Interprofessional practice in different patient care settings: A qualitative exploration.

Increasing interprofessional practice is seen as a path to improved quality, decreased cost, and enhanced patient experience. However, little is known about how context shapes interprofessional work and how interventions should be crafted to account for a specific setting of interprofessional practice. To better understand, how the work of interprofessional practice differs across patient care settings we sought to understand the social processes found in varying work contexts to better understand how care is provided. A case study design was used in this study to yield a picture of patient care across three different settings. Qualitative analysis of teams from three healthcare settings (rehabilitation, acute care, and code team) was conducted, through the use of ten in-depth semi-structured interviews. Interview data from each participant were analyzed via an inductive content analysis approach based upon theories of work and teams from organisational science, a framework for interprofessional practice, and competencies for interprofessional education. The work processes of interprofessional practice varied across settings. Information exchange was more physician-centric and decision-making was more physician dominant in the non-rehabilitation settings. Work was described as concurrent only for the code team. Goal setting varied by setting and interpersonal relationships were only mentioned as important in the rehabilitation setting. The differences observed across settings identify some insights into how context shapes the process of interprofessional collaboration and some research questions that need further study.

Classifying publications from the clinical and translational science award program along the translational research spectrum: a machine learning approach.

BACKGROUND: Translational research is a key area of focus of the National Institutes of Health (NIH), as demonstrated by the substantial investment in the Clinical and Translational Science Award (CTSA) program. The goal of the CTSA program is to accelerate the translation of discoveries from the bench to the bedside and into communities. Different classification systems have been used to capture the spectrum of basic to clinical to population health research, with substantial differences in the number of categories and their definitions. Evaluation of the effectiveness of the CTSA program and of translational research in general is hampered by the lack of rigor in these definitions and their application. This study adds rigor to the classification process by creating a checklist to evaluate publications across the translational spectrum and operationalizes these classifications by building machine learning-based text classifiers to categorize these publications. METHODS: Based on collaboratively developed definitions, we created a detailed checklist for categories along the translational spectrum from T0 to T4. We applied the checklist to CTSA-linked publications to construct a set of coded publications for use in training machine learning-based text classifiers to classify publications within these categories. The training sets combined T1/T2 and T3/T4 categories due to low frequency of these publication types compared to the frequency of T0 publications. We then compared classifier performance across different algorithms and feature sets and applied the classifiers to all publications in PubMed indexed to CTSA grants. To validate the algorithm, we manually classified the articles with the top 100 scores from each classifier. RESULTS: The definitions and checklist facilitated classification and resulted in good inter-rater reliability for coding publications for the training set. Very good performance was achieved for the classifiers as represented by the area under the receiver operating curves (AUC), with an AUC of 0.94 for the T0 classifier, 0.84 for T1/T2, and 0.92 for T3/T4. CONCLUSIONS: The combination of definitions agreed upon by five CTSA hubs, a checklist that facilitates more uniform definition interpretation, and algorithms that perform well in classifying publications along the translational spectrum provide a basis for establishing and applying uniform definitions of translational research categories. The classification algorithms allow publication analyses that would not be feasible with manual classification, such as assessing the distribution and trends of publications across the CTSA network and comparing the categories of publications and their citations to assess knowledge transfer across the translational research spectrum.

The effects of power, leadership and psychological safety on resident event reporting.

CONTEXT: Although the reporting of adverse events is a necessary first step in identifying and addressing lapses in patient safety, such events are under-reported, especially by frontline providers such as resident physicians. OBJECTIVES: This study describes and tests relationships between power distance and leader inclusiveness on psychological safety and the willingness of residents to report adverse events. METHODS: A total of 106 resident physicians from the departments of neurosurgery, orthopaedic surgery, emergency medicine, otolaryngology, neurology, obstetrics and gynaecology, paediatrics and general surgery in a mid-Atlantic teaching hospital were asked to complete a survey on psychological safety, perceived power distance, leader inclusiveness and intention to report adverse events. RESULTS: Perceived power distance (ß = -0.26, standard error [SE] 0.06, 95% confidence interval [CI] -0.37 to 0.15; p < 0.001) and leader inclusiveness (ß = 0.51; SE 0.07, 95% CI 0.38-0.65; p < 0.001) both significantly predicted psychological safety, which, in turn, significantly predicted intention to report adverse events (ß = 0.34; SE 0.08, 95% CI 0.18-0.49; p < 0.001). Psychological safety significantly mediated the direct relationship between power distance and intention to report adverse events (indirect effect: -0.09; SE 0.02, 95% CI -0.13 to 0.04; p < 0.001). Psychological safety also significantly mediated the direct relationship between leader inclusiveness and intention to report adverse events (indirect effect: 0.17; SE 0.02, 95% CI 0.08-0.27; p = 0.001). CONCLUSIONS: Psychological safety was found to be a predictor of intention to report adverse events. Perceived power distance and leader inclusiveness both influenced the reporting of adverse events through the concept of psychological safety. Because adverse event reporting is shaped by relationships and culture external to the individual, it should be viewed as an organisational as much as a personal function. Supervisors and other leaders in health care should ensure that policies, procedures and leadership practices build psychological safety and minimise power distance between low- and high-status members in order to support greater reporting of adverse events.

