Effect of Enhanced Primary Care for People with Serious Mental Illness on Service Use and Screening.

BACKGROUND: Strategies are needed to better address the physical health needs of people with serious mental illness (SMI). Enhanced primary care for people with SMI has the potential to improve care of people with SMI, but evidence is lacking. OBJECTIVE: To examine the effect of a novel enhanced primary care model for people with SMI on service use and screening. DESIGN: Using North Carolina Medicaid claims data, we performed a retrospective cohort analysis comparing healthcare use and screening receipt of people with SMI newly receiving enhanced primary care to people with SMI newly receiving usual primary care. We used inverse probability of treatment weighting to estimate average differences in outcomes between the treatment and comparison groups adjusting for observed baseline characteristics. PARTICIPANTS: People with SMI newly receiving primary care in North Carolina. INTERVENTIONS: Enhanced primary care that includes features tailored for individuals with SMI. MAIN MEASURES: Outcome measures included outpatient visits, emergency department (ED) visits, inpatient stays and days, and recommended screenings 18 months after the initial primary care visit. KEY RESULTS: Compared to usual primary care, enhanced primary care was associated with an increase of 1.2 primary care visits (95% confidence interval [CI]: 0.31 to 2.1) in the 18 months after the initial visit and decreases of 0.33 non-psychiatric inpatient stays (CI: - 0.49 to - 0.16) and 3.0 non-psychiatric inpatient days (CI: - 5.3 to - 0.60). Enhanced primary care had no significant effect on psychiatric service and ED use. Enhanced primary care increased the probability of glucose and HIV screening, decreased the probability of lipid screening, and had no effect on hemoglobin A1c and colorectal cancer screening. CONCLUSIONS: Enhanced primary care for people with SMI can increase receipt of some preventive screening and decrease use of non-psychiatric inpatient care compared to usual primary care.

Acute Crisis Care for Patients with Mental Health Crises: Initial Assessment of an Innovative Prehospital Alternative Destination Program in North Carolina.

OBJECTIVE: Emergency Departments (ED) are overburdened with patients experiencing acute mental health crises. Pre-hospital transport by Emergency Medical Services (EMS) to community mental health and substance abuse treatment facilities could reduce ED utilization and costs. Our objective was to describe characteristics, treatment, and outcomes of acute mental health crises patients who were transported by EMS to an acute crisis unit at WakeBrook, a North Carolina community mental health center. METHODS: We performed a retrospective cohort study of patients diverted to WakeBrook by EMS from August 2013-July 2014. We abstracted data from WakeBrook medical records and used descriptive statistics to quantify patient characteristics, diagnoses, length of stay (LOS), and 30-day recidivism. RESULTS: A total of 226 EMS patients were triaged at WakeBrook. The median age was 38 years, 55% were male, 58% were white, and 38% were uninsured. The most common chief complaints were suicidal ideation or self-harm (46%) and substance abuse (19%). The most common diagnoses were substance-related and addictive disorders (42%), depressive disorders (32%), and schizophrenia spectrum and other psychotic disorders (22%). Following initial evaluation, 28% of patients were admitted to facilities within WakeBrook, 40% were admitted to external psychiatric facilities, 18% were stabilized and discharged home, 5% were transferred to an ED within 4 hours for further medical evaluation, and 5% refused services. The median LOS at WakeBrook prior to disposition was 12.0 hours (IQR 5.4-21.6). Over a 30-day follow-up period, 60 patients (27%) had a return visit to the ED or WakeBrook for a mental health issue. CONCLUSIONS: A dedicated community mental health center is able to treat patients experiencing acute mental health crises. LOS times were significantly shorter compared to regional EDs. Successful broader programmatic implementation could improve care quality and significantly reduce the volume of patients treated in the ED for acute mental health disorders.

A Model of Enhanced Primary Care for Patients with Severe Mental Illness.

Life expectancy and other outcomes for patients with serious mental illness (SMI) are unacceptably poor, largely due to a high prevalence of poorly controlled chronic diseases, high rates of tobacco use, and low rates of preventive care services. Since many of these illnesses are effectively treated in primary care settings, integrating primary care with behavioral health care is necessary to narrow health disparities for patients with SMI.

