Disparities in Offering Enrollment in Remote Patient Monitoring for COVID-19.

Introduction: Remote patient monitoring (RPM) programs are increasingly common. There is a risk that inequitable use of RPM will perpetuate existing health care disparities. We conducted a study to determine if enrollment in a COVID-19 RPM program was offered differentially across demographic groups. Methods: From March through September 2020, patients with COVID-19 were evaluated within a large academic health system with a standardized care pathway that directed providers to refer the patients for RPM. We conducted a retrospective cohort study to evaluate the effects of social vulnerability and urbanicity of residence on the odds of referral. We estimated vulnerability using the CDC social vulnerability index (SVI) and used logistic regression to determine odds ratios (ORs) for referral based on SVI and urbanicity. Results: Of 16,739 patients who had a qualifying health care encounter, 2,946 (17.6%) were referred for RPM. Patients in census tracts with higher social vulnerability were less likely to be referred than those in tracts with lower vulnerability (OR 0.73, 95% confidence interval 0.63-0.84). Patients living in Micropolitan/Large Rural Cities or Small Towns/Small Rural Towns were more likely to be referred than those in Metropolitan/Urban areas. In the full regression model, including both SVI and urbanicity, urbanicity was the strongest predictor of referral, and patients living in Metropolitan/Urban areas were the most likely to be referred. Conclusions: We found disparities in who is offered access to remote monitoring despite the use of standardized care pathways. Health systems need to evaluate how they implement RPM programs and care pathways to ensure equitable care delivery.

Measuring continuity in primary care: how it is done and why it matters.

Continuity of care (COC) is a foundational element of primary care and is associated with improved patient satisfaction and health outcomes and decreased total cost of care. The patient-physician relationship is highly valued by both parties and is often the reason providers choose to specialize in primary care. In some settings, such as outpatient residency clinics, however, patients may only see their primary care provider (PCP) 50% or less of the time. Considering the many benefits of COC for patients and providers, there is a clear need for us in primary care to understand how to compare different COC measures across studies and how to choose the best COC measure when conducting quality improvement efforts. However, at least 32 different measures have been used to evaluate COC. The manifold variations for measuring COC arise from data source restrictions, purpose (research or clinical use), perspective (patient or provider), and patient visit frequency/type. Key factors distinguishing common COC formulas are data source (e.g. claims data or electronic medical records), and whether a PCP is identifiable. There is no "right" formula, so understanding the nuances of COC measurement is essential for primary care research and clinical quality improvement. While the full complexity of COC cannot be captured by formulas and indices, they provide an important measure of how consistently patients are interacting with the same provider.

Impact of Set-Day Clinic on Physician Continuity in a Family Medicine Residency Clinic.

BACKGROUND AND OBJECTIVES: Continuity of care between patients and their primary care providers is associated with improved patient outcomes and experience, decreased health care costs, and improved provider well-being. Strategies to enhance continuity of care in residency programs involve electronic health record, scheduling, and panel management methods. Our study compared physician-patient continuity rates (pre and post) for one family medicine residency's implementation of a set-day clinic (SDC) scheduling model. METHODS: In July 2019, Bethesda Clinic switched from a rotation-driven scheduling (RDS) model to SDC. Physicians were divided into two scheduling groups: Monday, Thursday, or Friday; or Tuesday, Wednesday, or Friday. We used visit data from two 6-month periods, October 2018 to March 2019 (RDS) and October 2021 to March 2022 (SDC), to calculate continuity using the continuity for physician formula. We used t tests to compare mean continuity rates between the RDS and SDC periods. In June 2022, faculty and residents were emailed a nine-question survey about SDC. RESULTS: Adherence to the SDC model ranged from 65% to 76%. Postgraduate year (PGY) 3 residents' continuity increased significantly (P<.001) from 44% (RDS) to 56% (SDC), while PGY2 residents' continuity increased, nonsignificantly, from 38% to 43%. Among those that completed the survey, 94% of residents and 78% of faculty were in favor of SDC. CONCLUSIONS: We demonstrated that SDC is feasible and well received by residents and faculty alike. Continuity was highest for PGY2 and PGY3 residents during the SDC period. Predictable clinic schedules have the potential to improve continuity in family medicine residency clinics and may improve physician well-being.

Remote Patient Monitoring for COVID-19: A Retrospective Study on Health Care Utilization.

