A qualitative investigation of uninsured patient and primary care provider perspectives on specialty care eConsults.

BACKGROUND: Uninsured and underinsured patients face specialty care access disparities that prevent them from obtaining the care they need and negatively impact their health and well-being. We aimed to understand how making specialty care electronic consultations (eConsults) available at a multi-site Federally Qualified Health Center (FQHC) in central Texas affected uninsured patients' care-seeking experiences and impacted their ability to receive the needed care. METHODS: We used concepts from Ecological Systems Theory to examine individual, interpersonal, organization-level, social, and health policy environment factors that impacted patients' access to specialty care and the use of eConsults. We conducted thematic analysis of semi-structured, qualitative interviews with patients about seeking specialty care while uninsured and with uninsured patients and FQHC PCPs about their experience using eConsults to obtain specialists' recommendations. RESULTS: Patients and PCPs identified out-of-pocket cost, stigma, a paucity of local specialists willing to see uninsured patients, time and difficulty associated with travel and transportation to specialty visits, and health policy limitations as barriers to obtaining specialty care. Benefits of using eConsults for uninsured patients included minimizing/avoiding financial stress, expanding access to care, expanding scope of primary care, and expediting access to specialists. Concerns about the model included patients' limited understanding of eConsults, concern about cost, and worry whether eConsults could appropriately meet their specialty needs. CONCLUSIONS: Findings suggest that eConsults delivered in a primary care FQHC addressed uninsured patients' specialty care access concerns. They helped to address financial and geographic barriers, provided time and cost savings to patients, expanded FQHC PCPs' knowledge and care provision options, and allowed patients to receive more care in primary care.

Impact of eConsults on Clinical Care in Primary Care: A Cross-Sectional Analysis of Primary Care Provider Behavior.

INTRODUCTION/OBJECTIVES: Asynchronous electronic consultations (eConsults) support primary care providers (PCPs) by providing rapid specialist feedback and improve medically underserved patients' access to care. METHODS: This cross-sectional study assessed all eConsults requested over a one-year period at a multi-site federally qualified health center in Texas. We analyzed eConsult content and quality and conducted chart reviews for a randomly selected subsample (n = 100) to determine whether PCPs implemented specialists' recommendations within 90 days. Semi-structured interviews with PCPs assessed their ability and willingness to follow recommendations. RESULTS: There were 367 eConsults submitted by 25 PCPs across 15 adult medical and surgical specialties. Of the 100 charts reviewed n = 77 (77.0%) contained documentation indicating that the PCP had followed at least 1 of the specialist's recommendations within 90 days. In two-thirds of the cases (n = 66, 66%) the reviewing specialist indicated that a face-to-face referral was not needed. PCPs were most likely to follow recommendations for new medications and least likely to document that they had obtained additional patient history. PCPs noted that they were sometimes unable to follow recommendations when patients could not afford or access treatment or did not return for follow up care, or when they felt that the specialist did not address their specific question. CONCLUSIONS: eConsults delivered to medically underserved patients in primary care help PCPs provide timely care for their patients. PCPs utilized a broad range of eConsult specialties and generally implemented eConsult specialists' recommendations within 90 days.

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.

The Impact of eConsults on Access to Specialty Care for the Uninsured in Rural Texas.

OBJECTIVE: This study evaluated the impact of eConsults on access to specialty care for uninsured patients in Central Texas. METHODS: eConsults for four specialties, cardiology, gastroenterology, rheumatology, and endocrinology, were implemented in a large, multi-site federally qualified health center. Data were collected on specialty care access and utilization for a one-year period before and after implementation of the new process. RESULTS: Prior to implementation, 23% of uninsured patients referred to the included specialties completed a visit with a specialist. After implementation, 62% received a specialty consultation either through an eConsult or with a face-to-face visit. Wait times for referrals improved from a median of 54 days to seven days. CONCLUSION: This project demonstrated that eConsults improve access and reduce wait times for specialty care for uninsured patients. Interventions such as this have the potential to reduce health inequalities by providing timely access to care for common specialty concerns.

Qualitative inquiry into barriers and facilitators to transforming primary care for lesbian, gay, bisexual and transgender people in US federally qualified health centres.

