Population Health Management Approach to Depression Symptom Monitoring in Primary Care via Patient Portal: A Randomized Controlled Trial.

Depression is undertreated in primary care. Using patient portals to administer regular symptom assessments could facilitate more timely care. At an urban academic medical center outpatient clinic, patients with active portal accounts and depression on their problem list or a positive screen in the past year were randomized to assessment during triage at visits (usual care) versus usual care plus assessment via portal (population health care). Portal invitations were sent regardless of whether patients had scheduled appointments. More patients completed assessments in the population health care arm than usual care: 59% versus 18%, P < 0.001. Depression symptoms were more common among patients who completed their initial assessment via the portal versus in the clinic. In the population health care arm, 57% (N = 80/140) of patients with moderate-to-severe symptoms completed at least 1 follow-up assessment versus 37% (N = 13/35) in usual care. A portal-based population health approach could improve depression monitoring in primary care.

Association between wait time and behavioral health appointment attendance across patient characteristics.

Adequate access to behavioral health (BH) services is a critical issue. Many patients who are referred to BH care miss their appointments. One barrier to BH care is that longer wait times decrease the likelihood of appointment attendance. The present study examines the relationship between the wait time for BH services and appointment attendance, overall and by multiple patient characteristics. Logistic regression was performed to analyze the association between wait time and patient attendance for BH referrals made from March 1, 2016, to February 28, 2019, at an urban academic medical center. In total, 1,587 referrals were included. Most patients were female (72%) and of non-Hispanic/Latinx Black race (55%). Each additional week of waiting between the referral and scheduled appointment was associated with a 5% decrease in odds of attendance. In adjusted race/ethnicity-stratified analyses, Hispanic/Latinx patients had a 9% lower odds of attendance per week of waiting. Non-Hispanic/Latinx White and Black patients had a 5% lower odds of attendance per week of waiting. Patients with private insurance had a 7% lower odds of attendance per week of waiting, and patients with Medicare had a 6% lower odds of attendance per week of waiting. Limiting scheduling may improve BH care utilization by decreasing the rate of "no shows." (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Medical Assistant Protocol Improves Disparities in Depression Screening Rates.

INTRODUCTION: Depression is a prevalent condition for which screening rates remain low and disparities in screening exist. This study examines the impacts of a medical assistant screening protocol on the rates of depression screening, overall and by sociodemographic groups, in a primary care setting. METHODS: Between September 2016 and August 2018, a quasi-experimental study of adult primary care visits was conducted at an urban academic clinic to ascertain the change in the rates of completion of the Patient Health Questionnaire-2 after the implementation of a medical assistant protocol (intervention) versus that of physician-only screening (control arm). Analyses were conducted between April 2019 and April 2020 and used interrupted time-series models with generalized estimating equations. RESULTS: A total of 45,157 visits by 21,377 unique patients were included. Overall, screening increased from 18% (physician-only screening) to 57% (medical assistant protocol) (p<0.0001). Screening increased for all measured demographics. With physician screening, depression screening was less likely to occur at visits by women (than at visits by men; OR=0.91, 95% CI=0.85, 0.98) and at visits by Black/African American patients (than at visits by White; OR=0.91, 95% CI=0.84, 0.99). However, with the medical assistant protocol, depression screening was more likely to occur at visits by women (than at visits by men; OR=1.07, 95% CI=1.0002, 1.14) and at visits by Black/African American patients (than at visits by White; OR=1.11, 95% CI=1.02, 1.20). In addition, age-related disparities were mitigated for visits by patients aged 40-64 and ≥65 years (e.g., age ≥65 years: physician, OR=0.66, 95% CI=0.59, 0.73; medical assistant protocol, OR=0.78, 95% CI=0.71, 0.85), compared with visits by patients aged 18-39 years. CONCLUSIONS: Implementation of a medical assistant protocol in a primary care setting may significantly increase depression screening rates while mitigating or removing sociodemographic disparities.

Improving Primary Care Behavioral Health Integration in an Academic Internal Medicine Practice: 2-Year Follow-Up.

