Research and Evaluation

CEPC builds the evidence base for primary care transformation by conducting research and evaluation on primary care innovations and alternative delivery models. Some of our projects include:

The COPD Health Coaching Study (2014-2017) is a randomized controlled trial scheduled to start in 2014 that will examine the impact of health coaching on the management of Chronic Obstructive Pulmonary Disease, compared to usual care. A collaboration between the UCSF Department of Family and Community Medicine, the Department of Pulmonology, and community clinics in San Francisco, this study will explore a unique model of medical assistant health coaching that supports linkages between primary care and specialty care as well as providing self-management support to patients living with COPD. Supported by the Patient Centered Outcomes Research Institute.

Patient and Family Engagement in Electronic Consultation and Referral Systems– Establishing a Framework for Achieving the Third Aim by Moving From Dyads to Triads(2015-2016). Electronic consultation and referral (eCR) systems have increased access to care, optimized efficiency, improved PCP capacity for complex decision-making, and promoted dialogue between PCPs and subspecialists. However, to date, eCR systems are limited to communication in the provider-to- provider dyad; the process is largely invisible to the patient. While the eCR model of specialty care delivery is spreading throughout the United States, no known studies have examined patient involvement with this model of care delivery. In response to this gap in knowledge, CEPC is partnering with the Center for Innovation in Access and Quality to conduct an observational study that will assess the level of understanding of patients, families, and caregivers in engaging in an electronic consultation model of specialty care delivery. This study will also explore their interest in participating in this process of exchange and potential components of a patient-centered electronic consultation and referral eCR system at San Francisco General Hospital. Funded by the Blue Shield of California Foundation.

Building the Case for Addressing Social Determinants of Health within Primary Care: A Strategy to Reduce Burnout in Providers Caring for Vulnerable Populations (2014-2016).A qualitative study to better understand clinician-level knowledge and attitudes about the intersection of social determinants of health in community health center (CHC) settings, and how clinician-level beliefs/skills and clinic capacity/resources relate to burnout. This study includes structured interviews of key informants and national experts in CHCs, as well as regional, national and cross-sectional surveys of primary care providers in CHC settings. It will provide necessary information to ultimately design, implement and evaluate interventions related to social determinants of health in CHC settings. Supported by the Hellman Foundation.

Spotlight on Health Coaching (2014-2015). Thanks to a grant from the Gordon & Betty Moore Foundation, the Center for Excellence in Primary Care is able to offer full scholarships to two organizations to receive the health coaching training on which CEPC’s research is based as well as technical assistance for implementation of a health coaching program in safety-net clinics. The clinics selected receive (1) full health coach training for staff on site, (2) an intensive in-person workshop with clinic leadership, supervisors, and front line staff to set up the infrastructure for a successful program, (3) follow-up calls with the to troubleshoot implementation challenges and foster accountability to carry out the program. From this project and evaluation CEPC hopes to learn more about how to successfully develop and implement health coaching in clinics outside of the research setting.

The Impact of the Patient-Centered Medical Home on Health Disparities: A Systematic Literature Review (2014-2015). The Patient-Centered Medical Home (PCMH) model has become increasingly recognized as part of the solution in fixing the fragmented U.S. health care system. Forty-four percent of Community Health Centers in the US are currently recognized as PCMHs, and many more are scheduled to transform in order to achieve the Health Resources and Services Administration target of 55% by 2015. Many PCMH demonstrations, pilots or transformations have shown remarkable success in financial, operational and clinical measures. However, the extent to which transformation to a PCMH reduces disparities or achieves health equity is still unknown. In this study, we are conducting a formal systematic review of the evidence on PCMH outcomes and, specifically improvements in health disparities. Identified successes and gaps will be critical in informing PCMH innovators, researchers and policymakers on future directions for the PCMH.

Empowering the Registered Nurse – A Report on the Role of the Registered Nurse in Primary Care Transformation (2014-2015). This report explores the role of the Registered Nurse (RN) in primary care safety net settings, primarily in California. The policy brief will highlight clinics that have maximized the RN as principal team members - empowered with standardized procedures - to provide clinical visits for patients with chronic disease and less complex acute problems. Supported by the California HealthCare Foundation.

Disseminating Best Practices in Medical Neighborhood Integration (2014-2015) is being accomplished by the creation of an exciting, interactive resource center which will serve a vast number of Community Health Centers nationwide. CEPC is identifying high performing and innovative models of care integration in the medical neighborhood by utilizing our vast network of organizations, embracing our recently published comprehensive literature review, conducting key informant interviews, and by piloting our self-assessment integration tool. CEPC is collaborating with the Center for Care Innovations, a leader in spreading innovation, to develop this novel online resource center. This collaborative online center will not only highlight and provide practical snapshots of successful innovators, but it will also provide a variety of practical tools and host multiple best practice webinars. It will provide a platform for inter-agency learning and collaboration as Community Health Centers tackle care integration challenges across the country. Supported by the Blue Shield of California Foundation.

Assessment of the Perceived Roles and Drivers of Electronic Health Record (EHR) Vendors in Optimizing Primary Care Practice Efficiency (2014-2015). This qualitative study explores the driving factors for EHR vendors during product development and how primary care practitioners may most effectively influence the process of EHR development. While a number of studies have examined the effects of EHRs on physician practices, none have examined the motivational forces on EHR vendors to optimize their products for use in a primary care setting. This study aims to understand and document these motivations among the leading EHR vendors in the United States. The results of this study will inform future opportunities to hone EHR software for use in the primary care setting and therefore reduce administrative burdens on primary care physicians.

