Mark Spofford

Developing a Network of Community Health Centers With a Common Electronic Health Record: Description of the Safety Net West Practice-based Research Network (SNW-PBRN)

In 2001, community health center (CHC) leaders in Oregon established an organization to facilitate the integration of health information technology, including a shared electronic health record (EHR), into safety net clinics. The Oregon Community Health Information Network (shortened to OCHIN as other states joined) became a CHC information technology hub, supporting a network-wide EHR with one master patient index, now linked across >40 safety net organizations serving >900,000 patients with nearly 800,000 distinct CHC visits. Recognizing the potential of OCHIN′s multiclinic network and comprehensive EHR database for conducting safety net-based research, OCHIN leaders and local researchers formed the Safety Net West practice-based research network (PBRN). The Safety Net West “community- based laboratory,” based at OCHIN, is positioned to become an important resource for many studies including: evaluation of the real-time impact of health care reform on uninsured populations; development of new models of primary care delivery; dissemination and translation of interventions from other EHR-based systems (e.g., Kaiser Permanente) into the community health setting; and analyses of factors influencing disparities in health and health care access. We describe the founding of Safety Net West, its infrastructure development, current projects, and the future goals of this community-based PBRN with a common EHR.

Cultivating Engaged Leadership Through a Learning Collaborative: Lessons From Primary Care Renewal in Oregon Safety Net Clinics

PURPOSE The aim of this study was to explore how learning collaboratives cultivate leadership skills that are essential for implementing patient-centered medical homes (PCMHs). METHODS We conducted an ethnographic evaluation of a payor-incentivized PCMH implementation in Oregon safety net clinics, known as Primary Care Renewal. Analyses primarily drew on in-depth interviews with organizational leaders who were involved in the initiative. We solicited perspectives on the history, barriers, facilitators, and other noteworthy factors related to the implementation of PCMH. We reviewed and summarized transcripts and created and applied a coding dictionary to identify emergent leadership themes. We reviewed field notes from clinic site visits and observations of learning collaborative activities for additional information on the role of engaged leadership. RESULTS Interview data suggested that organizations followed a similar, sequential process of Primary Care Renewal implementation having 2 phases—inspiration and implementation—and that leaders needed and learned different leadership skills in each phase. Leaders reported that collaborative learning opportunities were critical for developing engaged leadership skills during the inspiration phase of transformation. Facilitative and modeling aspects of engaged leadership were most important for codesigning a vision and plan for change. Adaptive leadership skills became more important during the implementation phase, when specific operational and management skills were needed to foster standardization and spread of the Primary Care Renewal initiative throughout participating clinics. CONCLUSIONS The PCMH has received much attention as a way to reorganize and potentially improve primary care. Documenting steps and stages for cultivating leaders with the vision and skills to transform their organizations into PCMHs may offer a useful roadmap to other organizations considering a similar transformation.

Clinical Perspectives on Colorectal Cancer Screening at Latino-Serving Federally Qualified Health Centers:

Purpose. Colorectal cancer is the second most common cause of cancer death in the United States, and rates of screening for colorectal cancer are low. We sought to gather the perceptions of clinic personnel at Latino-serving Federally Qualified Health Centers (operating 17 clinics) about barriers to utilization of screening services for colorectal cancer. Method. We conducted one-on-one interviews among 17 clinic personnel at four Latino-serving Federally Qualified Health Center networks in Oregon. All interviews were recorded, transcribed, and coded, and themes were grouped by influences at three levels: the patient, the organization, and the external environment. Results. Estimated proportions of eligible patients who are underscreened for colorectal cancer ranged from 20% to 70%. Underscreening was thought to occur among low-income, underinsured, and undocumented patients and patients having multiple health concerns. Limited funding to pay for follow-up testing in patients with positive screens was cited as the key factor contributing to underscreening. Conclusions. We identified health care provider perceptions about the underutilization of screening services for colorectal cancer; our findings may inform future efforts to promote guideline-appropriate cancer screening.

