Examining the Implementation of Health-Related Social Need (HRSN) Screenings at a Pediatric Community Health Center.

INTRODUCTION: Social determinants of health (SDoH) influence health outcomes and screening for health-related social needs (HRSN) is a recommended pediatric practice. In 2018, Denver Health and Hospitals (DH) implemented the Accountable Health Communities (AHC) model under the Centers for Medicare and Medicaid Services (CMS) and began using the AHC HRSN screening tool during selected well child visits (WCVs) at a DH Federally Qualified Health Center (FQHC). The current evaluation aimed to examine the program implementation and identify key lessons learned to inform the expansion of HRSN screening and referral to other populations and health systems. METHODS: Patients who completed a WCV between June 1, 2020 and December 31, 2021 (N = 13 750) were evaluated. Frequencies and proportions were used to describe patient characteristics of those that had a WCV, were screened, and received resource information. Multivariable logistic regression models with odds ratios (OR) and 95% confidence intervals (CI) were used to determine the association between patient characteristics and completing HRSN screening and provision of resource information. RESULTS: The screening tool was completed by 80% (n = 11 004) of caregivers bringing children to a WCV at the DH Westside Clinic, with over one-third (34.8%; n = 3830) reporting >1 social need. Food insecurity was the most common concern (22.3%; n = 2458). Non-English, non-Spanish (NENS) speakers were less likely to be screened (OR 0.43, 95% CI 0.33, 0.57) and less likely to report a social need (OR 0.59, 95% CI 0.42, 0.82) than speakers of English, after adjusting for age, race/ethnicity, and health insurance. CONCLUSIONS: A high rate of screening indicates feasibility of administering HRSN screenings for pediatric patients in a busy FQHC. More than a third of patients reported one or more social needs, underscoring the importance to identity these needs and the opportunity to offer personalized resources. Comparatively lower rates of screening and potential underreporting among NENS may be indicative of the availability and acceptability of current translation procedures as well as how the tool translates linguistically and culturally. Our experience highlights the need to partner with community organizations and involve patients and families to ensure SDoH screening and care navigation is part of culturally-appropriate patient-centered care.

"Do Their Own Thing": Radical Health Care and the Fair Haven Community Health Center.

Radical health reform movements of the 1960s inspired two widely adopted alternative health care models in the United States: free clinics and community health centers. These groundbreaking institutions attempted to realize bold ideals but faced financial, bureaucratic, and political obstacles. This article examines the history of Fair Haven Community Health Care (FHCHC) in New Haven, Connecticut, an organization that spanned both models and typified innovative aspects of each while resisting the forces that tempered many of its contemporaries' progressive practices. Motivated by a tradition of independence and struggling to address medical neglect in their neighborhood, FHCHC leaders chose not to affiliate with the local academic hospital, a decision that led many disaffected community members to embrace the clinic. The FHCHC also prioritized grant funding over fee-for-service revenue, thus retaining freedom to implement creative programs. Furthermore, the center functioned in an egalitarian manner, enthusiastically employing nurse practitioners and whole-staff meetings, and was largely able to avoid the conflicts that strained other community-controlled organizations. The FHCHC proved unusual among free clinics and health centers and demonstrated strategies similar institutions might employ to overcome common challenges. (Am J Public Health. 2021;111(10): 1806-1814. https://doi.org/10.2105/AJPH.2021.306417).

Patterns of Usage of Complementary and Alternative Medicine Among Adults Visiting Health Care Centers in Mysuru, India: A Questionnaire-Based Survey.

The study intended to assess extent of complementary and alternative medicine use among patients visiting health care facilities in Mysuru, India, and factors influencing its choice. Prevalence of complementary and alternative medicine use was 33% and was not influenced by sociodemographic factors and individual health perceptions and habits.

Standing Tall: Leadership Reflections from the Community Health Center Frontlines.

Community health centers have withstood adversity for several decades. As health-care systems seek to reverse health inequities experienced by Black, Indigenous, and People of Color (BIPOC), learnings from community health centers demonstrate tangible ways to improve access and health for all. During the COVID-19 pandemic many community health centers have engaged in innovations in services to build on trust and to reach community members with testing and other needed services. Lessons around leading these efforts could support systemic change in the health-care system.

Effectiveness of a Decentralized Hub and Spoke Model for the Treatment of Hepatitis C Virus in a Federally Qualified Health Center.

