"Anxiety, COVID, Burnout and Now Depression": a Qualitative Study of Primary Care Clinicians' Perceptions of Burnout.

BACKGROUND: Clinician burnout has become a major issue in the USA, contributing to increased mental health challenges and problems with quality of care, productivity, and retention. OBJECTIVE: The objective of this study was to understand primary care clinicians' perspectives on burnout during the COVID-19 pandemic as well as their perspectives on the causes of burnout and strategies to improve clinician well-being. APPROACH: This qualitative research involved in-depth interviews with 27 primary care clinicians practicing in a range of settings across the USA. Semi-structured interviews lasted between 60 and 90 min and were conducted using Zoom video conferencing software between July 2021 and February 2023. Transcripts were analyzed in NVivo software using multiple cycles of coding. KEY RESULTS: Clinicians shared their experiences with burnout and mental health challenges during the COVID-19 pandemic. Contributors to burnout included high levels of documentation, inefficiencies of electronic health record (EHR) systems, high patient volume, staffing shortages, and expectations for responding to patient emails and telephone calls. The majority of participants described the need to work after clinic hours to complete documentation. Many clinicians also discussed the need for health system leaders to make sincere efforts to enhance work-life balance and create a culture of health and well-being for health professionals. Suggested strategies to address these issues included supportive leadership, accessible mental health services, and additional administrative time to complete documentation. CONCLUSIONS: The results of this study provide an in-depth view of participating primary care clinicians' experiences and perceptions of burnout and other mental health challenges. These viewpoints can improve awareness of the issues and strategies to improve the health and well-being of our clinician workforce. Strategies include aligning payment models with the best approaches for delivering quality patient care, reducing administrative burden related to documentation, and redesigning EHR systems with a human factors approach.

Implementation strategies for large scale quality improvement initiatives in primary care settings: a qualitative assessment.

BACKGROUND AND OBJECTIVES: The EvidenceNOW: Advancing Heart Health in Primary Care was designed to assist primary care practices in the US in implementing evidence-based practices in cardiovascular care and building capacity for quality improvement. EvidenceNOW, NCT03054090, was registered with ClinicalTrials.gov on 15/02/2017. The goals of this study were to gain a comprehensive understanding of perspectives from research participants and research team members on the value of implementation strategies and factors that influenced the EvidenceNOW initiative in Virginia. METHODS: In 2018, we conducted 25 focus groups with clinicians and staff at participating practices, including 80 physicians, advanced practice clinicians, practice managers and other practice staff. We also conducted face-to-face and telephone interviews with 22 research team members, including lead investigators, practice facilitators, physician expert consultants, and evaluators. We used the integrated-Promoting Action on Research Implementation in the Health Services (i-PARIHS) framework in our qualitative data analysis and organization of themes. RESULTS: Implementation strategies valued by both practice representatives and research team members included the kick-off event, on-site practice facilitation, and interaction with physician expert consultants. Remote practice facilitation and web-based tools were used less frequently. Contextual factors that influence quality improvement efforts include leadership support, access to resources, previous quality improvement experience, and practice ownership type (independent compared to health system owned). Many clinicians and staff were overwhelmed by day-to-day activities and experience initiative fatigue, which hindered their ability to fully participate in the EvidenceNOW initiative. CONCLUSIONS: This study provides details on how the practice environment plays an essential role in the implementation of evidence-based practices in primary care. Future efforts to improve quality in primary care practices should consider the context and environment of individual practices, with targeted implementation strategies to meet the needs of independent and health system owned practices. Future efforts to improve quality in primary care practices require strategies to address initiative fatigue among clinicians and practice staff. External support for building capacity for quality improvement could help primary care practices implement and sustain evidence-based practices and improve quality of care. TRIAL REGISTRATION: This project was registered with ClinicalTrials.gov on 15/02/2017 and the identifier is NCT03054090.

