Preventive Care: Controversies, Challenges and Upcoming Changes in Guidelines

Objectives Organizations who make guidelines Current guidelines for average-risk adults, with a focus on guidelines with differing recommendations and challenges to implementation/operational issues Preview of upcoming changes in guidelines Cases to illustrate some of the common questions that come up in delivering office-based preventive care Some disclaimer

Feasibility Pilot Outcomes of a Mammography Decision Support and Navigation Intervention for Women With Serious Mental Illness Living in Supportive Housing Settings.

Objective: People with serious mental illness (SMI) experience significant disparities in morbidity and mortality from preventable and treatable medical conditions. Women with SMI have low mammography screening rates. SMI, poverty, and poor access to care can have a significant effect on a woman’s opportunity to learn about and discuss breast cancer screening with health care providers. This study examines the feasibility pilot outcomes of mammography decision support and patient navigation intervention (DSNI) for women with SMI living in supportive housing settings. The primary research question was: Does the DSNI increase knowledge, promote favorable attitudes, and decrease decisional conflict relating to screening mammography? Methods: We developed the intervention with the community using participatory methods. Women (n = 21) with SMI who had not undergone screening mammography in the past year participated in an educational module and decision counseling session and received patient navigation over a 6-month period. We conducted surveys and interviews at baseline and follow-ups to assess mammography decisional conflict. Results: Among study participants, 67% received a mammogram. The mammogram DSNI was feasible and acceptable to women with SMI living in supportive housing settings. From baseline to 1-month follow-up, decisional conflict decreased significantly (P= .01). The patient navigation process resulted in 270 attempted contacts (M= 12.86, SD = 10.61) by study staff (phone calls and emails with patient and/or case manager) and 165 navigation conversations (M= 7.86, SD = 4.84). A barrier to navigation was phone communication, with in-person navigation being more successful. Participants reported they found the intervention helpful and made suggestions for further improvement. Conclusions: The process and outcomes evaluation support the feasibility and acceptability of the mammography DSNI. This project provides initial evidence that an intervention developed with participatory methods can improve cancer screening outcomes in supportive housing programs for people with SMI

A learning community approach to identifying interventions in health systems to reduce colorectal cancer screening disparities.

Although colorectal cancer (CRC) screening in the United States has been increasing, screening rates are not optimal, and there are persistent disparities in CRC screening and mortality, particularly among minority patients. As most CRC screening takes place in primary care, health systems are well-positioned to address this important population health problem. However, most health systems have not actively engaged in identifying and implementing effective evidence-based intervention strategies that can raise CRC screening rates and reduce disparities. Drawing on the Collective Impact Model and the Interactive Systems Framework for Dissemination and Implementation, our project team applied a learning community strategy to help two health systems in southeastern Pennsylvania identify evidence-based CRC screening interventions for primary care patients. Initially, this approach involved activating a coordinating team, steering committee (health system leadership and stakeholder organizations), and patient and stakeholder advisory committee to identify candidate CRC screening intervention strategies. The coordinating team guided the steering committee through a scoping review to identify seven randomized trials that identified interventions that addressed CRC screening disparities. Subsequently, the coordinating team and steering committee applied a screening intervention classification typology to select an intervention strategy that involved using an outreach strategy to provide minority patients with access to both stool blood test and colonoscopy screening. Finally, the coordinating team and steering committee engaged the health system patient and stakeholder advisory committee in planning for intervention implementation, thus taking up the challenge of reducing and important health disparity in patient populations served by the two health systems

Accelerating Primary Care Transformation at Jefferson (JeffAPCT): Reflections from a Five- Year HRSA Grant

JeffAPCT Overview Five year HRSA-funded grant (7/1/15-6/30/20) Leadership team from Family Medicine, Internal Medicine, Physician Assistant Program Objective 1: To improve/ expand primary care and population health curriculum across the continuum of primary care providers and trainees (students, residents, and practitioners) Objective 2: To create an enhanced, sustainable model of primary care physician faculty development for PCMH Transformation Objective 3: To create a new, sustainable model of faculty development for community-based primary care preceptors (MD/DO, PA, NP, others

