communities in East and Northeast Calgary were disproportionately impacted by COVID-19, yet faced vaccine access barriers. Diverse multi-stakeholder coalitions and community partnerships can improve vaccine outreach strategies, but how stakeholders perceive these models is unknown. Methods: We conducted a formative evaluation of a low-barrier, community-engaged vaccine outreach clinic in Calgary, Alberta, Canada, on June 5-6, 2021. We delivered an online post-clinic survey to clinic stakeholders, to assess whether the clinic achieved its collectively derived pre-specified goals (effective, efficient, patient-centered, and safe), to asses whether the clinic model was scalable, and to solicit improvement recommendations. Survey responses were analyzed using descriptive statistics and thematic analysis. Results: Overall, 166/195 (85%) stakeholders responded. The majority were from non-healthcare positions (59%), between 30 and 49 years of age (87/136; 64%), and self-identified as racialized individuals (96/136; 71%). Respondents felt the clinic was effective (99.2%), efficient (96.9%), patient-centered (92.3%), and safe (90.8%), and that the outreach model was scalable 94.6% (123/130). There were no differences across stakeholder categories. The open-ended survey responses supported the scale responses. Improvement suggestions describe increased time for clinic planning and promotion, more multilingual staff, and further efforts to reduce accessibility barriers, such as priority check-in for people with disabilities. Conclusion: Diverse stakeholders almost universally felt that this community-engaged COVID-19 vaccine outreach clinic achieved its goals and was scalable. These findings support the value of community-engaged outreach to improve vaccine equity among other marginalized newcomer communities.

An Evaluation of Burnout Among US Rheumatology Fellows: A National Survey.

OBJECTIVE: To evaluate levels of burnout and correlates of burnout among US rheumatology fellows. METHODS: US rheumatology fellows were invited to complete an electronic survey in 2019. Burnout was assessed using the Maslach Burnout Inventory. Measures of depression, fatigue, quality of life, and training year were also collected. Open-ended questions about perceived factors to promote resiliency and factors leading to increased burnout were included. Bivariate and multivariate regression analyses were used to examine correlates of burnout. Open-ended responses were analyzed using thematic analysis. RESULTS: The response rate was 18% (105/582 pediatric and adult rheumatology fellows). Over one-third (38.5%) of postgraduate year (PGY) 4 and 16.7% of PGY5/6 fellows reported at least 1 symptom of burnout. Of PGY4 fellows, 12.8% met criteria for depression compared with 2.4% of PGY5/6 fellows. PGY4 fellows reported worse fatigue and poorer quality of life compared with PGY5/6. In multivariable models controlling for training year and gender, older age (> 31 years) was associated with lower odds of burnout. Thematic analysis of open-ended responses identified factors that help reduce burnout: exercise, family/friends, sleep, support at work, and hobbies. Factors contributing to burnout: pager, documentation, long hours, demands of patient care, and presentations and expectations. CONCLUSION: This national survey of US rheumatology fellows reveals that early trainee level and younger age are associated with worse levels of fatigue, quality of life, and burnout. Although awareness of and strategies to reduce burnout are needed for all fellows, targeted interventions for younger fellows and those in their first year of training may be of highest yield.

Association of Clinician Practice Ownership With Ability of Primary Care Practices to Improve Quality Without Increasing Burnout.

Importance: Work environments and practice structural features are associated with both burnout and the ability of practices to enhance quality of care. Objective: To characterize factors associated with primary care practices successfully improving quality scores without increasing clinician and staff burnout. Design, Setting, and Participants: This cross-sectional study assessed small- to medium-sized primary care practices that participated in the EvidenceNOW: Advancing Heart Health initiative using surveys that were administered at baseline (September 2015 to April 2017) and after the intervention (January 2017 to October 2018). Data were analyzed from February 2022 to January 2023. Main Outcomes and Measures: The primary outcome of being a quality and well-being positive deviant practice was defined as a practice with a stable or improved percentage of clinicians and staff reporting burnout over the study period and with practice-level improvement in all 3 cardiovascular quality measures: aspirin prescribing, blood pressure control, and smoking cessation counseling. Results: Of 727 practices with complete burnout and aspirin prescribing, blood pressure control, and smoking cessation counseling data, 18.3% (n = 133) met the criteria to be considered quality and well-being positive deviant practices. In analyses adjusted for practice location, accountable care organization and demonstration project participation, and practice specialty composition, clinician-owned practices had greater odds of being a positive deviant practice (odds ratio, 2.02; 95% CI, 1.16-3.54) than practices owned by a hospital or health system. Conclusions and Relevance: In this cross-sectional study, clinician-owned practices were more likely to achieve improvements in cardiovascular quality outcomes without increasing staff member burnout than were practices owned by a hospital or health system. Given increasing health care consolidation, our findings suggest the value of studying cultural features of clinician-owned practices that may be associated with positive quality and experience outcomes.