Hepatitis C virus (HCV) is a major cause of cirrhosis, liver cancer, and mortality in the United States. We assessed the effectiveness of decentralized HCV treatment delivered by nurse practitioners (NPs), primary care physicians (PMDs), or an infectious disease physician (ID MD) using direct-acting antivirals in a Federally Qualified Health Center (FQHC) in urban San Diego, CA. We conducted a cross-sectional analysis of 1,261 patients who received treatment from six NPs, 10 PMDs, and one ID MD practicing in 10 clinics between January 2014 and January 2020. Care was delivered based on the Extension for Community Healthcare Outcomes (Project ECHO) model with one hub and nine spokes. HCV was deemed cured if a patient had a sustained virologic response (SVR) after 12 weeks of treatment (SVR12). We evaluated differences in the prevalence of cure between provider types and hub or spoke status using Poisson regression. Patients were 34% Latino, 16% black, 63% were aged >50 years, and 59% were homeless; 53% had advanced fibrosis, 69% had genotype 1, and 5% were coinfected with human immunodeficiency virus. A total of 943 patients achieved SVR12 (96% per protocol and 73% intention to treat). Even after adjustment for demographics, resources, and disease characteristics, the prevalence of cure did not differ between the ID MD and PMDs (prevalence ratio [PR], 1.00; 95% confidence interval [CI], 0.95-1.04) or NPs (PR, 1.01; 95% CI, 0.96-1.05). Similarly, there were no differences between the hub and spokes (PR, 1.01; 95% CI, 0.98-1.04). Conclusion: Among a low-income and majority homeless cohort of patients at urban FQHC clinics, HCV treatment administered by nonspecialist providers was not inferior to that provided by a specialist.

A National Study of Community Health Centers' Readiness to Address COVID-19.

BACKGROUND: The coronavirus disease 2019 (COVID-19) outbreak poses serious health risks, particularly for older adults and persons with underlying chronic medical conditions. Community health centers (CHCs) serve as the patient medical home for populations that are disproportionately more susceptible to COVID-19; yet, there is a lack of understanding of current efforts in place by CHCs to prepare for and respond to the pandemic. METHODS: We used a comprehensive cross-sectional survey and focus groups with health care personnel to understand the needs and current efforts in place by CHCs, and we derived themes from the focus group data. RESULTS: Survey respondents (n = 234; 19% response rate) identified COVID-19 infection prevention and control (76%), safety precautions (72%), and screening, diagnostic testing, and management of patients (66%) as major educational needs. Focus group findings (n = 39) highlighted 5 key themes relevant to readiness: leadership, resources, workforce capacity, communication, and formal policies and procedures. CONCLUSION: The COVID-19 pandemic has exacerbated long-standing CHC capacity issues making it challenging for them to adequately respond to the outbreak. Policies promoting greater investment in CHCs may strengthen them to better meet the needs of the most vulnerable members of society, and thereby help flatten the curve.

Optimal staffing in community health centers to improve quality of care.

OBJECTIVE: To explore optimal workforce configurations in the production of care quality in community health centers (CHCs), accounting for interactions among occupational categories, as well as contributions to the volume of services. DATA SOURCES: We linked the Uniform Data System from 2014 to 2016 with Internal Revenue Service nonprofit tax return data. The final database contained 3139 center-year observations from 1178 CHCs. STUDY DESIGN: We estimated a system of two generalized linear production functions, with quality of care and volume of services as outputs, using the average percent of diabetic patients with controlled A1C level and hypertensive patients with controlled blood pressure as quality measures. To explore the substitutability and complementarity between staffing categories, we estimated a revenue function. FINDINGS: Primary care physicians and advanced practice clinicians achieve similar quality outcomes (3.2 percent and 3.0 percent improvement in chronic condition management per full-time equivalent (FTE), respectively). Advanced practice clinicians generate less revenue per FTE but are generally less costly to employ. CONCLUSION: As quality incentives are further integrated into payment systems, CHCs will need to optimize their workforce configuration to improve quality. Given the relative efficiency of advanced practice clinicians in producing quality, further hiring of these professionals is a cost-effective investment for CHCs.

A Practice-Based Research Network (PBRN) Roadmap for Evaluating COVID-19 in Community Health Centers: A Report From the OCHIN PBRN.