Burnout among Primary Care Providers and Staff: Evaluating the Association with Practice Adaptive Reserve and Individual Behaviors.

BACKGROUND: Workplace burnout among healthcare professionals is a critical public health concern. Few studies have examined organizational and individual factors associated with burnout across healthcare professional groups. OBJECTIVE: The purpose of this study was to examine the association between practice adaptive reserve (PAR) and individual behavioural response to change and burnout among healthcare professionals in primary care. DESIGN: This cross-sectional study used survey data from 154 primary care practices participating in the EvidenceNOW Heart of Virginia Healthcare initiative. PARTICIPANTS: We analysed data from 1279 healthcare professionals in Virginia. Our sample included physicians, advanced practice clinicians, clinical support staff and administrative staff. MAIN MEASURES: We used the PAR instrument to measure organizational capacity for change and the Change Diagnostic Index© (CDI) to measure individual behavioural response, which achieved a 76% response rate. Logistic regression analysis was used to estimate the effects of PAR and CDI on burnout. KEY RESULTS: As organizational capacity for change increased, burnout in healthcare professionals decreased by 51% (OR: 0.49; 95% CI, 0.33, 0.73). As healthcare professionals showed improved response toward change, burnout decreased by 84% (OR: 0.16; 95% CI, 0.11, 0.23). Analysis by healthcare professional type revealed a significant association between high organizational capacity for change, positive response to change and low burnout among administrative staff (OR: 2.92; 95% CI, 1.37, 6.24). Increased hours of work per week was associated with higher odds of burnout (OR: 1.07; 95% CI, 1.05, 1.10) across healthcare professional groups. CONCLUSION: As transformation efforts in primary care continue, it is critical to understand the influence of these initiatives on healthcare professionals' well-being. Efforts to reduce burnout among healthcare professionals are needed at both a system and organizational level. Building organizational capacity for change, supporting providers and staff during major change and consideration of individual workload may reduce levels of burnout.

Indicators of Workplace Burnout Among Physicians, Advanced Practice Clinicians, and Staff in Small to Medium-Sized Primary Care Practices.

BACKGROUND: The rising prevalence of burnout among physicians and other healthcare professionals has become a major concern in the United States. Identifying indicators of burnout could help reduce negative consequences such as turnover, loss of productivity, and adverse health behaviors. The goal of this study was to examine whether individual behaviors and attitudes towards major disruptive change has an effect on workplace burnout. METHODS: This study analyzed survey responses from 1273 healthcare professionals from 154 small to medium-sized primary care practices participating in the EvidenceNOW initiative in Virginia. Healthcare professionals' behaviors and attitudes, such as anxiety and withdrawal, were assessed to determine associations with workplace burnout. Results were examined by professional role. RESULTS: Workplace burnout was reported by 31.6% of the physicians, 17.2% of advanced practice clinicians, 18.9% of clinical support staff, and 17.5% of administrative staff. Regardless of burnout status, results show all healthcare professional groups had high levels of anxiety. Providers had significantly higher scores for anxiety than all other healthcare professionals. Providers who experienced higher levels of anxiety and withdrawal were more than three times as likely to report burnout compared to those who experienced low levels in these domains. CONCLUSIONS: Understanding individual behaviors and attitudes towards disruptive change may help practice leaders and policymakers develop strategies to reduce burnout among healthcare professionals. Programs should focus on strengthening the work environment of small to medium-sized practices to improve organizational capacity for change and address high levels of anxiety experienced by physicians, advanced practice clinicians and staff.

Care Experiences of Patients with Multiple Chronic Conditions in a Payer-Based Patient-Centered Medical Home.

