BACKGROUND:Practice facilitation (or practice coaching) is a scientifically supported approach for improving evidence-based guideline adoption in primary care. Practice facilitation has historically occurred in person; however, the COVID-19 pandemic led to the adoption of many hybrid and virtual practice facilitation (VPF) projects. The impact of VPF on quality improvement (QI) implementation outcomes is unknown. The purpose of this study was to describe the relationship between VPF and implementation of 18 evidence-based QI strategies, based on a hybrid cardiovascular QI project in 49 primary care clinics in Michigan. METHODS:This was an exploratory study drawing on interviews and descriptive statistics. The authors conducted interviews with 5 practice facilitators (PFs) to identify their perspectives on the strategies most appropriate for VPF and perceived effects of VPF on implementation. Descriptive statistics were used to report practices' use of VPF and total implementation scores after 12 months. RESULTS:Approximately 20% (62 of 304) of facilitation meetings were virtual. PFs reported that in-person facilitation was beneficial for strategies involving observation, demonstration, and workflow changes (for example, blood pressure measurement); virtual facilitation was appropriate for strategies involving information sharing (for example, referrals to quit line). Practices that received some or all of their QI time virtually showed a larger increase in total implementation score after one year, compared to those who received all visits in person. CONCLUSION:Some QI strategies, particularly those involving information sharing, may be well suited to VPF, while others that require observation or workflow change may benefit from in-person support. Practices that used at least some VPF showed greater improvements in implementation scores, though future research is needed to more rigorously assess how facilitation modality relates to implementation outcomes.

Burnout is prevalent among primary care clinicians, largely driven by systemic issues influencing how care is provided, documented, and reimbursed. Worksite health centers (WHCs), usually funded directly by employers, may shield clinicians from some of these pressures, yet little is known about their work environment. This mixed-methods study provides preliminary information on burnout among clinicians from twelve randomly selected WHCs and their perspectives on factors that mitigate or exacerbate stress associated with working in a WHC. We used Mini Z 2.0, a validated survey tool, and semi-structured interviews to assess burnout. Nineteen participants responded to the survey, and 11 of them also participated in an interview. Thirty-two percent of respondents reported experiencing burnout. Being able to follow up with patients regularly, having ample time with patients, and not being subject to Medicare and Medicaid requirements helped mitigate stress. Limitations of electronic health records systems, low patient utilization, and interference by company sponsors exacerbated stress. This study provides a first look at clinician burnout in WHC. Future research should be directed to validating these findings in a larger sample and identifying the positive characteristics of WHCs that may apply broadly to primary care, particularly regarding workforce sustainability and resource management reform.

BACKGROUND:Evidence-based quality improvement (QI) interventions and strategies often require adaptation before implementation in new settings. The goal of this study was to describe the adaptation process of QI strategies from an evidence-based cardiovascular initiative, previously tested in community-based primary care clinics, for use in worksite health centers (WHC). Participating WHCs were located at large manufacturing plants. The adapted QI strategies were offered as part of the Healthy Hearts in Manufacturing initiative. METHODS:Our team followed the ADAPT-ITT framework to adapt the QI strategies for twelve randomly selected WHCs. Meetings were held with WHC leaders, and semi-structured interviews were conducted with WHC clinicians and staff to understand current workflows and identify contextual factors that could help or hinder the implementation of the QI strategies. Data were analyzed using qualitative content analysis. Adaptations were then identified and developed by clinical experts and a practice facilitator, with input from an Advisory Panel. Proposed adaptations were shared with WHC leaders and clinicians for feedback before implementation protocols were finalized. RESULTS:Phase 1 (Assessment) showed that manufacturing communities had high rates of heart disease and its risk factors. Four QI interventions from the Million Hearts campaign were selected for implementation using evidence-based QI strategies during Phase 2 (Decision). Phase 3 (Administration) revealed helpful implementation factors, including strong patient-clinician relationships and leadership support, as well as hindering factors, including deficiencies of electronic health records systems, high staff turnover, and poor patient adherence to treatment. These factors informed the Phase 4 (Production) development of implementation materials, for example, tailored blood pressure measurement protocols and patient educational tools. During Phase 5 (Topical experts), clinicians and WHC leaders provided feedback on the adaptations, which were then integrated in Phase 6 (Integration) into a flexible implementation protocol for the practice facilitator. The final phase (Testing) is ongoing. CONCLUSION:This study describes the adaptation process of a primary care cardiovascular QI initiative to meet the unique clinical settings of WHCs. The findings suggest that with contextual adaptation of QI strategies, WHCs have the potential to implement evidence-based interventions to improve cardiovascular care, providing insights for future initiatives in non-traditional clinical care settings.

