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Past MWCN Research & Publications

Diabetes Group Visits

Staff were trained to conduct a 6-month Group Visits (GV) intervention at six community health centers (CHCs) for adults with uncontrolled diabetes from the MWCN. Patient satisfaction was analyzed using postintervention surveys. Clinician satisfaction was analyzed through pre and post-training surveys and 1:1 semi-structured interviews. Twenty-seven staff and clinicians were trained. 51 adult patients were enrolled and 90% reported high satisfaction with the program. Patients enjoyed longer visits with peer support and felt better equipped to manage barriers to diabetes control. 88% of staff reported that they enjoyed taking part in the program and noted improved team morale, professional development, and increased interdisciplinary collaboration. Perceived challenges of GVs included time investment for a new program, integration into workflow, and staff turnover. Patient and staff satisfaction was high across multiple domains. Staff noted many benefits but reported challenges with patient recruitment and retention as well as the time needed to implement GVs. Naik, A.G., Staab, E., Li, J., Siddiqui, S., Wan, W., Schaefer, C.T., Campbell, A., Quinn, M. and Baig, A.A., (2023). Factors related to recruitment and retention of patients into diabetes group visits in Federally Qualified Health Centers. Journal of Evaluation in Clinical Practice, 29(1), pp.146-157. Baig, A., Staab, E.M., Benitez, A., Hermans, A., Ham, S.A., Wan, W., Campbell, A., Schaefer, C.T, and Quinn.M.T. (2022) "Impact of diabetes group visits on patient clinical and self-reported outcomes in community health centers." BMC Endocrine Disorders 22, no. 1: 1-10 Barnes, P. A., Barouhas, I., Staab, E.M., Benitez, A., Li, J., Campbell, A., Schaefer, C.T., Quinn, M.T., and Baig, A.A. (2022) "Assessing the effectiveness of a diabetes group visit training for health center staff: a pilot study of five Midwestern community health centers." BMC Health Services Research 22, no. 1 pp 1-10. Dinh, T., Staab, E., M., Nunez, D. Zhu, M., Wan, W., Schaefer, C., T., Campbell, A., Quinn, M., T., and Baig. A., A., "Evaluating virtual group visits for diabetes care during the COVID-19 pandemic." Journal of General Internal Medicine (2022): S143-S143. Nuñez, D., Marino-Nuñez, D., Staab, E., M. Dinh, T., Zhu, M., Wan,W., Schaefer, C., T., Campbell, A., Quinn, M., T.,and Baig. A., A. (2022) "Adapting in-person diabetes group visits to a virtual setting across federally qualified health centers." Frontiers in Health Services 2. Baig, A. A., Staab, E.M., Siddiqui, S., Zhu, M., Wan, W., Schaefer, C.T., Campbell, A., and Quinn, M.T. (2021)"Impact of diabetes group visit on patient clinical outcomes: results from a cluster randomized intervention trial among midwestern health centers." In Journal of General Internal Medicine, vol. 36, no. SUPPL 1, pp. S43-S43. Mannion, S. E., Staab, E.M., Li, J., Benitez, A., Wan, W., Campbell, A., Schaefer, C.T., Quinn, M.T., and Baig. A.A. (2021) "Patient and clinician satisfaction with diabetes group visits in community health centers." Journal of Patient Experience 8: 23743735211056467 Barnes, P.A., Staab, E.M., Campbell, A., Schaefer, C., Quinn, M.T., and Baig, A.A. (2020). Organizational factors influencing the early implementation process of Diabetes group visits by five Midwestern Community Health Centers: A Multisite Case Study Analysis. Population Health Management.

Community Health Center Program Integration Implementation

A survey was mailed to 128 community health centers (CHCs) in the MWCN in 2016 to assess associations between program characteristics and stage of integration implementation (precontemplation, contemplation, preparation, action, or maintenance). Content analysis of open-ended responses identified integration barriers. RESULTS: Response rate was 60% (N = 77). Most CHCs had co-located behavior health (BH) and primary care services, warm hand-offs from primary care to BH clinicians, shared scheduling and electronic health record (EHR) systems, and depression and substance use disorder screening. Thirty-two CHCs (42%) indicated they had completed integration and were focused on quality improvement (maintenance). Being in the maintenance stage was associated with having a psychologist on staff, a system for tracking referrals, a registry, primary care primary home designation, and a lower proportion of Black/African American patients. The most common barriers to integration were difficulty recruiting and retaining BH clinicians and inadequate reimbursement. Staab, E.M., Wan, W., Li, M., Quinn, M.T., Campbell, A., Gedeon, S., Schaefer, C., and Laiteerapong, N.(2022). Integration of primary care and behavioral health services in Midwestern Community Health Centers: A Mixed Methods Study. Families, Systems, and Health.

