Advancing the Science of Implementation in Primary Health Care

Recommendations from Thought Leaders on Advancing Implementation Science in Primary Care

Its relative youth and breadth of challenges make primary care implementation science ripe for informative commentary and visioning from thought leaders in the field. Summers Holtrop et al⁵ lead off the theme issue with an overview of dissemination and implementation science by defining this nascent field of research in context for both the researcher and primary care provider. The authors go on to provide 2 case studies that “uncover the factors important to making the adoption, implementation, and maintained use of evidence-based approaches successful,” important insights as we attempt to shorten the time between evidence creation and routine practice. Gottlieb et al⁶ highlight 3 areas of needed implementation research for social prescribing: 1) screening tools used to capture information needs; 2) workforce models to implement social prescribing; 3) and payment models for offering services (Federally Qualified Health Centers), including reporting on how to reinvest funds back into a program. Gelmon et al⁷ described strategies to overcome challenges for implementing patient-centered primary care homes (PCPCH). Twenty exemplary PCPCH programs in Oregon were identified, and interviews with 85 key informants identified 10 recommended strategies for PCPCH implementation. Despite differences in size, ownership, geography, and populations, all clinic leaders were proponents of building a Primary Care Learning Organization (see the articles for more information on what a learning organization means).

Sharing Best Practices in Policy and Primary Health Care Implementation across International Borders

Implementation science also concerns itself with identifying barriers to and enablers of policymaking that supports effective primary care.⁸ Two articles in this issue report on the 2017 summit of thought leaders in the United States and Canada titled, “Advancing the Science of Transformation in Integrated Primary Care: Informing Policy Options for Scaling-up Innovation.”⁹ Supported by Canadian and US research agencies, this conference attracted 150 leaders to share lessons in addressing multi-morbidity and equity through payment, and equity in primary health care. Haggerty et al¹⁰ summarized principal insights and proposed solutions from symposium discussions addressing health inequities, and best evidence on their mitigation through policy and delivery innovations. Their recommendations include proactive efforts, shifting emphasis from equality to equity, building on strength-based approaches, and taking the public health population focus. A second report from the symposium¹¹ summarized stakeholder discussions of rapidly evolving alternative payment models (APMs) from both countries that influence primary care delivery and innovation. Attendees noted that APMs should include flexible and upfront payments to foster primary care innovations, and reward measuring and achieving global rather than intermediate outcomes. Thought leaders also noted that efforts to alter payment models would fail to expedite primary care implementation or correct health system inefficiencies, absent increased proportional spending on primary care overall, and additional incentives for innovation and continuous learning. Experts cautioned against the risk of “pilotitis,” or developing, implementing, and evaluating new payment models without the ability to scale up and sustain them. They lauded efforts to “learn at scale” launched by the US Centers for Medicare and Medicaid Innovations and called for a similar national center to drive innovation across provincial health systems in Canada.^12,13

Dissemination and Implementation of Best Evidence in Primary Care

An additional verb morpheme often precedes “Implementation” in descriptions of this growing field—“Dissemination.” This alternative label, Dissemination & Implementation science, or “D&I,”^14,15 emphasizes the importance of communication in propagating new evidence in primary care practice and to creating continuous learning systems in primary care. Many existing guidelines and journal formats seem ill-suited to the task of capturing and communicating lessons from primary care implementation, and even a barrier to innovators hoping to share their best practices. Grandes et al¹⁶ review and promote the use of what they describe as a more suitable framework, the Standards for Reporting Implementation Studies (StaRI). StaRI offers authors and publishers with guidelines for reporting context, adoption and adaptation strategies, and evaluation methods for both the intervention and the implementation strategy. The authors posit that the use of StaRI guidelines might reduce the diffusion gap between evidence creation and common practice, raise the volume of publications, and improve the clarity and utility of implementation research narratives.

Social Determinants of Health and Health Promotion

Renewed attention to the importance of social determinants of health is considerable, and identifying effective strategies to address them in practice is a source of considerable attention and discussion in primary care.^{17⇓⇓–20} This critical challenge for primary care implementation scientists is addressed by several authors herein. Liaw et al²¹ report on a novel approach to geocoded practice and population data to help primary care physicians identify and understand the effects of living in “cold spots”—areas with lower education, lower income, and greater composite scores of deprivation—on their patients. They used these methods to help 12 practices recognize that their patients living in cold spots had lower rates of receiving certain, but not all, preventive services and screening tests, a potential first step in targeting at-risk patients and developing mitigating interventions. A related study by this group, and led by Tong²² reports on how providers are responding and reacting to the results of a social needs assessment surveys completed by their patients. The findings reveal both the potential power of using such a social needs screening on the patient-provider interaction, and the challenges of implementing increasingly pervasive social screening tools in practices struggling with provider burnout and high levels of administrative burden.