BACKGROUND: Primary care practice-based research networks (PBRNs) are critical laboratories for generating evidence from real-world settings, including studying natural experiments. Primary care's response to the novel coronavirus-19 (COVID-19) pandemic is arguably the most impactful natural experiment in our lifetime. EVALUATING THE IMPACT OF COVID-19: We briefly describe the OCHIN PBRN of community health centers (CHCs), its partnership with implementation scientists, and how we are leveraging this infrastructure and expertise to create a rapid research response evaluating how CHCs across the country responded to the COVID-19 pandemic. COVID-19 RESEARCH ROADMAP: Our research agenda focuses on asking: How has care delivery in CHCs changed due to COVID-19? What impact has COVID-19 had on the delivery of preventive services in CHCs? Which PBRN services (e.g., data surveillance, training, evidence synthesis) are most impactful to real-world practices? What decision-making strategies were used in the PBRN and its practices to make real-time changes in response to the pandemic? What critical factors in successfully and sustainably transforming primary care are illuminated by pandemic-driven changes? DISCUSSION AND CONCLUSIONS: PBRNs enable real-world evaluation of practice change and natural experiments, and thus are ideal laboratories for implementation science research. We present a real-time example of how a PBRN Implementation Laboratory activated a response to study a historic natural experiment, to help other PBRNs charting a course through this pandemic.

Real world experience of poly (ADP-ribose) polymerase inhibitor use in a community oncology practice.

OBJECTIVE: This study aims to describe the real-world experience, including the clinical and financial burden, associated with PARP inhibitors in a large community oncology practice. METHODS: Retrospective chart review identified patients prescribed olaparib, niraparib or rucaparib for maintenance therapy or treatment of recurrent ovarian, primary peritoneal or fallopian tube cancer across twelve gynecologic oncologists between December 2016 and November 2018. Demographic, financial and clinical data were extracted. One PARP cycle was defined as a single 28-day period. For patients treated with more than one PARPi, each course was described separately. RESULTS: A total of 47 patients and 506 PARP cycles were identified (122 olaparib, 24%; 89 rucaparib, 18%; 294 niraparib, 58%). Incidence of grade ≥ 3 adverse events were similar to previously reported. Toxicity resulted in dose interruption, reduction and discontinuation in 69%, 63% and 29% respectively. Dose interruptions were most frequent for niraparib but resulted in fewer discontinuations (p-value 0.01). Mean duration of use was 7.46 cycles (olaparib 10.52, rucaparib 4.68, niraparib 7.34). Average cost of PARPi therapy was $8018 per cycle. A total of 711 phone calls were documented (call rate 1.4 calls/cycle) with the highest call volume required for care coordination, lab results and toxicity management. CONCLUSIONS: Although the toxicity profile was similar to randomized clinical trials, this real-world experience demonstrated more dose modifications and discontinuations for toxicity management than previously reported. Furthermore, the clinical and financial burden of PARP inhibitors may be significant and future studies should assess the impact on patient outcomes.

[welcome to the Château]. / Bienvenue au Château !

Le Château en santé is a community health center in Marseille (13), which has some cousins in France and soon new ones. Its multi-professional medical and social team welcomes residents from surrounding areas. The fight against inequalities in access to care, which are particularly affected people with complex administrative situations is one of his fight.

Patient-perceived service needs and health care utilization in people with type 2 diabetes: A multicenter cross-sectional study.

The aim of this study was to investigate service needs and health care utilization among people with type 2 diabetes, further to identify the relationship between service needs and health care utilization.We used a self-reported questionnaire to collect data regarding demographic and diabetes characteristics, service needs toward self-management and follow-up care, and 4 health care utilizations during past year. Multiple linear regression and binary logistic regression were used to test the impacts of demographic and diabetes characteristics on service needs and health care utilizations, respectively. Spearman rank correlations were used to explore correlation between service needs and health care utilization.We recruited 1796 participants with type 2 diabetes from 20 community health centers across 12 cities of Sichuan Province in China. Needs of self-management and follow-up had significant positive correlations with health care utilization. Participants rated that nutrition was the most needed aspects of self-management (78.5%), and out-patient visit was the most popular type of follow-up (66.8%). Educational level and treatment modality were predictors of self-management needs. Low educational level (elementary school or blow, ß = 0.11, P = .008; middle school, ß = 0.10, P = .015) and insulin treatment (ß = 0.08, P = .007) were positive factors of self-management needs. Younger age (age < 45 years old, ß = 0.07, P = .046), being employed (ß = 0.14, P < .001), and underdeveloped region (ß = 0.16, P < .001) were positive factors of follow-up care needs. Elementary educational level (OR: 0.53; CI: 0.30-0.96) and underdevelopment region (OR: 0.01; CI: 0.01-0.07) were protective factors of general practitioner visit, in contrast, those factors were risk factors of specialist visit (elementary educational level, OR: 1.69; CI: 1.13-2.5; underdevelopment region, OR: 2.93; CI: 2.06-4.16) and emergency room visit (elementary educational level, OR: 2.97; CI: 1.09, 8.08; underdevelopment region, OR: 6.83; CI: 2.37-14.65).The significant positive relationship between service needs and health care utilization demonstrated the role of service needs in influencing health care utilization. When self-management education is provided, age, educational level, employment status, treatment modality, and region should be considered to offer more appropriate education and to improve health care utilization.

