Teledermatology Operational Considerations, Challenges, and Benefits: The Referring Providers' Perspective

Implementation of a dermatology teletriage system to improve access in an underserved clinic: A retrospective study

The American Academy of Pediatrics (AAP) policy statement entitled “The New Morbidity Revisited: A Renewed Commitment to the Psychosocial Aspects of Pediatric Care”1 from the Committee on Psychosocial Aspects of Child and Family Health is found in this month's issue of Pediatrics . Few experienced pediatric practitioners would disagree with this description of our life's work. Most embrace this “renewed commitment” to relevant and comprehensive care for our children and families. It is not hard to look past the examination room and appreciate the struggles, tensions, and morbidities that this complex world presents our patients as they grow and develop. But what about the complex world of our practices? We are well-intended, but are we well-trained, and are we able to follow through on our “commitment”? “ Mental health needs of children and adolescents are increasing while access to behavioral health, mental health, and substance abuse service is decreasing .”2 The rate of psychosocial problems identified by primary care physicians in the children they care for has increased from 7% to 18% in the past 20 years. Information accumulated by the Pediatric Research in Office Settings (PROS) group3 confirmed what practicing pediatricians already know: the children we see for earaches bring with them symptoms of their behavioral health. These children may have attentional difficulties, conduct issues, or significant problems of mood. They may suffer acute adjustment difficulties or evidence posttraumatic stress from physical, emotional, or sexual abuse, and may experience family poverty, family divorce, or a host of other intrinsic or situational problems that impact on their health and the ability of their family and caregivers to provide for their health. We are seeing more problems and, lacking referral sources, often have to provide more care. Skills needed to address the new morbidities are part of our …

Provider perceptions regarding barriers to and facilitators of hepatitis C (HCV) treatment initiation and adherence have not been fully evaluated in the interferon-free treatment era. New treatments have provided opportunities for non-specialists to treat HCV, underscoring the importance of understanding primary care provider (PCP) and specialist perspectives. Based on qualitative sampling principles, 12 PCPs and 12 hepatology providers (HPs) from the VA Pittsburgh Healthcare System completed audio-recorded semi-structured interviews. Qualitative analysts coded perceived barriers and facilitators from the interviews with 100% double coding. Codes were thematized and analyzed using Atlas.ti. Key barriers to treatment described by HPs and PCPs included patients' substance use disorders, mental health, transportation availability, history of non-adherence, and concern about side effects. PCPs also focused on medication cost as a system-based barrier. The main facilitators of treatment initiation and adherence described by both HPs and PCPs were provider education and encouragement. HPs focused almost exclusively on provider-based facilitators, while PCPs noted patient-based facilitators including past adherence, media exposure to information about HCV medications, a desire to clear the virus, and positive feedback regarding treatment response. Providers generally focused on perceived patient-level barriers to HCV treatment initiation and adherence, as well as provider-level facilitators; PCPs additionally noted patient preferences and system-level issues that guide decision making regarding treatment initiation. While HPs focused almost exclusively on provider-level facilitators, PCPs additionally focused on patient-level facilitators of treatment. These data provide novel insights and suggest focusing on patient, provider, and system-level strategies to further improve HCV treatment initiation and adherence.