Background Unhealthy alcohol use is a leading cause of preventable mortality and a risk factor for an array of social and health problems. The Intervention in Small primary care Practices to Implement Reduction in unhealthy alcohol use (INSPIRE) study is part of a nationwide campaign to improve the identification and treatment of patients engaging in unhealthy alcohol use. Methods We conducted a single arm, pragmatic study consisting of seventeen primary care practices in the Chicago metropolitan area, Wisconsin, and California across two waves with a 6-month latent period, a 12-month intervention period, followed by a 6-month sustainability period. Enrolled practices were independent, Federally Qualified Health Centers, network-based, and academic health centers. INSPIRE utilized the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework to examine implementation feasibility, fidelity, and performance of clinicians on practice adoption of screening, brief intervention, referral to treatment (SBIRT) and medication for unhealthy alcohol use (MAUD) activities in primary care clinics. Results Seventeen eligible primary care practices were enrolled over the course of 21 months beginning in March of 2020 through December of 2021. There was a pause in recruitment from March of 2020 through July of 2020 due to the Covid-19 pandemic. The majority of enrolled practices were small (<6 clinicians) and were part of a network. 57% of clinicians completed the educational modules in part or in full.This paper will outline the INSPIRE protocol and design. Additionally, we will present practice demographic data, recruitment data and results related to on-line learning module completion. Conclusion The INSPIRE study will evaluate the ability of primary care clinicians in small practices to participate in practice education programs and implement standard screening and treatment protocols, adapted for documentation in the electronic health record (EHR). The study will also identify the factors that facilitated or hindered improvement and sustainability using quantitative and qualitative analysis methods.

BACKGROUND:Clinical guidelines recommend medications from four drug classes, collectively referred to as quadruple therapy, to improve outcomes for patients with heart failure with reduced ejection fraction (HFrEF). Wide gaps in uptake of these therapies persist across a range of settings. In this qualitative study, we identified determinants (i.e., barriers and facilitators) of quadruple therapy intensification, defined as prescribing a new class or increasing the dose of a currently prescribed medication. METHODS:We conducted interviews with physicians, nurse practitioners, physician assistants, and pharmacists working in primary care or cardiology settings in an integrated health system or federally qualified health centers (FQHCs). We report results with a conceptual model integrating two frameworks: (1) the Theory of Planned Behavior (TPB), which explains how personal attitudes, perception of others' attitudes, and perceived behavioral control influence intentions and behaviors; and (2) the Consolidated Framework for Implementation Research (CFIR) 2.0 to understand how multi-level factors influence attitudes toward and intention to use quadruple therapy. RESULTS:Thirty-one clinicians, including 18 (58%) primary care and 13 (42%) cardiology clinicians, participated in the interviews. Eight (26%) participants were from FQHCs. A common facilitator in both settings was the belief in the importance of quadruple therapy. Common barriers included challenges presented by patient frailty, clinical inertia, and time constraints. In FQHCs, primary care comfort and ownership enhanced the intensification of quadruple therapy while limited access to and communication with cardiology specialists presented a barrier. Results are presented using a combined TPB-CFIR framework to help illustrate the potential impact of contextual factors on individual-level behaviors. CONCLUSIONS:Determinants of quadruple therapy intensification vary by clinician specialty and care setting. Future research should explore implementation strategies that address these determinants by specialty and setting to promote health equity.

