Predictors of Interest in Offered Social Care Assistance Among People with Uncontrolled Diabetes.

Despite increasing resources dedicated to identifying and addressing social risks in health care settings, many patients screening positive for social risks either decline assistance or do not follow up with offered resources. This study assessed predictors of engagement with offered social care assistance through guided self-navigation or in-person assistance. Data came from a cross-sectional analysis of 6-month follow-up survey data from an ongoing trial of participants with poorly controlled diabetes and a positive social risk screen randomized to guided online self-navigation or in-person social care assistance. Multivariable logistic regression models estimated participant characteristics associated with engagement with offered assistance. Mean age was 55 years (standard deviation = 12). Of 407 participants, 41% (n = 165) engaged with offered assistance: 76% (n = 137) of those in the guided self-navigation arm and 13% (n = 28) of those in the in-person assistance arm. A sizable proportion of participants endorsed already using assistance for medications (30%), food (26%), and employment (22%). Female gender [OR 1.57, 95% CI (1.03-2.40), P < 0.05] and being out of the workforce [OR 1.71, 95% CI (1.07-2.73), P < 0.05] predicted engagement with social care assistance. Those already using assistance for medications [OR 4.71, 95% CI (1.69-13.15), P < 0.05] and blood glucose supplies [OR 6.25, 95% CI (1.45-26.78) P < 0.05] were also more likely to engage with offered assistance. Fewer than half of individuals engaged with offered social assistance through either guided online self-navigation or in-person assistance; limited demographic and clinical factors predicted uptake. More investments are needed to understand how best to support uptake of offered assistance.

Motivators, Barriers, and Preferences to Engagement With Offered Social Care Assistance Among People With Diabetes: A Mixed Methods Study.

INTRODUCTION: A substantial proportion of patients screening positive for social risks either decline assistance or do not follow-up with offered resources. This study examined patient interest in and engagement with offered social care assistance among adults with poorly controlled diabetes at an academic medical center. METHODS: Surveys (n=307) and purposively sampled follow-up interviews (n=40) were conducted 6 months after randomization to receive guided online self-navigation or in-person assistance to address unmet social needs. Integrated mixed methods (data collected in 2019-2021) explored the motivators, barriers, and preferences regarding the uptake of offered assistance. Results were analyzed in 2021 using descriptive statistics, rapid qualitative analysis, and joint display models. RESULTS: A total of 77% of people randomized to online self-navigation and 14% randomized to in-person assistance engaged with offered assistance. Motivators for engagement were similar across groups and included ease of use, anticipating assistance that could address 1 or more needs, and interest in learning more about available resources. Barriers to engagement included not needing or desiring assistance, participants perceiving that offered assistance was not relevant to their needs or that they would not qualify, competing priorities/forgetting, previous negative experiences or stigma, and technology or access challenges (online self-navigation group). Preferences around offered assistance that directly addressed barriers to uptake included changing messaging and framing around offered help and the ability to tailor modalities. CONCLUSIONS: There are key barriers to the use of social care assistance that may directly reflect the process by which individuals are screened and offered assistance. Strategies to increase uptake should be patient centered and ideally provide multiple options for type of assistance and mode of engagement.

A Scoping Review of Behavioral Interventions Addressing Medical Financial Hardship.

Little information has been compiled across studies about existing interventions to mitigate issues of medical financial hardship, despite growing interest in health care delivery. The purpose of this qualitative systematic scoping review was to examine content and outcomes of interventions to address medical financial hardship. PRISMA guidelines were applied to present results using PubMed, Scopus, and CINAHL, published between January 1980 and August 2020. Additional studies were identified through reference lists of selected papers. Included studies focused on mitigating medical financial hardship from out-of-pocket (OOP) health care expenses as an intervention strategy with at least 1 evaluation component. Screening 2412 articles identified 339 articles for full-text review, 12 of which met inclusion criteria. Variation was found regarding targets and outcome measurement of intervention. Primary outcomes were in the following categories: financial outcomes (eg, OOP expenses), behavioral outcomes, psychosocial, health care utilization, and health status. No included studies reported significant reduction in OOP expenses, perceptions of financial burden/toxicity, or health status. However, changes were observed for behavioral outcomes (adherence to treatment, patient needs addressed), some psychosocial outcomes (mental health symptoms, perceived support, patient satisfaction), and care utilization such as routine health care. No patterns were observed in the achievement of outcomes across studies based on intensity of intervention. Few rigorous studies exist in this emerging field, and studies have not shown consistent positive effects. Future research should focus on conceptual clarity of the intervention, align outcome measurement and achieve consensus around outcomes, and employ rigorous study designs, measurement, and outcome follow-up.