Adult Primary Care Physician Visits Increasingly Address Mental Health Concerns.

A high prevalence of mental health diagnoses in adults alongside ongoing shortages of mental health specialists and expansion of the patient-centered medical home have increased the involvement of primary care clinicians in treating mental health concerns. Using nationally representative serial cross-sectional data from the 2006-18 National Ambulatory Medical Care Surveys regarding visits to outpatient primary care physicians by patients ages eighteen and older, we sought to characterize temporal trends in primary care visits addressing a mental health concern. Based on a sample of 109,898 visits representing 3,891,233,060 weighted visits, we found that the proportion of visits that addressed mental health concerns increased from 10.7 percent of visits in 2006-07 to 15.9 percent by 2016 and 2018. Black patients were 40 percent less likely than White patients to have a mental health concern addressed during a primary care visit, and Hispanic patients were 40 percent less likely than non-Hispanic patients to have a mental health concern addressed during a primary care visit. These findings emphasize the need for payment and billing approaches (that is, value-based care models and billing codes for integrated behavioral health) as well as organizational designs and supports (that is, colocated therapy or psychiatry providers, availability of e-consultation, and longer visits) that enable primary care physicians to adequately address mental health needs.

Early Impact of VA MISSION Act Implementation on Primary Care Appointment Wait Time.

BACKGROUND: Through Community Care Networks (CCNs) implemented with the VA MISSION Act, VA expanded provider contracting and instituted network adequacy standards for Veterans' community care. OBJECTIVE: To determine whether early CCN implementation impacted community primary care (PC) appointment wait times overall, and by rural/urban and PC shortage area (HPSA) status. DESIGN: Using VA administrative data from February 2019 through February 2020 and a difference-in-differences approach, we compared wait times before and after CCN implementation for appointments scheduled by VA facilities that did (CCN appointments) and did not (comparison appointments) implement CCNs. We ran regression models with all appointments, and stratified by rural/urban and PC HPSA status. All models adjusted for Veteran characteristics and VA facility-level clustering. APPOINTMENTS: 13,720 CCN and 40,638 comparison appointments. MAIN MEASURES: Wait time, measured as number of days from authorization to use community PC to a Veteran's first corresponding appointment. KEY RESULTS: Overall, unadjusted wait times increased by 35.7 days ([34.4, 37.1] 95% CI) after CCN implementation. In adjusted analysis, comparison wait times increased on average 33.7 days ([26.3, 41.2] 95% CI, p < 0.001) after CCN implementation; there was no significant difference for CCN wait times (across-group mean difference: 5.4 days, [-3.8, 14.6] 95% CI, p = 0.25). In stratified analyses, comparison wait time increases ranged from 29.6 days ([20.8, 38.4] 95% CI, p < 0.001) to 42.1 days ([32.9, 51.3] 95% CI, p > 0.001) after CCN implementation, while additional differences for CCN appointments ranged from 13.4 days ([3.5, 23.4] 95% CI, p = 0.008) to -15.1 days ([-30.1, -0.1] 95% CI, p = 0.05) for urban and PC HPSA appointments, respectively. CONCLUSIONS: After early CCN implementation, community PC wait times increased sharply at VA facilities that did and did not implement CCNs, regardless of rural/urban or PC HPSA status, suggesting community care demand likely overwhelmed VA resources such that CCNs had limited impact.

Hospital Readmissions Among Veterans Within 90 Days of Discharge Following Initial Hospitalization for COVID-19.