ObjectiveThe aim of the study was to systematically review the cost-effectiveness or return on investment (ROI) from worksite health centers (WHCs) in the US.MethodsWe searched four databases and the gray literature for studies that conducted economic evaluation and provided economic outcomes of US-based WHCs. The quality and risk of bias were assessed using JBI Critical Appraisal Tools of Economic Evaluations.ResultsTen studies met the inclusion criteria. Nine reported WHCs were cost-effective or yielded positive ROI for employers, with annual cost savings per WHC ranging from $35,479 to $2,124,723 and ROI from $1.09 to $15.88 per $1 of investment. Key contributors to higher ROI included company size, utilization, and duration of operations.ConclusionsWHCs may provide economic savings for large employers. Future studies should consider clinical effectiveness and service quality and investigate the specific mechanisms driving employer cost savings.Protocol RegistrationPROSPERO (CRD42024506086)

Background Heart disease is the leading cause of mortality in the United States and contributes more than $320 billion annually in health care costs and lost productivity. Manufacturing employment is associated with higher rates of hypertension and smoking. Many large manufacturers provide health services to employees and their family members through worksite health centers (WHCs). Several quality improvement interventions for hypertension and tobacco cessation have shown to be effective in community-based primary care sites. The Healthy Hearts in Manufacturing (HHM) study aims to implement and test these interventions in WHCs. Methods Two organizations that operate WHCs at manufacturing sites volunteered to participate in the 58-month HHM research study. The HHM intervention involves monthly coaching to assist WHCs with implementing evidence-based strategies for hypertension management and tobacco cessation advocated by the Million Hearts initiative and the U.S. Preventive Services Task Force. A pragmatic, Type II hybrid effectiveness-implementation study design is used to evaluate HHM. The approach is inspired by the stepped-wedge cluster-randomized trial to assess intervention effectiveness. We will conduct interviews to identify facilitators and barriers to implementation and budget impact analysis to estimate the financial impact of the HMM interventions and the potential healthcare savings to companies and Medicare. Results Twelve WHCs were randomly selected to enroll in HHM. The WHCs are in nine states and provide primary care services for employees and family members of four manufacturing companies. Baseline patient smoking rates ranged from 13% to 59% across WHCs. The percentage of patients with blood pressure of 140/90 or greater ranged from 7% to 56% across WHCs. Conclusion This exploratory five-year research study will identify facilitators and barriers to implementing the HHM interventions in WHCs, evaluate the effectiveness of hypertension management and use of tobacco screening and cessation, and provide evidence of HHM’s potential cost-effectiveness for employers and Medicare.

Objective(s)To investigate the impact of consumer direction programs on caregivers of older adults and people living with disabilities (PLWD). Consumer direction programs provide older adults and PLWD with the authority to direct their own care, including hiring family and friends to provide personal care services. By allowing recipients and families to have a say in how their needs are met and financially reimbursing family caregivers for their time, consumer direction may also improve outcomes for caregivers.Data SourcesSearch was conducted in eight databases (PubMed, CINAHL, PsycINFO, Embase, Cochrane, Scopus, Global Health, Web of Science) and the gray literature.Study SelectionQuantitative and mixed-methods studies that reported any outcomes related to the caregiver were included. Two authors independently screened studies; two additional authors resolved conflicts.Data ExtractionExtracted data included study setting and design, participant characteristics, description of consumer direction program, and caregiver outcomes. Two authors independently appraised risk of bias using Joanna Briggs Institute checklists. Data extraction was completed by one author and verified by a second author.Data SynthesisSeventeen articles were included in this review. Consumer direction programs were associated with caregivers’ 1) increased respite care use, 2) better personal wellbeing, 3) intention to continue caring for recipient, 4) perception of choice, and 5) improved access to services/decreased unmet needs as reported by caregivers in all studies that examined these outcomes. There were inconsistent findings for improvement of caregivers’ physical and mental health, employment, financial wellbeing, and reduction of caregiver burden.ConclusionsConsumer direction may improve outcomes for caregivers through supporting caregivers’ wellbeing and caregiving needs. By supporting caregivers, consumer direction may also enable caregivers to care for their loved ones at home longer. Future studies should examine what aspects of consumer direction are associated with caregiver outcomes (e.g., caregiver payment, increased control).Author(s) DisclosuresS.K. is a postdoctoral fellow supported by the National Institute on Disability, Independent Living, and Rehabilitation Research (Grant No. 90ARPO0001).

