Gayla M. Ferguson’s research while affiliated with The University of Texas Health Science Center at Houston and other places

Background Despite the critical need for comprehensive and effective chronic pain care, delivery of such care remains challenging. Group medical visits (GMVs) offer an innovative and efficient model for providing comprehensive care for patients with chronic pain. The purpose of this systematic review was to identify barriers and facilitators (determinants) to implementing GMVs for adult patients with chronic pain. Methods The review included peer-reviewed studies reporting findings on implementation of GMVs for chronic pain, inclusive of all study designs. Pubmed, EMBASE, Web of Science, and Cochrane Library were searched. Studies of individual appointments or group therapy were excluded. The Mixed Methods Appraisal Tool was used to determine risk of bias. Data related to implementation determinants were extracted independently by two reviewers. Data synthesis was guided by the updated Consolidated Framework for Implementation Research. Results Thirty-three articles reporting on 25 studies met criteria for inclusion and included qualitative observational (n = 8), randomized controlled trial (n = 6), quantitative non-randomized (n = 9), quantitative descriptive (n = 3), and mixed methods designs (n = 7). The studies included in this review included a total of 2364 participants. Quality ratings were mixed, with qualitative articles receiving the highest quality ratings. Common multi-level determinants included the relative advantage of GMVs for chronic pain over other available models, the capability and motivation of clinicians, the cost of GMVs to patients and the health system, the need and opportunity of patients, the availability of resources and relational connections supporting recruitment and referral to GMVs within the clinic setting, and financing and policies within the outer setting. Conclusions Multi-level factors determine the implementation of GMVs for chronic pain. Future research is needed to investigate these determinants more thoroughly and to develop and test implementation strategies addressing these determinants to promote the scale-up of GMVs for patients with chronic pain. Trial registration This systematic review was registered with PROSPERO 2021 CRD42021231310.

Objective: Medication discrepancies between clinical systems may pose a patient safety hazard. In this paper, we identify challenges and quantify medication discrepancies across transitions of care. Materials and methods: We used structured clinical data and free-text hospital discharge summaries to compare active medications lists at four time points: pre-admission (outpatient), at-admission (inpatient), at-discharge (inpatient) and post-discharge (outpatient). Medication lists were normalized to RxNorm. RxNorm identifiers were further processed using the RxNav API to identify the ingredient. The specific drugs and ingredients from inpatient and outpatient medication lists were compared. Results: Using RxNorm drugs, the median percentage intersection when comparing active medication lists within the same EHR system ranged between 94.1% and 100% indicating substantial overlap. Similarly, when using RxNorm ingredients the median percentage intersection was 94.1% to 100%. In contrast, the median percentage intersection when comparing active medication lists across EHR systems was significantly lower (RxNorm drugs: 6.1-7.1%; RxNorm ingredients: 29.4-35.0%) indicating that the active medication lists were significantly less similar (p < 0.05). Discussion: Medication lists in the same EHR system are more similar to each other (fewer discrepancies) than medication lists in different EHR systems when comparing specific RxNorm drug and the more general RxNorm ingredients at transitions of care. Transitions of care that require interoperability between two EHR systems are associated with more discrepancies than transitions where medication changes are expected (e.g., at-admission vs at-discharge). Challenges included lack of access to structured, standardized medication data across systems and difficulty distinguishing medications from orderable supplies such as lancets and diabetic test strips. Conclusion: Despite the challenges to medication normalization, there are opportunities to identify and assist with medication reconciliation across transitions of care between institutions.

Teach Back is a commonly used communication method to improve patient understanding and retention of health information. The method has been shown to be effective in improving patient and healthcare system outcomes, including patient health literacy and hospital readmissions. Community health workers (CHWs) are frontline healthcare workers who can help address patient health and social needs associated with hospital readmissions. However, a gap exists in Teach Back curricula and training methods reflecting the scope of work for CHWs. The objective of this training was to provide CHWs with didactic information and skill building practice curriculum focused on the integration of Teach Back into clinical patient interactions, care coordination, and follow-up support. A multidisciplinary team of academic and clinical partners at a large academic health university developed, implemented, and evaluated a 3-week pilot Teach Back training with CHWs through a quality improvement approach. The CHWs reported overall satisfaction with the training and instructors. The academic clinical partnership allowed the training to be tailored to the daily clinical workflow as reflected in the CHWs agreement that the training was relevant and practical. With the repeated exposure to Teach Back each week, the CHWs also reported an increase in confidence and conviction in using Teach Back. Additional implementation and evaluation of the training curriculum for CHWs is needed to gain further insights into Teach Back and training best practices and translation into practice.

