Factors contributing to differences in cervical cancer screening in rural and urban community health centers.

INTRODUCTION: Community health centers (CHCs) provide historically marginalized populations with primary care, including cancer screening. Previous studies have reported that women living in rural areas are less likely to be up to date with cervical cancer screening than women living in urban areas. However, little is known about rural-urban differences in cervical cancer screening in CHCs and the contributing factors, and whether such differences changed during the COVID-19 pandemic. METHODS: Using 8-year pooled Uniform Data System (2014-2021) data and Oaxaca-Blinder decomposition, the extent to which CHC- and catchment area-level characteristics explained rural-urban differences in up-to-date cervical cancer screening was estimated. RESULTS: Up-to-date cervical cancer screening was lower in rural CHCs than urban CHCs (38.2% vs 43.0% during 2014-2019), and this difference increased during the pandemic (43.5% vs 49.0%). The rural-urban difference in cervical cancer screening in 2014-2019 was mostly explained by differences in CHC-level proportions of patients with limited English proficiency (55.9%) or income below the poverty level (12.3%) and females aged 21 to 64 years (9.8%), and catchment area-level's unemployment (3.4%) and primary care physician density (3.2%). However, Medicaid (-48.5%) or no insurance (-19.6%) counterbalanced the differences between rural-urban CHCs. The contribution of these factors to rural-urban differences in cervical cancer screening generally increased in 2020-2021. CONCLUSIONS: Rural-urban differences in cervical cancer screening were mostly explained by multiple CHC-level and catchment area-level characteristics. The findings call for tailored interventions, such as providing resources and language services, to improve cancer screening utilization among uninsured, Medicaid, and patients with limited English proficiency in rural CHCs.

A pragmatic randomized trial of mailed fecal immunochemical testing to increase colorectal cancer screening among low-income and minoritized populations.

BACKGROUND: Colorectal cancer (CRC) screening is underused, particularly among low-income and minoritized populations, for whom the coronavirus disease 2019 (COVID-19) pandemic has challenged progress in achieving equity. METHODS: A hub-and-spoke model was used. The hub was a nonacademic organization and the spokes were three community health center (CHC) systems overseeing numerous clinic sites. Via a cluster-randomized trial design, nine clinic sites were randomized to intervention and 16 clinic sites were randomized to usual care. Patient-level interventions included invitation letters, mailed fecal immunochemical tests (FITs), and call/text-based reminders. Year 1 intervention impact, which took place during the COVID-19 pandemic, was assessed as the proportion completing screening among individuals not up to date at baseline, which compared intervention and nonintervention clinics accounting for intraclinic cluster variation; confidence intervals (CIs) around differences not including 0 were interpreted as statistically significant. RESULTS: Among 26,736 patients who met eligibility criteria, approximately 58% were female, 55% were Hispanic individuals, and 44% were Spanish speaking. The proportion completing screening was 11.5 percentage points (ppts) (95% CI, 6.1-16.9 ppts) higher in intervention versus usual care clinics. Variation in differences between intervention and usual care clinics was observed by sex (12.6 ppts [95% CI, 7.2-18.0 ppts] for females; 8.8 ppts [95% CI, 4.7-13.9 ppts] for males) and by racial and ethnic group (13.8 ppts [95% CI, 7.0-20.6 ppts] for Hispanic individuals; 13.0 ppts [95% CI, 3.6-22.4 ppts] for Asian individuals; 11.3 ppts [95% CI, 5.8-16.8 ppts] for non-Hispanic White individuals; 6.1 ppts [95% CI, 0.8-10.4 ppts] for Black individuals). CONCLUSIONS: A regional mailed FIT intervention was effective for increasing CRC screening rates across CHC systems serving diverse, low-income populations.

Eye Care in Federally Qualified Health Centers.