Introduction: Data are limited on the effectiveness of remote patient monitoring (RPM) for acute illnesses, including COVID-19. We conducted a study to determine if enrollment in a COVID-19 RPM program was associated with better outcomes. Methods: From March through September 2020, patients with respiratory symptoms and presumptive COVID-19 were referred to the health system's COVID-19 RPM program. We conducted a retrospective cohort study comparing outcomes for patients enrolled in the RPM (n = 4,435) with those who declined enrollment (n = 2,742). Primary outcomes were emergency room, hospital, and intensive care unit admissions, and death. We used logistic regression to adjust for demographic differences and known risk factors for severe COVID-19. Results: Patients enrolled in the RPM were less likely to have risk factors for severe COVID-19. There was a significant decrease in the odds of death for the group enrolled in the RPM (adjusted odds ratio [OR] = 0.50; 95% confidence interval [CI], 0.30-0.83) and a nonsignificant decrease in the odds of the other primary outcomes. Increased number of interactions with the RPM significantly decreased the odds of hospital admission (OR = 0.92; 95% CI, 0.88-0.95). Conclusions: COVID-19 RPM enrollment was associated with decreased odds of death, and the more patients interacted with the RPM, the less likely they were to require hospital admission. RPM is a promising tool that has the potential to improve patient outcomes for acute illness, but controlled trials are necessary to confirm these findings.

Team-based care: an expanded medical assistant role - enhanced rooming and visit assistance.

Primary care practices face significant challenges as they pursue the Quadruple Aim. Redistributing care across the interprofessional primary care team by expanding the role of the medical assistant (MA) is a potential strategy to address these challenges. Two sequential, linked processes to expand the role of the MA, called Enhanced Rooming and Visit Assistance, were implemented in four family medicine residency clinics in Minnesota. In Enhanced Rooming, MAs addressed preventive services, obtained a preliminary visit agenda, and completed a warm hand-off to the provider. In Visit Assistance, MAs stayed in the room the entire visit to assist with the visit workflow. Enhanced Rooming and Visit Assistance processes were successfully implemented and sustained for over one year. MAs and providers were satisfied with both processes, and patients accepted the expanded MA roles. Mammogram ordering rates increased from 10% to 25% (p < 0.0001). After Visit Summary (AVS) print rates increased by 12% (p < 0.0001). Visit Turn-Around-Time (TAT) decreased 3.1 minutes per visit (p = 0.0001). Expanding the MA role in a primary care interprofessional team is feasible and a potentially useful tool to address the Quadruple Aim.

Optimal training in communication model (OPTiCOM): A programmatic roadmap.

OBJECTIVES: Teaching primary care residents patient communication skills is essential, complex, and impeded by barriers. We find no models guiding faculty how to train residents in the workplace that integrate necessary system components, the science of physician-patient communication training and competency-based medical education. The aim of this project is to create such a model. METHODS: We created OPTiCOM using four steps: (1) communication educator interviews, analysis and theme development; (2) initial model construction; (3) model refinement using expert feedback; (4) structured literature review to validate, refine and finalize the model. RESULTS: Our model contains ten interdependent building blocks organized into four developmental tiers. The Foundational value tier has one building block Naming relationship as a core value. The Expertize and resources tier includes four building blocks addressing: Curricular expertize, Curricular content, Leadership, and Time. The four building blocks in the Application and development tier are Observation form, Faculty development, Technology, and Formative assessment. The Language and culture tier identifies the final building block, Culture promoting continuous improvement in teaching communication. CONCLUSIONS: OPTiCOM organizes ten interdependent systems building blocks to maximize and sustain resident learning of communication skills. Practice Implications Residency faculty can use OPTiCOM for self-assessment, program creation and revision.

Lean Implementation for Graduating Optimally Controlled Stable Type 2 Diabetics from Endocrine Specialty Clinic Back to Primary Care.

