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Objective: According to the Joint Commission (2012), about 80% of serious medical errors are related to miscommunication between healthcare providers. The Joint Commission (2012) recommended the utilization of standardized communication tools to reduce the number of medical errors related to the miscommunication. The Situation-Background-Assessment-Recommendation (SBAR) communication tool is a standardized tool that has been used to improve the effectiveness of communication between healthcare providers. The purpose of this project was to evaluate the effectiveness of using SBAR communication tool for warm handoff between primary care providers and behavioral health providers in order to provide a continuous and complete transition of care for patients with psychiatric disorders or psychosocial issues. Method: A mixed method design was implemented in an integrated primary care clinic at two locations in Phoenix, Arizona. A brief presentation about the SBAR tool and copies of the SBAR tool was provided for the clinic staff. Data were gathered from four participants (two nurse practitioners and two behavioral health workers) using structured observation, pre-and post-test surveys, and structured interviews. Length of study was one month. Results: During the data collection, there were 40 observed warm handoffs, 12 unobserved warm handoffs between primary care nurse practitioners and behavioral health workers. Seventy-five percent of the participants felt that the SBAR helped them in organizing their thoughts and providing/obtaining adequate information during warm handoff. They reported satisfaction when using the SBAR tool. There was no statistically significant difference in the scores of collaboration and satisfaction about care decisions between pre and post-SBAR intervention. Conclusion: The SBAR communication tool has the potential to improve communication between primary care providers and behavioral health workers to improve the quality and safety of care for patients with psychosocial concerns. Utilizing SBAR may increase teamwork and ensures adequate hand-off information on the warm handoff. Multiple PDSA cycles should be conducted to refine the change and make it applicable and sustainable in the integrated care setting.

Suicide is an issue that plagues adolescents in the United States. Suicide crosses socioeconomic, racial, and gender divides and is difficult to predict and prevent. Primary care providers (PCPs) are in a position to detect suicidality in adolescents; however, PCPs lack the knowledge and confidence necessary to accurately identify suicidal adolescents. The author conducted an extensive review of current literature (meta-analyses, systematic reviews, literature reviews, case reports, and existing clinical practice guidelines) on identification of adolescent suicidality in pediatric primary care settings. This paper provides a set of recommendations for primary care providers on how to properly identify adolescents with suicidal ideation and behavior.

The Patient Protection and Affordable Care Act (ACA) aimed to increase accessibility to medical resources for those previously uninsured. Certainly, the ACA has expanded insurance to millions of Americans, however, the evidence and discourse surrounding health accessibility calls into question why, despite the growth of insured Americans, the increase in health insurance coverage under the ACA has not lead to greater accessibility for low income minorities. I propose that disparities in preventive care, the emergency room, and primary care provider services stand as barriers for low income minorities. Insurance coverage does not necessarily equate to greater accessibility if individuals do not have the means to utilize those resources.

Youth tobacco use is a public health concern in the United States (U.S.) with about 2.8 million middle and high school youth reporting current tobacco use in 2023. Healthcare providers (HCPs) can play a crucial role in addressing youth tobacco use through screening and counseling, yet rates of these interventions are suboptimal. Tennessee has a high prevalence of youth tobacco use and not much is known about these interventions in Northeast Tennessee. This study has several objectives: 1) conduct a scoping review of available evidence on screening and counseling for youth tobacco use and identify related gaps; 2) assess youth self-reported rates of HCPs’ screening and counseling for tobacco use among U.S. youth, and identify associated factors; 3) explore HCPs’ experiences and identify barriers and facilitators in implementing screening and counseling interventions for youth tobacco use in Northeast Tennessee; and 4) provide recommendations for policy and practice based on identified gaps. This multi-method study employed 1) a scoping review, adhering to the Johanna Briggs Institute methodology; 2) a cross-sectional analysis of data from the 2022 National Youth Tobacco Survey using logistic regression models; 3) a qualitative study using a blended-inductive coding of semi-structured interviews and thematic analysis, and 4) a research brief highlighting the policy and practice implications of study findings. The scoping review analyzed 22 articles and revealed disparities in HCPs’ tobacco screening and counseling interventions. The quantitative study showed tobacco screening and counseling rates of 43.7% and 3 45.6%, respectively. Younger youth (9–12 years) and non-Hispanic (NH) Black, Hispanic, and NH Asian youth were less likely to receive screening and counseling compared to NH White youth. In-depth interviews with 12 primary care providers (PCPs) revealed varying levels of confidence in screening and counseling for tobacco use. PCPs primarily conduct formal screening for older youth (12–18 years), and barriers such as time constraints, lack of confidentiality, and resistance from youth were frequently mentioned. Efforts should be made to improve screening and counseling interventions for youth tobacco use by implementing policies to reduce barriers and increase HCPs’ awareness regarding early intervention for all age groups, races, and ethnicities.