Early adopters of electronic prescribing struggle to make meaningful use of formulary checks and medication history documentation.

INTRODUCTION: Use of electronic prescribing (e-prescribing) can improve safety and reduce costs of care by alerting prescribers to drug-drug interactions, patient nonadherence to therapies, and insurance coverage information. Deriving these benefits will require clinical decision support based on presentation of accurate and complete formulary and benefit (F&B) and medication history (RxH) data to prescribers, but relatively little is known about how this information is used in primary care. METHODS: This is a multimethod comparative case study of 8 practices, which were selected to ensure practice size and physician specialty variation, implementing a stand-alone e-prescribing program. Field researchers observed prescription workflow and interviewed physicians and office staff. RESULTS: Before implementation, few prescribers reported using F&B references when making medication choices; all used paper-based methods for tracking medication history. After implementation, some prescribers reported using F&B data to inform medication choices but missing information reduced confidence in these resources. Low confidence in RxH data led to paper-based workarounds. CONCLUSIONS: Challenges experienced with formulary checks and RxH documentation led to prescriber distrust and unwillingness to rely on e-prescribing-based information. Greater data accuracy and completeness must be assured if e-prescribing is to meet meaningful use objectives to improve the efficiency and safety of prescribing in primary care settings.

Examining role change in primary care practice.

PURPOSE: While experts suggest that primary care needs far-reaching transformation that includes adding or reconfiguring roles to improve patient care, little is known about how role change occurs in practice settings. Methods This was a cross-case comparative analysis of 3 projects designed to improve health behavior counseling in primary care practices by adding to or changing clinical support staff roles. Qualitative data (site visits notes, grantee reports, interviews with grantees, and online diary entries) were analyzed to examine instances of role change in depth, using role change theory as an organizing framework. Results Practice team members had greater success taking on new roles when patients valued the services provided. Often, it was easier to a hire a new person into a new role rather than have an existing practice member shift responsibilities. This was because new personnel had the structural autonomy, credibility, and organizational support needed to develop new responsibilities and routines. CONCLUSION: As primary care delivery systems are redesigned in ways that rely on new roles to deliver care, understanding how to effectively add or change staff roles is essential and requires attention to patients', practice members', and institutions' support for new roles.

Coordination of health behavior counseling in primary care.

PURPOSE: We wanted to examine how coordinated care is implemented in primary care practices to address patients' health behavior change needs. METHODS: Site visit notes, documents, interviews, and online implementation diaries were collected from July 2005 to September 2007 from practice-based research networks (PBRNs) participating in Prescription for Health: Promoting Healthy Behaviors in Primary Care Research Networks (P4H). An iterative group process was used to conduct a cross-case comparative analysis of 9 interventions. Published patient outcomes reports from P4H interventions were referenced to provide information on intervention effectiveness. RESULTS: In-practice health risk assessment (HRA) and brief counseling, coupled with referral and outreach to a valued and known counseling resource, emerged as the best way to consistently coordinate and encourage follow-through for health behavior counseling. Findings from published P4H outcomes suggest that this approach led to improvement in health behaviors. Automated prompts and decision support tools for HRA, brief counseling and referral, training in brief counseling strategies, and co-location of referral with outreach facilitated implementation. Interventions that attempted to minimize practice or clinician burden through telephone and Web-based counseling systems or by expanding the medical assistant role in coordination of health behavior counseling experienced difficulties in implementation and require more study to determine how to optimize integration in practices. CONCLUSIONS: Easy-to-use system-level solutions that have point-of-delivery reminders and decision support facilitate coordination of health behavior counseling for primary care patients. Infrastructure is needed if broader integration of health behavior counseling is to be achieved in primary care.

The patient medication list: can we get patients more involved in their medical care?