INTRODUCTION: Endocrine specialty clinics (SCs) are occupied by a high percentage of stable follow-up patients, limiting access to new patients with greater needs. AIM: Feasibility project to improve access to diabetes SC by reducing the number of stable optimally controlled follow-up type 2 diabetic patients. SETTING: M Health Fairview (MHFV), a hybrid network of University of Minnesota academic and Fairview Health community hospitals and clinics with affiliated providers. PROGRAM DESCRIPTION: A team-based lean methodology quality improvement graduation program including medical assistants, nurses, physicians, and a compact with primary care (PC) was used to identify within the Endocrine clinic population the graduation-eligible optimally controlled stable type 2 diabetic patients, acclimate them to the graduation concept, engage in shared decision-making, and transition them back to PC with a warm hand-off and graduation certificate. PROGRAM EVALUATION: Seventeen percent (58/341) of eligible patients with optimally controlled diabetes graduated by 6 months, ranging between 0 and 83% per week. DISCUSSION: The innovation and feasibility of opening SC access through the use of a team-based graduation program to transfer stable diabetes patients back to their home clinic was demonstrated. This innovation has the potential to support health system triage of new patients to limited access specialty care.

Implementing Clinic First Guiding Actions Across 4 Family Medicine Residency Clinics.

PROBLEM: Family medicine faculty and residents have observed that continuity clinic is often unsatisfying, attributed to a lack of patient and team continuity and erratic clinic schedules pieced together after the prioritization of hospital service and rotation schedules. APPROACH: In 2019, a 3-year Clinic First project, called Clinic as Curriculum (CaC), was launched across the 4 family medicine residencies of the Department of Family Medicine and Community Health, University of Minnesota Medical School. The department began publishing quarterly CaC dashboard data. Each clinic completed a baseline assessment of their performance on the 13 Building Blocks of High-Performing Primary Care. Using their baseline data, each clinic identified which block or blocks, in addition to the blocks on continuity of care and resident scheduling, to focus on. The plan is to collaboratively implement the overall and local goals using dashboard data and iterative process improvement over 3 years. OUTCOMES: At baseline, clinics functioned quite well with respect to the 13 building blocks, but CaC dashboard data varied across the 4 clinics, with large variation between clinics on how frequently faculty were scheduled in the clinic and the proportion of total clinic visits seen by faculty. Resident continuity rates were low (range, 38%-47%). Level loading (consistent physician availability to meet patient demand) rates ranged from 1 to 11 days a month. Regarding resident schedules, 2 programs are moving from 4-week to 2-week inpatient blocks, and 2 programs are exploring longitudinal scheduling. One clinic will assign faculty and residents to specific clinic days. Two clinics are implementing microteams of 1 faculty and 3-4 residents. NEXT STEPS: The authors plan to analyze the dashboard data longitudinally; explore microteams, team continuity, and team scheduling adherence; and develop and implement resident scheduling changes over the next 3 years.

Implementation of a direct observation and feedback tool using an interprofessional approach: a pilot study.

Primary care trainees must learn how to communicate effectively with patients during brief outpatient encounters, and direct observation and feedback is necessary to improve these skills. At the same time, programs are seeking more interprofessional learning opportunities for skills that transcend professions. We sought to assess the feasibility of implementing a direct observation tool, the Patient Centered Observation Form (PCOF), for communication training across three professions at the graduate level. The PCOF was introduced to trainees at an interprofessional workshop, while faculty completed PCOF training online or in person. Following use of the PCOF, we surveyed participants to determine if using the PCOF increased a) trainee-reported confidence in providing patient-centered communication, and b) faculty-reported confidence in giving feedback about patient-centered communication. The PCOF appears to be a useful adjunct to standard precepting for teaching patient-centered communication skills, extending beyond medical residents to pharmacy residents and less so, to advanced practice nursing students. In addition, PCOF training and implementation can successfully occur simultaneously across disciplines, leveraging resources and encouraging interprofessional learning.

Financial Impact of Universal Precepting in Family Medicine Residency Clinics.

BACKGROUND AND OBJECTIVES: Precepting methods have significant impact on the financial viability of family medicine residency programs. Following an adverse event, four University of Minnesota Family Medicine residency clinics moved from using Medicare's Primary Care Exception (PCE) and licensure precepting (LP) to a "universal precepting" method in which preceptors see every patient face to face. Variation in the implementation of universal precepting created a natural experiment of its financial impact. METHODS: Universal precepting was implemented in October 2013 across four residency programs. Billing codes were measured 1 year before and 2.5 years after implementation by clinic and residency year. RESULTS: There were significant financial differences between clinics based on original precepting method and implementation quality of universal precepting. The clinic moving from PCE to universal precepting with excellent implementation increased higher-level billing (99214) by 8%-10%. Clinics moving from LP demonstrated wide variation ranging from an 18% increase to a 13% decrease, consistent with the implementation quality. CONCLUSIONS: Clinics transitioning from PCE to universal precepting can see a significant increase in 99214 billing. Clinics transitioning from LP to universal precepting are at significant financial risk if poorly implemented, but may see increased 99214 billing with effective implementation. This suggests that both implementation quality and original precepting method impact 99214 billing rates when transitioning to universal precepting.

