With health equity growing as a priority within health care, health systems must transform that calling into action within their social, economic, and political environments. The current literature has not compared how different organizations manage the same health disparities intervention. This qualitative study aims to illustrate how different organizations navigated the implementation and sustainability of a hypertension disparities intervention by comparing experiences across Federally Qualified Health Centers (FQHCs), a private health system, and other non-clinical partnering organizations. As a study within a randomized controlled trial designed to reduce disparities in hypertension care, we conducted interviews with health care leaders before and after participation in the trial\'s multi-level intervention. Before participation, we interviewed five health care leaders representing five health systems. Following the intervention, we interviewed 14 leaders representing the five health systems and two partnering organizations. Discussions focused on intervention implementation and plans for sustainability. The primary considerations in implementation were appropriate staffing and multi-level organizational buy-in. When discussing long-term planning, health systems prioritized the structure of a stepped-care protocol incorporating community health workers (CHWs) and case managers. The sustainability of the CHW intervention at FQHCs was dependent on funding, whereas a private, non-FQHC physician practice network focused on expanding current resources for more patients. These findings serve as anticipatory guidance for organizations aiming to reduce hypertension disparities and provide support for policies that financially assist these interventions. Further investigation is warranted on the organizational factors that may influence the degree of success in eliminating health care disparities.

Federally qualified health centers (FQHC) aim to improve cancer prevention by providing screening options and efforts to prevent harmful behavior. Patient portals are increasingly being used to deliver health promotion initiatives. However, little is known about patient portal activation rates in FQHC settings and the factors associated with activation. This study examined patient portal activation among FQHC patients and assessed correlations with demographic, clinical, and health service use variables. We analyzed electronic health record data from adults >18 years old with at least one appointment. Data were accessed from the electronic health records for patients seen between 1 September 2018 and 31 August 2022 (n = 40,852 patients). We used multivariate logistic regression models to examine the correlates of having an activated EPIC-supported MyChart patient portal account. One-third of patients had an activated MyChart portal account. Overall, 35% of patients with an activated account had read at least one portal message, 69% used the portal to schedule an appointment, and 90% viewed lab results. Demographic and clinical factors associated with activation included younger age, female sex, white race, English language, being partnered, privately insured, non-smoking, and diagnosed with a chronic disease. More frequent healthcare visits were also associated with an activated account. Whether or not a patient had an email address in the EHR yielded the strongest association with patient portal activation. Overall, 39% of patients did not have an email address; only 2% of those patients had activated their accounts, compared to 54% of those with an email address. Patient portal activation rates were modest and associated with demographic, clinical, and healthcare utilization factors. Patient portal usage to manage one\'s healthcare needs is increasing nationally. As such, FQHC clinics should enhance efforts to improve the uptake and usage of patient portals, including educational campaigns and eliminating email requirements for portal activation, to reinforce cancer prevention efforts.

UNASSIGNED: Colorectal cancer is the third leading cause of cancer-related deaths in the United States. Despite the Healthy People 2030 goal of 70.5%, colorectal cancer (CRC) screening rates in Federally Qualified Health Centers (FQHCs) are suboptimal at about 40%. The Colorectal Cancer Awareness, Research, Education and Screening-Rural Expansion, Access, and Capacity for Health (CARES-REACH) study seeks to address this disparity and accelerate the adoption and utilization of effective, evidence-based CRC screening practices. This paper describes the CARES-REACH study design and implementation methods.
UNASSIGNED: Informed by a community-based participatory research (CBPR) framework and enriched by implementation science approaches, CARES-REACH features a stepped wedge design with extension for maintenance to support an implementation strategy focused on multiple levels: organizational, provider, and patient levels that entail processes to boost initial and repeat screening among average risk and age-eligible adults. This multilevel study entails the implementation of a core set of evidence-based interventions (EBIs) that include low literacy patient education (English, Spanish, and Haitian Creole language); provider education, system-wide electronic medical record (EMR) tools including provider prompts and patient reminders, FIT (fecal immunochemical test) kit distribution, plus an organization-wide cancer control champion who motivates providers, coaches and navigates patients, and monitors system-wide CRC screening activities.
UNASSIGNED: NCT04464668.

