Racial and Ethnic Disparities in Blood Pressure and Glycemic Control in the US Community Health Center Patient Population

OBJECTIVE

To describe blood pressure and glycemic control by racial/ethnic group in the US Community Health Center (CHC) patient population, and whether center characteristics, proxying for higher resource levels and better quality of care, were associated with greater rates of controlled cardiometabolic conditions.

METHODS

Data came from the Uniform Data System, representing aggregate patient clinical data for individual health centers in 2019. Descriptive analyses were conducted weighting by health center patient populations to produce race-specific national rates of blood pressure and glycemic control, and linear regression is used to test whether cardiometabolic control rates varied by center characteristics.

RESULTS

Hypertension was controlled for 67.2% of non-Hispanic White, 66.9% of Hispanic, and 56.7% of non-Hispanic Black patients. Diabetes was controlled for 70.7% of non-Hispanic White, 65.7% of Hispanic, and 66.1% of non-Hispanic Black patients. The rate of blood pressure control was 2.54 to 3.99 percentage points higher across racial/ethnic groups in health centers that adopted a patient-centered medical home (PCMH) model of care relative to non-PCMH centers, while glycemic control was 1.08 to 2.27 pp. higher as a function of PCMH certification. Results for other center characteristics did not show consistent patterns across racial groups or outcomes.

CONCLUSION

This study documented racial and ethnic health disparities in the CHC patient population after major expansion of the CHC program. CHCs with PCMH certification have improved clinical outcomes among patients with hypertension and diabetes across racial/ethnic groups relative to centers without this certification.

A Novel Curriculum for Internal Medicine Residents to Care for High-Need, High-Cost Patients

OBJECTIVES

High-need, high-cost (HNHC) patients represent a small proportion of patients in the US, but result in disproportionately higher healthcare utilization. Teaching Internal Medicine (IM) resident trainees to provide high value care for HNHC patients is critical. We sought to improve resident attitudes and increase clinical skills associated with treating HNHC patients by creating a curriculum that leveraged the UCLA Extensivist Program, a patient-centered medical home for HNHC patients.

METHODS

We developed a curriculum for PGY-2 and PGY-3 IM residents centered on caring for HNHC patients over the course of 6, 4h sessions during 1 academic year. Participants completed pre- and post-intervention surveys assessing self-rated attitudes and skills associated with caring for an HNHC patient population.

RESULTS

Twenty-one IM residents completed the curriculum and 41 were in the control group. There were no statistically significant differences in assessed attitudes and skills, but there were trends of improvement, including a decrease in participants who agreed or strongly agreed they felt overwhelmed when seeing patients for posthospital discharge follow up (45.0% pre- to 41.7% post-intervention) and an increase in participants who agreed or strongly agreed they have the skills to successfully transition HNHC patients between inpatient and ambulatory settings (20.0% pre- to 33.3% post-intervention). Participants reported better understanding of resources available to HNHC patients, effective coordination of transitions of care, and comprehensive assessment of social determinants of health.

CONCLUSION

A curriculum to improve resident attitudes and skills associated with caring for HNHC patients was successfully implemented in an IM program at a large academic medical center. The curriculum may be adapted for other training programs; long-term training woven throughout training may be important to significantly improve resident education on how to care for HNHC patients.

The Pediatric Inflammatory Bowel Disease Medical Home: A Proposed Model

Care for patients with inflammatory bowel disease (IBD) can be complex and costly. Care delivery models to address these challenges and improve care quality are essential. The patient-centered medical home (PCMH), which was developed in the primary care setting, has recently been applied successfully to the adult IBD population. Following the tenets of the PCMH, this specialty medical home (SMH) emphasizes team-based care that is accessible, comprehensive, patient/family-centered, coordinated, compassionate, and continuous and has demonstrated improved patient outcomes. Children and young adults with IBD have equally complex care needs, with additional challenges not faced by the adult population such as growth, physical and psychosocial development, and transition of care from pediatric to adult providers. Thus, we advocate that the components of the PCMH are equally-if not more-important in caring for the pediatric patient population. In this article, we review what is known about the application of the PCMH model in adult IBD care, describe care delivery within the Center for Pediatric and Adolescent IBD at Nationwide Children's Hospital as an example of a pediatric IBD medical home, and propose a research agenda to further the development and dissemination of comprehensive care delivery for children and adolescents with IBD.

