Development and validation of the Readiness to Train Assessment Tool (RTAT).

BACKGROUND: In recent years, health centers in the United States have embraced the opportunity to train the next generation of health professionals. The uniqueness of the health centers as teaching settings emphasizes the need to determine if health professions training programs align with health center priorities and the nature of any adjustments that would be needed to successfully implement a training program. We sought to address this need by developing and validating a new survey that measures organizational readiness constructs important for the implementation of health professions training programs at health centers where the primary role of the organizations and individuals is healthcare delivery. METHODS: The study incorporated several methodological steps for developing and validating a measure for assessing health center readiness to engage with health professions programs. A conceptual framework was developed based on literature review and later validated by 20 experts in two focus groups. A survey-item pool was generated and mapped to the conceptual framework and further refined and validated by 13 experts in three modified Delphi rounds. The survey items were pilot-tested with 212 health center employees. The final survey structure was derived through exploratory factor analysis. The internal consistency reliability of the scale and subscales was evaluated using Chronbach's alpha. RESULTS: The exploratory factor analysis revealed a 41-item, 7-subscale solution for the survey structure, with 72% of total variance explained. Cronbach's alphas (.79-.97) indicated high internal consistency reliability. The survey measures: readiness to engage, evidence strength and quality of the health professions training program, relative advantage of the program, financial resources, additional resources, implementation team, and implementation plan. CONCLUSIONS: The final survey, the Readiness to Train Assessment Tool (RTAT), is theoretically-based, valid and reliable. It provides an opportunity to evaluate health centers' readiness to implement health professions programs. When followed with appropriate change strategies, the readiness evaluations could make the implementation of health professions training programs, and their spread across the United States, more efficient and cost-effective. While developed specifically for health centers, the survey may be useful to other healthcare organizations willing to assess their readiness to implement education and training programs.

A quasi-experiment assessing the six-months effects of a nurse care coordination program on patient care experiences and clinician teamwork in community health centers.

BACKGROUND: Recognition that coordination among healthcare providers is associated with better quality of care and lower costs has increased interest in interventions designed to improve care coordination. One intervention is to add care coordination to nurses' role in a formal way. Little is known about effects of this approach, which tends to be pursued by small organizations and those in lower-resource settings. We assessed effects of this approach on care experiences of high-risk patients (those most in need of care coordination) and clinician teamwork during the first 6 months of use. METHODS: We conducted a quasi-experimental study using a clustered, controlled pre-post design. Changes in staff and patient experiences at six community health center practice locations that introduced the added-role approach for high-risk patients were compared to changes in six locations without the program in the same health system. In the pre-period (6 months before intervention training) and post-period (about 6 months after intervention launch, following 3 months of training), we surveyed clinical staff (N = 171) and program-qualifying patients (3007 pre-period; 2101 post-period, including 113 who were enrolled during the program's first 6 months). Difference-in-differences models examined study outcomes: patient reports about care experiences and clinician-reported teamwork. We assessed frequency of patient office visits to validate access and implementation, and contextual factors (training, resources, and compatibility with other work) that might explain results. RESULTS: Patient care experiences across all high-risk patients did not improve significantly (p > 0.05). They improved somewhat for program enrollees, 5% above baseline reports (p = 0.07). Staff-perceived teamwork did not change significantly (p = 0.12). Office visits increased significantly for enrolled patients (p < 0.001), affirming program implementation (greater accessing of care). Contextual factors were not reported as problematic, except that 41% of nurses reported incompatibility between care coordination and other job demands. Over 75% of nurses reported adequate training and resources. CONCLUSIONS: There were some positive effects of adding care coordination to nurses' role within 6 months of implementation, suggesting value in this improvement strategy. Addressing compatibility between coordination and other job demands is important when implementing this approach to coordination.

A cost-effectiveness analysis of cardiology eConsults for Medicaid patients.

