Perceptions of Medically Complex Patients Enrolled in an Ambulatory Intensive Care Unit at a Healthcare-for-the-Homeless Clinic.

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.

Ambulatory Intensive Care for Medically Complex Patients at a Health Care Clinic for Individuals Experiencing Homelessness: The SUMMIT Randomized Clinical Trial.

Importance: Intensive primary care interventions have been promoted to reduce hospitalization rates and improve health outcomes for medically complex patients, but evidence of their efficacy is limited.

Objective: To assess the efficacy of a multidisciplinary ambulatory intensive care unit (A-ICU) intervention on health care utilization and patient-reported outcomes.

Design, Setting, And Participants: The Streamlined Unified Meaningfully Managed Interdisciplinary Team (SUMMIT) randomized clinical trial used a wait-list control design and was conducted at a health care clinic for patients experiencing homelessness in Portland, Oregon.

Trajectories of care and outcomes of Veterans receiving home-based primary care.

Background: Veterans Affairs (VA) home-based primary care (HBPC) provides comprehensive longitudinal care to patients with complex, chronic disabling disease. While enrollment is associated with lower hospitalization rates and costs, detailed trajectories have not been well described.

Methods: We performed a longitudinal descriptive study of patients newly enrolled in VA HBPC in fiscal year (FY) 2015.

"What We're Doing Now…Is More Than Water Cooler": Perspectives of Primary Care Leaders on Leading Through (and Beyond) COVID-19.

Background: COVID-19 presented numerous challenges to primary care, but little formal research has explored the experience of practice leaders and their strategies for managing teams as the crisis unfolded.

Objective: Describe the experience of leaders in US primary care delivery organizations, and their strategies for leading teams during COVID-19 and beyond.

Design: Qualitative study using semi-structured interviews performed between 9/15/2020 and 8/31/2021.

Estimating the Cardiovascular Disease Risk Reduction of a Quality Improvement Initiative in Primary Care: Findings from EvidenceNOW.

Background: This study estimates reductions in 10-year atherosclerotic cardiovascular disease (ASCVD) risk associated with EvidenceNOW, a multi-state initiative that sought to improve cardiovascular preventive care in the form of (A)spirin prescribing for high-risk patients, (B)lood pressure control for people with hypertension, (C)holesterol management, and (S)moking screening and cessation counseling (ABCS) among small primary care practices by providing supportive interventions such as practice facilitation.

Design: We conducted an analytic modeling study that combined (1) data from 1,278 EvidenceNOW practices collected 2015 to 2017; (2) patient-level information of individuals ages 40 to 79 years who participated in the 2015 to 2016 National Health and Nutrition Examination Survey ( = 1,295); and (3) 10-year ASCVD risk prediction equations.

Measures: The primary outcome measure was 10-year ASCVD risk.

Vaccines for all: A formative evaluation of a multistakeholder community-engaged COVID-19 vaccine outreach clinic for migrant communities.

Background: Racialized, low-income, and migrant populations experience persistent barriers to vaccines against COVID-19. These communities in East and Northeast Calgary were disproportionately impacted by COVID-19, yet faced vaccine access barriers. Diverse multi-stakeholder coalitions and community partnerships can improve vaccine outreach strategies, but how stakeholders perceive these models is unknown.

Association of Clinician Practice Ownership With Ability of Primary Care Practices to Improve Quality Without Increasing Burnout.

Importance: Work environments and practice structural features are associated with both burnout and the ability of practices to enhance quality of care.

Objective: To characterize factors associated with primary care practices successfully improving quality scores without increasing clinician and staff burnout.

Design, Setting, And Participants: This cross-sectional study assessed small- to medium-sized primary care practices that participated in the EvidenceNOW: Advancing Heart Health initiative using surveys that were administered at baseline (September 2015 to April 2017) and after the intervention (January 2017 to October 2018).

An Evaluation of Burnout Among US Rheumatology Fellows: A National Survey.

Objective: To evaluate levels of burnout and correlates of burnout among US rheumatology fellows.

