Increasing Capacity for Treatment of Opioid Use Disorder in Rural Primary Care Practices.

PURPOSE: Evidence supports treatment for opioid use disorder (OUD) with buprenorphine in primary care practices (PCPs). Barriers that slow implementation of this treatment include inadequately trained staff. This study aimed to increase the number of rural PCPs providing OUD treatment with buprenorphine. This evaluation describes the impact of a practice team training on the implementation and delivery of OUD treatment with buprenorphine in PCPs of rural Colorado. METHODS: Implementing Technology and Medication Assisted Treatment Team Training in Rural Colorado (IT MATTTRs) was a multilevel implementation study that included a practice-focused intervention to improve awareness, adoption, and use of buprenorphine treatment for OUD. Participating PCP teams received the IT MATTTRs Practice Team Training and support. Practices' implementation of treatment components was assessed before and after training. Practice-reported and population-level data from the Prescription Drug Monitoring Program were obtained to describe changes in delivery of treatment after training. RESULTS: Forty-two practices received team training. Practices reported an average of 4.7 treatment-related components in place at baseline compared with 13.0 at 12-month follow-up (F[2,56] = 31.17, P <.001). The proportion of participating practices providing or referring patients for treatment increased from 18.8% to 74.4%. The increase in number of people with a prescription for buprenorphine was significantly greater in the study region over a 4-year period compared with the rest of the state (Wald χ2 = 15.73, P <.001). CONCLUSIONS: The IT MATTTRs training for PCP teams in OUD treatment with buprenorphine addressed elements beyond clinician waiver training to make implementation feasible and effectively increased implementation and delivery of this treatment in rural Colorado.

Does a Rural Community-Based Intervention Improve Knowledge and Attitudes of Opioid Use Disorder and Medication-Assisted Treatment? A Report From the IT MATTTRs Study.

PURPOSE: Understanding knowledge of and attitudes toward medication-assisted treatment (MAT) for opioid use disorder (OUD) is important to changing the conversation about this devastating public health problem. While several studies report clinician knowledge and attitudes and training, less is known about community member perspectives. As part of the Implementing Technology and Medication Assisted Treatment Team Training in Rural Colorado study (IT MATTTRs), this study describes the implementation of community-based interventions developed by rural community members and researchers to increase awareness and promote positive attitudes toward MAT for OUD and explores changes in community members' OUD and MAT knowledge and beliefs. METHODS: Using the Boot Camp Translation process, the High Plains Research Network and Colorado Research Network MAT Advisory Councils developed multicomponent interventions on MAT for OUD. Baseline and postintervention surveys were administered using venue-based sampling of community members in rural communities. FINDINGS: Surveys were completed by 789 community members at baseline and 798 at postintervention. Nearly half (49%) reported exposure to at least 1 intervention product. Greater exposure to intervention materials was associated with beliefs that using opioids to get high in rural communities is a problem (P < .0001), that opioid addiction is a chronic disease (P = .0032), and that OUD can be treated locally (P = .0003). CONCLUSIONS: Partnering with local community members resulted in the successful development and implementation of community-based interventions, exposure to which was associated with OUD knowledge and beliefs. Locally created interventions should be included in comprehensive approaches to stem the OUD epidemic.

Impact of Cancer Survivorship Care Training on Rural Primary Care Practice Teams: a Mixed Methods Approach.

With the increasing numbers of individuals surviving a diagnosis of cancer, an aging population, and more individuals experiencing multi-morbidity, primary care providers (PCPs) are seeing more patients with a history of cancer. Effective strategies are needed to adequately prepare the primary care workforce for the phase of cancer care now widely recognized as survivorship. A survivorship education program for rural primary care practices was developed using a community engagement process and delivered at the practice level by community health liaisons. A mixed method approach was used to evaluate the program impact which included a questionnaire and interviews. Descriptive analyses and generalized linear regression were used to evaluate quantitative outcomes from the questionnaires. Immersion crystallization was used to define themes from the qualitative components. Thirty-two (32) practices participated, averaging 10.3 team members/practice. The percent of correct responses to the knowledge questionnaire increased significantly, almost doubling between baseline and post-test (25% vs 46%, p < .001). Four major themes emerged from the interviews which included positive impact of the training, putting the training into practice, intention to change care delivery, contextual influences in survivorship care. Evidence from the cancer survivorship education program evaluation supports its value to key stakeholders and the potential wider dissemination of the iSurvive Program. These data also suggest the need for additional investigation into other ways beyond education that primary care practices can be supported to ensure the needs of the growing cancer survivor population in the US are met.