Individuals with multiple chronic health conditions require additional support and medical services, incur higher health care costs, and often have a higher risk of hospitalization. The goal of this study was to examine care experiences of patients with multiple chronic conditions in the CareFirst patient-centered medical home (PCMH). The study used a repeated cross-sectional research design and included 1308 adult CareFirst plan members with multiple chronic conditions. Patient care experiences were collected using a structured telephone survey in 2015 and 2017. Composite scores and individual question responses for patient-provider communication, coordination of care, access to care, and self-management support were analyzed to determine differences between survey years. Overall, patients reported positive care experiences with communication, self-management support, and care coordination. Access to care indicators received lower composite scores. Between 2015 and 2017, patients reported higher ratings for appointment reminders, communicating test results, providers listening carefully, and care plan effectiveness. Patients who completed their CareFirst PCMH care plan had higher care experience scores than patients who did not. A key finding of this study is that care plan completion is associated with positive care experiences, indicating the importance of the care plan to this PCMH model. Lower scores on access to care measures suggest a need for improved pathways for patients to obtain care during nontraditional office hours. Payer-based PCMH models that include enhanced care coordination and additional provider payments to support these activities may be beneficial to patients with multiple chronic conditions.

Pseudophakic mini-monovision: high patient satisfaction, reduced spectacle dependence, and low cost.

BACKGROUND: Cataract surgery with pseudophakic mini-monovision has lower out-of-pocket patient expense than premium multifocal intraocular lenses (IOL). The purpose of this study was to evaluate patient-reported satisfaction and spectacle dependence for key activities of daily living after cataract surgery with pseudophakic mini-monovision. The study also examined statistical relationships between patient demographic variables, visual acuity and satisfaction. METHODS: Prospective cohort study of 56 patients (112 eyes) who underwent bilateral cataract surgery with pseudophakic mini-monovision. Mini-monovision corrects one eye for distance vision and the other eye is focused at near with - 0.75 to - 1.75 D of myopia. All patients with 1 diopter or greater of corneal astigmatism had a monofocal toric IOLs implanted or limbal relaxing incision. The main study outcomes were assessed at the last follow-up appointment and included refraction, visual acuity, patient reported spectacle use, and patient satisfaction. Descriptive statistics, correlation matrixes and Pearson's chi-square tests were examined. RESULTS: Uncorrected visual acuity was significantly better post-operatively. Most patients reported the surgery met their expectations for decreased dependence on spectacles (93%). Most patients report little or no use of spectacles post-operatively for computer use (93%), distance viewing (93%) and general use throughout the day (87%). A small number of patients report spectacle use for reading (9%) and night driving (18%). There were no relationships detected between demographic variables and visual acuity or patient satisfaction. CONCLUSIONS: Aging of the population presents one of the biggest challenges in the health sector, which includes a rising number of individuals with chronic vision impairment and increased demand for accessible treatment strategies. Cataract surgery with pseudophakic mini-monovision results in high patient satisfaction and considerable reduction in spectacle dependence. Pseudophakic mini-monovision technique is a low-cost, valuable option for patients who would like to reduce dependence on spectacles post-operatively and should be considered along with premium multifocal IOLs in options available for patients based on their needs, preferences and clinical indicators. Reducing spectacle dependence with the pseudophakic mini-monovision technique could improve the functionality, independence and quality of life for many patients who are unsuitable or are unable to pay additional fees associated with premium multifocal IOLs.

Primary Care Residents in Teaching Health Centers: Their Intentions to Practice in Underserved Settings After Residency Training.