Pediatric Practice Transformation and Long-Acting Reversible Contraception (LARC) Use in Adolescents

OBJECTIVE

Long acting reversible contraceptives (LARCs) are recommended as highly effective for adolescents. Although the uptake of LARCs has increased, overall use remains low due to barriers for both providers and patients. We evaluate whether pediatric medical home transformation, including implant placement in pediatrics, may increase LARC use or decrease adolescent pregnancy rates.

METHODS

Retrospective interrupted time-series analysis of adolescents ages 11 to 19 years at 2 pediatric practices in academically affiliated community health centers during 2005-2015. The intervention practice underwent medical home transformation including team-based care with family planning and health coaching, youth-friendly policies, and contraceptive implant placement. The control practice continued usual care. Differential changes in population event rates were evaluated using a segmented longitudinal regression model.

RESULTS

The study population included 4946 adolescent females at the intervention practice and 1992 at the control practice. Following practice transformation, LARC use increased significantly more at the intervention practice compared to the control (1.73 versus 0.28 events per 1000 patients quarterly P = 0.004). Pregnancy rate declined at both practices without temporal correlation to the LARC intervention. During the medical home transformation period, the intervention practice showed a greater decline in pregnancy rate, though this difference did not reach statistical significance (2.01 versus 0.81 events per 1000 patients quarterly P = 0.090).

CONCLUSIONS

Adolescents had higher LARC use where implant placement was offered within the pediatric practice as part of medical home transformation. Although LARC did not impact pregnancy rate, the process of practice transformation may have accelerated its decline through heightened adolescent health focus.

Impact of an Advanced Practice Pharmacist Type 2 Diabetes Management Program: A Pilot Study

BACKGROUND

The purpose of this study was to describe the impact of an Advanced Practice Pharmacist (APh) on lowering hemoglobin A1c (HbA1c) in patients with type 2 diabetes within a patient centered medical home (PCMH) and to classify the types of therapeutic decisions made by the APh.

METHODS

This was a retrospective study using data from electronic health records. The study evaluated a partnership between Chapman University School of Pharmacy and Providence St. Joseph Heritage Healthcare that provided diabetes management by an Advanced Practice Pharmacist in a PCMH under a collaborative practice agreement. Change in the HbA1c was the primary endpoint assessed in this study. The type of therapeutic decisions made by the APh were also evaluated. Descriptive analysis and Wilcoxon signed ranktest were used to analyze data.

RESULTS

The study included 35 patients with diagnosis of type 2 diabetes mellitus managed by an APh from May 2017 to December 2017. Most of the patients were 60-79 years old (68.5%), 45.7% were female, and 45.7% were of Hispanic/Latino ethnicity. The average HbA1cwas 8.8%±1.4% (range=6.0%-12.4%) and 7.5%±1.4% (range=5.5%-12.4%) at the initial and final APh visit, respectively (p<0.0001). Therapeutic decisions made by the APh included drug dose increase (35.5% of visits), drug added (16.4%), drug dose decrease (6.4%), drug switch (5.5%), and drug discontinuation (1.8%).

CONCLUSION

The Advanced Practice Pharmacist's interventions had a significant positive impact on lowering HbA1c in patients with type 2 diabetes mellitus in a PCMH. The most common therapeutic decisions made by the APh included drug dose increase and adding a new drug.

Readmission Rates Associated with Pharmacist Involvement in a Geriatric Transitional Care Management Clinic

Objective:

To evaluate the impact of a post-discharge pharmacist telephone call on 30- and 90- day readmission rates as part of a transitional care management (TCM) service in a geriatric patient-centered medical home (PCMH).