PURPOSE: To assess changes in vision care availability at Federally Qualified Health Centers (FQHCs) between 2017 and 2021 and whether neighborhood-level demographic social risk factors (SRFs) associated with eye care services provided by FQHCs. DESIGN: Secondary data analysis of the Health Resources and Services Administration (HRSA) data and 2017-2021 American Community Survey (ACS). PARTICIPANTS: Federally Qualified Health Centers. METHODS: Patient and neighborhood characteristics for SRFs were summarized. Differences in FQHCs providing and not providing vision care were compared via Wilcoxon-Mann-Whitney tests for continuous measures and chi-square tests for categorical measures. Logistic regression models were used to test the associations between neighborhood measures and FQHCs providing vision care, adjusted for patient characteristics. MAIN OUTCOME MEASURES: Odds ratios (ORs) with 95% confidence intervals (CIs) for neighborhood-level predictors of FQHCs providing vision care services. RESULTS: Overall, 28.5% of FQHCs (n = 375/1318) provided vision care in 2017 versus 32% (n = 435/1362) in 2021 with some increases and decreases in both the number of FQHCs and those with and without vision services. Only 2.6% of people who accessed FQHC services received eye care in 2021. Among the 435 FQHCs that provided vision care in 2021, 27.1% (n = 118) had added vision services between 2017 and 2021, 71.5% (n = 311) had been offering vision services since at least 2017, and 1.4% (n = 6) were newly established. FQHCs providing vision care in 2021 were more likely to be in neighborhoods with a higher percentage of Hispanic/Latino individuals (OR, 1.08, 95% CI, 1.02-1.14, P = 0.0094), Medicaid-insured individuals (OR, 1.08, 95% CI, 1.02-1.14, P = 0.0120), and no car households (OR, 1.07, 95% CI, 1.01-1.13, P = 0.0142). However, FQHCs with vision care, compared to FQHCs without vision care, served a lower percentage of Hispanic/Latino individuals (27.2% vs. 33.9%, P = 0.0007), Medicaid-insured patients (42.8% vs. 46.8%, P < 0.0001), and patients living at or below 100% of the federal poverty line (61.3% vs. 66.3%, P < 0.0001). CONCLUSIONS: Vision care services are available at a few FQHCs, localized to a few states. Expanding eye care access at FQHCs would meet patients where they seek care to mitigate vision loss to underserved communities. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Bundling Colorectal Cancer Screening Outreach with Screening for Social Risk in Federally Qualified Health Centers: A Stepped-Wedge Implementation-Effectiveness Study.

BACKGROUND: Bundling is combining individual interventions to meet quality metrics. Bundling offers of cancer screening with screening for social determinants of health (SDOH) may enable health centers to assist patients with social risks and yield efficiencies. OBJECTIVE: To measure effects of bundling fecal immunochemical testing (FIT) and SDOH screening in federally qualified health centers (FQHCs). DESIGN: Clustered stepped-wedge trial. PARTICIPANTS: Four Massachusetts FQHCs randomized to implement bundled FIT-SDOH over 8-week "steps." INTERVENTION: Outreach to 50-75-year-olds overdue for CRC screening to offer FIT with SDOH screening. The implementation strategy used facilitation and training for data monitoring and reporting. MAIN MEASURES: Implementation process descriptions, data from facilitation meetings, and CRC and SDOH screening rates. Rates were compared between implementation and control FQHCs in each "step" by fitting generalized linear mixed-effects models with random intercepts for FQHCs, patients, and "step" by FQHC. KEY RESULTS: FQHCs tailored implementation processes to their infrastructure, workflows, and staffing and prioritized different groups for outreach. Two FQHCs used population health outreach, and two integrated FIT-SDOH within established programs, such as pre-visit planning. Of 34,588 patients overdue for CRC screening, 54% were female; 20% Black, 11% Latino, 10% Asian, and 47% white; 32% had Medicaid, 16% Medicare, 32% private insurance, and 11% uninsured. Odds of CRC screening completion in implementation "steps" compared to controls were higher overall and among groups prioritized for outreach (overall: adjusted odds ratio (aOR) 2.41, p = 0.005; prioritized: aOR 2.88, p = 0.002). Odds of SDOH screening did not differ across "steps." CONCLUSIONS: As healthcare systems are required to conduct more screenings, it is notable that outreach for a long-standing cancer screening requirement increased screening, even when bundled with a newer screening requirement. This outreach was feasible in a real-world safety-net clinical population and may conserve resources, especially compared to more complex or intensive outreach strategies. CLINICAL TRIALS REGISTRATION: NCT04585919.