INTRODUCTION: Some patients experience ongoing sequelae after discharge, including rehospitalization; therefore, outcomes following COVID-19 hospitalization are of continued interest. We examined readmissions within 90 days of hospital discharge for veterans hospitalized with COVID-19 during the first 10 months of the pandemic in the US. METHODS: Veterans hospitalized with COVID-19 at a Veterans Health Administration (VA) hospital from March 1, 2020, through December 31, 2020 were followed for 90 days after discharge to determine readmission rates. RESULTS: Of 20,414 veterans hospitalized with COVID-19 during this time period, 13% (n = 2,643) died in the hospital. Among survivors (n = 17,771), 16% (n = 2,764) were readmitted within 90 days of discharge, with a mean time to readmission of 21.6 days (SD = 21.1). Characteristics of the initial COVID-19 hospitalization associated with readmission included length of stay, mechanical ventilator use, higher comorbidity index score, current smoking, urban residence, discharged against medical advice, and hospitalized from September through December 2020 versus March through August 2020 (all P values <.02). Veterans readmitted from September through December 2020 were more often White, lived in a rural or highly rural area, and had shorter initial hospitalizations than veterans hospitalized earlier in the year. CONCLUSION: Approximately 1 of 6 veterans discharged alive following a COVID-19 hospitalization from March 1 through December 31, 2020, were readmitted within 90 days. The longer the hospital stay, the greater the likelihood of readmission. Readmissions also were more likely when the initial admission required mechanical ventilation, or when the veteran had multiple comorbidities, smoked, or lived in an urban area. COVID-19 hospitalizations were shorter from September through December 2020, suggesting that hospital over-capacity may have resulted in earlier discharges and increased readmissions. Efforts to monitor and provide support for patients discharged in high bed-capacity situations may help avoid readmissions.

Outpatient Care Fragmentation and Acute Care Utilization in Veterans Affairs Home-Based Primary Care.

Importance: Veterans Affairs (VA) Home-Based Primary Care (HBPC) provides comprehensive, interdisciplinary primary care at home to patients with complex, chronic, disabling disease, but little is known about care fragmentation patterns and consequences among these patients. Objective: To examine outpatient care fragmentation patterns and subsequent acute care among HBPC-engaged patients at high risk of hospitalization or death. Design, Setting, and Participants: This retrospective cohort study included VA patients aged at least 65 years who were enrolled in the VA and Medicare, whose risk of hospitalization or death was in the top 10%, and who had at least 4 outpatient visits between October 1, 2013, and September 30, 2014. HBPC engagement was defined as having at least 2 HBPC encounters between July 1, 2014, and September 30, 2014. Data were analyzed from March 2020 to March 2022. Exposures: Two indices of outpatient care fragmentation: practitioner count and the Usual Provider Continuity Index (UPC), based on VA and non-VA health care use from October 1, 2013, to September 30, 2014. All care delivered by HBPC clinicians was analyzed as coming from a single practitioner. Main Outcomes and Measures: Emergency department (ED) visits and hospitalizations for ambulatory care sensitive conditions (ACSC) from VA records and Medicare claims from October 1, 2014, to September 30, 2015. Results: Among 8908 identified HBPC patients, 8606 (96.6%) were male, 1562 (17.5%) were Black, 249 (2.8%) were Hispanic, 6499 (73.0%) were White, 157 (1.8%) were other race or ethnicity, and 441 (5.0%) had unknown race or ethnicity; the mean (SD) age was 80.0 (9.02) years; patients had a mean (SD) of 11.25 (3.87) chronic conditions, and commonly had disabling conditions such as dementia (38.8% [n = 3457]). In adjusted models, a greater number of practitioners was associated with increased odds of an ED visit (adjusted odds ratio [aOR], 1.05 [95% CI, 1.03-1.07]) and hospitalization for an ACSC (aOR, 1.04 [95% CI, 1.02-1.06]), whereas more concentrated care with a higher UPC was associated with reduced odds of these outcomes (highest vs lowest tertile of UPC: aOR for ED visit, 0.77 [95% CI, 0.67-0.88], aOR for ACSC hospitalization, 0.78 [95% CI, 0.68-0.88]). Conclusions and Relevance: Among patients in HBPC, fragmented care was associated with more ED visits and ACSC hospitalizations. These findings suggest that consolidating or coordinating fragmented care may be a target for reducing preventable acute care.