Introduction A multitude of HRSN interventions are undergoing testing in the U.S., with the CMS Accountable Health Communities (AHC) Model as the largest. HRSN interventions typically include screening for social needs, referral to community resources, and patient navigation to ensure needs are met. There is currently a paucity of evidence on implementation of HRSN interventions. The Consolidated Framework for Implementation Research (CFIR) is a determinant framework widely used to plan and assess implementation. To the authors knowledge, there are no published studies assessing CFIR constructs for HRSN intervention implementation in the U.S. In the Assessment step of the Strengthening Peer AHC Navigation (SPAN) model, a between-site qualitative assessment methodology was used to examine implementation within and between AHC bridge organizations (BOs) within six ERIC implementation strategies identified by the authors based on AHC Model requirements. Objective Our aim was to identify and present between-site barriers and facilitators to AHC Model implementation strategies. Design A multi-site qualitative analysis methodology was used. CFIR determinants were linked to six Expert Recommendations for Implementing Change (ERIC) strategies: staff training, identify and prepare champions, facilitation, community resource engagement (alignment through advisory boards and working groups), data systems, and quality monitoring and assurance. Interviews were analyzed using thematic content analysis in NVivo 12 (QSR International). Setting Five health-related bridge organizations participating in the AHC Model. Results Fifty-eight interviews were completed with 34 staff and 24 patients or patient proxies. Facilitators were identified across five of the six ERIC strategies. Barriers were identified across all six. While organizations found the AHC Model compatible and facilitators to implementation included previous experience, meeting patient needs and resources, and leadership engagement and support, a number of barriers presented challenges to implementation. Issues with adequate staff training, staff skills to resolve HRSN, including patient communication and boundary spanning, setting staff goals, beneficiary caseloads and measurement of progress, data infrastructure (including EHR), available resources to implement and differences in perceptions between clinical delivery site (CDS), and CSP of how to measure and resolve HRSN. Conclusions and relevance The conduct of a pre-implementation readiness assessment benefited from identifying CFIR determinants linked to various ERIC implementation strategies.

Background: Effective provider communication skills are important for patient decision-making and understanding, particularly for those with low health literacy. A gap exists in training methods and curriculum for community health workers (CHWs). Brief description of activity: Through a clinical and academic partnership, pilot training curriculum focused on patient communication skills was developed to align with CHW scope of work. Implementation: The curriculum was implemented in three 2-hour training sessions over WebEx with seven state-certified CHWs. The goal was for CHWs to understand the key elements and application of active listening, Teach Back, and action planning in a clinical setting. The sessions included didactic and skills practice modules for each skill. Results: A survey was distributed to CHWs to evaluate knowledge, skills, and attitudes and reactions to training methods, instructors, and relevance using the Kirkpatrick's evaluation model (Reaction and Learning). Although CHWs agreed that they had actively participated in the training and that the instructors were well-prepared, there was less agreement that the course was relevant. CHWs reported an increase in understanding of active listening and action planning, capability of using Teach Back and providing social support, and ability to teach, whereas a decrease was reported in the capability to use action planning. When probed about training relevance, CHWs felt action listening and Teach Back were relevant, but that action planning was not relevant to their responsibilities. This gap in responsibilities was also acknowledged by the clinical leadership. Lessons learned: The training allowed the CHWs to build on subsequent skills from previous sessions and to discuss struggles. A need for tools for integrating the skills in the clinical workflow were requested by CHWs and clinical leadership. These tools offer the opportunity to tailor future trainings on communication skills or patient scenarios. Future trainings should include CHWs to provide insight into scope of work. [HLRP: Health Literacy Research and Practice. 2022;6(2):e142-e150.] Plain Language Summary: It is important for community health workers to communicate with patients so that patients can understand information and make their own decisions. There is not enough known about the best way to train CHWs in patient communication. This training was created to help CHWs use three patient communication skills in their clinic.

Background Integration of health-related social needs (HRSNs) data into clinical care is recognized as a driver for improving healthcare. However, few published studies on HRSNs and their impact are available. CMS sought to fill this gap through the Accountable Health Communities (AHC) Model, a national RCT of HRSN screening, referral, and navigation. Data from the AHC Model could significantly advance the field of HRSN screening and intervention in the USA. Objective To present data from the Greater Houston AHC (GH-AHC) Model site on HRSN frequency and the association between HRSNs, sociodemographic factors, and self-reported ED utilization using a cross-sectional design. Analyses included descriptive statistics and multinomial logistic regression. Participants (or Patients or Subjects) All community-dwelling Medicare, Medicaid, or dually covered beneficiaries at participating GH-AHC clinical delivery sites were eligible. Main Measures Self-reported ED utilization in the previous 12 months served as the outcome; demographic characteristics including race, ethnicity, age, sex, income, education level, number of people living in the household, and insurance type were treated as covariates. HRSNs included food insecurity, housing instability, transportation, difficulty paying utility bills, and interpersonal safety. Clinical delivery site type was used as the clustering variable. Key Results Food insecurity was the most common HRSN identified (38.7%) followed by housing instability (29.0%), transportation (28.0%), and difficulty paying utility bills (26.7%). Interpersonal safety was excluded due to low prevalence. More than half of the beneficiaries (56.9%) reported at least one of the four HRSNs. After controlling for covariates, having multiple co-occurring HRSNs was strongly associated with increased risk of two or more ED visits (OR 1.8–9.47 for two to four needs, respectively; p < 0.001). Beneficiaries with four needs were at almost 10 times higher risk of frequent ED utilization ( p < 0.001). Conclusions To our knowledge, this is only the second published study to report screening data from the AHC Model. Future research focused on the impact of multiple co-occurring needs on health outcomes is warranted.

