Literature Collection

PURPOSE: Practice transformation initiatives have the potential to promote collaborations between public health, primary care, and behavioral health, but limited empirical evidence is available on how these programs affect participating clinical practices. OBJECTIVE: To report the findings from a mixed-methods program evaluation of the Washington Practice Transformation Support Hub (Hub), a publicly funded, multicomponent practice transformation initiative in Washington State. DESIGN: We used quantitative and qualitative methods to evaluate the impact of Hub activities on participating primary care and behavioral health practices. Pre- and posttest survey data were combined with administrative program data to understand the effect of program components. Qualitative interviews contextualized findings. SETTING: Urban and rural primary care and behavioral health practices in Washington State. PARTICIPANTS: One hundred seventy-five practices that were recruited to receive Hub coaching and facilitation from 8 coaches; of these, 13 practices and all coaches participated in key informant interviews. INTERVENTION: Practice coaching and facilitation supported by an online resource portal, from January 2017 through January 2019. MAIN OUTCOME MEASURES: Self-reported progress in specific activities in 3 practice-level domains: bidirectional integration of physical and behavioral health care (care integration); alignment with community-based services for whole-person care (clinical-community linkages); and value-based payment. RESULTS: Participation in Hub activities was associated with improvements in care integration and clinical-community linkages but not with progress toward value-based payment. Qualitative results indicated that practice progress was influenced by communication with practices, the culture of the practice, resource constraints (particularly in rural areas), and perceptions about sustainability. CONCLUSIONS: This statewide practice transformation initiative was successful in strengthening primary care and behavioral health integration and clinical-community linkages among participating practices but not value-based payment. Future practice transformation efforts may benefit from addressing barriers posed by communication, limited application of value-based payment, culture change, competing priorities, and resource limitations, particularly for rural communities.

Emergency medical services (EMS) are integral to public health and safety and provide health care to both individuals and communities. Community paramedicine (CP) and mobile integrated health care (MIH) programs are expanded models of EMS that provide needs-based, patient-centered care in the community. Successful implementation requires a community health needs assessment, engaged EMS medical directors, multidisciplinary collaboration, and sustainable reimbursement that recognizes prehospital care delivery beyond traditional payment for transport.; Engaged and knowledgeable EMS physician medical directors, preferably with EMS board certification, must guide CP and MIH programs.CP and MIH programs should be tailored to meet local community needs based on a community health needs assessment and designed to bridge local gaps in access or care without duplication of services. The role of EMS clinicians should be clearly defined by the physician medical director and reflect the boundaries of collaborative practice.Physician medical directors may seek additional guidance on CP and MIH practice from state regulatory bodies, though practice regulations and standards should not stifle innovation and be established upon available data and outcome measures. Any state training or certification regulations should be dependent upon the expanded services provided and made with input from physician EMS medical directors.Clinician training programs intending to be comprehensive in approach should use standardized curricula. In programs with a limited expanded scope of practice, modularized training specific to the targeted disease processes may be appropriate. In both cases, CP and MIH clinicians should undergo regular competency evaluation supported by the physician medical director.State and federal agencies should establish reimbursement systems under Medicare and Medicaid, and EMS agencies should work with private payors to ensure reimbursement for the provision of community paramedicine and mobile integrated health care, decoupled from reimbursement for transportation.Data collection and analysis using standardized tools, methods, and reporting structures are essential for the evaluation and growth of CP and MIH programs. CP and MIH research should develop a standard taxonomy for describing programs, identify common data definitions and outcomes measures, collaboratively aggregate data, and advocate for development of data reporting standards.; eng

IMPORTANCE: The demand for medications for opioid use disorder (MOUD) in rural US counties far outweighs their availability. Novel approaches to extend treatment capacity include telemedicine (TM) and mobile treatment on demand; however, their combined use has not been reported or evaluated. OBJECTIVE: To evaluate the use of a TM mobile treatment unit (TM-MTU) to improve access to MOUD for individuals living in an underserved rural area. DESIGN, SETTING, AND PARTICIPANTS: This quality improvement study evaluated data collected from adult outpatients with a diagnosis of OUD enrolled in the TM-MTU initiative from February 2019 (program inception) to June 2020. Program staff traveled to rural areas in a modified recreational vehicle equipped with medical, videoconferencing, and data collection devices. Patients were virtually connected with physicians based more than 70 miles (112 km) away. Data analysis was performed from June to October 2020. INTERVENTION: Patients received buprenorphine prescriptions after initial teleconsultation and follow-up visits from a study physician specialized in addiction psychiatry and medicine. MAIN OUTCOMES AND MEASURES: The primary outcome was 3-month treatment retention, and the secondary outcome was opioid-positive urine screens. Exploratory outcomes included use of other drugs and patients' travel distance to treatment. RESULTS: A total of 118 patients were enrolled in treatment, of whom 94 were seen for follow-up treatment predominantly (at least 2 of 3 visits [>50%]) on the TM-MTU; only those 94 patients' data are considered in all analyses. The mean (SD) age of patients was 36.53 (9.78) years, 59 (62.77%) were men, 71 (75.53%) identified as White, and 90 (95.74%) were of non-Hispanic ethnicity. Fifty-five patients (58.51%) were retained in treatment by 3 months (90 days) after baseline. Opioid use was reduced by 32.84% at 3 months, compared with baseline, and was negatively associated with treatment duration (F = 12.69; P = .001). In addition, compared with the nearest brick-and-mortar treatment location, TM-MTU treatment was a mean of 6.52 miles (range, 0.10-58.70 miles) (10.43 km; range, 0.16-93.92 km) and a mean of 10 minutes (range, 1-49 minutes) closer for patients. CONCLUSIONS AND RELEVANCE: These data demonstrate the feasibility of combining TM with mobile treatment, with outcomes (retention and opioid use) similar to those obtained from office-based TM MOUD programs. By implementing a traveling virtual platform, this clinical paradigm not only helps fill the void of rural MOUD practitioners but also facilitates access to underserved populations who are less likely to reach traditional medical settings, with critical relevance in the context of the COVID-19 pandemic.