Social determinants of health affect a person’s health at least as much as their interactions with the healthcare system. Increased patient activation and self-efficacy are associated with decreased cost and improved quality. Patient-reported health confidence has been proposed as a more easily measured proxy for self-efficacy. Evaluation of the association between unmet social needs and health confidence is limited. Our objective was to identify and address our patients’ unmet social needs and assess health confidence levels. From November 2017 through July 2018 we screened 2018 patients of an urban academic family medicine residency practice for unmet social needs, measured their health confidence, and made referrals to community resources if desired. Patients reporting the presence of any social need reported lower health confidence scores on average than those with no needs (8.49 vs 9.30, median 9 vs 10, Wilcoxon test P < .001). Low health confidence scores (<7) were strongly associated with number of needs ( P < .001) after adjusting for age, gender, race, ethnicity, payer, and visit type (1 vs 0 needs, odds ratio [OR] = 2.566, 95% CI 1.546-4.259; 2 or more vs 0 needs, OR = 6.201, 95% CI 4.022-9.561). Results of this quality improvement project suggest that patients with unmet social needs may have decreased perceived ability to manage health problems. Further study is needed to determine if this finding is generalizable, and if interventions addressing unmet social needs can increase health confidence.

PURPOSE We compared the transformation experience of 2 family medicine practices that implemented the Primary Care Redesign (PCR) team-based model to improve access, quality, and experience without increasing cost. The University of Colorado's A.F. Williams Family Medicine clinic (pilot practice) implemented the model in February 2015, and a smaller, community-based practice (wave 2 practice) did so 2 years later, in February 2017. METHODS The PCR model increased the ratio of medical assistants to clinicians from about 1:2 to 2.5:1 while expanding the role of the medical assistants, through enhanced rooming procedures, in-room support (eg, scribing), postclinician wrap-up, and in-basket assistance. We assessed access, clinical quality metrics, staffing costs, and clinician and staff experience and burnout for at least 7 months before and 42 months after the intervention. RESULTS In the pilot practice, compared with preimplementation, there were improvements in total appointments and rates of hypertension control, colorectal cancer screening, and most diabetic quality metrics. In the wave 2 practice, total appointments increased slightly when clinicians were added pre-PCR and then increased substantially after implementation; initially variable hypertension control improved rapidly after implementation. The wave 2 practice's colorectal cancer screening improved gradually, then accelerated postimplementation, while diabetic metrics initially remained stable or declined, then improved postimplementation. New patient appointments began to increase for both practices in late 2015, but grew faster in the pilot practice under PCR. Over time, all experiential domains improved for clinicians; most remained stable for staff. Clinician burnout was reduced by at least one-half in both practices except during low staffing periods, which also adversely affected staff. After a ramp-up period, the number of staff hours per visit remained stable. CONCLUSIONS The PCR model is associated with simultaneous improvements in quality, access, and clinician experience, as well as reductions in burnout, while maintaining staffing costs.

PURPOSE EvidenceNOW Southwest is a cluster-randomized trial evaluating the differential impact on cardiovascular disease (CVD) care of engaging patients and communities in practice transformation in addition to standard practice facilitation support. The trial included development of locally tailored CVD patient engagement materials through Boot Camp Translation (BCT), a community engagement process that occurred before practice recruitment but after cluster randomization. METHODSWe introduce a cluster randomization method performed before recruitment of small to medium-size primary care practices in Colorado and New Mexico, which allowed for balanced study arms while minimizing contamination. Engagement materials for the enhanced study arm were developed by means of BCT, which included community members, practice members, and public health professionals from (1) metropolitan Denver, (2) rural northeast Colorado, (3) Albuquerque, and (4) rural southeast New Mexico. Outcome measures were messages and materials from BCTs and population characteristics of study arms after using geographic-based covariate constrained randomization. RESULTSThe 4 BCTs' messages and materials developed by the BCT groups uniquely reflected each community and ranged from family or spiritual values to early prevention or adding relevance to CVD risk. The geographic-based covariate of a cluster randomization method constrained randomization-assigned regions to study arms, allowing BCTs to precede practice recruitment, reduce contamination, and balance populations.CONCLUSIONS Cluster-randomized trials with community-based interventions present study design and implementation challenges. The BCTs elicited unique contextual messages and materials, suggesting that interventions designed to help primary care practices decrease CVD risk may not be one size fits all. 3 The benefits of engaging patients and families in the care of individual patients is well established.4-11 The outcomes of engaging communities, patients, and families at the practice level, however, are less well documented.12,13 The EvidenceNOW: Advancing Heart Health in Primary Care is an Agency for Healthcare Research and Quality grant initiative dedicated to using the latest evidence to improve the heart health of Americans. EvidenceNOW Southwest is a regional cooperative that has sought to test the differential impacts on cardiovascular disease (CVD) of interventions focused on patient, family, and community engagement to standard practice transformation approaches. S59In EvidenceNOW Southwest, enhanced-arm practices received practice facilitation plus additional support to engage patients and families in practice transformation. These practices were able to order free heart health materials that were developed through a community engagement method known as Boot Camp Translation (BCT) in 4 communities within the enhanced-arm geographic regions (2 in Colorado, 2 in New Mexico). Community members and health professionals worked together to learn about complex health to...

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