An exploratory study of an assessment tool derived from the competencies of the interprofessional education collaborative.

Linking the outcomes from interprofessional education to improvements in patient care has been hampered by educational assessments that primarily measure the short-term benefits of specific curricular interventions. Competencies, recently published by the Interprofessional Education Collaborative (IPEC), elaborate overarching goals for interprofessional education by specifying desired outcomes for graduating health professions students. The competencies define a transition point between the prescribed and structured educational experience of a professional degree program and the more self-directed, patient-oriented learning associated with professional practice. Drawing on the IPEC competencies for validity, we created a 42-item questionnaire to assess outcomes related to collaborative practice at the degree program level. To establish the usability and psychometric properties of the questionnaire, it was administered to all the students on a health science campus at a large urban university in the mid-Atlantic of the United States. The student responses (n = 481) defined four components aligned in part with the four domains of the IPEC competencies. In addition, the results demonstrated differences in scores by domain that can be used to structure future curricula. These findings suggest a questionnaire based on the IPEC competencies might provide a measure to assess programmatic outcomes related to interprofessional education. We discuss directions for future research, such as a comparison of results within and between institutions, and how these results could provide valuable insights about the effect of different curricular approaches to interprofessional education and the success of various educational programs at preparing students for collaborative practice.

Reimagining Physician Development and Lifelong Learning: An Ecological Framework.

ABSTRACT: Learners and leaders in medical education recognize the remarkable growth in clinically relevant information, persistent changes in the organization of health care, and the need to develop physicians able to adapt successfully to changes in their lives and practices. The success of those physicians and of those who facilitate their learning depends on a careful understanding of the psychological, social, and biological factors that influence physician development and lifelong learning. To improve research and policy, development and learning must be explored for finer understandings of physicians in relation to other beings and to the physical and social surroundings most conducive to better learning and outcomes.

Development of a Framework to Describe Functions and Practice of Community Health Workers.

There is evidence to support the effectiveness of community health workers (CHWs), as they practice in a wide range of health care settings; yet, the perceived value of CHWs suffers from a lack of uniform credentialing and from a dearth of billing and payment structures to recognize their individual work. In turn, credentialing and billing for the work of CHWs is hampered by widely variable regulation, conflicting job titles and position descriptions, and general confusion about CHW identity, sometimes complicated by service boundaries that overlap with those of other health care and social service occupations. This article presents evidence from a rapid review of the CHW literature from 2003 to 2018. It includes clinical trials, meta-analyses, and policy reports summarizing more than 200 CHW interventions intended to improve patient health status or care delivery. The evidence is used to identify CHW roles, responsibilities, behaviors, and competencies. Four categories of CHW practice are developed from the evidence: peer CHW, general CHW, clinical CHW, and health navigator. A framework is proposed to recognize unique CHW roles, promote and further integrate varied levels of CHW function into health care-related organizations, and to inform decisions regarding certification, education, and payment for CHW services in the United States.

An Interprofessional Quality Improvement Training Program That Improves Educational and Quality Outcomes.

A key component of quality improvement (QI) is developing leaders who can implement QI projects collaboratively. A yearlong interprofessional, workplace-based, continuing professional development program devoted to QI trained 2 cohorts of teams (dyads or triads) to lead QI projects in their areas of work using Plan-Do-Study-Act methodology. Teams represented different specialties in both inpatient and outpatient settings. They spent 4 to 6 hours/week on seminars, online modules, bimonthly meetings with a QI coach, and QI project work. Evaluations conducted after each session included pre-post program QI self-efficacy and project milestones. Post-program participants reported higher levels of QI self-efficacy (mean = 3.47; SD = 0.39) compared with pre program (mean = 2.02, SD = 0.51; P = .03, Cohen's d = 3.19). Impact on clinical units was demonstrated, but varied. The coach was identified as a key factor for success. An interprofessional, workplace-based, continuing professional development program focused on QI increased QI knowledge and skills and translated to improvements in the clinical setting.