OBJECTIVE: We examined the extent to which funded satellite clinics could sustain the California Colon Cancer Control Program (C4P) strategies implemented in health systems to increase uptake of the fecal immunochemical test (FIT) or immunochemical fecal occult blood test (iFOBT) for colorectal cancer (CRC) screening in the absence of future C4P funds.
BACKGROUND: Seven health systems consisting of 38 satellite clinics participated in C4P to examine the sustainability of the program in the absence future Centers for Disease Control and Prevention (CDC) funding.
METHODS: Quantitative and qualitative methods with a close and open-ended survey approach, and a prospective cohort design were used to examine the sustainability of the C4P in health systems.
RESULTS: A total of 61% of satellite clinics could not sustain funding stability. Only 26% could sustain funding stability. About, 71%, 26%, and 21% of the satellite clinics could sustain the small media platform, patient navigation services, and community health workers (CHWs), respectively. All the satellite clinics sustained the provider reminder system and professional development. Roughly, 71% and 42% of funded satellite clinics could not sustain the patient navigators and CHWs, respectively. The satellite clinics that could sustain funding stability, sustained patient navigation services and CHWs. Health systems that could not sustain funding stability, could not sustain patient navigation services and CHWs. Qualitatively, the need to support uninsured priority populations, health educators, patient navigators, care coordination activities, outreach services, and provision of enhanced services emerged. The need to support enhanced quality measures, expansion of funding, Medi-Cal Public Hospital Redesign and Incentive coverage, health plan, community linkages, resource sharing, and best practices specifically on CRC screening emerged. Themes such as automated reminder, limited personalized care delivery and capacity, transportation barriers, staff salary, expansion of care through patient navigation, and culturally appropriate media campaign also emerged.
CONCLUSIONS: Overall, to address sustainability barriers, funding stability should be maintained in the health systems.

Academic Medical Centers (AMCs) and Federally Qualified Health Centers (FQHCs) are similarly tasked with managing the health of their local community, yet they each face unique challenges in their ability to do so. Integrating AMCs and FQHCs into novel care delivery models can leverage both organizations strengths, providing care in a comprehensive and sustainable fashion. Johns Hopkins Medicine (JHM) implemented this model with a large East Baltimore medical center, creating an AMC-FQHC collaboration focused on providing care to the East Baltimore patient population. This system provided various improvements in care delivery, including increased staffing, new wraparound services, improved access to funding dollars, and decreased out of pocket costs for patients qualifying for financial assistance. The academic missions of research and training were preserved, serving as the primary continuity clinic for several residency programs and as a community site for research. These changes resulted in more robust care for patients while improving the financial standing of the clinic. Through AMC and FQHC partnership, progress can be made toward providing holistic and financially sustainable primary care services in underserved areas while preserving the tripartite mission of academic medicine, with significant pedagogical and research opportunities.

Background: Patient portals can improve access to electronic health information and enhance patient engagement. However, disparities in patient portal utilization remain, affecting disadvantaged communities disproportionately. This study examined patient- and provider-level factors associated with portal usage among Medicaid recipients in a large federally qualified health center (FQHC) network in Texas. Methods: Deidentified electronic medical records of patients 18 years or older from a large Texas FQHC network were analyzed. The dependent variable was a binary flag indicating portal usage during the study period. Independent variables included patient- and provider-level factors. Patient-level factors included sociodemographic, geographic, and clinical characteristics. Provider characteristics included primary service line, provider type, provider language, and years in practice. Because the analysis was at the individual level, a multivariable logistic regression model focused on adjusted associations between independent variables and portal usage. Results: The analytic sample consisted of 9,271 individuals. Compared with individuals 18-39 years, patients 50 years and older had lower odds (50-64 OR: 0.60, p < 0.001; 65+ OR: 0.51, p < 0.001) of portal usage. Males were less likely to use portals (OR: 0.44, p = 0.03), and compared to Non-Hispanic Whites, Non-Hispanic Black (OR: 0.86, p = 0.02) and Hispanics (OR: 0.83, p < 0.001) were significantly less likely to use portals. Individuals with 1 or more telemedicine consults had a two-times greater odds of portal usage (OR: 1.97, p < 0.001). Compared to individuals who had clinic visits in December 2018, portal usage was significantly higher in the pandemic months (March 2020-November 2020, all p\'s < 0.01). Importantly, the behavioral health service line had the greatest odds (OR: 1.52, p < 0.001), whereas the dental service line had the lowest odds (OR: 0.69, p = 0.01) compared to family practice. No other provider characteristics were significant. Conclusion: Our finding of significant patient-level factors is important and can contribute to developing appropriate patient-focused health information technology approaches to ensure equitable access and maximize the potential benefits of patient portals in health care delivery.

UNASSIGNED: To examine factors of influence in diabetes management and their association with self-reported health outcomes in patients with type 2 diabetes treated at Federally Qualified Health Centers (FQHCs).
UNASSIGNED: This cross-sectional study examined data from the 2014 Health Center Patient Survey (HCPS). Predictor variables were categorized across three levels of the National Institute on Minority Health and Health Disparities research framework. Outcome variables retrieved from HCPS included self-reports of blood glucose levels, and diabetes-related emergency department (ED)/hospital visits during past year.
UNASSIGNED: A total of 936 patients with diabetes were included. Most (65%) participants received a diabetes self-management plan. During the previous year, 72% received > = 2 A1C checks, 52% reported high blood glucose levels, and 12% visited an ED/hospital. Multivariable results showed that insulin use and receiving a self-management plan were associated with high blood glucose levels and ED/hospital visits. Community factors of being unable to get medications and receiving a specialist foot exam were respectively associated with high blood glucose levels and ED/hospital visits.
UNASSIGNED: Different factors were associated with health outcomes in patients with diabetes treated at FQHCs. Identifying these factors can help with targeted screening and follow-up and assessing potential interventions to improve health outcomes.
UNASSIGNED: The online version contains supplementary material available at 10.1007/s40200-024-01388-5.

