Clinician Experiences With Telepsychiatry Collaborative Care for Posttraumatic Stress Disorder and Bipolar Disorder.

OBJECTIVE: Posttraumatic stress disorder (PTSD) and bipolar disorder are common in primary care. Evidence supports collaborative care in primary care settings to treat depression and anxiety, and recent studies have evaluated its effectiveness in treating complex conditions such as PTSD and bipolar disorder. This study aimed to examine how primary care clinicians experience collaborative care for patients with these more complex psychiatric disorders. METHODS: The authors conducted semistructured interviews with 22 primary care clinicians participating in a pragmatic trial that included telepsychiatry collaborative care (TCC) to treat patients with PTSD or bipolar disorder in rural or underserved areas. Analysis utilized a constant comparative method to identify recurring themes. RESULTS: Clinicians reported that TCC improved their confidence in managing medications for patients with PTSD or bipolar disorder and supported their ongoing learning and skill development. Clinicians also reported improvements in patient engagement in care. Care managers were crucial to realizing these benefits by fostering communication within the clinical team while engaging patients through regular outreach. Clinicians valued TCC because it included and supported them in improving the care of patients' mental health conditions, which opened opportunities for clinicians to enhance care and address co-occurring general medical conditions. Overall, benefits of the TCC model outweighed its minimal burdens. CONCLUSIONS: Clinicians found that TCC supported their care of patients with PTSD or bipolar disorder. This approach has the potential to extend the reach of specialty mental health care and to support primary care clinicians treating patients with these more complex psychiatric disorders.

How Does Prior Experience Pay Off in Large-Scale Quality Improvement Initiatives?

INTRODUCTION: To examine the association of prior investment on the effectiveness of organizations delivering large-scale external support to improve primary care. METHODS: Mixed-methods study of 7 EvidenceNOW grantees (henceforth, Cooperatives) and their recruited practices (n = 1720). Independent Variable: Cooperatives's experience level prior to EvidenceNOW, defined as a sustained track record in delivering large-scale quality improvement (QI) to primary care practices (high, medium, or low). Dependent Variables: Implementation of external support, measured as facilitation dose; effectiveness at improving (1) clinical quality, measured as practices' performance on Aspirin, Blood Pressure, Cholesterol, and Smoking (ABCS); and (2) practice capacity, measured using the Adaptive Reserve (AR) score and Change Process Capacity Questionnaire (CPCQ). Data were analyzed using multivariable linear regressions and a qualitative inductive approach. RESULTS: Cooperatives with High (vs low) levels of prior experience with and investment in large-scale QI before EvidenceNOW recruited more geographically dispersed and diverse practices, with lower baseline ABCS performance (differences ranging from 2.8% for blood pressure to 41.5% for smoking), delivered more facilitation (mean=+20.3 hours, P = .04), and made greater improvements in practices' QI capacity (CPCQ: +2.04, P < .001) and smoking performance (+6.43%, P = .003). These Cooperatives had established networks of facilitators at the start of EvidenceNOW and leadership experienced in supporting this workforce, which explained their better recruitment, delivery of facilitation, and improvement in outcomes. DISCUSSION: Long-term investment that establishes regionwide organizations with infrastructure and experience to support primary care practices in QI is associated with more consistent delivery of facilitation support, and greater improvement in practice capacity and some clinical outcomes.

Effective Facilitator Strategies for Supporting Primary Care Practice Change: A Mixed Methods Study.

PURPOSE: Practice facilitation is an evidence-informed implementation strategy to support quality improvement (QI) and aid practices in aligning with best evidence. Few studies, particularly of this size and scope, identify strategies that contribute to facilitator effectiveness. METHODS: We conducted a sequential mixed methods study, analyzing data from EvidenceNOW, a large-scale QI initiative. Seven regional cooperatives employed 162 facilitators to work with 1,630 small or medium-sized primary care practices. Main analyses were based on facilitators who worked with at least 4 practices. Facilitators were defined as more effective if at least 75% of their practices improved on at least 1 outcome measure-aspirin use, blood pressure control, smoking cessation counseling (ABS), or practice change capacity, measured using Change Process Capability Questionnaire-from baseline to follow-up. Facilitators were defined as less effective if less than 50% of their practices improved on these outcomes. Using an immersion crystallization and comparative approach, we analyzed observational and interview data to identify strategies associated with more effective facilitators. RESULTS: Practices working with more effective facilitators had a 3.6% greater change in the mean percentage of patients meeting the composite ABS measure compared with practices working with less effective facilitators (P <.001). More effective facilitators cultivated motivation by tailoring QI work and addressing resistance, guided practices to think critically, and provided accountability to support change, using these strategies in combination. They were able to describe their work in detail. In contrast, less effective facilitators seldom used these strategies and described their work in general terms. Facilitator background, experience, and work on documentation did not differentiate between more and less effective facilitators. CONCLUSIONS: Facilitation strategies that differentiate more and less effective facilitators have implications for enhancing facilitator development and training, and can assist all facilitators to more effectively support practice changes.

