Beyond knowledge and confidence: a mixed methods evaluation of a Project ECHO course on dementia for primary care.

Primary care clinicians have an important role in the management of dementia and have expressed interest in continuing education. The authors describe a model they used for providing dementia education in primary care, Project ECHO (Extension for Community Healthcare Outcomes), and an overview of its major features. A partnership including academic institutions and a national healthcare association is then outlined, including the unique features of the ECHO model developed through this partnership. A mixed-methods methodology was used for programmatic evaluation. This use of mixed methods adds vital new knowledge and learner perspectives that are key to planning subsequent ECHO courses related to dementia and primary care. The discussion includes an exploration of the significance of these findings for understanding the motivations of primary care providers for participation in the educational program, as well as the limitations of the current study. A final section explores the next steps in the continued development of the model and its implications for geriatrics education in dementia care, especially the supportive role that ECHO courses can play in meeting the challenges of dementia care.

Care Coordination for Breast Cancer Survivors in Urban Underserved Communities: Will Treatment Summaries and Survivorship Care Plans Be Enough?

BACKGROUND: Few studies have examined cancer care coordination at federally qualified health centers (FHQCs). The Commission on Cancer's (CoC) standard 3.3, i.e., treatment summaries and survivorship care plans (TS-SCPs), is aimed at improving communication between cancer specialists and primary care providers (PCPs) across all healthcare systems. Whether this will improve care at FQHCs is unclear. We sought to understand breast cancer care coordination at FQHCs before the stepwise implementation of standard 3.3. METHODS: In 2014, we conducted a retrospective chart review at five Chicago FQHCs. We used ICD-9 codes to identify 109 breast cancer cases diagnosed within 5 years of the chart review. We examined charts for (1) external cancer records, (2) PCP documentation of breast cancer histories, and (3) documentation of PCP engagement in cancer-relevant follow-up care. RESULTS: Less than 50% of the charts had PCP documentation of more than one area of cancer-relevant follow-up care. Availability of external records did not increase PCP engagement in cancer-relevant follow-up care. Instead, PCPs who documented information about their patient's breast cancer treatments also documented more cancer-relevant follow-up care. CONCLUSION: Before the stepwise implementation of TS-SCPs, less than 50% of the charts had PCP documentation of more than one area of cancer-related follow-up care. The TS-SCP is designed to facilitate care coordination between specialists and PCPs through increased communication. Our results suggest the availability of external cancer information did not necessarily translate into care delivery. This suggests communication of information alone is insufficient.

The importance of transdisciplinary collaborations for understanding and resolving health disparities.

Group disparities in health have been documented for several decades. Despite recent efforts to eliminate them, group differences persist and challenge the ability of scientists to address them using traditional research paradigms. Because the determinants of disparities occur at multiple levels, from the molecular to the societal, and interact with one another in ways not yet fully understood, they represent a challenge to researchers attempting to capture their complexity. After reviewing existing models of disciplinary collaboration, we outline the challenges of a transdisciplinary approach and its ability to afford the holistic view of disparities needed to develop effective interventions.

Targeting health disparities: a model linking upstream determinants to downstream interventions.

Certain social/environmental factors put some groups at extraordinary risk for adverse health outcomes, creating health disparities. We present a downward causal model, originating at the population level and ending at disease, with psychological and behavioral responses linking the two. This approach identifies how specific social environments "get under the skin" to cause disease, illustrated with the disparity in mortality from aggressive premenopausal breast cancer suffered by black women. Broadening our lens to consider the entire chain of causal factors, spanning multiple levels and interacting across the life span, heightens our ability to craft specific interventions to address group differences in health.

Early-life conditions and mechanisms of population health vulnerabilities.

The social status of groups is key to determining health vulnerability at the population level. The impact of material and psychological stresses imposed by social inequities and marginalization is felt most intensely during perinatal/early childhood and puberty/adolescent periods, when developmental genes are expressed and interact with social-physical environments. The influence of chronic psychosocial stresses on gene expression via neuroendocrine regulatory dysfunction is crucial to understanding the biological bases of adult health vulnerability. Studying childhood biology vulnerabilities to neighborhood environments will aid the crafting of multifaceted, multilevel public policy interventions providing immediate benefits and compounded long-term population health yields.