OBJECTIVE:The aim of the study was to systematically review the cost-effectiveness or return on investment (ROI) from worksite health centers (WHCs) in the US. METHODS:We searched four databases and the gray literature for studies that conducted economic evaluation and provided economic outcomes of US-based WHCs. The quality and risk of bias were assessed using JBI Critical Appraisal Tools of Economic Evaluations. RESULTS:Ten studies met the inclusion criteria. Nine reported WHCs were cost-effective or yielded positive ROI for employers, with annual cost savings per WHC ranging from $35,479 to $2,124,723 and ROI from $1.09 to $15.88 per $1 of investment. Key contributors to higher ROI included company size, utilization, and duration of operations. CONCLUSIONS:WHCs may provide economic savings for large employers. Future studies should consider clinical effectiveness and service quality and investigate the specific mechanisms driving employer cost savings. PROTOCOL REGISTRATION:PROSPERO (CRD42024506086).

Objectives Hypertension is associated with high morbidity and mortality. The complications of hypertension disproportionately impact African American residents in Chicago’s South Side neighborhood. To inform the implementation of an evidence-based multilevel hypertension management intervention, we sought to identify community member– and clinician-level barriers to diagnosing and treating hypertension, and strategies for addressing those barriers. Methods We conducted 5 focus groups with members of faith-based organizations (FBOs) (n=40) and 8 focus groups with clinicians and administrators (n=26) employed by community health centers (CHCs) located in Chicago’s South Side. Results Participants across groups identified the physical environment, including lack of access to clinics and healthy food, as a risk factor for hypertension. Participants also identified inconsistent results from home blood pressure monitoring and medication side effects as barriers to seeking diagnosis and treatment. Potential strategies raised by participants to address these barriers included (1) addressing patients’ unmet social needs, such as food security and transportation; (2) offering education that meaningfully engages patients in discussions about managing hypertension (eg, medication adherence, diet, follow-up care); (3) coordinating referrals via community-based organizations (including FBOs) to CHCs for hypertension management; and (4) establishing a setting where community members managing hypertension diagnosis can support one another. Conclusions Clinic-level barriers to the diagnosis and treatment of hypertension, such as competing priorities and resource constraints, are exacerbated by community-level stressors. Community members and clinicians agreed that it is important to select implementation strategies that leverage and enhance both community- and clinic-based resources.

Research ObjectivesIn response to the Veteran pain crisis and the national opioid epidemic, the TelePain-Empower Veterans Program (EVP) was developed as a non-pharmacological intervention to help Veterans manage chronic pain. This evaluation aimed to identify determinants of program implementation, user experiences, and benefits and challenges to participation.DesignQualitative descriptive evaluation using semi-structured telephone interviews, as part of a larger mixed-methods prospective study.SettingA Veterans Health Administration facility in southeastern United States.ParticipantsData were collected with program leaders (n=3), staff (n=10), and Veteran participants (n=15).InterventionsTelePain-EVP is a 10-week synchronous virtual pain management training program incorporating complementary integrated health, acceptance and commitment therapy, and mindful movement.Main Outcome MeasuresInterview questions aligned with the Consolidated Framework for Implementation Research (CFIR). Rapid analysis was used to generate themes for actionable feedback to inform implementation.ResultsCFIR domains and constructs emerged as relevant to program implementation, including innovation, inner and outer settings, individuals, and implementation processes. Identified determinants informed factors which were facilitators and barriers to implementation. Clinical care and administrative respondents reported on factors relevant to intervention characteristics, technology factors, team dynamics and organizational and structural characteristics, which impact implementation. Analysis of Veteran reports gleaned data about intervention experience, outcomes, and recommendations for improving the intervention from a patient-centered perspective.ConclusionsRemotely delivered pain management programs provide a nonpharmacological approach while improving access to care and benefitting participants with chronic pain. Data findings warrant electronic data collection for TelePain-EVP to improve accountability and real-time outcomes assessment. Data warrant consideration for using centralized staff and data management networks to address Staffing needs, training, and data management.Author(s) DisclosuresFunding: Department of Veterans Affairs, Veterans Health Administration, Office of Rural Health (PEC-21-129) and Pain Management, Opioid Safety and Prescription Drug Monitoring Program (SP8E-PMTIA160).

