One-Stop-Shop Cancer Screening Clinic: Acceptability Testing.

Cancer screenings aid in the early detection of cancer and can help reduce cancer-related mortality. The current model of care for cancer screening is often siloed, based on the targeted cancer site. We tested the acceptability of a new model of care, called the One-Stop-Shop Cancer Screening Clinic, that centralizes cancer screenings and offers patients the option to complete all their recommended cancer screenings within one to two visits. We administered surveys to 59 community members and 26 healthcare providers to gather feedback about the One-Stop-Shop model of care. Both community members and providers identified potential benefits (e.g., decreased patient burden, increased completion of cancer screenings) and also potential challenges (e.g., challenges with workflow and timing of care) of the model of care. The results of the study support the acceptability of the model of care. Of the community members surveyed, 89.5% said, if offered, they would be interested in participating in the One-Stop-Shop Cancer Screening Clinic. Future studies are needed to formally evaluate the impact and cost effectiveness of the One-Stop-Shop Cancer Screening Clinic.

Becoming a patient-centered medical home: a 9-year transition for a network of Federally Qualified Health Centers.

PURPOSE: The patient-centered medical home (PCMH) model has great potential for optimizing the care of chronically ill patients, yet there is much to be learned about various implementations of this model and their impact on patient care processes and outcomes. METHODS: We examined changes in patterns of health care use in a network of Federally Qualified Health Centers throughout a 9-year period of practice transformation that included recognition of all centers by the National Committee for Quality Assurance (NCQA) as Level 3 PCMH practices. We analyzed deidentified data from electronic health records for the period 2003 to 2011 to identify patterns of service use for all 4,595 patients with diabetes. We also examined a subsample of 545 patients who were in care throughout the study period to track improvement in glycated hemoglobin levels as a clinical measure over time. RESULTS: Through the transition to a PCMH, the mean number of encounters with outreach, diabetes educators, and psychosocial services increased for all diabetic patients; virtually all patients had visits with a primary care clinician, but the mean number of visits decreased slightly. Among patients in the subsample, mean annual levels of glycated hemoglobin decreased steadily during the 9-year study period, mainly driven by a reduction in patients having baseline levels exceeding 9%. CONCLUSIONS: This retrospective study conducted in a real-world setting using electronic health record data demonstrates a shift in resource use by diabetic patients from the primary care clinician to other members of the care team. The findings suggest that PCMH implementation has the potential to alter processes of care and improve outcomes of care, especially among those with higher disease burden.

Design and rationale of GUARDD-US: A pragmatic, randomized trial of genetic testing for APOL1 and pharmacogenomic predictors of antihypertensive efficacy in patients with hypertension.

RATIONALE AND OBJECTIVE: APOL1 risk alleles are associated with increased cardiovascular and chronic kidney disease (CKD) risk. It is unknown whether knowledge of APOL1 risk status motivates patients and providers to attain recommended blood pressure (BP) targets to reduce cardiovascular disease. STUDY DESIGN: Multicenter, pragmatic, randomized controlled clinical trial. SETTING AND PARTICIPANTS: 6650 individuals with African ancestry and hypertension from 13 health systems. INTERVENTION: APOL1 genotyping with clinical decision support (CDS) results are returned to participants and providers immediately (intervention) or at 6 months (control). A subset of participants are re-randomized to pharmacogenomic testing for relevant antihypertensive medications (pharmacogenomic sub-study). CDS alerts encourage appropriate CKD screening and antihypertensive agent use. OUTCOMES: Blood pressure and surveys are assessed at baseline, 3 and 6 months. The primary outcome is change in systolic BP from enrollment to 3 months in individuals with two APOL1 risk alleles. Secondary outcomes include new diagnoses of CKD, systolic blood pressure at 6 months, diastolic BP, and survey results. The pharmacogenomic sub-study will evaluate the relationship of pharmacogenomic genotype and change in systolic BP between baseline and 3 months. RESULTS: To date, the trial has enrolled 3423 participants. CONCLUSIONS: The effect of patient and provider knowledge of APOL1 genotype on systolic blood pressure has not been well-studied. GUARDD-US addresses whether blood pressure improves when patients and providers have this information. GUARDD-US provides a CDS framework for primary care and specialty clinics to incorporate APOL1 genetic risk and pharmacogenomic prescribing in the electronic health record. TRIAL REGISTRATION: ClinicalTrials.govNCT04191824.

