CAT HALLIWELL
PRO-EHR Program with University of Colorado Department of Family Medicine

The Colorado Patient Reported Outcomes and Electronic Health Record Program (PRO-EHR) partnered with a rural primary care practice in Colorado to use EHR and Quality of Life data to help vulnerable, high-risk patients during the COVID-19 pandemic. We report on significant challenges encountered. Our intent is to build a replicable, automated clinical decision-making tool for high-risk individuals. Challenges included time, EHR extraction and work-flow issues. We offer suggestions to limit the challenges described.

Mid-Valley Family Practice (MVFP) is a rural private practice in Basalt, CO with robust IT support. Patient population is 22% Medicaid, 27% Medicare, 17% 65+, 30% Hispanic, 70% white. It has 1 physician, 1 nurse practitioner, 1 physician assistant, 3 nurses, 2 medical assistants, 3 front desk staff, 1 IT Manager and 2 administrative staff.

We implemented three phases: start up, QOL administration, and EHR data extraction. Patients completed the QGEN and QDIS (Ware 2019) QOL surveys on iPads, generating a convenience sample of 250 patients. Survey responses were immediately EHR-accessible during the visit. For each respondent, EHR data was extracted based on the C-19 Index (Closed Loop). Data analysis is ongoing.

The project took 16 months from initiation to completion of data extraction. Participation was not paid for. It included 58 meetings. Role specific time requirements: Clinic director = 105 hrs, Practice manager = 27 hrs, Front desk staff = 19 hrs, and IT manager = 204 hrs, for a total of 355 hrs. Front desk staff helped with Spanish translation, and administered an additional 28 surveys in Spanish after collecting 244 in English. IT manager time included 24 hours for QOL survey incorporation, access, extraction, and quality control, and 180 hours for VI query creation, testing, and data extraction. The practice contacted an estimated 500 patients to yield 272 surveys. 12 of 40 VI variables were available in the EHR with over 80% complete data. Challenges included the amount of time needed, technical requirements, and extra attention to ensure inclusion of patients with additional barriers (e.g. language). Upcoming efforts now move to usability in addition to further analysis.

Implementation of practice-based EHR and patient reported measures requires a significant investment in clinic, provider, and staff time, and is feasible for other practices if the time commitment is available. Thus far we have accommodated the challenges, including the demands on clinic time by the ongoing COVID pandemic, novel demands on the EHR, and new workflows for collection of QOL data. Factors to consider include flexible time, designated EHR personnel, and inclusion of patients with barriers to care. Next critical usability issues include using QOL and EHR data to create a risk score that informs point of care clinical decision-making pathways for additional primary care sites.

CLAUDIA AMURA, PhD, MPH
University of Colorado College of Nursing

Opioid use disorders (OUD) remain a national crisis. Over 750,000 people have died from drug overdose in the US in the last two decades, with rural counties showing the highest rates. Colorado ranks 12th nationally in non-medical use of opioids. A considerable proportion of rural Colorado represent low socio-economic, Hispanic, underserved populations. In July 2019, the Colorado Senate approved the expansion the Medication for Opioid Use Disorders (MOUD) program to increase access to care in rural areas for Coloradoans with OUD. Several rural Colorado counties were identified as health professional Shortage Areas, and prioritized by the legislature due to highest drug overdose deaths.

Under SB 19-001, 8 clinical service organizations received funding to bring MOUD into 21 rural Colorado counties in a Hub and Spoke system that expanded to 51 sites. In collaboration with the Center for Prescription Drug Abuse Prevention, the CU College of Nursing provided clinical expertise, oversight, and evaluation of the program.

The Reach, Effectiveness, Adoption, Implementation, and Maintenance and Practical Robust Implementation and Sustainability Model (RE-AIM/PRISM) frameworks informed the program planning and evaluation using de-identified patient-level data to measure OUD’s impact across various life domains. Organizational data collected by each Hub helped understand needs and plan for MOUD program sustainability.

Since January 2020, the Hub and Spoke system doubled the health provider capacity serving over 1700 new individuals with OUD. Patients identified as White (79%), half as Hispanics (49%), with a mean age of 26 yr. old. The vast majority were under Medicaid or uninsured (>80%), with unstable house and work situations and reported had low to fair health. The COVID-19 pandemic deeply impacted services and patient’s lives. Clinical sites focused on social determinant of health and patient centric care, , building organizational capacity in multidisciplinary teams, and developing a network for treatment and referral through community partners, care coordination systems, and peer-support specialists for resource connection. While these adaptions prove impactful for patient care and opioid use (p=0.01), only a portion of patients were retained in treatment during the pandemic. Stakeholder-informed plans for sustainability include leveraging existing partnerships, solidifying care coordination systems and pipelines for referral, integration with behavioral health, and utilization of case management and peer support specialists for patient retention in treatment.

Lessons learned from this implementation informed quality improvements to program implementation though enhanced capacity to offer services in rural healthcare clinics, stronger care coordination and community partnerships, and bring sustainable solutions for addressing the opioid crisis in rural Colorado.

DENNIS GURFINKEL, MPH
University of Colorado

Pragmatic trials examine effectiveness of health interventions in real-world settings. To enhance relevance and scalability, interventions can be delivered by existing healthcare practice personnel, necessitating implementation strategies such as staff training. Invested in Diabetes is a pragmatic trial of two models of diabetes shared medical appointments (SMA) delivered in primary care settings. SMAs are delivered by care teams including health educators, behavioral health specialists, peer mentors, and providers with prescribing privileges. This abstract describes SMA care team training content, resources, evaluations, and adaptations.

Practice staff and peer mentors recruited to deliver SMAs at 21 primary care sites.

Health educators and behavioral health specialists participated in a 6-hour SMA facilitator training to learn about the project protocols, assigned SMA model, group facilitation skills, and SMA curriculum. Peer mentors participated in a 4-hour training adapted from materials from Peers for Progress; some participated in the general SMA facilitator training. Providers participated in one-hour “lunch & learns.” Training events were summarized via agendas and notes. Adaptations, including number of trainings, content, and style, were documented. Satisfaction surveys were collected after facilitator trainings.

There were 26 facilitator, 9 peer mentor and 13 provider trainings delivered to a total of 166 individuals across 22 practices from 2018-2021. Initially, trainings were held in-person; virtual and hybrid trainings were introduced for those with travel barriers and/or pandemic restrictions. Trainee satisfaction was high in both in-person and virtual delivery, while virtual delivery was easier to schedule and reduced travel time/expenses. Based on satisfaction surveys, trainings began incorporating facilitation techniques and role play rather than just intervention protocol and curriculum. The role of the main trainer changed from investigators to research assistants; the number of research staff present at trainings varied between 4 in earlier iterations to 1-2 later iterations. A total of ~412 hours of research staff time was used for trainings.

Pragmatic trialists should plan for adequate effort and resources to train practice personnel in delivery of an intervention. Notably, plan to offer trainings throughout the course of the study as new staff are identified. Approaches that decrease personnel and time burden, such as virtual and pre-recorded trainings, may optimize use of available resources.