Introduction: Student-run free clinics (SRFCs) are a recent popular addition to medical school education, and a subset of studies has looked at the influence of SRFC volunteering on the medical student’s career development. The majority of the research done in this area has focused on understanding if these SRFCs produce physicians who are more likely to practice medicine in underserved communities, caring for the uninsured. The remainder of the research has investigated if volunteering in an SRFC influences the specialty choice of medical school students. The results of these specialty choice studies give no definitive answer as to whether medical students chose primary or specialty care residencies as a result of their SRFC experience.Keeping Neighbors in Good Health through Service (KNIGHTS) is the SRFC of the University of Central Florida College of Medicine (UCF COM). Both primary and specialty care is offered at the clinic. It is the goal of this study to determine if volunteering in the KNIGHTS SRFC influences UCF COM medical students to choose primary care, thereby helping to meet the rising need for primary care physicians in the United States.Methods: A survey was distributed to first, second, and third-year medical students at the UCF COM to collect data on demographics, prior volunteering experience, and specialty choice for residency. Responses were then combined with records of volunteer hours from the KNIGHTS Clinic and analyzed for correlations. We analyzed the frequency and Pearson’s chi-squared values. A p value of less than 0.05 was considered statistically significant.Results: Our survey had a total response rate of 39.8%. We found that neither the act of becoming a KNIGHTS Clinic volunteer nor the hours volunteered at the KNIGHTS Clinic influenced the UCF COM student’s choice to enter a primary care specialty (p = NS). Additionally, prior volunteering/clinical experience or the gender of the medical school student did not influence a student’s choice to volunteer at the KNIGHTS Clinic.Discussion: Volunteering at KNIGHTS Clinic did not increase student choice to enter primary care, with students choosing other specialties at equal rates, probably due to the variety of specialties present at the KNIGHTS Clinic. This suggests that the volunteer attending physicians present at an SRFC may influence the choice of residency for students. It also suggests that SFRCs are not a viable tool to increase the number of primary care doctors in the United States.

Nearly 14.5 million individuals are enrolled in California's Medicaid program, better known as "Medi-Cal." Medi-Cal enrollees receive their primary care from both Federally Qualified Health Centers (FQHCs) and non-FQHC clinics and providers. However, not much is known about the extent to which subgroups of Medi-Cal enrollees use these different providers. Developing a better understanding of where different subgroups of Medi-Cal enrollees receive their primary care could inform efforts to improve support for primary care providers and the patients they serve. Using Medi-Cal data from 2022, RAND researchers identified and described the types of providers delivering primary care to Medi-Cal enrollees overall and by select patient characteristics, including race or ethnicity, age, geography, and levels of English-language proficiency. With these data, they were able to (1) identify the providers delivering primary care services to enrollees in FQHC and non-FQHC settings, (2) pinpoint key characteristics about these providers, (3) examine what percentage of providers deliver a high proportion of primary care visits to Medi-Cal enrollees, and (4) determine whether this percentage varies by Medi-Cal enrollee group and county.

BackgroundCurrent educational strategies to integrate HIV care into primary medical care in Central America have traditionally targeted managers or higher-level officials, rather than local health care workers (HCWs). We developed a complementary online and on-site interactive training program to reach local HCWs at the primary care level in underserved communities.MethodsThe training program targeted physicians, nurses, and community HCWs with limited access to traditional onsite training in Panama, Nicaragua, Dominican Republic, and Guatemala. The curriculum focused on principles of HIV care and health systems using a tutor-supported blended educational approach of an 8-week online component, a weeklong on-site problem-solving workshop, and individualized project-based interventions.ResultsOf 258 initially active participants, 225 (225/258 = 87.2%) successfully completed the online component and the top 200 were invited to the on-site workshop. Of those, 170 (170/200 = 85%) attended the on-site workshop. In total, 142 completed all three components, including the project phase. Quantitative and qualitative evaluation instruments included knowledge assessments, reflexive essays, and acceptability surveys. The mean pre and post-essay scores demonstrating understanding of social determinants, health system organization, and integration of HIV services were 70% and 87.5%, respectively, with an increase in knowledge of 17.2% (p<0.001). The mean pre- and post-test scores evaluating clinical knowledge were 70.9% and 90.3%, respectively, with an increase in knowledge of 19.4% (p<0.001). A survey of Likert scale and open-ended questions demonstrated overwhelming participant satisfaction with course content, structure, and effectiveness in improving their HIV-related knowledge and skills.ConclusionThis innovative curriculum utilized technology to target HCWs with limited access to educational resources. Participants benefited from technical skills acquired through the process, and could continue working within their underserved communities while participating in the online component and then implement interventions that successfully converted theoretical knowledge to action to improve integration of HIV care into primary care.

Primary health care system in transition: the patient's experience.

