This presentation was supported by Cooperative Agreement Numbers U48-DP001909, U48-DP001946, U48-DP001924, U48-DP001934, U48-DP001938(03), U48-DP001944, U48-DP001936, U48-DP001949-02, U48–DP001911, & U48-DP001903 from the Centers for Disease Control and Prevention. The findings and conclusions in this presentation are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Shin-Ping Tu, MD, MPH ; Maria Fernandez, PhD, Vicki Young, PhDon behalf of the CPCRN FQHC Workgroup Investigators

Emory University University of California Los AngelesUniversity of Colorado University of South Carolina

University of Texas Houston University of WashingtonWashington University at St. Louis

CDCSeptember 24, 2013

The Cancer Prevention and Control Research Network:

Federally Qualified Health Centers Workgroup  

CPCRN CHC Survey

FQHC Workgroup

Partnership Committee

Qualitative Inquiry

Subgroup

Data Subgroup

CHC Survey

Subgroup

Align with CHCs’ missions

Guided by real world

health policy

&health

care delivery

landscapes Health Care Reform

Meaningful Use of EHRPatient-Centered Medical Home

National Association of Community Health Centers (NACHC)

Primary Care Associations

Community Health Centers (CHCs)

CPCRN CHC Survey• Frameworks

• PCMH & Practice Change and Development Model• Consolidated Framework for Implementation Research (CFIR)

• SectionsA - Clinician Staff Questionnaire (Transformed’s NDP)

23 item Practice Adaptive Reserve (PAR) ScaleB - Primary CRC screening modality recommended at clinicC - 4 Community Guide EBIs to increase CRC screening:

Provider reminders, Patient reminders One-on-one education, Provider assessment and feedback

EBI specific CFIR itemsD - 8 CRC screening best practices - NCQA PCMH standards

How often performed best practices in past monthE - Age, gender, race and ethnicity, languages spoken,

number of hours/wk and years worked at clinic

CPCRN CHC Survey• Convenience sample of CHC clinics from 7 states• Completed May 30, 2013• 327 providers, nurses, MAs, QI/operations staff

Primary CRC Screening Test promoted in CHCs

Frequency Percent %

Colonoscopy 92 29.11

Fecal Occult Blood Test (FOBT) - at home 144 45.57

Fecal Immunochemical Test (FIT) - at home 74 23.42

Sigmoidoscopy 1 0.32

None 5 1.58

Total 316 100

Missing Frequencies =11

Clinic Characteristics Survey - Content

• Patients served • Uninsured, below poverty level, LEP, race/ethnicity

• Number of encounters• Staffing - FTEs & shortages• EHR• Ease to generate information & accuracy of data• PCMH best practices• 8 Community Guide EBAs• Provider reminder implementation

• Pressures, incentives, alignment with QI• Feedback on CRC screening• CDC funding of CRC screening program• CRC screening reporting to outside organization

• Scores well – additional income/reimbursements/other rewards

CHC Clinic CharacteristicsNumber of CHC Clinics (% Total)

Number patients served in 2012<5,0005,000-20,000>20,000-30,000>30,000

17 (36%)22 (47%)

3 (6%)5 (11%)

Number of clinics in CHC1-23-56-10>10

19 (38%)18 (36%)7 (14%)6 (12%)

Percent of patients uninsured<20%20-50%>50-70%>70%

6 (13%)21 (47%)10 (21%)10 (21%)

Percent of patients with limited English proficiency<10%10-40%>40-60%>60%

18 (38%)11 (23%)8 (17%)10 (21%)

Respondents - CEO (6); CMO/Med Director (8); CNO/Nursing Director (3); COO/Clinic Operations Director (3); QI Director/Manager (11); Others (19)

CHC Staffing Shortages

Provide

rs

Nurses

Medica

l Ass

istan

ts

Enabli

ng S

ervice

s0%

10%

20%

30%

40%

50%

60%

Percent of

clinics

Practice Change and Development Model

Miller et al. Primary Care Practice Development: A Relationship-Centered Approach. Ann Fam Med 2010;8(Suppl 1):s68-s79.

Robust Practice Core consistent performance & delivery of reliable primary care

Miller et al. Primary Care Practice Development: A Relationship-Centered Approach. Ann Fam Med 2010;8(Suppl 1):s68-s79.