Fibromyalgia (FMS) goes undiagnosed in as many as 3 out of 4 people who have the disease. Primary care providers (PCPs) are the first to evaluate patients; therefore, PCPs need to be able to recognize FMS, implement initial treatment, and refer for further consultation. The Fibromyalgia Diagnostic Screening Tool (FDST), a validated instrument to identify FMS, can improve the speed and accuracy of FMS diagnosis. The purpose of this project was to familiarize PCPS with the FDST, evaluate their receptiveness to the tool, and train them in its use. The Leventhal, Diefenbach, and Levanthal, common sense model of illness provided the theoretical framework to guide this quality improvement project. A 45-minute in-service and accompanying reference manual was given to 4 participating PCPs, along with a demographic questionnaire asking about their age, race, gender, marital status, and years in practice. Following the in-service, a 10-question self-completed questionnaire consisting of a combination of open-ended and nominal scale yes/no questions, was administered. A thematic analysis revealed 2 primary barriers for diagnosis without the FDST: lengthy screening time and trouble differentiating FMS from a patient's other conditions. In response to one of the yes/no questions, the participants all replied that the in-service on FDST was helpful in diagnosing FMS. Implications for social change include improved diagnosis with a diagnostic screening instrument, improved quality of health care, and cost effectiveness at the system level for chronic disease prevention and management. This project demonstrates in a localized primary care setting that the FDST may offers PCPs a reliable method to diagnose FMS.