OBJECTIVES: Health systems must rapidly move knowledge into practice to address disparities impacting sexual and gender minority (SGM) patients. This qualitative study explores barriers and facilitators that arose during an initiative to improve care for SGM patients in federally qualified health centres (FQHCs) from the perspectives of FQHC staff. DESIGN: Cross-sectional qualitative content analysis, using a general inductive approach, of secondary data from transcripts of intervention events offered to FQHC staff and semistructured interviews with staff and FQHC leadership during the intervention. SETTING: 10 FQHCs from nine states in the USA. PARTICIPANTS: FQHC quality improvement (QI) and clinical care staff, and leaders at each FQHC. INTERVENTIONS: The transforming care for lesbian, gay, bisexual and transgender people QI initiative combined two evidence-based programmes, Learning Collaborative (LC) and Project Extension for Community Healthcare Outcomes (ECHO), to assist primary care health centres in developing capacity to identify SGM patients, monitor their health and care, and improve disparities. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was identification of barriers and facilitators to implementing initiatives to improve care for SGM patients. The secondary outcome was clarification of how intervention participants used Project ECHO sessions versus LC meetings to obtain information that influenced implementation of the initiative at their FQHC. RESULTS: Barriers and facilitators mapped to two major themes: 'Clinical' (patients' health, wellness, and available treatment) and Health Systems and Institutional Culture (FQHC operations, and customs and social institutions within the FQHCs and in the external environment). Common 'Clinical' inquiries were for assistance with behavioural health, pre-exposure prophylaxis and transgender hormone therapy. Prevalent facilitators included workflow change and staff training, while adapting electronic health records for data collection, decision support and data extraction was the most prevalent barrier. CONCLUSIONS: Project ECHO and LC provided complimentary forums to explore clinical and operational changes needed to improve care for SGM at FQHCs.

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.

Impact of dermoscopy-aided pediatric teledermatology program on the accessibility and efficiency of dermatology care at community health centers.

BACKGROUND: There are few studies focusing on pediatric teledermatology, and the impact of a large-scale pediatric teledermatology program on the accessibility and efficiency of dermatology care remains unclear. This study evaluated the impact of a state-wide implementation of a store-and-forward teledermatology program augmented by the incorporation of dermoscopy in pediatric patients visiting community health centers. METHODS: It was a descriptive, retrospective cohort study of 876 pediatric dermatology referrals. RESULTS: In the traditional referral system, only 60 patients (17.6%) were seen by dermatologists with average waiting times of 75 days due to limited access. In comparison, with an implementation of dermoscopy-aided teledermatology, all 536 teledermatology referrals received dermatological care within 24 h, of which only 64 (12%) patients requires face-to-face (F2F) consultation. Patients referred for F2F consultation via eConsults had a much lower no-show rate as compared to the traditional referral system (39% vs. 71%). Side by side comparison between general population and pediatric population has demonstrated shared features in efficiency and access improvement but revealed specific characteristics of pediatric teledermatology in terms of diagnosis and treatment. CONCLUSION: Coordinated store-and-forward teledermatology platform with incorporation of dermoscopy between large community care network and dermatology provider can greatly improve access to pediatric dermatology care especially in underserved population. The efficiency of teledermatology in access improvement for pediatric population is comparable with adult population in eConsults. There are also unique features and challenges in pediatric teledermatology that require further research.

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.

Evaluation of Combined Financial Incentives and Deposit Contract Intervention for Smoking Cessation: A Randomized Controlled Trial.

INTRODUCTION: We evaluate whether a combination of financial incentives and deposit contracts improves cessation rates among low- to moderate-income smokers. METHODS: We randomly assigned 311 smokers covered by Medicaid at 12 health clinics in Connecticut to usual care or one of the three treatment arms. Each treatment arm received financial incentives for two months and either (i) nothing further ("incentives only"), (ii) the option to start a deposit contract with incentive earnings after the incentives ended ("commitment"), or (iii) the option to precommit any earned incentives into a deposit contract starting after the incentives ended ("precommitment"). Smoking cessation was confirmed biochemically at two, six, and twelve months. RESULTS: At two, six, and twelve months after baseline, our estimated treatment effects on cessation are positive but imprecise, with confidence intervals containing effect sizes estimated by prior studies of financial incentives alone and deposit contracts alone. At two months, the odds ratio for quitting was 1.4 in the incentive-only condition (95% CI: 0.5 to 3.5), 2.0 for incentives followed by commitment (95% CI: 0.6 to 6.1), and 1.9 for incentives and precommitment (95% CI: 0.7 to 5.3). CONCLUSIONS: A combined incentive and deposit contract program for Medicaid enrollees, with incentives offering up to $300 for smoking cessation and use of support services, produced a positive but imprecisely estimated effect on biochemically verified cessation relative to usual care and with no detectable difference in cessation rates between the different treatment arms.