Practice Adaptive Reserveenhances resilience & facilitates adaptation and development

Miller et al. Primary Care Practice Development: A Relationship-Centered Approach. Ann Fam Med 2010;8(Suppl 1):s68-s79.

Practice Adaptive Reserve Scores by State

Scores are scaled so as to range from 0.00 to 1.00; 1.00 = perfect score of agreement

State N Mean SD Min Q1 Q2 Q3 Max

California 28 0.60 0.23 0.02 0.46 0.65 0.78 0.96

Colorado 52 0.66 0.18 0.26 0.52 0.66 0.78 1.00

Georgia 25 0.71 0.19 0.24 0.63 0.73 0.83 1.00

Missouri 4 0.65 0.06 0.58 0.61 0.65 0.69 0.73

S. Carolina 19 0.68 0.17 0.21 0.60 0.65 0.77 1.00

Texas 79 0.66 0.18 0.07 0.54 0.70 0.79 0.98

Washington 89 0.66 0.15 0.21 0.57 0.68 0.75 0.95

Combined 296 0.66 0.18 0.02 0.55 0.67 0.77 1.00

National Demonstration Project - Highly-motivated practices w/ significant capability for change • Mean baseline PAR score 0.69 (s.d. 0.35)• Post intervention PAR score increased to 0.74

PCMH CRC Screening Best Practices (%)

Never Rarely Occasionally Usually Always

Daily huddles, huddle sheets or checklists to go over scheduled patients who need CRC screening.

175 (59.1) 8 (2.7) 16 (5.4) 54 (18.3) 43 (14.5)

Standing CRC screening orders or orders prepared by nurses/medical assistants then signed by providers.

167 (56.4) 3 (1.0) 17 (5.7) 62 (21.0) 47 (15.9)

Tracking of patients who had CRC screening orders. 140 (47.3) 20 (6.8) 22 (7.4) 59 (19.9) 55 (18.6)

Tracking of patients who completed CRC screening tests.

129 (43.6) 15 (5.1) 23 (7.8) 64 (21.6) 65 (21.9)

Tracking of abnormal CRC screening tests. 104 (35.1) 12 (4.0) 13 (4.4) 68 (23.0) 99 (33.5)

Referrals for diagnostic work-up of abnormal CRC screening tests.

57 (19.3) 6 (2.0) 23 (7.8) 66 (22.3) 144 (48.6)

Tracking of diagnostic work-up completed by patients with abnormal CRC screening tests.

96 (32.4) 9 (3.1) 21 (7.1) 69 (23.3) 101 (34.1)

Referrals to specialists for patients with abnormal colonoscopies.

52 (17.5) 10 (3.4) 26 (8.8) 55 (18.6) 153 (51.7)

Adjusted Regression Analysis PCMH Best Practices and PAR

PAR PCMH Best Practices (0-32)

  Mean 95% CI

0.08 – 1.00 20.68 17.51, 23.86

0.60 - <0.80 15.84 13.31, 18.36

0.00 - <0.60 12.67 9.90, 15.44

PCMH Best Practices Mean Composite Score (0-32)

Adjusted for state, age, job type, years worked at the clinic, hours worked each week

Differences b/t PCMH BP Mean Composite Scores all statistically significant: 0.08 - 1.00 vs. 0.06 - <0.80 (p = 0.0013) 0.08 - 1.00 vs. 0.00 - <0.60 (p = <0.0001) 0.06 - <0.80 vs. 0.00 - <0.60 (p = 0.0155)

Adjusted Logistic Regression Frequency of PCMH Best Practices and PAR Scores

PAR Frequency of PCMH Best Practices (6-8 vs. 0-5)

  OR 95% CI

0.08 – 1.00 5.49 2.31,13.06

0.60 - <0.80 2.23 1.11,4.47

0.00 - <0.60 Referent

PCMH Best Practices Dichotomized Score (6-8 vs. 0-5)Respondent reported performing PCMH best practices “usually” or “always”

Adjusted for state, age, job type, years worked at the clinic, hours worked each week