The System Transformation Evaluation (2011–2015) explores changes in staff experience and quality of care at 28 primary care clinics in San Francisco. The evaluation will assess the effectiveness of practice coaching – tailored training and mentoring provided to a clinic as they implement new models of care. This evaluation explores changes in how staff and providers perceive team functioning, burn-out, and confidence to conduct panel management. Structured observations of medical assistants are being conducted as an additional way of determining the degree of panel management implementation within the clinics. Participating sites will conduct a semi-annual self-assessment to track progress in implementation of the Building Blocks of Primary Care, and measures of clinical quality and access will be measured over time. Results from the evaluation are being shared with participating sites to guide their practice improvement efforts. Results on the linkages between team structure, team culture, and burnout for clinicians and staff have been published.

Patient Engagement as Transformation Partners in Primary Care Practices: A Needs Assessment (2014). We are conducting a mixed methods needs assessment to learn more about how primary care practices engage patients and families to improve the way the clinic provides care, through strategies such advisory boards, focus groups, surveys, or quality improvement committees. A web-based survey will be conducted with key clinic staff, and interviews/focus groups will be conducted with patients and staff who work together in an advisory capacity.

Facilitating Care Integration in Community Health Centers (2013–2014) is a literature review of care integration strategies linking primary care to specialty care, oral health, diagnostic imaging, pharmacy services, and hospital care. This study developed a conceptual model and taxonomy of care integration strategies, identified promising practices and case studies of care integration, and developed a tool to assess care integration progress along the continuum. Read our report here. To learn more about the Facilitating Care Integration Resource Center, click here. Supported by the Blue Shield of California Foundation.

Health Team Support for Patient Informed Decision Making (2012-2014) is a mixed methods study of patient decision making with health coaches, primary care clinicians, and family or friends. The study uses focus groups; individual interviews with patients, health coaches, clinicians and patient friends/family; and direct observation of patient encounters with clinicians and health coaches. Data are analyzed using modified grounded theory and combined with survey results to create a conceptual framework of the role of health coaches in supporting patient decision making, including how it differs from, and interacts with, the patient-clinician relationship. The results will provide insights that may improve the training and deployment of health coaches as well as a framework for future investigation of the patient-health coach relationship. Supported by the Patient Centered Outcomes Research Institute.

The Health Coaching in Primary Care Study (2010–2013) is a randomized control trial that examined whether medical assistants trained as health coaches could help patients with diabetes, high blood pressure, and high cholesterol to improve their conditions more than usual medical care over the course of 12 months. This study found evidence of improved clinical outcomes and patient experience associated with health coaching. The clinical outcomes, impact on medical adherence and patient experience, lessons learned from the medical assistant health coaches, and findings about the health coach impact on trust in primary care clinicians are available through open access journals. Additional finding from a cost analysis and results from a follow-up conducted one year after the study’s end are forthcoming. Supported by the Gordon and Betty Moore Foundation.

The Defining and Measuring Integrated Care to Eliminate Inequities in Care project (2010-2012) is a multipronged effort to explore, describe and measure new concepts in care coordination and integration. Research has identified many factors that contribute to racial and ethnic disparities in health care, including how care is organized and structured. Inequities in care may not be simply a matter of factors such as insurance status or inadequate cultural competence, but are also a reflection of differences across communities in how the delivery of care is organized. Interest in the relationship between disparities and integrated care coincides with growing recognition in the US of the need to more generally redesign the delivery of health care around the principles of primary care and to promote a model of integrated care across healthcare settings. This work plans to develop needed survey instruments that can measure integration from a variety of vantage points, including a patient’s experience of integration. Better measures of integrated care can help to guide and evaluate ongoing interventions and future policies focused on improving health care delivery. Supported by the Aetna Foundation, UCSF Center for Aging in Diversity Communities (NINH award No.P30AG015272), and CTSI’s Award as the sponsor (NIH award No. 2UL1RR024131-06, RAS Award ID No. A117088).

Peers for Progress (2009–2011) was a multicenter, randomized control trial designed to study the impact of peer coaching on clinical outcomes and self-management skills in low-income patients with poorly controlled diabetes. Coaching was provided by patients with diabetes who were trained as health coaches. This study found that patients with a peer coach improved their diabetes control more than patients without a peer coach and this effect was strongest for patients with poor self-management skills. Supported by the American Academy of Family Physicians Foundation and Peers for Progress.

The Treat to Target study (2009–2010) was a randomized control trial that explored whether health coaching with titration of anti-hypertensive medications by patients and coaches between medical visits using standardized protocols lowered systolic blood pressure more than health coaching alone. The study did not find added benefits to the medication titration protocols, but it did find that patients In both arms had a drop in SBP (mean 22 mm Hg) at 6 months. There was a dose response: the amount of BP reduction was significantly associated with the number of health coaching encounters. In addition, most BP improvement resulted from improved medication adherence rather than more medications. Supported by Kaiser Permanente Community Benefits Program and the Kaiser Foundation Northern California Region (Grant Reference Number 20602348).

 
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