Syndromic surveillance using ambulatory electronic health records.

OBJECTIVE: To assess the performance of electronic health record data for syndromic surveillance and to assess the feasibility of broadly distributed surveillance. DESIGN: Two systems were developed to identify influenza-like illness and gastrointestinal infectious disease in ambulatory electronic health record data from a network of community health centers. The first system used queries on structured data and was designed for this specific electronic health record. The second used natural language processing of narrative data, but its queries were developed independently from this health record. Both were compared to influenza isolates and to a verified emergency department chief complaint surveillance system. MEASUREMENTS: Lagged cross-correlation and graphs of the three time series. RESULTS: For influenza-like illness, both the structured and narrative data correlated well with the influenza isolates and with the emergency department data, achieving cross-correlations of 0.89 (structured) and 0.84 (narrative) for isolates and 0.93 and 0.89 for emergency department data, and having similar peaks during influenza season. For gastrointestinal infectious disease, the structured data correlated fairly well with the emergency department data (0.81) with a similar peak, but the narrative data correlated less well (0.47). CONCLUSIONS: It is feasible to use electronic health records for syndromic surveillance. The structured data performed best but required knowledge engineering to match the health record data to the queries. The narrative data illustrated the potential performance of a broadly disseminated system and achieved mixed results.

A risk-based intervention approach to eliminate diabetes health disparities.

Type 2 diabetes plays a major role in racial/ethnic health disparities. We conducted the first study to examine whether multifaceted interventions targeting patients with poorly controlled diabetes (HgbA1c >9%) can reduce racial/ethnic disparities in diabetes control. Among 4595 patients with diabetes at a Federally Qualified Health Center in New York, a higher percentage of blacks (32%) and Hispanics/Latinos (32%) had poorly controlled diabetes than whites (25%) at baseline (prevalence ratio, 1.28; 95% CI, 1.14-1.43; P<0.001). After four years, this percentage was reduced in all groups (blacks, 21%; Hispanics/Latinos, 20%; whites, 20%; P<0.001 for each relative to baseline). Disparities in diabetes control also were significantly reduced (change in disparity relative to whites: blacks, P=0.03; Hispanics/Latinos, P=0.008). In this diverse population, interventions targeting patients with poorly controlled diabetes not only improved diabetes control in all racial/ethnic groups, but significantly reduced disparities. This approach warrants further testing and may help reduce disparities in other populations.

Implementation of Care Management: An Analysis of Recent AHRQ Research.

Care management (CM) is a promising team-based, patient-centered approach "designed to assist patients and their support systems in managing medical conditions more effectively." As little is known about its implementation, this article describes CM implementation and associated lessons from 12 Agency for Healthcare Research and Quality-sponsored projects. Two rounds of data collection resulted in project-specific narratives that were analyzed using an iterative approach analogous to framework analysis. Informants also participated as coauthors. Variation emerged across practices and over time regarding CM services provided, personnel delivering these services, target populations, and setting(s). Successful implementation was characterized by resource availability (both monetary and nonmonetary), identifying as well as training employees with the right technical expertise and interpersonal skills, and embedding CM within practices. Our findings facilitate future context-specific implementation of CM within medical homes. They also inform the development of medical home recognition programs that anticipate and allow for contextual variation.

The role of faith-based institutions in addressing health disparities: a case study of an initiative in the southwest Bronx.