In response to the opioid epidemic and high rates of chronic pain among the veteran population, the U.S. Department of Veterans Affairs implemented the TelePain-Empower Veterans Program (EVP), a nonpharmacological pain management program for veterans. Delivered virtually, TelePain-EVP incorporates integrated health components (Whole Health, Acceptance and Commitment Therapy, and Mindful Movement) through interdisciplinary personalized coaching. The objective of this quality improvement project was to evaluate the implementation of TelePain-EVP to identify determinants to implementation, benefits and challenges to participation, and recommendations for future direction. We used a qualitative descriptive design to conduct semistructured telephone interviews with TelePain-EVP leaders (n = 3), staff (n = 10), and veterans (n = 22). The interview guides aligned with the Consolidated Framework for Implementation Research (CFIR). Thematic content analysis organized and characterized findings. Several CFIR domains emerged as determinants relevant to program implementation, including innovation (eg, design); individuals (eg, deliverers, recipients); inner (eg, communications) and outer settings (eg, local conditions); and implementation process (eg, reflecting and evaluating). Identified determinants included facilitators (eg, virtual delivery) and barriers (eg, staff shortages). Participants reported improvements in pain management coping skills, interpersonal relationships, and sense of community, but no self-reported reductions in pain or medication use. Program improvement recommendations included using centralized staff to address vacancies, collecting electronic data, offering structured training, and providing course materials to veteran participants. Qualitative data can inform the sustained implementation of TelePain-EVP and other similar telehealth pain management programs. These descriptive data should be triangulated with quantitative data to objectively assess participant TelePain-EVP outcomes and associated participant characteristics. PERSPECTIVE: A qualitative evaluation of a telehealth program to manage chronic pain, guided by the CFIR framework, identified determinants of program implementation. Additionally, participants reported improvements in pain management coping skills, interpersonal relationships, and sense of community, but no self-reported reductions in pain or medication use.

Objectives Hypertension affects 1 in 3 adults in the United States and disproportionately affects African Americans. Kaiser Permanente demonstrated that a “bundle” of evidence-based interventions significantly increased blood pressure control rates. This paper describes a multiyear process of developing the protocol for a trial of the Kaiser bundle for implementation in under-resourced urban communities experiencing cardiovascular health disparities during the planning phase of this biphasic award (UG3/UH3). Methods The protocol was developed by a collaboration of faith-based community members, representatives from community health center practice-based research networks, and academic scientists with expertise in health disparities, implementation science, community-engaged research, social care interventions, and health informatics. Scientists from the National Institutes of Health and the other grantees of the Disparities Elimination through Coordinated Interventions to Prevent and Control Heart and Lung Disease Risk (DECIPHeR) Alliance also contributed to developing our protocol. Results The protocol is a hybrid type 3 effectiveness-implementation study using a parallel cluster randomized trial to test the impact of practice facilitation on implementation of the Kaiser bundle in community health centers compared with implementation without facilitation. A central strategy to the Kaiser bundle is to coordinate implementation via faith-based and other community organizations for recruitment and navigation of resources for health-related social risks. Conclusions The proposed research has the potential to improve identification, diagnosis, and control of blood pressure among under-resourced communities by connecting community entities and healthcare organizations in new ways. Faith-based organizations are a trusted voice in African American communities that could be instrumental for eliminating disparities.

Vertical integration of health systems-the common ownership of different aspects of the health care system-continues to occur at increasing rates in the United States. This systematic review synthesizes recent evidence examining the association between two types of vertical integration-hospital-physician (n = 43 studies) and hospital-post-acute care (PAC; n = 10 studies)-and cost, quality, and health services utilization. Hospital-physician integration is associated with higher health care costs, but the effect on quality and health services utilization remains unclear. The effect of hospital-PAC integration on these three outcomes is ambiguous, particularly when focusing on hospital-SNF integration. These findings should raise some concern among policymakers about the trajectory of affordable, high-quality health care in the presence of increasing hospital-physician vertical integration but perhaps not hospital-PAC integration.

