Care Coordination in Primary Care: Views of Clinicians and Clinic Leaders.

BACKGROUND: Care coordination is an important strategy for addressing patient needs and improving outcomes of care. PURPOSE: The Minnesota Care Coordination Effectiveness Study sought to better understand the perspectives and experiences of clinicians/clinic leaders regarding the value, barriers, and facilitators for care coordination in primary care. METHODS: We conducted semi-structured interviews with 18 clinic managers, physicians, and advanced practice clinicians. Data were analyzed using a directed content analysis approach. RESULTS: Five themes arose in the interviews: financial issues were perceived as a primary barrier to care coordination; participants valued care coordination as an important asset; they employed significant variation in how care coordination was structured; they identified both medical and social needs of patients as important; and care coordinators' background, experience, and integration were viewed as critical to program success. CONCLUSIONS: Care coordination received strong support from clinicians and clinic leaders who viewed it as a valuable component of successful care delivery.

Patient Experiences and Perceptions of Care Coordination in Primary Care.

BACKGROUND: Understanding patient perceptions of care coordination in primary care can help improve responsiveness to patients' needs, outcomes, and quality of care. PURPOSE: The purpose of this study was to explore patient experiences and perceptions of care coordination in primary care. METHOD: Interviews with 13 patients from 10 clinics were conducted and analyzed using directed content analysis. RESULTS: Three primary themes arose: care coordinators provide a gateway to accessing needed care; patients needed and valued the support and trusted advice of their care coordinators; and patients valued care coordinators' help with navigating, engaging, and educating them about their care. CONCLUSIONS: Understanding what patients value in care delivery can help frame a vision for a more responsive approach in delivering primary care, as well as create a pathway to quality improvement, moving toward a truly patient-centered focus in primary care.

Care coordination in primary care: mapping the territory.

OBJECTIVE: To document the current approaches to care coordination among different types of care systems in Minnesota. STUDY DESIGN: Observational survey of leaders of most of the care systems in Minnesota that have implemented care coordination. METHODS: Survey questions about organizational structure, size, and approach to care coordination were sent to the leaders of 42 care systems with a total of 327 primary care clinics. RESULTS: Surveys were completed by leaders at every care system participating in this study (100% response rate); 16 small care systems (each with 1-2 clinics) had a total of 26 primary care clinics, 15 medium care systems (3-9 clinics) had 57 clinics, and 11 large care systems (> 9 clinics) had 244 clinics. The large care systems had larger clinics (clinicians per clinic, 8.6 in large vs 4.3 in small and 5.2 in medium; P = .03) and more clinicians per care coordinator (5.7 vs 3.3 and 4.0; P = .04). They also more frequently included a social worker in their care coordination team: 82% vs 25% of small and 40% of medium care systems (P = .01). However, the services provided and complexity tools used were similar. Nearly all reported addressing both medical and social needs for their complex patients with multiple chronic conditions. CONCLUSIONS: Although there are large differences in resources and capabilities between large and small care systems, they were not associated with much difference in the approach taken to care coordination. This map of the care coordination territory in Minnesota has the potential to be valuable to researchers and care system leaders for understanding current implementation trends and directing further evaluations.

Reach in a pragmatic hypertension trial: A critical RE-AIM component.

BACKGROUND: Hypertension control is falling in the US yet efficacious interventions exist. Poor patient reach has limited the ability of pragmatic trials to demonstrate effectiveness. This paper uses quantitative and qualitative data to understand factors influencing reach in Hyperlink 3, a pragmatic hypertension trial testing an efficacious pharmacist-led Telehealth Care intervention in comparison to a physician-led Clinic-based Care intervention. Referrals to both interventions were ordered by physicians. METHODS: A sequential-explanatory mixed methods approach was used to understand barriers and facilitators to reach. Reach was assessed quantitatively using EHR data, defined as the proportion of eligible patients attending intended follow-up hypertension care and qualitatively, via semi-structured interviews with patients who were and were not reached. Quantitative data were analyzed using descriptive and inferential statistics. Qualitative data were analyzed via combined deductive and inductive content analysis. RESULTS: Of those eligible, 27% of Clinic-based (n = 532/1945) and 21% of Telehealth patients (n = 385/1849) were reached. In both arms, the largest drop was between physician-signed orders and patients attending initial intended follow-up care. Qualitative analyses uncovered patient barriers related to motivation, capability, and opportunity to attend follow-up care. CONCLUSIONS: Although the proportion of eligible patients with signed orders was high in both arms, the proportion ultimately reached was lower. Patients described barriers related to the influence of one's own personal beliefs or priorities, decision making processes, logistics, and patient perceptions on physician involvement on reach. Addressing these barriers in the design of pragmatic interventions is critical for future effectiveness. TRIAL REGISTRATION: NCT02996565.

