Revitalizing Primary Care, Part 2: Hopes for the Future

Integrating Ambulatory Care Pharmacists Into Value-Based Primary Care: A Scalable Solution to Chronic Disease

INTRODUCTION/OBJECTIVES

Patients living with chronic diseases require more medical attention, including more visits to primary care. However, primary care providers are overburdened, and this specialty is attracting fewer new providers than before. Clinical pharmacists can augment these efforts by improving disease state control. In this cohort study, we aimed to demonstrate a retail pharmacy hired and trained clinical pharmacist within a value-based primary care clinic network can improve hypertension (HTN) and type 2 diabetes mellitus (T2DM) control.

METHODS

In this cohort study, a pharmacist, enabled by a collaborative drug therapy management agreement, prescribed and titrated therapies for HTN and T2DM. Primary outcomes were pre- to post-index changes in hemoglobinA1c, systolic, and diastolic blood pressure (BP) measures.

RESULTS

The HTN cohort consisted of 43 patients and the T2DM cohort consisted of 125 patients. The difference-in-differences (β) in the HTN group was -10.2 mmHg (P < .01) for systolic BP and -2.0 mmHg (P = .42) for diastolic BP. The β in the T2DM group was -1.16% (P < .001).

CONCLUSIONS

Statistically significant reductions in systolic BP and hemoglobinA1c were observed in the pharmacist-managed group compared with matched controls. These results demonstrate that pharmacist integration into a value based primary care clinic may improve measures of chronic disease associated with morbidity and mortality.

Disparities in the Timeliness of Addressing Patient-Initiated Telephone Calls in a Primary Care Clinic: The Impact of Quality Improvement Interventions

A timely response to patient-initiated telephone calls can affect many aspects of patient health, including quality of care and health equity. Historically, at a family medicine residency clinic, at least 1 out of 4 patient calls remained unresolved three days after the call was placed. We sought to explore whether there were differential delays in resolution of patient concerns for certain groups and how these were affected by quality improvement interventions to increase responsiveness to patient calls. A multidisciplinary team at a primary care residency clinic applied Lean education and tools to improve the timeliness of addressing telephone encounters. Telephone encounter data were obtained for one year before and nine months after the intervention. Data were stratified by race, ethnicity, preferred language, sex, online portal activation status, age category, zip code, patient risk category, and reason for call. Stratified data revealed consistently worse performance on telephone encounter closure by 72 hours for Black/African American patients compared to Hispanic and non-Hispanic White patients pre-intervention. Interventions resulted in statistically significant overall improvement, with an OR of 2.9 (95% CI: 2.62 to 3.21). Though interventions did not target a specific population, pre-intervention differences based on race and ethnicity resolved post-intervention. Telephone calls serve as an important means of patient communication with care teams. General interventions to improve the timeliness of addressing telephone encounters can lead to sustainable improvement in a primary care academic clinic and may also alleviate disparities.

"Advocates for Each Other": The creation and evaluation of a pragmatic peer navigation program for black patients in primary care with uncontrolled hypertension

BACKGROUND

Black individuals in the U.S. and in our primary care clinic experience worse control of blood pressure compared to White individuals.

OBJECTIVE

To address this inequity, our objectives were to (1) elicit from patients and community members their ideas for barriers and facilitators to blood pressure control; and (2) use their input to design and pilot a navigator program for Black patients in our clinic to improve blood pressure management.

PATIENT INVOLVEMENT

We conducted three focus groups with 27 individuals and identified two main areas of need that informed the peer navigator program: (1) community-based services and (2) skill development for hypertension self-management.

METHODS

Peer navigators from the Black community called participants at least monthly for 6-12 months and connected them with medical and social services. Available blood pressure data was used as the primary outcome to measure change pre- to post-peer navigation program.

RESULTS

Among 499 eligible patients in the clinic, 53 (10.6%) enrolled in the peer navigation program. For those with baseline and follow-up blood pressure data, mean systolic blood pressure decreased from 155.9 to 142.4 mmHg after the program (change of -13.6, 95% CI -24.7 to -2.4) for the enrolled patients (N = 17) and from 139.1 to 137.1 mmHg (change of -2.5, -4.8 to 1.9) for unenrolled, comparison patients (N = 183).

DISCUSSION

This community-informed peer navigation program to support Black patients with uncontrolled hypertension led to a 11.1 mmHg greater decrease in average systolic blood pressure for enrolled patients compared to the comparison group. However, the enrolled group started with a significantly higher systolic blood pressure at baseline with more room for improvement. While this study was conducted during the pandemic years, low uptake of this program needs to be addressed in expansion efforts.