Continuing medical education, professional development, and requirements for medical licensure: a white paper of the Conjoint Committee on Continuing Medical Education.

To provide the best care to patients, a physician must commit to lifelong learning, but continuing education and evaluation systems in the United States typically require little more than records of attendance for professional association memberships, hospital staff privileges, or reregistration of a medical license. While 61 of 68 medical and osteopathic licensing boards mandate that physicians participate in certain numbers of hours of continuing medical education (CME), 17 of them require physicians to participate in legislatively mandated topics that may have little to do with the types of patients seen by the applicant physician. Required CME should evolve from counting hours of CME participation to recognizing physician achievement in knowledge, competence, and performance. State medical boards should require valid and reliable assessment of physicians' learning needs and collaborate with physician and CME communities to assure that legislatively mandated CME achieves maximal benefit for physicians and patients. To assure the discovery and use of best practices for continuing professional development and for maintenance of competence, research in CME and physician assessment should be raised as a national priority.

Predictors of Emergent Emergency Department Visits and Costs in Community-Dwelling Older Adults.

BACKGROUND: The number of yearly emergency department (ED) visits by older adults in the United States has been increasing. PURPOSE: The objectives were to (1) describe the demographics, health-related variables, and ED visit characteristics for community-dwelling older adults using an urban, safety-net ED; (2) examine the association between demographics, health-related variables, and ED visit characteristics with emergent vs nonemergent ED visits; and (3) examine the association between demographics, health-related variables, ED visit characteristics, and ED visit costs. METHODS: A cross-sectional, retrospective analysis of administrative electronic medical record and billing information from 2010 to 2013 ED visits (n = 7805) for community-dwelling older adults (⩾65 years old) from an academic medical center in central Virginia was conducted. RESULTS: Most of the ED visits were by women (62%), African Americans (75%), and approximately 50% of ED visits were nonemergent (n = 3871). Men had 1.2 times the odds of an emergent ED visit (95% confidence interval [CI]: 1.02-1.37). The ED visits by white patients had 1.3 times the odds of an emergent ED visit (95% CI: 1.09-1.57) and 14% higher costs (white race: 95% CI: 1.07-1.21) compared with African American patients. Emergent ED visits were 60% more likely to have higher costs than nonemergent visits (95% CI: 1.52-1.69). White race and arrival by ambulance were associated with both emergent ED visits and higher total ED visit costs in this sample of ED visits by community-dwelling older adults. CONCLUSIONS: Strategies to maximize opportunities for care in the primary care setting are warranted to potentially reduce nonemergent ED utilization in community-dwelling older adults.

Low-Income Senior Housing Residents' Emergency Department Use and Care Transition Problems.

Older adults may be at risk of adverse outcomes after emergency department (ED) visits due to ineffective transitions of care. Semi-structured interviews were employed to identify and categorize reasons for ED use and problems that occur during transition from the ED back to home among 14 residents of low-income senior housing. Qualitative thematic and descriptive analyses were used. Ambulance use, timely ED use or a wait-and-see approach, and lack of health-care provider contact before ED visit were emergent themes. Delayed medication receipt, no current medication list, and medication knowledge gaps were identified. Lack of a personal health record, follow-up care instruction, and worsening symptoms education emerged as transition problems from ED to home. After an ED visit, education opportunities exist around seeing primary care providers for nonurgent conditions, follow-up care, medications, and worsening condition symptoms. Timely receipt of discharge medications and medication education may improve medication-related transition problems.

Use of personal digital assistants (PDAs) in reflection on learning and practice.