Levels of Community Guide EBI Implementation

No Plan

Planning to implement EBI in

the future

Level 3 Early stage of implementing EBI at

the clinicLevel 2

EBI implemented but inconsistently across the clinic

Level 1EBI implemented fully and systematically across the clinic

Implementation Levels of CRC Screening EBIs

Provider Reminders

Patient Reminders

One-on-one Education

Provider Assessment & Feedback

0%10%20%30%40%50%60%70%80%90%

100%

29.9720.52

30.62 25.08

20.20

13.36

27.0418.89

18.89

16.61

17.26

20.52

22.15

32.57

11.419.22

8.79 16.94 13.68 16.29

No planPlanningLevel 3Level 2Level 1

Missing Frequencies: 20

General Predictors of Implementation of Provider Reminders

General Organizational Factors Odds Ratio* P-value

Practice Adaptive Reserve 48.56 0.0088Patient-centeredness 2.35 0.0345

Organizational Resources 3.51 0.0003

Communication 2.05 0.0096

Innovation & Flexibility 4.53 0.0108

Leadership 1.90 0.0184

Reflection & Evaluation 2.33 0.0057

• *Odds ratio over 1 means associated with higher levels of provider reminder implementation• Adjusted for age, education, and state.• Number of respondents =296; Number of clinics: 75/62 Unit of Analysis: multilevel

PAR (Scaled 0-5) Odds Ratio=2.33; P value=0.0238

EBI-Specific Predictors of Implementation of Provider Reminders

EBI (Provider Reminders) -Specific Factors Odds Ratio* P-value

Compatibility with the clinic 3.10 0.0048

Learning Climate 2.13 0.0488

Relative advantage 2.33 0.0133

Engaging champions 1.88 0.0158

• *Odds ratio over 1 means associated with higher levels of provider reminder implementation• Adjusted for age, education, and state.• Number of respondents =296; Number of clinics: 75/62 Unit of Analysis: multilevel

Electronic Health Record Adoption

90%

10%

EHRNo EHR

N=50

Electronic Health Record Functionality

CHC clinics that use EHR data to (a)-(d)

CHC clinics that use EHR & can EASILY (a)-(d)

Number (%) (n=43 to 45)

Number (%)(n=37 or 30)

(a) Create list of patient panels by provider 37 (84%) 30 (81%)

(b) Identify patients due or overdue for CRC screening 37 (82%) 21 (57%)

(c) Send reminders to patients when they are due for CRC screening

30 (70%) 8 (27%)

(d) Estimate CRC screening rates 37 (82%) 23 (62%)

Electronic Health Record Accuracy

24.4%

68.9%

6.7%

Very accurate*Somewhat accu-rate**Not at all accu-rate***

*Primary source for reports or patient care decision **Need a secondary audit or cross check with additional documentation***Would not use for reports or patient care decision

Summary

• In 3 months since survey concluded, we have identified:• Positive associations of PAR with CRC

screening BPs • Room to go to fully and systematically

implement the CG EBIs at participating clinics• Associations of PAR and certain CFIR

constructs with implementation of Provider Reminders

• Limitations of EHR CRC screening data

Summary

• In 3 months since survey concluded, we have identified:• Positive associations of PAR with CRC

screening BPs • Room to go to fully and systematically

implement the CG EBIs at participating clinics• Associations of PAR and certain CFIR

constructs with implementation of Provider Reminders

• Limitations of EHR CRC screening data

FQHC Survey Subgroup: Manuscripts

MANUSCRIPT FOCUS LEADSITE U Co Emory UCLA USC UT-H UW WU

CFIR Measures/ Survey development* UTH x x x x X x xSurvey results – Practice Adaptive Reserve (PAR)/PCMH Best Practices UW x x x x x X x

Survey results – EHR/?PCMH Best Practices UW x x x x x X xSurvey results – Practice Adaptive Reserve/PCMH BP/Clinic characteristics ?UW

Survey results – CG EBAs/Practice Adaptive Reserve TBD

Survey results – CG EBA/CFIR measures UTH/UCo X x x x X x xSurvey results – CG generic EBAs/CFIR measures Emory x X x x x x x

? Survey results – CG EBAs/Clinic Characteristics TBD

Agreement b/t staff reports and clinic contact of CG EBAs/ PCMH Best Practices TBD

Acknowledgements

Special thanks to:CPCRN FQHC Workgroup Team

Alan Kuniyuki MS, Letoynia Coombs PhDAllison Cole, MD, MPH

Jim Hotz MDKathleen Clark CHC contacts

Survey respondents

Contact Information: shinping@uw.edu

This work was also supported by National Cancer Institute grants R21 CA 136460 and R01 CA124397