Expansion of Services to Primary Care in the Retail Clinics

One of the key determinants of health is the ability to access health care services within different spectrums, which also plays a critical role in ensuring that people achieve their expected health outcomes. When defining the concept of access of health care, Hoffmann (2010) notes health care as, “ the overall ability to obtain quality, acceptable, and affordable health care service in a manner that is timely depending on the needs and expectation” (p.482). The United States, having one of the most advanced health care systems in the world today, recognizes the need for implementation of effective and strategic approaches that would aid in promoting access. The enactment and implementation of the Affordable Care Act (ACA) of 2010, replaced by the American Health Care Act (AHCA) of 2017, is viewed as one of the notable milestones for the government in its bid towards improving access to health care. 

However, one of the key challenges to note is that a lack of health insurance whereby the population with health insurance is limited remains as one of the key issues affecting access to health care services. Studies suggest that lack of clear-cut strategy to help increase uptake of health insurance is viewed as one of the key factors contributing to less preventive care among the populations. Additionally, this also acts as a contributing factor to situations where most people are diagnosed at very advanced disease stages with majority of these patients relying on emergency services. From an economic perspective, reduced uptake of medical insurance tends to have serious implications from an economic perspective as it contributes to a significant increase in health care costs. 

Background of the Study 

Ambulatory care is considered as one of the key areas of health care service delivery, which plays a critical role towards boosting positive outcomes in dealing with a wide array of patients’ needs and expectations. Through ambulatory care, a new model, retail clinics, has been developed with the target population being the uninsured or underinsured populations requiring a wide array of health care services. Retail clinics do not only seek to provide convenience for the patients in terms of access but also work towards ensuring that they provide patients with a transparent avenue for pricing. The long-term effect that this has had is that it has helped in cutting down on the costs of health care services from the patients’ perspective while ensuring that patients receive the best quality of health care services. Additionally, the adoption of retail clinics also works as a model focused on introducing preventive care as part creating an advanced platform for quality health care services. 

The need for expansion of retail clinics can be seen from the fact that access to quality health care services remains as one of the key challenges for majority of the low-income earning population without health care insurance. The idea of using retail clinics revolves around the idea of having to introduce Nursing Practitioners (NPs) as part of providing health care services with the focus being towards ensuring that the cost of health care reduced significantly. In retail clinics, NPs tend to ensure that their patients meet their respective health care goals at a much lower cost when compared to health facilities. Thus, this acts as a clear indication of the need to work out a strategic approach that would seek to achieve probable expansion of services offered as primary care in retail clinics. 

Plan 

Assessment of the Environment 

When assessing the environment associated with the retail clinics, one of the key aspects to note is that the clinics are comprised of the microsystem, mesosystem, and macrosystem, each of which plays a key role towards defining effective outcomes in service delivery. The functioning of these systems is as follows: 

Microsystem 

The microsystem of the retail clinics comprise of health care teams made up of different health care professionals. The key focus for these teams is to workout effective avenues from which to boost the quality of health services offered with the focus being towards ensuring that patients achieve positive outcomes. The health teams also play a critical role as part of the retail clinics in collecting information on some of the changes that ought to be made within the clinics as part creating a better platform for enhanced performance. 

Mesosystem 

The mesosystem of the retail clinics reflects solely on the processes and services offered within the clinics with the focus being towards ensuring that patients achieve the best possible health outcomes. The mesosystem is one of the important systems in the clinics as it seeks to define the probability of achieving positive outcomes as part of health care service delivery expectations from individual patients. 

Macrosystem 

The macrosystem of the retail clinics reflects solely on the idea of having to partner with multispecialty health facilities that would be of value in dealing with some of the most severe cases. The retail clinics tend to experience major challenges in their bid to offering health services due to a limitation in specialty health professionals, thus, creating the need for having to partner with other health facilities. 

Aim and Specific Measurable Targets 

The aim is to workout an expansion plan that would seek to ensure that retail clinics advance in terms of the services that they offer to their patients with an intention of ensuring that they promote quality health outcomes. The expansion plan will seek to include areas such as screening, diagnosis, management, education, and patient follow-up programs focusing on chronic conditions that include hypertension and hypercholesterolemia. The retail clinics’ ability to expand with the focus towards ensuring that they offer such services will seek to determine the general perspective from which to deliver quality and affordable health services to their patients. The expansion is expected to build on the general prospect of ensuring that patients receive the best quality of health care services within the retail clinics. 