OBJECTIVES: To evaluate the cost-effectiveness of electronic consultations (eConsults) for cardiology compared with traditional face-to-face consults. STUDY DESIGN: Cost-effectiveness analysis for a subset of Medicaid-insured patients in a cluster-randomized trial of eConsults versus the traditional face-to-face consultation process in a statewide federally qualified health center. METHODS: A total of 369 Medicaid patients were referred for cardiology consultations by primary care providers who were randomly assigned to use either eConsults or their usual face-to-face referral process. Primary care providers in the eConsult arm transmitted consults to cardiologists using a secure peer-to-peer communication platform in an electronic health record. Intention-to-treat analysis was used to assess the total cost of care and cost across 7 categories: inpatient, outpatient, emergency department, pharmacy, labs, cardiac procedures, and "all other." Costs are from the payer's perspective. RESULTS: Six months after the cardiology consult, patients in the eConsult group had significantly lower mean unadjusted total costs by $655 per patient, or lower mean costs by $466 per patient when adjusted for non-normality, compared with those in the face-to-face arm. The eConsult group had a significantly lower cost by $81 per patient in the outpatient cardiac procedures category. CONCLUSIONS: These findings suggest that eConsults are associated with total cost savings to payers due principally to reductions in the cost of cardiac outpatient procedures.

Improving Pain Care with Project ECHO in Community Health Centers.

OBJECTIVE: Pain is an extremely common complaint in primary care, and patient outcomes are often suboptimal. This project evaluated the impact of Project ECHO Pain videoconference case-based learning sessions on knowledge and quality of pain care in two Federally Qualified Health Centers. DESIGN: Quasi-experimental, pre-post intervention, with comparison group. SETTING: Two large, multisite federally qualified health centers in Connecticut and Arizona. SUBJECTS: Intervention (N = 10) and comparison (N = 10) primary care providers. METHODS: Primary care providers attended 48 weekly Project ECHO Pain sessions between January and December 2013, led by a multidisciplinary pain specialty team. Surveys and focus groups assessed providers' pain-related knowledge and self-efficacy. Electronic health record data were analyzed to evaluate opioid prescribing and specialty referrals. RESULTS: Compared with control, primary care providers in the intervention had a significantly greater increase in pain-related knowledge and self-efficacy. Providers who attended ECHO were more likely to use formal assessment tools and opioid agreements and refer to behavioral health and physical therapy compared with control providers. Opioid prescribing decreased significantly more among providers in the intervention compared with those in the control group. CONCLUSIONS: Pain is an extremely common and challenging problem, particularly among vulnerable patients such as those cared for at the more than 1,200 Federally Qualified Health Centers in the United States. In this study, attendance at weekly Project ECHO Pain sessions not only improved knowledge and self-efficacy, but also altered prescribing and referral patterns, suggesting that knowledge acquired during ECHO sessions translated into practice changes.

Improving pain care through implementation of the Stepped Care Model at a multisite community health center.

PURPOSE: Treating pain in primary care is challenging. Primary care providers (PCPs) receive limited training in pain care and express low confidence in their knowledge and ability to manage pain effectively. Models to improve pain outcomes have been developed, but not formally implemented in safety net practices where pain is particularly common. This study evaluated the impact of implementing the Stepped Care Model for Pain Management (SCM-PM) at a large, multisite Federally Qualified Health Center. METHODS: The Promoting Action on Research Implementation in Health Services framework guided the implementation of the SCM-PM. The multicomponent intervention included: education on pain care, new protocols for pain assessment and management, implementation of an opioid management dashboard, telehealth consultations, and enhanced onsite specialty resources. Participants included 25 PCPs and their patients with chronic pain (3,357 preintervention and 4,385 postintervention) cared for at Community Health Center, Inc. Data were collected from the electronic health record and supplemented by chart reviews. Surveys were administered to PCPs to assess knowledge, attitudes, and confidence. RESULTS: Providers' pain knowledge scores increased to an average of 11% from baseline; self-rated confidence in ability to manage pain also increased. Use of opioid treatment agreements and urine drug screens increased significantly by 27.3% and 22.6%, respectively. Significant improvements were also noted in documentation of pain, pain treatment, and pain follow-up. Referrals to behavioral health providers for patients with pain increased by 5.96% (P=0.009). There was no significant change in opioid prescribing. CONCLUSION: Implementation of the SCM-PM resulted in clinically significant improvements in several quality of pain care outcomes. These findings, if sustained, may translate into improved patient outcomes.

Patient-Provider Social Concordance and Health Outcomes in Patients with Type 2 Diabetes: a Retrospective Study from a Large Federally Qualified Health Center in Connecticut.