This report details ongoing efforts to improve integration in the 2 years following implementation of the Primary Care Behavioral Health model at a general internal medicine clinic of an urban academic medical center. Efforts were informed by a modified version of the validated Level of Integration Measure, sent to all faculty and staff annually. At baseline, results indicated that the domains of systems integration, training, and integrated clinical practices had the greatest need for improvement. Over the 2 years, the authors increased availability of behavioral medicine appointments, improved depression screening processes, offered behavioral health training for providers, disseminated clinical decision support tools, and provided updates about integration progress during clinic meetings. Follow-up survey results demonstrated that physicians and staff perceived improvements in integration overall and in targeted domains. However, the main ongoing barrier to integration was insufficient behavioral health staff to meet patient demand for behavioral health services.

Measuring Perceived Level of Integration During the Process of Primary Care Behavioral Health Implementation.

Provider- and staff-perceived levels of integration were measured during implementation of a primary care behavioral health clinic; these data were used to tailor and evaluate quality improvement strategies. Providers and staff at an urban, academic, adult primary care clinic completed the 32-item Level of Integration Measure (LIM) at baseline and 7 months. The LIM assesses 6 domains of integrated care. Overall and domain scores were calibrated from 0 to 100, with ≥80 representing a highly integrated clinic. Response rate was 79% (N = 46/58) at baseline and 83% (N = 52/63) at follow-up. Overall, LIM score increased from 64.5 to 70.1, P = .001. The lowest scoring domains at baseline were targeted for quality improvement and increased significantly: integrated clinical practice, 60.0 versus 68.4, P < .001; systems integration, 57.0 versus 63.8, P = .001; and training, 56.7 versus 65.3, P = .001. Ongoing quality improvement, including organizational and financial strategies, is needed to achieve higher levels of integration.

Hypertension Control in the University of Chicago Primary Care Group.

In Brief "Quality Improvement Success Stories" are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc., and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes a successful project by faculty at the University of Chicago to improve blood pressure control among hypertensive patients at a general internal medicine clinic on the South Side of Chicago, Ill.

Using feedback to change primary care physician behavior.

Recognizing the gap between high-quality care and the care actually provided, health care providers across the country are under increasing institutional and payer pressures to move toward more high-quality care. This pressure is often leveraged through data feedback on provider performance; however, feedback has been shown to have only a variable effect on provider behavior. This study examines the cognitive behavioral factors that influence providers to participate in feedback interventions, and how feedback interventions should be implemented to encourage more provider engagement and participation.

"Ms. B changes doctors": using a comic and patient transition packet to engineer patient-oriented clinic handoffs (EPOCH).

BACKGROUND: Few patient-centered interventions exist to improve year-end residency clinic handoffs. AIM: Our purpose was to assess the impact of a patient-centered transition packet and comic on clinic handoff outcomes. SETTING: The study was conducted at an academic medicine residency clinic. PARTICIPANTS: Participants were patients undergoing resident clinic handoff 2011-2013 PROGRAM DESCRIPTION: Two months before the 2012 handoff, patients received a "transition packet" incorporating patient-identified solutions (i.e., a new primary care provider (PCP) welcome letter with photo, certificate of recognition, and visit preparation tool). In 2013, a comic was incorporated to stress the importance of follow-up. PROGRAM EVALUATION: Patients were interviewed by phone with response rates of 32 % in 2011, 43 % in 2012 and 36 % in 2013. Most patients who were interviewed were aware of the handoff post-packet (95 %). With the comic, more patients recalled receiving the packet (44 % 2012 vs. 64 % 2013, p< 0.001) and correctly identified their new PCP (77 % 2012 vs. 98 % 2013, p< 0.001). Among patients recalling the packet, most (70 % 2012; 65 % 2013) agreed it helped them establish rapport. Both years, fewer patients missed their first new PCP visit (43 % in 2011, 31 % in 2012 and 26 % in 2013, p< 0.001). DISCUSSION: A patient-centered transition packet helped prepare patients for clinic handoffs. The comic was associated with increased packet recall and improved follow-up rates.

Using a resident discharge clinic for resident education and patient care: a feasibility study.