Some of the measures that will be used to determine the effectiveness of the retail clinics after their expansion include: 

Number of patients treated at the retail clinics with a diagnosis of hypertension and hypercholesterolemia. An evaluation of the number of patients will help determine whether the number is increasing or reducing with the focus being towards defining whether the clinics are effective in meeting their health care needs. 

Number of patients achieving expected blood pressure and lipid goals according to the measures provided by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII) (Hermanson, Berkshire, Leaming, & Piland, 2013) and the National Cholesterol Education Program (NCEP) (Arthur, Fisher, Shoemaker, Pozniak, & Stokley, 2015) guidelines. 

Patients’ compliance to medication, lifestyle regimen and follow-up, and satisfaction 

Preparation for Change 

Before implementation of the expected changes within the retail clinics, it is important to take note of several key preparation steps that will be essential to help determine the general outcomes in terms of efficiency in promoting service delivery. The first step in the preparation process involves promotion and advertisement of the new services offered within the retail clinics. In this step, the focus is ensuring that patients get a good understanding of the general quality of services that the retail clinics seek to offer as part of their general expansion. The second step involves the process of writing down the procedures and policies that would help govern the primary care services offered as part of the retail clinics. In this step, the regional and lead NPs will be involved in an in-depth evaluation of the performance expectations from the retail clinics to determine the procedures and policies. 

The NPs will also create a plan that would involve the process of patient transfer from the retail clinics to the partner health care facilities in the event of need. In other words, the NPs will be involved in a process of having to create a health care network to help boost overall probability in dealing with individual patients. The third step involves the orientation and training of the NPs involved in the retail clinics with the focus being towards ensuring that they help improve on the quality of services offered. During the course of training and orientation, the NPs will go through the actual process of primary care screening within the retail clinics to give them a glimpse of how they are expected to perform specific services. 

The NPs, going through training and orientation, will be taken through the entire procedure of patient check-in and check-out with the focus being to help ensure that they are well aware of these procedures. On the other hand, the NPs will also be expected to go through a mandatory webex seminar that would orient them to usage of electronic health records (EHRs) as part of their service delivery expectations. The fourth process involves having to set up an effective health care network that seeks to ensure that the retail clinics have access to laboratories that would offer services at a subsidized cost margin. The key expectation for the retail clinics is to ensure that the uninsured or underinsured populations receive the best quality of services. Thus, it creates the need for having to ensure that the clinics have access to laboratories at low cost margins. 

The role of the regional and lead NPs during the preparation is to set up a patient management system that would be mandated with the sole task of ensuring that the retail clinics engage in patient follow-ups for purposes of discussing laboratory results. The management system will also be of value in monitoring whether patients are complying with the set out prescriptions as part of their approach towards achieving the best possible outcomes. The NPs will be expected to engage with outside consultants, who will help in the development of this particular management system. The consultants, who may include technological professionals, will seek to ensure that the management system achieves its expected functionality expectation in patient management. 

The role of the quality improvement department cannot be ignored taking into account that this department is expected to create prospective measures focused on improving the quality of health services offered. The department will be expected to engage in a process of preparing tools to help measure the efficacy of the expansion of the retail clinics with the focus being towards determining the efficiency of the facility in delivery of expected primary health services. The tools will evaluate each of the targets associated with the expansion of the retail clinics as a way of ensuring that patients achieve the best possible outcomes in terms of quality of health services offered. The process of change in terms of the expansion of the retail clinics is expected involve members of the micro, meso, and macrosystems as a way of ensuring that expansion moves along seamlessly. 

The Organizational Culture 

When reflecting on the organizational culture associated with the retail clinics, it is important to take note of the fact that this culture is open to change taking into account the inclusion of quality improvement initiatives. The NPs involved in the retail clinics are expected to undertake a continuous process of quality improvement with the focus being towards ensuring that the clinics achieve the best possible quality measures. Continuous improvement of quality measures means that the expected quality outcomes associated with the retail clinics will shift significantly as part of creating a new dimension in terms of health care delivery system. Consequently, this acts as a clear indication that the organizational culture associated with the retail clinics is expected to change throughout the entire period of the clinics depending on the improvements made. 