Association between ethnicity, language and metformin prescriptions in U.S. community health center patients with diabetes.

BACKGROUND: Metformin treatment is a recommended first-line medication for patients with type 2 diabetes. Latino patients are subject to factors that may modify their level of diabetes care, including medication prescription. We evaluated the odds of and times to metformin prescription among non-Latino whites, English-preferring Latinos, and Spanish-preferring Latinos with diabetes. METHODS: We constructed a retrospective cohort of 154,368 adult patients from 835 community health centers (CHCs) across 20 states who were diagnosed with diabetes during the study. Patients were from non-Latino white, English-preferring Latino, and Spanish-preferring Latino ethnic/language groups. We modeled adjusted odds of metformin prescription and adjusted hazards (time-to-event) of metformin prescription after diabetes diagnosis and high hemoglobin A1c (HbA1c > 9) test results. RESULTS: English-preferring Latinos had similar odds of metformin prescription (Odds Ratio (OR) = 1.01 (95% CI = 0.93, 1.09)), slightly lower time to metformin prescription after diabetes diagnosis (Hazard Ratio (HR) = 1.06(95% CI = 1.04, 1.09)), and similar time to metformin prescription after a high HbA1c result (HR = 1.04 (0.99, 1.09)) compared to non-Latino whites. Spanish-preferring Latinos had higher odds of metformin prescription (OR) = 1.42 (95% CI = 1.33, 1.52), and less time to prescription after diabetes diagnosis (HR = 1.18 (1.15, 1.20)) and after a high HbA1c result (HR = 1.15 (1.11, 1.20)). CONCLUSIONS: Our analysis of metformin prescription patterns among non-Latino whites, English-preferring Latinos, and Spanish-preferring Latinos did not suggest a lower or slower tendency to prescribe metformin in Latino patients. Understanding disparities in diabetes diagnosis may require further investigation of medication adherence barriers, diet and exercise counseling, and multi-level influences on diabetes outcomes in Latino patients.

implementation of healthy heart ambassador to improve blood pressure control at community health centers in Texas.

BACKGROUND: Hypertension is one of the most prevalent chronic diseases in the United States and can increase a person's risk of stroke and other cardiovascular complications. Yet only 1 in 4 people with high blood pressure in the United States have their blood pressure managed. To improve hypertension control, we supported 9 health centers in Texas with the implementation of the Healthy Heart Ambassador Blood Pressure Self-Monitoring (HHA) Program. METHODS: We provided health center training using the HHA Program Facilitation Training Guide, recorded barriers to implementing the HHA program, and employed strategies to overcome those barriers. RESULTS: There were 68 staff members from the health centers trained to deliver the HHA program. Three health centers successfully implemented all three major components of HHA, three were able to implement two components, two adopted two components, and one withdrew due to insufficient capacity. Capability, technology infrastructure, and motivation were among the barriers most referenced. CONCLUSION: Clinic non-physician team members delivering the HHA program will need training and ongoing technical assistance to overcome implementation barriers.

Mental health care use and quality among Medicaid adults with serious mental illness receiving care at Federally Qualified Health Centers vs. other settings.