BACKGROUND: Patient involvement is essential to maintain accurate and updated medication lists, provide quality care, and decrease potential errors. The purpose of this study was to determine the acceptance of medication lists maintained by patients and if their use affected perceptions of patient and physician responsibility and patients' knowledge of their medical care. METHODS: A foldable, wallet-sized medication list card was distributed to a convenience sample of 104 patients>or=40 years of age at an outpatient residency site. They were also given a survey of demographic variables and the Patient Medication Scale, which measures their perceptions of patient responsibility, physician responsibility, and patients' knowledge of their medical care. They were contacted by phone 4 to 11 months later to ascertain if they were using the medication card and the Patient Medication Scale was readministered. RESULTS: Forty-two of 66 patients contacted after the intervention consented to a full interview. Thirty-eight percent (25 of 66) reported using the card. The patients using the card showed increased scores in perceived patient knowledge and patient responsibility, with no change in their perceptions of physician responsibility. Among the 41 respondents not using the card, approximately half indicated interest in using the card in the future or were using a card of their own. CONCLUSIONS: A significant percentage of patients were willing to use the medication list card. Use of the card also seemed to increase their sense of responsibility and perceived knowledge of their medical care.

Organizational culture influences health care workers' influenza immunization behavior.

BACKGROUND AND OBJECTIVES: Low rates of influenza immunization among health care workers (HCWs) pose a potential health risk to patients in primary care practices. Despite previous educational efforts and programs to reduce financial barriers, HCW influenza immunization rates remain low. Variation in practice-level organizational culture may affect immunization rates. To explore this relationship, we examined organizational cultures and HCWs' influenza immunization behaviors in three family medicine practices. METHODS: We used a multi-method comparative case study. A field researcher used participant observation, in-depth interviews, and key informant interviews to collect data in each practice in November-December 2003. A diverse team used grounded theory to analyze text data. RESULTS: Organizational culture varied among practices and differing HCW immunization rates were observed. The most structured and business-like practice achieved immunization of all HCWs, while the other two practices exhibited greater variation in HCW immunization rates. Physicians in the practices characterized as chaotic/disorganized or divided were immunized at higher rates than other members of the practices. CONCLUSIONS: In these practices, organizational culture was associated with varying rates of influenza immunization for HCWs, especially among nonphysicians. Addressing elements of organizational culture such as beliefs regarding influenza immunization and office policies may facilitate the immunization of all staff members.

Influenza immunization disparities in primary care offices--a comparative case study.

Without insight into the primary care environment, further improvements in influenza immunization rates are unlikely. We conducted a comparative case study of family medicine offices during the 2003 influenza immunization season. Practice 1 (P1) served an urban African American population, practice 2 (P2) served a suburban non-minority population, practice 3 (P3) served an urban Hispanic population. Influenza immunization rates among patients age 65 years and older in P1, P2, and P3 were 32%, 33%, and 67% by medical chart. Rates were highest in P3, where medical staff supported vaccination, promoted communication with patients and staff, and made use of systems to identify eligible patients. Characteristics that appear to affect influenza immunization in the primary care environment include the presence of a practice champion, issues of communication and collaboration, and the use of systems approaches. These data support the need for investigation of how these factors affect population level disparities.

Fidelity versus flexibility: translating evidence-based research into practice.

BACKGROUND: Understanding the process by which research is translated into practice is limited. This study sought to examine how interventions change during implementation. METHODS: Data were collected from July 2005 to September 2007. A real-time and cross-case comparison was conducted, examining ten interventions designed to improve health promotion in primary care practices in practice-based research networks. An iterative group process was used to analyze qualitative data (survey data, interviews, site visits, and project diary entries made by grantees approximately every 2 weeks) and to identify intervention adaptations reported during implementation. RESULTS: All interventions required changes as they were integrated into practice. Modifications differed by project and by practice, and were often unanticipated. Three broad categories of changes were identified and include modifications undertaken to accommodate practices' and patients' circumstances as well as personnel costs. In addition, research teams played a crucial role in fostering intervention uptake through their use of personal influence and by providing motivation, retraining, and instrumental assistance to practices. These efforts by the research teams, although rarely considered an essential component of the intervention, were an active ingredient in successful implementation and translation. CONCLUSIONS: Changes are common when interventions are implemented into practice settings. The translation of evidence into practice will be improved when research design and reporting standards are modified to help quality-improvement teams understand both these adaptations and the effort required to implement interventions in practice.

Bridging primary care practices and communities to promote healthy behaviors.