The Economics of Depression in Primary Care: Defragmentation in the Oregon Medicaid Market

The Oregon Medicaid program legislatively separates the administration of physical health and mental health services, even though behavioral and physical health conditions significantly impact each other. To overcome this barrier and enhance integrated care, CareOregon, a large Medicaid only health plan partnered with two of its largest provider groups to pilot two different models of integration. In one, an “ownership” model, behavioral health specialists were employed by Federally Qualified Health Center primary care clinics and functioned in a common care model with other providers. In the other, a “loaned” model, behavioral specialists were placed in primary care clinics by community mental health centers and continued to function in a specialty mental health model. The qualitative effects of these two models are discussed.

Using health-related quality of life assessments to evaluate care support within Medicaid.

CareOregon, an Oregon-based not-for-profit Medicaid health plan, successfully piloted a “CareSupport” model that identifies high-risk members and clinically stratifies them for intervention. Internal analyses indicate that CareSupport lowers utilization and cost; CareOregon, however, has lacked patient-reported outcome data on the health-related quality of life (HRQL) of CareSupport participants. Between September 2005 and November 2006, we conducted a pilot study in which the Health Utilities Index Mark 3 (HUI3), a generic preference-based measure of health status and HRQL, was integrated into CareOregon’s existing screening algorithm for possible admission into CareSupport. We obtained baseline data on 616 CareSupport candidates and 4-month HUI3 follow-up data on 143 candidates (104 CareSupport, 39 non-CareSupport). On a 0.00 (dead)-to-1.00 (perfect health) scale, the mean overall baseline HUI3 score for CareSupport patients was 0.18 (0.20 for non-CareSupport patients), comparable to baseline means reported elsewhere for much older patients immediately after suffering serious acute medical events, such as stroke or hip fracture. A 0.05 mean 4-month improvement in overall HRQL among CareSupport enrollees relative to non-CareSupport enrollees was clinically important but not statistically significant. A 0.10 improvement in HUI3 emotion was both statistically significant and clinically important. Study results provide good preliminary evidence of the value of patient-reported outcomes in clarifying individual illness burden and assessing intervention effectiveness.

PS1-16: Directions for Future Patient-Centered and Comparative Effectiveness Research for People with Serious Mental Illness

Background/Aims Individuals with serious mental illnesses can experience significant disability, affecting ability to guide and adhere to treatment and navigate systems. Needs for a range of services are common, yet despite recent efforts to improve care quality, persistent challenges blunt or derail reforms. Obstacles include: difficulties changing the focus of care from acute symptom control/relapse prevention to patient-centered/recovery-focused care; constructing coherent, integrated services; coordinating care while managing multiple, fluctuating funding streams; and high staff turnover that produces poor continuity of care. Our goal is to provide guidance for future comparative effectiveness and patient-centered outcomes research (CER, PCOR) to improve individual-level patient-centered outcomes (PCOs). Methods With stakeholders and technical experts, using an iterative consensus approach, we created a definition of what constitutes a care and service delivery intervention, constructed a theoretical model of a learning system to improve quality and coordination of care, developed an analytic framework, and conducted a narrative review to identify research gaps, high leverage points, and key questions for future CER and PCOR. Results (1) We need more patient centered outcomes developed by or in concert with service users. (2) Information regarding the outcomes service users value most and least remains limited. Value-based information is fundamental to patient-centered care and PCOs. (3) Most efforts to improve quality of mental health services have focused on care processes and necessary institutional structures. Links between indicators of process and structure, and PCOs, are nearly non-existent. (4) Few efforts have been made to aggregate PCOs to provide performance feedback at the clinician, organization, or system level; methods and processes are needed. (5) Financing of services is structured in ways that complicate and impede coherent, integrated delivery, and research comparisons. (6) Current CER information is not adequate to produce system change. Complexity theory suggests focusing on organizational culture/climate, supporting employees and promoting high-quality interactions/teamwork. Interactions are the nexus of information processing/sense-making that are necessary in a learning system. Conclusions Health care reform is creating multiple opportunities to exceed current incremental efforts to improve outcomes. Developing learning systems that provide real patient-centered/patient-directed care to individuals with serious mental illnesses should capitalize on these openings.