Development and validation of the Readiness to Train Assessment Tool (RTAT).

BACKGROUND: In recent years, health centers in the United States have embraced the opportunity to train the next generation of health professionals. The uniqueness of the health centers as teaching settings emphasizes the need to determine if health professions training programs align with health center priorities and the nature of any adjustments that would be needed to successfully implement a training program. We sought to address this need by developing and validating a new survey that measures organizational readiness constructs important for the implementation of health professions training programs at health centers where the primary role of the organizations and individuals is healthcare delivery. METHODS: The study incorporated several methodological steps for developing and validating a measure for assessing health center readiness to engage with health professions programs. A conceptual framework was developed based on literature review and later validated by 20 experts in two focus groups. A survey-item pool was generated and mapped to the conceptual framework and further refined and validated by 13 experts in three modified Delphi rounds. The survey items were pilot-tested with 212 health center employees. The final survey structure was derived through exploratory factor analysis. The internal consistency reliability of the scale and subscales was evaluated using Chronbach's alpha. RESULTS: The exploratory factor analysis revealed a 41-item, 7-subscale solution for the survey structure, with 72% of total variance explained. Cronbach's alphas (.79-.97) indicated high internal consistency reliability. The survey measures: readiness to engage, evidence strength and quality of the health professions training program, relative advantage of the program, financial resources, additional resources, implementation team, and implementation plan. CONCLUSIONS: The final survey, the Readiness to Train Assessment Tool (RTAT), is theoretically-based, valid and reliable. It provides an opportunity to evaluate health centers' readiness to implement health professions programs. When followed with appropriate change strategies, the readiness evaluations could make the implementation of health professions training programs, and their spread across the United States, more efficient and cost-effective. While developed specifically for health centers, the survey may be useful to other healthcare organizations willing to assess their readiness to implement education and training programs.

A quasi-experiment assessing the six-months effects of a nurse care coordination program on patient care experiences and clinician teamwork in community health centers.

BACKGROUND: Recognition that coordination among healthcare providers is associated with better quality of care and lower costs has increased interest in interventions designed to improve care coordination. One intervention is to add care coordination to nurses' role in a formal way. Little is known about effects of this approach, which tends to be pursued by small organizations and those in lower-resource settings. We assessed effects of this approach on care experiences of high-risk patients (those most in need of care coordination) and clinician teamwork during the first 6 months of use. METHODS: We conducted a quasi-experimental study using a clustered, controlled pre-post design. Changes in staff and patient experiences at six community health center practice locations that introduced the added-role approach for high-risk patients were compared to changes in six locations without the program in the same health system. In the pre-period (6 months before intervention training) and post-period (about 6 months after intervention launch, following 3 months of training), we surveyed clinical staff (N = 171) and program-qualifying patients (3007 pre-period; 2101 post-period, including 113 who were enrolled during the program's first 6 months). Difference-in-differences models examined study outcomes: patient reports about care experiences and clinician-reported teamwork. We assessed frequency of patient office visits to validate access and implementation, and contextual factors (training, resources, and compatibility with other work) that might explain results. RESULTS: Patient care experiences across all high-risk patients did not improve significantly (p > 0.05). They improved somewhat for program enrollees, 5% above baseline reports (p = 0.07). Staff-perceived teamwork did not change significantly (p = 0.12). Office visits increased significantly for enrolled patients (p < 0.001), affirming program implementation (greater accessing of care). Contextual factors were not reported as problematic, except that 41% of nurses reported incompatibility between care coordination and other job demands. Over 75% of nurses reported adequate training and resources. CONCLUSIONS: There were some positive effects of adding care coordination to nurses' role within 6 months of implementation, suggesting value in this improvement strategy. Addressing compatibility between coordination and other job demands is important when implementing this approach to coordination.

A cost-effectiveness analysis of cardiology eConsults for Medicaid patients.

OBJECTIVES: To evaluate the cost-effectiveness of electronic consultations (eConsults) for cardiology compared with traditional face-to-face consults. STUDY DESIGN: Cost-effectiveness analysis for a subset of Medicaid-insured patients in a cluster-randomized trial of eConsults versus the traditional face-to-face consultation process in a statewide federally qualified health center. METHODS: A total of 369 Medicaid patients were referred for cardiology consultations by primary care providers who were randomly assigned to use either eConsults or their usual face-to-face referral process. Primary care providers in the eConsult arm transmitted consults to cardiologists using a secure peer-to-peer communication platform in an electronic health record. Intention-to-treat analysis was used to assess the total cost of care and cost across 7 categories: inpatient, outpatient, emergency department, pharmacy, labs, cardiac procedures, and "all other." Costs are from the payer's perspective. RESULTS: Six months after the cardiology consult, patients in the eConsult group had significantly lower mean unadjusted total costs by $655 per patient, or lower mean costs by $466 per patient when adjusted for non-normality, compared with those in the face-to-face arm. The eConsult group had a significantly lower cost by $81 per patient in the outpatient cardiac procedures category. CONCLUSIONS: These findings suggest that eConsults are associated with total cost savings to payers due principally to reductions in the cost of cardiac outpatient procedures.

Strengthening the role the workforce plays in health policy engagement in underserved communities: lessons from a multi-site federally qualified health center.

Studies on the engagement of the CHC workforce in health policy are limited. Most uninsured Americans do not understand how the ACA affects them. We assessed knowledge and interest of our workforce in health policy, and applied the Socio-Ecological model to a plan for engagement, sharing strategies for similar settings.

Comprehensive assessment of chronic pain management in primary care: a first phase of a quality improvement initiative at a multisite Community Health Center.

BACKGROUND: The objective of this study was to conduct a comprehensive formative assessment of chronic pain management in a large, multisite community health centre and use the results to design a quality improvement initiative based on an evidence-based practice model developed by the Veterans Health Administration. Improving quality and safety by incorporating evidence-based practices (EBP) is challenging, particularly in busy clinical practices such as Federally Qualified Health Centers (FQHCs). FQHCs grapple with financial constraints, lack of resources and complex patient populations. METHODS: The Promoting Action on Research Implementation in Health Services (PARIHS) Framework served as a basis for the comprehensive assessment. We used a range of measures and tools to examine pain care from a variety of perspectives. Patients with chronic pain were identified using self-reported pain scores and opioid prescription records. We employed multiple data collection strategies, including querying our electronic health records system, manual chart reviews and staff surveys. RESULTS: We found that patients with chronic pain had extremely high primary care utilisation rates while referral rates to pain-related specialties were low for these patients. Large gaps existed in primary care provider adherence to standards for pain care documentation and practice. There was wide provider variability in the prescription of opioids to treat pain. Staff surveys found substantial variation in both pain care knowledge and readiness to change, as well as low confidence in providers' ability to manage pain, and dissatisfaction with the resources available to support chronic pain care. CONCLUSIONS: Improving chronic pain management at this Community Health Center requires a multifaceted intervention aimed at addressing many of the problems identified during the assessment phase. During the intervention we will put a greater emphasis on increasing options for behavioural health and complementary medicine support, increasing access to specialty consultation, providing pain-specific CME for providers, and improving documentation of pain care in the electronic health records.