Methods:

Adults 60 years of age and older who had established primary care at the PCMH for at least one year and were discharged from the hospital between 7/1/2013 and 2/21/2016 were included. Readmission rates for patients who received and did not receive a pharmacist TCM phone call were compared. Secondary data analysis was conducted between individuals who received all three components of the service compared with those who received on a nurse navigator plus primary care provider (PCP) visit.

Results:

Among 513 discharges of unique patients (mean age, 80.4 years; women 63%), 269 (52.4%) received a pharmacist phone call. Readmission rates at 30 days were 8.9% for patients who received a pharmacist TCM phone call compared to 12.7% for those who did not receive this service (OR 0.67 [95% CI, 0.38-1.18; P=0.17]). When comparing only those individuals who received all three components of the service (pharmacist, nurse navigator, and PCP) (n=215) compared to those who received only a nurse navigator plus PCP visit (n=66), there was no difference in 30-day readmission rates (7.9% vs. 10.6%, p=0.49). However, there were significantly fewer readmissions within 90-days (16.3% vs. 31.8%, p=0.01).

Conclusion:

Pharmacist phone calls as part of an interdisciplinary TCM service did not result in a statistically significant difference regarding readmission rates at 30 days; however, patients who received all three components of the service had significantly fewer readmissions at 90 days, compared to patients who did not speak with a pharmacist but did complete a visit with a nurse navigator and physician. Future research is needed to determine which patients may benefit the most from this service and to identify strategies to increase patient participation.

Differences in Team Mental Models Associated With Medical Home Transformation Success

PURPOSE

Primary care transformation is widely seen as essential to improving patient outcomes and health care costs. The medical home model can achieve these ends, but dissemination and scale-up of practice transformation is challenging. We sought to understand how to move past successful pilot efforts by early adopters to widespread adoption by applying cognitive task analysis using the diffusion of innovations framework.

METHODS

We undertook a qualitative cross-sectional comparison of 3 early adopter practices and 15 early majority practices in Alberta, Canada. Practices completed a total of 42 cognitive task analysis interviews. We conducted a framework-guided qualitative analysis, with allowance for emergent themes, using the macrocognition framework on which cognitive task analysis is based. Independent codings of interview transcripts for key macrocognitive functions were reviewed in group analysis meetings to describe macrocognitive functions and team mental models, and identify emergent themes. Two external focus groups provided support for these findings.

RESULTS

Three prominent findings emerged. The first was a spectrum of mental models from "doctor with helpers," through degrees of delegation, to fully team based care. The second was differences in how teams distributed macrocognitive functions among members, with early adopters distributing these functions more widely across the team than early majority practices. Finally, we saw emergence of several themes also common in the diffusion of innovations literature, such as the importance of trying new practices in small, reversible steps.

CONCLUSIONS

Our findings provide guidance to practice teams, health systems, and policymakers seeking to move beyond early adopters, to improve team functioning and advance the medical home transformation at scale.

Using an interprofessional team to provide refugee healthcare in an academic medical centre

Introduction

The International Family Medicine Clinic (IFMC) was established in 2002 by the University of Virginia Department of Family Medicine to provide comprehensive, timely, culturally sensitive and high-quality healthcare to the growing refugee and special immigrant population in Central Virginia, USA.

Methods

The purpose of this paper is to describe the IFMC, with a specific focus on interprofessional roles, interprofessional collaboration, community partnerships and the services and resources available to IFMC patients.

Results

The clinic has served over 3100 refugees from 60 countries in its 16-year history. In 2019, the clinic staff now includes 4 attending physicians, 2 nurse practitioners and 14 residents who have dedicated clinic time to see refugees; a registered nurse care coordinator and a social worker dedicated to the IFMC refugee population; 2 clinical psychologists and doctoral students in clinical psychology; and a clinical pharmacist. The IFMC also provides onsite psychiatric care. A process flow map depicts the interconnectivity of interprofessional team members working together with other specialty care providers within the medical centre and with community partners on behalf of refugee patients through the resettlement process.

