Postresidency Practice Setting and Clinical Care Features According to 3 Versus 4 Years of Training in Family Medicine: A Length of Training Pilot Study.

BACKGROUND AND OBJECTIVES: Factors associated with physician practice choice include residency location, training experiences, and financial incentives. How length of training affects practice setting and clinical care features postgraduation is unknown. METHODS: In this Length of Training Pilot (LoTP) study, we surveyed 366 graduates of 3-year (3YR) and 434 graduates of 4-year (4YR) programs 1 year after completion of training between 2013 and 2021. Variables assessed included reasons for practice setting choice, practice type, location, practice and community size, specialty mix, and clinical care delivery features (eg, integrated behavioral health, risk stratified care management). We compared different length of training models using χ2 or Fisher's exact tests for categorical variables and independent samples, and t test (unequal variances) for continuous variables. RESULTS: Response rates ranged from 50% to 88% for 3YR graduates and 68% to 95% for 4YR graduates. Scope of practice was a predominant reason for graduates choosing their eventual practice, and salary was a less likely reason for those completing 4 years versus 3 years of training (scope, 72% vs 55%, P=.001; salary, 15% vs 22%, P=.028). Community size, practice size, practice type, specialty mix, and practice in a federally designated underserved site did not differ between the two groups. We found no differences in patient-centered medical home features when comparing the practices of 3YR to 4YR graduates. CONCLUSIONS: Training length did not affect practice setting or practice features for graduates of LoTP programs. Future LoTP analyses will examine how length of training affects scope of practice and clinical preparedness, which may elucidate other elements associated with practice choice.

Does engagement matter? The impact of patient and community engagement on implementation of cardiovascular health materials in primary care settings.

BACKGROUND: Engaging patients and community members in healthcare implementation, research and evaluation has become more popular over the past two decades. Despite the growing interest in patient engagement, there is scant evidence of its impact and importance. Boot Camp Translation (BCT) is one evidence-based method of engaging communities in research. The purpose of this report is to describe the uptake by primary care practices of cardiovascular disease prevention materials produced through four different local community engagement efforts using BCT. METHODS: EvidenceNOW Southwest (ENSW) was a randomized trial to increase cardiovascular disease (CVD) prevention in primary care practices. Because of its study design, Four BCTs were conducted, and the materials created were made available to participating practices in the "enhanced" study arm. As a result, ENSW offered one of the first opportunities to explore the impact of the BCT method by describing the uptake by primary care practices of health messages and materials created locally using the BCT process. Analysis compared uptake of locally translated BCT products vs. all other products among practices based on geography, type of practice, and local BCT. RESULTS: Within the enhanced arm of the study that included BCT, 69 urban and 13 rural practices participated with 9 being federally qualified community health centers, 14 hospital owned and 59 clinician owned. Sixty-three practices had 5 or fewer clinicians. Two hundred and ten separate orders for materials were placed by 43 of the 82 practices. While practices ordered a wide variety of BCT products, they were more likely to order materials developed by their local BCT. CONCLUSIONS: In this study, patients and community members generated common and unique messages and materials for cardiovascular disease prevention relevant to their regional and community culture. Primary care practices preferred the materials created in their region. The greater uptake of locally created materials over non-local materials supports the use of patient engagement methods such as BCT to increase the implementation and delivery of guideline-based care. Yes, patient and community engagement matters. TRIAL REGISTRATION AND IRB: Trial registration was prospectively registered on July 31, 2015 at ClinicalTrials.gov (NCT02515578, protocol identifier 15-0403). The project was approved by the Colorado Multiple Institutional Review Board and the University of New Mexico Human Research Protections Office.

Behavioral health integration and specialty medical care: Opportunities for applying knowledge from primary care integration.

While education and advocacy regarding behavioral health (BH) integration in primary care have been in full force at the state and national level for many years, specialty care BH integration has not received the same attention in terms of practice transformation, workforce development, and payment reform. Models of BH care have been tested in primary care and can be easily adapted to improve specialty patient care. There are many opportunities for using the knowledge base gained from integrated primary care to help move integration forward in the specialty medical setting. The timing for this is rife, as the benefits of integrated BH for patient health outcomes are well established. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Resident Visit Productivity and Attitudes About Continuity According to 3 Versus 4 Years of Training in Family Medicine: A Length of Training Study.