This paper presents service provider perspectives about primary health care services for refugee and refugee claimant mothers when their preschool child had an acute and minor illness. Information was collected from primary health care providers in Hamilton Ontario between August 2004 and February 2006 as part of a larger study about the health of children in recently arrived refugee and refugee claimant families. Primary health care providers in this study represented the full array of primary health care services available at the time. Information included details of services available and preparation of staff to work with a diverse population including immigrants in general and refugees in particular. The main finding was that primary health care providers and staff had little or no training and preparation for working with refugee or refugee claimant families and had little understanding about health insurance or their entitlement to health care. Services were significantly reduced in number and variety after 5pm and during nights or weekends; most providers reported that they would accept refugees and fewer reported that they would accept refugee claimants as clients. The conclusion of this study was that primary health care providers need training for working with culturally diverse populations and in particular clear information about health insurance for refugee and refugee claimant families. Disparities in health care have been associated with limited cultural sensitivity, lack of knowledge or awareness of support systems including health insurance for refugees and refugee claimants and failures in understanding. These factors limit access to needed health care services and diminish the effectiveness of services provided. Recent changes to health insurance eligibility for refugees and refugee claimants are concerning as entitlements to health insurance have been reduced or eliminated.

California's Medicaid program, Medi‐Cal, expanded its benefits in July 2022 for older members to include an annual screening for dementia. Providers using this benefit were required to take an accompanying training and therefore funded a program called Dementia Care Aware to provide the training and disseminate it to eligible primary care clinicians across the state. Led by the University of California, San Francisco (UCSF), Dementia Care Aware initially partnered with other UC campuses and dementia‐focused community‐based organizations to realize the goal of reaching primary care in all of California's 58 counties. As of October 2024, Dementia Care Aware continues in a partnership between the West Health Institute and UCSF. Attendees will learn the key accomplishments of the program, including the training of almost 6000 learners in the state; the process and outcomes of creating the screening approach called the “cognitive health assessment”; strategies for attracting more learners; environmental factors improving or hindering uptake of the training and screening benefit; and the success in building a research consortium in two county public health systems (Los Angeles, San Francisco) to study the impact of screening programs there on the quality of care provided to patients who screened positive. The presentation will summarize the key learnings and challenges of standing up a statewide program to support diverse primary care practices in taking up a cognitive screening benefit for low‐income residents.

BackgroundThere are gaps in knowledge and understanding about the relationships between primary care and community-based health and social services in the context of healthy aging at home and system navigation. This study examined provider perspectives on: a) older adults’ health and social needs; b) barriers to accessing services; c) the nature of relationships between primary care and health and social services; and d) ways to facilitate primary care and health and social services navigation to optimize older adults’ health.MethodsFour focus groups were conducted involving providers (n = 21) in: urban primary care clinics and health and social services organizations serving older adults in Hamilton, Ontario, Canada. Purposive sampling was employed to recruit community health and social services managers, directors or supervisors and primary health care providers in a Family Health Team via email.ResultsHealth and social services needs were exacerbated for community-dwelling older adults with multiple chronic conditions. Strong family/caregiver social support and advocacy was often lacking. Access barriers for older adults included: financial challenges; lack of accessible transportation; wait times and eligibility criteria; and lack of programs to address older adults’ needs. Having multiple providers meant that assessments among providers and older adults resulted in contradictory care pathways. Primary care and health and social services linkages were deficient and complicated by poor communication with patients and health literacy barriers. Primary care had stronger links with other health services than with community-based health and social services; primary care providers were frustrated by the complex nature of health and social services navigation; and care coordination was problematic. Health and social services referred older adults to primary care for medical needs and gathered patient information to gauge program eligibility, but not without challenges.ConclusionsResults point to strategies to strengthen primary care and health and social services system navigation for older adults including: using a person-focused approach; employing effective primary care and health and social services communication strategies; applying effective system navigation; building trust between primary care and health and social services providers; advocating for improved program access; and adapting services/programs to address access barriers and meet older adults’ needs.

Do Canada and the United States Differ in Prevalence of Depression and Utilization of Services?