Conclusion

Individuals who arrive in the USA as refugees are a particularly vulnerable patient group and often require an interprofessional team approach. The IFMC may serve as a model for other institutions interested in starting a similar interprofessional, refugee-centred medical home.

Medical home transformation and breast cancer screening

OBJECTIVES

The patient-centered medical home (PCMH) continues to gain momentum as a primary care delivery system. We evaluated whether medical home transformation of primary care practices is associated with the use of breast cancer screening, a broadly endorsed preventive service.

STUDY DESIGN

Retrospective cohort study evaluating 12 Brigham and Women's Hospital (BWH)-affiliated primary care clinics in greater Boston, Massachusetts.

METHODS

Practice transformation was measured quarterly using a continuous PCMH transformation score (range = 0-100) modeled after National Committee for Quality Assurance recognition requirements. We included women aged 50 to 74 years who had at least 1 primary care visit at a participating clinic between April 2012 and December 2013 (n = 20,349)-a period of medical home transformation. The main measures included: a) whether screening was up-to-date at the time of the visit (mammography completion within 24 months prior to the visit); and b) if screening was overdue at the visit (ie, it had been more than 24 months since the last mammogram), and whether timely screening was completed within 3 months after the visit.

RESULTS

In adjusted analyses, PCMH transformation scores were negatively associated with up-to-date screening status (odds ratio [OR] for a 20-point change, 0.93; 95% confidence interval [CI], 0.89-0.96) and with timely screening of women who were overdue (OR, 0.94; 95% CI, 0.87-1.02).

CONCLUSIONS

Preventative care, such as breast cancer screening, may not improve in early PCMH implementation.

An Assessment of Future Clinical Pharmacy Service Delivery in the Patient-Centered Medical Home

Two health care reform initiatives-patient-centered medical home (PCMH) and payment reform-in combination have the potential to increase clinical pharmacy involvement in patient care. However, the effects of these reforms on clinical pharmacy are highly uncertain. In particular, which clinical pharmacy services will be provided, how the services will be requested and delivered, and in what practice settings the services will be provided are not known. To gain insight into future clinical pharmacy service delivery in the PCMH, the authors examined current clinical pharmacy service delivery models at 4 sites in Massachusetts and assessed how the service delivery would change in PCMH settings with a payment approach of comprehensive payments to the PCMH. The findings suggest that (1) clinical pharmacy participation in the PCMH will increase at ambulatory care sites if supported by payment reform and (2) changes in addition to payment reform will be necessary to increase participation of community pharmacists. Needed changes are described.

Treatment outcomes of overweight children and parents in the medical home

OBJECTIVE

To test in the primary care setting the short- and long-term efficacy of a behavioral intervention that simultaneously targeted an overweight child and parent versus an information control (IC) targeting weight control only in the child.

METHODS

Two- to 5-year-old children who had BMI ≥85th percentile and an overweight parent (BMI >25 kg/m2) were randomized to Intervention or IC, both receiving diet and activity education over 12 months (13 sessions) followed by 12-month follow-up (3 sessions). Parents in the Intervention group were also targeted for weight control and received behavioral intervention. Pediatricians in 4 practices enrolled their patients with the assistance of embedded recruiters (Practice Enhancement Assistants) who assisted with treatment too.

RESULTS

A total of 96 of the 105 children randomized (Intervention n = 46; IC n = 50) started the program and had data at baseline. Children in the Intervention experienced greater reductions in percent over BMI (group × months; P = .002) and z-BMI (group × months; P < 0.001) compared with IC throughout treatment and follow-up. Greater BMI reduction was observed over time for parents in the Intervention compared with IC (P < .001) throughout treatment and follow-up. Child weight changes were correlated with parent weight changes at 12 and 24 months (r = 0.38 and 0.26; P < .001 and P = .03).

CONCLUSIONS

Concurrently targeting preschool-aged overweight and obese youth and their parents in primary care with behavioral intervention results in greater decreases in child percent over BMI, z-BMI, and parent BMI compared with IC. The difference between Intervention and IC persists after 12 months of follow-up.

