The Odyssey of HOMER: Comparative Effectiveness Research on Medication for Opioid Use Disorder During the COVID-19 Pandemic.

The usual challenges of conducting primary care research, including randomized trials, have been exacerbated, and new ones identified, during the COVID-19 pandemic. HOMER (Home versus Office for Medication Enhanced Recovery; subsequently, Comparing Home, Office, and Telehealth Induction for Medication Enhanced Recovery) is a pragmatic, comparative-effectiveness research trial that aims to answer a key question from patients and clinicians: What is the best setting in which to start treatment with buprenorphine for opioid use disorder for this patient at this time? In this article, we describe the difficult journey to find the answer. The HOMER study began as a randomized trial comparing treatment outcomes in patients starting treatment with buprenorphine via induction at home (unobserved) vs in the office (observed, synchronous). The study aimed to enroll 1,000 participants from 100 diverse primary care practices associated with the State Networks of Colorado Ambulatory Practices and Partners and the American Academy of Family Physicians National Research Network. The research team faced unexpected challenges related to the COVID-19 pandemic and dramatic changes in the opioid epidemic. These challenges required changes to the study design, protocol, recruitment intensity, and funding conversations, as well as patience. As this is a participatory research study, we sought, documented, and responded to practice and patient requests for adaptations. Changes included adding a third study arm using telehealth induction (observed via telephone or video, synchronous) and switching to a comprehensive cohort design to answer meaningful patient-centered research questions. Using a narrative approach based on the Greek myth of Homer, we describe here the challenges and adaptations that have provided the opportunity for HOMER to thrive and find the way home. These clinical trial strategies may apply to other studies faced with similar cultural and extreme circumstances.

Continuous glucose monitoring among nurse practitioners in primary care: Characteristics associated with prescribing and resources needed to support use.

BACKGROUND: Continuous glucose monitoring (CGM) can improve health for people with diabetes but is limited in primary care (PC). Nurse Practitioners (NPs) in PC can improve diabetes management through CGM, but NPs' interest in CGM and support needed are unclear. PURPOSE: We describe behaviors and attitudes related to CGM for diabetes management among NPs in PC. METHODOLOGY: This cross-sectional web-based survey of NPs practicing in PC settings used descriptive statistics to describe CGM experience and identify resources to support prescribing. We used multivariable regression to explore characteristics predicting prescribing and confidence using CGM for diabetes. RESULTS: Nurse practitioners in hospital-owned settings were twice as likely to have prescribed CGM (odds ratio [OR] = 2.320, 95% CI [1.097, 4.903]; p = .002) than private practice; those in academic medical centers were less likely (OR = 0.098, 95% CI [0.012, 0.799]; p = .002). Past prescribing was associated with favorability toward future prescribing (coef. = 0.7284, SE = 0.1255, p < .001) and confidence using CGM to manage diabetes (type 1: coef. = 3.57, SE = 0.51, p < .001; type 2: coef. = 3.49, SE = 0.51, p < .001). Resources to prescribe CGM included consultation with an endocrinologist (62%), educational website (61%), and endocrinological e-consultations (59%). CONCLUSIONS: Nurse practitioners are open to prescribing CGM and can improve diabetes management and health outcomes for PC patients. IMPLICATIONS: Research should explore mechanisms behind associations with CGM experience and attitudes. Efforts to advance CGM should include educational websites and endocrinology consultations for NPs in PC.

A Unique Model and Workforce to Address Health-Related Social Needs and Health Equity: Regional Health Connectors in Colorado.

Unmet health-related social needs contribute to high morbidity and poor population health. Improving social conditions are likely to reduce health disparities and improve the health of the overall U.S. population. The primary objective of this article is to describe an innovative workforce model, called Regional Health Connectors (RHCs), and how they address health-related social needs in Colorado. This is a program evaluation that analyzed field notes and interview data from 2021-2022. We applied our findings to the framework developed by the National Academies of Sciences, Engineering, and Medicine's (NASEM's) report on strengthening social care integration into health care (2019). We found that RHCs address the following health-related social needs most commonly: food insecurity (n = 18 of 21 regions or 85% of all regions), housing (n = 17 or 81% of all regions), transportation (n = 11 or 52% of all regions), employment opportunities (n = 10 or 48% of all regions), and income/financial assistance (n = 11 or 52% of all regions). RHCs interacted across many sectors to address health-related social needs and provided multiple types of support to primary care practices at the organizational level. Examples of emerging impact of RHCs are described and mapped onto the NASEM framework. Findings from this program evaluation add to the growing landscape of knowledge and importance of detecting and addressing health-related social needs. We conclude that RHCs are a unique and emerging workforce that addresses multiple domains needed to integrate social care into health care.

Continuous Glucose Monitoring in Primary Care: Understanding and Supporting Clinicians' Use to Enhance Diabetes Care.