BACKGROUND AND OBJECTIVES: Training models in the Length of Training Pilot (LOTP) vary. How innovations in training length affect patient visits and resident perceptions of continuity is unknown. METHODS: We analyzed resident in-person patient encounters (2013-2014 through 2018-2019) for each postgraduate year (PGY) and total visits at graduation derived from the Accreditation Council for Graduate Medical Education reports for each LOTP program. We collected data on residents' perceptions of continuity from annual surveys (2015-2019). We analyzed continuous variables using independent samples t tests with unequal variance and categorical variables using χ2 tests in comparing 3-year (3YR) versus 4-year (4YR) programs. RESULTS: PGY-1 and PGY-2 residents in 4YR programs saw statistically more patients than their counterparts in 3YR programs. In PGY3, 3YR program residents had statistically higher visit volume compared to 4YR program residents. Visits conducted in PGY4 ranged from 832 to 884. The additional year of training resulted in approximately 1,000 more total patient visits. Most residents in 3YR and 4YR programs rated their continuity clinic experience as somewhat or very adequate (range 86.3% to 93.7%), which did not statistically differ according to length of training. CONCLUSIONS: Resident visits were significantly different at each PGY level when comparing 3YR and 4YR programs in the LOTP and the additional year of training resulted in about 1,000 more total visits. Resident perspectives on the adequacy of their continuity clinic experience appeared to not be affected by length of training. Future research should explore how the volume of patient visits performed in residency affects scope of practice and clinical preparedness.

Something Republicans and Democrats can agree on: Support for integrated behavioral health.

Barriers to the spread of integrated behavioral health and primary care continue to limit progress on meeting critical needs for mental health and substance use disorder services. The recent Bipartisan Policy Center Report (2021) provides key policy recommendations to address these barriers and accelerate the adoption of integrated behavioral health in Medicaid and Medicare. Having bipartisan support presents a policy window of opportunity to advance integrated behavioral health through advocacy for implementation of these recommendations, parallel changes to occur in employer-based and other commercial insurance plans, and development of operationalized standards for core service delivery elements. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

An Exploratory Mixed Methods Study of Experiences of Interprofessional Teams Who Received Coaching to Simultaneously Redesign Primary Care Education and Clinical Practice.

INTRODUCTION/OBJECTIVES: Coaching is emerging as a form of facilitation in health professions education. Most studies focus on one-on-one coaching rather than team coaching. We assessed the experiences of interprofessional teams coached to simultaneously improve primary care residency training and interprofessional practice. METHODS: This three-year exploratory mixed methods study included transformational assistance from 9 interprofessional coaches, one assigned to each of 9 interprofessional primary care teams that included family medicine, internal medicine, pediatrics, nursing, pharmacy and behavioral health. Coaches interacted with teams during 2 in-person training sessions, an in-person site visit, and then as requested by their teams. Surveys administered at 1 year and end study assessed the coaching relationship and process. RESULTS: The majority of participants (82% at end of Year 1 and 76.6% at end study) agreed or strongly agreed that their coach developed a positive working relationship with their team. Participants indicated coaches helped them: (1) develop as teams, (2) stay on task, and (3) respond to local context issues, with between 54.3% and 69.2% agreeing or strongly agreeing that their coaches were helpful in these areas. Cronbach's alpha for the 15 coaching survey items was 0.965. Challenges included aligning the coach's expertise with the team's needs. CONCLUSIONS: While team coaching was well received by interprofessional teams of primary care professionals undertaking educational and clinical redesign, the 3 primary care disciplines have much to learn from each other regarding how to improve inter- and intra-professional collaborative practice among clinicians and staff as well as with interprofessional learners rotating through their outpatient clinics.

A Taxonomy for External Support for Practice Transformation.

