Practical implementation insights from 2 population health pharmacist project approaches to improve blood pressure control.

BACKGROUND: Population health pharmacists (PHPs) can optimize medication regimens for blood pressure (BP) control using various approaches based on the timing of medication recommendations sent to providers. OBJECTIVE: To identify the contextual factors and implementation insights from 2 PHP approaches to consider when implementing PHP initiatives. PRACTICE DESCRIPTION: A federally qualified health center with 14 sites throughout Connecticut. PRACTICE INNOVATION: A centralized PHP performed medication reviews and sent recommendations to providers. The providers reviewed the recommendations for implementation into patients' care plans. The 2 PHP approaches used were: JUST-IN-TIME (JIT) APPROACH: A part-time, contracted PHP used weekly reports to identify 204 patients with uncontrolled hypertension (BP ≥140/90 mm Hg) and same-week provider appointments. ANYTIME (ANY) APPROACH: A full-time staff PHP used a registry report to identify 41 patients with uncontrolled hypertension (systolic BP: 140-150 mm Hg) and diabetes (glycosylated hemoglobin: 9%-10%) regardless of the next appointment date. EVALUATION METHODS: Four of the 5 Reach, Effectiveness, Adoption, Implementation, and Maintenance framework dimensions were used to assess the JIT and ANY approaches. Quantitative data were analyzed using descriptive statistics and chi-square or Fisher exact tests. RESULTS: The contextual factors that affected the reach, effectiveness, adoption, and implementation of the 2 projects included the timing of PHP recommendations, PHP employment status, and PHP's prior work experience. The PHP insights to consider when implementing these projects include the need to (1) build trusted relationships with providers/other team members; (2) demonstrate sensitivity and respect for providers' workload/workflow; (3) send concise, actionable, and timely recommendations; and (4) measure value/impact of PHP interventions with defined metrics. The organizational implementation insights to consider include clearly defining the role of the PHP, providing clinical/administrative buy-in and support, fostering a strong organizational culture for team-based care, and collaboration with the data analytics team to identify patients classified as high impact. CONCLUSION: The contextual factors and implementation insights identified can be used pragmatically by primary care clinical leaders to integrate a limited PHP resource on an existing population health team.

Are Pain Screening and Functional Assessment Results Associated with New Diagnoses and Treatment for Pain in Primary Care? An Observational Study.

Purpose: To determine if pain screening and functional assessment results are associated with new diagnoses and treatment for pain in primary care. Patients and Methods: Observational study at 13 primary care sites of a statewide federally qualified health center that implemented routine screening and functional assessment for all adults in primary care. The study group included 10,091 adults aged 18+ who had an in-person visit between July 2, 2018, and June 1, 2019, where they screened positive for chronic pain and completed a 3-question functional assessment with the PEG (Pain, Enjoyment of Life, General Activity). Multivariate logistic regressions quantified associations between pain frequency, diagnosis and treatment, sociodemographics, comorbidities, and self-reported severe pain impairment with pain diagnoses and treatment documented after screening. Results: Patients were mostly women (60.3%), Latinx (41.1%), English-speaking (80.1%), and Medicaid-insured (62.0%); they averaged 49.1 years old (SD = 13.7 years). Patients with severe pain impairment or who were Latinx were more likely to get a newly documented pain diagnosis (absolute risk difference [ARD]: 13.2% and 8.6%, ps < 0.0001), while patients with mental health/substance use or medical comorbidities were less likely (ARDs: -20.0% to -6.2%, ps < 0.001). Factors most consistently associated with treatment were prior treatment of the same modality (4 of 7 treatments, ARDs = 27.3% to 44.1%, ps <0.0001), new pain diagnosis (5 of 7, ARDs = 3.2% to 27.4%, ps <0.001), and severe impairment (4 of 7, ARDs = 2.6% to 6.5%, ps < 0.0001). A new diagnosis had the strongest association with non-opioid pain analgesics and physical medicine (ARD = 27.0% and 27.4%, p < 0.0001). Latinx patients were less likely to receive opioid analgesics and mental health/substance use medications and counseling (ARDs = -3.3% to 7.5%, ps <0.0001). Conclusion: Screening and assessment with patient-reported tools may influence pain care. Care for Latinx patients differed from non-Latinx white patients.