BACKGROUND:Persons living with dementia (PLWD) experience frequent and costly emergency department (ED) visits, with poor outcomes attributed to suboptimal care and postdischarge care transitions. Yet, patient-centered data on ED care experiences and postdischarge needs are lacking. The objective of this study was to examine the facilitators and barriers to successful ED care and care transitions after discharge, according to PLWD and their caregivers. METHODS:We conducted a qualitative study involving ED patients ages 65 and older with confirmed or suspected dementia and their caregivers. The semistructured interview protocol followed the National Quality Forum's ED Transitions of Care Framework and addressed ED care, care transitions, and outpatient follow-up care. Interviews were conducted during an ED visit at an urban, academic ED. Traditional thematic analysis was used to identify themes. RESULTS:We interviewed 11 patients and 19 caregivers. Caregivers were more forthcoming than patients about facilitators and challenges experienced. Characteristics of the patients' condition (e.g., resistance to care, forgetfulness), the availability of family resources (e.g., caregiver availability, primary care access), and system-level factors (e.g., availability of timely appointments, hospital policies tailored to persons with dementia) served as facilitators and barriers to successful care. Some resources that would ameliorate care transition barriers could be easily provided in the ED, for example, offering clear discharge instructions and care coordination services and improving patient communication regarding disposition timeline. Other interventions would require investment from other parts of the health care system (e.g., respite for caregivers, broader insurance coverage). CONCLUSIONS:ED care and care transitions for PLWD are suboptimal, and patient-level factors may exacerbate existing system-level deficiencies. Insight from patients and their caregivers may inform the development of ED interventions to design specialized care for this patient population. This qualitative study also demonstrated the feasibility of conducting ED-based studies on PLWD during their ED visit.

BACKGROUND AND OBJECTIVES:Self-direction is an approach that allows older adults and people with disabilities to determine the home- and community-based services they receive, including the ability to hire caregivers of their choice. Self-direction has been shown to improve outcomes for the service recipients. The promotion of choice and control in self-direction may also affect family caregivers. We conducted a systematic review examining the impact of self-direction on a broad range of caregiver outcomes. RESEARCH DESIGN AND METHODS:We conducted a systematic review guided by PRISMA guidelines. Literature search was conducted in 8 databases. We appraised risk of bias using the Joanna Briggs Institute critical appraisal checklists and assessed certainty of evidence using the GRADE framework. RESULTS:Sixteen studies meeting inclusion criteria were included. We found, with moderate certainty, that self-direction is associated with improved caregivers' personal and social well-being. Caregivers also reported reduced unmet needs and increased access to care for the care recipients under self-direction. Self-direction did not appear to reduce caregiving hours. With less certainty, self-direction was also positively associated with increased respite care use, perception of choice, and intention to continue caregiving by caregivers. DISCUSSION AND IMPLICATIONS:Beyond delivering person-centered services that improve recipient outcomes, self-direction may also improve the outcomes of family caregivers.

INTRODUCTION:Patients with opioid use disorder (OUD) experiencing withdrawal or nonfatal overdose often present to emergency departments (EDs). While professional societies endorse the initiation of evidence-based medications for OUD (MOUD) in the ED, low uptake persists. The purpose of this systematic review is to synthesize what is known about implementation of MOUD in EDs and to identify potential strategies to improve the uptake of MOUD in the ED. METHODS:We reviewed articles that examined implementation outcomes (acceptability, adoption, appropriateness, feasibility, fidelity, penetration, sustainability, and cost) of MOUD in United States EDs. Peer-reviewed studies that used quantitative, qualitative, or mixed methods approaches were eligible for inclusion. RESULTS:Twenty-seven articles met the inclusion criteria for one or more implementation outcomes. Forty-four percent (n = 11) reported on acceptability, 78 % (n = 21) reported on adoption, 26 % (n = 7) reported on appropriateness, and 15 % (n = 4) reported on feasibility. Eleven percent (n = 3) reported on fidelity, 7 % (n = 2) reported on penetration, and 7 % (n = 2) reported on sustainability. No articles reported on implementation cost. While physicians found MOUD acceptable, their comfort levels with the intervention varied. Rates of MOUD adoption were often low, but uptake may be facilitated by implementation strategies. MOUD may constrain ED time resources and exacerbate overcrowding, hindering appropriateness. CONCLUSION:Results suggest that ED physicians and administrators have encountered barriers to the initiation of MOUD. There may be opportunities to overcome these implementation barriers using multi-component strategies consisting of educational interventions that address safety and monitoring and process interventions, such as clinical decision support systems.