PRACTICAL VALUE

Clinic-based peer navigation for hypertension improved blood pressure control and was highly regarded by the subset of enrolled patients. Increasing uptake and sustainable funding for non-billable clinic roles remain areas of need.

FUNDING

Grant from the Pacific Hospital Preservation & Development Authority.

How CPC+ supported patient care during the COVID-19 pandemic: Lessons for alternative payment models

BACKGROUND

A growing literature documents how primary care practices adapted to the COVID-19 pandemic. We examine a topic that has received less attention-how participants in an advanced alternative payment model perceive the model influenced their ability to meet patients' care needs during the pandemic.

METHODS

Analysis of closed- and open-ended questions from a 2021 survey of 2496 practices participating in the Comprehensive Primary Care Plus (CPC+) model (92% response rate) and a 2021 survey of 993 randomly selected primary care physicians from these practices (55% response rate). Both surveys asked whether respondents agreed or disagreed that they or their practice was "better positioned to meet patients' care needs during the coronavirus pandemic" because of participation in CPC+. Both also included an open-ended question about CPC+'s effects.

RESULTS

Half of practices and one-third of physicians agreed or strongly agreed that participating in CPC+ better positioned them to meet patients' care needs during the pandemic. One in 10 practices and 2 in 10 physicians, disagreed or strongly disagreed, while 4 in 10 practices and slightly more than half of physicians neither agreed nor disagreed (or, for physicians, didn't know). The most commonly identified CPC+ activities that facilitated meeting patient care needs related to practices' work on care management (e.g., risk stratification), access (e.g., telehealth), payment outside of fee-for-service (FFS), and staffing (e.g., supporting care managers).

CONCLUSIONS

Most CPC+ practices and physicians were positive or neutral about participating in CPC+ in the context of COVID-19, indicating more benefit than risk to payment alternatives to FFS.

Public experiences and perspectives of primary care in Canada: results from a cross-sectional survey

BACKGROUND

Through medicare, residents in Canada are entitled to medically necessary physician services without paying out of pocket, but still many people struggle to access primary care. We conducted a survey to explore people's experience with and priorities for primary care.

METHODS

We conducted an online, bilingual survey of adults in Canada in fall 2022. We distributed an anonymous link through diverse channels and a closed link to 122 053 people via a national public opinion firm. We weighted completed responses to mirror Canada's population and adjusted for sociodemographic characteristics using regression models.

RESULTS

We analyzed 9279 completed surveys (5.9% response rate via closed link). More than one-fifth of respondents (21.8%) reported having no primary care clinician, and among those who did, 34.5% reported getting a same or next-day appointment for urgent issues. Of respondents, 89.4% expressed comfort seeing another team member if their doctor recommended it, but only 35.9%, 9.5%, and 12.4% reported that their practice had a nurse, social worker, or pharmacist, respectively. The primary care attribute that mattered most was having a clinician who "knows me as a person and considers all the factors that affect my health." After we adjusted for respondent characteristics, people in Quebec, the Atlantic region, and British Columbia had lower odds of reporting a primary care clinician than people in Ontario (adjusted odds ratio 0.30, 0.33, and 0.39, respectively; p < 0.001). We also observed large provincial variations in timely access, interprofessional care, and walk-in clinic use.

INTERPRETATION

More than 1 in 5 respondents did not have access to primary care, with large variation by province. Reforms should strive to expand access to relationship-based, longitudinal care in a team setting.

Identifying strategies to support implementation of interprofessional primary care teams in Nova Scotia: Results of a survey and knowledge sharing event

BACKGROUND

Interprofessional primary care teams (IPCTs) work together to enhance care. Despite evidence on the benefits of IPCTs, implementation remains challenging. This research aims to 1) identify and prioritize barriers and enablers, and 2) co-develop team-level strategies to support IPCT implementation in Nova Scotia, Canada.

METHODS

Healthcare providers and staff of IPCTs were invited to complete an online survey to identify barriers and enablers, and the degree to which each item impacted the functioning of their team. Top ranked items were identified using the sum of frequency x impact for each response. A virtual knowledge sharing event was held to identify strategies to address local barriers and enablers that impact team functioning.

