Unpacking patient perspectives on social needs screening: A mixed methods study in western Colorado primary care practices.

OBJECTIVE: Explore factors influencing patient comfort with and perceived helpfulness of screening for health-related social needs. METHODS: In a parallel secondary mixed-methods analysis of data from three primary care clinics, we used logistic regression to examine effects of practice- and patient-level factors on comfort with and perceived helpfulness of social needs screening. We applied narrative analysis to 20 patient interviews to further understand how patients' lived experiences influenced their perceptions of screening. RESULTS: Among 511 patients, receiving an explanation about screening was associated with increased odds of comfort (OR 2.1, 95% CI [1.1-4.30]) and perceived helpfulness (OR 4.7 [2.8-7.8]). Those experiencing more needs were less likely to report comfort (3 + needs vs. 0: OR 0.2 [0.1-0.5]). Narratives elucidated how a history of stigmatizing experiences increased discomfort disclosing needs and captured how relationship quality with healthcare teams influenced perceptions of screening for patients with extensive needs. CONCLUSION: Practice-level (screening explanation and therapeutic rapport) and patient-level factors (history and extent of needs) are key influences on comfort with and perceived helpfulness of screening. PRACTICE IMPLICATIONS: Good communication about screening benefits all patients. Patients with extensive social needs may require additional sensitivity to their past experiences.

Models for Delivering Weight Management in Primary Care: Qualitative Results from the MOST Obesity Study.

BACKGROUND: Obesity is a leading cause of morbidity and mortality in the United States (US). Primary care medical practices can educate patients about the health effects of obesity and help patients with obesity lose and manage their weight. However, implementation of weight management in primary care is challenging. We sought to examine how practices that implement weight management services do so feasibly. METHODS: Multiple methods including site visits, observations, interviews, and document reviews were utilized to identify and learn from primary care practices located across the US. A qualitative multidimensional classification of empirical cases was performed to identify unique delivery features that were feasible to implement in primary care. RESULTS: Across 21 practices, 4 delivery models were identified: group, integrated into standard primary care, hiring an "other" professional, and using a specific program. Model characteristics included who delivered the weight management services, whether delivered to an individual or group, the types of approaches used, and how the care was reimbursed or paid. Most practices integrated weight management services and primary care delivery, although some created specific carve-out programs. CONCLUSION: This study identified 4 models that may serve to overcome challenges in delivering weight management services in primary care. Based on practice characteristics, preferences, and resources, primary care practices can identify a model for successfully implementing weight management services that best fits their context and needs. It is time for primary care to truly address obesity care as the health issue it is and make it a standard of care for all patients with obesity.

Points of Concordance, Points of Discordance: A Qualitative Examination of Telemedicine Implementation.

INTRODUCTION: Health systems undertook a rapid transition to increase the use of telemedicine in the wake of the COVID-19 pandemic. A continued need for telemedicine services in the coming years is likely. This article examines telemedicine from multiple stakeholders' perspectives considering reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) outcomes. METHODS: Semistructured interviews were conducted with primary care practice team members and patients. Rapid qualitative analysis was used to identify themes in experiences and perceptions related to telemedicine implementation. The RE-AIM implementation framework was applied to thematic findings to understand influences on implementation outcomes. RESULTS: Twenty-four practice members and 17 patients across 5 clinics participated. All stakeholder groups reported that technological capabilities influenced patients' access to telemedicine and that certain patients and reasons for visits were not appropriate for telemedicine. All groups felt that telemedicine was a good option for some patients some of the time but not all patients all of the time. DISCUSSION: Telemedicine works well if it is used for the appropriate visits and patient types and with needed technological elements. Older age may limit the feasibility of telehealth for some patients. Added administrative work and associated costs support systematic screening to determine visit appropriateness for telemedicine.

Implementing health-related social needs screening in western Colorado primary care practices: Qualitative research to inform improved communication with patients.

