Emergence of Gun Violence as a Patient Priority.

PURPOSE: Gun violence is a growing public health epidemic that disproportionately affects underserved and minority communities. Our study sought to document patient experiences of community gun violence as a theme that emerged in the context of interviews exploring community-level factors influencing patients' engagement in primary care within the context of a larger study on cardiovascular health. METHODS: We completed semistructured qualitative interviews of individuals with uncontrolled hypertension recruited from primary care practices serving underserved communities in metro Richmond, Virginia that were participating in a larger study on improving cardiovascular health. RESULTS: Of 19 individuals interviewed, 11 discussed without prompting the negative effects of gun violence in their community. Themes that emerged included both the acute and chronic traumatic experience, the physiologic and cognitive effects of gun violence and the negative effects on ability to manage heart health. CONCLUSIONS: The effects of gun violence on not only cardiovascular health but also all aspects of health emerged unprompted in qualitative interviews about community level factors influencing management of cardiovascular health. Given the widespread negative effects of experiencing gun violence on health, family physicians could play an important role in identifying and managing the effects of gun violence. Future studies on how primary care clinicians can address gun violence in the caring for their patients comprehensively are needed.

Medicare Access and CHIP Reauthorization Act in Small to Medium-Sized Primary Care Practices.

BACKGROUND: Despite major efforts to transition to a new physician payment system under the Medicare Access and CHIP Reauthorization Act (MACRA), little is known about how well practices are prepared. This study aimed to understand how small and medium-sized primary care practices in the Heart of Virginia Healthcare (https://www.vahealthinnovation.org/hvh/) perceive their quality incentives under MACRA. METHODS: This study analyzed data from 16 focus-groups (70 participants), which yielded a range of physician, advanced practice clinician, office manager, and staff perspectives. Focus-groups were audio-recorded and transcribed, then imported into NVivo for coding and analysis of themes. A multidisciplinary research team reviewed the transcripts to maximize coding insights and to improve validity. RESULTS: The main findings from the focus-groups are: 1) MACRA awareness is relatively higher in independent practices, 2) steps taken toward MACRA differ by practice ownership, and 3) practices have mixed perceptions about the expected impact of MACRA. Two additional themes emerged from data: 1) practices that joined accountable care organizations are taking proactive approaches to MACRA, and 2) independent practices face ongoing challenges. CONCLUSIONS: This study highlights a dilemma in which independent practices are proactively attempting to prepare for MACRA's requirements, yet they continue to have major challenges. Practices are under extreme pressure to comply with reimbursement regulations, which may force some practices joining a health system or merging with another practice or completely closing the practices. Policy makers should assess the unintended consequences of payment reform policies on independent practices and provide support in transitioning to a new payment system.

Enhanced care planning and clinical-community linkages versus usual care to address basic needs of patients with multiple chronic conditions: a clinician-level randomized controlled trial.

BACKGROUND: Many patients with poorly controlled multiple chronic conditions (MCC) also have unhealthy behaviors, mental health challenges, and unmet social needs. Medical management of MCC may have limited benefit if patients are struggling to address their basic life needs. Health systems and communities increasingly recognize the need to address these issues and are experimenting with and investing in new models for connecting patients with needed services. Yet primary care clinicians, whose regular contact with patients makes them more familiar with patients' needs, are often not included in these systems. METHODS: We are starting a clinician-level cluster-randomized controlled trial to evaluate how primary care clinicians can participate in these community and hospital solutions and whether doing so is effective in controlling MCC. Sixty clinicians in the Virginia Ambulatory Care Outcomes Research Network will be matched by age and sex and randomized to usual care (control condition) or enhanced care planning with clinical-community linkage support (intervention). From the electronic health record we will identify all patients with MCC, including cardiovascular disease or risks, diabetes, obesity, or depression. A baseline assessment will be mailed to up to 50 randomly selected patients for each clinician (3000 total). Ten respondents per clinician (600 patients total) with uncontrolled MCC will be randomly selected for study inclusion, with oversampling of minorities. The intervention includes two components. First, we will use an enhanced care planning tool, My Own Health Report (MOHR), to screen patients for health behavior, mental health, and social needs. Patients will be supported by a patient navigator, who will help patients prioritize needs, create care plans, and write a personal narrative to guide the care team. Patients will update care plans every 1 to 2 weeks. Second, we will create community-clinical linkage to help address patients' needs. The linkage will include community resource registries, personnel to span settings (patient navigators and a community health worker), and care team coordination across team members through MOHR. DISCUSSION: This study will help inform efforts by primary care clinicians to help address unhealthy behaviors, mental health needs, and social risks as a strategy to better control MCC. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03885401. Registered on 19 September 2019.