PURPOSE: To describe the residents who chose to train in teaching health centers (THCs), which are community-based ambulatory patient care sites that sponsor primary care residencies, and their intentions to practice in underserved settings. METHOD: The authors surveyed all THC residents training in academic years 2013-2014, 2014-2015, and 2015-2016, comparing their demographic characteristics with data for residents nationally, and examined THC residents' intentions to practice in underserved settings using logistic regression analysis. RESULTS: The overall survey response rate was 89% (1,031/1,153). THC resident respondents were similar to residents nationally in family medicine, geriatrics, internal medicine, obstetrics-gynecology, pediatrics, and psychiatry in terms of gender, age, race, and ethnicity. Twenty-nine percent (283) of respondents came from a rural background, and 46% (454) had an educationally and/or economically disadvantaged background. More than half (524; 55%) intended to practice in an underserved setting on completion of their training. Respondents were more likely to intend to practice in an underserved area if they came from a rural background (odds ratio 1.58; 95% confidence interval 1.08, 2.32) or disadvantaged background (odds ratio 2.81; 95% confidence interval 1.91, 4.13). CONCLUSIONS: THCs attract residents from rural and/or disadvantaged backgrounds who seem to be more inclined to practice in underserved areas than those from urban and economically advantaged roots. THC residents' intentions to practice in underserved areas indicate that primary care training programs sponsored by community-based ambulatory patient care sites represent a promising strategy to improve the U.S. health care workforce distribution.

Dual Eligibles' Experience of Care with North Carolina's Patient-Centered Medical Home.

Although individuals enrolled in both Medicare and Medicaid (dual eligibles) are among those with the nation's greatest need, at $300 billion per year, their care is also expensive and beset by quality problems. Previous research found problems associated with inadequate coordination of benefits and services; however, these studies have largely used quantitative approaches and focused on providers-few studies have explored the perspective of dual eligible patients. In an effort to improve care and reduce costs, North Carolina (NC) developed a Patient-Centered Medical Home (PCMH) model centered on a continuous relationship with a primary care provider who is responsible for coordination of services and addressing patients' health care needs by providing direct services or arranging care with other qualified professionals. This article presents the history of the NC PCMH model and describes results of an in-depth qualitative investigation of dual eligible patients' experience of care with this model. Experience of care was captured through 11 focus groups with 61 dual eligible patients. Focus groups were audio recorded and analyzed using NVivo 9 software, which supported the categorization of data into themes based on frequency and intensity of discussions. Findings indicate that dual eligible patients were generally satisfied by the care received through the NC PCMH program. However, many patients reported continuity of care issues, problems accessing necessary prescription drugs, and difficulties navigating the health care delivery system. Findings also revealed that conflicting state and federal Medicaid drug co-pay policies confused and limited access for some patients.

Collaboration Across the Safety Net in the Era of Health Reform: Opportunities or Obstacles?

While implementation of the Patient Protection and Affordable Care Act brings significant opportunities for safety net providers (SNP), local systems vary in how well they adapt to the rapidly evolving environment. Collaboration may enhance SNP capacity to leverage opportunities in the health reform era. Our study examines key opportunities and challenges SNPs face under health reform and how providers use collaboration as a strategy to adapt to the new environment. A qualitative study of 78 executives at safety net organizations identified six priorities that pose both opportunities and challenges for SNP, and around which collaboration is used as a strategy to achieve common goals: Medicaid expansion, outreach and enrollment, capacity and access, health system transformation, health insurance exchanges, and reductions in government funding. Three types of collaborations emerged: policy and advocacy, community action, and practice-based. Types of collaborations and stakeholders involved appeared to vary by priority.

Privacy and Confidentiality Practices In Adolescent Family Planning Care At Federally Qualified Health Centers.

CONTEXT: The confidentiality of family planning services remains a high priority to adolescents, but barriers to implementing confidentiality and privacy practices exist in settings designed for teenagers who are medically underserved, including federally qualified health centers (FQHCs). METHODS: A sample of 423 FQHCs surveyed in 2011 provided information on their use of five selected privacy and confidentiality practices, which were examined separately and combined into an index. Regression modeling was used to assess whether various state policies and organizational characteristics were associated with FQHCs' scores on the index. In-depth case studies of six FQHCs were conducted to provide additional contextual information. RESULTS: Among FQHCs reporting on confidentiality, most reported providing written or verbal information regarding adolescents' rights to confidential care (81%) and limiting access to family planning and medical records to protect adolescents' confidentiality (84%). Far fewer reported maintaining separate medical records for family planning (10%), using a security block on electronic medical records to prevent disclosures (43%) or using separate contact information for communications regarding family planning services (50%). Index scores were higher among FQHCs that received Title X funding than among those that did not (coefficient, 0.70) and among FQHCs with the largest patient volumes than among those with the smallest caseloads (0.43). Case studies highlighted how a lack of guidelines and providers' confusion over relevant laws present a challenge in offering confidential care to adolescents. CONCLUSIONS: The organizational practices used to ensure adolescent family planning confidentiality in FQHCs are varied across organizations.