BACKGROUND: Federally Qualified Health Centers (FQHCs) are a critical source of care for medically underserved populations and often serve as medical homes for individuals with serious mental illness (SMI). Many FQHCs provide mental health services and could facilitate access to mental health treatment within and outside of FQHCs. This study compared mental health care utilization and acute care events for adult Medicaid enrollees with SMI who receive care at Federally Qualified Health Centers (FQHCs) vs. other settings. METHODS: This study used the 2015-2016 Massachusetts All-Payer Claims Database to examine outpatient mental health care and acute care events for 32,330 Medicaid adults, ages 18-64 and with major depressive, bipolar, or schizophrenia spectrum disorders (SSD), who resided in FQHC service areas and received care from FQHCs vs. other settings in 2015. Multivariable linear regressions assessed associations between receiving care at FQHCs and outpatient mental health visits, psychotropic medication fills, and acute care events in 2016. RESULTS: There were 8,887 (27.5%) adults in the study population (N = 32,330) who had at least one FQHC visit in 2015. Those who received care at FQHCs were more likely to have outpatient mental health visits (73.3% vs. 71.2%) and psychotropic medication fills (73.2% vs. 69.0%, both p < .05), including antidepressants among those with depressive disorders and antipsychotics among those with SSD. They were more likely to have ED visits (74.0% vs. 68.7%), but less likely to be hospitalized (27.8% vs. 31.9%, both p < .05). However, there was no significant difference in the likelihood of having an acute psychiatric hospitalization (9.5% vs. 9.8%, p = .35). CONCLUSIONS: Among Medicaid enrollees with SMIs who had access to care at FQHCs, those receiving care at FQHCs were more likely to have outpatient mental health visits and psychotropic medication fills, with lower rates of hospitalization, suggesting potentially improved quality of outpatient care. Higher ED visit rates among those receiving care at FQHCs warrant additional investigation.

The potential feasibility of tobacco-focused medication therapy management in pharmacies affiliated with Federally Qualified Health Centers: Perspectives of pharmacists.

BACKGROUND: Tobacco-focused medication therapy management (MTM) interventions executed in pharmacies located in Federally Qualified Health Centers (FQHC) may provide an innovative means to reach smokers with low incomes and reduce health disparities. However, greater understanding of the intervention's potential feasibility in this setting is needed. OBJECTIVE: To inform the feasibility of implementing an MTM program to address tobacco and nicotine dependence in the FQHC setting by assessing the experience and perceptions of pharmacists working in pharmacies associated with FQHCs. METHODS: A convergent mixed methods approach was used to assess indicators associated with the domains of the Consolidated Framework for Implementation Research (CFIR). Pharmacists from FQHC-based pharmacies in the Southeast United States completed surveys (n=24) and interviews (n=15). Quantitative data were summarized descriptively. Qualitative data were content coded. RESULTS: Quantitative and qualitative data were mapped across all five CFIR domains. Pharmacists report high rates of tobacco and nicotine use among their patients and that addressing their use is important. 62.5% of pharmacists had some or a great deal of experience with tobacco and nicotine dependence. Quantitative and qualitative data demonstrate that the pharmacists and their FQHCs would support MTM efforts focused on tobacco and nicotine dependence. Qualitative findings highlight that pharmacists view an MTM intervention as aligning with their current workflow. Quantitative and qualitative data highlight how factors related to pharmacists' engagement in introducing tobacco and nicotine dependence treatment programs to patients, the electronic medical record, time, staffing, and patient-level barriers could impact the feasibility of an MTM intervention focused on tobacco and nicotine dependence. CONCLUSION: Findings suggest an MTM intervention focused on tobacco and nicotine dependence has the potential to be feasible within FQHC-based pharmacies. Considerations related to training, staffing, time, identifying participants, and supporting participant engagement must be taken into account to support its implementation.

The Impact of Structural Integration on Clinical Outcomes among Individuals with Serious Mental Illness and Chronic Illness.

Though considered a best practice, there is substantial variation in how integrated behavioral health (IBH) services are structured. This study examined the impact of IBH structure on health outcomes among individuals with serious mental illness (SMI) and chronic disease receiving care in community health centers (CHCs). Data from the ADVANCE network identified 8,548 individuals with co-occurring SMI diabetes and 16,600 with an SMI and hypertension. Logistic regression tested whether IBH type impacted disease specific health outcomes among these populations. Among those with diabetes or hypertension, colocated care was associated with better health outcomes related to HbA1c, blood pressure control, and BMI compared to less coordinated and unintegrated care, though there was significant variation in this relationship across SMI diagnoses. Results reflect that colocation of primary care and behavioral health may improve outcomes for individuals with bipolar disorder or major depression and chronic disease, but that CHC-based integrated care may not be optimized for individuals with schizophrenia.