Improving Delivery of Cardiovascular Disease Preventive Services in Small-to-Medium Primary Care Practices.

BACKGROUND: The EvidenceNOW initiative provided smaller primary care practices with external support interventions to implement quality improvement strategies focused on cardiovascular disease prevention. This manuscript reports effectiveness of EvidenceNOW interventions in improving quality metrics. METHODS: Seven regional Cooperatives delivered external support interventions (practice facilitation, health information technology support to assist with audit and feedback, performance benchmarking, learning collaboratives, and establishing community linkages) to 1278 smaller primary care practices. Outcomes included proportion of eligible patients meeting Centers for Medicaid and Medicare Services-specified ABCS metrics, that is, Aspirin for those at risk of ischemic vascular disease; achieving target Blood pressure among hypertensives; prescribing statin for those with elevated Cholesterol, diabetes, or increased cardiovascular disease risk; and screening for Smoking and providing cessation counseling. An event study compared prepost changes in outcomes among intervention practices and a difference-in-differences design compared intervention practices to 688 external comparison practices. RESULTS: Mean baseline outcomes ranged from 61.5% (cholesterol) to 64.9% (aspirin). In the event study, outcomes improved significantly (aspirin: +3.39 percentage points, 95% CI, 0.61-6.17; blood pressure: +1.59, 95% CI, 0.12-3.06; cholesterol: +4.43, 95% CI, 0.33-8.53; smoking: +7.33, 95% CI, 4.70-9.96). Difference-in-differences estimates were similar in magnitude but statistically significant for smoking alone. Preintervention trends were significant for smoking, but parallel-trends tests were not significant. CONCLUSIONS: EvidenceNOW Cooperatives improved cardiovascular prevention quality metrics among small and medium sized primary care practices across the US. While estimated improvements were small, they reflected average changes across a large and diverse sample of practices.

Association of Time-Based Billing With Evaluation and Management Revenue for Outpatient Visits.

Importance: Time-based billing options for physicians have expanded, enabling many physicians to bill according to time spent instead of medical decision-making (MDM) level for fee-for-service outpatient visits. However, no study to date has estimated the revenue changes associated with time-based billing. Objective: To compare evaluation and management (E/M) reimbursement for physicians using time-based billing vs MDM-based billing for outpatient visits of varying lengths. Design, Setting, and Participants: This economic evaluation used 2019 billing data for outpatient E/M codes and 2021 reimbursement rates from the Centers for Medicare & Medicaid Services. Modeling of generic clinic templates was performed to estimate expected yearly E/M revenues for a single full-time physician working in an outpatient clinic using fee-for-service billing. Main Outcomes and Measures: Yearly E/M revenues for different patient visit templates were modeled. The standardized length of return patient visits was 10 to 45 minutes, and new patient visits were twice as long in duration. Results: Under MDM-based billing, increased visit length was associated with decreased E/M revenue ($564 188 for 30-minute new patient visit/15-minute return patient visit vs $423 137 for 40-minute new patient visit/20-minute return patient visit). Under time-based billing, yearly E/M revenue remained similar across increasing visit lengths ($400 432 for 30-minute new patient visit/15-minute return patient visit vs $458 718 for 40-minute new patient visit/20-minute return patient visit). Compared with time-based billing, MDM-based billing was associated with higher E/M revenue for 10- to 15-minute return patient visits ($400 432 vs $564 188). Time-based billing was associated with higher E/M revenue for return patient visits lasting 20 minutes or longer. The highest modeled E/M revenue of $846 273 occurred for 10-minute return patient visits under MDM-based billing. Conclusions and Relevance: Results of this study showed that the relative economic benefits of MDM-based billing and time-based billing differed and were associated with the length of patient visits. Physicians with longer patient visits were more likely to experience revenue increases from using time-based billing than physicians with shorter patient visits.

Psychiatric disorders newly diagnosed among veterans subsequent to hospitalization for COVID-19.