Behavioral Health in Community Health Centers

Two surveys were given 132 MWCN community health centers (CHCs): The Health Center Survey and the Behavioral Health and Diabetes Provider Survey. A total of 77 CHCs and 515 primary care clinicians, respectively, responded to the surveys. RESULTS: CHCs that received Medicaid behavioral health reimbursement were five times as likely as those that did not to offer addiction counseling and to employ certified addiction counselors. CHCs that received targeted HRSA funding for addiction services were more than 20 times as likely as those that did not to provide MAT and more than three times as likely to employ psychiatrists. Staab, E. M., Wan, W., Campbell, A., Gedeon, S., Schaefer, C., T., Quinn, M., T., and Laiteerapong, N., (2022)"Elements of integrated behavioral health associated with primary care provider confidence in managing depression at Community Health Centers." Journal of General Internal Medicine: 1-10. Staab, E. M., Wan,W., Li,M. Quinn, M.T., Campbell, A., Gedeon, S., Schaefer, C.T., and Laiteerapong, N.(2022) "Integration of primary care and behavioral health services in midwestern community health centers: A mixed methods study." Families, Systems, & Health 40, no. 2 :182. Laiteerapong, N., Staab, E.M., Wan, W., Quinn, M.T., Campbell, A., Gedeon, S., Schaefer, C.T., Burnet, D.L., and Chin, M.H. (2021). Integration of Diabetes and depression care is associated with glucose control in Midwestern Federally Qualified Health Centers. Journal of General Internal Medicine. Jones, E., Staab, E., Wan, W., Quinn, M., Schaefer, C., Gedeon, S., Campbell, A., Chin, M., and Laiteerapong, N. (2020). Addiction treatment capacity in Health Centers: The role of Medicaid reimbursement and targeted grant funding. Psychiatric Services.

Provider and Staff Perceptions of Integrated Care

This cross-sectional study was conducted to develop and test of the Provider and Staff Perceptions of Integrated Care Survey (PSPIC), a 21-item questionnaire that was sent to 2,936 providers and staff at 100 community health centers (CHCs) in the MWCN; 781 (30%) responded from 97 CHCs. The 21-question PSPIC appears to be an internally consistent measure of integrated care as used by providers and staff working at CHCs. Item analyses indicate that all questions were more strongly correlated with their theoretical domain based on the Framework for Measuring Integrated Patient Care than with the other six domains. Derrett, S., Gunton, K., Samaranayake, A., Singer, S., Nocon, R., Quinn, M., Breheny, M., Campbell, A., Schaefer, C., Heuer, L., & Chinn, M. (2019) “Development and testing of the provider and staff perceptions of the integrated care (PSPIC) survey”. The Journal for Medical Care Research and Review, 76(6): 807-829.

Community Health Center Access to Resources

Between August 2010 and November 2010, a survey was mailed to 1,471 eligible providers at 97 community health center (CHC) sites affiliated with MWCN. A 28-item questionnaire included multiple-choice questions on participant and workplace characteristics and CHC resources. We analyzed survey data from 577 providers and staff who manage diabetes from 85 sites. Respondents were labeled as high proportion (HP) providers if >25 % of their site’s diabetes population was Latino. HP providers were more likely than non-HP providers to have access to physician’s assistants and certified diabetes educators, but less access to endocrinologists. HP providers had greater access to Spanish-speaking providers, on-site interpreters, culturally tailored diabetes education programs, and community outreach programs. Providers at HP sites reported greater access to a range of personnel and culturally tailored programs. Baig, A., Benitez, A., Locklin, C., Campbell, A., Schaefer, C.T., Heuer, L., Sang, M.L., Solomon, M., Quinn,M.,T., Burnet, D.L., Chin, M.H.,(2014). “Community Health Center provider and staff’s Spanish language ability and cultural awareness”. Journal of Health Care for the Poor and Undersrved, 25(2): 527-545. Baig, A., Locklin, C., Campbell, A., Schaefer, C., Heuer, L., Lee, S., & ... Chin, M. (2013). “Community Health Center access to resources for their patients with diabetes”. Journal of Immigrant and Minority Health / Center for Minority Public Health, January 12, 1557-1920.