Enhancing Behavioral Health Implementation in a Care Coordination Program at a Federally Qualified Health Center: A Case Study Applying Implementation Frameworks.

Federally Qualified Health Centers are charged with providing comprehensive health care in traditionally underserved areas, underscoring their importance in caring for and promoting health equity for the large portion of historically marginalized communities in this setting. There is a significant need to ensure Federally Qualified Health Centers are equipped to appropriately address the immense behavioral health needs common among patients served. Care coordination is an evidence-based model that is increasingly utilized in Federally Qualified Health Centers to improve care equity and outcomes. Addressing and supporting behavioral health needs is a key aspect of such care coordination models. Context-specific considerations and programmatic supports, particularly those that address the needs of care coordinators and the complex patients they serve, are needed to ensure such models can appropriately meet and address the behavioral health concerns of the diverse populations served. The goal of this study was to present a mixed-methods case study that systematically applies implementation frameworks to conduct a needs and context assessment to inform the development and testing of evidence-based practice strategies and implementation support as part of a care coordination program within a partnered Federally Qualified Health Center.

Optimizing process flow diagrams to guide implementation of a colorectal cancer screening intervention in new settings.

PURPOSE: The goal of this study was to assess acceptability of using process flow diagrams (or process maps) depicting a previously implemented evidence-based intervention (EBI) to inform the implementation of similar interventions in new settings. METHODS: We developed three different versions of process maps, each visualizing the implementation of the same multicomponent colorectal cancer (CRC) screening EBI in community health centers but including varying levels of detail about how it was implemented. Interviews with community health professionals and practitioners at other sites not affiliated with this intervention were conducted. We assessed their preferences related to the map designs, their potential utility for guiding EBI implementation, and the feasibility of implementing a similar intervention in their local setting given the information available in the process maps. RESULTS: Eleven community health representatives were interviewed. Participants were able to understand how the intervention was implemented and engage in discussions around the feasibility of implementing this type of complex intervention in their local system. Potential uses of the maps for supporting implementation included staff training, role delineation, monitoring and quality control, and adapting the components and implementation activities of the existing intervention. CONCLUSION: Process maps can potentially support decision-making about the adoption, implementation, and adaptation of existing EBIs in new contexts. Given the complexities involved in deciding whether and how to implement EBIs, these diagrams serve as visual, easily understood tools to inform potential future adopters of the EBI about the activities, resources, and staffing needed for implementation.

Uptake of colorectal cancer screening after mailed fecal immunochemical test (FIT) outreach in a newly eligible 45-49-year-old community health center population.

PURPOSE: We assessed fecal immunochemical test (FIT) uptake following a mailed FIT intervention among 45-49-year-olds newly eligible for colorectal cancer (CRC) screening based on 2021 United States Preventive Services Task Force screening recommendations. We also tested the effect of an enhanced versus plain mailing envelope on FIT uptake. METHODS: In February 2022 we mailed FITs to eligible 45-49-year-olds at one Federally Qualified Health Center (FQHC) clinic. We determined the proportion who completed FITs within 60 days. We also conducted a nested randomized trial comparing uptake using an enhanced envelope (padded with tracking label and colored messaging sticker) versus plain envelope. Finally, we determined the change in CRC screening by any modality (e.g., FIT, colonoscopy) among all clinic patients in this age group (i.e., clinic-level screening) between baseline and 6 months post-intervention. RESULTS: We mailed FITs to 316 patients. Sample characteristics: 57% female, 58% non-Hispanic Black, and 50% commercially insured. Overall, 54/316 (17.1%) returned a FIT within 60 days, including 34/158 (21.5%) patients in the enhanced envelope arm versus 20/158 (12.7%) in the plain envelope arm (difference 8.9 percentage points, 95% CI: 0.6-17.2). Clinic-level screening among all 45-49-year-olds increased 16.6 percentage points (95% CI: 10.9-22.3), from 26.7% at baseline to 43.3% at 6 months. CONCLUSION: CRC screening appeared to increase following a mailed FIT intervention among diverse FQHC patients aged 45-49. Larger studies are needed to assess acceptability and completion of CRC screening in this younger population. Visually appealing mailers may improve uptake when implementing mailed interventions. Trial registration The trial was registered on May 28, 2020 at ClinicalTrials.gov (identifier NCT04406714).

