A Framework for Applying Global Learning to Improve Primary Health Care in the United States.

Background and objectives: Lessons from global health have long informed efforts to improve primary health care (PHC) in the United States (US). Despite this history, no generalizable framework exists to guide US stakeholders in the identification and application of ideas from abroad related to the key PHC components of community engagement and service delivery. We sought to develop such a framework. Methods: We reviewed the experience of Global to Local, a community-based organization (CBO) founded with a mission to apply global health strategies to improve the health in vulnerable populations in the US, and examined the experience of care delivery organizations in the US that have successfully implemented global-to-local solutions. Based on that experience, and supported by the advice of an expert panel, we developed a framework for applying global learning to improve US PHC. Findings: The framework includes six change concepts under three broad categories. The first category focuses on the need to actively and intentionally incorporate a global perspective in organizational program design and improvement activities. The second category addresses approaches to identifying global solutions related to community engagement and to health service delivery. The third category focuses on adaptation and implementation of lessons from global health in domestic contexts by applying relevant insights from dissemination and implementation science and diffusion of innovation theory. Conclusions: In the absence of a robust literature providing implementation guidance to US health systems and CBOs open to adopting or adapting PHC strategies and practices from other countries, the proposed framework synthesizing the experience of organizations that have done so can inform efforts to apply lessons from global health to improve PHC in the US.

Patient navigation for hereditary colorectal cancer: Design of a randomized controlled trial to determine the effectiveness of pathways to genetic counseling.

BACKGROUND: Diagnosis of Lynch and other hereditary colorectal cancer (CRC) syndromes through germline genetic testing has important implications for treatment and risk-management, yet guideline-recommended genetic counseling referral and attendance is suboptimal. METHODS: Our team developed an adapted patient navigation program-Pathways to Genetic Counseling-to address multilevel barriers to genetic counseling referral and receipt. This paper describes the methods of a randomized controlled trial (RCT) testing Pathways to Genetic Counseling's effectiveness at increasing genetic counseling attendance in the University of Washington Medicine health system. We will identify CRC patients eligible for genetic counseling (diagnosed before age 50 or at any age with evidence of inherited mismatch repair deficiency) through a combination of structured electronic health record queries and manual chart review. Patients will be randomized 1:1 prior to consent and receive either care as usual (no contact) or be invited to participate in patient navigation. We will use chart review to compare rates of genetic counseling referral and attendance within six months of randomization, regardless of patients' engagement with navigation. We plan to identify and randomize 161 eligible CRC patients over a nine-month period beginning in late 2021. DISCUSSION: Our pragmatic RCT design will provide real-world data on the potential for patient navigation to address longstanding care gaps in preventive genomic medicine. If effective, we hope to pilot Pathways to Genetic Counseling in additional settings with a long-term goal of improving appropriate diagnosis of hereditary CRC syndromes and subsequent cascade screening of eligible family members.