RESULTS

IPCT members (n = 117), with a mix of clinic roles and experience, completed the survey. The top three enablers identified were access to technological tools to support their role, standardized processes for using the technological tools, and having a team manager to coordinate collaboration. The top three barriers were limited opportunity for daily team communication, lack of conflict resolution strategies, and lack of capacity building opportunities. IPCT members, administrators, and patients attended the knowledge sharing event (n = 33). Five strategies were identified including: 1) balancing patient needs and provider scope of practice, 2) holding regular and accessible meetings, 3) supporting team development opportunities, 4) supporting professional development, and 5) supporting involvement in non-clinical activities.

INTERPRETATION

This research contextualized evidence to further understand local perspectives and experiences of barriers and enablers to the implementation of IPCTs. The knowledge exchange event identified actionable strategies that IPCTs and healthcare administrators can tailor to support teams and care for patients.

Family physicians' preferences for education to support family caregivers: a sequential mixed methods study

BACKGROUND

One in four Canadians is a family caregiver. Family caregivers (carers, care-partners) are relatives or chosen family, friends, or neighbors who provide 75 to 90% of the care for people with physical or mental illness, disabilities, or frailty living in community homes and assist with 15 to 30% of the care in congregate care. However, a recent (2022) Statistics Canada population health study reports 44% of family caregivers are distressed. Family physicians and primary care teams are well-positioned to support family caregivers; yet, family caregiver needs assessments tend to be ad hoc and their most common needs remain unmet. Research recommends training healthcare professionals to enhance their knowledge and skills to support family caregivers.

METHODS

The objective of this sequential mixed methods research, a survey followed by qualitative interviews, was to explore family physicians' desire and preferences for education about supporting family caregivers. 85 family physicians completed the online survey and eight took part in the interviews. Results from the survey and interviews were compared, contrasted, and interpreted together.

RESULTS

Primary care physicians expressed a desire to be better equipped to assess and support FCGs' needs. Even though most physicians (61%) were very/confident about addressing family caregivers' needs, 72% were highly/interested in education to support family caregivers of their patients. Topics with the most interest were assessing family caregivers needs in an organized way, assisting family caregivers to access resources, and address system and practice barriers to support family caregivers. The overarching theme running through the interviews was physicians hope for education to help change the patient-focused culture to inclusion of FCGs. The three themes reflect physicians' conviction about including family caregivers in patient care: We need to take care of their caregivers, Practice and system barriers thwart including family caregivers, and Practical education might help.

CONCLUSIONS

This study of family physicians' preferences for education to support family caregivers will inform the development of education about supporting family caregivers for family physicians and trainees.

Facilitators Associated with Nursing Burnout in the Ambulatory Care Setting as COVID-19 Subsides: A Rapid Review

The COVID-19 pandemic has significantly impacted the healthcare industry and its workforce, particularly nurses, who have been at the forefront of patient care. As the world begins to emerge from the pandemic, attention is turning to the long-term effects of the crisis on nurses' mental health and well-being, and specifically nursing burnout. Prevalent risk factors related to nursing burnout often historically involve high workload, insufficient support and/or resources, work-life imbalance, and even lack of autonomy and organization climate challenges. Understanding the factors that contribute to nursing burnout to help mitigate it is vital to ensuring the ongoing health and well-being of the nursing workforce, especially since the ongoing waning of coronavirus (COVID-19). This rapid review identifies 36 articles and explores the latest research on nursing burnout in outpatient (ambulatory care) healthcare facilities as the global pandemic continues to subside, and therefore identifies constructs that suggest areas for future research beyond previously identified contributing factors of nursing burnout while the pandemic virus levels were high.

Evaluation of a national e-booking system for medical consultation in primary care in a universal health system

PURPOSE

The Rendez-vous Santé Québec is a national online booking (e-booking) system of medical appointments in primary care rolled out in 2018 in Québec (Canada). The objectives of this study were to describe the adoption by targeted users, and analyze the facilitating and limiting factors at the technological, individual and organizational levels to inform policy makers.

METHODS

A mixed methods evaluation was conducted involving interviews with key stakeholders (n = 40), audit logs of the system in 2019, and a population-based survey (n = 2 003). All data were combined to analyze facilitating and limiting factors, based on the DeLone and McLean framework.

RESULTS

The RVSQ e-booking system had a low adoption across the province mainly because it was poorly aligned with the diversity of organizational and professional practices. The other commercial e-booking systems already used by clinics seemed better adapted to interdisciplinary care, patient prioritization and advanced access. e-Booking system was appreciated by patients, but has implications for the performance of primary care organization that goes beyond scheduling management issues, with potential detrimental consequences for care continuity and appropriateness. Further research is needed to define how e-booking systems could support a better alignment between primary care innovative practices and improve the fit between patients' needs and resources availability in primary care.