The Community Preceptor Crisis: Recruiting and Retaining Community-Based Faculty to Teach Medical Students-A Shared Perspective From the Alliance for Clinical Education.

ISSUE: Community-based instruction is invaluable to medical students, as it provides "real-world" opportunities for observing and following patients over time while refining history taking, physical examination, differential diagnosis, and patient management skills. Community-based ambulatory settings can be more conducive to practicing these skills than highly specialized, academically based practice sites. The Association of American Medical Colleges and other national medical education organizations have expressed concern about recruitment and retention of preceptors to provide high-quality educational experiences in community-based practice sites. These concerns stem from constraints imposed by documentation in electronic health records; perceptions that student mentoring is burdensome resulting in decreased clinical productivity; and competition between allopathic, osteopathic, and international medical schools for finite resources for medical student experiences. EVIDENCE: In this Alliance for Clinical Education position statement, we provide a consensus summary of representatives from national medical education organizations in 8 specialties that offer clinical clerkships. We describe the current challenges in providing medical students with adequate community-based instruction and propose potential solutions. IMPLICATIONS: Our recommendations are designed to assist clerkship directors and medical school leaders overcome current challenges and ensure high-quality, community-based clinical learning opportunities for all students. They include suggesting ways to orient community clinic sites for students, explaining how students can add value to the preceptor's practice, focusing on educator skills development, recognizing preceptors who excel in their role as educators, and suggesting forms of compensation.

Enhanced Primary Care for People With Serious Mental Illness: A Propensity Weighted Cohort Study.

Objective: People with serious mental illness (SMI) have high rates of cardiometabolic illness, receive low quality care, and experience poor outcomes. Nevertheless, studies of existing integrated care models have not consistently shown improvements in cardiometabolic health for people with SMI. This study assessed the effect of a novel model of enhanced primary care for people with SMI on cardiometabolic outcomes. Enhanced primary care is a model of integrated care wherein comprehensive primary care delivery is adapted to the needs of people with SMI in coordination with behavioral care.Methods: We conducted a propensity-weighted cohort study comparing 234 patients with SMI receiving enhanced primary care to 4,934 patients with SMI receiving usual primary care using electronic health data from a large academic medical system covering the years 2014-2018. The propensity-weighted models controlled for baseline differences in outcome measures and patient characteristics between groups.Results: Compared to usual primary care, enhanced primary care increased hemoglobin A1c (HbA1c) screening by 18 percentage points (95% confidence interval [CI], 10 to 25), low-density lipoprotein (LDL) screening by 16 percentage points (CI, 8.8 to 24), and blood pressure screening by 7.8 percentage points (CI, 5.8 to 9.9). Enhanced primary care reduced HbA1c by 0.27 percentage points (CI, -0.47 to -0.060) and systolic blood pressure by 3.9 mm Hg (CI, -5.2 to -2.5) compared to usual primary care. We did not find evidence that enhanced primary care consistently affected glucose screening, LDL values, or diastolic blood pressure.Conclusions: Enhanced primary care can achieve clinically meaningful improvements in cardiometabolic health compared to usual primary care.

Medication documentation in a primary care network serving North Carolina medicaid patients: results of a cross-sectional chart review.

BACKGROUND: Medical records that do not accurately reflect the patient's current medication list are an open invitation to errors and may compromise patient safety. METHODS: This cross-sectional study compares primary care provider (PCP) medication lists and pharmacy claims for 100 patients seen in 8 primary care practices and examines the association of congruence with demographic, clinical, and practice characteristics. Medication list congruence was measured as agreement of pharmacy claims with the entire PCP chart, including current medication list, visit notes, and correspondence sections. RESULTS: Congruence between pharmacy claims and the PCP chart was 65%. Congruence was associated with large chronic disease burden, frequent PCP visits, group practice, and patient age ≥45 years. CONCLUSION: Agreement of medication lists between the PCP chart and pharmacy records is low. Medication documentation was more accurate among patients who have more chronic conditions, those who have frequent PCP visits, those whose practice has multiple providers, and those at least 45 years of age. Improved congruence among patients with multiple chronic conditions and in group practices may reflect more frequent visits and reviews by providers.

The North Carolina Community Preceptor Experience: Third Study of Trends Over 12 Years.