UPSTREAM! Together evaluation results from community efforts to prevent mental, emotional, and behavioral health problems.

Mental, emotional, and behavioral (MEB) health problems are prevalent globally. Despite effective programs that can prevent MEB problems and promote mental health, there has not been widespread adoption. UPSTREAM! Together was a planning project in three Colorado communities. Communities partnered with academic and policy entities to 1) translate evidence about MEB problem prevention into locally-relevant messages and materials and 2) develop long-term plans for broad implementation of interventions to prevent high-priority MEB problems. Community members recognized the need to talk about MEB problems to prevent them. The UPSTREAM! communities localized messages designed to start conversations and sustain attention on preventing MEB problems. The communities understood that prevention takes sustained community attention and advocacy, knowing that important outcomes may be years away. Long-term implementation plans aimed to strengthen families and enhance social connections among youth. Despite community readiness and capacity to implement evidence-based programs, there were few funding opportunities, delaying program implementation and revealing gaps between funding policies and community readiness. This community-engaged experience suggests an achievable approach, acceptable to communities, and worthy of further development and testing. Policies that cultivate and support local expertise may help to increase wider community adoption of evidence-based programs that promote mental health among youth.

Building Capacity for Medication Assisted Treatment in Rural Primary Care Practices: The IT MATTTRs Practice Team Training.

OBJECTIVES: In response to rural communities and practice concerns related to opioid use disorder (OUD), the Implementing Technology and Medication Assisted Treatment Team Training in Rural Colorado study (IT MATTTRs) developed a training intervention for full primary care practice (PCP) teams in MAT for OUD. This evaluation reports on training implementation, participant satisfaction, and impact on perceived ability to deliver MAT. METHODS: PCPs in the High Plains Research Network and Colorado Research Network were randomized to receive team training either in-person or through virtual tele-mentoring. Training attendance logs recorded the number of participants and their roles. Participants completed a survey within one month of the last training session to evaluate satisfaction and ability to deliver components of MATs. RESULTS: 441 team members at 42 PCPs were trained, including 22% clinicians, 47% clinical support staff, 24% administrative support staff. Survey respondents reported high levels of satisfaction, including 82% reporting improved understanding of the topic, and 68% identifying actions to apply information. Self-rated ability was significantly higher after training for all items (P < .0001), including ability to identify patients for MAT and to manage patients receiving MAT. Mean change scores, adjusted for role, were significantly greater for all measures (P < .001) in SOuND practices compared to ECHO practices. CONCLUSIONS: The IT MATTTRs Practice Team Training successfully engaged PCP team members in diverse roles in MAT for OUD training and increased self-efficacy to deliver MAT. Results support the training as a resource for a team-based approach to build rural practices' capacity to deliver MAT.

Success in the Achieving CARdiovascular Excellence in Colorado (A CARE) Home Blood Pressure Monitoring Program: A Report from the Shared Networks of Colorado Ambulatory Practices and Partners (SNOCAP).

BACKGROUND: Blood pressure (BP) control among primary care patients with hypertension is suboptimal. Home BP monitoring (HBPM) has been shown to be effective but is underused. METHODS: This study was a quasi-experimental evaluation of the impact of the A CARE HBPM program on hypertension control. Nonpregnant adults with hypertension or cardiovascular disease risk factors were given validated home BP monitors and reported monthly average home BP readings by Internet or phone. Patients and providers received feedback. Change in average home and office BP and the percentage of patients achieving target BP were assessed based on patient HBPM reports and a chart audit of office BPs. RESULTS: A total of 3578 patients were enrolled at 26 urban and rural primary care practices. Of these, 36% of participants submitted ≥2 HBPM reports. These active participants submitted a mean of 13.5 average HBPM reports, with a mean of 19.3 BP readings per report. The mean difference in home BP between initial and final HBPM reports for active participants was -6.5/-4.4 mmHg (P < .001) and -6.7/-4.7 mmHg (P < .001) for those with diabetes. The percentage of active participants at or below target BP increased from 34.5% to 53.3% (P < .001) and increased 24.6% to 40.0% (P < .001) for those with diabetes. The mean difference in office BP over 1 year between participants and nonparticipants was -5.4/-2.7 mmHg (P < .001 for systolic BP, P = .01 for diastolic BP) for all participants and -8.5/-1.5 mmHg (P = .014 for systolic BP, P = .405 for diastolic BP) for those with diabetes. CONCLUSIONS: An HBPM program with patient and provider feedback can be successfully implemented in a range of primary care practices and can play a significant role in BP control and decreased cardiovascular disease risk in patients with hypertension.