Social determinants profoundly impact health. Many primary care practices now seek to screen their patients for health-related social needs (HRSN) and refer them to resources in the community. However, there is little empirical evidence to guide communication with patients in order to ensure their comfort with the process and increase the likelihood that it results in positive outcomes. This paper describes the first phase of the Improving Messaging Around Gaps in Needs and rEfferals (IMAGINE) study-a multi-phase study aiming to develop and test patient-centred messages about screening and referral for HRSN. In this initial qualitative phase, our objective was to identify communication strategies that might make western Colorado primary care patients more comfortable with the HRSN screening and referral process. From May to July 2020 we interviewed 10 staff members responsible for HRSN screening from primary care practices participating in the western Colorado Accountable Health Communities (AHC) initiative and 20 patients from 2 of these practices. We used a rapid qualitative analysis process that involved summarising interview transcripts across key domains of interest and then identifying emergent themes within each domain using a data matrix. Through this process, we examined current communication about HRSN screening, as well as suggestions for messages and other strategies that could improve communication. In most practices, the AHC Screening Tool was handed to patients by front desk staff at check-in with little explanation as to its purpose. Patients and staff alike recommended that patients be provided with information that: normalises the screening and referral process; assures privacy; clarifies that the purpose is to help and support rather than judge or report; emphasises community benefits; and respects patient autonomy. Interviewees also suggested broader strategies to support more effective communication, such as practice staff and clinicians building trusting relationships with patients and understanding and acknowledging the complex structural barriers that often prevent patients from accessing meaningful assistance. These findings provide actionable suggestions for improving communication about HRSN screening and referral in primary care settings. The next steps include developing specific messages based on these findings and testing their impact on screening tool completion rate, referral uptake, and patient-reported comfort with the process.

The Joys and Challenges of Delivering Obesity Care: a Qualitative Study of US Primary Care Practices.

BACKGROUND: Obesity is of epidemic proportion in the USA but most people with obesity do not receive treatment. OBJECTIVE: To explore the experience of providing obesity management among primary care clinicians and their team members involved with weight loss in primary care practices. The study's focus was on examining the use of the Medicare payment code for intensive behavioral therapy for obesity (IBT), but other obesity management services and payment mechanisms were also studied. DESIGN/PARTICIPANTS: We conducted 85 interviews of clinicians (physician, advanced practice clinicians, registered dietitian, or other) practicing in primary care practices. Interviews gathered information about treatment approach to obesity, barriers, and facilitators to providing obesity care including the handling of billing and reimbursement (especially use of the IBT code), personal beliefs about the appropriateness of primary care providing weight loss services, and recommendations for improving weight management in primary care practice. The analysis was conducted using a grounded theory hermeneutic editing approach and the constant comparative method. KEY RESULTS: Seventy-five interviews were included in this analysis. We identified three primary themes: (1) clinicians and staff involved in obesity management in primary care believe that addressing obesity is an essential part of primary care services, (2) because providing obesity care can be challenging, many practices opt out of treatment, and (3) despite the challenges, many clinicians and others find treating obesity feasible, satisfying, and worthwhile. CONCLUSIONS: Treating obesity in primary care settings poses several challenges but can also be very satisfying and rewarding. To improve the ability of clinicians and practice members to treat obesity, important changes in payment, education, and work processes are necessary.

A Survey of Primary Care Practices on Their Use of the Intensive Behavioral Therapy for Obese Medicare Patients.