PURPOSE: To measure community-based preceptors' overall satisfaction and motivations, the influence of students on preceptors' practices, and compare with 2005 and 2011 studies. METHOD: North Carolina primary care preceptors across disciplines (physicians, pharmacists, advanced practice nurses, physician assistants) received survey invitations via e-mail, fax, postcard, and/or full paper survey. Most questions in 2017 were the same as questions used in prior years, including satisfaction with precepting, likelihood to continue precepting, perceived influence of teaching students in their practice, and incentives for precepting. A brief survey or phone interview was conducted with 62 nonresponders. Chi-square tests were used to examine differences across discipline groups and to compare group responses over time. RESULTS: Of the 2,786 preceptors contacted, 893 (32.1%) completed questionnaires. Satisfaction (816/890; 91.7%) and likelihood of continuing to precept (778/890; 87.4%) remained unchanged from 2005 and 2011. However, more preceptors reported a negative influence for patient flow (422/888; 47.5%) in 2017 than in 2011 (452/1,266; 35.7%) and 2005 (496/1,379; 36.0%) (P < .0001), and work hours (392/889; 44.1%) in 2017 than in 2011 (416/1,268; 32.8%) and 2005 (463/1,392; 33.3%) (P < .0001). Importance of receiving payment for teaching increased from 32.2% (371/1,152) in 2011 to 46.4% (366/789) in 2017 (P < .0001). CONCLUSIONS: This 2017 survey suggests preceptor satisfaction and likelihood to continue precepting have remained unchanged from prior years. However, increased reporting of negative influence of students on practice and growing value of receiving payment highlight growing concerns about preceptors' time and finances and present a call to action.

Community care of North Carolina: improving care through community health networks.

The United States leads the world in health care costs but ranks far below many developed countries in health outcomes. Finding ways to narrow this gap remains elusive. This article describes the response of one state to establish community health networks to achieve quality, utilization, and cost objectives for the care of its Medicaid recipients. The program, known as Community Care of North Carolina, is an innovative effort organized and operated by practicing community physicians. In partnership with hospitals, health departments, and departments of social services, these community networks have improved quality and reduced cost since their inception a decade ago. The program is now saving the State of North Carolina at least $160 million annually. A description of this experience and the lessons learned from it can inform others seeking to implement effective systems of care for patients with chronic illness.

Cardiometabolic Assessment, Diagnosis, and Treatment of Chronic Medical Illnesses During an Inpatient Psychiatric Hospitalization: Colocated Medical Care Versus Treatment as Usual.

BACKGROUND: Reverse colocation care models reduce lifestyle risk factors, emergency department visits, and readmissions. Persons with serious mental illness have higher than average rates of cardiovascular disease-related morbidity and mortality, with second-generation antipsychotics (SGAs) conferring added related risks. Little is written about reverse colocated medical care (RCL) in inpatient psychiatric settings. The objective of this study was to identify associations between screening, diagnosis, and treatment of chronic medical comorbidities and mode of medical care for patients discharged from 2 inpatient psychiatric units on SGAs. METHODS: This was a cross-sectional retrospective study of medical comorbidities identified and treated for adults consecutively admitted from January 1, 2015, to October 31, 2015, to 2 inpatient psychiatry units of an academic center and discharged on SGAs. One unit has a primary care team consisting of a physician assistant backed up by a medical doctor who provide medical care (RCL). The other unit has medical care provided by psychiatrists with hospitalists as needed (treatment as usual, TAU). We conducted a chart review of demographics, vital signs, laboratory values, diagnoses, and medications with comparative analysis of the evaluation, diagnosis, and treatment for hypertension, diabetes mellitus, hyperlipidemia, obesity, and tobacco use disorder. RESULTS: In total, 232 patients were discharged from the TAU group and 220 from the RCL group. Significantly more screening laboratory values (glucose, hemoglobin A1c, lipids) were obtained in the TAU group, while documented responses to abnormal tests were higher in the RCL group. Patients were more likely in the RCL group to be diagnosed with obesity, tobacco use disorder, and hyperlipidemia and to be treated for hypertension and hyperlipidemia. CONCLUSIONS: Reverse colocated medical care is effective in improving screening, diagnosis, and treatment of chronic medical diseases among psychiatric inpatients.​.

Recognizing the value of community involvement by AHC faculty: a case study.