How Does Prior Experience Pay Off in Large-Scale Quality Improvement Initiatives?

INTRODUCTION: To examine the association of prior investment on the effectiveness of organizations delivering large-scale external support to improve primary care. METHODS: Mixed-methods study of 7 EvidenceNOW grantees (henceforth, Cooperatives) and their recruited practices (n = 1720). Independent Variable: Cooperatives's experience level prior to EvidenceNOW, defined as a sustained track record in delivering large-scale quality improvement (QI) to primary care practices (high, medium, or low). Dependent Variables: Implementation of external support, measured as facilitation dose; effectiveness at improving (1) clinical quality, measured as practices' performance on Aspirin, Blood Pressure, Cholesterol, and Smoking (ABCS); and (2) practice capacity, measured using the Adaptive Reserve (AR) score and Change Process Capacity Questionnaire (CPCQ). Data were analyzed using multivariable linear regressions and a qualitative inductive approach. RESULTS: Cooperatives with High (vs low) levels of prior experience with and investment in large-scale QI before EvidenceNOW recruited more geographically dispersed and diverse practices, with lower baseline ABCS performance (differences ranging from 2.8% for blood pressure to 41.5% for smoking), delivered more facilitation (mean=+20.3 hours, P = .04), and made greater improvements in practices' QI capacity (CPCQ: +2.04, P < .001) and smoking performance (+6.43%, P = .003). These Cooperatives had established networks of facilitators at the start of EvidenceNOW and leadership experienced in supporting this workforce, which explained their better recruitment, delivery of facilitation, and improvement in outcomes. DISCUSSION: Long-term investment that establishes regionwide organizations with infrastructure and experience to support primary care practices in QI is associated with more consistent delivery of facilitation support, and greater improvement in practice capacity and some clinical outcomes.

Impact of Home Blood Pressure Data Visualization on Hypertension Medical Decision Making in Primary Care.

PURPOSE: Evidence shows the value of home blood pressure (BP) monitoring in hypertension management. Questions exist about how to effectively incorporate these readings into BP follow-up visits. We developed and implemented a tool that combines clinical and home BP readings into an electronic health record (EHR)-integrated visualization tool. We examined how this tool was used during primary care visits and its effect on physician-patient communication and decision making about hypertension management, comparing it with home BP readings on paper. METHODS: We video recorded the hypertension follow-up visits of 73 patients with 15 primary care physicians between July 2018 and April 2019. During visits, physicians reviewed home BP readings with patients, either directly from paper or as entered into the EHR visualization tool. We used conversation analysis to analyze the recordings. RESULTS: Home BP readings were viewed on paper for 26 patients and in the visualization tool for 47 patients. Access to home BP readings during hypertension management visits, regardless of viewing mode, positioned the physician and patient to assess BP management and make decisions about treatment modification, if needed. Length of BP discussion with the visualization tool was similar to or shorter than that with paper. Advantages of the visualization tool included ease of use, and enhanced and faster sense making and decision making. Successful use of the tool required patients' ability to obtain their BP readings and enter them into the EHR via a portal, and an examination room configuration that allowed for screen sharing. CONCLUSIONS: Reviewing home BP readings using a visualization tool is feasible and enhances sense making and patient engagement in decision making. Practices and their patients need appropriate infrastructure to realize these benefits.

Patient and Clinician Perspectives on Two Telemedicine Approaches for Treating Patients with Mental Health Disorders in Underserved Areas.