OBJECTIVE: This study was conducted to better understand the relationship between patient-provider social concordance and cardiovascular risk factor control in patients with type 2 diabetes. METHODS: A retrospective study was conducted on adult patients with type 2 diabetes receiving care at Community Health Center, Inc. between July 1, 2012, and June 30, 2013. We utilized a composite score comprised of four social dimensions-age, gender, language, and race/ethnicity-to determine patient-provider social concordance (SC) and used binary logistic regression to relate SC and other potentially influential covariates with cardiovascular outcomes of interest (HgA1c, LDL, BP control). RESULTS: Patients were more likely to have uncontrolled BP if they were in low or medium SC dyads with their providers (OR = 0.689, 95 % CI = 0.480, 0.989; OR = 0.673, 95 % CI 0.486, 0.931), and they were more likely to have controlled BP and LDL in the setting of care continuity with a regular provider (OR = 1.069, 95 % CI 1.005, 1.136; OR = 1.113, 95 % CI 1.048, 1.182). CONCLUSIONS: Certain health outcomes may be susceptible to patient-provider social concordance or discordance. Continuity of care may serve a protective role in offsetting effects of patient-provider social mismatching.

Stepped care model of pain management and quality of pain care in long-term opioid therapy.

Successful organizational improvement processes depend on application of reliable metrics to establish targets and to monitor progress. This study examined the utility of the Pain Care Quality (PCQ) extraction tool in evaluating implementation of the Stepped Care Model for Pain Management at one Veterans Health Administration (VHA) healthcare system over 4 yr and in a non-VHA Federally qualified health center (FQHC) over 2 yr. Two hundred progress notes per year from VHA and 150 notes per year from FQHC primary care prescribers of long-term opioid therapy (>90 consecutive days) were randomly sampled. Each note was coded for the presence or absence of key dimensions of PCQ (i.e., pain assessment, treatment plans, pain reassessment/outcomes, patient education). General estimating equations controlling for provider and facility were used to examine changes in PCQ items over time. Improvements in the VHA were noted in pain reassessment and patient education, with trends in positive directions for all dimensions. Results suggest that the PCQ extraction tool is feasible and may be responsive to efforts to promote organizational improvements in pain care. Future research is indicated to improve the reliability of the PCQ extraction tool and enhance its usability.

Electronic Consultations to Improve the Primary Care-Specialty Care Interface for Cardiology in the Medically Underserved: A Cluster-Randomized Controlled Trial.

PURPOSE: Communication between specialists and primary care clinicians is suboptimal, and access to referrals is often limited, which can lead to lower quality, inefficiency, and errors. An electronic consultation (e-consultation) is an asynchronous, non-face-to-face consultation between a primary care clinician and a specialist using a secure electronic communication platform. The purpose of this study was to conduct a randomized controlled trial of e-consultations to test its efficacy and effectiveness in reducing wait times and improving access to specialty care. METHODS: Primary care clinicians were randomized into a control (9 traditional) or an intervention (17 e-consultation) arm for referrals to cardiologists. Primary care clinicians were recruited from 12 practice sites in a community health center in Connecticut with mainly medically underserved patients. Two end points were analyzed with a Cox proportional hazards model where the hazard of either a visit or an e-consultation was linked to study arm, sex, race, and age. RESULTS: Thirty-six primary care clinicians participated in the study, referring 590 patients. In total, 69% of e-consultations were resolved without a visit to a cardiologist. After adjusting for covariates, median days to a review for an electronic consultation vs a visit for control patients were 5 and 24, respectively. A review of 6-month follow-up data found fewer cardiac-related emergency department visits for the intervention group. CONCLUSION: E-consultation referrals improved access to and timeliness of care for an underserved population, reduced overall specialty utilization, and streamlined specialty referrals without any increase in adverse cardiovascular outcomes. e-consultations are a potential solution for improving access to specialty care.

Development and validation of the Medical Home Care Coordination Survey for assessing care coordination in the primary care setting from the patient and provider perspectives.