Currently, the retail clinics have the expected equipment and facilities that would allow them to deliver the best quality outcomes focusing on the services that they offer. However, an expansion of the retail clinics will focus more on ensuring that the clinics focus on acquisition of new facilities and equipment to help in providing laboratory and radiology services. An expansion of the clinics would mean that the retail clinics must work towards ensuring that they seek to improve the quality of services that they offer to their patients (Simon et al., 2017). Consequently, this creates the need for having to establish a front from which to ensure that the generalized quality expectations associated with the retail clinics improve significantly. The quality improvement team will have the sole mandate of monitoring, assessing, analyzing, and communicating some of the notable results associated with data collection activities. 

The Process Change 

The process change that is expected to be tested is the expansion of the retail clinics with the focus being towards ensuring that they are able to deal with patients suffering from hypertension and hypercholesterolemia. During this process, the key expectation for the members of the micro, meso, and macrosystems is to ensure that they engage in a continuous process of promotion and advertisement of the new services. That means that the members of these systems will need to understand how the retail clinics are expected to help improve the quality of health services offered to patients. The lead NP, on the other hand, will be in charge of overseeing the pilot change focusing on ensuring that he or she is well positioned to answer any questions from the patients or NPs regarding the new services offered within the retail clinics as part of their expansion. 

During the course of implementing the new services, one of the key aspects to note is that both patients and NPs may have several key queries with regard to the functionality of the retail clinics in providing the new services. The role of the lead NP is to help ease the tension that may arise as part of the expansion considering that this may act as one of the key issues that may impact the general expectations of the retail clinics. The NPs, operating within the retail clinics, will be expected to conduct health risk assessments, screen, diagnose, treat, educate, and follow-up on the patients associated with hypertension and hypercholesterolemia. The NPs will make sure that these patients achieve the best possible health outcomes as part of the quality of services they receive. 

The NPs will also be mandated with the task of making relevant calls to individual patients with regard to their lab results and diagnosis with the main aim being towards ensuring that the NPs interact with the patients effectively. The idea of using NPs as part of the retail clinics reflects more on the fact that most of these NPs tend to have that basic understanding of what is expected of them in promoting health service delivery. The process change will also involve a process of data collection focused on the pilot change. The quality improvement team will collect data on the pilot change after which the data will be presented to the lead NP, as well as the members of the microsystem. The lead NP, members of the microsystem, and quality improvement team will be involved in data analysis to determine whether to refine, adopt, or discard the change. 

The Pilot and Data Collection 

The pilot is expected to start in September 2018 and end in February 2019, which gives a 6 month period from which to engage in an evaluation of the change. The education and orientation of the NPs involved in the retail clinics is expected to run for a 3 month period, which is between June 2018 and August 2018. The focus of having to allocate such periods is to ensure that the NPs involved with the retail clinics have a clear understanding of what is expected of them in trying to determine positive performance. The retail clinics are expected to create a major shift in terms of the quality of services that they offer, which, in turn, seeks to mean that the clinics must work towards improving the generalized outcomes through evaluation of the pilot focusing on the change. 

The role of the quality improvement team will be to focus on observation and data collection as part of the pilot, which will be used to make effective conclusions with regard to this particular change. For the quality improvement team to achieve expected results, it would be essential to work with the information technology (IT) department, which will be involved in keeping track of the number of patients coming into the facility. The collaboration between the quality improvement team and the information technology departments will help in highlighting the general outcomes in terms of the expected quality outcomes (Hoffmann, 2010). The focus is trying to analyze the general expectations associated with retail clinics by evaluating data associated with the pilot project. 

Another key area to note is that the quality improvement team will also seek to track and record trends associated with patients being in a position to achieve their expected blood pressure and lipid goals based on the JNC VII and NCEP guidelines. For the change to be considered as effective for the retail clinics, it is important to ensure that the patients meet these goals considering that this would determine whether the patients are well positioned to receive the best quality of health services. Thus, the idea of having to evaluate this targeted measure will help in determining the prospective outcomes for the patients in terms of the quality of health services offered through the retail clinics. Data on compliance on the part of the patients will also be tracked and recorded by the quality improvement team to help in determining whether retail clinics achieve their expected results. 

The teams involved in the pilot expect that the number of patients coming into the facility is expected to increase significantly considering that the facility will be in a better position from which to deliver the best possible results in terms of quality services for patients with hypertension and hypercholesterolemia. Additionally, the pilot expects to show a generalized improvement in the trends associated with early detection and diagnosis for hypertension and hypercholesterolemia. In other words, the retail clinics focus more on ensuring that patients are exposed to proper measures focused on improving the general quality of health services offered focusing in management of hypertension and hypercholesterolemia. The achievement of these results will mean that the expansion of the retail clinics will be considered as viable option towards increase service delivery to primary care. 