BACKGROUND: Primary care practices in underserved and/or rural areas have limited access to mental health specialty resources for their patients. Telemedicine can help address this issue, but little is known about how patients and clinicians experience telemental health care. METHODS: This pragmatic randomized effectiveness trial compared telepsychiatry collaborative care, where telepsychiatrists provided consultation to primary care teams, to a referral approach, where telepsychiatrists and telepsychologists assumed responsibility for treatment. Twelve Federally Qualified Health Centers in rural and/or underserved areas in 3 states participated. RESULTS: Patients and clinicians reported that both interventions alleviated barriers to accessing mental health care, provided quality treatment, and offered improvements over usual care. Telepsychiatry collaborative care was identified as better for patients with difficulty developing trust with new providers. This approach also required more primary care involvement than referral care, creating more opportunities for clinician learning related to mental health diagnosis and treatment. The referral approach was identified as better suited for patients with higher complexity or desiring specific psychotherapies. CONCLUSIONS: Both approaches addressed patient needs and provided access to specialty mental health care. Each approach better aligned with different patients' needs, suggesting that having both approaches available to practices is optimal for supporting patient-centered care.

The Effects of Major Disruptions on Practice Participation in Facilitation During a Primary Care Quality Improvement Initiative.

BACKGROUND: Disruptions in primary care practices, like ownership change, clinician turnover, and electronic health record system implementation, can stall quality improvement (QI) efforts. However, little is known about the relationship between these disruptions and practice participation in facilitated QI. METHODS: We explore this relationship using data collected from EvidenceNOW in a mixed-methods convergent design. EvidenceNOW was a large-scale facilitation-based QI initiative in small and medium primary care practices. Data included practice surveys, facilitator time logs, site visit field notes, and interviews with facilitators and practices. Using multivariate regression, we examined associations between disruptions during interventions and practice participation in facilitation, measured by in-person facilitator hours in 987 practices. We analyzed qualitative data on 40 practices that described disruptions. Qualitative and quantitative teams iterated analyses based on each other's emergent findings. RESULTS: Many practices (51%) reported experiencing 1 or more disruptions during the 3- to 15-month interventions. Loss of clinicians (31.6%) was most prevalent. In adjusted analyses, disruptions were not significantly associated with participation in facilitation. Qualitative data revealed that practices that continued active participation were motivated, had some QI infrastructure, and found value in working with their facilitators. Facilitators enabled practice participation by doing EHR-related work for practices, adapting work for available staff, and helping address needs beyond the explicit aims of EvidenceNOW. CONCLUSIONS: Disruptions are prevalent in primary care, but practices can continue participating in QI interventions, particularly when supported by a facilitator. Facilitators may benefit from additional training in approaches for helping practices attenuate the effects of disruptions and adapting strategies to help interventions work to continue building QI capacity.

Improving Smoking and Blood Pressure Outcomes: The Interplay Between Operational Changes and Local Context.

PURPOSE: We undertook a study to identify conditions and operational changes linked to improvements in smoking and blood pressure (BP) outcomes in primary care. METHODS: We purposively sampled and interviewed practice staff (eg, office managers, clinicians) from a subset of 104 practices participating in EvidenceNOW-a multisite cardiovascular disease prevention initiative. We calculated Clinical Quality Measure improvements, with targets of 10-point or greater absolute improvements in the proportion of patients with smoking screening and, if relevant, counseling and in the proportion of hypertensive patients with adequately controlled BP. We analyzed interview data to identify operational changes, transforming these into numeric data. We used Configurational Comparative Methods to assess the joint effects of multiple factors on outcomes. RESULTS: In clinician-owned practices, implementing a workflow to routinely screen, counsel, and connect patients to smoking cessation resources, or implementing a documentation change or a referral to a resource alone led to an improvement of at least 10 points in the smoking outcome with a moderate level of facilitation support. These patterns did not manifest in health- or hospital system-owned practices or in Federally Qualified Health Centers, however. The BP outcome improved by at least 10 points among solo practices after medical assistants were trained to take an accurate BP. Among larger, clinician-owned practices, BP outcomes improved when practices implemented a second BP measurement when the first was elevated, and when staff learned where to document this information in the electronic health record. With 50 hours or more of facilitation, BP outcomes improved among larger and health- and hospital system-owned practices that implemented these operational changes. CONCLUSIONS: There was no magic bullet for improving smoking or BP outcomes. Multiple combinations of operational changes led to improvements, but only in specific contexts of practice size and ownership, or dose of external facilitation.