INTRODUCTION: As the use of personal digital assistants (PDAs) grows, the value of reflection of learning and practice draws increased attention from policymakers and evaluators. To learn more about the use of PDAs in practice and learning, the present study describes use of (1) PDAs in patient care and (2) a PDA version of the Virginia Board of Medicine Continuing Competency and Assessment Form (CCAF), a learning portfolio intended to encourage documentation of reflection on practice and medical education. METHODS: A purposive sample of 10 practicing physicians (6 male, 7 primary care) was recruited from geographic regions throughout Virginia. Five participants were previous users of a PDA. Three sources of data were analyzed: (1) a questionnaire describing PDA usage, (2) transcripts from telephone interviews, and (3) CCAF written comments. A study team member installed the PDA system and conducted individualized training on the basis of current equipment, software, and skills of the learner. Telephone interviews were completed 4-6 months after training. RESULTS: All physicians accessed the system after training. Use of the PDA was associated with the value of information for making clinical decisions. Information accessed by PDA was used not only for clinical decisions but also for patient education and for teaching medical students. Use of the CCAF prompted physicians to reflect on changes in clinical practice. DISCUSSION: Training on the handheld equipment and applications should include assessment of systems connectivity and integration, access authority, existing skills, and previous use. Proponents of PDA use for clinical decisions should assure access to information that is useful to physicians for reflection on learning and practice.

Accuracy of physician self-assessment compared with observed measures of competence: a systematic review.

CONTEXT: Core physician activities of lifelong learning, continuing medical education credit, relicensure, specialty recertification, and clinical competence are linked to the abilities of physicians to assess their own learning needs and choose educational activities that meet these needs. OBJECTIVE: To determine how accurately physicians self-assess compared with external observations of their competence. DATA SOURCES: The electronic databases MEDLINE (1966-July 2006), EMBASE (1980-July 2006), CINAHL (1982-July 2006), PsycINFO (1967-July 2006), the Research and Development Resource Base in CME (1978-July 2006), and proprietary search engines were searched using terms related to self-directed learning, self-assessment, and self-reflection. STUDY SELECTION: Studies were included if they compared physicians' self-rated assessments with external observations, used quantifiable and replicable measures, included a study population of at least 50% practicing physicians, residents, or similar health professionals, and were conducted in the United Kingdom, Canada, United States, Australia, or New Zealand. Studies were excluded if they were comparisons of self-reports, studies of medical students, assessed physician beliefs about patient status, described the development of self-assessment measures, or were self-assessment programs of specialty societies. Studies conducted in the context of an educational or quality improvement intervention were included only if comparative data were obtained before the intervention. DATA EXTRACTION: Study population, content area and self-assessment domain of the study, methods used to measure the self-assessment of study participants and those used to measure their competence or performance, existence and use of statistical tests, study outcomes, and explanatory comparative data were extracted. DATA SYNTHESIS: The search yielded 725 articles, of which 17 met all inclusion criteria. The studies included a wide range of domains, comparisons, measures, and methodological rigor. Of the 20 comparisons between self- and external assessment, 13 demonstrated little, no, or an inverse relationship and 7 demonstrated positive associations. A number of studies found the worst accuracy in self-assessment among physicians who were the least skilled and those who were the most confident. These results are consistent with those found in other professions. CONCLUSIONS: While suboptimal in quality, the preponderance of evidence suggests that physicians have a limited ability to accurately self-assess. The processes currently used to undertake professional development and evaluate competence may need to focus more on external assessment.

Dissemination of Evidence From Systematic Reviews Through Academic CME Providers: A Feasibility Study.

INTRODUCTION: Although systematic reviews represent a source of best evidence to support clinical decision-making, reviews are underutilized by clinicians. Barriers include lack of awareness, familiarity, and access. Efforts to promote utilization have focused on reaching practicing clinicians, leaving unexplored the roles of continuing medical education (CME) directors and faculty in promoting systematic review use. This study explored the feasibility of working with CME directors and faculty for that purpose. METHODS: A convenience sample of five academic CME directors and faculty agreed to participate in a feasibility study exploring use in CME courses of systematic reviews from the Agency for Healthcare Research and Quality (AHRQ-SRs). AHRQ-SR topics addressed the comparative effectiveness of health care options. Participants received access to AHRQ-SR reports, associated summary products, and instructional resources. The feasibility study used mixed methods to assess 1) implementation of courses incorporating SR evidence, 2) identification of facilitators and barriers to integration, and 3) acceptability to CME directors, faculty, and learners. RESULTS: Faculty implemented 14 CME courses of varying formats serving 1700 learners in urban, suburban, and rural settings. Facilitators included credibility, conciseness of messages, and availability of supporting materials; potential barriers included faculty unfamiliarity with SRs, challenges in maintaining review currency, and review scope. SR evidence and summary products proved acceptable to CME directors, course faculty, and learners by multiple measures. DISCUSSION: This study demonstrates the feasibility of approaches to use AHRQ-SRs in CME courses/programming. Further research is needed to demonstrate generalizability to other types of CME providers and other systemic reviews.

