Better Together: A Descriptive Analysis of a Medical-Legal Partnership in Western North Carolina.

BACKGROUND The medical-legal partnership (MLP) is an innovative and proven-effective approach to addressing health-harming social needs that have legal remedies (e.g., housing concerns, intimate partner violence). Yet, few MLPs exist within outpatient primary care practices and in rural settings.METHODS We describe the impact of an MLP between Pisgah Legal Services and the Mountain Area Health Education Center, which serves rural North Carolina counties, over a 24-month period.RESULTS Overall, 629 cases were referred to the MLP. Three hundred seventy cases were opened and investigated by a lawyer. Three hundred sixty-four cases were closed (i.e., a resolution was reached), yielding 808 outcomes, with an average of 2.2 outcomes per case. Domestic violence/family law and housing were the main socio-legal concerns addressed by the MLP. Eighty-six (24%) of cases included at least 1 representation outcome; the success rate in representation cases was 90%.LIMITATIONS We did not examine the impact of the MLP on patient health outcomes, nor did we have comparative outcomes data for similar individuals with unmet social needs but who did not receive MLP services.CONCLUSIONS The MLP was successful in helping to address multiple social needs faced by patients that contribute to worse health status and outcomes. Monetary benefits to patients were $309,902 plus an additional $174,733 from tax returns and the Earned Income Tax Credit. The MLP lawyer provided education and training to support clinicians, learners, and community organizations. These data highlight the benefits of collaboration between health professionals and lawyers in advancing equity by addressing unmet social needs.

Drivers of Scope of Practice in Family Medicine: A Conceptual Model.

PURPOSE: The purpose of this study was to explore family medicine graduates' attitudes and perspectives on modifiable and unmodifiable factors that influenced their scope of practice and career choices. By understanding how these factors intersect to influence desired and actual scope of practice decisions, we hope to inform strategies to address training and health care workforce needs. METHODS: During 5 focus group discussions, comprised of a total of 32 family physicians who either resided in or attended a residency program in western North Carolina, we explored family physicians' attitudes and perspectives on their desired and actual scope of practice. We used thematic analysis to identify patterns in the qualitative data. RESULTS: We created a conceptual framework to understand the complex factors which influence family physicians' scope of practice. Personal factors were found to impact desired scope, while workplace, environmental, and population factors influenced actual scope of practice. Stressors in each of these 4 categories often caused family physicians to narrow their scope of practice. Our study highlights specific supports that, if in place, enable physicians to maintain their desired broad scope of practice. CONCLUSIONS: Our study indicates that the national trend toward family physicians narrowing their scope of practice can be addressed by providing specific supports during training, residency, and mid-career. Understanding personal, workplace, environmental, and population factors that influence scope of practice can inform specific interventions that create desirable jobs for family physicians and improve their ability to meet changing population needs.

Interconception Care for Mothers at Well Child Visits After Implementation of the IMPLICIT Model.

INTRODUCTION: Interconception care (ICC) is recommended to reduce maternal risk factors for poor birth outcomes between pregnancies. The IMPLICIT ICC model includes screening and brief intervention for mothers at well child visits (WCVs) for smoking, depression, multivitamin use, and family planning. Prior studies demonstrate feasibility and acceptability among providers and mothers, but not whether mothers recall receipt of targeted messages. METHODS: Mothers accompanying their child at 12- and 24-month WCVs at four sites of a family medicine academic practice were surveyed pre (2012) and post (2018) ICC model implementation. Survey items assessed health history, behaviors, and report of whether their child's physician addressed maternal depression, tobacco use, family planning, and folic acid supplementation during WCVs. Pre and post results are compared using logistic regression adjusting for demographics and insurance. RESULTS: Our sample included 307 distinct mothers with 108 and 199 respondents in the pre and post periods, respectively. Mothers were more likely to report discussions with their child's doctor post-intervention for family planning (31% pre to 86% post; aOR 18.65), depression screening (63-85%; aOR 5.22), and taking a folic acid supplement (53-68%; aOR 2.54). Among mothers who smoked, the percentage that reported their child's doctor recommended cessation increased from 56 to 75% (aOR = 3.66). DISCUSSION: The IMPLICIT ICC model resulted in increased reported health care provider discussions of four key areas of interconception health by mothers attending WCVs. This model holds promise as a primary care strategy to systematically address maternal risks associated with poor pregnancy outcomes.