Pharmacist eConsult service for primary care medication optimization and safety.

BACKGROUND: There is a critical need in primary care to proactively prevent, identify, and resolve poor medication-related outcomes. However, more than 80% of primary care practices do not have clinical pharmacists as members of expanded care teams. The emergence of eConsult services in primary care settings presents an opportunity for primary care providers (PCPs) to consult with clinical pharmacists as "on-demand" pharmacotherapy specialists. OBJECTIVES: The objectives were to (1) determine the use of a clinical pharmacist in an existing eConsult network, (2) characterize the use and type of clinical pharmacist eConsults sent by PCPs, and (3) measure the implementation percentage of pharmacist recommendations by PCPs. METHODS: The study was conducted in a federally qualified health center using an existing eConsult platform. A clinical pharmacist was contracted to receive eConsults and was expected to respond within 2 business days. PCPs were introduced to the pharmacist eConsult service through presentations that reviewed the clinical pharmacist's education/training, suitable pharmacist eConsult topics, and workflow for sending a pharmacist eConsult. RESULTS: A total of 57 eConsults containing 123 individual questions were answered. Advanced practice nurses (APRNs) sent 3 times the number of eConsults and individual questions per eConsult compared with physicians (P < 0.0001). Most eConsult questions from APRNs related to adverse drug events/drug interactions (44%), drug or dosage changes to reach therapeutic goals (18%), and renal/hepatic dosage adjustments (13%). However, physician eConsult questions were primarily targeted on patient-specific drug or dosage adjustments (62%) and comprehensive medication regimen reviews (17%). A total of 74% of the pharmacist eConsult responses had at least 50% of the recommendations implemented by PCPs. CONCLUSION: This study revealed the use of a pharmacist eConsult service for medication-related questions in an existing eConsult network for PCPs. As more practices enroll in value-based plans, pharmacist eConsults can improve the quality and safety of prescribing and chronic medication management.

Impact of Pediatric Electronic Consultations in a Federally Qualified Health Center.

Background: Access to pediatric specialty care is a challenge, particularly for medically underserved populations. Introduction: One evolving method that has shown promise in helping ameliorate this disparity is electronic consultations (e-consults). Materials and Methods: This retrospective cohort study compared two groups: patients referred to pediatric cardiology, endocrinology, or pulmonology from a Federally-Qualified Health Center 10 months before the implementation of an evidence-based care pathway and those referred in the 10 months after implementation. The care pathway included evidence-based referral guidelines for common pediatric diagnoses and an e-consult process. Data included patient demographics, dates of referral requests, appointment dates, e-consult response dates and times, diagnosis codes, and consultants' recommendations. Results: Twenty-three percent of all referrals made postimplementation were submitted for an e-consult, with 53% preventing an unnecessary face-to-face visit. The most common reason for an e-consult was heart murmur/chest pain for cardiology, short stature for endocrinology, and asthma for pulmonology. Discussion: Providers used e-consults for nearly one-quarter of all consultations postimplementation, resulting in 17% of consultations not needing a face-to-face visit. The use of e-consults combined with evidence-based referral guidelines provided a useful tool to help front line pediatric primary care providers manage complex problems and identify those not needing to see a specialist in person. Conclusions: Evidence-based care pathways combined with e-consults can help improve access to pediatric specialty care by reducing demand for in-person visits and allowing more care to be delivered in primary care.

A National Study of Community Health Centers' Readiness to Address COVID-19.

