Implementation and adoption of a health insurance support tool in the electronic health record: a mixed methods analysis within a randomized trial

Brigit Hatch, Carrie Tillotson, Nathalie Huguet, Miguel Marino, Andrea Baron, Joan Nelson, Aleksandra Sumic, Deborah Cohen, Jennifer E DeVoe, Brigit Hatch, Carrie Tillotson, Nathalie Huguet, Miguel Marino, Andrea Baron, Joan Nelson, Aleksandra Sumic, Deborah Cohen, Jennifer E DeVoe

Abstract

Background: In addition to delivering vital health care to millions of patients in the United States, community health centers (CHCs) provide needed health insurance outreach and enrollment support to their communities. We developed a health insurance enrollment tracking tool integrated within the electronic health record (EHR) and conducted a hybrid implementation-effectiveness trial in a CHC-based research network to assess tool adoption using two implementation strategies.

Methods: CHCs were recruited from the OCHIN practice-based research network. Seven health center systems (23 CHC clinic sites) were recruited and randomized to receive basic educational materials alone (Arm 1), or these materials plus facilitation (Arm 2) during the 18-month study period, September 2016-April 2018. Facilitation consisted of monthly contacts with clinic staff and utilized audit and feedback and guided improvement cycles. We measured total and monthly tool utilization from the EHR. We conducted structured interviews of CHC staff to assess factors associated with tool utilization. Qualitative data were analyzed using an immersion-crystallization approach with barriers and facilitators identified using the Consolidated Framework for Implementation Research.

Results: The majority of CHCs in both study arms adopted the enrollment tool. The rate of tool utilization was, on average, higher in Arm 2 compared to Arm 1 (20.0% versus 4.7%, p < 0.01). However, by the end of the study period, the rate of tool utilization was similar in both arms; and observed between-arm differences in tool utilization were largely driven by a single, large health center in Arm 2. Perceived relative advantage of the tool was the key factor identified by clinic staff as driving tool utilization. Implementation climate and leadership engagement were also associated with tool utilization.

Conclusions: Using basic education materials and low-intensity facilitation, CHCs quickly adopted an EHR-based tool to support critical outreach and enrollment activities aimed at improving access to health insurance in their communities. Though facilitation carried some benefit, a CHC's perceived relative advantage of the tool was the primary driver of decisions to implement the tool.

Trial registration: ClinicalTrials.gov: NCT02355262, Posted February 4, 2015.

Keywords: Community health centers; Electronic health record; Health information technology tools; Health insurance; Hybrid implementation-effectiveness; Mixed methods; Outreach and enrollment.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Rate of tool use per month between Arm 1 and Arm 2 clinics, among ‘high risk’ patients with at least 1 Medicaid-insured or uninsured visit during the study period, Sept 2016-Mar 2018. *Note: ‘HRSA (Health Resources and Services Agency) UDS (Unified Data Set) Change’ was a policy mandate that required health centers to report on health insurance enrollment assistance provided. This change was hypothesized to potentially impact tool utilization
Fig. 2
Fig. 2
Total monthly instances of tool utilization by health center, September, 2016 – March, 2018

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Source: PubMed

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