Race/Ethnicity, Gender, Weight Status, and Colorectal Cancer Screening

Background. The literature on colorectal cancer (CRC) screening is contradictory regarding the impact of weight status on CRC screening. This study was intended to determine if CRC screening rates among 2005 National Health Interview Survey (NHIS) respondent racial/ethnic and gender subgroups were influenced by weight status. Methods. Univariable and multivariable logistic regression analyses were performed to determine if CRC screening use differed significantly among obese, overweight, and normal-weight individuals in race/ethnic and gender subgroups. Results. Multivariable analyses showed that CRC screening rates did not differ significantly for individuals within these subgroups who were obese or overweight as compared to their normal-weight peers. Conclusion. Weight status does not contribute to disparities in CRC screening in race/ethnicity and gender subgroups

“Taking the Pulse of Jefferson Primary Care: Provider and Team Wellness Survey Results and Next Steps”

Agenda Context (Randa Sifri) Results (Amy Cunningham) Action Steps (Keith Sweigard) Q&

Primary Care in a Pandemic: A Qualitative Study on the Impact of COVID-19 on Workplace Wellness

Introduction: On March 16, 2020, the city of Philadelphia announced a state of emergency due to the COVID-19 global pandemic. The Primary Care Department of Thomas Jefferson Hospital had to alter operations to protect patients, providers and staff. These changes included an increase in telehealth, personal protective equipment (PPE), spacing in-person visits, and working from home. This study was designed to qualitatively assess how these changes have impacted providers and staff in Jefferson’s primary care settings. Methods: We conducted 31 qualitative semi-structured interviews with employees of Jefferson Primary Care practices. Though, our population was heavily skewed toward clinical staff (N=9), physician (N=8) and office managers (N=7), due to availability and interest, we also interviewed some behavioral health consultants (N=4), and administrative staff (N=3). The interviews were approximately 20 minutes long, recorded over Zoom, transcribed and analyzed utilizing NVIVO. The primary investigators designed and implemented standardized codes and reached consensus on the themes present in each interview before coding concluded. Results: While analysis is still ongoing, we have ascertained preliminary results from the study. The four primary themes that emerged are as followed: gratefulness, safety/PPE/communication, effect on burnout, and feeling relating to telehealth. Interviewees often spoke about the “silver linings” that they have focused on and found throughout the pandemic. Individuals often spoke about their feeling of safety in the workplace, access to PPE and communication from the Jefferson system, or lack thereof. While burnout was a common theme, the impact was highly variable. Telehealth was widely viewed as a positive addition and new staple to workflow. Conclusion: Our results provide preliminary insight to the immediate effects of COVID on primary care employees and providers. We ascertained many of the common reactions to working from home, utilizing telehealth, safety, as well as general wellbeing. This study was nested within a larger mixed methods project, including a follow-up quantitative study, to assess and improve burnout within Jefferson’s primary care department

Primary Care Providers\u27 Attitudes and Practices Regarding Cancer Screening in Older Adults.

Introduction: Cancer-screening decisions for older adults should be individualized. However, conducting such complex shared decisions may be challenging for primary care providers (PCPs). Additionally, there is little information on how PCPs make these decisions. This study consisted of a provider survey and chart review to assess current PCP approaches to breast and colorectal cancer (CRC) screening with patients age ≥75. Methods: PCP survey questions: panel age, comfort with discussion of screening harms and benefits, screening decision-making process, and discussion style. One Hundred charts were chosen from a random sample of male and female patients ≥75 with a recent office visit. Chart reviews assessed whether providers recommended screening for breast and/or colon cancer in patients ≥75, if there was a documented screening discussion, and if screening was completed. Results: Fifty-one PCPs completed the survey. PCPs varied in the proportions of older adults they recommended for breast and CRC screening. 90.2% reported feeling very (43.1%) or somewhat (47.1%) comfortable discussing reasons for/against screening with older patients. Top screening considerations: life expectancy (84.3%), patient preference (82.4%), and severity of medical conditions (70.6%). Three-quarters (74.55%) reported a shared decision-making approach with discussion of harms/ benefits. Of 61 eligible patients, 8(13.1%) had a documented discussion regarding mammography. Of 58 patients eligible for CRC screening, 7(12.1%) had a documented discussion. Discussion: Findings showed inconsistency in PCP approaches to cancer screening in older adults and in discussion documentation. There is ample room for improvement in standardizing approaches and documentation of cancer screening discussions with older patients