Physicians seek connections to their communities. Some health care and academic leaders believe that facilitating the creation of more such community connections is one way to reverse the trend of waning social and political legitimacy for the U.S. medical profession. For academic health centers (AHCs), such connections can maintain local and state support crucial to their long-term success. Multiple barriers exist to such involvement, especially for physicians in AHCs, where work done beyond direct patient care, administration, and research rarely contributes to the tenure and promotion process. The authors present a case study to show how one department in an AHC, beginning in the late 1990s, has been overcoming these barriers to incorporate the scholarship of community engagement into its mission and structure. The case study incorporates theoretical underpinnings to crystallize the following lessons that the department has learned so far: (1) If academic departments wish community service to be a central part of their mission, they need ways to institutionalize community engagement within organizational structures. (2) Community engagement can be scholarly. (3) If faculty members are to be recognized for their service activities, measures are necessary to determine what constitutes "excellence" and "scholarship" in community service. (4) Scholarship of community engagement goes beyond performing service activities in the community.

Attitudes and Approaches of Influential Role Models in Clinical Education.

The influence of a role model is a frequently cited factor in choosing a specialty choice among medical students, particularly primary care oriented students. While many studies have looked at role modeling from students' perspectives, very few have considered role modeling characteristics from the perspective of the role models. This study, using the principles of Bandura's social learning theory, determined and illuminated the characteristics and teaching methods associated with positive role modeling in clinical education from the perspective of the role model. A qualitative approach employing interviews and observations was used. Five themes emerged: the role models' approaches to teaching, their attitudes towards teaching and learning, their emphasis on clinical competence in their teaching, their roles external to their specific responsibilities, and their general affect. We found that role models were similar in their views of teaching and working with students. Also, their teaching characteristics were similar to the recommended approaches found in the literature and adhered to the principles of social learning theory. Role models were attentive to the needs of the students and tailored their teaching appropriately. They provided students with ample patient interaction so that students could apply their classroom knowledge. They also demonstrated how rewarding being an effective physician can be.

STFM's National Clerkship Curriculum: CERA reveals impact, clerkship director needs.

BACKGROUND AND OBJECTIVES: Consistency is needed in family medicine clerkships nationwide. The Society of Teachers of Family Medicine's (STFM) National Clerkship Curriculum (NCC) and supporting NCC website have been developed to address this need. A survey was used to measure these tools' effect and guide future improvements. METHODS: The Council of Academic Family Medicine's (CAFM) Educational Research Alliance (CERA) 2012 survey of clerkship directors (CD) was used to answer two research questions: (1) To what extent are clerkships teaching the minimum core curriculum? and (2) What resources do clerkship directors identify as important in their role? RESULTS: The survey response rate was 66% (88/134). Ninety-two percent of these CDs are aware of the NCC, 74% report having visited the NCC website, and 71% plan to visit it more than once per year in the future. A total of 21.6% strongly agree that their clerkship content matches the NCC. CDs rate the quality of materials on the website as high and place greatest value on materials that can be downloaded and adapted to their clerkships. CONCLUSIONS: STFM's NCC website and materials are familiar to CDs although only one in five state their clerkship curriculum matches the NCC minimum core curriculum. The NCC editorial board needs to better understand why so few teach curriculum that closely matches the minimum core. Continued outreach to CDs can answer this question and improve our ability to support CDs as they incorporate the NCC into family medicine clerkships.

Academic health centers and community health centers partnering to build a system of care for vulnerable patients: lessons from Carolina Health Net.

Academic health centers (AHCs) are challenged to meet their core missions in a time of strain on the health care system from rising costs, an aging population, increased rates of chronic disease, and growing numbers of uninsured patients. AHCs should be leaders in developing creative solutions to these challenges and training future leaders in new models of care. The authors present a case study describing the development, implementation, and early results of Carolina Health Net, a partnership between an AHC and a community health center to manage the most vulnerable uninsured by providing access to primary care medical homes and care management systems. This partnership was formed in 2008 to help transform the delivery of health care for the uninsured. As a result, 4,400 uninsured patients have been connected to primary care services. Emergency department use by enrolled patients has decreased. Patients have begun accessing subspecialty care within the medical home. More than 2,200 uninsured patients have been assisted to enroll in Medicaid. The experience of Carolina Health Net demonstrates that developing a system of care with primary care and wrap-around services such as pharmacy and case management can improve the cost-effectiveness and quality of care, thereby helping AHCs meet their broader missions. This project can serve as a model for other AHCs looking to partner with community-based providers to improve care and control costs for underserved populations.