Preventing and Addressing Chronic Disease in Primary Care Practice

Implementation science regularly reminds us that, when translating evidence from randomized trials and other rigorous forms of evidence into practice, one size does not fit all.^23,24 Rosas et al²⁵ provide an in-depth example, reporting on a successful community engagement approach to diabetes prevention in a Latino community. The process demonstrated the feasibility of using a well-known patient engagement rubric with culturally tailored, patient-centered strategies for achieving their project's health promotion goals. Similarly, despite excellent evidence and guidelines, actual hypertension diagnosis and management is often complicated by “white-coat” blood pressure elevation during office visits. Doane et al²⁶ describe a pragmatic approach, which trained patients in home blood pressure measurement that resulted in adequate blood pressure control in half of nearly 200 patients with clinic-identified white-coat hypertension. The approach is inexpensive and acceptable to both providers and patients. And sometimes, national surveys can remind us of the gaps in our implementation of well-established and evidence-based screening. The Medical Expenditure Panel Survey (MEPS) is a nationally representative, population-based survey that offers unique insight into costs, delivery, health status, and access to care in the United States. Kato et al²⁷ used MEPS data to evaluate the extent to which our adult population (age 35+ years) has been screened for depression, as recommended by the US Preventive Services Task Force. Population subgroups less likely to be screened include men, the elderly, minorities, and the uninsured. Much work in primary care is still needed to reduce these disparities.

Speeding Implementation and Practice Transformation down “Blue Highways” with Facilitators

Other paths exist to speed the transit of evidence into daily practice, for example, “Blue Highways” well known to the primary care research community, if often ignored on the larger US biomedical research “Roadmap.”²⁸ Practice-based research networks remain critical to the success of Implementation Science in primary care, and several articles highlight these efforts. Hemler et al²⁹ remind us of the power of practice facilitators as an effective strategy to support quality improvement and practice transformation efforts. Supported by the national EvidenceNOW initiative, which enrolled approximately 1500 small-to-medium-sized primary care practices and 136 facilitators, the authors describe the strategies facilitators employed to assist practices to improve cardiovascular preventive services. Facilitators worked with practices on electronic health record data challenges to obtain and use data for this quality improvement initiative. This article offers ideas on how a facilitator might be a useful team member in your practice. Another project with practice facilitators tk;1reported a successful outcome with fewer resources than previously described in the literature. Huguet et al³⁰ describe a trial to assess novel health insurance enrollment and heath information technology (HIT) support tools. Practices with a facilitator/coach had higher rates of using the HIT tools. They also noted that clinic early engagement in tool development was critical to successful implementation of the intervention.

Applying New Theories and Implementation Science to Transform Practice

Human factors engineering, which explores interactions between people and the workplace, has successfully improved antibiotic stewardship in hospital settings. Keller et al³¹ conducted a systematic literature review to explore the extent to which principles from the Systems Engineering Initiative for Patient Safety are applied in studies of ambulatory antibiotic stewardship. This review describes how a work system (ambulatory clinic) contributes to a process (antibiotic prescribing) that leads to outcomes. Effective antibiotic stewardship interventions focused on 5 components of the work system: tools and technology (eg, clinical decision support; point-of-care testing); the person (eg, clinician education); organization (eg, audit and feedback; academic detailing); tasks (delayed antibiotic prescribing); and the environment (eg, commitment posters; media campaigns).

Luig et al³² evaluated the implementation process of a randomized trial of an intervention to improve obesity prevention and management knowledge. The implementation evaluation used the Interactive Systems Framework theory, which conceptualizes interactions between organization/team capacity and intervention implementation. Key findings emerged from exploring interactions of context with implementation activities, such as knowledge exchange, capacity building, and practice integration.

Health technology solutions are often implemented without a deep understanding of the system-level problems they seek to address. Liddy et al³³ applied the Quadruple Aim Framework to evaluate the impact of a health technology innovation (eConsult). This case study demonstrates the eConsult's impact on patient experience, provider satisfaction, and reducing costs. However, the impact on key population health metrics could not be determined.

Agents of Primary Care Implementation

The implementation and scope of primary care and family medicine continues to rapidly evolve, as do its delivery teams. Sullivan et al³⁴ describe the implementation of a patient-centered medical home model for older individuals called Geriatric Patient Aligned Care Teams (GeriPACT) in the Veterans' Health Administration. GeriPACT is hypothesized to improve care quality through enhanced care coordination, improved personalized care, and a positive culture of service. The authors describe barriers to implementation, variation between centers, and other lessons learned during the process. These are important insights as models such as GeriPACT will become increasingly needed as the primary care population ages.

Maternal and infant mortality in the United States is increasing, with contributing factors including poor access to maternity care due to obstetric/gynecologist shortages, especially in rural communities. In addition, the proportion of family physicians practicing obstetrics is rapidly declining, despite findings that their outcomes are similar to those of obstetricians. Barreto et al³⁵ analyzed data from the 2016 Family Medicine National Graduate Survey (n = 2018) to determine the extent and barriers to obstetric practice. Two barriers to providing obstetrics care were given by over half of the 865 new family physicians interested in delivering babies: 1) obstetrics was not available in their practice; and 2) lifestyle considerations.