The Role of Primary Care Practices in Advancing Population Health.

Improving population health requires the contribution of many entities including state and local governments, hospitals, community organizations, health centers, and private practices. Primary care practices have the potential to play a key role in improving population health. While sporadic, primary care practices engage in a spectrum of practice- and community-based population health activities. Community-based activities are largely driven by altruistic motivations of physicians and staff. Patient and disease registries and access to comprehensive patient data are critical to improving population health. Guidance is needed for practices to engage in population health initiatives and appropriate incentives to motivate practices to address population health issues.

Hospital Culture of Transitions in Care: Survey Development.

Understanding hospital culture is important to effectively manage patient flow. The purpose of this study was to develop a survey instrument that can assess a hospital's culture related to in-hospital transitions in care. Key transition themes were identified using a multidisciplinary team of experts from 3 health care systems. Candidate items were rigorously evaluated using a modified Delphi technique. Findings indicate 8 themes associated with hospital culture-mediating transitions. Forty-four items reflect the themes.

The Role of Federally Qualified Health Centers in Delivering Family Planning Services to Adolescents.

PURPOSE: The purpose of this article was to examine the role of community health centers (CHCs) in providing comprehensive family planning services to adolescents, looking at the range of services offered and factors associated with provision of these services. METHODS: This study employed a mixed methods approach comprising a national survey of CHCs and six in-depth case studies of health centers to examine the organization and delivery of family planning services. We developed an adolescent family planning index comprising nine family planning services specifically tailored to adolescents. We analyzed the influence of state-level family planning policies, funding for adolescents, and organizational characteristics on the provision of these services in CHCs. The case studies identified barriers to the provision of family planning to adolescent patients. RESULTS: The survey found substantial variation in the provision of family planning services at CHCs, with a mean of 6.33 out of a maximum score of 13 on the family planning adolescent services index. Title X funding and location within a favorable state policy environment were significantly associated with higher scores on the family planning adolescent services index (p value < .001 and .002, respectively). Case studies revealed barriers to adolescent family planning, including lack of funding, lack of knowledge, and limitations on school-based clinical services. CONCLUSIONS: CHCs have the opportunity to play a significant role in providing high-quality family planning to low-income, medically underserved adolescents. Additional funding, resources, and a favorable policy climate would further improve CHCs' ability to serve the family planning needs of this special patient population.

The organization and delivery of family planning services in community health centers.

BACKGROUND: Family planning and related reproductive health services are essential primary care services for women. Access is limited for women with low incomes and those living in medically underserved areas. Little information is available on how federally funded health centers organize and provide family planning services. METHODS: This was a mixed methods study of the organization and delivery of family planning services in federally funded health centers across the United States. A national survey was developed and administered (n = 423) and in-depth case studies were conducted of nine health centers to obtain detailed information on their approach to family planning. FINDINGS: Study findings indicate that health centers utilize a variety of organizational models and staffing arrangements to deliver family planning services. Health centers' family planning offerings are organized in one of two ways, either a separate service with specific providers and clinic times or fully integrated with primary care. Health centers experience difficulties in providing a full range of family planning services. MAJOR CHALLENGES: Major challenges include funding limitations; hiring obstetricians/gynecologists, counselors, and advanced practice clinicians; and connecting patients to specialized services not offered by the health center. CONCLUSIONS: Health centers play an integral role in delivering primary care and family planning services to women in medically underserved communities. Improving the accessibility and comprehensiveness of family planning services will require a combination of additional direct funding, technical assistance, and policies that emphasize how health centers can incorporate quality family planning as a fundamental element of primary care.

