Developing a CKD Registry in Primary Care: Provider Attitudes and Input

BACKGROUND. Chronic disease registries have been successful at promoting delivery of guideline-concordant primary care for diabetes and hypertension but not for chronic kidney disease (CKD). To understand whether a registry could be designed to improve CKD management in primary care, we explored primary care provider (PCP) attitudes about the benefits (or lack thereof) of a CKD registry compared to other chronic diseases and the key facilitators of successfully implementing a CKD registry in safety-net primary care. STUDY DESIGN: Semistructured interview study. SETTING & PARTICIPANTS. We conducted and recorded semi-structured, one-hour interviews with medical directors and quality improvement champions from safety-net adult primary care clinics in San Francisco. ANALYTIC APPROACH. Recordings were transcribed and analyzed using a grounded theory approach until thematic saturation was achieved. RESULTS. Twenty primary care providers were interviewed. Four themes relevant to the development of a successful CKD registry for safety-net primary care were identified: (1) provider beliefs that a CKD registry could aid in the delivery of team-based, high-quality CKD care; (2) clinic workflow re-design and staffing are key facilitators to successful implementation of a CKD registry; (3) unique complexities of CKD, such as varying etiologies, may limit the use of a CKD registry by non-physicians; and (4) a CKD registry is aligned with current primary care priorities and health care delivery strategies. LIMITATIONS. Small sample size and reliance on clinician leaders within one health care delivery system. CONCLUSIONS. A CKD registry directed at the entire health care team, with the functionality to track, standardize and enhance CKD care through decision support, has potential to improve the management of CKD in safety-net primary care settings. These data directly informed the development of a CKD registry in these settings in San Francisco

Utilization of the Behavior Change Wheel framework to develop a model to improve cardiometabolic screening for people with severe mental illness

Abstract Background Individuals with severe mental illness (e.g., schizophrenia, bipolar disorder) die 10–25 years earlier than the general population, primarily from premature cardiovascular disease (CVD). Contributing factors are complex, but include systemic-related factors of poorly integrated primary care and mental health services. Although evidence-based models exist for integrating mental health care into primary care settings, the evidence base for integrating medical care into specialty mental health settings is limited. Such models are referred to as “reverse” integration. In this paper, we describe the application of an implementation science framework in designing a model to improve CVD outcomes for individuals with severe mental illness (SMI) who receive services in a community mental health setting. Methods Using principles from the theory of planned behavior, focus groups were conducted to understand stakeholder perspectives of barriers to CVD risk factor screening and treatment identify potential target behaviors. We then applied results to the overarching Behavior Change Wheel framework, a systematic and theory-driven approach that incorporates the COM-B model (capability, opportunity, motivation, and behavior), to build an intervention to improve CVD risk factor screening and treatment for people with SMI. Results Following a stepped approach from the Behavior Change Wheel framework, a model to deliver primary preventive care for people that use community mental health settings as their de facto health home was developed. The CRANIUM (cardiometabolic risk assessment and treatment through a novel integration model for underserved populations with mental illness) model focuses on engaging community psychiatrists to expand their scope of practice to become responsible for CVD risk, with significant clinical decision support. Conclusion The CRANIUM model was designed by integrating behavioral change theory and implementation theory. CRANIUM is feasible to implement, is highly acceptable to, and targets provider behavior change, and is replicable and efficient for helping to integrate primary preventive care services in community mental health settings. CRANIUM can be scaled up to increase CVD preventive care delivery and ultimately improve health outcomes among people with SMI served within a public mental health care system