BACKGROUND: There is no commonly accepted comprehensive framework for describing the practical specifics of external support for practice change. Our goal was to develop such a taxonomy that could be used by both external groups or researchers and health care leaders. METHODS: The leaders of 8 grants from Agency for Research and Quality for the EvidenceNOW study of improving cardiovascular preventive services in over 1500 primary care practices nationwide worked collaboratively over 18 months to develop descriptions of key domains that might comprehensively characterize any external support intervention. Combining literature reviews with our practical experiences in this initiative and past work, we aimed to define these domains and recommend measures for them. RESULTS: The taxonomy includes 1 domain to specify the conceptual model(s) on which an intervention is built and another to specify the types of support strategies used. Another 5 domains provide specifics about the dose/mode of that support, the types of change process and care process changes that are encouraged, and the degree to which the strategies are prescriptive and standardized. A model was created to illustrate how the domains fit together and how they would respond to practice needs and reactions. CONCLUSIONS: This taxonomy and its use in more consistently documenting and characterizing external support interventions should facilitate communication and synergies between 3 areas (quality improvement, practice change research, and implementation science) that have historically tended to work independently. The taxonomy was designed to be as useful for practices or health systems managing change as it is for research.

Practice Transformation Support and Patient Engagement to Improve Cardiovascular Care: From EvidenceNOW Southwest (ENSW).

PURPOSE: To improve cardiovascular care through supporting primary care practices' adoption of evidence-based guidelines. STUDY DESIGN: A cluster randomized trial compared two approaches: (1) standard practice support (practice facilitation, practice assessment with feedback, health information technology assistance, and collaborative learning sessions) and (2) standard support plus patient engagement support. METHODS: Primary outcomes were cardiovascular clinical quality measures (CQMs) collected at baseline, 9 months, and 15 months. Implementation of the first 6 "Building Blocks of High-Performing Primary Care" was assessed by practice facilitators at baseline and 3, 6, and 9 months. CQMs from practices not involved in the study served as an external comparison. RESULTS: A total of 211 practices completed baseline surveys. There were no differences by study arm (odds ratio [95% confidence interval]) for aspirin use (1.03 [0.99, 1.06]), blood pressure (0.98 [0.95, 1.01]), cholesterol (0.96 [0.92, 1.00]), and smoking (1.01 [0.96, 1.07]); however, there were significant improvements over time in aspirin use (1.04 [1.01, 1.07]), cholesterol (1.05 [1.03, 1.08]), and smoking (1.03 [1.01, 1.06]), but not blood pressure (1.01 [0.998, 1.03]). Improvement in enrolled practices was greater than external comparison practices across all 4 measures (all P < .05). Implementation improved in both arms for Team-Based Care, Patient-Team Partnership, and Population Management, and improvement was greater in enhanced intervention practices (all P < .05). Leadership and Data-Driven Improvement (P < .05) improved significantly, with no difference by arm. A greater improvement in Building Block implementation was associated with a greater improvement in blood pressure measures (P < .05). CONCLUSIONS: Practice transformation support can assist practices with improving quality of care. Patient engagement in practice transformation can further enhance practices' implementation of aspects of new models of care.

Exemplary Practices in Cardiovascular Care: Results on Clinical Quality Measures from the EvidenceNOW Southwest Cooperative.

BACKGROUND: Identifying characteristics of primary care practices that perform well on cardiovascular clinical quality measures (CQMs) may point to important practice improvement strategies. OBJECTIVE: To identify practice characteristics associated with high performance on four cardiovascular disease CQMs. DESIGN: Longitudinal cohort study among 211 primary care practices in Colorado and New Mexico. Quarterly CQM reports were obtained from 178 (84.4%) practices. There was 100% response rate for baseline practice characteristics and implementation tracking surveys. Follow-up implementation tracking surveys were completed for 80.6% of practices. PARTICIPANTS: Adult patients, staff, and clinicians in family medicine, general internal medicine, and mixed-specialty practices. INTERVENTION: Practices received 9 months of practice facilitation and health information technology support, plus biannual collaborative learning sessions. MAIN MEASURES: This study identified practice characteristics associated with overall highest performance using area under the curve (AUC) analysis on aspirin therapy, blood pressure management, and smoking cessation CQMs. RESULTS: Among 178 practices, 39 were exemplars. Exemplars were more likely to be a Federally Qualified Health Center (69.2% vs 35.3%, p = 0.0006), have an underserved designation (69.2% vs 45.3%, p = 0.0083), and have higher percentage of patients with Medicaid (p < 0.0001). Exemplars reported greater use of cardiovascular disease registries (61.5% vs 29.5%,), standing orders (38.5 vs 22.3%) or electronic health record prompts (84.6% vs 49.6%) (all p < 0.05), were more likely to have medical home recognition (74.4% vs 43.2%, p = 0.0006), and reported greater implementation of building blocks of high-performing primary care: regular quality improvement team meetings (3.0 vs 2.2), patient experience survey (3.1 vs 2.2), and resources for patients to manage their health (3.0 vs 2.3). High improvers (n = 45) showed greater improvement implementing team-based care (32.8 vs 11.7, p = 0.0004) and population management (37.4 vs 20.5, p = 0.0057). CONCLUSIONS: Multiple strategies-registries, prompts and protocols, patient self-management support, and patient-team partnership activities-were associated with delivering high-quality cardiovascular care over time, measured by CQMs. TRIAL REGISTRATION: ClinicalTrials.gov registration: NCT02515578.