Seven Years of Teaching Communication With the Patient-Centered Observation Form.

BACKGROUND AND OBJECTIVES: For years, family medicine has taught patient-centered communication through observations and observation checklists. We explored the utility of one checklist, the Patient-Centered Observation Form (PCOF), to teach and evaluate patient-centered communication in our family medicine residencies. METHODS: We conducted a mixed-method study of five University of Minnesota Family Medicine Residencies' seven years of experience teaching and evaluating residents' patient-centered communication skills. All programs have a behavioral health (BH) faculty-led observation curriculum that uses the PCOF to assess resident skills and give feedback. We conducted a BH faculty focus group and interviews, generated themes from the BH responses, and then queried family medicine (FM) faculty regarding these themes through an online survey. RESULTS: Ten BH faculty participated in the focus group/interviews, and 71% (25/35) of FM faculty completed the survey about themes derived from the BH interviews. The residencies complete between 1 to 11 observations per resident per year. Since implementation, four programs have continuously used the PCOF due to its versatility, design as a formative rather than summative feedback tool, and relative ease of use. BH faculty believe longitudinal observations with the PCOF resulted in improved resident patient-centered communication. Most importantly, all faculty described a shift in family medicine culture toward patient-centered communication. Time for observations and feedback is the primary curricular barrier. CONCLUSIONS: Our findings support the utility of the PCOF for teaching and evaluating patient-centered communication in family medicine training.

Essentials of Ambulatory Care: An Interprofessional Workshop to Promote Core Skills and Values in Team-based Outpatient Care.

Introduction: Team-based, interprofessional approaches to outpatient care are critical to high-quality patient care. However, few specific educational interventions promoting these skills in graduate level health care trainees have been described to date. Methods: University of Minnesota faculty from the Schools of Medicine, Pharmacy, and Nursing created an interprofessional workshop experience exploring core concepts in outpatient care for graduate level trainees in pediatrics, family medicine, medicine-pediatrics, internal medicine, graduate-level nursing, and pharmacy. We focused on four key content areas: teamwork, systems thinking, the patient-centered health care home, and patient-centered communication. The workshop included brief didactics, role-plays, team-based experiences, and interactive skill practice. Participants completed an end-of-day survey reflecting on knowledge and attitude. Results: From 2014-2017, nine workshops reached 305 trainees. Survey results from the 2015-2016 academic year are representative of our overall results and revealed that learners found the content high yield, and that they valued the opportunity to learn with their interprofessional colleagues. Improvements in perceived knowledge were noted in all domains. Trainees also reported increased skills, with 81% reporting both increased confidence in working within the interprofessional team, and change in attitude, and 90% reporting increased interest in working with their interprofessional colleagues after the workshop. Discussion: Creating an opportunity for postgraduate level trainees from a variety of disciplines and professions to convene and focus on interprofessional team-based skills can fill a gap in interprofessional learning as they enter practice. Trainees were able to draw on their everyday experiences and find common ground with their interprofessional colleagues.

Essentials of Ambulatory Care a postgraduate-level, interdisciplinary, interprofessional curriculum at the University of Minnesota. .

Team-based care is a cornerstone of primary care. However, in medical school and residency, trainees get little formal education on this as a concept and how it works in an outpatient setting. Faculty members from the University of Minnesota created a one-day workshop, "Essentials of Ambulatory Care," to help residents in primary care specialties as well as pharmacy and nursing students pursuing advanced degrees better understand the roles and responsibilities of members of the primary care team. The workshop also helped them develop new skills for doing patient-centered visits. This article describes the workshop and what we learned from those who participated in the first session.

Effects of team care of frequent attenders on patients and physicians.

Frequent clinic attenders consume a large portion of health care resources while feeling underserved. At the same time, physicians are frustrated trying to adequately care for these patients. Previous trials of team care in primary care have rarely included control groups. Adults with eight or more clinic visits in the past year were nonrandomly assigned to usual care or team care. For the latter group, a Care Team met to review each case and create a care plan. Changes in patient health care use, well-being, and satisfaction from baseline to 6 months were compared between team care and usual care patients. In addition, Care Team members' perceptions of team care were assessed by quantitative and qualitative methods. Study patients were medically complex. Self-reported overall well-being and overall care satisfaction improved in the 12-patient team care group, but remained unchanged in the 8 patient usual care group. Median 6-month visits fell by 3 visits among team care patients and increased by 1.5 among usual care patients. Most Care Team members rated team care as positive and as improving quality of care. Members were divided on its effect on care efficiency and workload. Team care is feasible within a family medicine residency practice and may improve care.