Experiences and Perceptions of Patients with Uncontrolled Hypertension Who are Dissatisfied with Their Hypertension Care.

BACKGROUND: Hypertension control has been decreasing recently. We compared the experience and attitudes toward care between patients with uncontrolled hypertension who are more and less satisfied with that care to identify ways to improve their care. METHODS: Baseline survey of 3072 patients with diagnosed hypertension and repeated blood pressure measurements at or above 150/95 mmHg during clinic appointments at 21 primary care clinics of a large Midwestern multi-specialty medical group. Survey questions were about previous hypertension care satisfaction, the degree to which that care was patient-centered, their feelings of self-confidence and treatment burden in managing hypertension, and medication side effects. RESULTS: A total of 1697 patients completed surveys (response rate = 55%). Of the 1697 patients, the 24% who were most dissatisfied (scored 0 to 5 on a 0 to 10 scale of satisfaction) significantly differed from those most satisfied (scored 9 to 10) on all demographic and clinical characteristics as well as on every measure of care experience and health status. After adjusting for those characteristics, reports of patient-centered care, self-confidence, stopping the medication because of side effects, and the burdensomeness of treatment were all significantly worse (P <.01 to P <.001) than for those with a higher rating of their hypertension care. Correlations among these measures were low, so the people with each problem with care seem to be different. CONCLUSIONS: Many patients with uncontrolled hypertension are dissatisfied with their care, but that is associated with different problems for different people. Identifying and attending to these problems may provide opportunities to help them achieve better control.

Potential Clinical Impact of Abdominal Aortic Calcification on Bone Density Lateral Spine Images.

Abdominal aortic calcification (AAC) predicts incident atherosclerotic cardiovascular disease (ASCVD) events and can be accurately identified on densitometric lateral spine images obtained at the time of bone densitometry. Our objective was to estimate the proportion of patients referred for bone densitometry who have a high level of AAC and are not already known to have ASCVD or to be at high risk for ASCVD. AAC was scored on densitometric lateral spine images of 2168 individuals blinded to clinical diagnoses or risk factors using the 24-point Framingham scale. We ascertained preexisting ASCVD diagnoses and risk factors using electronic health record data. We used the risk calculator of the American Heart Association (AHA) and the American College of Cardiology (ACC) to estimate the 10-yr risk of hard ASCVD outcomes (myocardial infarction, death caused by coronary heart disease, or nonfatal or fatal stroke). A high level of AAC (AAC score ≥5) was present in 41 (6.1%, 95% confidence interval [CI]: 4.4%-8.2%) of those aged less than 65 yr, in 253 (23.1%, 95% CI: 20.7%-25.7%) of those aged 65-74 yr, and in 153 (37.8%, 95% CI: 33.0%-42.7%) of those aged 75-80 yr. Among those aged 65-74 yr, 16.9% (95% CI: 14.7%-19.3%) had a high level of AAC and no prior clinical diagnosis of ASCVD, but only 2.4% had a high level of AAC and a predicted 10-yr risk of hard ASCVD outcomes <7.5%. AAC is common among those aged 65 yr and older who were referred for bone densitometry and had no known ASCVD, although these individuals can also be recognized as being at intermediate to high risk using the AHA-ACC ASCVD risk calculator. Further studies regarding the impact of identification of AAC on provider and patient cardiovascular disease risk management choices are warranted.

Medicare annual wellness visits. Understanding the patient and physician perspective.