Primary Care Practices' Ability to Report Electronic Clinical Quality Measures in the EvidenceNOW Southwest Initiative to Improve Heart Health.

Importance: The capability and capacity of primary care practices to report electronic clinical quality measures (eCQMs) are questionable. Objective: To determine how quickly primary care practices can report eCQMs and the practice characteristics associated with faster reporting. Design, Setting, and Participants: This quality improvement study examined an initiative (EvidenceNOW Southwest) to enhance primary care practices' ability to adopt evidence-based cardiovascular care approaches: aspirin prescribing, blood pressure control, cholesterol management, and smoking cessation (ABCS). A total of 211 primary care practices in Colorado and New Mexico participating in EvidenceNOW Southwest between February 2015 and December 2017 were included. Interventions: Practices were instructed on eCQM specifications that could be produced by an electronic health record, a registry, or a third-party platform. Practices received 9 months of support from a practice facilitator, a clinical health information technology advisor, and the research team. Practices were instructed to report their baseline ABCS eCQMs as soon as possible. Main Outcomes and Measures: The main outcome was time to report the ABCS eCQMs. Cox proportional hazards models were used to examine practice characteristics associated with time to reporting. Results: Practices were predominantly clinician owned (48%) and in urban or suburban areas (71%). Practices required a median (interquartile range) of 8.2 (4.6-11.9) months to report any ABCS eCQM. Time to report differed by eCQM: practices reported blood pressure management the fastest (median [interquartile range], 7.8 [3.5-10.4] months) and cholesterol management the slowest (median [interquartile range], 10.5 [6.6 to >12] months) (log-rank P < .001). In multivariable models, the blood pressure eCQM was reported more quickly by practices that participated in accountable care organizations (hazard ratio [HR], 1.88; 95% CI, 1.40-2.53; P < .001) or participated in a quality demonstration program (HR, 1.58; 95% CI, 1.14-2.18; P = .006). The cholesterol eCQM was reported more quickly by practices that used clinical guidelines for cardiovascular disease management (HR, 1.35; 95% CI, 1.18-1.53; P < .001). Compared with Federally Qualified Health Centers, hospital-owned practices had greater ability to report blood pressure eCQMs (HR, 2.66; 95% CI, 95% CI, 1.73-4.09; P < .001), and clinician-owned practices had less ability to report cholesterol eCQMs (HR, 0.52; 95% CI, 0.35-0.76; P < .001). Conclusions and Relevance: In this study, time to report eCQMs varied by measure and practice type, with very few practices reporting quickly. Practices took longer to report a new cholesterol measure than other measures. Programs that require eCQM reporting should consider the time and effort practices must exert to produce reports. Practices may benefit from additional support to succeed in new programs that require eCQM reporting.

Self-management support for chronic disease in primary care: frequency of patient self-management problems and patient reported priorities, and alignment with ultimate behavior goal selection.