BACKGROUND: The coronavirus disease 2019 (COVID-19) outbreak poses serious health risks, particularly for older adults and persons with underlying chronic medical conditions. Community health centers (CHCs) serve as the patient medical home for populations that are disproportionately more susceptible to COVID-19; yet, there is a lack of understanding of current efforts in place by CHCs to prepare for and respond to the pandemic. METHODS: We used a comprehensive cross-sectional survey and focus groups with health care personnel to understand the needs and current efforts in place by CHCs, and we derived themes from the focus group data. RESULTS: Survey respondents (n = 234; 19% response rate) identified COVID-19 infection prevention and control (76%), safety precautions (72%), and screening, diagnostic testing, and management of patients (66%) as major educational needs. Focus group findings (n = 39) highlighted 5 key themes relevant to readiness: leadership, resources, workforce capacity, communication, and formal policies and procedures. CONCLUSION: The COVID-19 pandemic has exacerbated long-standing CHC capacity issues making it challenging for them to adequately respond to the outbreak. Policies promoting greater investment in CHCs may strengthen them to better meet the needs of the most vulnerable members of society, and thereby help flatten the curve.

A mixed methods evaluation of the feasibility, acceptability, and impact of a pilot project ECHO for community health workers (CHWs).

BACKGROUND: Despite the positive effects of community health workers (CHWs) on addressing social determinants of health, improving patient health outcomes, and decreasing overall healthcare costs, there is a lack of standardization in training and certifying this workforce, resulting in different approaches to integrating this role into medical home models. The purpose of the current study is to evaluate the application of Project ECHO (Extension for Community Healthcare Outcomes) in enhancing CHWs' capacity to address health and social issues of vulnerable populations. METHODS: An explanatory sequential mixed methods design was applied in which all participants (N = 49) completed pre (January 2019) and post (July 2019) quantitative online surveys measuring changes in self-efficacy, behavior change intent, and knowledge. Virtual focus groups were conducted with a subset of participants (n = 20) in July 2019 to assess the feasibility, acceptability, and impact of Project ECHO. RESULTS: There was a statistically significant difference of + 0.453 in the composite self-efficacy mean score pre- to post-series. For every 1 additional Project ECHO CHW session attended, there was a .05 improvement in participants' self-efficacy to perform CHW-related job duties and address social determinants of health (SDOH). Four major themes emerged from the qualitative focus group data: value in learning from other participants' caseloads, CHW-care team integration, availability of training and resources, and shared decision-making with patients. CONCLUSIONS: This evaluation suggests that ECHO is a viable means of increasing access to training resources for CHWs. Future studies on the ECHO model as a means of educating and broadening implementation of CHWs are warranted. Programs such as Project ECHO can support CHWs by providing continuing education opportunities, as well as standardizing training content across large geographic areas.

Transforming Primary Care for Lesbian, Gay, Bisexual, and Transgender People: A Collaborative Quality Improvement Initiative.

PURPOSE: Lesbian, gay, bisexual, and transgender (LGBT) people experience multiple disparities in access to care and health outcomes. We developed a quality improvement initiative, Transforming Primary Care for LGBT People, to enhance the capacity of federally qualified health centers (FQHCs) to provide culturally affirming care for this population. METHODS: The 1-year intervention blended the models of Practice Improvement Collaboratives and Project ECHO (Extension for Community Health Outcomes) to facilitate learning and translate knowledge into action. FQHC teams received coaching in creating LGBT-inclusive environments, collecting sexual orientation and gender identity (SOGI) data, taking risk-based sexual histories, and screening LGBT people for syphilis, chlamydia and gonorrhea, and HIV. We used a preintervention-postintervention evaluation design. RESULTS: We selected 10 FQHCs serving 441,387 patients in 123 clinical sites in 9 states. The intervention spread from 10 clinicians in 10 clinical sites to 431 clinicians in 79 clinical sites. FQHCs reported increases in culturally affirming practices, including collecting patient pronoun information (42.9% increase) and identifying LGBT patient liaisons (300.0% increase). Postintervention, among 9 FQHCs reporting SOGI data from electronic health records, SOGI documentation increased from 13.5% to 50.8% of patients (276.3% increase). Among 8 FQHCs reporting number of LGBT patients, screening of LGBT patients increased from 22.3% (95% CI, 4.9%-40.0%) to 34.6% (95% CI, 19.4%-48.6%) for syphilis (86.5% increase); from 25.3% (95% CI, 7.6%-43.1%) to 44.1% (95% CI, 30.2%-58.1%) for chlamydia and gonorrhea (109.0% increase); and from 14.8% (95% CI, 3.2%-26.5%) to 30.5% (95% CI, 26.7%-34.3%) for HIV (132.4% increase). CONCLUSIONS: FQHCs participating in this initiative reported improved capacity to provide culturally affirming care and targeted screening for LGBT patients.

