January 17, 2023
It's a Catch-22. You can't improve community practice without evidence-based research, but it's challenging to incorporate research into a busy primary care practice. And there's a scarcity of researchers devoted to primary care.
"We're busy seeing patients and trying to deliver the best care possible. It's hard to find time to pause, step back and figure out how to do things better at a bigger scale than just our clinic," says Rozalina McCoy, M.D., Division of Community Internal Medicine, Geriatrics, and Palliative Care.
Dr. McCoy sees patients in the community clinic in northeastern Rochester and has started a new role as the vice chair for research in her division.
"Physicians in primary care are busy doing clinical work. The infrastructure and resources haven't existed to support dedicated time for research. However, research — the spirit of inquiry, innovation, improvement and discovery — is at the core of everything we do at Mayo Clinic," she says. "It's important to use a rigorous academic approach to study models of care in the primary care setting and provide evidence of what works and will lead to improved patient outcomes."
Dr. McCoy is doing that. After residency and fellowship training as a clinician–investigator and a master's degree in health sciences research — all at Mayo Clinic — Dr. McCoy joined the Mayo Clinic staff in 2015. As a clinician-researcher, she devotes most of her time to research. She knows how important it is that research in a primary care setting be minimally disruptive to the practice and not a burden for clinicians and staff.
"Improving community care and population health means studying it in real-world settings," Dr. McCoy says. "Many clinical trials take place in idealized settings that are highly controlled. That's not reflective of a real clinical practice. Research in a destination practice where patients leave after treatment and continue their care elsewhere doesn't inform the primary care practice. Mayo Clinic Health System gives us opportunities to do pragmatic trials in a real-world care environment and follow patients longitudinally. It also helps us understand how to deliver care better because we can engage with patients over time, see what works and why, and continually improve."
Prathibha Varkey, M.B.B.S., president of Mayo Clinic Health System, affirms the importance of research in Mayo Clinic Health System.
Enhancing the diabetes care model
A focus of Dr. McCoy's research is using real-world evidence to improve diabetes care. She analyzes data to understand patterns in care delivery and conducts pragmatic trials to determine best practices. She also is studying how to deliver care to make sure no one is left behind.
Patients in rural or low-income areas and those with greater racial/ethnic diversity have more health disparities, including higher rates of diabetes and complications from the disease. To combat those trends, Dr. McCoy's work centers on improving access to care, developing new ways to deliver care effectively and safely, and addressing care disparities.
In the last three years, Dr. McCoy has led the development, implementation and evaluation of a new model of care for patients with diabetes. The new model involves a care team nurse who supports patients with diabetes, engages with them and others on the team, and works to identify and remove barriers to optimal care.
The program launched in five Mayo Clinic Employee and Community Health clinics in Rochester and Kasson, Minnesota, that care for almost 8,000 adults who have diabetes. The program was expanded throughout the southeast Minnesota region of Mayo Clinic Health System to 10,000 patients who have diabetes.
Care team nurses identified patients who didn't meet diabetes quality indicators — glycemic and blood pressure control, nonsmoking, aspirin use for prevention of ischemic vascular disease, and statin use — with the goal of reviewing approximately 10 percent of patients not meeting those indicators each month. The nurses contacted patients for a diabetes review, discussed the care plan and patient needs, and continued longitudinal follow-up reviews until patients met the quality goals.
A comparison of how this patient-centered, evidenced-based diabetes care model performs compared to the traditional care model showed substantial improvement. The Rochester and Kasson practices saw the proportion of their patients who have diabetes and met diabetes care quality goals increase from 45 percent to 51 percent. In the southeast Minnesota region, they increased from 35 percent to 45 percent.
"This sustained improvement in diabetes quality has been striking, considering the challenges posed by the COVID-19 pandemic and that our clinics received no additional resources to support this work," says Dr. McCoy.
Priorities for the program in 2022 include continuing to expand it throughout Mayo Clinic Health System locations in southeastern Minnesota, engaging local champions to support the progress, implementing a process to allow patients to download their glucose monitoring data, and examining quality metrics by race/ethnicity and other social determinants of health.
The enhanced diabetes care model provides a framework for improving other chronic conditions, including hypertension and tobacco cessation.
Dr. McCoy considers it a priority to improve access to care and health outcomes among patients in rural and socioeconomically deprived areas. People in those areas face multiple barriers to optimal care.
She conducted studies that concluded adult patients who have diabetes and live in more deprived and rural areas were significantly less likely to have high-quality diabetes care and lower rates of recommended cancer screenings compared to those in less deprived and urban areas. Those findings highlight the need for interventions that may include community partnerships, patient engagement, and geographically targeted efforts to improve care quality and health outcomes for these at-risk populations.