The Peace of Mind Program is an evidence-based intervention to improve mammography appointment adherence in underserved women. The aim of this study was to assess effectiveness of the intervention and implementation of the intervention in safety net clinics. The intervention was implemented through a non-randomized stepped wedge cluster hybrid study design with 19 Federally Qualified Health Centers and charity care clinics within the Greater Houston area. A multivariable generalized estimating equation logistic regression was conducted to examine mammography appointment adherence. A survey assessing Consolidated Framework for Implementation Research constructs was also conducted with clinic staff prior to adoption and eight weeks post implementation. One-sided t -tests were conducted to analyze mean score changes between the surveys. A total of 4402 women (baseline period = 2078; intervention period = 2324) were included in the final regression analysis. Women in the intervention period were more likely to attend or reschedule their mammography appointment (OR = 1.30; p < 0.01) than those in the baseline period receiving usual care. Women who completed the intervention were more likely to attend or reschedule their mammography appointment than those who did not complete the intervention (OR = 1.62; p < 0.01). The mammography appointment no-show rates for those in the baseline period, in the intervention period, and who completed the intervention were, respectively, 22%, 19%, and 15%. A total of 15 clinics prior to adoption and eight clinics completed the survey at 8 weeks post implementation A statistically significant mean score decrease was observed in Inner Setting and in two Inner Setting CFIR constructs, Culture–Effort, and Implementation Climate. While the intervention improved mammography appointment adherence, there are opportunities to further integrate Consolidated Framework for Implementation Research constructs. Trial registration : Clinical trials registration number: NCT02296177.

Through an academic-community partnership, an evidence-based intervention to reduce mammography appointment no-show rates in underserved women was expanded to safety net clinics. The partnership implemented four strategies to improve the adoption and scale-up of evidence-based interventions with Federally Qualified Health Centers and charity care clinics: (1) an outreach email blast targeting the community partner member clinics to increase program awareness, (2) an adoption video encouraging enrollment in the program, (3) an outreach webinar educating the community partner member clinics about the program, encouraging enrollment and outlining adoption steps, and (4) an adoption survey adapted from Consolidated Framework for Implementation Research constructs from the Cancer Prevention and Control Research Network for cancer control interventions with Federally Qualified Health Centers. The development of academic-community partnerships can lead to successful adoption of evidence-based interventions particularly in safety net clinics.

Background he Peace of Mind Program – an adapted evidence-based intervention to improve mammography appointment adherence in underserved women – was expanded to safety net clinics. This study assessed effectiveness of the intervention in improving mammography appointment adherence and implementation of the intervention. Methods The intervention was implemented through a non-randomized stepped wedge cluster design with 19 Federally Qualified Health Centers and charity care clinics in the Greater Houston area. Clinics were their own control during the baseline period and conducted at least three mammography drives during the baseline and intervention period. A multivariable generalized estimating equation logistic regression was conducted to examine mammography appointment adherence. To examine adoption and implementation of the intervention, two surveys assessing Consolidated Framework for Implementation Research constructs were conducted with clinic leadership and staff. One-sided t-tests were conducted to analyze mean score changes between the adoption and implementation survey. Results total of 4402 women (baseline period = 2078; intervention period = 2324) were included in the final analysis. Women in the intervention period were more likely to attend or reschedule their mammography appointment (OR = 1.30; p < 0.01). Similarly, for those in the intervention period, women who completed the intervention were more likely to attend or reschedule their mammography appointment than those who did not complete the intervention (OR = 1.62; p < 0.01). The mammography appointment no-show rates for those in the baseline period, in the intervention period, and who completed the intervention were, respectively, 22%, 19%, and 15%. In terms of the adoption and implementation survey, a statistically significant mean score decrease was observed in Inner Setting overall and in two Inner Setting constructs, Culture – Effort and Implementation Climate. Conclusions This study provided a pragmatic approach to translating an evidence-based mammography intervention into practice in safety net clinics. While the intervention improved mammography appointment adherence, there our opportunities to further integrate Consolidated Framework for Implementation Research constructs in future implementation of the intervention. Future research on the effects of implementation moderators particularly Inner Setting constructs would be of value to implementation practitioners.

Multi-level organizational stakeholder engagement plays an important role across the research process in a clinical setting. Stakeholders provide organizational specific adaptions in evidence-based interventions to ensure effective adoption, implementation, and sustainability. Stakeholder engagement strategies involve building mutual trust, providing clear communication, and seeking feedback. Using constructs from the Consolidated Framework for Implementation Research and The International Association for Public Participation spectrum, a conceptual framework was created to guide stakeholder engagement in an evidence-based intervention to increase mammography appointment adherence in underserved and low-income women. A document review was used to explore the alignment of the conceptual framework with intervention activities and stakeholder engagement strategies. The results indicate an alignment with the conceptual framework constructs and a real-world application of stakeholder engagement in a mammography evidence-based intervention. The conceptual framework and stakeholder engagement strategies can be applied across a range of community-based cancer programs and interventions, organizations and clinical settings