Combating Obesity at Community Health Centers

The MWCN partnered with University of Chicago to develop the Combating Obesity at Community Health Centers (COACH) quality improvement collaborative. This pilot study aimed to determine whether the QI model can be feasibly implemented with limited resources at community health centers (CHCs) to improve weight management programs. Five CHCs with weight management programs enrolled with CHC staff as primary study participants. Tailored coaching addressed local needs. Topics rated most valuable were patient recruitment/retention strategies, QI techniques, evidence-based weight management, motivational interviewing. Challenges included garnering provider support, high staff turnover, and difficulty tracking patient-level data. This paper reports practical lessons about implementing a weight management QI collaborative in CHCs. Wilkes, A. E., John, P. M., Vable, A. M., Campbell, A. a., Heuer, L. a., Schaefer, C. T., & ... Burnet, D. L. (2013). “Combating obesity at Community Health Centers (COACH): A quality improvement collaborative for weight management programs”. Journal of Health Care for The Poor and Underserved, 24(2), 47-60.

Patients with Limited Health Literacy in Community Health Centers

To examine techniques used by community health center (CHC) providers to care for patients with limited health literacy (LHL). A survey was mailed to 803 CHC providers in the MWCN to measure what the perceived level of LHL was at CHCs. RESULTS: the average provider estimates of LHL prevalence among English-speaking and Spanish-speaking patients were 41% ±24% and 48% ±30%, respectively. Those with training in health literacy were more likely to have patients repeat instructions back to check understanding and were more likely to give out health education materials designed for patients with LHL. Providers differed by type in encouraging patients to bring friends or family members to appointments. Providers estimate LHL to be highly prevalent in their CHCs, and use various techniques to assist patients. Schlichting, J.A., Quinn, M.T., Heuer, L. J., Schaefer, C.T., Drum, M.L., & Chin, M.H., (2007). “Provider perceptions of limited health literacy in Community Health Centers.” Patient Education and Counseling, 69¸114-120.

Hypertension and Hyperlipidemia Management in Community Health Centers

We invited the 145 community health centers (CHCs) who were members of the MWCN in 2000 to provide a list of names of all providers who worked with patients with hypertension and hyperlipidemia We explored 251 providers’ (licensed practical nurses, registered nurses, physicians, physician assistants) perceptions of barriers to effective management of hypertension and hyperlipidemia from 72 CHCs. We developed a 76-question survey to address potential major barriers to providing optimal care within the key barrier domains. RESULTS: Providers in this study generally chose hypertension and hyperlipidemia target levels that met or were more stringent than national guidelines, but lacked confidence to address behavioral change and reported obstacles to modifying patient lifestyle. Kirchhoff, A.C., Drum, M.L., Zhang, J. X., Schlichting, J.A., Levie, J., Harriason, J.F., Lippold, S., Schaefer, C. T., & Chinn, M.H. (2008). “Hypertension and hyperlipidemia management in patients treated at community health centers.” Journal of Clinical Outcomes Management, 15(3), 125-131. Cook, S., Drum, M.L., Kirchhoff, A.C., Levie, J., Harrison, J.F., Lippold, S, Schaefer, C.T., & Chin, M. (2006) “Providers, assessment of barriers to effective management of hypertension and hyperlipidemia in Community Health Centers.” Journal of Health Care for the Poor and Underserved, 17(1), 70-85