Accessibility of long-acting reversible contraceptives (LARCs) in Federally Qualified Health Centers (FQHCs).

OBJECTIVE(S): This study examines the on-site availability of long-acting reversible contraception (LARC) methods, defined here as intrauterine devices and contraceptive implants, at Federally Qualified Health Centers (FQHCs). We also describe factors associated with on-site availability and specific challenges and barriers to providing on-site access to LARC as reported by FQHCs. STUDY DESIGN: An original survey of 423 FQHC organizations was fielded in 2011. RESULTS: Over two thirds of FQHCs offer on-site availability of intrauterine devices yet only 36% of FQHCs report that they offer on-site contraceptive implants. Larger FQHCs and FQHCs receiving Title X Family Planning program funding are more likely to provide on-site access to LARC methods. Other organizational and patient characteristics are associated with the on-site availability of LARC methods, though this relationship varies by the type of method. The most commonly reported barriers to providing on-site access to LARC methods are related to the cost of stocking or supplying the drug and/or device, the perceived lack of staffing and training, and the unique needs of special populations. CONCLUSION: Our findings indicate that patients seeking care in small FQHC organizations, FQHCs with limited dedicated family planning funding and FQHCs located in rural areas may have fewer choices and limited access to LARC methods on-site. IMPLICATIONS: Despite the presumed widespread coverage of contraceptives for women as a result of provisions in the Affordable Care Act, there is a limited understanding of how FQHCs may redesign their practices to provide on-site availability of LARC methods. This study sheds light on the current state of practice and challenges related to providing LARC methods in FQHC settings.

Scope of family planning services available in Federally Qualified Health Centers.

OBJECTIVES: Federally Qualified Health Centers (FQHCs) are a major and growing source of primary care for low-income women of reproductive age; however, only limited knowledge exists on the scope of family planning care they provide and the mechanisms for delivery of these essential reproductive health services, including family planning. In this paper, we report on the scope of services provided at FQHCs including on-site provision, prescription only and referral options for the range of contraceptive methods. STUDY DESIGN: An original survey of 423 FQHC organizations was fielded in 2011. RESULTS: Virtually all FQHCs reported that they provide at least one contraceptive method (99.8%) at one or more clinical sites. A large majority (87%) of FQHCs report that their largest primary care site prescribes oral contraceptives plus one additional method category of contraception, with oral contraception and injectables being the most commonly available methods. Substantial variation is seen among other methods such as intrauterine devices (IUDs), contraceptive implants, the patch, vaginal ring and barrier methods. For all method categories, Title-X-funded sites are more likely to provide the method, though, even in these sites, IUDs and implants are much less likely to be provided than other methods. CONCLUSION: There is clearly wide variability in the delivery of family planning services at FQHCs in terms of methods available, level of counseling, and provision of services on-site or through prescription or referral. Barriers to provision likely include cost to patients and/or additional training to providers for some methods, such as IUDs and implants, but these barriers should not limit on-site availability of inexpensive methods such as oral contraceptives. IMPLICATIONS: With the expansion of contraceptive coverage under private insurance as part of preventive health services for women, along with expanded coverage for the currently uninsured, and the growth of FQHCs as the source of care for women of reproductive age, it is critical that women seeking family planning services at FQHCs have access to a wide range of contraceptive options. Our study both highlights the essential role of FQHCs in providing family planning services and also identifies remaining gaps in the provision of contraception in FQHC settings.

Team-based care: a critical element of primary care practice transformation.