OBJECTIVE: To fill the gap in knowledge on systematic differences between primary care practices (PCP) that do or do not provide intensive behavioral therapy (IBT) for obese Medicare patients. METHODS: A mixed modality survey (paper and online) of primary care practices obtained from a random sample of Medicare databases and a convenience sample of practice-based research network practices. KEY RESULTS: A total of 287 practices responded to the survey, including 140 (7.4% response rate) from the random sample and 147 (response rate not estimable) from the convenience sample. We found differences between the IBT-using and non-using practices in practice ownership, patient populations, and participation in Accountable Care Organizations. The non-IBT-using practices, though not billing for IBT, did offer some other assistance with obesity for their patients. Among those who had billed for IBT, but stopped billing, the most commonly cited reason was billing difficulties. Many providers experienced denied claims due to billing complexities. CONCLUSIONS: Although the Centers for Medicare and Medicaid Services established payment codes for PCPs to deliver IBT for obesity in 2011, very few providers submitted fee-for-service claims for these services after almost 10 years. A survey completed by both a random and convenience sample of practices using and not using IBT for obesity payment codes revealed that billing for these services was problematic, and many providers that began using the codes discontinued using them over the past 7 years.

Practice Characteristics Associated with Better Implementation of Patient Self-Management Support.

BACKGROUND: Advanced primary care models emphasize patient-centered care, including self-management support (SMS). This study aimed to promote the translation of SMS into primary care practices and reported on key baseline practice characteristics that may impact SMS implementation. METHODS: Thirty-six practices in Colorado and California participated in the study from December 2013 to March 2017. Practice administrators completed a Practice Information Form describing practice characteristics. Clinicians and staff (n = 716) completed the Practice Culture Assessment and the Patient-Centered Medical Home (PCMH) Monitor. Descriptive statistics were computed to determine practice characteristics related to culture, quality improvement, level of PCMH, and SMS implementation. Field notes and key informant interviews provided contextual details about practices. Iterative qualitative analyses identified important facilitators and barriers and change capabilities around SMS implementation. RESULTS: In bivariate analyses, rural locations, fewer uncontrolled patients with diabetes, higher Medicaid or uninsured populations, underserved designation, and higher level of "PCMHness" were associated with greater reported implementation of patient SMS (all P < .05) at baseline. In the final multilevel model, specialty (FM vs mixed, P = .0081), rural location (P = .0109), and higher percent Medicaid (P < .0001) were associated with greater SMS. Practices described key facilitators (alignment, motivation, a visible champion, supporting infrastructure, and functional quality improvement and care teams) and barriers (no shared vision, no visible champion, siloed infrastructure, competing programs, turnover, and time constraints) to improving SMS delivery. CONCLUSIONS: Careful attention-and action-on key practice characteristics and context may create more favorable initial conditions for practice change efforts to improve SMS in primary care practices.

Enhancing quality of prosthetic services with process and outcome information.

BACKGROUND: Prosthetic clinics in the United States must attain accreditation in order to receive reimbursement from Medicare. The accreditation process requires clinics to establish and implement performance management plans and quality improvement activities. This report describes the experience of seven prosthetic clinics in collecting patient-reported outcome data and using it to improve quality of services. OBJECTIVES: To describe the experience of prosthetic clinics implementing outcome monitoring and quality improvement activities as part of routine patient care. STUDY DESIGN: Qualitative, ethnographic design. METHODS: Clinics incorporated the Orthotics Prosthetics Users' Survey into routine care for patients aged 18 years and older who received a new lower limb prosthesis or socket. Orthotics Prosthetics Users' Survey measures lower extremity functional status, quality of life, and satisfaction with device and services. Clinics selected Orthotics Prosthetics Users' Survey-derived indicators on which to implement quality improvement action plans. RESULTS: Seven clinics participated, but only three were able to sustain data collection. Two clinics initiated quality improvement activities focused on improving declining satisfaction or functional scores. CONCLUSIONS: Quality improvement activities based on patient-reported outcomes require a high degree of organizational commitment and support. External facilitation can support clinics' quality improvement activities. Clinical relevance This project illustrates the challenges of sustaining quality improvement activities using patient-reported outcome data in prosthetic clinics.

Outcome instruments for prosthetics: clinical applications.