Implementing Risk Stratification in Primary Care: Challenges and Strategies.

INTRODUCTION: Primary care risk stratification (RS) has been shown to help practices better understand their patient populations' needs and may improve health outcomes and reduce expenditures by targeting and tailoring care to high-need patients. This study aims to understand key considerations practices faced and practice experiences as they began to implement RS models. METHODS: We conducted semistructured interviews about experiences in RS with 34 stakeholders from 15 primary care practices in Oregon and Colorado and qualitatively analyzed the data. RESULTS: Three decisions were important in shaping practices' experiences with RS: choosing established versus self-created algorithms or heuristics, clinical intuition, or a combination; selecting mechanisms for assigning risk scores; determining how to integrate RS approaches into care delivery. Practices using clinical intuition found stratification time-consuming and difficult to incorporate into existing workflows, but trusted risk scores more than those using algorithms. Trust in risk scores was influenced by data extraction capabilities; practices often lacked sufficient data to calculate their perceived optimal risk score. Displaying the scores to the care team was a major issue. Finally, obtaining buy-in from care team members was challenging, requiring repeated cycles of improvement and workflow integration. DISCUSSION: Practices used iterative approaches to RS implementation. As a result, procedural and algorithmic changes were introduced and were influenced by practices' health IT, staffing, and resource capacities. Practices were most successful when able to make iterative changes to their approaches, incorporated both automation and human process in RS, educated staff on the importance of RS, and had readily accessible risk scores.

Practice Facilitator Strategies for Addressing Electronic Health Record Data Challenges for Quality Improvement: EvidenceNOW.

PURPOSE: Practice facilitators ("facilitators") can play an important role in supporting primary care practices in performing quality improvement (QI), but they need complete and accurate clinical performance data from practices' electronic health records (EHR) to help them set improvement priorities, guide clinical change, and monitor progress. Here, we describe the strategies facilitators use to help practices perform QI when complete or accurate performance data are not available. METHODS: Seven regional cooperatives enrolled approximately 1500 small-to-medium-sized primary care practices and 136 facilitators in EvidenceNOW, the Agency for Healthcare Research and Quality's initiative to improve cardiovascular preventive services. The national evaluation team analyzed qualitative data from online diaries, site visit field notes, and interviews to discover how facilitators worked with practices on EHR data challenges to obtain and use data for QI. RESULTS: We found facilitators faced practice-level EHR data challenges, such as a lack of clinical performance data, partial or incomplete clinical performance data, and inaccurate clinical performance data. We found that facilitators responded to these challenges, respectively, by using other data sources or tools to fill in for missing data, approximating performance reports and generating patient lists, and teaching practices how to document care and confirm performance measures. In addition, facilitators helped practices communicate with EHR vendors or health systems in requesting data they needed. Overall, facilitators tailored strategies to fit the individual practice and helped build data skills and trust. CONCLUSION: Facilitators can use a range of strategies to help practices perform data-driven QI when performance data are inaccurate, incomplete, or missing. Support is necessary to help practices, particularly those with EHR data challenges, build their capacity for conducting data-driven QI that is required of them for participating in practice transformation and performance-based payment programs. It is questionable how practices with data challenges will perform in programs without this kind of support.

Primary Care Practices' Abilities And Challenges In Using Electronic Health Record Data For Quality Improvement.

Federal value-based payment programs require primary care practices to conduct quality improvement activities, informed by the electronic reports on clinical quality measures that their electronic health records (EHRs) generate. To determine whether EHRs produce reports adequate to the task, we examined survey responses from 1,492 practices across twelve states, supplemented with qualitative data. Meaningful-use participation, which requires the use of a federally certified EHR, was associated with the ability to generate reports-but the reports did not necessarily support quality improvement initiatives. Practices reported numerous challenges in generating adequate reports, such as difficulty manipulating and aligning measurement time frames with quality improvement needs, lack of functionality for generating reports on electronic clinical quality measures at different levels, discordance between clinical guidelines and measures available in reports, questionable data quality, and vendors that were unreceptive to changing EHR configuration beyond federal requirements. The current state of EHR measurement functionality may be insufficient to support federal initiatives that tie payment to clinical quality measures.