Objective This study aimed to describe the actions used by health professionals employed by large, for-profit businesses to promote uptake of COVID-19 vaccines, and factors that facilitated and hindered coordination with local public health leaders. Methods In this qualitative multiple case study, we conducted telephone interviews with health professionals from businesses, health department leaders, and others who could provide information about local vaccination efforts (e.g., emergency managers, reporters). Results Businesses' self-interest (i.e., need to keep employees working), vaccine mandates, and characteristics of the businesses (e.g., ownership, expertise) facilitated leadership in COVID-19 vaccination efforts. Coordination with local health departments was influenced by the resources of the local health department and history of collaboration. Conclusions Health professionals employed by large businesses can serve as key public health partners, but their role is shaped by characteristics of the businesses and communities.

PURPOSE There are numerous supportive quality improvement (QI) projects to facilitate the implementation of evidence-based practices in primary care, but recruiting physician practices to join these projects is challenging, costly, and time consuming. We aimed to identify factors leading primary care practices to decline participation in QI projects, and strategies to improve the feasibility and attractiveness of QI projects in the future. METHODS For this qualitative study, we contacted 109 representatives of practices that had declined participation in 1 of 4 Agency for Healthcare Research and Quality-funded EvidenceNOW projects. The representatives were invited to participate in a 15-minute interview or complete a 5-question questionnaire. Thematic analysis was used to organize and characterize findings. RESULTS Representatives from 31 practices (28.4% of those contacted) responded. Overwhelmingly, respondents indicated that staff turnover, staffing shortages, and general time constraints, exacerbated by the pandemic, prevented participation in the QI projects. Challenges with electronic health records, an expectation of greater financial compensation for participation, and confidence in the practices' current care practices were secondary reasons for declining participation. Tying participation to value-based programs and offering greater compensation were identified as strategies to facilitate recruitment. None of the respondents' recommendations, however, addressed the primary issues of staffing challenges and time constraints. CONCLUSIONS Staffing challenges and general time constraints, exacerbated by the pandemic, are compromising primary care practices' ability to engage in QI research projects. To encourage participation, policy makers should consider direct supports for primary care, which may also help to alleviate burnout.

Background: The burden of cardiovascular disease (CVD) is particularly high in several US states, which include the state of Michigan. Hypertension and smoking are two major risk factors for mortality due to CVD. Rural Michigan is disproportionally affected by CVD and by primary care shortages. The Healthy Hearts for Michigan (HH4M) study aims to promote hypertension management and smoking cessation through practice facilitation and quality improvement efforts and is part of the multi-state EvidenceNOW: Building State Capacity initiative to provide external support to primary care practices to improve care delivery. Methods: Primary care practices in rural and underserved areas of Michigan were recruited to join HH4M, a pragmatic, single-arm hybrid Type 2 effectiveness-implementation study during which practice facilitation was delivered at the practice level for 12 months, followed by a 3-month maintenance period. Results: Fifty-four practices were enrolled over a 12-month recruitment period. At baseline, the mean proportion (standard deviation) of patients at the practice level meeting the clinical quality measures were: blood pressure, 0.72 (0.12); tobacco screening, 0.80 (0.30); tobacco cessation intervention, 0.57 (0.28); tobacco screening and cessation intervention: 0.78 (0.26). Conclusion: This three-year research program will evaluate the ability of rural and medically underserved primary care practices to implement the quality improvement model by identifying drivers of and barriers to sustainable implementation, and test whether the model improves (a) blood pressure control and (b) tobacco use screening and cessation.