Increasing Primary Care Utilization of Medication-Assisted Treatment (MAT) for Opioid Use Disorder.

BACKGROUND: With increasing prevalence of opioid use disorders (OUDs) there is an urgent need for OUD trained front line primary care providers (PCPs) who can help improve patient adherence to addiction treatment. Unfortunately, most physicians have had limited training for treating patients with addiction, leaving clinicians under prepared. To address this need, we created a Medication-Assisted Treatment (MAT) training program specifically designed for PCPs. INTERVENTION: A 4-hour PCP focused buprenorphine office-based implementation training was designed to supplement the 8-hour SAMHSA DATA 2000 waiver training. The intent of the supplemental training is to increase PCP likelihood of implementing MAT through practical evidenced-based implementation, addressing barriers reported by waivered PCPs. METHODS: We developed and validated a new pre- and postsurvey instrument that assesses changes in participants knowledge, skills, and attitudes. Data were entered into REDCap, and composite scales were created and analyzed to determine pre-post differences. RESULTS: A total of 183 participants completed pre-post evaluations. Pre-post comparisons indicated substantial improvement in learner levels of confidence in implementing MAT care processes and in their interactions with MAT patients (df = 4, F = 203.518, P < .001). Participants described themselves as more comfortable identifying patients who would benefit from MAT (t = 15.04, P < .001), more competent in implementing MAT (t = 21.27, P < .001) and more willing (t = 15.56, P < .001) to implement MAT after training. CONCLUSION: Evidence suggests that a new MAT training program that supplements the SAMHSA waiver training increases confidence and willingness to implement MAT among PCPs. Efforts to replicate this success to allow for further generalization and policy recommendations are warranted.

Virtual Care Adoption-Challenges and Opportunities From the Lens of Academic Primary Care Practitioners.

Telehealth and virtual care quickly became important tools in caring for patients while the COVID-19 pandemic evolved. Telehealth implementation can increase affordability for patients, eliminate access barriers, and improve patient satisfaction. Multiple challenges to successful telehealth implementation have been documented in the literature and are generally categorized as structural barriers of the health system, clinical barriers of the provider, and patient-centered barriers. In this study, we sought to collect themes and observations about this rapid transition to telehealth from practicing primary care clinicians, with the goal of identifying opportunities to improve adoption of telehealth. Themes reported in this article emerged from physician and physician assistant fellows of 2 HRSA-funded grants: (1) Primary Care Training and Enhancement (PCTE) and (2) Primary Care Training and Enhancement Training Primary Care Champions (Champions). The PCTE participants consisted of 8 providers from The MetroHealth System (MHS). The Champions participants consisted of 20 providers from MHS and Federally Qualified Health Centers in Northeast Ohio and Michigan. Participants identified 5 major themes that affected telehealth delivery in an academic medical system: reimbursement and productivity; social determinants of health; privacy and environment of care concerns; teaching; and communication skills. Examples within each theme are provided along with an identified improvement opportunity. As we create solutions to address these challenges, our hope is to pool our experience with others so that we can collectively learn how to best evolve and improve the telehealth experience for all.

Improving Influenza Vaccination Rates in an Underserved Primary Care Clinic Using a Simple Educational Tool.

BACKGROUND AND OBJECTIVES: Influenza is a preventable communicable illness that has a significant impact on people of all ages. In 2018, it was estimated that 80 000 people died of influenza-related illnesses. In the 2018-2019 influenza season, only 34.9% of individuals in the 18 to 49 years age group received the influenza vaccine. Despite the low vaccination rate for influenza, the vaccine has multiple evidence-based benefits that demonstrate the importance of improving its uptake among adults. According to data from the Centers for Disease Control and Prevention (CDC), the vaccine prevented around "6.2 million influenza illnesses, 3.2 million influenza-associated medical visits 91 000 influenza-associated hospitalizations, and 5700 influenza-associated deaths" in the 2017-2018 influenza season. In a suburban family medicine clinic, a primary care provider (PCP) observed that greater than 50% of adult patients in his family medicine practice declined influenza vaccine when offered during the 2018-2019 season compared with the site rate of 43.4% and the department rate of 47.9%. METHODS: The goal of this project was to educate patients who initially decline the vaccine to agree to receive the vaccine and to increase the percentage of patients who get an influenza vaccine from 43.4% to 50% in adult patients at a suburban primary care clinic by having them read the CDC document and asking them after they read the document whether they would like to receive the vaccine. From October 1, 2018, to February 28, 2019, adult patients in a primary care clinic were asked whether they wanted to receive the influenza vaccination and responses were recorded. During this time, 589 patients were questioned, with 56% (n = 330) answering no, or 43% of patients receiving the influenza vaccination. RESULTS: In total, 658 patients were offered the flu shot during the intervention period, representing 27.7% of the patients seen in this clinic. While there was some monthly variation, the PCP was able improve the percentage of patients receiving the influenza vaccination from 43% to 60.9% with this simple educational intervention. The overall clinic rate for this time frame increased from 56.6% to 58.2%. CONCLUSIONS: This simple intervention was effective in improving influenza vaccine rates for one provider in a suburban safety-net clinic. It added minimal workload to the provider, and the intervention is easily replicable in other settings.

