Changing Clinic-Community Social Ties in Immigrant-Serving Primary Care Practices in New York City: Social and Organizational Implications of the Affordable Care Act's Population-Health-Related Provisions

Abstract

Small primary care practices are critical to advancing Affordable Care Act (ACA) aims, yet their efforts and experiences remain little studied. We examine two strategies derived from ACA population-health provisions-enhanced use of electronic health records (EHRs) and community health worker (CHW)-led peer coaching-for hypertension control in sixteen small practices serving South Asian immigrant communities in New York City. Based on interviews with physicians, staff, and CHWs, we analyze "street-level" dilemmas encountered in implementing the strategies. Findings indicate that the strategies reinforce clinic-community social ties but present distinct challenges for small practices: internal management constraints that impede formal CHW-physician contact, and external incentives linked to EHR tools that, physicians and staff perceive, do not meet immigrant communities' needs and expectations in medical encounters.

Small Practices, Big (QI) Dreams: Customizing Quality Improvement (QI) Efforts for Under-Resourced Primary Care Practices to Improve Diabetes Disparities

“…A common thread underpinning the implementation strategies discussed in this paper is the importance of tailoring to the context of each clinic and using informal strategies to build trust, especially critical in small practice settings due to their relative lack of access to resources. Our body of work engaging small practices [ 17 , 21 , 40 ] underscores that relatively simple health information technology adjustments can confer great advantage to these under-resourced settings that often provide services to disadvantaged populations. As national trends demonstrate rising diabetes disparities among minority communities [ 23 , 41 ], it is imperative that clinical settings prioritize strategies to improve diabetes-related outcomes among patients.…”

Integrating Community Health Workers into Community-Based Primary Care Practice Settings to Improve Blood Pressure Control Among South Asian Immigrants in New York City: Results from a Randomized Control Trial

“…31 The study was designed as an integrated intervention; CHWs assisted clinic staff with translations and facilitated medication reminders/ refills and appointment scheduling; communication and activities varied by site based on clinic capacity and preferences. 32 This study was approved by the institutional review boards of New York University School of Medicine and the City University of New York Graduate School of Public Health and Health Policy.…”

An Engine of Change? The Affordable Care Act and the Shifting Politics of Demonstration Projects

“…In other instances, such as the Comprehensive Primary Care demonstration, success hinged on the ability to implement new health IT infrastructures and create competency among staff to use the new capacity. Preparing for a successful implementation, whether through investments in technical infrastructure, adjustments to practice patterns and cultures, or securing buy-in from an array of partners, is time intensive (see Gore et al 2020). Time, however, is not a luxury that demonstrations often have.…”

“…Available at https://www.rsfjournal.org/content /6/2/67/tab-supplemental. tion years (Gore et al 2020). Second, as CBO has noted, it can be difficult to isolate the effects of certain demonstration projects in a dynamic and complex environment in which multiple institutional changes are occurring simultaneously (Masi and Bradley 2015;Hadley 2016).…”