PURPOSE: Diabetes affects approximately 34 million Americans and many do not achieve glycemic targets. Continuous glucose monitoring (CGM) is associated with improved health outcomes for patients with diabetes. Most adults with diabetes receive care for their diabetes in primary care practices, where uptake of CGM is unclear. METHODS: We used a cross-sectional web-based survey to assess CGM prescribing behaviors and resource needs among primary care clinicians across the United States. We used descriptive statistics and multivariable regression to identify characteristics associated with prescribing behaviors, openness to prescribing CGM, and to understand resources needed to support use of CGM in primary care. RESULTS: Clinicians located more than 40 miles from the nearest endocrinologist's office were more likely to have prescribed CGM and reported greater likelihood to prescribe CGM in the future than those located within 10 miles of an endocrinologist. Clinicians who served more Medicare patients reported favorable attitudes toward future prescribing and higher confidence using CGM to manage diabetes than clinicians with lower Medicare patient volume. The most-needed resources to support CGM use in primary care were consultation on insurance issues and CGM training. CONCLUSIONS: Primary care clinicians are interested in using CGM for patients with diabetes, but many lack the resources to implement use of this diabetes technology. Use of CGM can be supported with education in the form of workshops and consultation on insurance issues targeted toward residents, recent graduates, and practices without a nearby endocrinologist. Continued expansion of Medicare and Medicaid coverage for CGM can also support CGM use in primary care.

Points of Concordance, Points of Discordance: A Qualitative Examination of Telemedicine Implementation.

INTRODUCTION: Health systems undertook a rapid transition to increase the use of telemedicine in the wake of the COVID-19 pandemic. A continued need for telemedicine services in the coming years is likely. This article examines telemedicine from multiple stakeholders' perspectives considering reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) outcomes. METHODS: Semistructured interviews were conducted with primary care practice team members and patients. Rapid qualitative analysis was used to identify themes in experiences and perceptions related to telemedicine implementation. The RE-AIM implementation framework was applied to thematic findings to understand influences on implementation outcomes. RESULTS: Twenty-four practice members and 17 patients across 5 clinics participated. All stakeholder groups reported that technological capabilities influenced patients' access to telemedicine and that certain patients and reasons for visits were not appropriate for telemedicine. All groups felt that telemedicine was a good option for some patients some of the time but not all patients all of the time. DISCUSSION: Telemedicine works well if it is used for the appropriate visits and patient types and with needed technological elements. Older age may limit the feasibility of telehealth for some patients. Added administrative work and associated costs support systematic screening to determine visit appropriateness for telemedicine.

Facilitators and Barriers to Patient-Centered Outcomes Research Partnership Sustainability in the United States.

PURPOSE: Engaging patients in research can enhance relevance and accelerate implementation of findings. Despite investment in patient-centered outcomes research (PCOR), short-term funding cannot maintain such efforts beyond the program timeframe. Sustained interaction between researchers, practitioners, patients, and other stakeholders is needed to sustain use of evidence-based practices and achieve maximum benefit. While previous literature describes components of public health program sustainability, such factors do not necessarily apply to the partnerships that implement those programs, and facilitators are likely to differ across disciplines. We sought to determine facilitators and barriers to PCOR partnership sustainability from participant experiences with sustainable and unsustainable community-academic partnerships across the United States. METHODS: From 2017 to 2019, a collaboration representing public health institutes, community-based organizations, and academic organizations convened PCOR partnership members in virtual focus groups and conducted qualitative analysis to identify facilitators and barriers to partnership sustainability. A grounded theory framework, which applied a combination of a priori codes (barriers, facilitators, sustainable, not sustainable) and open coding, guided participant selection, data collection, and analysis across all project stages. RESULTS: There was no single definition of partnership sustainability. Common facilitators of sustainability were investing time in relationships, connector role to promote communication and trust, equal power dynamics, shared motivation for participation, partnership institutionalization, and reciprocity. Barriers to partnership sustainability included external factors influencing participation and operations, funding-related challenges, and lack of institutionalization. CONCLUSIONS: PCOR partnerships should incorporate an early and ongoing focus on relationship development through intentional efforts to collaborate with specific partners and stakeholders according to the goals of the research. This would allow more patients to access the evidence-based practices resulting from research investments.

Making the Random the Usual: Appreciative Inquiry/Boot Camp Translation-Developing Community-Oriented Evidence That Matters.