A "Behind-the-Scenes" Look at Interprofessional Care Coordination: How Person-Centered Care in Safety-Net Health System Complex Care Clinics Produce Better Outcomes.

INTRODUCTION: While the effectiveness of team-based care and wrap-around services for high utilizers is clear, how complex care clinics deliver effective, person-centered care to these vulnerable populations is not well understood. This paper describes how interactions among interprofessional team members enabled individualized, rapid responses to the complex needs of vulnerable patients at the Virginia Commonwealth University Health System's Complex Care Clinic. METHODS: Researchers attended twenty weekly care coordination meetings, audio-recorded the proceedings, and wrote brief observational field notes. Researchers also qualitatively interviewed ten clinic team members. Emergent coding based on grounded theory and a consensus process were used to identify and describe key themes. RESULTS: Analysis resulted in three themes that evidence the structures, processes, and interactions which contributed to the ability to provide person-centred care: team-based communication strategies, interprofessional problem-solving, and personalized patient engagement efforts. CONCLUSION: Our study suggests that in care coordination meetings team members were able to strategize, brainstorm, and reflect on how to better care for patients. Specifically, flexible team leadership opened an inter-disciplinary communicative space to foster conversations, which revealed connections between the physical, and socio-emotional components of patients' lives and hidden factors undermining progress, while proactive strategies prevented patient's rapid deterioration and unnecessary use of inappropriate health services.

Practice facilitation to promote evidence-based screening and management of unhealthy alcohol use in primary care: a practice-level randomized controlled trial.

BACKGROUND: Unhealthy alcohol use is the third leading cause of preventable death in the United States. Evidence demonstrates that screening for unhealthy alcohol use and providing persons engaged in risky drinking with brief behavioral and counseling interventions improves health outcomes, collectively termed screening and brief interventions. Medication assisted therapy (MAT) is another effective method for treatment of moderate or severe alcohol use disorder. Yet, primary care clinicians are not regularly screening for or treating unhealthy alcohol use. METHODS AND ANALYSIS: We are initiating a clinic-level randomized controlled trial aimed to evaluate how primary care clinicians can impact unhealthy alcohol use through screening, counseling, and MAT. One hundred and 25 primary care practices in the Virginia Ambulatory Care Outcomes Research Network (ACORN) will be engaged; each will receive practice facilitation to promote screening, counseling, and MAT either at the beginning of the trial or at a 6-month control period start date. For each practice, the intervention includes provision of a practice facilitator, learning collaboratives with three practice champions, and clinic-wide information sessions. Clinics will be enrolled for 6-12 months. After completion of the intervention, we will conduct a mixed methods analysis to identify changes in screening rates, increase in provision of brief counseling and interventions as well as MAT, and the reduction of alcohol intake for patients after practices receive practice facilitation. DISCUSSION: This study offers a systematic process for dissemination and implementation of the evidence-based practice of screening, counseling, and treatment for unhealthy alcohol use. Practices will be asked to implement a process for screening, counseling, and treatment based on their practice characteristics, patient population, and workflow. We propose practice facilitation as a robust and feasible intervention to assist in making changes within the practice. We believe that the process can be replicated and used in a broad range of clinical settings; we anticipate this will be supported by our evaluation of this approach. TRIAL REGISTRATION: ClinicalTrials.gov, ClinicalTrials.gov Identifier: NCT04248023, Registered 5 February 2020.

Assessment of Addiction Medicine Training in Family Medicine Residency Programs: A CERA Study.

BACKGROUND AND OBJECTIVES: Substance use disorder (SUD) is a widespread problem but physicians may feel inadequately prepared to provide addiction care. We sought to assess current addiction medicine curricula in US family medicine residencies (FMRs) and evaluate barriers to improving or implementing addiction medicine curricula. METHODS: Questions regarding addiction medicine training were added to the December 2015 Council of Academic Family Medicine Educational Research Alliance (CERA) survey to US FMR program directors to evaluate each FMR's curriculum, potential workforce production, perceived barriers to improving or implementing curricula and faculty training in addiction medicine. RESULTS: Of 461 FMR directors, 227 (49.2%) responded; 28.6% reported a required addiction medicine curricula. Regional variations of having a required curriculum ranged from 41.3% in the Northeast to 20.0% in the South (P=0.07). Of residencies, 31.2% had at least one graduate obtain a buprenorphine prescription waiver in the past year and 8.6% had at least one graduate pursue an addiction medicine fellowship in the past 5 years. Lack of faculty expertise was the most commonly cited barrier to having a curriculum, with only 36.2% of programs having at least one buprenorphine waivered faculty member, 9.4% an addiction medicine board certified faculty, and 5.5% a fellowship trained faculty. CONCLUSIONS: Few FMRs have addiction medicine curricula and most graduates do not seek additional training. Multifaceted efforts, including developing model national curricula, training existing faculty, and recruiting addiction trained faculty, may improve addiction medicine training in family medicine residencies to better address the growing SUD epidemic.