Outcome measurement is crucial to assuring high-quality patient services and improving the quality of services provided by prosthetists. This article summarizes recent evidence on the measurement properties of outcome measures, and updates previously published summaries of outcome instruments. The review focuses on measures of mobility, functional status, quality of life, and patient satisfaction, and includes both performance-based and patient-reported outcomes. Amputation-specific and general measures that are suitable for patients served by prosthetists are discussed. It is encouraging that responsiveness of measures is often reported, as this information is needed to improve clinical utility.

A pneumatic glove and immersive virtual reality environment for hand rehabilitative training after stroke.

While a number of devices have recently been developed to facilitate hand rehabilitation after stroke, most place some restrictions on movement of the digits or arm. Thus, a novel glove was developed which can provide independent extension assistance to each digit while still allowing full arm movement. This pneumatic glove, the PneuGlove, can be used for training grasp-and-release movements either with real objects or with virtual objects in a virtual reality environment. Two groups of stroke survivors, with seven subjects in each group, completed a six-week rehabilitation training protocol, consisting of three 1-h sessions held each week. One group wore the PneuGlove during training, performed both within a novel virtual reality environment and outside of it with physical objects, while the other group completed the same training without the device. Across subjects, significant improvements were observed in the Fugl-Meyer Assessment for the upper extremity (p < 0.001), the hand/wrist portion of the Fugl-Meyer Assessment (p < 0.001), the Box and Blocks test (p < 0.005), and palmar pinch strength (p < 0.005). While changes in the two groups were not statistically different, the group using the PneuGlove did show greater mean improvement on each of these measures, such as gains of 3.7 versus 2.4 points on the hand/wrist portion of the Fugl-Meyer Assessment and 14 N versus 5 N in palmar pinch.

Use of a pneumatic glove for hand rehabilitation following stroke.

Hand impairment is common following stroke and is often resistant to traditional therapy methods. Successful interventions have stressed the importance of repeated practice to facilitate rehabilitation. Thus, we have developed a servo-controlled glove to assist extension of individual digits to promote practice of grasp-and-release movements with the hand. This glove, the PneuGlove, permits free movement of the arm throughout its workspace. A novel immersive virtual reality environment was created for training movement in conjunction with the device. Seven stroke survivors with chronic hand impairment participated in 18 training sessions with the PneuGlove over 6 weeks. Overall, subjects displayed a significant 6-point improvement in the upper extremity score on the Fugl-Meyer assessment and this increase was maintained at the evaluation held one month after conclusion of all training (p < 0.01). The majority of this gain came from an increase in the hand/wrist score (3.8-point increase, p < 0.01). Thus, the system shows promise for rehabilitative training of hand movements after stroke.

Effect of a gravity-compensating orthosis on reaching after stroke: evaluation of the Therapy Assistant WREX.

DESIGN: Within-subjects repeated-measures design evaluating reaching with and without the Therapy Assistant Wilmington Robotic Exoskeleton (WREX). SETTING: Laboratory. PARTICIPANTS: Stroke survivors (N=10) with chronic upper-extremity hemiparesis. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Arm movement kinematics (Optotrak Certus motion detection system), muscle activity for biceps, triceps, anterior deltoid, and brachioradialis muscles (bipolar surface electromyography). RESULTS: Significant improvements of reaching distance occurred for all subjects across all targets (P<.001) when using the Therapy Assistant WREX. While the self-selected peak speed of hand movement during the reach decreased significantly with the Therapy Assistant WREX (P<.001), use of the Therapy Assistant WREX led to improved quality of movement as signified by a decrease in jerk (P<.001) and a shift in the timing of the peak speed to an earlier point in the movement (P<.001). Electromyographic muscle activity analysis showed that use of the Therapy Assistant WREX led to a reduction in biceps activity across all targets during the reach (P<.05), in conjunction with a marginally significant reduction in activity of the anterior deltoid (P<.055). No changes were observed in triceps (P=.47) or brachioradialis activity (P=.28). CONCLUSIONS: By reducing requirements for shoulder activation, the Therapy Assistant WREX improved reaching performance among stroke survivors compared with free reaching, thereby potentially facilitating practice of functional tasks.