Recruiting Practices for Change Initiatives Is Hard: Findings From EvidenceNOW.

Engaging primary care practices in initiatives designed to enhance quality, reduce costs, and promote safety is challenging as practices are already participating in numerous projects and mandated programs designed to improve care delivery and quality. Recruiters must expand their recruitment tools to engage today's practices in quality improvement. Using grant proposals, online diaries, observational site visits, and interviews with key stakeholders, the authors identify successful practice recruitment strategies in the EvidenceNOW initiative, which aimed to recruit approximately 1500 small- to medium-sized primary care practices. Recruiters learned they needed to articulate how participation in EvidenceNOW aligned with other initiatives and could help practices succeed with federal and state initiatives, recognition programs, and existing or future payment requirements. Recruiters, initiative leaders, and funders must now consider how their efforts align with ongoing initiatives to successfully recruit and engage practices, ease practice burden, and encourage participation in efforts that support practice transformation.

Integrating behavioral health under an ACO global budget: barriers and progress in Oregon.

OBJECTIVES: This study describes challenges that coordinated care organizations (CCOs), a version of accountable care organizations, experienced when attempting to finance integrated care for Medicaid recipients in Oregon and the strategies they developed to address these barriers. STUDY DESIGN: Cross-case comparative study. METHODS: We conducted a cross-case comparative study of 5 diverse CCOs in Oregon. We interviewed key stakeholders: CCO leaders, practice leaders, and primary care and behavioral health clinicians. A multidisciplinary team analyzed data using an immersion-crystallization approach. Financial barriers to integrating care and strategies to address them emerged from this analysis. Findings were member-checked with a CCO integration workgroup to ensure wider applicability. RESULTS: State legislation that initiated CCOs promoted integration expansion. CCOs, however, struggled to create sustainable funding mechanisms to support integration. This was due to regulatory and financial silos that persisted despite CCO global budget formation; concerns about actuarial soundness that limited reasonable, yet creative, uses of federal funds to support integration; and billing difficulties connected to licensing and documentation requirements for behavioral and mental health providers. Despite these barriers, CCOs, with the help of the state, supported expanding integrated care in primary care by using state funds to pilot test integration models and to promote alternative payment methodologies. CONCLUSIONS: Oregon's CCO mandate included a focus on better integrating medical and behavioral healthcare for Medicaid recipients. Despite this intention, challenges exist in the financing of integration, many of which state and federal leaders can address through payment and regulatory reform.

Reporting From the Front Lines: Implementing Oregon's Alternative Payment Methodology in Federally Qualified Health Centers.

Alternative payment models have been proposed as a way to facilitate patient-centered medical home model implementation, yet little is known about how payment reform translates into changes in care delivery. We conducted site visits, observed operations, and conducted interviews within 3 Federally Qualified Health Center organizations that were part of Oregon's Alternative Payment Methodology demonstration project. Data were analyzed using an immersion-crystallization approach. We identified several care delivery changes during the early stages of implementation, as well as challenges associated with this new model of payment. Future research is needed to further understand the implications of these changes.

Designing Health Information Technology Tools to Prevent Gaps in Public Health Insurance.

BACKGROUND: Changes in health insurance policies have increased coverage opportunities, but enrollees are required to annually reapply for benefits which, if not managed appropriately, can lead to insurance gaps. Electronic health records (EHRs) can automate processes for assisting patients with health insurance enrollment and re-enrollment. OBJECTIVE: We describe community health centers' (CHC) workflow, documentation, and tracking needs for assisting families with insurance application processes, and the health information technology (IT) tool components that were developed to meet those needs. METHOD: We conducted a qualitative study using semi-structured interviews and observation of clinic operations and insurance application assistance processes. Data were analyzed using a grounded theory approach. We diagramed workflows and shared information with a team of developers who built the EHR-based tools. RESULTS: Four steps to the insurance assistance workflow were common among CHCs: 1) Identifying patients for public health insurance application assistance; 2) Completing and submitting the public health insurance application when clinic staff met with patients to collect requisite information and helped them apply for benefits; 3) Tracking public health insurance approval to monitor for decisions; and 4) assisting with annual health insurance reapplication. We developed EHR-based tools to support clinical staff with each of these steps. CONCLUSION: CHCs are uniquely positioned to help patients and families with public health insurance applications. CHCs have invested in staff to assist patients with insurance applications and help prevent coverage gaps. To best assist patients and to foster efficiency, EHR based insurance tools need comprehensive, timely, and accurate health insurance information.