BACKGROUND: Many patients in internal medicine resident continuity clinics experience difficulty accessing care, making posthospitalization ambulatory follow-up challenging. Experiential learning in care transitions is also lacking for residents. OBJECTIVE: We sought to assess the feasibility and impact of a weekly Resident Discharge Clinic (RDC) in increasing access to early posthospitalization follow-up and providing learning opportunities for residents. METHODS: We staffed the RDC with an ambulatory block resident, an internal medicine preceptor, and a clinical pharmacist. We assessed time to posthospitalization follow-up, readmission rates, and resident perceptions of postdischarge care for resident-clinic patients, comparing data before and after RDC implementation. RESULTS: There were 636 discharges in the baseline group, 662 during the intervention period, and 56 in the RDC group. Six months after RDC implementation, the percentage of discharged resident-clinic patients with follow-up within 7 days improved from 6.6% at baseline to 9.7% (P  =  .04). The mean interval to the posthospitalization follow-up appointment in the RDC group was 7.4 days compared with 33.9 days in the baseline group (P < .001). The percentage of surveyed residents (n  =  72) who agreed that early follow-up was easy to arrange increased from 21% to 77% (P < .001). There was no significant decrease in the 30-day readmission rate for patients in the RDC group (18.1% versus 12.5%, P  =  .29). CONCLUSIONS: The RDC was easily implemented, increased access to timely posthospitalization follow-up, and provided a platform for resident learning about care transitions.

The Quality and Safety Track: Training Future Physician Leaders.

Future physician leaders will need the knowledge and skills necessary to improve systems of care. To address this need, Pritzker School of Medicine implemented a 4-year scholarly track in quality and patient safety for medical students. The Quality and Safety Track (QST) includes an intensive elective that teaches basic quality-improvement skills, an individual mentored scholarly project, and engagement in the Institute for Healthcare Improvement Open School. The first-year elective incorporates a group project that allows students to apply basic process improvement skills. Institutional quality and safety leaders also present their work, giving students context for how these skills are used. To date, 23 students have completed the elective, and 11 chose to pursue QST throughout their medical school experience. Students who completed the elective reported improved confidence in using core quality improvement skills. QST is a feasible and innovative program to develop future health care leaders in quality and safety.

Results of an enhanced clinic handoff and resident education on resident patient ownership and patient safety.

PURPOSE: Although internal medicine resident clinic handoffs present risks for patients, few interventions exist. The authors evaluated an enhanced handoff. METHOD: In 2011, the authors formalized a handoff protocol including a standardized sign-out process, resident education, improved scheduling, and time to establish care through telephone visits. The authors surveyed 25 residents in 2011 and 19 in 2010 regarding their perceptions and performed chart audits to examine patient outcomes. RESULTS: Compared with 2010, residents in 2011 reported longer handoffs (>20 minutes, 52% versus 6%, P<.01), more verbal handoffs (80% versus 38%, P<.01), more patients aware of the handoff (100% versus 74%, P=.01), less discomfort with paperwork for patients not yet seen (40% versus 74%, P=.03), and more ownership of patients before the first visit (56% versus 26%, P=.05). In 2011, more patients saw their correct primary care provider (82% versus 44%, P<.01), and more tests were followed up appropriately (67% versus 46%, P=.02). The authors detected in 2011 a trend for patients to be seen the month their physician intended (40% versus 33%, P=.06) and a trend toward fewer acute (hospital and emergency department) visits three months post handoff (20% versus 26%, P=.06). CONCLUSIONS: Enhancing clinic handoffs can improve the handoff process, increase the likelihood of patients seeing the correct primary care provider within the target time frame, reduce missed tests, and possibly reduce acute visits.

A resident-led quality improvement initiative to improve obesity screening.

Instruction on quality improvement (QI) methods is required as part of residency education; however, there is limited evidence regarding whether internal medicine residents can improve patient care using these methods. Because obesity screening is not done routinely in clinical practice, residents aimed to improve screening using QI techniques. Residents streamlined body mass index (BMI) documentation, created educational materials about obesity, and launched an obesity screening QI initiative in a residency clinic. Residents designed plan-do-study-act cycles focused on increasing awareness and maintaining improvements in screening over a 1-year period. Documentation rates were collected at baseline, 2 weeks, 6 months, and 1 year post-intervention. At 1 year, obesity treatment rates also were collected. BMI documentation rates after 1 year were higher than baseline (43% vs 4%, P < .0001). In obese patients, BMI documentation was associated with lifestyle counseling (34% vs 14%, P < .01). An internal medicine resident-led QI project targeting obesity can improve screening.

Effect of a quality improvement curriculum on resident knowledge and skills in improvement.