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After cancer patients have completed active cancer treatment, they have specific follow-up care needs. These needs include ongoing surveillance for new and recurring cancers, managing the side effects of cancer treatment, and psychosocial concerns (Rushton et al., 2015). In the past, cancer centres and oncology specialists provided follow-up care; however, new models of care are needed because cancer centres can no longer provide treatment and follow-up care to all cancer survivors (Jefford et al., 2022). To allocate health care resources, low risk cancer survivors (i.e., breast and colorectal cancer survivors) are being discharged from cancer centres after primary treatment back to their primary care provider (PCP) for follow-up care. Survivorship care plans (SCPs) have been identified as a tool to help survivors and their PCPs with this transition (Rushton et al., 2015). SCPs generally consist of a treatment summary, a schedule for follow-up and surveillance tests, and general health recommendations (i.e., diet and exercise; Howell et al., 2011; Ruston et al., 2015). While SCPs are widely accepted, research on their effectiveness as transition tools has been inconclusive (Hill et al., 2019; Jacobsen et al., 2018). Some studies show positive, neutral, and negative impacts of SCP use, and there are three potential reasons for these mixed findings: 1) there is wide variety in the content, format, delivery, and timing of SCPs which adds considerable variance when studying the impact of SCPs; 2) the use of outcomes to measure the usefulness of SCPs as transition tools that are beyond the scope that information about treatment history and follow-up guidelines could impact and; 3) that SCPs are not effective as transition tools (Hill et al., 2019; Jacobsen et al., 2018). An important first step in clarifying whether SCPs are effective transition tools is to understand how SCPs are being used in real world practice (Hill et al., 2019; Jacobsen et al., 2018). The overall purpose of this study was to develop best practice recommendations for implementing SCPs. This was achieved through three study objectives: 1) to comprehensively identify barriers and facilitators perceived to influence SCP use among cancer survivors and primary care providers (PCPs); 2) to identify evidence-based approaches to address barriers and enhance facilitators of SCP use; and 3) to develop best practice recommendations that can be used by implementors of SCPs that are adaptable across different contexts. Article 1 presents the results of semi-structured interviews with breast and colorectal cancer survivors who had received a SCP at least 12 months prior to the interview. The interviews were based on the Theoretical Domains Framework, version two (TDF-2; Cane et al., 2012) and comprehensively identified barriers and facilitators of SCP use amongst breast and colorectal cancer survivors. Thirty cancer survivors (17 female, 13 male) participated in the 30–45-minute interviews, which were then analyzed using content and thematic analysis. Survivors who had received education about the purpose of SCPs and how to use them reported finding their SCP helpful and that they used it to schedule appointments and communicate with their healthcare providers. Barriers to SCP use that were reported by cancer survivors included having lost or not remembering receiving a SCP, not understanding the importance of their SCP, and wanting information about additional supports to be able to follow the SCP (e.g., regular contact from the cancer centre, avenues for peer support). Overall, study 1 found that in order to SCPs to be used as intended transition tools, survivors benefit from receiving education about how to use them and be informed of the expectation that they be actively involved in their follow-up care. Article 2 presents the TDF-based semi-structured interviews with primary care providers (PCPs). Thirteen PCPs completed 15-20 minute interviews, and content and thematic analysis was conducted. PCPs reported finding SCPs helpful and that they contained relevant information to provide follow-up care. A key facilitator of using the SCP was the table of follow-up tasks (e.g., mammography, colonoscopy) and their frequencies included in the SCP. Two significant barriers for PCPs using SCPs were: a) logistical issues with ordering follow-up tests and receiving results; and b) a lack of clear avenues to consult with oncology specialists (e.g., managing side effects of medications, actions that need to be taken when follow-up tests are abnormal). Overall, article 2 showed that PCPs appreciate and readily use SCPs, and contextual changes to facilitate clear avenues of communication between primary and tertiary care may be beneficial when implementing SCPs. Article 3 is a methodology article that presents a detailed explanation and rationale for the implementation science frameworks used and the data analysis chosen. The TDF-2 and Behaviour Change Techniques Taxonomy (BCTTv1; Michie, et al., 2008; Michie et al., 2013). The Human Behaviour Change Project researchers have empirically linked the 14 TDF domains to behaviour change techniques (BCTs), which allowed for multiple options to be developed to address barriers (and promote facilitators) of SCP use among breast and colorectal cancer survivors and PCPs (https://theoryandtechniquetool.humanbehaviourchange.org/tool; Michie et al., 2021). Using the TDF and BCTTv1 showed a dynamic between oncology specialists (e.g., oncologists, oncology nurses), cancer survivors, and PCPs that is involved in ensuring SCPs are implemented in an optimal way. A logic model was used to organize the barriers and enablers into different phases of SCP development, content, delivery, and use by PCPs and cancer survivors in their follow-up care (Mills et al., 2019). A flowchart organizing the recommendations of implementing SCPs was developed, and comprised 10 steps representing interrelationships between cancer centers, PCPs, and cancer survivors. The detailed methodology article also includes lessons learned and suggestions for implementation science researchers using the TDF and BCTTv1. Finally, article 4 is written for anyone looking for guidance implementing SCPs or improving upon how SCPs have been implemented already. It differs from article 3 in that it provides practical solutions for implementers. Because this work generated many recommendations, article 4 provides a worked example of how to use the results of this study. It is written in a way that outlines who would benefit from using the recommendations, and how to use the flow chart to narrow down the recommendation to those most relevant to implementors. The recommendations are organized into one of the 10 relationships in the flow chart, along with the purpose of the recommendations, how to implement it, to whom the recommendation targets, and those responsible for enacting the recommendations. The core factors associated with facilitating SCP use by PCPs and cancer survivors were: a) a treatment summary and follow-up guidelines included in the SCP; b) SCP provided to both cancer survivors and their PCP; and c) educating cancer survivors about their role as self-managers of their own care and the expectation that they participate in their follow-up cancer care. Future research on the usefulness of SCPs in follow-up care should include detailed information about the content, format, and receivers of SCPs and the outcomes most realistically influenced by the information included in SCPs. Before throwing the proverbial baby out with the bathwater, the implementation of SCPs requires additional standardization before meaningful investigation of their effectiveness as transition tools can be conducted.

Background: While value-based payment models emphasizing care coordination have been widely implemented to improve quality and lower expenditures, supporting empirical evidence is sparse. Our objective was to quantify the impact of specialist-to-primary care physician involvement within accountable care organization (ACO) and its association with lower spending. Methods: We conducted a retrospective cohort study of Medicare Shared Savings Program ACOs from 2012-2016 using publicly available data provided by the Centers for Medicare and Medicaid Services at the ACO level. We examined the association between the proportion of primary care services delivered by specialists versus other types of care providers and ACO spending using a generalized estimating equation model. Results: The analytic dataset included 1381 MSSP-years. When compared to ACOs at the lowest (60) levels of providing primary care services through specialists, ACOs who had 35% to 40% of primary care services delivered by specialists spent $1,124 (95% CI, $358 to $1,891) and $969 (95% CI, $250 to $1,688) less per capita, respectively. When stratified at varying levels of specialists providing primary care services, having four years of experience in the Medicare Shared Savings Program was consistently associated with lower spending when compared to having one to three years of experience. Conclusions and Relevance: The optimal portion of specialists providing primary care services - to reduce spending - was found to be 35% to 40%. These findings suggest that integrating specialists in to the activities and objectives of MSSP ACOs could lead to lower spending and better performance.