During this phase, pilot project, the most essential tool will be the proprietary EMR, which has the capability of tracking the number of patients seen, as well as, keeping track of the number of patients contacted as part of the follow-up. The EMR system is also expected to play a critical role in mapping and graphing patients’ blood pressure readings and lipid results (Nelson, 2007). The long term effectiveness of using this system is that it will work towards evaluating whether the patients are moving towards a positive direction based on the target measures, as have been indicated. The quality improvement team will use this system as part of its approach towards understanding how the pilot is fairing, which would be of value in meeting the long term objectives of determining its viability. 

Do 

Implementation of the Practice (Process) Change Pilot 

The implementation of the practice process change is a significant factor in the study as it helps to understand the key elements associated with the process. The process change begins when a patient seeks health risk assessment and screening procedures for hypertension and hypercholesterolemia for early diagnosis of the medical conditions. Upon signing in at the health facility for the mentioned procedures, the patient will undergo a medical assessment in the examination room where the medical practitioners will focus on identifying health complaints of the patient and obtain a medical history. According to Ashwood, Gaynor, Setodji, Reid, Weber, & Mehrotra (2013), obtaining a medical history from patients is one of the important aspects that help in making proper diagnosis relating to their current medical conditions. The patient will undergo a physical examination where the nurse will focus on identifying the vital signs and symptoms presented. Physical examination is necessary as it helps in ruling in or out some medical conditions. 

The second important procedure that help in enhancing proper diagnosis of possible medical condition entails undertaking lab tests and other diagnostic tests to ensure accuracy of the process. In this case, the nurse practitioners will order lab tests such as repeated blood pressure tests in order to determine whether the patient has a possibility of hypertension. In the case where the blood pressure is greater or equal to 140/90, the patient is advised to undertake another test in 10 to 15 minutes in order to determine whether there could be changes regarding the level of blood pressure (Bowman, Mehrotra, & Ashwood, 2016). Upon taking another test with the same reading, the nursing practitioner will administer anti-hypersensitive medication, which helps in stabilizing the level of blood pressure within the body. According to Ahmed & Fincham (2010), the JNC 7 guidelines mandate the medical practitioners to ensure that patients with blood pressure of greater or equal to 140/90 should be started on medication to help in regulating the blood pressure. 

Upon the administration of the anti-hypersensitive medication, the patient is asked to return after two weeks for another evaluation considering there are no other signs and symptoms being presented. One of the critical roles of the nurse practitioners entails the provision of relevant education to the patient regarding basic elements that are necessary in monitoring blood pressure at home. Providing patients with proper information regarding different measures that could be taken in monitoring is an important step towards enhancing their overall health. Patients that present high risks regarding the hypertension are advised to engage in recording keeping of their blood pressure in order to assist the medical practitioners in understanding the patterns associated with the blood pressure within a patient. The nurse practitioner will focus on creating a discussion regarding the risks factors associated with hypertension and the importance of capitalizing on healthy lifestyles. 

According to Mehrotra, Wang, Lave, Adams, & McGlynn (2008), some of the critical elements that need to be communicated to patients entail the need to engage in regular physical activities that focuses on stress reduction, maintain healthy diet, and disassociate with harmful behaviors such as smoking. The nurse will ensure that the patients have information regarding the lipid profile, which is a critical element in enhancing proper monitoring of the blood pressure levels among the patients. The other important factor in the process change is focusing on a follow up of the patients that were engaged in the health risk assessment and screening of the hypertension and hypercholesterolemia. The follow up process ensures that the patients receive a call from the nurse practitioner within 48 to 72 hours after they are discharged from the health facilities. The purpose of the call is to discuss the results obtained from lab tests and other diagnostic tests to ensure that the patients have a proper understanding of the results. 