BACKGROUND: While many residency programmes have implemented quality improvement (QI) training programmes, few have been rigorously evaluated. METHODS: Residents at the authors' institution participated in a required course, the Quality Assessment and Improvement Curriculum during two 1-month-long rotations. The American Board of Internal Medicine (ABIM) Practice Improvement Module (PIM) was used to guide residents through chart reviews for quality measures, surveys of patient satisfaction and an assessment of clinic systems. Residents received 12 h of training in QI skills (ie, using Plan-Do-Study-Act cycles). Residents worked in groups to test the effect of a small QI project of their choosing. Residents completed the Quality Improvement Knowledge Assessment Tool (QIKAT) to assess QI knowledge, and a self assessment of QI skills. Third-year residents who did not participate in the curriculum served as a historical control group. RESULTS: 87% (26/30) of PGY2s (intervention group) and 83% (24/29) of PGY3 residents (historical controls) completed the self assessment and QIKAT. PGY2 residents showed a significant improvement in QIKAT scores (Pre: 6.98 (6.23 to 7.72) vs Post: 9.70 (8.92 to 10.50); p<0.001) and all 12 QI skills. In addition, the post-PGY2 intervention group outperformed the PGY3 historical control group in QIKAT scores (PGY2 Post-9.59 (8.82 to 10.36) vs PGY3 Control 7.34 (6.48 to 8.20); p<0.001) and all QI skills. CONCLUSION: A QI curriculum using the ABIM PIMs and small-group, resident chosen QI projects can result in improvements in resident knowledge and self-assessed skills in QI. The use of a historical control group was a helpful way to account for the effects of accumulating experience in the pre-post evaluation of this curriculum.

Problems after discharge and understanding of communication with their primary care physicians among hospitalized seniors: a mixed methods study.

BACKGROUND: Communication and coordination with primary care physicians (PCPs) is recommended to ensure safe care transitions for hospitalized older patients. Understanding patient experiences of problems after discharge can help clinical teams design more patient-centered care transitions. OBJECTIVE: To report older patients' experiences with problems after hospital discharge and investigate whether PCPs were aware of their hospitalization. DESIGN: Prospective mixed methods study. SETTING: Single academic medical center. PATIENTS: Hospitalized patients and PCPs. MEASUREMENTS: Telephone interviews of frail, older general medical patients conducted 2 weeks after discharge to elicit patient problems after discharge, such as: (1) obtaining medications, or follow-up appointments; and (2) perceptions of hospital physician communication with their PCP. For each patient interviewed, their PCP was faxed a survey 2 weeks after discharge to assess awareness of hospitalization. RESULTS: Forty-two percent (27) of patients reported 42 different post-discharge problems. The most frequently reported problems were difficulty with follow-up appointments or tests (12). Other reported problems included readmission and return to the Emergency Department (10), problems with medications (8), not-prepared for discharge (8), and hospital complications or questions (4). Thirty percent of PCPs were unaware of patient hospitalization. Patients were twice as likely to report a problem if their PCP was unaware of the hospitalization (31% PCP aware, vs. 67% PCP not aware; P < 0.05). CONCLUSION: This study suggests that many frail, older patients reported problems after discharge and were twice as likely to do so when the patient's PCP was not aware of the hospitalization. Systematic interventions to improve communication with PCPs during patient hospitalization are needed.

Cardiovascular health disparities: a systematic review of health care interventions.

Racial and ethnic disparities in cardiovascular health care are well documented. Promising approaches to disparity reduction are increasingly described in literature published since 1995, but reports are fragmented by risk, condition, population, and setting. The authors conducted a systematic review of clinically oriented studies in communities of color that addressed hypertension, hyperlipidemia, physical inactivity, tobacco, and two major cardiovascular conditions, coronary artery disease and heart failure. Virtually no literature specifically addressed disparity reduction. The greatest focus has been African American populations, with relatively little work in Hispanic, Asian, and Native American populations. The authors found 62 interventions, 27 addressing hypertension, 9 lipids, 18 tobacco use, 8 physical inactivity, and 7 heart failure. Only 1 study specifically addressed postmyocardial infarction care. Data supporting the value of registries, multidisciplinary teams, and community outreach were found across several conditions. Interventions addressing care transitions, using telephonic outreach, and promoting medication access and adherence merit further exploration.