Recruiting for a randomized controlled trial from an ethnically diverse population: lessons from the Maternal Infection and Preterm Labor Study.

OBJECTIVES: To compare recruitment rates for Caucasians and minorities in a randomized, controlled trial based in a family practice residency clinic. STUDY DESIGN: A retrospective chart review of all patients eligible for the Maternal Infection and Preterm Labor (MIPTL) study. POPULATION: All prenatal patients at 1 clinic site presenting for care at earlier than 34 weeks gestation. RESULTS: African-American patients were recruited at the same rate as Caucasians (28% of each eligible population). Immigrants and patients requiring a translator were less likely to enroll (P =.014 and.008, respectively). CONCLUSIONS: Clinic-based research studies in a family practice residency program can successfully recruit African-American patients. Immigration status and the ability to speak English were important factors impacting participation. More research is needed to understand the role of clinic-based research in recruitment of minorities for clinical trials.

Should intrathecal narcotics be used as a sole labor analgesic? A prospective comparison of spinal opioids and epidural bupivacaine.

OBJECTIVE: Intrathecal narcotics (ITNs) are being used in some settings as a sole labor analgesic. However, they have not been directly compared to epidural analgesia. STUDY DESIGN: We used a prospective observational design. POPULATION: Eighty-two women with uncomplicated full-term pregnancies were enrolled upon analgesia request during spontaneous labor with cervical dilation 3 to 7 cm. Sixty-three chose ITNs (morphine and fentanyl), and 19 chose epidural analgesia (continuous infusion of bupivacaine and fentanyl). OUTCOMES MEASURED: Pain scores were documented using a visual analog scale. Satisfaction and side effects were rated with Likert scales during a structured interview on the first postpartum day. Outcomes were analyzed with multivariate regression techniques. RESULTS: Intrathecal narcotics were associated with significantly higher pain scores than was epidural analgesia during the first and second stages of labor and on an overall postpartum rating. The median effective duration of action for ITNs was between 60 and 120 minutes; however, ITNs provided excellent analgesia for a subgroup of women who delivered within 2 to 3 hours of receiving them. Although women in both groups were satisfied with their pain management, women receiving ITNs had statistically lower overall satisfaction scores. CONCLUSIONS: Within the limitations of a nonrandomized study, a single intrathecal injection of morphine and fentanyl has a shorter duration of action and provides less effective pain control than a continuous epidural infusion of bupivacaine and fentanyl. However, ITNs may have a role in settings with limited support from anesthesiologists or for women whose labors are progressing rapidly.

Household composition and risk of fatal child maltreatment.

OBJECTIVE: Approximately 2000 children die annually in the United States from maltreatment. Although maternal and child risk factors for child abuse have been identified, the role of household composition has not been well-established. Our objective was to evaluate household composition as a risk factor for fatal child maltreatment. METHODOLOGY: Population-based, case-control study using data from the Missouri Child Fatality Review Panel system, 1992-1994. Households were categorized based on adult residents' relationship to the deceased child. Cases were all maltreatment injury deaths among children <5 years old. Controls were randomly selected from natural-cause deaths during the same period and frequency-matched to cases on age. The main outcome measure was maltreatment death. RESULTS: Children residing in households with adults unrelated to them were 8 times more likely to die of maltreatment than children in households with 2 biological parents (adjusted odds ratio [aOR]: 8.8; 95% confidence interval [CI]: 3.6-21.5). Risk of maltreatment death also was elevated for children residing with step, foster, or adoptive parents (aOR: 4.7; 95% CI: 1.6-12.0), and in households with other adult relatives present (aOR: 2.2; 95% CI: 1.1-4.5). Risk of maltreatment death was not increased for children living with only 1 biological parent (aOR: 1.1; 95% CI: 0.8-2.0). CONCLUSIONS: Children living in households with 1 or more male adults that are not related to them are at increased risk for maltreatment injury death. This risk is not elevated for children living with a single parent, as long as no other adults live in the home.