Advancing Cancer Prevention Practice Facilitation Work in Rural Primary Care During COVID-19.

COVID-19 and the response to slow the virus spread in West Virginia (WV), including a statewide stay-at-home order, presented challenges to rural primary care clinics on the frontlines. These challenges affected critical quality improvement work, including cancer screening services. In this commentary, the authors present the results of a survey of WV primary care practices that highlight potential long-term implications and identifies opportunities for practice facilitators to partner with rural primary care clinics to address them.

COVID-19-related adaptations to the implementation and evaluation of a clinic-based intervention designed to improve opioid safety.

The United States faces an opioid crisis with an unprecedented and increasing death rate from opioid overdose. Successfully reducing the rates of opioid use disorder (OUD) and overdose will require the engagement of frontline clinicians to prescribe opioids more safely and to build their capacity to treat patients with OUD using evidence-based approaches. The COVID-19 pandemic has created significant challenges for patients, clinicians and health systems and has been associated with increasing risks of overdoses and deaths. Herein, we review a multidisciplinary project designed to implement and evaluate clinic-based interventions in Oregon, USA, to improve pain management, opioid prescribing and treatment of OUD. The intervention, called Improving PaIn aNd OPiOId MaNagemenT in Primary Care (PINPOINT), combines practice facilitation, academic detailing and education through the Oregon ECHO Network. Implementation of PINPOINT has occurred across the Oregon Rural Practice-based Research Network and has involved 49 clinic sites to date. To evaluate the impact of the intervention, the research team created the Provider Results of Opioid Management and Prescribing Training (PROMPT), a dataset that links information from the state prescription drug monitoring program, all-payer claims database, emergency medical services, vital records and substance use disorder treatment system. The PROMPT dataset will allow evaluation of the impact of the intervention at both the clinician and clinic levels. Due to the constraints of the COVID-19 pandemic, elements of both implementation and evaluation required significant adaptations to continue to meet the original project goals.

The Importance of Practice Facilitation in Primary Care When Pandemic Takes Hold: Relationships of Resilience.

The COVID-19 pandemic is unprecedented in recent history as radically and forcefully changing healthcare delivery. Practice facilitators, who often use tools of improvement science, have long played a critical role in supporting routine primary care practice transformation when healthcare system and policy changes occur. However, current events have taken many healthcare systems to the brink of collapse. Our practice facilitation team, which has a long history of sustained primary care partnerships in rural under-resourced settings, is finding creative solutions to carry forward work in research and quality improvement, and the tools of improvement science are well-suited to address rapidly changing demands of primary care during such a crisis. We reflect here on practice facilitation through the pandemic-the value of applied improvement science, and the critical necessity of strong relationships, flexibility, and creativity to support ongoing primary care partnerships.

The Balanced Opioid Initiative: protocol for a clustered, sequential, multiple-assignment randomized trial to construct an adaptive implementation strategy to improve guideline-concordant opioid prescribing in primary care.

BACKGROUND: Rates of opioid prescribing tripled in the USA between 1999 and 2015 and were associated with significant increases in opioid misuse and overdose death. Roughly half of all opioids are prescribed in primary care. Although clinical guidelines describe recommended opioid prescribing practices, implementing these guidelines in a way that balances safety and effectiveness vs. risk remains a challenge. The literature offers little help about which implementation strategies work best in different clinical settings or how strategies could be tailored to optimize their effectiveness in different contexts. Systems consultation consists of (1) educational/engagement meetings with audit and feedback reports, (2) practice facilitation, and (3) prescriber peer consulting. The study is designed to discover the most cost-effective sequence and combination of strategies for improving opioid prescribing practices in diverse primary care clinics. METHODS/DESIGN: The study is a hybrid type 3 clustered, sequential, multiple-assignment randomized trial (SMART) that randomizes clinics from two health systems at two points, months 3 and 9, of a 21-month intervention. Clinics are provided one of four sequences of implementation strategies: a condition consisting of educational/engagement meetings and audit and feedback alone (EM/AF), EM/AF plus practice facilitation (PF), EM/AF + prescriber peer consulting (PPC), and EM/AF + PF + PPC. The study's primary outcome is morphine-milligram equivalent (MME) dose by prescribing clinicians within clinics. The study's primary aim is the comparison of EM/AF + PF + PPC versus EM/AF alone on change in MME from month 3 to month 21. The secondary aim is to derive cost estimates for each of the four sequences and compare them. The exploratory aim is to examine four tailoring variables that can be used to construct an adaptive implementation strategy to meet the needs of different primary care clinics. DISCUSSION: Systems consultation is a practical blend of implementation strategies used in this case to improve opioid prescribing practices in primary care. The blend offers a range of strategies in sequences from minimally to substantially intensive. The results of this study promise to help us understand how to cost effectively improve the implementation of evidence-based practices. TRIAL REGISTRATION: NCT04044521 (ClinicalTrials.gov). Registered 05 August 2019.