Collaborative hypertension case management by registered nurses and clinical pharmacy specialists within the Patient Aligned Care Teams (PACT) model

BACKGROUND

Clinical Pharmacy Specialists (CPSs) and Registered Nurses (RNs) are integrally involved in the Patient Aligned Care Teams (PACT) model, especially as physician extenders in the management of chronic disease states. CPSs may be an alternative to physicians as a supporting prescriber for RN case management (RNCM) of poorly controlled hypertension.

OBJECTIVE

To compare CPS-directed versus physician-directed RNCM for patients with poorly controlled hypertension.

DESIGN

Non-randomized, retrospective comparison of a natural experiment.

SETTING

A large Midwestern Veterans Affairs (VA) medical center.

INTERVENTION

Utilizing CPSs as alternatives to physicians for directing RNCM of poorly controlled hypertension.

PATIENTS

All 126 patients attended RNCM appointments for poorly controlled hypertension between 20 September 2011 and 31 October 2011 with either CPS or physician involvement in the clinical decision making. Patients were excluded if both a CPS and a physician were involved in the index visit, or they were enrolled in Home Based Primary Care, or if they displayed non-adherence to the plan.

MAIN MEASURES

All data were obtained from review of electronic medical records. Outcomes included whether a patient received medication intensification at the index visit, and as the main measure, blood pressures between the index and next consecutive visit.

KEY RESULTS

All patients had medication intensification. Patients receiving CPS-directed RNCM had greater decreases in systolic blood pressure compared to those receiving physician-directed RNCM (14 ± 13 mmHg versus 10 ± 11 mmHg; p = 0.04). After adjusting for the time between visits, initial systolic blood pressure, and prior stroke, provider type was no longer significant (p = 0.24). Change in diastolic blood pressure and attainment of blood pressure < 140/90 mm Hg were similar between groups (p = 0.93, p = 0.91, respectively).

CONCLUSIONS

CPS-directed and physician-directed RNCM for hypertension demonstrated similar blood pressure reduction. These results support the utilization of CPSs as prescribers to support RNCM for chronic diseases.

Primary care residents want to learn about the patient-centered medical home

BACKGROUND AND OBJECTIVES

The patient-centered medical home (PCMH) is an important model of primary care with a promise of improving quality, reducing costs, and improving patient satisfaction. Many primary care residency programs have PCMH initiatives, but it is unclear if residents are interested in learning more about the PCMH. Our objective was to examine primary care residents' attitudes and knowledge about the PCMH model and how it relates to them.

METHODS

A total of 82 first- through third-year family medicine and internal medicine residents participated in a survey with 25 questions. Descriptive statistics were performed to describe the responses.

RESULTS

The survey response rate was 91%. Sixty-one percent of residents thought they had "poor" or "fair" knowledge of the PCMH, and 84% thought it was important to be knowledgeable about the PCMH. Thirty-four percent rated their ability to describe the PCMH as "well" or "very well." Eighty-six percent thought they learned "too little" or "way too little" about the PCMH during medical school. The majority (88%) of residents were interested in learning more about the PCMH.

CONCLUSIONS

Family and internal medicine residents are interested in learning more about the PCMH during residency. Residents may benefit from experiential learning that focuses on the PCMH.

Training family medicine residents to build and remodel a patient centered medical home in Rhode Island: a team based approach to PCMH education

Primary Care practices in the United States are undergoing rapid transformation into Patient Centered Medical Homes (PCMHs), prompting a need to train resident physicians in this new model of primary care. However, few PCMH curricula are described or evaluated in the literature. We describe the development and implementation of an innovative, month-long, team-based, block rotation, integrated into the Brown Family Medicine Residency Program, within the context of statewide PCMH practice transformation in Rhode Island. The PCMH resident team (first-, second- and third-year residents) gain PCMH skills, with progressive levels of responsibility through residency. In addition to traditional supervised direct outpatient care, learning activities include: active participation in PCMH transformation projects, population health level patient management, quality improvement activities, interdisciplinary teamwork, chronic disease management (including leading group medical visits), and PCMH specific didactics paired with weekly projects. This new clinical block rotation and team holds promise as a model to train residents for future PCMH primary care practices.