"It's exciting to see research at the primary care level being prioritized," says Dr. McCoy. "I think we'll see growth in research in Mayo Clinic Health System, with the community practices driving research questions and primary care clinicians driving the research and serving as investigators."
Taking diabetes care to the patient
Dr. McCoy also is medical director of the community paramedic program of Mayo Clinic Ambulance Service, which serves 14 locations in eastern and central Minnesota and western Wisconsin. She has conducted research to employ community paramedics — the highest level of EMS certification — to extend primary care and help fill in gaps in health care in underserved communities. This includes serving an aging population with increasing needs for acute, chronic and preventive care; delivering care to people experiencing homelessness; providing patients who have diabetes with access to self-management education and support; and improving the availability of health care services in rural areas.
According to a national survey, community paramedicine programs deliver care at a lower cost, reduce use of emergency departments, reduce use of EMS and emergency department transport among people who frequently call EMS, reduce hospital readmissions, reduce unreimbursed care, extend primary care, improve chronic disease management, provide a bridge to home health services, improve patient satisfaction and improve performance on quality metrics.
Community paramedics are trained to make health status assessments and recognize and manage life-threatening conditions outside of the hospital. They commonly perform, monitor and educate about chronic diseases and medication, provide immunizations and vaccinations, collect laboratory specimens, provide follow-up care after hospital discharge and perform minor medical procedures.
Community paramedics practice under the guidance of a physician medical director and have training in nonemergency medicine including primary and preventive care, chronic disease management, patient education and social determinants of health — in addition to their paramedic certification in emergency care. Although Minnesota was the first state to define the community paramedicine role in state statute, at least 33 states offer community paramedic or mobile integrated health care programs.
In a seven-month pilot trial of community paramedicine in northwestern Wisconsin, a full-time paramedic provided 412 visits to 42 patients with high rates of health care utilization. The service focused on chronic disease management, preventive care, and prevention of emergency department visits and hospitalizations. The community paramedicine program reduced primary care visits by 53.3 percent, emergency department visits by 59.3 percent, and hospitalizations by 60 percent.
Dr. McCoy subsequently partnered with Mayo Clinic Ambulance Service to scale the program to support the southeast Minnesota region, hiring additional community paramedics in a Mayo Clinic Center for Health Equity and Community Engagement Research-funded trial of this new care model for patients with uncontrolled diabetes.
Dr. McCoy spearheads another community paramedicine pragmatic trial, funded by the National Institute of Diabetes and Digestive and Kidney Diseases, that seeks to improve diabetes management among patients with severe hypoglycemia.
In an average of four visits per month, community paramedics work with patients on diabetes management to prevent emergency department visits and hospitalizations, reduce diabetes distress, and improve diabetes self-efficacy and quality of life. Community paramedics check how patients store, administer and dispose of medications; observe patients checking blood glucose and ensure glucose meters function properly; review glucose log with patients; discuss signs of and risk factors for hypo- and hyperglycemia; take stock of medication and supplies; identify areas for improvement; and review goals.
The community paramedicine program recently expanded to determine its effectiveness in shortening and preventing hospitalizations and emergency department care. This expansion is being studied in a large pragmatic randomized controlled trial conducted in Rochester and Barron, Wisconsin, service areas. The trial is funded by a Mayo Clinic Pragmatic Trial Award, the Mayo Clinic Center for Clinical and Translational Science, and the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery.
In this trial, some patients will get care from community paramedics, and others will get traditional care. Outcomes include comparing the number of days patients remain at home, and their quality of life and satisfaction with care. A major component of the trial is to understand how best to research and conduct pragmatic trials in different practice settings, particularly in Mayo Clinic Health System. According to Dr. McCoy, this is the first large randomized controlled trial of community paramedics in the U.S.
"I'm continually awed by what our community paramedics can do. They deliver high-quality patient-centered care, with reduced ED visits and hospital admissions and improved quality metrics and high patient satisfaction," says Dr. McCoy. "Community paramedics anywhere in the country can do this. We're showing what is possible in and highly cost-effective for rural and community practices."
In addition, the academic model of community paramedicine offers career growth opportunities for community paramedics and others on Dr. McCoy's team. Community paramedics and clinician partners across the Ambulance Service and Mayo Clinic Health System can participate in these research studies, co-author peer-reviewed manuscripts, and contribute to the development and growth of this new care delivery model.
"In the last year, because of our enhanced diabetes care team process, more than 1,100 patients in southeastern Minnesota have had optimal diabetes care, making them less likely to lose their vision, need dialysis, have a heart attack or die," says Dr. McCoy. "And because of the community paramedic service, we've brought urgently needed care to patients when, where and how they need it.
This story originally appeared in issue 3 of the 2022 Mayo Clinic Alumni Magazine.