Central versus Local Quality Efforts: The Need for Both.

Healthcare is in need of improvement. It harms too often, costs too much, learns and improves too slowly, and burns out its workforce. Large healthcare systems (HCS) have an important role in influencing the quality and value of care. Still, as systems that, in most cases, have grown and emerged rapidly in the last 20 years, few have organizational structures to support and foster the last aim, creating the conditions for the healthcare workforce to find joy and meaning in their work. HCS struggle to develop quality improvement (QI) because they are diverse and dynamic in composition, size, resources, culture and social structures, and needs. This diversity may drive forces for change or may undermine QI efforts. Clinical teams often rely on local QI efforts to improve care at the delivery site. At the same time, managers and executives focus on a centralized, system-wide approach, generally focused on externally reported metrics. We propose that a hybrid of the 2 most popular healthcare QI approaches, local QI and centralized QI, might be the best method for achieving and sustaining quality care across a wide variety of conditions.

Improving Regional Blood Pressure Control: a Positive Deviance Tiered Intensity Approach.

BACKGROUND: Accelerated translation of real-world interventions for hypertension management is critical to improving cardiovascular outcomes and reducing disparities. OBJECTIVE: To determine whether a positive deviance approach would improve blood pressure (BP) control across diverse health systems. DESIGN: Quality improvement study using 1-year cross sections of electronic health record data over 5 years (2013-2017). PARTICIPANTS: Adults ≥ 18 with hypertension with two visits in 2 years with at least one primary care visit in the last year (N = 114,950 at baseline) to a primary care practice in Better Health Partnership, a regional health improvement collaborative. INTERVENTIONS: Identification of a "positive deviant" and dissemination of this system's best practices for control of hypertension (i.e., accurate/repeat BP measurement; timely follow-up; outreach; standard treatment algorithm; and communication curriculum) using 3 different intensities (low: Learning Collaborative events describing the best practices; moderate: Learning Collaborative events plus consultation when requested; and high: Learning Collaborative events plus practice coaching). MAIN MEASURES: We used a weighted linear model to estimate the pre- to post-intervention average change in BP control (< 140/90 mmHg) for 35 continuously participating clinics. KEY RESULTS: BP control post-intervention improved by 7.6% [95% confidence interval (CI) 6.0-9.1], from 67% in 2013 to 74% in 2017. Subgroups with the greatest absolute improvement in BP control included Medicaid (12.0%, CI 10.5-13.5), Hispanic (10.5%, 95% CI 8.4-12.5), and African American (9.0%, 95% CI 7.7-10.4). Implementation intensity was associated with improvement in BP control (high: 14.9%, 95% CI 0.2-19.5; moderate: 5.2%, 95% CI 0.8-9.5; low: 0.2%, 95% CI-3.9 to 4.3). CONCLUSIONS: Employing a positive deviance approach can accelerate translation of real-world best practices into care across diverse health systems in the context of a regional health improvement collaborative (RHIC). Using this approach within RHICs nationwide could translate to meaningful improvements in cardiovascular morbidity and mortality.

Primary Care Practice Workplace Social Capital: A Potential Secret Sauce for Improved Staff Well-Being and Patient Experience.

Patient experiences with the health-care system are increasingly seen as a vital measure of health-care quality. This study examined whether workplace social capital and employee outcomes are associated with patients' perceptions of care quality across multiple clinic sites in a diverse, urban safety net care setting. Data from clinic staff were collected using paper and pencil surveys and data from patients were collected via a telephone survey. A total of 8392 adult primary care patients and 265 staff (physicians, nurses, allied health, and support staff) were surveyed at 10 community health clinics. The staff survey included brief measures of workplace social capital, burnout, and job satisfaction. The patient-level outcome was patients' overall rating of the quality of care. Factor analysis and reliability analysis were conducted to examine measurement properties of the employee data. Data were aggregated and measures were examined at the clinic site level. Workplace social capital had moderate to strong associations with burnout (r = -0.40, P < .01) and job satisfaction (r = 0.59, P < .01). Mean patient quality of care rating was 8.90 (95% confidence interval: 8.86-8.94) ranging from 8.57 to 9.18 across clinic sites. Pearson correlations with patient-rated care quality were high for workplace social capital (r = 0.88, P = .001), employee burnout (r = -0.74, P < .05), and satisfaction (r = 0.69, P < .05). Patient-perceived clinic quality differences were largely explained by differences in workplace social capital, staff burnout, and satisfaction. Investments in workplace social capital to improve employee satisfaction and reduce burnout may be key to better patient experiences in primary care.

Increases in HIV screening in primary care clinics through an electronic reminder: an interrupted time series.