BACKGROUND: To enable delivery of high quality patient-centered care, as well as to allow primary care health systems to allocate appropriate resources that align with patients' identified self-management problems (SM-Problems) and priorities (SM-Priorities), a practical, systematic method for assessing self-management needs and priorities is needed. In the current report, we present patient reported data generated from Connection to Health (CTH), to identify the frequency of patients' reported SM-Problems and SM-Priorities; and examine the degree of alignment between patient SM-Priorities and the ultimate Patient-Healthcare team member selected Behavioral Goal. METHODS: CTH, an electronic self-management support system, was embedded into the flow of existing primary care visits in 25 primary care clinics and was used to assess patient-reported SM-Problems across 12 areas, patient identified SM-Priorities, and guide the selection of a Patient-Healthcare team member selected Behavioral Goal. SM-Problems included: BMI, diet (fruits and vegetables, salt, fat, sugar sweetened beverages), physical activity, missed medications, tobacco and alcohol use, health-related distress, general life stress, and depression symptoms. Descriptive analyses documented SM-Problems and SM-Priorities, and alignment between SM-Priorities and Goal Selection, followed by mixed models adjusting for clinic. RESULTS: 446 participants with ≥ one chronic diseases (mean age 55.4 ± 12.6; 58.5% female) participated. On average, participants reported experiencing challenges in 7 out of the 12 SM-Problems areas; with the most frequent problems including: BMI, aspects of diet, and physical activity. Patient SM-Priorities were variable across the self-management areas. Patient- Healthcare team member Goal selection aligned well with patient SM-Priorities when patients prioritized weight loss or physical activity, but not in other self-management areas. CONCLUSION: Participants reported experiencing multiple SM-Problems. While patients show great variability in their SM-Priorities, the resulting action plan goals that patients create with their healthcare team member show a lack of diversity, with a disproportionate focus on weight loss and physical activity with missed opportunities for using goal setting to create targeted patient-centered plans focused in other SM-Priority areas. Aggregated results can assist with the identification of high frequency patient SM-Problems and SM-Priority areas, and in turn inform resource allocation to meet patient needs. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT01945918 .

The Role of Health Extension in Practice Transformation and Community Health Improvement: Lessons From 5 Case Studies.

Passage of the Patient Protection and Affordable Care Act triggered 2 successive grant initiatives from the Agency for Healthcare Research and Quality, allowing for the evolution of health extension models among 20 states, not limited to support for in-clinic primary care practice transformation, but also including a broader concept incorporating technical assistance for practices and their communities to address social determinants of health. Five states stand out in stretching the boundaries of health extension: New Mexico, Oklahoma, Oregon, Colorado, and Washington. Their stories reveal lessons learned regarding the successes and challenges, including the importance of building sustained relationships with practices and community coalitions; of documenting success in broad terms as well as achieving diverse outcomes of meaning to different stakeholders; of understanding that health extension is a function that can be carried out by an individual or group depending on resources; and of being prepared for political struggles over "turf" and ownership of extension. All states saw the need for long-term, sustained fundraising beyond grants in an environment expecting a short-term return on investment, and they were challenged operating in a shifting health system landscape where the creativity and personal relationships built with small primary care practices was hindered when these practices were purchased by larger health delivery systems.

Colorado Residency PCMH Project: Results From a 6-Year Transformation Effort.

BACKGROUND AND OBJECTIVES: Our objective was to describe the results of a 6-year patient-centered medical home (PCMH) transformation program in 11 Colorado primary care residency practices. METHODS: We used a parallel qualitative and quantitative evaluation including cross-sectional surveys of practice staff and clinicians, group and individual interviews, meeting notes, and longitudinal practice facilitator field notes. Survey analyses assessed change over time, adjusting for practice-level random effects. Qualitative data analysis used iterative template coding and matrix analyses to synthesize data over time and across cases. RESULTS: There were significant improvements in clinicians' self-reported routine delivery of patient-centered care, team-based care, self-management support, and use of information systems (P<.0001). Clinicians and staff reported significant gains in practice change culture (P=.001). Self-reported practice-level assessments pointed to additional significant improvements in quality improvement (QI) processes, continuity of care, self-management support/care coordination, and the use of data and population management (P≤.0215). Practices and their practice facilitators reported important changes in how practices operated, significantly improving their QI processes, shared leadership, change culture, and achieving Level III PCMH NCQA Recognition. Important barriers to further progress remain, including inadequate payment models, inflexible staff roles, and difficult access to clinical data. CONCLUSIONS: The success of these 11 primary care residency practices in making significant improvements in their delivery of patient-centered care, team-based care, self-management support, and use of information systems took time, effort, and external support. Further practice redesign for advanced primary care models will take sustained sources of well-aligned support, flexibility, shared leadership, and partnerships across residency programs for collaborative learning to assist in their transformation efforts.

Practice Characteristics Associated with Better Implementation of Patient Self-Management Support.