Heat stress phenotypes of Arabidopsis mutants implicate multiple signaling pathways in the acquisition of thermotolerance.

To investigate the importance of different processes to heat stress tolerance, 45 Arabidopsis (Arabidopsis thaliana) mutants and one transgenic line were tested for basal and acquired thermotolerance at different stages of growth. Plants tested were defective in signaling pathways (abscisic acid, salicylic acid, ethylene, and oxidative burst signaling) and in reactive oxygen metabolism (ascorbic acid or glutathione production, catalase) or had previously been found to have temperature-related phenotypes (e.g. fatty acid desaturase mutants, uvh6). Mutants were assessed for thermotolerance defects in seed germination, hypocotyl elongation, root growth, and seedling survival. To assess oxidative damage and alterations in the heat shock response, thiobarbituric acid reactive substances, heat shock protein 101, and small heat shock protein levels were determined. Fifteen mutants showed significant phenotypes. Abscisic acid (ABA) signaling mutants (abi1 and abi2) and the UV-sensitive mutant, uvh6, showed the strongest defects in acquired thermotolerance of root growth and seedling survival. Mutations in nicotinamide adenine dinucleotide phosphate oxidase homolog genes (atrbohB and D), ABA biosynthesis mutants (aba1, aba2, and aba3), and NahG transgenic lines (salicylic acid deficient) showed weaker defects. Ethylene signaling mutants (ein2 and etr1) and reactive oxygen metabolism mutants (vtc1, vtc2, npq1, and cad2) were more defective in basal than acquired thermotolerance, especially under high light. All mutants accumulated wild-type levels of heat shock protein 101 and small heat shock proteins. These data indicate that, separate from heat shock protein induction, ABA, active oxygen species, and salicylic acid pathways are involved in acquired thermotolerance and that UVH6 plays a significant role in temperature responses in addition to its role in UV stress.

A human cellular protein activity (OF-1), which binds herpes simplex virus type 1 origin, contains the Ku70/Ku80 heterodimer.

In an effort to identify host proteins involved in herpes simplex virus type 1 replication, monkey and human cellular protein activities (called OF-1) that bind the viral replication origin, oriS, have been described. We show by mass spectrometry that the DNA-binding component of human OF-1 contains Ku70 and Ku80 proteins.

Arabidopsis UVH6, a homolog of human XPD and yeast RAD3 DNA repair genes, functions in DNA repair and is essential for plant growth.

To evaluate the genetic control of stress responses in Arabidopsis, we have analyzed a mutant (uvh6-1) that exhibits increased sensitivity to UV light, a yellow-green leaf coloration, and mild growth defects. We have mapped the uvh6-1 locus to chromosome I and have identified a candidate gene, AtXPD, within the corresponding region. This gene shows sequence similarity to the human (Homo sapiens) XPD and yeast (Saccharomyces cerevisiae) RAD3 genes required for nucleotide excision repair. We propose that UVH6 is equivalent to AtXPD because uvh6-1 mutants carry a mutation in a conserved residue of AtXPD and because transformation of uvh6-1 mutants with wild-type AtXPD DNA suppresses both UV sensitivity and other defective phenotypes. Furthermore, the UVH6/AtXPD protein appears to play a role in repair of UV photoproducts because the uvh6-1 mutant exhibits a moderate defect in the excision of UV photoproducts. This defect is also suppressed by transformation with UVH6/AtXPD DNA. We have further identified a T-DNA insertion in the UVH6/AtXPD gene (uvh6-2). Plants carrying homozygous insertions were not detected in analyses of progeny from plants heterozygous for the insertion. Thus, homozygous insertions appear to be lethal. We conclude that the UVH6/AtXPD gene is required for UV resistance and is an essential gene in Arabidopsis.