BACKGROUND: Primary care practices able to create linkages with community resources may be more successful at helping patients to make and sustain health behavior changes. METHODS: Health behavior-change interventions in eight practice-based research networks were examined. Data were collected July 2005-October 2007. A comparative analysis of the data was conducted to identify and understand strategies used for linking primary care practices with community resources. RESULTS: Intervention practices developed three strategies to initiate and/or implement linkages with community resources: pre-identified resource options, referral guides, and people external to the practice who offered support and connection to resources. To initiate linkages, practices required the capacity to identify patients, make referrals, and know area resources. Linkage implementation could still be defeated if resources were not available, accessible, affordable, and perceived as valuable. Linkages were facilitated by boundary-spanning strategies that compensated for the lack of infrastructure between practices and resources, and by brokering strategies that identified interested community partners and aided mutually beneficial connections with them. Linkages were stronger when they incorporated practice or resource abilities to motivate the patient, such as brief counseling or postreferral outreach. Further, data suggested that sustaining linkages requires continuous attention and ongoing communication between practices and resources. CONCLUSIONS: Creating linkages between primary care practices and community resources has the potential to benefit both patients and clinicians and to lessen the burden on the U.S. healthcare system resulting from poor health behaviors. Infrastructure support and communication systems must be developed to foster sustainable linkages between practices and local resources.

Practice-level approaches for behavioral counseling and patient health behaviors.

BACKGROUND: There is little empirical evidence to show that a practice-level approach that includes identifying patients in need of health behavior advice and linking them to counseling resources either in the practice or in the community results in improvements in patients' behaviors. This study examined whether patients in primary care practices that had practice-level approaches for physical activity and healthy-diet counseling were more likely to have healthier behaviors than patients in practices without practice-level approaches. METHODS: A cross-sectional study of 54 primary care practices was conducted from July 2005 to January 2007. Practices were categorized into four groups depending on whether they had both identification tools (health risk assessment, registry) and linking strategies (within practice or to community resources); identification tools but no linking strategies; linking strategies but no identification tools; or neither identification tools nor linking strategies. RESULTS: Controlling for patient and practice characteristics, practices that had both identification tools and linking strategies for physical activity counseling were 80% more likely (95% CI=1.25, 2.59) to have patients who reported exercising regularly compared to practices that lacked both. Also, practices that had either identification tools or linking strategies but not both were approximately 50% more likely to have patients who reported exercising regularly. The use of a greater number of practice-level approaches for physical activity counseling was associated with higher odds of patients' reporting exercising regularly (p for trend=0.0002). Use of identification tools and linking strategies for healthy-eating counseling was not associated with patients' reports of healthy diets. CONCLUSIONS: This study suggests that practice-level approaches may enable primary care practices to help patients improve physical activity. However, these approaches may have different effects on different behaviors, and merit further research to determine if causal pathways exist and, if so, how they should be applied.

Variation in electronic prescribing implementation among twelve ambulatory practices.

BACKGROUND: Electronic prescribing has been advocated as an important tool for improving the safety and quality of medication use in ambulatory settings. However, widespread adoption of e-prescribing in ambulatory settings has yet to be realized. The determinants of successful implementation and use in these settings are not well understood. OBJECTIVE: To describe the practice characteristics associated with implementation and use of e-prescribing in ambulatory settings. DESIGN: Multi-method qualitative case study of ambulatory practices before and after e-prescribing implementation. PARTICIPANTS: Sixteen physicians and 31 staff members working in 12 practices scheduled for implementation of an e-prescribing program and purposively sampled to ensure a mix of practice size and physician specialty. MEASUREMENTS: Field researchers used observational and interview techniques to collect data on prescription-related clinical workflow, information technology experience, and expectations. RESULTS: Five practices fully implemented e-prescribing, 3 installed but with only some prescribers or staff members using the program, 2 installed and then discontinued use, 2 failed to install. Compared to practice members in other groups, members of successful practices exhibited greater familiarity with the capabilities of health information technologies and had more modest expectations about the benefits likely to accrue from e-prescribing. Members of unsuccessful practices reported limited understanding of e-prescribing capabilities, expected that the program would increase the speed of clinical care and reported difficulties with technical aspects of the implementation and insufficient technical support. CONCLUSIONS: Practice leaders should plan implementation carefully, ensuring that practice members prepare for the effective integration of this technology into clinical workflow.