Fitting Community-Centered Population Health (CCPH) Into the Existing Health Care Delivery Patchwork: The Politics of CCPH.

The COVID-19 crisis has nakedly exposed the problems and huge holes in the health care system of the United States. For today, we need to address the current pandemic from the point of view of both control and suppression. But such efforts could also provide insights into a post-pandemic restructuring of health care. If one or several states succeed in addressing the COVID pandemic together with an associated modest economic resurgence, citizens could develop the trust in state leadership necessary to finally make fundamental changes in our health care system. Such change is a once in a century opportunity.

COVID-19 Crisis Creates Opportunities for Community-Centered Population Health: Community Health Workers at the Center.

Dealing with the COVID-19 coronavirus requires a coordinated transnational effort. We propose a 2-stage state-led effort that utilizes community health workers (CHWs). We spell out what is beginning to occur in states to control and suppress COVID-19. In the second stage, we suggest working with these CHWs as a key element in the next evolution of our health care system: community-centered population health.

Implementation and adoption of a health insurance support tool in the electronic health record: a mixed methods analysis within a randomized trial.

BACKGROUND: In addition to delivering vital health care to millions of patients in the United States, community health centers (CHCs) provide needed health insurance outreach and enrollment support to their communities. We developed a health insurance enrollment tracking tool integrated within the electronic health record (EHR) and conducted a hybrid implementation-effectiveness trial in a CHC-based research network to assess tool adoption using two implementation strategies. METHODS: CHCs were recruited from the OCHIN practice-based research network. Seven health center systems (23 CHC clinic sites) were recruited and randomized to receive basic educational materials alone (Arm 1), or these materials plus facilitation (Arm 2) during the 18-month study period, September 2016-April 2018. Facilitation consisted of monthly contacts with clinic staff and utilized audit and feedback and guided improvement cycles. We measured total and monthly tool utilization from the EHR. We conducted structured interviews of CHC staff to assess factors associated with tool utilization. Qualitative data were analyzed using an immersion-crystallization approach with barriers and facilitators identified using the Consolidated Framework for Implementation Research. RESULTS: The majority of CHCs in both study arms adopted the enrollment tool. The rate of tool utilization was, on average, higher in Arm 2 compared to Arm 1 (20.0% versus 4.7%, p < 0.01). However, by the end of the study period, the rate of tool utilization was similar in both arms; and observed between-arm differences in tool utilization were largely driven by a single, large health center in Arm 2. Perceived relative advantage of the tool was the key factor identified by clinic staff as driving tool utilization. Implementation climate and leadership engagement were also associated with tool utilization. CONCLUSIONS: Using basic education materials and low-intensity facilitation, CHCs quickly adopted an EHR-based tool to support critical outreach and enrollment activities aimed at improving access to health insurance in their communities. Though facilitation carried some benefit, a CHC's perceived relative advantage of the tool was the primary driver of decisions to implement the tool. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02355262, Posted February 4, 2015.

From Alma-Ata to Astana: the path of Primary Health Care in Portugal, 1978-2018 and the genesis of Family Medicine. / De Alma-Ata a Astana: o percurso dos Cuidados de Saúde Primários em Portugal,1978-2018 e a génese da Medicina Familiar.

Throughout the twentieth century, the profound changes that have taken place in Medicine can only be wholly explained if observed from a historical perspective, for they have always occurred in response to external influences, some scientific and technological, others of a social nature. Modern Family Medicine is one of the many new disciplines that have developed during medical history, and we critically discuss the last 40 years of primary health care in Portugal, which started in 1971, long before the Alma-Ata Declaration (1978). Along the way, in 2005, the Primary Health Care Reform emerges in Portugal, along with the new family health facilities, which until September 2019, attended about 94 % of Portuguese citizens, i.e., 9,5 million people. At the end of this course, in solidarity and voluntarily, this Reform inspired another one in Brazil, in Rio de Janeiro, in 2009. Finally, we present the challenges pointed out in the 2018 Astana Declaration, among them, the issue of the workforce in primary health care as an essential factor for the performance and sustainability of health systems.