Trends in the rate and type of antipsychotic medications prescribed to persons with schizophrenia.

This article examines trends in antipsychotic medication use in a treated population of publicly funded patients with schizophrenia between 1991 and 1996. Findings from administrative claims data show that antipsychotic prescription rates increased from 79 percent to 83 percent between 1991 and 1996. Atypical antipsychotics were used by 39 percent of the population and comprised 41 percent of all antipsychotic agents prescribed compared to 59 percent for typical agents. Duration on a typical agent was 8 months versus 7.4 months for newer atypicals, with duration 11 months for those on clozapine. The highest switching behavior is found in users of atypicals (58% versus 25% for those on typicals) as is the percent of those who received an antidepressant concurrently with an antipsychotic, which was 44 percent for newer atypical users versus 31 percent for typical users. The lowest antidepressant use was among clozapine users (28%). Atypical users were more likely to be younger Caucasian men with higher use of inpatient and ambulatory mental health services compared to those on typical medications. The newer antipsychotic medications appear to be displacing traditional medications; however, contrary to what the literature suggests, duration is shorter and switching behavior and concurrent use of antidepressants is higher than in typical users.

Economic impact of prior authorization policies for atypical antipsychotics in the treatment of schizophrenia.

Prior authorization (PA) policies are increasingly being used to manage atypical antipsychotic (AA) Medicaid drug expenditures; however, some studies suggest that PAs may actually lead to higher rates of treatment discontinuation and hospitalization. A decision analytic model was developed to compare the cost of schizophrenia treatment from a Medicaid perspective when a PA policy for AA is in place with the cost of no PA, over a 1-year time horizon. Deterministic sensitivity analyses were conducted to assess the robustness of the model results when the parameters were varied. A second analysis was performed to assess the incremental impact of PA on hospitalization. The base case model calculates the mean yearly total medical cost for a patient with schizophrenia to be $12,967 (SD $798) under the PA arm and $12,996 (SD $925) with no PA. Results of the probabilistic sensitivity analysis suggest that PA is likely to produce modest cost savings 56% of the time. Analysis of the incremental impact of hospitalization on treatment cost showed that just a 0.5% increase in hospitalization rate in the PA arm will make the PA arm more costly. This analysis suggests that PA is likely to produce only modest cost savings approximately half the time. Sensitivity analyses show that small increases in hospitalizations will make PA the more costly option. Rigorous analysis of the PA policy for AAs is required to ensure that attempts to reduce pharmacy spending do not increase the risk for negative medical outcomes that would offset benefits.

Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain.

UNLABELLED: Use of chronic opioid therapy for chronic noncancer pain has increased substantially. The American Pain Society and the American Academy of Pain Medicine commissioned a systematic review of the evidence on chronic opioid therapy for chronic noncancer pain and convened a multidisciplinary expert panel to review the evidence and formulate recommendations. Although evidence is limited, the expert panel concluded that chronic opioid therapy can be an effective therapy for carefully selected and monitored patients with chronic noncancer pain. However, opioids are also associated with potentially serious harms, including opioid-related adverse effects and outcomes related to the abuse potential of opioids. The recommendations presented in this document provide guidance on patient selection and risk stratification; informed consent and opioid management plans; initiation and titration of chronic opioid therapy; use of methadone; monitoring of patients on chronic opioid therapy; dose escalations, high-dose opioid therapy, opioid rotation, and indications for discontinuation of therapy; prevention and management of opioid-related adverse effects; driving and work safety; identifying a medical home and when to obtain consultation; management of breakthrough pain; chronic opioid therapy in pregnancy; and opioid-related policies. PERSPECTIVE: Safe and effective chronic opioid therapy for chronic noncancer pain requires clinical skills and knowledge in both the principles of opioid prescribing and on the assessment and management of risks associated with opioid abuse, addiction, and diversion. Although evidence is limited in many areas related to use of opioids for chronic noncancer pain, this guideline provides recommendations developed by a multidisciplinary expert panel after a systematic review of the evidence.