Community Health Center Staff Perspectives on Financial Payments for Social Care.

Policy Points State and federal payers are actively considering strategies to increase the adoption of social risk screening and interventions in health care settings, including through the use of financial incentives. Activities related to social care in Oregon community health centers (CHCs) provided a unique opportunity to explore whether and how fee-for-service payments for social risk screening and navigation influence CHC activities. CHC staff, clinicians, and administrative leaders were often unaware of existing financial payments for social risk screening and navigation services. As currently designed, fee-for-service payments are unlikely to strongly influence CHC social care practices. CONTEXT: A growing crop of national policies has emerged to encourage health care delivery systems to ask about and try to address patients' social risks, e.g., food, housing, and transportation insecurity, in care delivery contexts. In this study, we explored how community health center (CHC) staff perceive the current and potential influence of fee-for-service payments on clinical teams' engagement in these activities. METHODS: We interviewed 42 clinicians, frontline staff, and administrative leaders from 12 Oregon CHC clinical sites about their social care initiatives, including about the role of existing or anticipated financial payments intended to promote social risk screening and referrals to social services. Data were analyzed using both inductive and deductive thematic analysis approaches. FINDINGS: We grouped findings into three categories: participants' awareness of existing or anticipated financial incentives, uses for incentive dollars, and perceived impact of financial incentives on social care activities in clinical practices. Lack of awareness of existing incentives meant these incentives were not perceived to influence the behaviors of staff responsible for conducting screening and providing referrals. Current or anticipated meaningful uses for incentive dollars included paying for social care staff, providing social services, and supporting additional fundraising efforts. Frontline staff reported that the strongest motivator for clinic social care practices was the ability to provide responsive social services. Clinic leaders/managers noted that for financial incentives to substantively change CHC practices would require payments sizable enough to expand the social care workforce as well. CONCLUSIONS: Small fee-for-service payments to CHCs for social risk screening and navigation services are unlikely to markedly influence CHC social care practices. Refining the design of financial incentives-e.g., by increasing clinical teams' awareness of incentives, linking screening to well-funded social services, and changing incentive amounts to support social care staffing needs-may increase the uptake of social care practices in CHCs.

The impact of Community Health Centers on inappropriate use of emergency services.

Community Health Centers offer coordinated and comprehensive responses to primary care needs. Our study aims at assessing whether the introduction of such organizational model improved health outcomes measured by inappropriate emergency visits among diabetics in the Emilia-Romagna region of Italy. Using difference-in-differences methods within a staggered treatment setting, we estimate the effect of Community Health Center participation on inappropriate hospital emergency visits between year 2010 and year 2016. We distinguish between emergency department admissions for varying time spans, occurring at daytime during working days, at night-time, as well as during weekends. We show that, the causal effect of the adoption of the community care model leads to a reduction in the probability of inappropriate admissions by an amount ranging between 1.6 and 1.7% points during working days at daytime, with large facilities responsible for most gains by experiencing a decrease ranging between 4 and 3% points. Conversely, we detect no difference at night-time and during weekends. Our results point out that the coordinated care model increases appropriateness among vulnerable patients, and that extending opening hours and the range of services can further enhance such benefits.

Role of ethnicity/language in documented rates of pediatric asthma prescription refills.

