Utilizing PRISM and RE-AIM to implement and evaluate the Rural Telementoring Training Center (RTTC) for health care workforce development in rural communities.

Introduction: Amid rural health worker shortages and hospital closures, it is imperative to build and maintain the local workforce. Telementoring (TM) or technology-enabled mentoring, is a tool for improving health care quality and access by increasing workforce capacity and support. The national Rural Telementoring Training Center (RTTC) was developed to compile and disseminate TM best practices by delivering free training, tools, and technical assistance to support the implementation, sustainability, and evaluation of new and current TM programs for rural health workers. This paper details how the Practical, Robust Implementation and Sustainability Model (PRISM) was used to understand the context that shaped implementation as well as how Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) was concurrently applied to frame outcomes. Methods: The RTTC has three implementation strategies: outreach, training and technical assistance (TTA), and a Quality Measure Toolkit. Ongoing periodic reflections with the RTTC team, informed by PRISM, were collected, as were RE-AIM outcomes. Central to this design was the continuous review of incoming data in team meetings to inform programmatic changes by identifying challenges and applying modifications to strategies in real time. Results: Major implementation changes discussed during reflections included providing timely and relevant messaging through various platforms, streamlining and customizing a TTA approach, and offering different options for accessing the Toolkit. The outreach strategy resulted in high Reach across the US, with over 300 organizations contacted. The effectiveness of the RTTC was demonstrated by counts of people engaging with outreach (ex. over 8,300 impressions on LinkedIn), the website (over 6,400 views), and e-bursts (33% open rate). Moreover, there were 32 TTA requests and 70 people accessing the Toolkit. Adoption was demonstrated by 27 people participating in TTA and 14 individuals utilizing the Toolkit. Discussion: The integration of PRISM and RE-AIM frameworks promoted a holistic implementation and evaluation plan. Using PRISM, the RTTC team was able to reflect on the implementation strategies through the lens of contextual factors and make rapid programmatic changes within team meetings. That process resulted in outcomes framed by RE-AIM. The integration of two frameworks in tandem provided an adaptive and comprehensive approach to implementing a large-scale, national program.

Hepatitis C Virus Screening and Care: Complexity of Implementation in Primary Care Practices Serving Disadvantaged Populations.

Background: Hepatitis C virus (HCV) disproportionately affects disadvantaged communities. Objective: To examine processes and outcomes of Screen, Treat, Or Prevent Hepatocellular Carcinoma (STOP HCC), a multicomponent intervention for HCV screening and care in safety-net primary care practices. Design: Mixed-methods retrospective analysis. Setting: 5 federally qualified health centers (FQHCs) and 1 family medicine residency program serving low-income communities in diverse locations with largely Hispanic populations. Patients: Persons born in 1945 through 1965 (baby boomers) who had never been tested for HCV and were followed through May 2018. Intervention: The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) model guided implementation and evaluation. Test costs were covered for uninsured patients. Measurements: All practices tested patients for anti-HCV antibody (anti-HCV) and HCV RNA. For uninsured patients with chronic HCV in 4 practices, quantitative data also enabled assessment of HCV staging, specialist teleconsultation, direct-acting antiviral (DAA) treatment, and sustained virologic response (SVR). Implementation fidelity and adaptation were assessed qualitatively. Results: Anti-HCV screening was done in 13 334 of 27 700 baby boomers (48.1%, varying by practice from 19.8% to 71.3%). Of 695 anti-HCV-positive patients, HCV RNA was tested in 520 (74.8%; 48.9% to 92.9% by practice), and 349 persons (2.6% of those screened) were diagnosed with chronic HCV. In 4 FQHCs, 174 (84.9%) of 205 uninsured patients with chronic HCV had disease staging, 145 (70.7%) had teleconsultation review, 119 (58.0%) were recommended to start DAA therapy, 82 (40.0%) initiated free DAA therapy, 74 (36.1%) completed therapy (27.8% to 60.0% by practice), and 70 (94.6% of DAA completers) achieved SVR. Implementation was promoted by multilevel practice engagement, patient navigation, and anti-HCV screening with reflex HCV RNA testing. Limitation: No control practices were included, and data were missing for some variables. Conclusion: Despite a similar framework for STOP HCC implementation, performance varied widely across safety-net practices, which may reflect practice engagement as well as infrastructure or cost challenges beyond practice control. Primary Funding Source: Cancer Prevention & Research Institute of Texas and Centers for Medicare & Medicaid Services.

Cost-Effectiveness of Hepatitis C Screening and Treatment in Low-Income, Primarily Hispanic Baby Boomers.

The cost-effectiveness of hepatitis C virus (HCV) screening and treatment was examined in low-income, primarily Hispanic baby boomers born 1945-1965 using a Markov model of the natural history of HCV. The model was parameterized using costs and diagnostic data from 2008-2016 and from literature on disease progression and effectiveness of screening and treatment using direct acting anti-viral (DAA) therapy. The incremental cost-effectiveness ratio (ICER) was computed from the perspective of Medicare as payer, calculated over 20 years, and discounted at 3% per year. In the base case, HCV screening cost $3,334 versus $3,797 for no screening, and yielded more quality-adjusted life years (QALYs; 14.08 vs 13.96, respectively). The ICER for screening was still less than $20,000 per additional QALY with drug costs up to $100,000. Among low-income Hispanics, HCV screening was less costly for Medicare and more effective than no screening under most assumptions. This analysis supports investment in screening and treatment in Hispanics.

Gaps in the Public's Knowledge About Chronic Pain: Representative Sample of Hispanic Residents From 5 States.

Educating the general public about chronic pain and its care is a national health priority. We evaluated knowledge, attitudes, and beliefs (KAB) of a 5-state, population-based sample of Hispanic individuals aged 35 to 75 years without chronic pain, representing more than 8.8 million persons. A Web-based survey assessed KAB using an adapted version of the Survey of Pain Attitudes-Brief and self-reported knowledge about chronic pain (nothing, a little, a lot). In unweighted analyses of participants (N = 349), the mean age was 52.0 (±10.6) years, 54% were women, 53% preferred Spanish, and 39% did not graduate from high school. More participants reported knowing nothing about chronic pain (24%) than a lot (12%). In weighted logistic models with knowing nothing as the reference, knowing a lot was associated with greater KAB for chronic pain-related emotions, functioning, and cure (all P < .01) but poorer KAB about pain medications (P < .001). Associations were similar for those knowing a little. Men and women preferring Spanish had poorer KAB about pain medications than men preferring English (both P < .001). In view of Hispanic individuals' disparities in chronic pain care, these data underscore the need for effective public educational campaigns about chronic pain. PERSPECTIVE: In this 5-state representative sample of Hispanic individuals without chronic pain, one-quarter reported knowing nothing about chronic pain and had poorer KAB about multiple aspects of this disease. This study reinforces the need to evaluate and address gaps in the general public's knowledge about chronic pain.