BACKGROUND: Community health centers are increasingly embracing the Patient Centered Medical Home (PCMH) model to improve quality, access to care, and patient experience while reducing healthcare costs. Care coordination (CC) is an important element of the PCMH model, but implementation and measurability of CC remains a problem within the outpatient setting. Assessing CC is an integral component of quality monitoring in health care systems. This study developed and validated the Medical Home Care Coordination Survey (MHCCS), to fill the gap in assessing CC in primary care from the perspectives of patients and their primary healthcare teams. METHODS: We conducted a review of relevant literature and existing care coordination instruments identified by bibliographic search and contact with experts. After identifying all care coordination domains that could be assessed by primary healthcare team members and patients, we developed a conceptual model. Potentially appropriate items from existing published CC measures, along with newly developed items, were matched to each domain for inclusion. A modified Delphi approach was used to establish content validity. Primary survey data was collected from 232 patients with care transition and/or complex chronic illness needs from the Community Health Center, Inc. and from 164 staff members from 12 community health centers across the country via mail, phone and online survey. The MHCCS was validated for internal consistency, reliability, discriminant and convergent validity. This study was conducted at the Community Health Center, Inc. from January 15, 2012 to July 15, 2014. RESULTS: The 13-item MHCCS - Patient and the 32-item MHCCS - Healthcare Team were developed and validated. Exploratory Structural Equation Modeling was used to test the hypothesized domain structure. Four CC domains were confirmed from the patient group and eight were confirmed from the primary healthcare team group. All domains had high reliability (Cronbach's α scores were above 0.8). CONCLUSIONS: Patients experience the ultimate output of care coordination services, but primary healthcare staff members are best primed to perceive many of the structural elements of care coordination. The proactive measurement and monitoring of the core domains from both perspectives provides a richer body of information for the continuous improvement of care coordination services. The MHCCS shows promise as a valid and reliable assessment of these CC efforts.

Using health information technology to improve adherence to opioid prescribing guidelines in primary care.

OBJECTIVE: To evaluate the impact of a clinical dashboard for opioid analgesic management on opioid prescribing and adherence to opioid practice guidelines in primary care. METHODS: A pre/postimplementation evaluation using electronic health record (EHR) data from patients receiving chronic opioid therapy (COT) between April 1, 2011 and March 31, 2013. Measures include annual proportions of COT patients who received urine drug testing, signed an opioid treatment agreement, had a documented assessment of pain-related functional status, and had at least 1 visit with a behavioral health provider. RESULTS: Adherence to several opioid prescribing guidelines improved in the postimplementation year compared with the preimplementation year: (1) the proportions of COT patients with a signed opioid treatment agreement and urine drug testing increased from 49% to 63% and 66% to 86%, respectively. The proportion of COT patients with a documented assessment of functional status increased from 33% to 46% and those with a behavioral health visit increased from 24% to 28%. However, there was a small decline in the proportion of patients prescribed COT from 3.4% to 3.1%. DISCUSSION: Implementation of an opioid dashboard led to increased adherence to certain opioid practice guidelines and a decline in COT. This may be attributable to more efficient team-based pain management facilitated by the dashboard and increased transparency of opioid prescription practices. Health Information Technology solutions such as clinical dashboards can increase adherence to practice guidelines.

Strengthening the role the workforce plays in health policy engagement in underserved communities: lessons from a multi-site federally qualified health center.

Studies on the engagement of the CHC workforce in health policy are limited. Most uninsured Americans do not understand how the ACA affects them. We assessed knowledge and interest of our workforce in health policy, and applied the Socio-Ecological model to a plan for engagement, sharing strategies for similar settings.

Using electronic health records data to identify patients with chronic pain in a primary care setting.

OBJECTIVE: To develop and validate an accurate method to identify patients with chronic pain using electronic health records (EHR) data at a multisite community health center. MATERIALS AND METHODS: We identified patients with chronic pain in our EHR system using readily available data elements pertaining to pain: diagnostic codes (International Classification of Disease, revision 9; ICD-9), patient-reported pain scores, and opioid prescription medications. Medical chart reviews were used to evaluate the accuracy of these data elements in all of their combinations. We developed an algorithm to identify chronic pain patients more accurately based on these evaluations. The algorithm's results were validated for accuracy by comparing them with the documentation of chronic pain by the patient's treating clinician in 381 random patient charts. RESULTS: The new algorithm, which combines pain scores, prescription medications, and ICD-9 codes, has a sensitivity and specificity of 84.8% and 97.7%, respectively. The algorithm was more accurate (95.0%) than pain scores (88.7%) or ICD-9 codes (93.2%) alone. The receiver operating characteristic was 0.981. DISCUSSION: A straightforward method for identifying chronic pain patients solely using structured electronic data does not exist because individual data elements, such as pain scores or ICD-9 codes, are not sufficiently accurate. We developed and validated an algorithm that uses a combination of elements to identify chronic pain patients accurately. CONCLUSIONS: We derived a useful method that combines readily available elements from an EHR to identify chronic pain with high accuracy. This method should prove useful to those interested in identifying chronic pain patients in large datasets for research, evaluation or quality improvement purposes.

Comprehensive assessment of chronic pain management in primary care: a first phase of a quality improvement initiative at a multisite Community Health Center.