OBJECTIVE: Medication maintenance is critical in the management of asthma. We investigated the differences in electronic health record (EHR) documentation of medication refills for Spanish- and English-speaking Latino children and non-Hispanic white children by examining rates of albuterol rescue inhaler refills from 2005 to 2017, and and inhaled corticosteroid refills from 2015 to 2017 in a multi-state network of community health centers (CHCs). METHODS: We used data from the ADVANCE network of CHCs. Our sample consisted of children aged 3-17, with a diagnosis of asthma and either albuterol or inhaled corticosteroid prescriptions (n = 39,162; n = 4,738 children, respectively). Negative binomial regression was used to calculate rates of refills per prescription adjusted for relevant patient-level covariates. Analyses stratified by asthma severity were also conducted. RESULTS: English-speaking Latino children had lower rates of albuterol refills compared with non-Hispanic white children (rate ratio [RR] = 0.88, 95% confidence interval [CI]: 0.80-0.98), a trend that persisted among children with moderate/severe persistent asthma severity (RR = 0.85, 95% CI: 0.76-0.95). Spanish-speaking Latino and non-Hispanic white children had similar albuterol refills. Inhaled corticosteroid refill rates were comparable between all groups. CONCLUSIONS: In a multi-state network, these findings suggest that CHCs deliver equitable asthma care related to prescription refills between their Latino and white patients, but there is still opportunity for providers to ensure that their English-speaking Latino patients have access to necessary emergency asthma medication.

The Paradoxical Politics of Community Health Centers from the Great Society to the COVID-19 Pandemic.

CONTEXT: Although community health centers (CHCs) arose in the 1960s as part of a Democratic policy push committed to social justice, subsequent support has been shaped by paradoxical politics wherein Republican and Democratic support for CHCs continually morphed in response to changes in the health policy landscape. METHODS: Drawing on the CHC literature and empirical examples from firsthand accounts and reporting, this article explains CHCs' curious historical development from 1965 to the present. FINDINGS: Both Republicans and Democrats have calibrated their support for CHCs in response to a broader set of political considerations, from antiwelfare policy commitments to aspirations of establishing a national health care plan. CONCLUSIONS: CHCs have proven to be a politically malleable policy tool within the broader context of American health care policy. The COVID-19 pandemic raised new questions about CHCs' sustainability and future, but CHCs will continue to play a critical role in providing health care access to underserved populations. They also will continue to be an attractive bipartisan policy option within the larger framework of US health policy.

Improving Fecal Immunochemical Test Return Rates: A Colorectal Cancer Screening Quality Improvement Project in a Multisite Federally Qualified Health Center.

The goal of this quality improvement project was to improve colorectal cancer (CRC) screening rates in a multicenter federally qualified health center (FQHC) within the Central Appalachian region of rural, southwestern Virginia. Guided by the Plan-Do-Study-Act (PDSA) cycle, the objectives were to (1) evaluate implementation processes and effectiveness of an automated electronic medical record patient reminder system to promote fecal immunochemical test (FIT) completion, compared with live telephone reminders delivered by a care coordinator (i.e., usual care), and (2) explore staff perceptions related to improving CRC screening rates. In total, 119 FITs were distributed with 59 assigned to usual care and 60 to the automated groups. In the usual care group, 79% patients with completed protocol returned their FIT; 9% were positive. In the automated reminder group, 76% patients with completed protocol returned their FIT; 10% were positive. There was no significant difference in the number of contacts per patients between the usual care (2.0, SD = 0.82 contacts/patient) and automated (1.8, SD = 0.98 contacts/patient) groups (p = .248). In total, the usual care and automated groups required 56 and 17 live calls, respectively. Overall, FQHC system-wide CRC screening rates increase from 30.5% to 47.3%. Ten staff interviews revealed perceptions of CRC screening, the QI project, and organizational change processes that may inform future cancer control projects. Researcher and practitioners should consider PDSA quality improvement projects as an initial step to build capacity and improve CRC screening rates, especially when working in FQHC with limited resources to engage in large complex research projects.

Qualitative inquiry of a community dance program for older adults in Singapore.

Dance programs promote physical and psychosocial well-being. However, studies focusing on the experiences of older adults in dancing are limited. This study aims to develop a community dance program (CDP) for older adults at senior activity centers in Singapore, as well as to explore the older adults' and student instructors' experiences of the CDP. A qualitative inquiry of semi-structured and in-depth focus group discussions was conducted. In total, 20 older adults and 10 student dance instructors participated in the study. Student instructors who were undergraduate students from a dance society were trained in how to provide step-by-step instructions for the older adults. An inductive approach of thematic analysis was undertaken. Three main themes were identified: (i) promotion of physical, cognitive, and psychosocial health with dance; (ii) imagination is power-travel through dance; and (iii) further enhancement of the dance program. The themes highlighted the prominence of CDP in improving memory, physical health, mood, and social interactions-thus mitigating the risk of social isolation. The findings illustrated the benefits of CDP in cultivating intergenerational bonds amongst older adults and student instructors.

