A number of evidence-based preventive services have been recommended by the United States Preventive Services Task Force, the Advisory Committee on Immunization Practices, and disease-specific guideline developers but delivery of most of these services remains suboptimal. Some reasons include lack of time and staff, misaligned reimbursement mechanisms, and lack of coordination. The Care Model recommends the use of registries to drive proactive, population-based care. The Institute of Medicine has urged closer alignment of primary care and public health. Accountable Care Organizations and other payment reform concepts require collaboration between primary care clinicians and hospitals. We propose to implement, evaluate, and spread a sustainable, rural county-based preventive service delivery model in which wellness coordinators (WCs), working with primary care practices (PCPs), county health departments (CHDs), and hospitals, help patients obtain evidence-based preventive services. These entities will be linked by County Health Improvement Organizations (CHIOs) that we are developing currently in Oklahoma, as part of the federally funded IMPaCT project. The WCs will use a registry connected to a patient portal and health risk appraisal tool that are also linked to practice records through a regional health information exchange system. This registry makes it possible to track delivery and receipt of preventive services and to estimate individuals'life expectancies and changes in life expectancies in response to interventions. In addition to the WCs and registry functions, we will help PCPs develop systematic processes to address tobacco use and physical inactivity using established implementation strategies (performance feedback, academic detailing, and practice facilitation). Grant funds will be used by the participating counties for initial advertising and promotions and for 50% of the salaries and benefits of the WCs, the remainder to be contributed in-kind by the counties. The PI and QI Coordinator will be responsible for project administration, WC training, supervision of IT interface development, and PCP training and support. We will document a variety of standard contextual variables, track delivery of a list of preventive services, and document changes in estimated life expectancies. A separate Financial Analysis Team will analyze the cost and financial benefits and produce appropriate reports. Costs and benefits will be tracked from the perspectives of the CHDs, PCPs, and hospitals. As benefits accrue, CHIOs will accept more financial responsibility and grant funds will be used to spread the model to additional counties. The PI and Financial Analysis Team will develop a guidebook for use by other counties that wish to replicate the model. We expect that the model will increase delivery/receipt of preventive services by 10-40% depending on their baseline, increase average estimated population life expectancy (LE) by 3-6 months per year of participation, and produce a financial return on investment of 2.5:1 for CHDs, hospitals, and PCPs. In summary, we will use advanced health information technology and established implementation strategies to increase delivery of evidence-based preventive services to approximately 70,000 individuals cared for by about 59 clinicians in 20 primary care practices within 3 rural counties. Then, by disseminating the information gained, we will make it easier for other counties to implement similar models. This project will advance a number of AHRQ priority research areas, including care coordination in rural and underserved populations, prevention, health information technology / exchange, patient-centered care, primary care redesign, and population health.
We propose to implement a sustainable, county-based preventive services delivery model that aligns incentives for primary care practices (PCPs), county health departments (CHDs), and hospitals in 3 rural counties. Wellness coordinators will remind patients of recommended primary (immunizations), secondary (screening), and tertiary (chronic disease management) services and direct them to the most appropriate services and resources. Primary care practices will implement systematic screening for tobacco use and physical inactivity and provide brief counseling and referrals. The model will be supported by a comprehensive, web-based Preventive Services Registry and Wellness Portal/Health Risk Assessment tool interfaced to PCPs'electronic health record systems (EHRs). We expect to reach about 70,000 patients cared for by 59 clinicians in 20 primary care practices (PCPs), increasing delivery of preventive services and average estimated life expectancies, while producing financial and other benefits (e.g. improved health care quality metrics, a better community-level coordination of care, etc) to local hospitals, PCPs, and county health departments (CHDs). We will carefully document context, implementation, and outcomes in a guidebook that can be used to spread the model to other rural counties.