BACKGROUND: Advanced primary care models emphasize patient-centered care, including self-management support (SMS). This study aimed to promote the translation of SMS into primary care practices and reported on key baseline practice characteristics that may impact SMS implementation. METHODS: Thirty-six practices in Colorado and California participated in the study from December 2013 to March 2017. Practice administrators completed a Practice Information Form describing practice characteristics. Clinicians and staff (n = 716) completed the Practice Culture Assessment and the Patient-Centered Medical Home (PCMH) Monitor. Descriptive statistics were computed to determine practice characteristics related to culture, quality improvement, level of PCMH, and SMS implementation. Field notes and key informant interviews provided contextual details about practices. Iterative qualitative analyses identified important facilitators and barriers and change capabilities around SMS implementation. RESULTS: In bivariate analyses, rural locations, fewer uncontrolled patients with diabetes, higher Medicaid or uninsured populations, underserved designation, and higher level of "PCMHness" were associated with greater reported implementation of patient SMS (all P < .05) at baseline. In the final multilevel model, specialty (FM vs mixed, P = .0081), rural location (P = .0109), and higher percent Medicaid (P < .0001) were associated with greater SMS. Practices described key facilitators (alignment, motivation, a visible champion, supporting infrastructure, and functional quality improvement and care teams) and barriers (no shared vision, no visible champion, siloed infrastructure, competing programs, turnover, and time constraints) to improving SMS delivery. CONCLUSIONS: Careful attention-and action-on key practice characteristics and context may create more favorable initial conditions for practice change efforts to improve SMS in primary care practices.

A Cluster Randomized Trial Comparing Strategies for Translating Self-Management Support into Primary Care Practices.

INTRODUCTION: Self-management support (SMS) is a key factor in diabetes care, but true SMS has not been widely adopted by primary care practices. Interactive behavior-change technology (IBCT) can provide efficient methods for adoption of SMS in primary care. Practice facilitation has been effective in assisting practices in implementing complex evidence-based interventions, such as SMS. This study was designed to study the incremental impact of practice education, the Connection to Health (CTH) IBCT tool, and practice facilitation as approaches to enhance the translation of SMS for patients with diabetes in primary care practices. METHODS: A cluster-randomized trial compared the effectiveness of 3 implementation strategies for enhancing SMS for patients with diabetes in 36 primary care practices: 1) SMS education (SMS-ED); 2) SMS-ED plus CTH availability (CTH); and 3) SMS-ED, CTH availability, plus brief practice facilitation (CTH + PF). Outcomes including hemoglobin A1c (HbA1c) levels and SMS activities were assessed at 18 months post study initiation in a random sample of patients through medical record reviews. RESULTS: A total of 488 patients enrolled in the CTH system (141 CTH, 347 CTH + PF). In the intent-to-treat analysis of patients with medical record reviews, HbA1c slopes did not differ between study arms (CTH vs SMS-ED: P = .2243, CTH + PF vs SMS-ED: P = .8601). However, patients from practices in the CTH + PF arm who used CTH showed significantly improved HbA1c trajectories over time compared with patients from SMS-ED practices (P = .0422). SMS activities were significantly increased in CTH and CTH + PF study arms compared with SMS-ED (CTH vs SMS-ED: P = .0223, CTH + PF vs SMS-ED: P = .0013). The impact of CTH on SMS activities was a significant mediator of the impact of the CTH and CTH + PF interventions on HbA1c. CONCLUSION: An interactive behavior change technology tool such as CTH can increase primary care practice SMS activities and improve patient HbA1c levels. Even brief practice facilitation assists practices in implementing SMS.

Supporting Family Medicine Research Capacity: The Critical Role and Current Contributions of US Family Medicine Organizations.

BACKGROUND AND OBJECTIVES: Family medicine is continuously advanced by a reinforcing research enterprise. In the United States, each national family medicine organization contributes to the discipline's research foundations. We sought to map the unique and interorganizational roles of the eight US family medicine professional organizations participating in Family Medicine for America's Health (FMAHealth) in supporting family medicine research. METHODS: We interviewed leaders and reviewed supporting materials from organizations participating in FMAHealth. We explored existing activities, capacity, and collaboration. We identified areas of strength and opportunities for growth and synergy with respect to how the family of family medicine nurtures family medicine research. RESULTS: The FMAHealth organizations support certain aspects of the family medicine research infrastructure. Six domains were identified through this work: showcasing scholarship, communication and dissemination, workforce development, data-driven initiatives, performing primary research, and advocacy for family medicine research. Each organization's areas of emphasis differ, but we found substantial collaboration on initiatives across organizations, possibly attributable to the fact that many members belong to more than one organization. CONCLUSIONS: Deliberate contributions to each of the six domains identified herein will be important for the future success of family medicine research. Key opportunity areas described here include coordinated and strategic advocacy for increased funding for family medicine research, dedicated investment in training opportunities, protected effort to grow the next generation of family medicine researchers, pilot funding to build a research base for future high-impact research, and infrastructure to facilitate cross-institutional collaboration and data sharing.