Identifying Future High Cost Individuals within an Intermediate Cost Population.

BACKGROUND: Improving health and controlling healthcare costs requires better tools for predicting future health needs across populations. We sought to identify factors associated with transitioning of enrollees in an indigent care program from an intermediate cost segment to a high cost segment of this population. METHODS: We analyzed data from 9,624 enrollees of the Virginia Coordinated Care program between 2010 and 2013. Each fiscal year included all enrollees who were classified in intermediate cost segment in the preceding year and also enrolled in the program in the following year. Using information from the preceding year, we built logistic regression models to identify the individuals in the top 10% of expenditures in the following year. The effect of demographics, count of chronic conditions, presence of the prevalent chronic conditions, and utilization indicators were evaluated and compared. Models were compared via the Bayesian information criterion and c-statistic. RESULTS: The count of chronic conditions, diagnosis of congestive heart failure, and numbers of total hospital visits and prescriptions were significantly and independently associated with being in the future high cost segment. Overall, the model that included demographics and utilization indicators had a reasonable discrimination (c=0.67). CONCLUSIONS: A simple model including demographics and health utilization indicators predicted high future costs. The count of chronic conditions and certain medical diagnoses added additional predictive value. With further validation, the approach could be used to identify high-risk individuals and target interventions that decrease utilization and improve health.

Team-based care: a critical element of primary care practice transformation.

The purpose of this study was to gain an in-depth understanding of how primary care practices in the United States are transforming their practice to deliver patient-centered care. The study used qualitative research methods to conduct case studies of small primary care practices in the state of Virginia. The research team collected data from practices using in-depth interviews, structured telephone questionnaires, observation, and document review. Team-based care stood out as the most critical method used to successfully transform practices to provide patient-centered care. This article presents 3 team-based care models that were utilized by the practices in this study.

EHRs in primary care practices: benefits, challenges, and successful strategies.

OBJECTIVES: To understand the current use of electronic health records (EHRs) in small primary care practices and to explore experiences and perceptions of physicians and staff toward the benefits, challenges, and successful strategies for implementation and meaningful use of advanced EHR functions. STUDY DESIGN: Qualitative case study of 6 primary care practices in Virginia. METHODS: We performed surveys and in-depth interviews with clinicians and administrative staff (N = 38) and observed interpersonal relations and use of EHR functions over a 16-month period. Practices with an established EHR were selected based on a maximum variation of quality activities, location, and ownership. RESULTS: Physicians and staff report increased efficiency in retrieving medical records, storing patient information, coordination of care, and office operations. Costs, lack of knowledge of EHR functions, and problems transforming office operations were barriers reported for meaningful use of EHRs. Major disruption to patient care during upgrades and difficulty utilizing performance tracking and quality functions were also reported. Facilitators for adopting and using advanced EHR functions include team-based care, adequate technical support, communication and training for employees and physicians, alternative strategies for patient care during transition, and development of new processes and work flow procedures. CONCLUSIONS: Small practices experience difficulty with implementation and utilization of advanced EHR functions. Federal and state policies should continue to support practices by providing technical assistance and financial incentives, grants, and/or loans. Small practices should consider using regional extension center services and reaching out to colleagues and other healthcare organizations with similar EHR systems for advice and guidance.

Elements of the patient-centered medical home in family practices in Virginia.

PURPOSE: The patient-centered medical home (PCMH) is a widely accepted theory of a practice model to improve quality of care, patient satisfaction, and access to primary care services. This study explores existing elements of the PCMH and characteristics of family practices in Virginia. METHOD: We developed and administered a survey questionnaire to capture information on practice characteristics and PCMH elements. We randomly sampled 700 family medicine offices in Virginia from a population of practices derived from the Virginia Board of Medicine Practitioner Information Database. We used a mixed-mode survey, allowing practices in the sample to respond by mail or Internet or at a regional family medicine conference. RESULTS: The survey resulted in a response rate of 56%, with 342 office locations participating in the study. Most practices reported continuity-of-care processes (87%) and clinical guidelines (77%). Fewer reported use of patient surveys (48%), electronic medical record for internal coordination (38%), community linkages for care (31%), and clinical performance measurement (28%). A small number reported patient registries for multiple diseases (19%). Very few practices exhibited all elements outlined in the PCMH model (1%). Practice size (number of physicians) is significantly related to PCMH model alignment. CONCLUSIONS: Most family practices in Virginia exhibit some elements of the PCMH model. Full implementation of the PCMH model is low. Baseline information on practice characteristics, prevalence of PCMH, and challenges of small practices should be considered in guiding efforts, evaluating progress, and developing policies for care model reform.