Methods: US rheumatology fellows were invited to complete an electronic survey in 2019. Burnout was assessed using the Maslach Burnout Inventory.

Adult Primary Care Physician Visits Increasingly Address Mental Health Concerns.

A high prevalence of mental health diagnoses in adults alongside ongoing shortages of mental health specialists and expansion of the patient-centered medical home have increased the involvement of primary care clinicians in treating mental health concerns. Using nationally representative serial cross-sectional data from the 2006-18 National Ambulatory Medical Care Surveys regarding visits to outpatient primary care physicians by patients ages eighteen and older, we sought to characterize temporal trends in primary care visits addressing a mental health concern. Based on a sample of 109,898 visits representing 3,891,233,060 weighted visits, we found that the proportion of visits that addressed mental health concerns increased from 10.

Hospital Readmissions Among Veterans Within 90 Days of Discharge Following Initial Hospitalization for COVID-19.

Introduction: Some patients experience ongoing sequelae after discharge, including rehospitalization; therefore, outcomes following COVID-19 hospitalization are of continued interest. We examined readmissions within 90 days of hospital discharge for veterans hospitalized with COVID-19 during the first 10 months of the pandemic in the US.

Methods: Veterans hospitalized with COVID-19 at a Veterans Health Administration (VA) hospital from March 1, 2020, through December 31, 2020 were followed for 90 days after discharge to determine readmission rates.

Early Impact of VA MISSION Act Implementation on Primary Care Appointment Wait Time.

Background: Through Community Care Networks (CCNs) implemented with the VA MISSION Act, VA expanded provider contracting and instituted network adequacy standards for Veterans' community care.

Objective: To determine whether early CCN implementation impacted community primary care (PC) appointment wait times overall, and by rural/urban and PC shortage area (HPSA) status.

Design: Using VA administrative data from February 2019 through February 2020 and a difference-in-differences approach, we compared wait times before and after CCN implementation for appointments scheduled by VA facilities that did (CCN appointments) and did not (comparison appointments) implement CCNs.

Improving Delivery of Cardiovascular Disease Preventive Services in Small-to-Medium Primary Care Practices.

METHODS: RESULTS: CONCLUSIONS:

Outpatient Care Fragmentation and Acute Care Utilization in Veterans Affairs Home-Based Primary Care.

Importance: Veterans Affairs (VA) Home-Based Primary Care (HBPC) provides comprehensive, interdisciplinary primary care at home to patients with complex, chronic, disabling disease, but little is known about care fragmentation patterns and consequences among these patients.

Objective: To examine outpatient care fragmentation patterns and subsequent acute care among HBPC-engaged patients at high risk of hospitalization or death.

Design, Setting, And Participants: This retrospective cohort study included VA patients aged at least 65 years who were enrolled in the VA and Medicare, whose risk of hospitalization or death was in the top 10%, and who had at least 4 outpatient visits between October 1, 2013, and September 30, 2014.

Association of Time-Based Billing With Evaluation and Management Revenue for Outpatient Visits.

Importance: Time-based billing options for physicians have expanded, enabling many physicians to bill according to time spent instead of medical decision-making (MDM) level for fee-for-service outpatient visits. However, no study to date has estimated the revenue changes associated with time-based billing.

Objective: To compare evaluation and management (E/M) reimbursement for physicians using time-based billing vs MDM-based billing for outpatient visits of varying lengths.

Psychiatric disorders newly diagnosed among veterans subsequent to hospitalization for COVID-19.

Objective: The goal of our study was to evaluate the development of new mental health diagnoses up to 6-months following COVID-19 hospitalization for in a large, national sample.

Method: Data were extracted for all Veterans hospitalized at Veterans Health Administration hospitals for COVID-19 from March through August of 2020 utilizing national administrative data. After identifying the cohort, follow-up data were linked through six months post-hospitalization.

Patient selection strategies in an intensive primary care program.