Evaluation of the Diabetes Health Disparities Collaborative

To evaluate the Diabetes Health Disparities Collaborative, an initiative by the Bureau of Primary Health Care to reduce health disparities and improve the quality of diabetes care in community health centers. We reviewed charts of 969 random adults for American Diabetes Association standards, surveyed 79 diabetes quality improvement team members, and performed qualitative interviews. RESULTS: The performance of several key processes of care assessed by chart review increased, including rates of HbA1c measurement, eye examination referral, foot examination, and lipid assessment. Mean value of HbA1c tended to improve. Over 90% of survey respondents stated that the Diabetes Collaborative was worth the effort and was successful. Major challenges included needing more time and resources, initial difficulty developing computerized patient registries, team and staff turnover, and occasional need for more support by senior management. Birken, S., Lee, S., Weiner, B., Chin, M., Chiu, M., & Schaefer, C. (2015). “From strategy to action: How top managers' support increases middle managers' commitment to innovation implementation in health care organizations”. Health Care Management Review, 40 (2), 159-68 Birken, S. A., Lee, S., Weiner, B. J., Chin, M. H., & Schaefer, C. T. (2013). “Improving the effectiveness of health care innovation implementation: Middle managers as change agents”. Medical Care Research & Review, 70(1), 29-45. doi:10.1177/1077558712457427 Chien, A.T., Kirchhoff, A.C., Schaefer, C.T., Huang, E.S., Brown, S.E., Heuer, L., Graber, J., Tang, H., Casalino, L.P., & Chin, M.H. (2010). “Positive and negative spillover of the Health Disparities Collaborative in federally qualified health centers: Staff perceptions.” Medical Care, 48 (12), 1050-1056. Zhang, J. X., Huang, E.S., Drum, M. L., Kirchhoff, A. C., Schlichting, J. A.; Schaefer, C. T., Heuer, L. J., & Chin, M. H. (2009). “Insurance status and quality of diabetes care in community health centers.” American Journal of Public Health, 99 (4), 742-747 Cheung, K., Moiduddin, A., Chin, M.H., Drum, M.L., Brown, S.E.S., Graber, J.E., Heuer, L., Quinn, M.T., Schaefer, C.T., Walters, A.E., & Huang, E. S. (2008). “The perceived financial impact of quality improvement efforts in community health centers.” Journal of Ambulatory Care Management, 31(2), 111-119. Chin,M.H., Kirchhoff, A.C., Schlotthauer, A.E., Graber, J.E., Brown, S.E., Rimington, A., Drum, M.L., Schaefer, C.T., Heuer, L.J., Huang, E.S., Shook, M.E., Tang, H., & Casalino, L.P. (2008). “Sustaining quality in community health centers: Perceptions of leaders and staff.” The Journal of Ambulatory Care Management, 31(4), 319-329. Graber, J.E., Huang, E.S., Drum, M.L., Chin, M.H., Walters, A. E., Heuer, L., Tang, T., Schaefer, C.T., & Quinn, M.T. (2008). “Predicting changes in staff morale and burnout at community health centers participating in the health disparities collaboratives.” Health Services Research, 43 (4), 1403-1423. Huang, E.S., Brown, S.E.S., Zhang, J.X., Kirchhoff, A.C., Schaefer, C.T., Casalino, L.P., & Chin, M.H. (2008) “The cost consequences of improving diabetes care: The community health center experience.” The Joint Commission on Quality and Patient Safety, 34, 138-146. Chin M.H., Drum, M.L., Guillen, M., Rimington, A., Levie, J. R., Kirchhoff, A.C., Quinn, M.T., & Schaefer, C.T. (2007) “Improving and sustaining Diabetes care in Community Health Centers with the Health Disparities Collaboratives.” Medical Care, 45 (12), 1135-1143. Chin, M.H., Cook, S., Drum, M.L., Jin, L.,Guillen, M., Humikowski, C.A., Koppert, J., Harrison, J.F., Lippold, S., Schaefer, C.T., & Midwest Cluster Health Disparities Collaborative. (2004) “Improving diabetes care in Midwest Community Health Centers with the Health Disparities Collaborative” Diabetes Care, 27(1), 2-8

Quality of Diabetes Care in Community Health Centers

This study assessed the quality of diabetes care in community health centers (CHCs). From 55 midwestern CHCs, we reviewed the charts of 2865 diabetic adults for American Diabetes Association measures of quality. Each CHC was asked to randomly select up to 80 adults between 18 and 75 years of age with diabetes for the 1995 year. RESULTS: On average showed, 70% of the patients in each community health center had measurements of glycosylated hemoglobin, 26% had dilated eye examinations, 66% had diet intervention, and 51% received foot care. The average glycosylated hemoglobin value per CHC was 8.6%. Practice guidelines were independently associated with higher quality of care. Chin, M.H., Cook, S., Jin, L., Drum, M.L., Harrison, M.F., Koppert, J., Theil, F., Harrand, A.G., Schaefer, C.T., Takashima, H.T., & Chiu, S.C. (2001) “Barriers to providing diabetes care in Community Health Centers” Diabetes Care, 24(2), 268-74 Chinn, M.H., Auerbach, S.B., Cook, S, Harrison, J.F., Koppert, J., Jin, L., Theil, F., Karrison, T.G., Harrand, A.G., Schaefer, C., Takashima, H.T., Egbert, N., Chiu, S.C., & Mn Nabb (2000) “Quality of diabetes care in Community Health Center” American Journal of Public Health, 90(3), 431-4

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