Innovation & Transformation in Primary Care
OHSU's Department of Family Medicine studies how innovation and transformation in primary care works, and how it affects clinical workflow, workforce, and patients' health outcomes. We experiment with new tools and functions in the electronic health record; implementation of care teams; integration of physical, mental and behavioral health; and expansion of new types of services to be more patient-centered. We also pioneer the use of health data to inform innovation and transformation efforts through the use of dashboards and reporting.
Innovation & Transformation in Primary Care
Innovative Methods for Parents and Clinics to Create Tools for Kids' Care (IMPACCT)
Principal Investigators: Deb Cohen, PhD;Jen DeVoe, MD,
DPhil
This project engages stakeholder groups (including families,
policy makers, and CHCs) in an iterative process to develop patient-centered IT
tools that facilitate Community Health Centers' ability to conduct public
health insurance outreach to families of their pediatric patients. The tools
will be adapted from IT strategies proven to help patients and clinics manage
chronic diseases.
Principal Investigator: Deb
Cohen, PhD
This study thoroughly examines an innovative and novel technological
solution in the Epic EHR that can be used as a model for documenting, sharing,
and monitoring patients' mental and physical health needs and that holds
promise for defragmenting current information systems and supporting integrated
clinical practice.
Principal Investigator: Deb
Cohen, PhD
This study focuses on identifying the clinically relevant information
that clinicians and clinical teams commonly need when caring for complex
patient populations, and examine how clinical teams use health IT to address
the social and economic circumstances that are often central to their complex
patients' health and healthcare (known as social determinants of health). The
information needs are identified to ensure effective care coordination for
complex patients through extensive ethnographic assessment and interviews, and
employ state-of-the-art user-centered design methods to rapidly develop and
test health IT tools that address these needs.
Principal Investigator: Jen
DeVoe, MD, DPhil
This project will
conduct a clinic-level cluster randomized trial in 12 CHCs (~47,000 patients
aged 18-64) to test the effectiveness of Community-based HIT Tools
for Cancer Screening and Health Insurance romotion
("CATCH-UP" tools) at improving rates of (1) cancer screening and
prevention services, and (2) health insurance coverage. The CATCH-UP tools are
designed to identify and reach uninsured CHC patients who are eligible for
enrollment in public insurance coverage, and to encourage re-enrollment of
publicly-insured patients before coverage gaps occur.
Principal Investigator: Scott Fields, MD
The goal of this project is to develop the infrastructure to
create and utilize a system of quality analytics (the tools used to drive
decisions and actions), design the educational programs necessary to prepare
physicians to manage and analyze information and processes of continuous
quality improvement, and build a partnership between clinicians and researchers
to study the effectiveness of data-based interventions and delivery system
improvements on quality care.
Principal Investigator: Ern
Teuber, PhD
For more than 15 years it has served the generally
underserved population of southeast Portland, an area with two designated
Medically Underserved Areas. It is also a training site for 12 family medicine physician
residents. As a Federally Qualified Health Center, the clinic has received
supplemental funding for projects in the following areas:
Maternity/Perinatal: Grow and strengthen capability for labor and deliveries. Improve
services for prenatal care, newborn home visits, prenatal and parenting
education, and coordination of care. Grow the opportunities for residents to
participate in supervised deliveries.
Clinical Pharmacy: Involvement
in medication therapy management, working directly with patients and primary
care providers about effective management of disease through medications,
medication reconciliation, and home visits to assess the total pharmacological
picture.
Behavioral Health Integration (BHI): Establish appropriate leadership for
implementation of behavioral health integration practice change strategies,
identify and implement the most appropriate health risk assessment data
collection tools, divide our patient population into groups with similar needs
and probabilities for improvement, define the most appropriate pathways for
addressing the health risks of each segmented patient group, develop and test
appropriate "pathways" for each population segment, promote patient-centered
development and implementation of self-care plans, and create the
infrastructure to track and evaluate the process.
Principal Investigator: John
Muench, MD
This project develops a teaching faculty that delivers
training curriculum with high fidelity that increases learners' knowledge, attitudes,
and behavior towards delivering SBIRT to patients as part of routine care. It
will more fully actualize the integration of behavioral health providers into
primary care settings in Oregon by meeting the training needs of both medical
clinicians and behavioral health specialists, producing a critical mass of
medical professionals who can perform, implement, and sustain evidence-based
SBIRT practices into the future. The goal is to deliver training curricula to
at least 150 medical residents at OHSU, 405 social work students at Portland
State University (PSU), and 125 counseling students at Oregon State University
(OSU)-Cascades.