Connecting the dots and merging meaning: using mixed methods to study primary care delivery transformation

OBJECTIVE

To demonstrate the value of mixed methods in the study of practice transformation and illustrate procedures for connecting methods and for merging findings to enhance the meaning derived.

DATA SOURCE/STUDY SETTING

An integrated network of university-owned, primary care practices at the University of Utah (Community Clinics or CCs). CC has adopted Care by Design, its version of the Patient Centered Medical Home.

STUDY DESIGN

Convergent case study mixed methods design.

DATA COLLECTION/EXTRACTION METHODS

Analysis of archival documents, internal operational reports, in-clinic observations, chart audits, surveys, semistructured interviews, focus groups, Centers for Medicare and Medicaid Services database, and the Utah All Payer Claims Database.

PRINCIPAL FINDINGS

Each data source enriched our understanding of the change process and understanding of reasons that certain changes were more difficult than others both in general and for particular clinics. Mixed methods enabled generation and testing of hypotheses about change and led to a comprehensive understanding of practice change.

CONCLUSIONS

Mixed methods are useful in studying practice transformation. Challenges exist but can be overcome with careful planning and persistence.

Mental health collaborative care and its role in primary care settings

Collaborative care models (CCMs) provide a pragmatic strategy to deliver integrated mental health and medical care for persons with mental health conditions served in primary care settings. CCMs are team-based intervention to enact system-level redesign by improving patient care through organizational leadership support, provider decision support, and clinical information systems, as well as engaging patients in their care through self-management support and linkages to community resources. The model is also a cost-efficient strategy for primary care practices to improve outcomes for a range of mental health conditions across populations and settings. CCMs can help achieve integrated care aims underhealth care reform yet organizational and financial issues may affect adoption into routine primary care. Notably, successful implementation of CCMs in routine care will require alignment of financial incentives to support systems redesign investments, reimbursements for mental health providers, and adaptation across different practice settings and infrastructure to offer all CCM components.

Urologists and the patient centered medical home

PURPOSE

Hopes are high that the delivery system reforms embodied in the patient centered medical home will improve the quality of care for patients with chronic diseases. While primary care physicians, given their training, will likely be the locus of care under this model, there are certain conditions for which urologists are well suited to provide the continuous and comprehensive care called for by the patient centered medical home. To assess the feasibility of the urology based patient centered medical home, we analyzed national survey data.

MATERIALS AND METHODS

For our measure of medical home infrastructure, we mapped items from the 2007 and 2008 NAMCS (National Ambulatory Medical Care Survey) to the NCQA (National Committee on Quality Assurance) standards for patient centered medical home recognition. We determined the proportion of urology practices in the United States that would achieve patient centered medical home recognition. Finally, we used NAMCS data to estimate the impact of consolidating genitourinary cancer (ie prostate, bladder, kidney and testis) followup care among the current supply of urologists.

RESULTS

Nearly three-quarters of urology practices meet NCQA standards for patient centered medical home recognition. At present, primary care physicians spend 9,295 cumulative workweeks providing direct and indirect care to survivors of genitourinary cancers. Off-loading half of this care to urology practices, in the context of the patient centered medical home, would generate an average of 0.73 additional workweeks for each practicing urologist.

CONCLUSIONS

Urology practices may possess the capacity needed to direct medical homes for their patients with genitourinary cancers. Successful implementation of this model would likely require a willingness to manage some nonurological conditions.

Undergoing transformation to the patient centered medical home in safety net health centers: perspectives from the front lines

OBJECTIVES

Safety net health centers (SNHCs), which include federally qualified health centers (FQHCs) provide primary care for underserved, minority and low income patients. SNHCs across the country are in the process of adopting the patient centered medical home (PCMH) model, based on promising early implementation data from demonstration projects. However, previous demonstration projects have not focused on the safety net and we know little about PCMH transformation in SNHCs.

DESIGN

This qualitative study characterizes early PCMH adoption experiences at SNHCs.

