Journal of the American Board of Family Medicine最新文献

Introduction: Colorectal cancer (CRC) is the second leading cause of cancer death in the United States. While patient-reported barriers have been previously described, few studies have analyzed how patients' social needs affect screening rates.

Methods: This cross-sectional study includes 3,443 Kaiser Permanente (KP) patients ages 50 to 75 years who completed the 2020 KP National Social Needs Survey. Five social needs categories were assessed: "Financial Strain," "Housing Instability," "Transportation Issues," "Social Isolation," and "Food Insecurity." Being up to date on CRC screening was determined from patients' electronic health records, defined as meeting Health care Effectiveness Data and Information (HEDIS) criteria for screening. We used multivariable analyses to explore associations between social needs and completion of colorectal cancer screening in 2020, adjusting for demographic factors.

Results: Among the survey respondents, 2,805 (81.5%) were up to date on their colorectal cancer screening. Patients were less likely to be screened if they had severe financial strain (OR 2.1, 95% CI 1.3-3.4), severe social isolation (OR 1.9, 95% CI 1.2 to 3.2), and severe food insecurity (OR 2.5, 95% CI 1.2-5.3). There was a nonsignificant increase in odds of not being up to date with screening for severe transportation issues (OR 3, 95% CI 0.93-10) and severe housing instability (OR 1.7, 95% CI 0.93-3).

Conclusion: Even within a fully insured population with high screening rates, respondents with financial strain, social isolation, and food insecurity had lower odds of being up to date with CRC screening. Future efforts should assess how addressing patients' social needs could lead to increased CRC screening rates.

Income is an important social determinant of health, yet it is rarely discussed among patients and clinicians. Discussing income could open the door to addressing issues like high deductibles, prescription costs, copays, housing expenses, and medical debt. We identify ways to overcome obstacles to talking about this taboo subject.

Background: There is great interest in intensive primary care interventions to address high utilization among medically and socially complex patients. How patients experience these interventions has received less attention.

Objective: To better understand patients' experience of intensive primary care, we interviewed patients receiving care from the Streamlined Unified Meaningfully Managed Interdisciplinary Team (SUMMIT), an ambulatory intensive care intervention at an urban federally qualified health center.

Methods: We interviewed 25 participants enrolled in the SUMMIT randomized controlled trial and conducted a Reflective Thematic Analysis using a hybrid inductive-deductive approach.

Results: Patients reported high levels of medical and social needs that outstripped prior levels of care and resources. They perceived multiple benefits of SUMMIT through the following themes: 1) Team-based care with improved access to services. Patients appreciated their medical and social needs being met, through higher-level, multidisciplinary care. 2) Caring relationships. Patients described the SUMMIT team as being like family and felt that team members had a genuine sense of duty and obligation toward them. 3) Overcoming stigma. Patients felt valued and treated with dignity. 4) Evolving self-efficacy. Over time, patients experienced increasing success, including engagement in care and improved health behaviors.

Conclusion: Patients perceived the SUMMIT team as better meeting their health-related needs, compared with traditional primary care. They spoke of the team as family and felt humanized and supported in overcoming barriers to engagement, which led to increased self-efficacy. Evaluations assessing the effectiveness of intensive primary care should measure potential patient-centered benefits beyond short-term utilization and cost reduction.

Background: Integrated behavioral health (IBH) is a promising approach which embeds behavioral health services into primary care. Yet, IBH has had limited implementation. Our objective was to identify strategies to successfully implement the "Cherokee" IBH model by examining a 2013 to 2019 IBH demonstration project in New Jersey that included Federally Qualified Health Centers (FQHCs) and Community Health Centers (CHCs).

Methods: We conducted qualitative semistructured interviews of 18 primary care and behavioral health clinicians from 10 FQHCs/CHCs in 2022. Interview guide questions drew on the Proctor Implementation Outcomes Framework to capture strategies to optimize acceptability, appropriateness, feasibility, fidelity, penetration, and sustainability of IBH implementations. A template approach was used to code data and identify themes.

Results: All participating FQHCs/CHCs were still offering IBH services 3 years after the demonstration project, suggesting that strategies were successful in implementing and sustaining IBH. Strategies these FQHCs/CHCs employed included: (1) select champions with experience leading organizational change; (2) provide training that emphasizes how brief behavioral health interventions differ from traditional therapy; (3) develop on-going IBH training procedures for new staff; (4) create physical spaces for behavioral health consultants; (5) establish scheduling systems; and (6) identify local IBH billing codes, policies, and procedures.

Discussion: Change management approaches can help in the implementation of IBH; however, additional strategies unique to IBH may be needed to address the attitudinal, organizational, and financial challenges inherent to IBH.

Conclusion: Future implementations should apply multi-faceted approaches that address persistent and seemingly intractable barriers that have inhibited IBH integration.

Many academic departments and programs struggle with the challenge of how to begin a meaningful research program. A useful place to start is with the work they already are doing in communities. Using work in practices and other clinical venues as a springboard can build helpful relationships that can catalyze research and build infrastructure that matters to family medicine clinicians, researchers, and the communities they serve.

In this commentary, the authors present opportunities for the family medicine's strategic plan for research to build and expand research infrastructure by leveraging the federally funded Clinical and Translational Science and Clinical and Translational Research Awards programs. These include engaging patients and communities historically underrepresented in research throughout the research design, development, implementation, and dissemination process; building and expanding practice-based research networks; leveraging research resources, facilities, trainings, and mentorship opportunities; obtaining pilot funding; using informatics expertise to improve care quality; and embedding dissemination and implementation science expertise to promote the use of evidence-based interventions in real world clinical primary care settings.

Despite producing mountains of data in the daily course of care, the documentation labors of frontline clinicians currently return very little value to them or to the health system. The potential of these painstakingly collected data are enormous and clinical registries can extract the extraordinary capacity of these data and transform them into research-ready datasets while protecting the confidentiality of the patients and clinicians. Clinical registries represent transformative tools for primary care research, bringing together the dimensions of clinical practice, research, quality improvement, and policy impact from a large, nationally reflective, diverse sample of practices and patients. The PRIME Registry is one such clinical registry that extracts electronic health record data from more than 600 primary care practices across the United States that is helping advance research, improve quality, and shape the policies required to achieve high-performing primary care for all. Other examples of primary care registries exist, but most of the painstakingly captured data from frontline care remains fallow. Enabling use of these data are important for research, to prevent harm from mis-trained machine learning algorithms, and for monitoring the health of the public.