Training and Assessing Interprofessional Virtual Teams Using a Web-Based Case System.

PURPOSE: Today, clinical care is often provided by interprofessional virtual teams-groups of practitioners who work asynchronously and use technology to communicate. Members of such teams must be competent in interprofessional practice and the use of information technology, two targets for health professions education reform. The authors created a Web-based case system to teach and assess these competencies in health professions students. METHOD: They created a four-module, six-week geriatric learning experience using a Web-based case system. Health professions students were divided into interprofessional virtual teams. Team members received profession-specific information, entered a summary of this information into the case system's electronic health record, answered knowledge questions about the case individually, then collaborated asynchronously to answer the same questions as a team. Individual and team knowledge scores and case activity measures--number of logins, message board posts/replies, views of message board posts--were tracked. RESULTS: During academic year 2012-2013, 80 teams composed of 522 students from medicine, nursing, pharmacy, and social work participated. Knowledge scores varied by profession and within professions. Team scores were higher than individual scores (P < .001). Students and teams with higher knowledge scores had higher case activity measures. Team score was most highly correlated with number of message board posts/replies and was not correlated with number of views of message board posts. CONCLUSIONS: This Web-based case system provided a novel approach to teach and assess the competencies needed for virtual teams. This approach may be a valuable new tool for measuring competency in interprofessional practice.

Physician migration, education, and health care.

Physician migration is a complex and multifaceted phenomenon that is intimately intertwined with medical education. Imbalances in the production of physicians lead to workforce shortages and surpluses that compromise the ability to deliver adequate and equitable health care to large parts of the world's population. In this overview, we address a special section of the journal and briefly describe the current state of affairs in physician migration and its effects on donor and recipient countries. Global forms of practice and education, based on initiatives such as telemedicine and the International Virtual Medical School, hold promise of redressing some of these imbalances without requiring physicians to leave their countries. Other initiatives, such as those to raise the standards of medical education across the continuum, will improve the quality of care locally and permit the movement of physicians, resulting in better distribution of the workforce. All of these actions require a uniquely global perspective that places a premium on the long-term benefits to humankind while respecting the rights of patients and physicians.

Understanding primary care residency choices: a test of selected variables in the Bland-Meurer model.

PURPOSE: This study tested the predictive validity of variables related to student characteristics of the Bland-Meurer Model of Career Decision-Making. METHOD: A study was conducted using Association of American Medical Colleges' Graduate Student Questionnaire and career data from one medical school. Logistic regression analyses generated predictive models of primary care residency choice, including family medicine, general internal medicine, and pediatrics for 555 medical school graduates over five years. RESULTS: Variables predictive of primary care residency choice were gender; student ratings of psychiatry, surgery, and internal medicine clerkships; not having participated in a research project in medical school; attitudes toward "the changing health care system on physicians" and "access to medical care"; and planned practice in a medically underserved area. Results differed for each field within each residency choice. CONCLUSIONS: The Bland-Meurer Model may be used for variable selection in multivariate predictive models of family medicine, internal medicine and pediatrics residency choice. The authors' results may help guide admissions decisions, while providing medical educators and health care policymakers with a clearer picture of residency choice and a better understanding of how to meet the demands of selected patient populations.

Are researcher development interventions, alone or in any combination, effective in improving researcher behavior? A systematic review.

Academic institutions funded by the Clinical and Translational Science Awards (CTSA) Program of the National Institutes of Health were challenged recently by the Institute of Medicine to expand traditional mentoring of graduate and postdoctoral scholars to include training and continuing education for faculty, professional staff, and community partners. A systematic review was conducted to determine whether researcher development interventions, alone or in any combination, are effective in improving researcher behavior. PubMed, CINAHL, and Education Research Complete databases and select journals were searched for relevant articles published from January 2000 through October 2012. A total of 3,459 papers were identified, and 114 papers were retrieved for in-depth analysis. None included randomization. Twenty-two papers reported subjects with professional degrees, interventions, and outcomes. Interventions were meetings, outreach visits, colleague mediation, audit and feedback, and multifaceted interventions. Most studies reported multifaceted interventions (68.2%), often involving mentored learning experiences, and meetings. All studies reported a change in performance, including numbers of publications or grant applications. Nine studies reported changes in competence, including writing, presentation, or analytic skills, and performance in research practice (40.9%). Even as, the quality of evidence was weak to establish causal linkages between researcher development and improved researcher behavior, nearly all the projects (81.8%) received funding from governmental agencies, professional societies, or other organizations. Those who design researcher development activities and those who evaluate the programs are challenged to develop tools and conduct studies that measure the effectiveness, costs, and sustainability of researcher development in the CTSA Program.