How do rural patients benefit from the patient-centred medical home? A card study in the High Plains Research Network.

Context The patient-centred medical home (PCMH) has become a dominant model for improving the quality and cost of primary care. Geographic isolation, small populations, privacy concerns and staffing requirements may limit implementation of the PCMH in clinical practice. Objective To determine the primary care provider perceived benefit of PCMH for patients in rural Colorado. Design, setting and participants The High Plains Research Network (HPRN) is a community and practice-based research network spanning 30 000 square miles in 16 counties in eastern Colorado. The HPRN consists of 58 practices, 120 primary care clinicians and 145 000 residents. Main outcome measures Providers' perceived benefit of PCMH for individual patients. Results Seventy-eight providers in 37 practices saw 1093 patients and completed 1016 surveys. There was wide variation among the provider-perceived benefits of PCMH elements ranging from 9% for group visits to 64% for electronic prescribing. Provider-perceived benefit was higher for patients with a chronic medical condition. Conclusions Rural primary care providers perceived patient benefit for numerous elements of the PCMH. There is need to consider what PCMH elements may be required in practice and what components might be optional. Our findings reveal that rural practices share PCMH aspirations including commitment to quality, safety, outcomes, cost reduction, and patient and provider satisfaction. These findings support the need for ongoing conversation about how to best provide a locally relevant medical home.

Translating the medical home into patient-centred language.

Background The patient-centred medical home (PCMH) is a healthcare delivery model that aims to make health care more effective and affordable and to curb the rise in episodic care resulting from increasing costs and sub-specialisation of health care. Although the PCMH model has been implemented in many different healthcare settings, little is known about the PCMH in rural or underserved settings. Further, less is known about patients' understanding of the PCMH and its effect on their care. Aims The goal of this project was to ascertain the patient perspective of the PCMH and develop meaningful language around the PCMH to help inform and promote patients' participation with the PCMH. Method The High Plains Research Network Community Advisory Council (CAC) is comprised of a diverse group of individuals from rural eastern Colorado. The CAC and its academic partners started this project by receiving a comprehensive education on the PCMH. Using a community-based participatory research approach, the CAC translated technical medical jargon on the PCMH into a core message that the 'Medical Home is Relationship'. Results The PCMH should focus on the relationship of the patient with their personal physician. Medical home activities should be used to support and strengthen this relationship. Conclusion The findings serve as a reminder of the crucial elements of the PCMH that make it truly patient centred and the importance of engaging local patients in developing and implementing the medical home.

Testing to prevent colon cancer: results from a rural community intervention.

PURPOSE: Colon cancer is the second leading cause of cancer death in the United States. Despite tests that can detect and enable removal of precancerous polyps, effectively preventing this disease, screening for colon cancer lags behind other cancer screening. The purpose of this study was to develop and test a community-based participatory approach to increase colon cancer screening. METHODS: Using a community-based participatory research approach, the High Plains Research Network and their Community Advisory Council developed a multicomponent intervention-Testing to Prevent Colon Cancer-to increase colon cancer screening. A controlled trial compared 9 intervention counties in northeast Colorado with 7 control counties in southeast Colorado. We performed a baseline and postintervention random digit-dial telephone survey and conducted both intent-to-treat and on-treatment analyses. RESULTS: In all, 1,050 community members completed a preintervention questionnaire and 1,048 completed a postintervention questionnaire. During the study period, there was a 5% absolute increase in the proportion of respondents who reported ever having had any test in the intervention region (from 76% to 81%) compared with no increase in the control region (77% at both time points) (P = .22). No significant differences between these groups were found in terms of being up to date generally or on specific tests. The extent of exposure to intervention materials was associated with a significant and cumulative increase in screening. CONCLUSIONS: This community-based multicomponent intervention engaged hundreds of community members in wide dissemination aimed at increasing colorectal cancer screening. Although we did not find any statistically significant differences, the findings are consistent with an intervention-related increase in screening and provide preliminary evidence on the effectiveness of such interventions to improve colon cancer screening.