This retrospective, observational report describes an innovative quality improvement process, Phase-based Care (PBC), that eliminated wait times and achieved positive clinical outcomes in a community mental health center\'s (CMHC) mood disorder clinic without adding staff. PBC accomplishes this by eliminating the ingrained cultural practice of routinely scheduling stable patients at rote intervals of 1-3 months, regardless of clinical need or medical necessity. Based on four organizational transformations and using mathematical algorithms developed for this process, PBC re-allocates therapy and medical resources away from routinely scheduled appointments and front-loads those resources to patients in an acute phase of illness. To maintain wellness for patients in recovery, lower frequency and intensity approaches are used. This report describes the development of the PBC methodology focusing on the Rapid Recovery Clinic (RRC) comprised of 182 patients with a primary diagnosis of a mood disorder, the largest of the 14 PBC clinics created. Over an 18-month period, wait times were reduced from several months to less than one week and recovery rates, meaning no longer in an acute phase, were 63% and 78% at weeks 6 and 12, respectively for patients who engaged in the program.

OBJECTIVE: The objective of this paper is to assess implementation facilitators and challenges for advanced team-based care (aTBC) in a federally qualified health center (FQHC). In aTBC, care team coordinators room patients, perform vitals and agenda setting during patient intake, and remain present alongside providers during patient visits.
METHODS: The authors conducted a qualitative post-hoc analysis of the aTBC implementation using data from several sources. They used content analysis to code items as facilitators or challenges and thematic analysis to group those into larger themes. Finally, they applied a priori codes from the revised consolidated framework for implementation research (CFIR) to organize the facilitators and barriers into subdomains.
RESULTS: The existing evidence-base around aTBC, the FQHC\'s ability to pilot and adapt it, and strong implementation leads were key facilitating factors. Challenges included an external shock (i.e., the COVID-19 pandemic), aTBC complexity, and uncertainty about whether success required implementation of the full model versus easier-to-integrate smaller components.
CONCLUSIONS: FQHCs that wish to implement aTBC models need strong champions and internal structures for piloting, adapting, and disseminating interventions. FQHC leaders must think strategically about how to build support and demonstrate success to improve an FQHC\'s chances of expanding and sustaining aTBC.

BACKGROUND: Despite decades of evidence demonstrating the efficacy of hypertension care delivery in reducing morbidity and mortality, a majority of hypertension cases remain uncontrolled. There is an urgent need to elucidate and address multilevel facilitators and barriers clinical staff face in delivering evidence-based hypertension care, patients face in accessing it, and clinical systems face in sustaining it. Through a rigorous pre-implementation evaluation, we aimed to identify facilitators and barriers bearing the potential to affect the planned implementation of a multilevel technology-facilitated hypertension management trial across six primary care sites in a large federally qualified health center (FQHC) in New York City.
METHODS: During a dedicated pre-implementation period (3-9 months/site, 2021-2022), a capacity assessment was conducted by trained practice facilitators, including (1) online anonymous surveys (n = 124; 70.5% of eligible), (2) hypertension training analytics (n = 69; 94.5% of assigned), and (3) audio-recorded semi-structured interviews (n = 67; 48.6% of eligible) with FQHC leadership and staff. Surveys measured staff sociodemographic characteristics, adaptive reserve, evidence-based practice attitudes, and implementation leadership scores via validated scales. Training analytics, derived from end-of-course quizzes, included mean score and number attempts needed to pass. Interviews assessed staff-reported facilitators and barriers to current hypertension care delivery and uptake; following audio transcription, trained qualitative researchers employed a deductive coding approach, informed by the Consolidated Framework for Implementation Research (CFIR).
RESULTS: Most survey respondents reported moderate adaptive reserve (mean = 0.7, range = 0-1), evidence-based practice attitudes (mean = 2.7, range = 0-4), and implementation leadership (mean = 2.5, range = 0-4). Most staff passed training courses on first attempt and demonstrated high scores (means > 80%). Findings from interviews identified potential facilitators and barriers to implementation; specifically, staff reported that complex barriers to hypertension care, control, and clinical communication exist; there is a recognized need to improve hypertension care; in-clinic challenges with digital tool access imposes workflow delays; and despite high patient loads, staff are motivated to provide high-quality cares.
CONCLUSIONS: This study serves as one of the first to apply the CFIR to a rigorous pre-implementation evaluation within the understudied context of a FQHC and can serve as a model for similar trials seeking to identify and address contextual factors known to impact implementation success.
BACKGROUND: ClinicalTrials.gov NCT03713515 , date of registration: October 19, 2018.