OBJECTIVE: The goal of our study was to evaluate the development of new mental health diagnoses up to 6-months following COVID-19 hospitalization for in a large, national sample. METHOD: Data were extracted for all Veterans hospitalized at Veterans Health Administration hospitals for COVID-19 from March through August of 2020 utilizing national administrative data. After identifying the cohort, follow-up data were linked through six months post-hospitalization. Data were analyzed using logistic regression. RESULTS: Eight percent of patients developed a new mental health diagnosis following hospitalization. The most common new mental health diagnoses involved depressive, anxiety, and adjustment disorders. Younger and rural patients were more likely to develop new mental health diagnoses. Women and those with more comorbidities were less likely to develop new diagnoses. CONCLUSION: A subpopulation of patients hospitalized for COVID-19 developed new mental health diagnoses. Unique demographics predictors indicate the potential need for additional outreach and screening to groups at elevated risk of post-hospitalization, mental health sequelae.

Patient selection strategies in an intensive primary care program.

BACKGROUND: Intensive primary care programs have had variable impacts on clinical outcomes, possibly due to a lack of consensus on appropriate patient-selection. The US Veterans Health Administration (VHA) piloted an intensive primary care program, known as Patient Aligned Care Team Intensive Management (PIM), in five medical centers. We sought to describe the PIM patient selection process used by PIM teams and to explore perspectives of PIM team members regarding how patient selection processes functioned in context. METHODS: This study employs an exploratory sequential mixed-methods design. We analyzed qualitative interviews with 21 PIM team and facility leaders and electronic health record (EHR) data from 2,061 patients screened between July 2014 and September 2017 for PIM enrollment. Qualitative data were analyzed using a hybrid inductive/deductive approach. Quantitative data were analyzed using descriptive statistics. RESULTS: Of 1,887 patients identified for PIM services using standardized criteria, over half were deemed inappropriate for PIM services, either because of not having an ambulatory care sensitive condition, living situation, or were already receiving recommended care. Qualitative analysis found that team members considered standardized criteria to be a useful starting point but too broad to be relied on exclusively. Additional data collection through chart review and communication with the current primary care team was needed to adequately assess patient complexity. Qualitative analysis further found that differences in conceptualizing program goals led to conflicting opinions of which patients should be enrolled in PIM. CONCLUSIONS: A combined approach that includes clinical judgment, case review, standardized criteria, and targeted program goals are all needed to support appropriate patient selection processes.

Balancing the benefits of patient-clinician relationships with professional boundaries in Home-based Primary Care.

In the home care setting, boundaries may be difficult to identify when behavioral changes are made to accommodate the nature of care being delivered. In this secondary qualitative study, we examined how Home-based Primary Care (HBPC) clinicians understand role and relationship boundaries with patients and how these dynamics support patient care. The data set consisted of 14 semi-structured interviews with HBPC clinicians representing multiple disciplines and field observations of 6 HBPC team meetings. Using a directed approach to content analysis, we identified and described how HBPC clinicians worked to build relationships with patients, experienced challenges with emotional attachment, and negotiated boundaries in the patient-clinician relationship. Our findings illustrate how the home care setting is a site for which strong, therapeutic patient-clinician relationships can be developed while also highlighting the work that clinicians must do to balance addressing patient needs stemming from social isolation and adherence to their own professional boundaries.

The Effects of Major Disruptions on Practice Participation in Facilitation During a Primary Care Quality Improvement Initiative.

BACKGROUND: Disruptions in primary care practices, like ownership change, clinician turnover, and electronic health record system implementation, can stall quality improvement (QI) efforts. However, little is known about the relationship between these disruptions and practice participation in facilitated QI. METHODS: We explore this relationship using data collected from EvidenceNOW in a mixed-methods convergent design. EvidenceNOW was a large-scale facilitation-based QI initiative in small and medium primary care practices. Data included practice surveys, facilitator time logs, site visit field notes, and interviews with facilitators and practices. Using multivariate regression, we examined associations between disruptions during interventions and practice participation in facilitation, measured by in-person facilitator hours in 987 practices. We analyzed qualitative data on 40 practices that described disruptions. Qualitative and quantitative teams iterated analyses based on each other's emergent findings. RESULTS: Many practices (51%) reported experiencing 1 or more disruptions during the 3- to 15-month interventions. Loss of clinicians (31.6%) was most prevalent. In adjusted analyses, disruptions were not significantly associated with participation in facilitation. Qualitative data revealed that practices that continued active participation were motivated, had some QI infrastructure, and found value in working with their facilitators. Facilitators enabled practice participation by doing EHR-related work for practices, adapting work for available staff, and helping address needs beyond the explicit aims of EvidenceNOW. CONCLUSIONS: Disruptions are prevalent in primary care, but practices can continue participating in QI interventions, particularly when supported by a facilitator. Facilitators may benefit from additional training in approaches for helping practices attenuate the effects of disruptions and adapting strategies to help interventions work to continue building QI capacity.