Evaluating Primary Care Providers' Readiness for Delivering Genetic and Genomic Services to Underserved Populations.

INTRODUCTION: Increased genomics knowledge and access are advancing precision medicine and care delivery. With the translation of precision medicine across health care, genetics and genomics will play a greater role in primary care services. Health disparities and inadequate representation of racial and ethnically diverse groups threaten equitable access for those historically underserved. Health provider awareness, knowledge, and perceived importance are important determinants of the utilization of genomic applications. METHODS: We evaluated the readiness of primary care providers at a Federally Qualified Health Center, the Community Health Center, Inc. (CHCI) for delivering genetic and genomic testing to underserved populations. Online survey questions focused on providers' education and training in basic and clinical genetics, familiarity with current genetic tests, and needs for incorporating genetics and genomics into their current practice. RESULTS: Fifty of 77 (65%) primary care providers responded to the survey. Less than half received any training in basic or clinical genetics (40%), were familiar with specific genetic tests (36%), or felt confident with collecting family health history (44%), and 70% believed patients would benefit from genetic testing. CONCLUSION: Despite knowledge gaps, respondents recognized the value and need to bring these services to their patients, though would like more education on applying genetics and genomics into their practice, and more training about discussing risk factors associated with race or ethnicity. We provide further evidence of the need for educational resources and standardized guidelines for providers caring for underserved populations to optimize appropriate use and referral of genetic and genomic services and to reduce disparities in care.

Evaluation of a Chronic Pain Screening Program Implemented in Primary Care.

Importance: Although pain is among the most common symptoms reported by patients, primary care practitioners (PCPs) face substantial challenges identifying and assessing pain. Objective: To evaluate a 2-step process for chronic pain screening and follow-up in primary care. Design, Setting, and Participants: A cross-sectional study of patients with a primary care visit between July 2, 2018, and June 1, 2019, was conducted at a statewide, multisite federally qualified health center. Participants included 68 PCPs and 58 medical assistants from 13 sites who implemented the screening process in primary care, and 38 866 patients aged 18 years or older with a primary care visit during that time. Exposures: Single-question assessment of pain frequency, followed by a 3-question PEG (pain, enjoyment of life, general activity) functional assessment for patients with chronic pain. Main Outcomes and Measures: Adherence to a 2-step chronic pain screening and PEG process, proportion of patients with positive screening results, mean PEG pain severity greater than or equal to 7, and documented chronic painful condition diagnosis in patient's electronic health record between 1 year before and 90 days after screening. Results: Of 38 866 patients with a primary care visit, 31 600 patients (81.3%) underwent screening. Mean (SD) age was 46.2 (15.4) years, and most were aged 35 to 54 years (12 987 [41.1%]), female (18 436 [58.3%]), Hispanic (14 809 [46.9%]), and English-speaking (22 519 [71.3%]), and had Medicaid insurance (18 442 [58.4%]). A total of 10 262 participants (32.5%) screened positive and, of these, 9701 (94.5%) completed the PEG questionnaire. PEG responses indicated severe pain interference with activities of daily living (PEG ≥7) in 5735 (59.1%) participants. A chronic painful condition had not been diagnosed in 4257 (43.9%) patients in the year before screening. A new chronic painful condition was diagnosed at screening or within 90 days in 2250 (52.9%) patients. Care teams found the workflow acceptable, but cited lengthy administration time, challenges with comprehension of the PEG questions, and limited comprehensiveness as implementation barriers. Conclusions and Relevance: A systematic, 2-step process for chronic pain screening and functional assessment in primary care appeared to identify patients with previously undocumented chronic pain and was feasible to implement. Patient-provided information on the frequency of pain, pain level, and pain interference can help improve the assessment and monitoring of pain in primary care.