"I was not able to keep myself away from tending to her immediate needs": Primary Care Physicians' Perspectives of Serious Illness Conversations at Community Health Centers.

PURPOSE: Seriously ill patients in low-income and minority populations have lower rates of advance care planning. Initiatives that promote serious illness (SI) conversations in community health centers (CHCs) can reach broad, diverse patient populations. This qualitative study explored the experiences of primary care physicians in conducting SI conversations at CHCs in order to understand challenges and needs in this setting. METHODS: An initiative to increase SI conversations was implemented at two CHCs in the Bronx, NY. Eleven participating family physicians who together conducted 37 SI conversations underwent semi-structured in-depth interviews. The 11 interviews were analyzed using inductive thematic analysis. RESULTS: Eight themes emerged: (1) Structured approaches to SI conversations are useful even in longstanding patient-doctor relationships; (2) Discussion of prognosis is meaningful but difficult; (3) Emotional work is humanizing but draining; (4) Poverty and underinsurance are high priorities; (5) Social context affects patient readiness; (6) Communication barriers take multiple forms; (7) Patient characteristics make it "easier" or "harder" to initiate the SI conversation; (8) Time constraints limit the ability to meet multiple patient needs. CONCLUSIONS: Physicians at CHCs identified challenges in SI conversations at personal, interpersonal, organizational, and societal levels. These challenges should be addressed by initiatives that aim to increase SI conversations in primary care, and especially at CHCs.

Prevalent Multimorbidity Combinations Among Middle-Aged and Older Adults Seen in Community Health Centers.

BACKGROUND: Multimorbidity (≥ 2 chronic diseases) is associated with greater disability and higher treatment burden, as well as difficulty coordinating self-management tasks for adults with complex multimorbidity patterns. Comparatively little work has focused on assessing multimorbidity patterns among patients seeking care in community health centers (CHCs). OBJECTIVE: To identify and characterize prevalent multimorbidity patterns in a multi-state network of CHCs over a 5-year period. DESIGN: A cohort study of the 2014-2019 ADVANCE multi-state CHC clinical data network. We identified the most prevalent multimorbidity combination patterns and assessed the frequency of patterns throughout a 5-year period as well as the demographic characteristics of patient panels by prevalent patterns. PARTICIPANTS: The study included data from 838,642 patients aged ≥ 45 years who were seen in 337 CHCs across 22 states between 2014 and 2019. MAIN MEASURES: Prevalent multimorbidity patterns of somatic, mental health, and mental-somatic combinations of 22 chronic diseases based on the U.S. Department of Health and Human Services Multiple Chronic Conditions framework: anxiety, arthritis, asthma, autism, cancer, cardiac arrhythmia, chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), congestive heart failure, coronary artery disease, dementia, depression, diabetes, hepatitis, human immunodeficiency virus (HIV), hyperlipidemia, hypertension, osteoporosis, post-traumatic stress disorder (PTSD), schizophrenia, substance use disorder, and stroke. KEY RESULTS: Multimorbidity is common among middle-aged and older patients seen in CHCs: 40% have somatic, 6% have mental health, and 24% have mental-somatic multimorbidity patterns. The most frequently occurring pattern across all years is hyperlipidemia-hypertension. The three most frequent patterns are various iterations of hyperlipidemia, hypertension, and diabetes and are consistent in rank of occurrence across all years. CKD-hyperlipidemia-hypertension and anxiety-depression are both more frequent in later study years. CONCLUSIONS: CHCs are increasingly seeing more complex multimorbidity patterns over time; these most often involve mental health morbidity and advanced cardiometabolic-renal morbidity.