The How Matters: How Primary Care Provider Communication With Team Relates to Patients' Disease Management.

BACKGROUND: Investigating primary care provider (PCP)-team communication can provide insight into how colleagues work together to become high-functioning teams more able to address an increasingly complex set of tasks associated with chronic disease management. OBJECTIVE: To assess how PCP communication with their care team relates to patients' health. RESEARCH DESIGN: Longitudinal study of how 3 aspects of PCP-care team communication-participation, time spent listening, and uninterrupted speaking length-relate to disease management of patients with hypertension or diabetes, and the effect of these team communication behaviors on PCP-patient communication as a pathway by which this relationship might exist. We used multilevel regression models. SUBJECTS: Twenty-seven PCPs and 98 team members, and 18,067 patients with hypertension and 8354 patients with diabetes affiliated with a federally qualified health center with 12 practice sites. MEASURES: Primary data on communication collected using sociometric sensors worn by PCPs and team members, patient-PCP communication data collected with surveys, and patient health, PCP and patient characteristics extracted from electronic records. RESULTS: PCPs participated in 75% of care team conversations, spent 56% of conversation time listening, and had an average uninterrupted speaking length of 2.42 seconds. PCP participation, listening, and length of uninterrupted speaking time were associated with significantly higher odds that their patients had controlled hypertension and diabetes and improvements in disease control over time. PCP-patient communication mediates this relationship. CONCLUSIONS: PCP-team communication is associated with patient health management. How team members speak with one another may be as important as the content of their communication.

A quasi-experiment assessing the six-months effects of a nurse care coordination program on patient care experiences and clinician teamwork in community health centers.

BACKGROUND: Recognition that coordination among healthcare providers is associated with better quality of care and lower costs has increased interest in interventions designed to improve care coordination. One intervention is to add care coordination to nurses' role in a formal way. Little is known about effects of this approach, which tends to be pursued by small organizations and those in lower-resource settings. We assessed effects of this approach on care experiences of high-risk patients (those most in need of care coordination) and clinician teamwork during the first 6 months of use. METHODS: We conducted a quasi-experimental study using a clustered, controlled pre-post design. Changes in staff and patient experiences at six community health center practice locations that introduced the added-role approach for high-risk patients were compared to changes in six locations without the program in the same health system. In the pre-period (6 months before intervention training) and post-period (about 6 months after intervention launch, following 3 months of training), we surveyed clinical staff (N = 171) and program-qualifying patients (3007 pre-period; 2101 post-period, including 113 who were enrolled during the program's first 6 months). Difference-in-differences models examined study outcomes: patient reports about care experiences and clinician-reported teamwork. We assessed frequency of patient office visits to validate access and implementation, and contextual factors (training, resources, and compatibility with other work) that might explain results. RESULTS: Patient care experiences across all high-risk patients did not improve significantly (p > 0.05). They improved somewhat for program enrollees, 5% above baseline reports (p = 0.07). Staff-perceived teamwork did not change significantly (p = 0.12). Office visits increased significantly for enrolled patients (p < 0.001), affirming program implementation (greater accessing of care). Contextual factors were not reported as problematic, except that 41% of nurses reported incompatibility between care coordination and other job demands. Over 75% of nurses reported adequate training and resources. CONCLUSIONS: There were some positive effects of adding care coordination to nurses' role within 6 months of implementation, suggesting value in this improvement strategy. Addressing compatibility between coordination and other job demands is important when implementing this approach to coordination.

Impact of Endocrinology eConsults on Access to Endocrinology Care for Medicaid Patients.