Recruiting Primary Care Practices for Research: Reflections and Reminders.

BACKGROUND: Recruiting primary care practices for research projects has always required carefully tended relationships, a compelling message, and good timing. Recruiting practices to participate in practice transformation research trials may take more and different efforts. We reflect on practice recruitment for a recently-concluded trial of a diabetes self-management support system in 2 states and 36 practices. METHODS: Iterative qualitative analysis of field notes, semistructured clinician and staff interviews, and meeting notes from a 2-state, cluster-randomized trial that aimed to improve self-management support for patients with type 2 diabetes mellitus. RESULTS: Although all 36 enrolled practices finished the study, fully recruiting practices early on took considerable effort, yielding 2 primary lessons: 1) practice-based research networks (PBRNs) must recruit more stakeholders at more levels, at the clinic, in the system, and across roles; and 2) practice recruitment is a process and may take longer than expected with unplanned turnover of key contacts. Adjusting our recruitment strategies required: helping with communication efforts in practices; aligning our study message according to stakeholders' interests; allowing for minor adaptations at the practice-level to align with critical practice workflows, staffing, and resources; re-engaging with clinical leadership over time; and identifying a "backup" champion due to turnover. CONCLUSIONS: When undertaking a pragmatic clinical trial requiring substantial practice change in a PBRN setting across a large number of practices, it is important that PBRN leaders develop a comprehensive strategy to identify and engage a broad group of stakeholders within each practice, understand their needs and priorities around research, and design and implement a structured communications strategy to maintain engagement throughout every phase of the project.

A protocol for a cluster randomized trial comparing strategies for translating self-management support into primary care practices.

BACKGROUND: Advanced primary care models emphasize patient-centered care, including self-management support (SMS), but the effective use of SMS for patients with type 2 diabetes (T2DM) remains a challenge. Interactive behavior-change technology (IBCT) can facilitate the adoption of SMS interventions. To meet the need for effective SMS intervention, we have developed Connection to Health (CTH), a comprehensive, evidence-based SMS program that enhances interactions between primary care clinicians and patients to resolve self-management problems and improve outcomes. Uptake and maintenance of programs such as CTH in primary care have been limited by the inability of practices to adapt and implement program components into their culture, patient flow, and work processes. Practice facilitation has been shown to be effective in helping practices make the changes required for optimal program implementation. The proposed research is designed to promote the translation of SMS into primary care practices for patients with T2DM by combining two promising lines of research, specifically, (a) testing the effectiveness of CTH in diverse primary-care practices, and (b) evaluating the impact of practice facilitation to enhance implementation of the intervention. METHODS: A three-arm, cluster-randomized trial will evaluate three discrete strategies for implementing SMS for patients with T2DM in diverse primary care practices. Practices will be randomly assigned to receive and implement the CTH program, the CTH program plus practice facilitation, or a SMS academic detailing educational intervention. Through this design, we will compare the effectiveness, adoption and implementation of these three SMS practice implementation strategies. Primary effectiveness outcomes including lab values and evidence of SMS will be abstracted from medical records covering baseline through 18 months post-baseline. Data from CTH assessments and action plans completed by patients enrolled in CTH will be used to evaluate practice implementation of CTH and the impact of CTH participation. Qualitative data including field notes from encounters with the practices and interviews of practice personnel will be analyzed to assess practice implementation of SMS. DISCUSSION: This study will provide important information on the implementation of SMS in primary care, the effectiveness of an IBCT tool such as CTH, and the use of practice facilitation to assist implementation. TRIAL REGISTRATION: Registered with ClinicalTrials.gov - ClinicalTrials.gov ID: NCT01945918 , date 08/27/2013. Modifications have been updated.