Commitment to change and assessment of confidence: tools to inform the design and evaluation of interprofessional education.

INTRODUCTION: This study examines use of the commitment-to-change model (CTC) and explores the role of confidence in evaluating change associated with participation in an interprofessional education (IPE) symposium. Participants included students, faculty, and practitioners in the health professions. METHODS: Satisfaction with the symposium and levels of commitment and confidence in implementing a change were assessed with a post-questionnaire and a follow-up questionnaire distributed 60 days later. Participants who reported changed behavior were compared with those who did not make a change. Independent sample t-tests determined whether there were differences between groups in their average level of commitment and/or confidence immediately following the symposium and at follow-up. RESULTS: At post-symposium, attendees were satisfied with content and format. Sixty-eight percent said they would make a change in profession related activities. At 60 days, 53% indicated they had implemented a change. In comparison to those who reported no change, those who made a change reported higher levels of commitment and higher levels of confidence. Logistic regression suggested that the combination of commitment and confidence did not predict implementation in this sample; however, confidence had a higher odds ratio for predicting success than did commitment. DISCUSSION: Confidence should be studied further in relation to commitment as a predictor of behavioral change associated with participation in an IPE symposium. Evaluators and instructional designers should consider use of follow-up support activities to improve learners' confidence and likelihood of successful behavior change in the workplace.

Evaluation and the NIH clinical and translational science awards: a "top ten" list.

Since 2006, a total of 61 Clinical and Translational Science Institutes (CTSAs) have been funded by the National Institutes of Health (NIH), with the aim of reducing translation time from a bench discovery to when it impacts patients. This special issue of Evaluation & the Health Professions focuses on evaluation within and across the large, complex system of the CTSA Program of NIH. Through insights gained by reading the articles in this special edition and the experience of the authors, a "top ten" list of lessons learned and insights gained is presented. The list outlines issues that face those who evaluate the influence of the CTSA Program, as they work to anticipate what will be needed for continuing success. Themes include (1) considering the needs of stakeholders, (2) the perspective of the evaluators, (3) the importance of service improvement, (4) the importance of teams and people, (5) costs and return on investments, (6) methodology considerations to evaluate the CTSA enterprise, (7) innovation in evaluation, (8) defining the transformation of research, (9) evaluating the long-term impact of the CTSAs on public health, and (10) contributing to science policy formulation and implementation. The establishment of the CTSA Program, with its mandated evaluation component, has not only influenced the infrastructure and nature of translational research but will continue to impact policy and management in science.

The effects of expanding primary care access for the uninsured: implications for the health care workforce under health reform.

The Patient Protection and Affordable Care Act seeks to improve health equity in the United States by expanding Medicaid coverage for adults who are uninsured and/or socioeconomically disadvantaged; however, when millions more become eligible for Medicaid in 2014, the health care workforce and care delivery systems will be inadequate to meet the care needs of the U.S. population. To provide high-quality care efficiently to the expanded population of insured individuals, the health care workforce and care delivery structures will need to be tailored to meet the needs of specific groups within the population.To help create a foundation for understanding the use patterns of the newly insured and to recommend possible approaches to care delivery and workforce development, the authors describe the 13-year-old experience of the Virginia Coordinated Care program (VCC). The VCC, developed by Virginia Commonwealth University Health System in Richmond, Virginia, is a health-system-sponsored care coordination program that provides primary and specialty care services to patients who are indigent. The authors have categorized VCC patients from fiscal year 2011 by medical complexity. Then, on the basis of the resulting utilization data for each category over the next fiscal year, the authors describe the medical needs and health behaviors of the four different patient groups. Finally, the authors discuss possible approaches for providing primary, preventive, and specialty care to improve the health of the population while controlling costs and how adoption of the approaches might be shaped by care delivery systems and educational institutions.