Satisfaction, motivation, and future of community preceptors: what are the current trends?

PURPOSE: To measure overall satisfaction of community-based preceptors, their anticipated likelihood of continuing to teach, professional satisfaction, influence of having students, motivation for teaching, satisfaction with professional practice, and satisfaction with and value of incentives, and to compare results with those of a similar 2005 statewide survey. METHOD: In 2011, the authors distributed a 25-item survey to all 2,359 community-based primary care preceptors (physicians, pharmacists, advanced practice nurses, physician assistants) served by the North Carolina Area Health Education Centers system's Offices of Regional Primary Care Education. The survey targeted the same items and pool of eligible respondents as did the North Carolina Area Health Education Center 2005 Preceptor Survey. RESULTS: Of 2,359 preceptors contacted, 1,278 (54.2%) completed questionnaires. The data from 2011 did not differ significantly from the 2005 data. In 2011, respondents were satisfied with precepting (91.7%), anticipated continuing to precept for the next five years (88.7%), and were satisfied overall with their professional life (93.7%). Intrinsic reasons (e.g., enjoyment of teaching) remained an important motivation for teaching students. Physicians reported significantly lower overall satisfaction with extrinsic incentives (e.g., monetary compensation) and felt more negativity about the influence of students on their practices. CONCLUSIONS: This study found that preceptors continue to be satisfied with teaching students. Intrinsic reasons remain an important motivation to precept, but monetary compensation may have increasing importance. Physicians responded more negatively than other health provider groups to several questions, suggesting that their needs might be better met by redesigned teaching models.

Creating a multi-institutional family medicine clerkship examination: lessons learned.

BACKGROUND AND OBJECTIVES: Multiple choice examinations assess learners' attainment of medical knowledge. Developing multiple choice examinations that discriminate among learners is difficult and time-consuming. Many institutions avoid this effort by using the National Board of Medical Examiners (NBME) subject examinations, which can also provide comparisons to a national norm. The family medicine subject examination has been criticized, however, because the test's content does not reflect the learning expected during the clerkship. Additionally, the test results cannot guide clerkship directors sufficiently to help students study or to improve the curriculum. METHODS: Family medicine clerkships at three different institutions used a common 75-item examination based on the textbook Essentials of Family Medicine, Fifth Edition, for one academic year. Data were pooled and analyzed. The Raush Item Response Theory assessed student and item performance. RESULTS: A total of 451 students took the examination. Across the three schools: (1) item separations (Rasch) were high (8.64), indicating good spread in item difficulty, (2) person separations were lower (1.65), indicating that medical students are likely a relatively homogeneous group, (3) Rasch item reliabilities were strong (ranging from .96-.99), and (4) Rasch person reliabilities (.54-.73) were lower. True internal consistencies across items as measured by the Kuder-Richardson 20 (KR-20) reliabilities were just adequate at .71-.77. CONCLUSIONS: By pooling resources, clerkship directors can share the creation and implementation of a written examination that has acceptable reliability and greater face validity than the NBME subject examination. They also have more control over examination content and can guide students' learning and curriculum improvements more accurately.

International crises and global health electives: lessons for faculty and institutions.

Student participation in global health electives and community service initiatives is associated with a number of favorable outcomes, and student interest in participating in such experiences is high. Increasingly, medical schools are facilitating and supervising global health opportunities. The inherent risks and uncertainties of global community service deserve careful consideration as schools engage more actively in this area. This article presents how one institution managed three crises in three electives in a single year. The H1N1 flu epidemic impacted a group of students bound for Mexico, a political upheaval affected a student group working in Honduras, and a hurricane threatened a student group in Nicaragua. This article outlines lessons learned from responding to these crises. Well-defined institutional travel policies, clear communication plans in the event of an emergency, a responsible administrative entity for global experiences, and formal predeparture training for students and faculty can help institutions better respond to unpredictable events. A comprehensive examination of these lessons and reflections on how to institutionalize the various components may help other institutions prepare for such events and lessen negative impact on student learning.