Cardiovascular Disease Preventive Services Among Smaller Primary Care Practices.

INTRODUCTION: Cardiovascular disease preventive services (aspirin use, blood pressure control, and smoking-cessation support) are crucial to controlling cardiovascular diseases. This study draws from 1,248 small-to-medium-sized primary care practices participating in the EvidenceNOW Initiative from 2015-2016 across 12 states to provide practice-level aspirin use, blood pressure control, and smoking-cessation support estimates; report the percentage of practices that meet Million Hearts targets; and identify the practice characteristics associated with better performance. METHODS: This cross-sectional study utilized linear regression modeling (analyzed in 2020-2021) to examine the association of aspirin use, blood pressure control, and smoking-cessation support performance with practice characteristics that included structural attributes (e.g., size, ownership, rurality), practice capacity and contextual characteristics, health information technology, and patient panel demographics. RESULTS: On average, practice performance on aspirin use, blood pressure control, and smoking-cessation support quality measures was 64% for aspirin, 63% for blood pressure, and 62% for smoking-cessation support. The 2012 Million Hearts goal of achieving the rates of 70% was achieved by 52% (aspirin), 32% (blood pressure), and 54% (smoking) of practices. Practice characteristics associated with aspirin use, blood pressure control, and smoking-cessation support performance included ownership (hospital/health system-owned practices had 11% higher aspirin performance than clinician-owned practices [p=0.001]), rurality (rural practices had lower performance than urban practices in all aspirin use, blood pressure control, and smoking-cessation support quality metrics [difference in aspirin=11.1%, p=0.001; blood pressure=4.2%, p=0.022; smoking=14.4%, p=0.009]), and disruptions (practices that experienced >1 major disruption showed lower aspirin performance [-7.1%, p<0.001]). CONCLUSIONS: Achieving the Million Hearts targets may be assisted by collecting and reporting practice-level performance, which can promote change at the practice level and identify areas where additional support is needed to achieve initiative goals.

Integrating Interprofessional Trainees into a Complex Care Program for Veterans Experiencing Homelessness: Effects on Health Services Utilization.

PURPOSE: High-quality, comprehensive care of vulnerable populations requires interprofessional ambulatory care teams skilled in addressing complex social, medical, and psychological needs. Training health professionals in interprofessional settings is crucial for building a competent future workforce. The impacts on care utilization of adding continuity trainees to ambulatory teams serving vulnerable populations have not been described. We aim to understand how the addition of interprofessional trainees to an ambulatory clinic caring for Veterans experiencing homelessness impacts medical and mental health services utilization. METHODS: Trainees from five professions were incorporated into an interprofessional ambulatory clinic for Veterans experiencing homelessness starting in July 2016. We performed clinic-level interrupted time series (ITS) analyses of pre- and post-intervention utilization measures among patients enrolled in this training continuity clinic, compared to three similar VA homeless clinics without training programs from October 2015 to September 2018. RESULTS: Our sample consisted of 37,671 patient- months. There was no significant difference between the intervention and comparison groups' post-intervention slopes for numbers of primary care visits (difference in slopes =-0.16 visits/100 patients/month; 95% CI -0.40, 0.08; p=0.19), emergency department visits (difference in slopes = 0.08 visits/100 patients/month; 95% CI -0.16, 0.32; p=0.50), mental health visits (difference in slopes = -1.37 visits/month; 95% CI -2.95, 0.20; p= 0.09), and psychiatric hospitalizations (-0.005 admissions/100 patients/month; 95% CI -0.02, 0.01; p= 0.62). We found a clinically insignificant change in medical hospitalizations. CONCLUSIONS: Adding continuity trainees from five health professions to an interprofessional ambulatory clinic caring for Veterans experiencing homelessness did not adversely impact inpatient and outpatient care utilization. An organized team-based care approach is beneficial for vulnerable patients and provides a meaningful educational experience for interprofessional trainees by building health professionals' capabilities to care for vulnerable populations.