BACKGROUND: The objective of this study was to conduct a comprehensive formative assessment of chronic pain management in a large, multisite community health centre and use the results to design a quality improvement initiative based on an evidence-based practice model developed by the Veterans Health Administration. Improving quality and safety by incorporating evidence-based practices (EBP) is challenging, particularly in busy clinical practices such as Federally Qualified Health Centers (FQHCs). FQHCs grapple with financial constraints, lack of resources and complex patient populations. METHODS: The Promoting Action on Research Implementation in Health Services (PARIHS) Framework served as a basis for the comprehensive assessment. We used a range of measures and tools to examine pain care from a variety of perspectives. Patients with chronic pain were identified using self-reported pain scores and opioid prescription records. We employed multiple data collection strategies, including querying our electronic health records system, manual chart reviews and staff surveys. RESULTS: We found that patients with chronic pain had extremely high primary care utilisation rates while referral rates to pain-related specialties were low for these patients. Large gaps existed in primary care provider adherence to standards for pain care documentation and practice. There was wide provider variability in the prescription of opioids to treat pain. Staff surveys found substantial variation in both pain care knowledge and readiness to change, as well as low confidence in providers' ability to manage pain, and dissatisfaction with the resources available to support chronic pain care. CONCLUSIONS: Improving chronic pain management at this Community Health Center requires a multifaceted intervention aimed at addressing many of the problems identified during the assessment phase. During the intervention we will put a greater emphasis on increasing options for behavioural health and complementary medicine support, increasing access to specialty consultation, providing pain-specific CME for providers, and improving documentation of pain care in the electronic health records.

Primary care physicians' dementia care practices: evidence of geographic variation.

PURPOSE: This article explores primary care physicians' (PCPs) self-reported approaches and barriers to management of patients with dementia, with a focus on comparisons in dementia care practices between PCPs in 2 states. DESIGN AND METHODS: In this cross-sectional study, questionnaires were mailed to 600 randomly selected licensed PCPs in Connecticut and to all 1,017 licensed PCPs in Maine. RESULTS: A total of 422 eligible PCPs responded. Nearly 90% of PCPs prescribed donepezil in the previous year for their dementia patients. Connecticut PCPs were more likely to prescribe several other therapeutics than their Maine counterparts. Connecticut PCPs were more likely to refer dementia patients to adult day care (85% vs. 59%) but less likely to refer to Area Agencies on Aging (21% vs. 44%; both ps < .05); referral rates to Alzheimer's Association chapters were low in both states (30%). A greater proportion of Connecticut PCPs reported barriers to optimal dementia care, including time constraints (54% vs. 31% of Maine PCPs), unfamiliarity with community resources (46% vs. 30%), and reimbursement constraints (45% vs. 23%; all ps

Self-identity after cancer: "survivor", "victim", "patient", and "person with cancer".

BACKGROUND: Living through cancer often involves developing new identities which may strongly influence well-being and relationships with care providers, yet little is currently known about these post-cancer identities. OBJECTIVES: To examine (1) the extent to which four post-cancer identities (patient, person who has had cancer, victim, and survivor) are adopted, (2) relations between each identity and involvement in cancer-related activities and mental and physical well-being, and (3) correlates of these identities. DESIGN: Cross-sectional questionnaire-based study. PARTICIPANTS: 168 young to middle-aged adults who had previously experienced cancer. MEASUREMENTS: Cancer identifications, background variables, psychological functioning, cancer risk appraisals and coping, cancer-related activities, and mental and physical well-being. RESULTS: At least somewhat, 83% endorsed survivor identity, 81% identity of "person who has had cancer", 58% "patient", and 18% "victim". Identities were minimally correlated with one another and differentially associated with involvement in cancer-related activities. Survivor and person who has had cancer identities correlated with involvement in most cancer-related activities such as wearing cancer-related items and talking about prevention (ps < 0.5). Survivor identity correlated with better psychological well-being and post-traumatic growth, victim identity with poorer well-being (ps < 0.5); neither identifying as a patient nor a person with cancer was related to well-being. Through regression analyses, identities were shown to be explained by unique combination of background, functioning, appraisal and coping variables. CONCLUSIONS: Survivor identity appears most common and most associated with active involvement and better psychological well-being, but other identifications are also common and simultaneously held. Adoption of specific cancer identities is likely to impact interactions with health care providers, including those in general internal medicine, and health behavior changes.