SETTING AND PARTICIPANTS

We interviewed 98 staff (administrators, providers, and clinical staff) at 20 of 65 SNHCs, from five states, who were participating in the first of a five-year PCMH collaborative, the Safety Net Medical Home Initiative.

MAIN MEASURES

We conducted 30-45 minute, semi-structured telephone interviews. Interview questions addressed benefits anticipated, obstacles encountered, and lessons learned in transition to PCMH.

RESULTS

Anticipated benefits for participating in the PCMH included improved staff satisfaction and patient care and outcomes. Obstacles included staff resistance and lack of financial support for PCMH functions. Lessons learned included involving a range of staff, anticipating resistance, and using data as frequent feedback.

CONCLUSIONS

SNHCs encounter unique challenges to PCMH implementation, including staff turnover and providing care for patients with complex needs. Staff resistance and turnover may be ameliorated through improved health care delivery strategies associated with the PCMH. Creating predictable and continuous funding streams may be more fundamental challenges to PCMH transformation.

Mental health in ACOs: missed opportunities and low-hanging fruit

Accountable Care Organizations (ACOs) have potential to improve care for chronic conditions through incentives for better performance and bundled payments that promote care coordination. The Chronic Care Model (CCM) is a framework for providing health services for chronic conditions in primary care settings consistent with the organizational and financial goals of ACOs. Integrated mental health care – collaborative care by mental health and primary care providers for selected patients – improves care and is consistent with the Chronic Care Model. However, under the Medicare Shared Savings Program ACOs currently do not specify financial or organizational incentives for providing integrated mental health care through the CCM, leaving a missed opportunity to realize the full potential of ACOs to improve patient outcomes. We describe the rationale for incorporating mental health care into ACOs; how it can benefit consumers, providers, and ACOs; and what health care organizations can do to implement integrated mental health care.

Teaching motivational interviewing to primary care staff in the Veterans Health Administration

BACKGROUND

The Veterans Health Administration (VHA) is implementing the patient-centered medical home (PCMH) model of primary care which emphasizes patient-centered care and the promotion of healthy lifestyle changes. Motivational Interviewing (MI) is effective for promoting various health behaviors, thus a training protocol for primary care staff was implemented in a VHA health care setting.

OBJECTIVES

We examined the effect of the training protocol on MI knowledge, confidence in ability to use MI-related skills and apply them to written vignettes, perceived comfort level and skill in lifestyle counseling, and job-related burnout.

DESIGN

Training was provided by experts in MI. The training protocol consisted of three sessions--one half day in-person workshop followed by a 60-minute virtual training, followed by a second workshop. Each of the sessions were spaced two weeks apart and introduced trainees to the theory, principles, and skills of using MI in health care settings.

PARTICIPANTS

All primary care staff at the Veterans Affairs Palo Alto Health Care System were invited to participate.

MEASUREMENTS

Trainees completed a short set of questionnaires immediately before and immediately after the training.

RESULTS

We found support for our primary hypotheses related to knowledge, confidence, and written responses to the vignettes. Changes in perceived comfort level and skill in lifestyle counseling, and job-related burnout were not observed.

CONCLUSIONS

Training primary care staff in MI is likely to become increasingly common as health care systems transition to the PCMH model of care. Therefore, it is important for health care systems to have low-cost methods for evaluating the effectiveness of such trainings. This study is a first step in developing a brief written assessment with the potential of measuring change in a range of behaviors and skills consistent with MI.

How to scale up primary care transformation: what we know and what we need to know?

Becoming a medical home is a radical change, requiring both a new mental model for primary care and the skills and resources to accomplish it. Although numerous reports indicate practice change is feasible--particularly with technical support and either insulation from or alignment with financial incentives--sustained transformation appears difficult. We identified the following critical success factors: leadership, financial resources, personal and organizational relationships, engagement with patients and families, competence in management, improvement methods and coaching, health information technology properly applied, care coordination support, and staff development. Each factor raises researchable questions about what policies can facilitate achieving success so that transformation becomes mainstream rather than the province of the innovative few.