OBJECTIVE AIM: Identify and eliminate barriers to HIV testing in primary care and to decrease the rates of patients never being tested, and limit unnecessary repeat testing. SETTING: Primary care clinics within an urban publicly funded safety net hospital and community health system in Cleveland, Ohio. Reported HIV prevalence among male Cleveland residents is 1193.5/100 000. DESIGN: A time series analysis using statistical process control was used. METHODS: Primary care encounters of patients aged 13-64 years from selected sites were reviewed throughout the initiative for HIV testing prior to the visit and associated with the visit. RESULTS: Run charts of the proportion of men and women never tested for HIV demonstrated marked improvement and special cause variation with six sequential quarters falling outside of the trend lines. Evaluation of encounters associated with a first HIV test confirmed testing occurring within primary care rather than elsewhere in the health system. CONCLUSIONS: Implementing an electronic medical record-based reminder effectively increased HIV testing among primary care patients not previously tested, while education and practice feedback alone did not.

Development of the objective, structured communication assessment of residents (OSCAR) tool for measuring communication skills with patients.

BACKGROUND: Although interpersonal and communication skills are essential to physician practice, there is a dearth of effective tools to meaningfully teach and assess communication skills. OBJECTIVE: The purpose of our study was to create a standardized tool for evaluation of communication skills for residents across specialties. METHODS: We designed an Objective, Structured Communication Assessment of Residents (OSCAR) tool, consisting of 4 clinical stations, to assess intern communication skills with relationship development, their establishment of case goals, and their organization and time management skills. Interns from 11 training programs completed the stations, with senior residents trained to function as standardized patients. The 4 stations' scenarios were a disruptive patient, handling a phone call for a narcotics refill, disclosing a medical mistake, and delivering bad news. RESULTS: Eighty-three interns completed OSCAR during orientation. The assessment took interns about 40 minutes to complete, and participants were given immediate feedback by the standardized patients. The total possible score for each station was 50. Resident performance was highest for disclosing a medical error (94%, 47 of 50), followed by handling a disruptive patient (90%, 45 of 50), disclosing bad news (86%, 43 of 50), and handling the phone call for the narcotics refill (62%, 31 of 50). Multivariate analysis of variance results indicated differences between residents from US and international medical schools, but there were no significant differences across specialties. Interrater reliability was excellent for each station (> 0.80). CONCLUSIONS: OSCAR is a practical tool for assessing interns' communication skills to provide timely results to program directors.

The outcomes card. Development of a systems-based practice educational tool.

INTRODUCTION: The Accreditation Council for Graduate Medical Education requires competence in systems-based practice (SBP) demonstrating understanding of complex interactions between systems of care and its impact upon care delivery. Patient safety is a useful vehicle to facilitate learning about these interactions. AIM: Develop an educational tool, Outcomes Card (OC), to reinforce core concepts of SBP. SETTING: Urgent Care Center at Louis Stokes Cleveland Department of Veterans Affairs Medical Center. PROGRAM DESCRIPTION: Pilot study of an educational intervention for residents that included patient safety didactic sessions and analysis of 2 self-identified clinical cases using the OC. Residents entered the following information on the OC: case description, type of event (error, near miss, and/or adverse event), error type(s), systems, and system failures. PROGRAM EVALUATION: Two reviewers independently analyzed 98 cards completed during 60 two-week trainee rotations (81.7% return rate). Interrater reliability for error types between residents and physician supervisor and between reviewers was excellent (kappa=0.88 and 0.95, respectively), and for system identification was good (kappa=0.66 and 0.68, respectively). The self-assessment survey (56.6% return rate) suggests that residents improved their knowledge of patient safety and had positive attitudes about the curriculum. DISCUSSION: This pilot study suggests that OCs are feasible and reliable educational tools for enhancing competence in SBP.

Measuring performance improvement: total organizational commitment or clinical specialization.

BACKGROUND: Resources for hospitals are limited when they are faced with multiple publicly reported performance measures as tools to assess quality. The leadership in these organizations may choose to focus on 1 or 2 of these outcomes. An alternative approach is that the leadership may commit resources or create conditions that result in improved quality over a broad range of measures. METHODS: We used aggregated data on mortality, length of stay, and obstetrical outcomes from Greater Cleveland Health Quality Choice data to test these theories. We used Pearson correlation analysis to determine of outcomes were correlated with one another. We used repeated-measures ANOVA to determine if an association existed between outcome and time and outcome and hospital. RESULTS: All of the outcomes across all hospitals demonstrate a trend of overall improvement. Both the Pearson and ANOVA result support the hypothesis for the organization-wide approach to quality improvement. CONCLUSIONS: Hospital that make improvements in one clinical area trend to make improvements in others. Hospitals that produce improvements in limited clinical or administrative areas may not have completely adopted CQI into their culture or may not have yet realized the benefits of their organizational commitments, but use some of the concepts to improve quality outcomes.