Although many public health initiatives have been implemented through collaborations with faith-based institutions, little is known about best practices for developing such programs. Using a community-based participatory approach, this case study examines the implementation of an initiative in the Bronx, New York, that is designed to educate community members about health promotion and disease management and to mobilize church members to seek equal access to health care services. The study used qualitative methods, including the collaborative development of a logic model for the initiative, focus groups, interviews, analysis of program reports, and participant observation. The paper examines three key aspects of the initiative's implementation: (1) the engagement of the church leadership; (2) the use of church structures as venues for education and intervention; and (3) changes in church policies. Key findings include the importance of pre-existing relationships within the community and the prominent agenda-setting role played by key pastors, and the strength of the Coalition's dual focus on health behaviors and health disparities. Given the churches' demonstrated ability to pull people together, to motivate and to inspire, there is great potential for faith-based interventions, and models developed through such interventions, to address health disparities.

Racial and ethnic disparities in health: a view from the South Bronx.

This study seeks to understand the perspective of Black and Hispanic/Latino residents of the South Bronx, New York, on the causes of persistent racial and ethnic disparities in health outcomes. In particular, it focuses on how people who live in this community perceive and interact with the health care system. Findings from 9 focus groups with 110 participants revealed a deep and pervasive distrust of the health care system and a sense of being disrespected, exacerbated by difficulties that patients experience in communicating with their providers. The paper suggests how health care institutions might respond to these perceptions.

Fostering organizational change through a community-based initiative.

Program funders and managers are increasingly interested in fostering changes in the policies, practices, and procedures of organizations participating in community-based initiatives. But little is known about what factors contribute to the institutionalization of change. In this study, the authors assess whether the organizational members of the Bronx Health REACH Coalition have begun to change their functioning and role with regard to their clients and their staff and in the broader community, apart from their implementation of the funded programs for which they are responsible. The study identifies factors that seemed to contribute to or hinder such institutional change and suggests several strategies for coalitions and funders that are seeking to promote and sustain organizational change.

ENHANCING COMMUNITY HEALTH BY IMPROVING PHYSICIAN PARTICIPATION.

Leading medical associations have called for renewed standards of medical professionalism, including stronger public advocacy, a commitment to social justice in health care, and greater community engagement. New strategies are needed to enhance community participation among physicians, which can improve public trust in the medical profession and contribute needed expertise and teamwork to matters of community health. One strategy is to incorporate community participation and leadership in medical training through community-based organization (CBO) placement of residents. We describe a model CBO placement program within a family medicine residency in Harlem, New York City. This program enables residents to partner with organizations that address social, political, economic, and environmental determinants of health in underserved populations, and to assume leadership roles in community health activities. Broader implementation of this model in other settings, both urban and rural, can enhance community participation by physicians within a sustainable framework, and promote medical professionalism and community health.

Primary care and health reform.

Skyrocketing health care costs are burdening our people and our economy, yet health care indicators show how little we are achieving with the money we spend. Federal and state governments, along with public-health experts and policymakers, are proposing a host of new initiatives to find solutions. The Patient Protection and Affordable Care Act is designed to address both the quality and accessibility of health care, while reducing its cost. This article provides an overview of models supported by the Affordable Care Act that address one or more goals of the "Triple Aim": better health care for individuals, better health outcomes in the community, and lower health care costs. The models described below rely on the core principles of primary care: comprehensive, coordinated and continuous primary care; preventive care; and the sophisticated implementation of health information technology designed to promote communication between health care providers, enhance coordination of care, minimize duplication of services, and permit reporting on quality. These models will support better health care and reduced costs for people who access health care services but will not address health outcomes in the community at large. Health care professionals, working in concert with community-based organizations and advocates, must also address conditions that influence health in the broadest sense to truly improve the health of our communities and reduce health care costs.

"Lost to follow-up": the public health goals of accountable care.