Background: Access to endocrinologists is a particular challenge for medically underserved populations. Introduction: Electronic consultations (eConsults) are a promising tool to help address this problem. Materials and Methods: This retrospective cohort study compared two groups: (1) Medicaid patients referred to an endocrinologist 1 year before the implementation of eConsults and (2) those referred in the 1 year after implementation. Data included patient demographics, dates of referral requests, appointment dates, eConsult response dates and times, diagnosis codes, and consultants' recommendations. Provider perspectives of eConsults were determined by using a survey. Results: Before eConsult implementation, only 138 out of 365 (37.8%) of referrals to endocrinology were completed. Postimplementation, 281 out of 469 (59.9%) of referrals were completed either by a confirmed face-to-face visit with an endocrinologist or by an eConsult, of whom 194 (41.4%) did not require a face-to-face visit. Thyroid conditions were the most common reason for a consult, accounting for roughly 40% of all consults. Overall, 32 out of 36 (89%) primary care providers (PCPs) indicated that they were satisfied with eConsults and 19 out of 36 (53%) felt that the process did not create additional work or burden for them. Discussion: These findings demonstrate that eConsult use can help address poor access to specialty care for Medicaid-insured patients. eConsults were able to significantly decrease the need for face-to-face visits and enabled PCPs to address specialty-related issues in primary care. Conclusions: Widespread adoption of eConsults could be a potential solution for major challenges that our health care system faces today.

Project ECHO Chronic Pain: A Qualitative Analysis of Recommendations by Expert Faculty and the Process of Knowledge Translation.

INTRODUCTION: Previous studies of the same Project ECHO Chronic Pain cohort demonstrated that recommendations to primary care providers (PCPs) by expert faculty follow CDC Guidelines for Prescribing Opioids and that participating PCPs change their practice accordingly. The purpose of this study was to identify how expert faculty translates knowledge, so that PCPs can act on it. METHODS: One hundred ninety-seven PCPs from 82 practices in 14 states attended at least one Project ECHO Chronic Pain session over 10 months, hosted by a large federally qualified health center. Expert faculty was a multidisciplinary panel of six clinicians. Recommendations for 25 randomly selected case presentations were transcribed, yielding 406 discrete units of data. A thematic analysis contributed to a concept map for knowledge translation. RESULTS: Expert faculty addressed psychosocial issues in 40% of recommendations. Three themes represented a familiar clinical decision-making process: recommendations for treatment accounted for risk factors and patient engagement and behavior. A concept map placed the recommendations for selected cases in the first phase of the action cycle in the Knowledge-to-Action framework, where knowledge is shared but not yet acted on. DISCUSSION: Project ECHO Chronic Pain is an example of iterative guided practice, wherein expert faculty use published guidelines and professional experience to make recommendations for patient care to PCPs. This occurs using shared social-cultural-historical language and context consistent with social constructivist theories of learning.

Variation and Change Over Time in PROMIS-29 Survey Results Among Primary Care Patients With Type 2 Diabetes.

PURPOSE: We sought to describe results of patient-reported outcome measures implemented among primary care patients with diabetes and explore factors associated with changes in scores over time. METHODS: Two organizations serving diverse patient populations collected the PROMIS-29 survey at baseline and 3-month follow-up for patients with type 2 diabetes. Bayesian regression analysis was used to examine the relationship between patient characteristics and changes in PROMIS-29 scores. Exploratory analyses assessed relationships between goal-setting and changes in scores. RESULTS: The study population reported substantially more problems with physical functioning (mean: 42.5 at Site 1 and 38.9 at Site 2) and pain interference (mean: 58.0 at Site 1 and 61.1 at Site 2) compared to the general population (mean: 50; standard deviation: 10). At least 33% of patients had a clinically meaningful change (ie, at least half the standard deviation, or 5 points) in each PROMIS domain. For pain interference, 55% had no change, 22% improved by 5 or more points, and 23% worsened by 5 or more points. Bayesian regression analyses suggest that chronic conditions, insurance status, and Hispanic ethnicity are likely associated with decreased functioning over time. Exploratory analyses found that setting a mental health goal did not appear to be associated with improvement for anxiety or depression. CONCLUSIONS: Use of patient-reported outcome measures in routine clinical care identified areas of functional limitations among people with diabetes. However, changes in participants' PROMIS-29 scores over time were minimal. Research is needed to understand patterns of change in global and domain-specific functioning, particularly among racial/ethnic minorities.