Background: Intensive primary care programs have had variable impacts on clinical outcomes, possibly due to a lack of consensus on appropriate patient-selection. The US Veterans Health Administration (VHA) piloted an intensive primary care program, known as Patient Aligned Care Team Intensive Management (PIM), in five medical centers. We sought to describe the PIM patient selection process used by PIM teams and to explore perspectives of PIM team members regarding how patient selection processes functioned in context.

Balancing the benefits of patient-clinician relationships with professional boundaries in Home-based Primary Care.

In the home care setting, boundaries may be difficult to identify when behavioral changes are made to accommodate the nature of care being delivered. In this secondary qualitative study, we examined how Home-based Primary Care (HBPC) clinicians understand role and relationship boundaries with patients and how these dynamics support patient care. The data set consisted of 14 semi-structured interviews with HBPC clinicians representing multiple disciplines and field observations of 6 HBPC team meetings.

The Effects of Major Disruptions on Practice Participation in Facilitation During a Primary Care Quality Improvement Initiative.

Background: Disruptions in primary care practices, like ownership change, clinician turnover, and electronic health record system implementation, can stall quality improvement (QI) efforts. However, little is known about the relationship between these disruptions and practice participation in facilitated QI.

Methods: We explore this relationship using data collected from EvidenceNOW in a mixed-methods convergent design.

Cardiovascular Disease Preventive Services Among Smaller Primary Care Practices.

Introduction: Cardiovascular disease preventive services (aspirin use, blood pressure control, and smoking-cessation support) are crucial to controlling cardiovascular diseases. This study draws from 1,248 small-to-medium-sized primary care practices participating in the EvidenceNOW Initiative from 2015-2016 across 12 states to provide practice-level aspirin use, blood pressure control, and smoking-cessation support estimates; report the percentage of practices that meet Million Hearts targets; and identify the practice characteristics associated with better performance.

Methods: This cross-sectional study utilized linear regression modeling (analyzed in 2020-2021) to examine the association of aspirin use, blood pressure control, and smoking-cessation support performance with practice characteristics that included structural attributes (e.

Integrating Interprofessional Trainees into a Complex Care Program for Veterans Experiencing Homelessness: Effects on Health Services Utilization.

Purpose: High-quality, comprehensive care of vulnerable populations requires interprofessional ambulatory care teams skilled in addressing complex social, medical, and psychological needs. Training health professionals in interprofessional settings is crucial for building a competent future workforce. The impacts on care utilization of adding continuity trainees to ambulatory teams serving vulnerable populations have not been described.

Cultural And Structural Features Of Zero-Burnout Primary Care Practices.

Although much attention has been focused on individual-level drivers of burnout in primary care settings, examining the structural and cultural factors of practice environments with no burnout could identify solutions. In this cross-sectional analysis of survey data from 715 small-to-medium-size primary care practices in the United States participating in the Agency for Healthcare Research and Quality's EvidenceNOW initiative, we found that zero-burnout practices had higher levels of psychological safety and adaptive reserve, a measure of practice capacity for learning and development. Compared with high-burnout practices, zero-burnout practices also reported using more quality improvement strategies, more commonly were solo and clinician owned, and less commonly had participated in accountable care organizations or other demonstration projects.

Association of Home-Based Primary Care Enrollment with Social Determinants of Health for Older Veterans.

Background: Home-based Primary Care (HBPC) provides comprehensive primary care to Veterans who may be at risk of adverse health outcomes due to their social determinants of health. Area Deprivation Index (ADI) can be used as a surrogate measure of a Veteran's social needs.

Objective: To estimate the effect of neighborhood disadvantage, as measured by ADI, on HBPC enrollment for a sample of Veterans.

"Eyes in the Home": Addressing Social Complexity in Veterans Affairs Home-Based Primary Care.

Background: Home-Based Primary Care (HBPC) has demonstrated success in decreasing risk of hospitalization and improving patient satisfaction through patient targeting and integrating long-term services and supports. Less is known about how HBPC teams approach social factors.

Objective: Describe HBPC providers' knowledge of social complexity among HBPC patients and how this knowledge impacts care delivery.