When focusing on patients with elevated lipid profile, it is necessary to note that such patients are treated based on the NCEP guidelines that offers patients with proper treatment procedures that helps in lowering the cholesterol levels. In this case, the patient receives a cholesterol-lowering agent and is advised to repeat fasting cholesterol profile and undertake liver function tests in cases of increased levels of cholesterol in the body (Weinick, Burns, & Mehrotra, 2010). The presentation of signs indicating end-organ damage requires the patient to visit a specialist in order to ensure proper management of the condition and proper implementation of medication to protect the patient from experiencing more organ damage, which is fatal. When dealing with such a patient, it is important to provide an opportunity to discuss issues such as compliance to the medication and allow the patient to ask question that are relevant in managing the level of cholesterol in the body. Additionally, follow-up is a necessary step among the patient in order to monitor the lipid profile. 

To capitalize on enhancing the process change pilot, it is important to ensure that a lead nurse practitioner is mandated to oversee the entire process, which is a critical element in capitalizing on success (Kaissi & Charland, 2013). Additionally, it is important to ensure that the nurse practitioner collaborates with the quality improvement team for effective data collection relating to the number of patients that seek health risk assessment and screening for various health conditions such as hypertension and hypercholesterolemia. The lead nurse and the quality improvement team will also focus on document unexpected events and request the participants, in this case the patients, to present their feedback relating to the entire process. Feedback is a critical aspect that helps in identifying areas that require improvement in order to ensure adequate success of the process. 

Study 

Evaluation 

In this section, the lead nurse practitioner and the quality improvement team will focus on the analysis of data collected during the pilot test in order to provide a platform for reflection on the given results. The evaluation of the process change will focus on the number of patients that sought health risk assessment and screening procedures for hypertension and hypercholesterolemia. The evaluation will identify the number of patients diagnosed with hypertension and with hypercholesterolemia and demonstrate the medical condition that presented a majority of the patients. According to Thygeson, Van Vorst, Maciosek, & Solberg (2008), evaluation of patients is a critical element in any given study considering that it helps in providing an overview of the total number of patients that are diagnosed with various medical conditions upon undertaking health risk assessment and screening tests. 

The second important aspect in the evaluation process entails determining the number of patients that were in a position to achieve their target BP and lipid goals focusing on the time taken for the achievements. Undertaking measurement regarding the duration taken for each patient to achieve his or her target on BP and lipid goals is a critical element that helps in demonstrating the ability of the body in dealing with the given medical condition. The evaluation will take into consideration the number of patients that portrayed end-organ damage and those that were referred for special treatment regarding the given condition. Additionally, the number of patients adhered to their follow-ups regarding their condition will be evaluated in order to determine the patients characteristics relating to their adherence to medical advice involving their individual health. 

Another important aspect in the evaluation process involves tabulation and interpretation of the results of patients’ survey. The results from patients’ survey are critical considering thy entail feedback regarding key elements that should be addressed in order to enhance effectiveness of the process. The lead nurse practitioner and the quality improvement team will focus on the implementation of EMR as the critical evaluation tool that help in providing proper interpretation of the results (Kaissi, 2010). The evaluation will focus on the positive and negative results in order to determine areas that require improvement within the next PDSA cycle. At the end of the evaluation process, the team will undertake a comparison of what happened during the process and what was expected in order to determine the level of expectations that were. Additionally, the team will present a summary of the lessons learnt during the process change, which is an important aspect in the evaluation. 

Act 

Snapshot of Improvement and Dissemination of Information 

Upon the collection of data, there will be a display of graph charts in the bulletin board with the office to provide an illustration of the number of patients seen with regard to health risk assessment and screening of the hypertension and hypercholesterolemia. The charts will illustrate the number of patients diagnosed, treated and those that achieved their target regarding BP and lipid goals based on their medical conditions. The bar charts will provide an illustration of the number of patients that were referred to specialist regarding the severity of their conditions and identify those that adhered to follow up checks that were scheduled for different time regarding the level of severity of individual conditions. Additionally, the use of charts in this case will help in demonstrating the positive and negative aspects of change regarding to the results obtained from the patients’ surveys. 

According to Pollack, Gidengil, & Mehrotra (2010), proper dissemination of information is a critical element that helps in enhancing the level of effectiveness in change process. In this case, the team will focus on the use of electronic mail system as an avenue for disseminating information within the organization. The use of the electronic mail system is necessary as it helps in providing a platform for sending and receiving updates effectively within the course of the study, which is an effective tool in enhancing success. Another important aspect that will be implemented in this case is the establishment of weekly meetings that will provide an avenue for communication that is necessary in debriefing during the pilot study. The team will ensure that the scheduled meetings offer a platform for communicating feedback regarding the entire process and share their experiences concerning their interactions with the patients in the pilot study. Additionally, the team will focus on outlining the possible and unexpected results that may be encountered in the future upon undertaking such similar studies. Additionally, the team would be in a position to determine whether the change being tested is adapted, modified, or abandoned based on the reaction of the patients. 