Background: The evidence underlying clinical guidelines arising from typical scientific inquiry may not always match the needs and concerns of local communities. Our High Plains Research Network Community Advisory Council (HPRN CAC) identified a need for evidence regarding how to assist members of their community suffering from mental health issues to recognize their need for help and then obtain access to mental health care. The lack of evidence led our academic team to pursue linking Appreciative Inquiry with Boot Camp Translation (AI/BCT). This article describes the development and testing of this linked method. Method: We worked with the HPRN CAC and other communities affiliated with the State Networks of Colorado Ambulatory Practices and Partners (SNOCAP) practice-based research networks to identify 5 topics for testing of AI/BCT. For each topic, we developed AI interview recruitment strategies and guides with our community partners, conducted interviews, and analyzed the interview data. Resulting themes for each topic were then utilized by 5 groups with the BCT method to develop community relevant messages and materials to communicate the evidence generated in each AI set of interviews. At each stage for each topic, notes on adaptations, barriers, and successes were recorded by the project team. Results: Each topic successfully led to generation of community specific evidence, messages, and materials for dissemination using the AI/BCT method. Beyond this, 5 important lessons emerged regarding the AI/BCT method: Researchers must (1) first ensure whether the topic is a good fit for AI, (2) maintain a focus on "what works" throughout all stages, (3) recruit one or more experienced qualitative analysts, (4) ensure adequate time and resources for the extensive AI/BCT process, and (5) present AI findings to BCT participants in the context of existing evidence and the local community and allow time for community partners to ask questions and request additional data analyses to be done. Conclusions: AI/BCT represents an effective way of responding to a community's need for evidence around a specific topic where standard evidence and/or guidelines do not exist. AI/BCT is a method for turning the "random" successes of individuals into "usual" practice at a community level.

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.

Primary Care Practices' Implementation of Patient-Team Partnership: Findings from EvidenceNOW Southwest.

INTRODUCTION: Care teams partnering with patients are integral to quality primary care. Effective patient-team partnership recognizes patients' contributions in decision-making and respecting patients' goals and social context. We report practice characteristics associated with greater patient-team partnership scores. METHODS: EvidenceNOW Southwest was a multistate initiative to improve cardiovascular care in primary care practices through guideline-concordant aspirin use, blood pressure control, cholesterol management, and smoking cessation. EvidenceNOW Southwest provided 9 months of practice facilitation and information technology support through regular meetings and training to 211 Colorado and New Mexico primary care practices from 2015 to 2017. We analyzed surveys from 97% of participating practices regarding patient-team partnership activities of self-management support, social need assessment, resource linkages, and patient input. We used linear and mixed effects regression modeling to examine relationships between patient-team partnership and practice characteristics. RESULTS: Practice characteristics significantly associated with greater patient-team partnership were using patient registries, medically underserved area designation, multispecialty mix, and using clinical cardiovascular disease management guidelines. Our findings suggest that patient-team partnership implementation in small primary care practices is moderate, with mean practice- and member-level scores of 52 of 100 (range, 0-100) and 71 of 100 (range, 10-100), respectively. CONCLUSION: Practices can improve efforts to partner with patients to assess social needs, gather meaningful input on practice improvement and patient experience, and offer resource connections. Our findings supplement recent evidence that patient registries and evidence-based guidelines may effectively prevent and manage cardiovascular disease. These strategies may also promote primary care patient-team partnership.

What Makes for Successful Registry Implementation: A Qualitative Comparative Analysis.

PURPOSE: Registry implementation is an important component of successfully achieving patient-centered medical home designation and an important part of population-based health. The purpose of this study was to examine what factors are evident in the successful implementation of a registry in a selection of Colorado practices involved in quality-improvement activities. METHODS: In-depth, small-group interviews occurred at 13 practices. The data were recorded, transcribed, and qualitatively analyzed to identify key themes regarding elements of successful registry implementation. Key elements were described as conditions, then calibrated and analyzed using qualitative comparative analysis (QCA). RESULTS: The QCA revealed several formulas to successful registry implementation. Key conditions included the importance of Resources and Leadership along with either a Quality Improvement Mindset or a Key Person driving efforts (or both). Health System membership affected the specific formula. DISCUSSION: This study is innovative in that it examines which factors and in what combination are necessary for successful implementation of a registry. The findings have implications for primary care quality-improvement efforts.

Understanding adaptations to patient-centered medical home activities: The PCMH adaptations model.

Primary care practices have increasingly adopted the patient-centered medical home (PCMH) model and often adapted quality improvement efforts to fit local context. This paper implemented a modified framework for understanding adaptations in the context of primary care PCMH transformation efforts. We combined an adaptations model by Stirman et al. that categorized adaptations to evidence-based interventions in research studies with dimensions from the RE-AIM framework, as well as items specific to PCMH. The resulting constructs were translated into a "plain English" adaptations interview. We conducted interviews with 27 practices and used resulting descriptive categories to inform exploratory analyses of the relationships between adaptation characteristics and improvement outcomes in PCMH domains of team-based care and data capacity. Practices most commonly focused on development and use of disease registries and enhancements to team-based care (not disease-specific outcomes). Adaptations were common, with practices most frequently making changes to format or personnel. Adaptations were most often intended to increase effectiveness and based on pragmatic considerations. Generally similar adaptation themes emerged across different content topics (registry and quality improvement team). Adaptations initiated or carried out by the entire team or made in early to middle stages of the project were most related to outcome measures of team-based care and data capacity. This paper extends adaptation models from specific interventions in research studies to PCMH quality improvement efforts. Despite limitations, the PCMH Adaptations Model provided a useful framework to understand adaptations in this context.