Since 2011, Medicare has covered annual wellness visits (AWVs), yet few who are eligible for this benefit take advantage of it. To better understand why, we interviewed physicians and patients within our St. Louis Park-based health system. The interview questions were designed to identify physicians' and patients' perceptions of the value of the AWV and reasons people don't take advantage of this Medicare benefit. This article presents the results of this qualitative study and offers strategies health care organizations can.adopt to promote more effective, consistent use of AWVs. These strategies include standardizing policies regarding the AWV across the organization and incorporating them into team care.

Views of primary care providers on follow-up care of cancer patients.

BACKGROUND AND OBJECTIVES: Primary care providers (PCPs) are often involved in the care of cancer survivors. This study asked PCPs about their role in the follow-up care of breast and colorectal cancer patients and elicited opinions on improving the transfer of care from oncologists to PCPs. METHODS: A total of 175 PCPs in a large health care system with an electronic medical record system were mailed a questionnaire that addressed (1) their comfort and confidence regarding surveillance for cancer recurrence, (2) when patients should be seen in primary care, (3) evaluation of the transfer of care, (4) potential problems with that process, and (5) suggestions for improving that process. RESULTS: The response rate was 75.4%. Overall, 52% were comfortable having responsibility for surveillance of cancer recurrence, and 43% were confident they are following standard guidelines for cancer recurrence. Both of the aforementioned measures increased with years of practice. More than half rated the current transfer of care from oncologist to PCP as fair or poor. The most common problems identified were uncertainty regarding the type (62.6% for breast, 56.5% for colorectal), frequency (72.5%, 66.4%), and duration (74.8%, 67.2%) of surveillance testing. CONCLUSIONS: Levels of comfort, confidence, and satisfaction were generally low. PCPs need more specific guidance regarding surveillance for cancer recurrence.

Clinician gender is more important than gender concordance in quality of HIV care.

BACKGROUND: Previous studies have examined the impact of physician gender and gender concordance on preventive care, satisfaction, and communication. Less is known about how physician gender and gender concordance affect care for chronic illnesses, including HIV. OBJECTIVE: This study sought to determine whether patient-clinician gender concordance (patient and clinician are of the same gender) influences receipt of protease inhibitor (PI) therapy and ratings of care among HIV-infected patients. METHODS: We reviewed data from 1860 patients and 397 clinicians in the HIV Cost and Services Utilization Study, a nationally representative the association between gender concordance and time to first PI use, and multivariable logistic regression was utilized to examine the association of gender concordance with patients' problems with care and their overall rating of care. RESULTS: Patients who had a male clinician received PIs earlier than those who had a female clinician (adjusted time ratio = 0.69 for having a male vs having a female clinician; P

Medication costs: the role physicians play with their senior patients.

OBJECTIVES: To determine how often primary care physicians discuss medication costs with their senior patients and what cost-reducing strategies they employ. DESIGN: Cross-sectional, random-sample mail questionnaire. SETTING: State of California. PARTICIPANTS: Six hundred seventy-eight of 1,098 (62%) internal medicine and family practice physicians selected from the American Medical Association Masterfile. MEASUREMENTS: Main outcomes included frequency of cost discussions with senior patients in the previous 30 days and choice of cost-reducing strategy when a senior expresses financial difficulty with medication costs. RESULTS: Forty-three percent of physicians reported discussing medication cost with at least half of their senior patients in the previous 30 days. Patients initiated most of these discussions. Forty percent reported that, at least one time in the previous 30 days, they had not discussed cost but wished they had. The most common reason given was "I ran out of time" (36%). Physicians with high perceived knowledge of medication costs were more likely to discuss cost (odds ratio (OR)=3.49, 95% confidence interval (CI)=1.66-7.3) versus low perceived knowledge, but this trend was not seen in physicians who scored high on actual knowledge of medication costs (OR=0.78, 95% CI=0.43-1.43) versus low actual knowledge. The most common cost-reducing strategies were generic substitution (33%) and offering samples (25%). CONCLUSION: The frequency of medication cost discussions between physicians and senior patients is low, and when it occurs, is often initiated by patients. Physicians' perception of their knowledge of medication costs may be an important factor in initiating cost discussions.