The Affordable Care Act made admirable strides toward the "triple aim" of reducing health care costs, increasing health care quality, and improving the health of the community at large. A key element of reform is the accountable care organization (ACO), which restructures health care delivery such that networks of providers are held responsible for a group of patients they serve. The recently announced Medicare ACO program lays the foundation for 2 of its 3 major goals by allowing ACOs to share in any cost savings, provided they meet quality criteria. Yet it seems that the public health goals of accountable care-arguably the most important of the 3-have been left behind. To better address public health goals, we propose a novel method for quality reporting within ACOs: introducing an "expanded denominator" that attributes patients to a health system if they have ever been seen within the system. An expanded denominator would ensure that ACOs are held accountable not only for patients already engaged in primary care but also for patients with fragmented care and high-risk community members not receiving adequate care. Ultimately, payment reform in Medicare, and potentially Medicaid, must support this new approach to quality measurement for it to have lasting ramifications.

Family medicine: a specialty for all ages.

After a diminishing of its ranks following the post-World War II explosion of growth in medical discoveries, advanced medical technology, and the concomitant specialization of the physician workforce, family medicine is re-establishing itself as a leading medical specialty that has garnered growing interest among recent medical-school graduates. Family physicians provide care for patients of all ages, from newborns to the elderly. In addition to its wide scope of practice, family medicine is characterized by its emphasis on understanding of the whole person, its partnership approach with patients over many years, and its command of medical complexity. Family physicians are trained both to use community resources to assist individual patients in meeting medical or social needs and to identify and address community-wide needs. The specialty of family medicine is uniquely positioned to provide a leadership role in health-reform efforts that are accelerating across the country. Health care models that are gaining traction, such as the patient-centered medical home model, health homes, and accountable care organizations, share the characteristics of providing comprehensive, coordinated patient care with an emphasis on disease prevention and health promotion. This model of care, provided in the context of family and community, has been the hallmark of family medicine since its creation as a distinct medical specialty more than 40 years ago. In addition, family physicians' ability to care for patients of all ages make them particularly cost-effective as the new models of care move to improve access to care through expanded hours and locations.

Patient registries in primary care: essential element for quality improvement.

Primary care in the United States has been in the midst of a transformation from a system based solely on individual office interactions to one that includes managing health at a population level. The chronic care model provides a robust framework for health systems to transform and restructure their delivery of care to one that is committed to delivering multidisciplinary quality care with a proactive approach. Patient and disease registries are the essential tools necessary to inform all elements of the chronic care model and guide practices though this transformation. Nationally as well as internationally, when used as part of a robust continuous quality-improvement program, registries have demonstrated to improve patient outcomes and reduce healthcare costs. Despite challenges practices may confront when initially developing a patient registry, it is evident that population management is now an important and integral component of a successful primary-care practice whose aim is to improve quality of patient care.

A model for expanded public health reporting in the context of HIPAA.

The advent of electronic medical records and health information exchange raise the possibility of expanding public health reporting to detect a broad range of clinical conditions and of monitoring the health of the public on a broad scale. Expanding public health reporting may require patient anonymity, matching records, re-identifying cases, and recording patient characteristics for localization. The privacy regulations under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) provide several mechanisms for public health surveillance, including using laws and regulations, public health activities, de-identification, research waivers, and limited data sets, and in addition, surveillance may be distributed with aggregate reporting. The appropriateness of these approaches varies with the definition of what data may be included, the requirements of the minimum necessary standard, the accounting of disclosures, and the feasibility of the approach.

Opening doors and building capacity: employing a community-based approach to surveying.

Although many community-based initiatives employ community residents to undertake door-to-door surveys as a form of community mobilization or for purposes of needs assessment or evaluation, very little has been published on the strengths and weaknesses of this approach. This article discusses our experience in undertaking such a survey in collaboration with a coalition of community-based organizations (CBOs) in the South Bronx, New York. Although resource constraints limited the already-strained capacity of the CBOs to provide supervision, the CBOs and community surveyors helped us gain access to neighborhood buildings and to individuals who might otherwise have been inaccessible. The survey process also contributed to the coalition's community outreach efforts and helped to link the CBO leadership and staff more closely to the coalition and its mission. Many of the surveyors enhanced their knowledge and skills in ways that have since benefited them or the coalition directly. The participating CBOs continue to be deeply engaged in the coalition's work, and many of the surveyors are active as community health advocates and have taken leadership roles within the coalition.