Ao longo século XX, as profundas alterações que ocorreram na Medicina apenas podem ser completamente esclarecidas se forem observadas numa perspectiva histórica, pois elas sempre ocorreram em resposta a influências externas, umas científicas e tecnológicas, outras de ordem social. A moderna Medicina Familiar é uma das muitas disciplinas novas que se desenvolveram durante o curso da história da Medicina e aqui debatemos de forma crítica, os últimos 40 anos dos cuidados primários em saúde em Portugal, começando em 1971, mesmo antes da Declaração de Alma-Ata (1978). Ao longo do percurso, em 2005, surge a Reforma dos Cuidados Primários em Saúde em Portugal e as novas unidades de saúde familiar, que até setembro de 2019 atendiam cerca de 94% dos cidadãos portugueses, ou seja, mais de nove milhões e meio de pessoas. No final dessa trajetória, de forma solidária e voluntária, esta Reforma serviu de inspiração para outra, no Brasil, na cidade do Rio de Janeiro, em 2009. Por fim, apresentamos os desafios apontados na Declaração de Astana de 2018, dentre elas, a questão da força de trabalho nos cuidados de saúde primários, como fator essencial para o desempenho e a sustentabilidade dos sistemas de saúde.

De Alma-Ata a Astana: o percurso dos Cuidados de Saúde Primários em Portugal, 1978-2018 e a génese da Medicina Familiar / From Alma-Ata to Astana: the path of Primary Health Care in Portugal, 1978-2018 and the genesis of Family Medicine

Resumo Ao longo século XX, as profundas alterações que ocorreram na Medicina apenas podem ser completamente esclarecidas se forem observadas numa perspectiva histórica, pois elas sempre ocorreram em resposta a influências externas, umas científicas e tecnológicas, outras de ordem social. A moderna Medicina Familiar é uma das muitas disciplinas novas que se desenvolveram durante o curso da história da Medicina e aqui debatemos de forma crítica, os últimos 40 anos dos cuidados primários em saúde em Portugal, começando em 1971, mesmo antes da Declaração de Alma-Ata (1978). Ao longo do percurso, em 2005, surge a Reforma dos Cuidados Primários em Saúde em Portugal e as novas unidades de saúde familiar, que até setembro de 2019 atendiam cerca de 94% dos cidadãos portugueses, ou seja, mais de nove milhões e meio de pessoas. No final dessa trajetória, de forma solidária e voluntária, esta Reforma serviu de inspiração para outra, no Brasil, na cidade do Rio de Janeiro, em 2009. Por fim, apresentamos os desafios apontados na Declaração de Astana de 2018, dentre elas, a questão da força de trabalho nos cuidados de saúde primários, como fator essencial para o desempenho e a sustentabilidade dos sistemas de saúde.

Abstract Throughout the twentieth century, the profound changes that have taken place in Medicine can only be wholly explained if observed from a historical perspective, for they have always occurred in response to external influences, some scientific and technological, others of a social nature. Modern Family Medicine is one of the many new disciplines that have developed during medical history, and we critically discuss the last 40 years of primary health care in Portugal, which started in 1971, long before the Alma-Ata Declaration (1978). Along the way, in 2005, the Primary Health Care Reform emerges in Portugal, along with the new family health facilities, which until September 2019, attended about 94 % of Portuguese citizens, i.e., 9,5 million people. At the end of this course, in solidarity and voluntarily, this Reform inspired another one in Brazil, in Rio de Janeiro, in 2009. Finally, we present the challenges pointed out in the 2018 Astana Declaration, among them, the issue of the workforce in primary health care as an essential factor for the performance and sustainability of health systems.

Unmet information needs of clinical teams delivering care to complex patients and design strategies to address those needs.

OBJECTIVES: To identify the unmet information needs of clinical teams delivering care to patients with complex medical, social, and economic needs; and to propose principles for redesigning electronic health records (EHR) to address these needs. MATERIALS AND METHODS: In this observational study, we interviewed and observed care teams in 9 community health centers in Oregon and Washington to understand their use of the EHR when caring for patients with complex medical and socioeconomic needs. Data were analyzed using a comparative approach to identify EHR users' information needs, which were then used to produce EHR design principles. RESULTS: Analyses of > 300 hours of observations and 51 interviews identified 4 major categories of information needs related to: consistency of social determinants of health (SDH) documentation; SDH information prioritization and changes to this prioritization; initiation and follow-up of community resource referrals; and timely communication of SDH information. Within these categories were 10 unmet information needs to be addressed by EHR designers. We propose the following EHR design principles to address these needs: enhance the flexibility of EHR documentation workflows; expand the ability to exchange information within teams and between systems; balance innovation and standardization of health information technology systems; organize and simplify information displays; and prioritize and reduce information. CONCLUSION: Developing EHR tools that are simple, accessible, easy to use, and able to be updated by a range of professionals is critical. The identified information needs and design principles should inform developers and implementers working in community health centers and other settings where complex patients receive care.

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.