<h3>Context</h3> Tools designed for primary care clinicians to provide cancer survivorship care have been largely oncology-driven without considering primary care needs. <h3>Objective</h3> Describe requirements of primary care-centered cancer survivorship care delivery interventions with EHR-integrated tools. <h3>Study design and analysis</h3> As part of an NCI-funded hybrid type 1 effectiveness-implementation study using co-design principles and practice facilitators, a prototype of an EHR-integrated breast cancer survivorship intervention was implemented in 13 primary care practices. Facilitator fieldnotes recorded practice champions’ engagement and reflections on the intervention during facilitation meetings. A research team met weekly to qualitatively analyze the fieldnotes, using an editing style to identify suggestions for new tools, improvements, and workarounds. We iteratively reviewed coded segments, developed categories of latent needs, and refined themes. <h3>Setting</h3> Large integrated health system <h3>Population studied</h3> 36 practice champions (clinicians, office managers, medical assistants) <h3>Intervention</h3> Virtual facilitation <h3>Outcome measures</h3> Suggestions for improvements, new tools, and workarounds. <h3>Results</h3> Champion suggestions were informed by their experiences and need for actionable information to provide clarity on their role in survivorship follow-up. Easy identification and documentation of cancer history were considered critical but often inadequate within their current EHR. Suggestions culminated in the following design requirements for a primary care-centered intervention to support breast cancer survivorship care delivery: (1) Include oncology-directed, summarized, accessible information about treatment history and follow-up care (2) Adjust to and account for differences in clinician documentation and patient preferences, (3) Address patient and clinician ambivalence about the relevance of cancer history to current care, (4) Provide role clarity both across clinicians on the care team and within the practice setting on responsibilities, and (5) Integrate into existing workflows. <h3>Conclusions</h3> Cancer survivorship care remains ambiguous in primary care, making it challenging to design tools for this context. Engaging practices using co-design principles can leverage ambiguity to uncover tacit needs and recommendations. Future development of interventions for primary care delivery of survivorship care should consider these requirements.

Exploring the Generalist-Subspecialist Interface in Internal Medicine

Context: Diabetes care in the Netherlands is acknowledged to be outstanding and ranked second in the latest Euro Diabetes Index.Type 2 diabetic patients are treated predominantly in the primary care groups.Patients with more complex co-morbidities and type 1 diabetic patients are treated in secondary care.Systematic and nationwide care quality assessment is rather well developed in primary care, but not in secondary care.Due to such lack of information, overall care assessment and further improvement is not possible. Pilot:In 2014, eight hospitals collaborated with Achmea the largest Dutch healthcare insurance company and the diabetes centre Zwolle to perform a first formal survey on diabetes core set data in secondary care in the Netherlands.This was an observational pilot study to test the feasibility of standardised data collection in secondary care comparable to the methods used in primary care in the Netherlands.

Objective: Much has been written about the patients’ perspectiveconcerning weight management in health care. The purpose of this survey studywas to assess perspectives of primary care providers (PCPs) and nurses towardpatient weight management and identify possible areas of growth. Patientsand Methods: We emailed a weight management–focused survey to 674eligible participants (437 [64.8%] nurses and 237 [35.2%] PCPs) located in 5outpatient primary care clinics. The survey focused on opportunities, practices,knowledge, confidence, attitudes, and beliefs. A total of 219 surveys werereturned (137 [62.6%] from nurses and 82 [34.4%] from PCPs).Results: Among 219 responders, 85.8% were female and 93.6% werewhite non-Hispanic. In this study, PCPs and nurses believed obesity to be amajor health problem. While PCPs felt more equipped than nurses to addressweight management (P < .001) and reported receiving moretraining than nurses (50.0% vs 17.6%, respectively), both felt the need for moretraining on obesity (73.8% and 79.4%, respectively). Although, PCPs also spentmore patient contact time providing weight management services versus nurses(P < .001), the opportunity/practicesscore was lower for PCPs than nurses (−0.35 ± 0.44 vs −0.17 ± 0.41,P < .001) with PCPs more likely to say they lacked thetime to discuss weight and they worried it would cause a poor patient-PCPrelationship. The knowledge/confidence score also differedsignificantly between the groups, with nurses feeling less equipped to deal withweight management issues than PCPs (−0.42 ± 0.43 vs −0.03 ± 0.55,P < .001). Neither group seemed very confident, withthose in the PCP group only answering with an average score of neutral.Conclusion: By asking nurses and PCP general questions aboutexperiences, attitudes, knowledge, and opinions concerning weight management inclinical care, this survey has identified areas for growth in obesitymanagement. Both PCPs and nurses would benefit from additional educationaltraining on weight management.