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The United States leads the world in health care costs but ranks far below many developed countries in health outcomes. Finding ways to narrow this gap remains elusive. This article describes the response of one state to establish community health networks to achieve quality, utilization, and cost objectives for the care of its Medicaid recipients. The program, known as Community Care of North Carolina, is an innovative effort organized and operated by practicing community physicians. In partnership with hospitals, health departments, and departments of social services, these community networks have improved quality and reduced cost since their inception a decade ago. The program is now saving the State of North Carolina at least $160 million annually. A description of this experience and the lessons learned from it can inform others seeking to implement effective systems of care for patients with chronic illness. 1 Despite these high expenditures, the quality of care remains unsatisfactory. For example, only 27% of patients with hypertension have adequate blood pressure control, and only 17% of patients with coronary artery disease have cholesterol at levels suggested by national guidelines. 2 The United States ranks last in preventable deaths among 19 Organization for Economic Cooperation and Development (OECD) countries. 3 One reason for this quality gap is that, although the prevalence of chronic disease is increasing, our health care delivery system is based on a model that is best suited to episodic care for acute illnesses. Optimal delivery of chronic care and preventive services requires restructuring our health care system. In recent years, much research and discussion have focused on how best to adapt our system to chronic care and prevention. For example, the Chronic Care Model lays out several key elements of high-quality care for chronic diseases, including community resources, health care organization, self-management support, delivery system design, decision support, and clinical information systems. 4 More recently the concept of the patient-centered medical home has received widespread attention as a model to improve care. 5 Seven key principles outline the characteristics of the patient-centered medical home: a personal physician, physician-directed medical practice, a whole-person orientation, coordinated care, quality and safety, enhanced access, and a system of payment that refl ects the added value of a patient-centered medical home.Although these models have shown promise in controlled research settings and small demonstration projects, they have been diffi cult to disseminate widely. 6 One problem with implementation of models in indi- 362 CO M MUNI T Y C A R E O F NOR T H C A ROL INAvidual practices is that the current funding structure of health care is based on acute care. When practices are reimbursed on a fee-for-service basis for episodic care, fi nding the resources to redesign a practice, develop systems of care, and implement the elements of these new models of care can ...

Introduction: Although correlates of overall medication adherence have been studied, little is known about primary medication non-adherence-patients' failing to fill a prescription provided by a practitioner-and whether it relates to how patients view their physician, satisfaction with their care, and how easy or hard it is for them to travel for care.Methods: This study uses telephone survey data from adults in 150 rural counties in 8 southeastern states. Bivariate and multivariable analyses were used to identify factors associated with adults' selfreports of delaying or not filling prescriptions.Results: Of the 3926 respondents who had received care in the previous year, 894 (21.6%) reported that they had delayed or did not fill a prescription over that time. In multivariate analysis, delaying or not filling prescriptions was more common among respondents who were under age 65, African American, reported incomes less than $25,000, and reported fair or poor health. Non-adherence was also more common among patients who reported transportation problems, a lack of confidence in their doctor's ability to help them, a lack of satisfaction with the concern shown them by their physicians, and a lack of satisfaction with how welcome and comfortable they are made to feel by office staff. Conclusions: Prescription primary non-adherence is prevalent in the rural

PURPOSE We wanted to determine how much it costs primary care practices to participate in programs that require them to gather and report data on care quality indicators.METHODS Using mixed quantitative-qualitative methods, we gathered data from 8 practices in North Carolina that were selected purposively to be diverse by size, ownership, type, location, and medical records. Formal practice visits occurred between January 2008 and May 2008. Four quality-reporting programs were studied: Medicare's Physician Quality Reporting Initiative (PQRI), Community Care of North Carolina (CCNC), Bridges to Excellence (BTE), and Improving Performance in Practice (IPIP). We estimated direct costs to the practice and on-site costs to the quality organization for implementation and maintenance phases of program participation. RESULTSMajor expenses included personnel time for planning, training, registry maintenance, visit coding, data gathering and entry, and modifi cation of electronic systems. Costs per full-time equivalent clinician ranged from less than $1,000 to $11,100 during program implementation phases and ranged from less than $100 to $4,300 annually during maintenance phases. Main sources of variation included program characteristics, amount of on-site assistance provided, experience and expertise of practice personnel, and the extent of data system problems encountered. CONCLUSIONSThe costs of a quality-reporting program vary greatly by program and are important to anticipate and understand when undertaking quality improvement work. Incentives that would likely improve practice participation include fi nancial payment, quality improvement skills training, and technical assistance with electronic system troubleshooting.

Objective: To assess the effect of dissemination and implementation of an intervention consisting of practice facilitation and a risk-stratified, population management dashboard on cardiovascular risk reduction for patients at high risk in small, primary care practices. Study Setting: A total of 219 small primary care practices (≤10 clinicians per site) across North Carolina with primary data collection from electronic health records (EHRs) from the fourth quarter of 2015 through the second quarter of 2018. Study Design: We performed a stepped-wedge, stratified, cluster randomized trial of a one-year intervention consisting of practice facilitation utilizing quality improvement techniques coupled with a cardiovascular dashboard that included lists of riskstratified adults, aged 40-79 years and their unmet treatment opportunities. The primary outcome was change in 10-Year ASCVD Risk score among all patients with a baseline score ≥10 percent from baseline to 3 months postintervention. Data Collection/ Extraction Methods: Data extracts were securely transferred from practices on a nightly basis from their EHR to the research team registry. Principle Findings: ASCVD risk scores were assessed on 437 556 patients and 146 826 had a calculated 10-year risk ≥10 percent. The mean baseline risk was 23.4 percent (SD ± 12.6 percent). Postintervention, the absolute risk reduction was 6.3 percent (95% CI 6.3, 6.4). Models considering calendar time and stepped-wedge controls revealed most of the improvement (4.0 of 6.3 percent) was attributable to the intervention and not secular trends. In multivariate analysis, male gender, age >65 years, low-income (<$40 000), and Black race (P < .001 for all variables) were each associated with greater risk reductions. Conclusion: A risk-stratified, population management dashboard combined with practice facilitation led to substantial reductions of 10-year ASCVD risk for patients at high risk. Similar approaches could lead to effective dissemination and implementation of other new evidence, especially in rural and other under-resourced practices.