The purpose of this study was to gain an in-depth understanding of how primary care practices in the United States are transforming their practice to deliver patient-centered care. The study used qualitative research methods to conduct case studies of small primary care practices in the state of Virginia. The research team collected data from practices using in-depth interviews, structured telephone questionnaires, observation, and document review. Team-based care stood out as the most critical method used to successfully transform practices to provide patient-centered care. This article presents 3 team-based care models that were utilized by the practices in this study.

Why do some primary care practices engage in practice improvement efforts whereas others do not?

OBJECTIVE: To understand what motivates primary care practices to engage in practice improvement, identify external and internal facilitators and barriers, and refine a conceptual framework. DATA SOURCES: In-depth interviews and structured telephone surveys with clinicians and practice staff (n = 51), observations, and document reviews. STUDY DESIGN: Comparative case study of primary care practices (n = 8) to examine aspects of the practice and environment that influence engagement in improvement activities. DATA COLLECTION METHODS: Three on-site visits, telephone interviews, and two surveys. PRINCIPAL FINDINGS: Pressures from multiple sources create conflicting forces on primary care practices' improvement efforts. Pressures include incentives and requirements, organizational relationships, and access to resources. Culture, leadership priorities, values set by the physician(s), and other factors influence whether primary care practices engage in improvement efforts. CONCLUSIONS: Most primary care practices are caught in a cross fire between two groups of pressures: a set of forces that push practices to remain with the status quo, the "15-minute per patient" approach, and another set of forces that press for major transformations. Our study illuminates the elements involved in the decision to stay with the status quo or to engage in practice improvement efforts needed for transformation.

Primary care in the United States: practice-based innovations and factors that influence adoption.

PURPOSE: This study aims to explore the use of specific innovations in primary care practices. The research seeks to examine whether a relationship exists between environmental factors and organizational characteristics and the level of innovation in primary care practices in Virginia. DESIGN/METHODOLOGY/APPROACH: The study utilized multiple secondary data sets and an organizational survey of primary care practices to define the external environment and the level of innovation. Institutional theory was used to explain the connection between innovations in primary care practices and institutional forces within the environment. Resource dependency theory was used to explain motivators for change based on a dependence on scarce financial, human, and information resources. FINDINGS: Results show a positive association between organizational size, organizational relationships, and stakeholder expectations on the level of innovation. A negative association was found between competition and the level of innovation. No relationship was found between degree of Medicare and managed care penetration and innovation, nor between knowledge of, and difficulty complying with, payer organization requirements and innovation. ORIGINALITY/VALUE: Primary care physician practices exist in a market-driven environment characterized by high pressure from regulatory sources, decreasing reimbursement levels, increasing rate of change in technologies, and increasing patient and community expectations. This study contributes new information on the relationship between organizational characteristics, the external environment and specific innovations in primary care practices. Information on the contributing factors to innovation in primary care is important for improving delivery of health care services and the ability of these practices to survive.

Development and alumni assessment of an interdisciplinary PhD program offered through a blended learning environment.

There is a growing need for doctoral-prepared allied health professionals in health care practice, research, and teaching. This paper describes the development and evolution of the PhD Program in Health Related Sciences at Virginia Commonwealth University, which was designed to meet the demand for flexible learning environments by working allied health professionals. The program, now on its 14th year, offers interdisciplinary education in allied health fields through a blended learning environment that includes online and on-site education. An alumni assessment of the program was conducted in 2006 and 2008 to understand how well the program trained its graduates and how well the program responded to the needs of students. Six primary areas were reviewed: 1) extent to which program goals were achieved, 2) general skills and knowledge development for the student, 3) adequacy of the advising function of the program, 4) specific skill development for the student, 5) adequacy of instructional technology, and 6) impressions of the overall program. Findings from the alumni assessment led to changes in curriculum, enhanced use of distance education teaching, additional instructor training on distance-based multimedia technologies, and enhanced student-faculty interaction. Assessment of this program identified key areas, such as technology support, student-student interaction, and student-instructor interaction, which should be emphasized in the development or redesign of allied health educational programs offered in blended learning formats.