The concept of retail clinics is relatively new in health care service delivery as it involves the idea of ensuring that patients gain access to quality, acceptable, convenient, and affordable health services. Retail clinics operate under ambulatory care focusing on the uninsured, as well as the underinsured population as part of ensuring that the quality of services they receive match their expectations. Usage of retail clinics is essential towards ensuring that patients focus on maintaining that generalized approach from which to deliver positive outcomes in terms of the quality of services. Nursing practitioners (NPs) are expected to use the retail clinics as part of their approaches to ensure that they deliver the best possible health services to their patients at an affordable cost. 

The expansion of the services to focus on primary case as part retail clinics seeks to introduce new avenues for screening, diagnosis, treatment, and follow-up of patients suffering from hypertension and hypercholesterolemia through the retail clinics. The main objective of the expansion is to ensure that patients suffering from hypertension and hypercholesterolemia receive quality health services. The health services may help towards improving preventive care considering that this is one of the lacking areas for majority of patients. The long-term focus is to work out a positive platform from which to ensure that patients receive the best possible health outcomes as part of enhancing their capacities for quality outcomes in the management of hypertension and hypercholesterolemia. 

References 

Ahmed, A., & Fincham, J. E. (2010). Physician office vs retail clinic: patient preferences in care seeking for minor illnesses.  The Annals of Family Medicine ,  8 (2), 117-123. 

Arthur, B. C., Fisher, A. K., Shoemaker, S. J., Pozniak, A., & Stokley, S. (2015). Business models, vaccination services, and public health relationships of retail clinics: a qualitative study.  Journal of Healthcare Management ,  60 (6), 429-440. 

Ashwood, J. S., Gaynor, M., Setodji, C. M., Reid, R. O., Weber, E., & Mehrotra, A. (2016). Retail clinic visits for low-acuity conditions increase utilization and spending.  Health Affairs ,  35 (3), 449-455. 

Bowman, J., Mehrotra, A., & Ashwood, J. S. (2016). Use of retail clinics for low-acuity conditions/use of retail clinics: The authors reply.  Health Affairs ,  35 (5), 937. 

Hermanson, P. M., Berkshire, S. D., Leaming, L., & Piland, N. (2013). Retail health clinics: Sustain or close? A case study.  Journal of Management Policy and Practice ,  14 (6), 37. 

Hoffmann, A. (2010). Minute medicine: Examining retail clinic legal issues and legislative challenges.  Health Matrix ,  20 , 467-497. 

Kaissi, A. (2010). Hospital-affiliated and hospital-owned retail clinics: strategic opportunities and operational challenges.  Journal of Healthcare Management ,  55 (5), 334-337. 

Kaissi, A., & Charland, T. A. (2013). How satisfied are hospital systems with their ownership of retail clinics?.  Journal of Healthcare Management ,  58 (2), 143-153. 

Mehrotra, A., Wang, M. C., Lave, J. R., Adams, J. L., & McGlynn, E. A. (2008). Retail clinics, primary care physicians, and emergency departments: a comparison of patients’ visits.  Health Affairs ,  27 (5), 1272-1282. 

Nelson, R. (2007). Retail health clinics on the rise.  AJN The American Journal of Nursing ,  107 (7), 25-26. 

Pollack, C. E., Gidengil, C., & Mehrotra, A. (2010). The growth of retail clinics and the medical home: two trends in concert or in conflict?.  Health Affairs ,  29 (5), 998-1003. 

Simon, M., Choudhry, N. K., Frankfort, J., Margolius, D., Murphy, J., Paita, L., ... & Milstein, A. (2017). Exploring attributes of high-value primary care.  The Annals of Family Medicine ,  15 (6), 529-534. 

Thygeson, M., Van Vorst, K. A., Maciosek, M. V., & Solberg, L. (2008). Use and costs of care in retail clinics versus traditional care sites.  Health Affairs ,  27 (5), 1283-1292. 

Weinick, R. M., Burns, R. M., & Mehrotra, A. (2010). Many emergency department visits could be managed at urgent care centers and retail clinics.  Health affairs ,  29 (9), 1630-1636.