Primary Care Research Center

Primary Care Innovation

Jefferson Primary Care has emerged as a national leader in person-centered primary care measurement and implementation science.  For instance, a Jefferson primary care team led by Geoffrey Mills, MD, PhD, in partnership with Rebecca Etz, PhD at the Larry A. Green Center, distributed a newly-developed Person-Centered Primary Care Measure (PCPCM) to 329,450 patients across 78 primary care practices. Core findings were that the PCPCM was feasible to administer, showed strong internal reliability, captured meaningful variation in patients’ experience of primary care, and revealed important demographic and equity-relevant patterns, especially around whether care teams understand patients’ communities (Mills et al., 2025. Implementation of the Person-Centered Primary Care Measure. Journal of the American Board of Family Medicine). This work is important because it moves primary care evaluation beyond narrow satisfaction metrics toward what matters most: access, continuity, comprehensiveness, trust, coordination, and care that reflects patients’ lives, goals, families, and communities.

Jefferson Health Virtual Primary Care represents an innovative approach to increasing patient access to primary care and alleviating PCP patient panels. Led by Anna Flattau, MD, MSc, MS, this model has become one of our system’s fastest-growing offerings, reflecting patients’ desire and need for timely and accessible care. In parallel, it serves as an important platform for developing areas of research focused on the implementation and evaluation of scalable telehealth care models, as well as research examining telehealth as an intervention to improve access, quality, and patient outcomes.

Jefferson Primary Care is advancing the measurement and implementation of continuity of care, a core feature of effective primary care that reflects the extent to which patients receive coordinated, longitudinal care through an ongoing relationship with a clinician or care team. In collaboration with the American Board of Family Medicine and Jefferson partners, our team has evaluated and implemented multiple continuity measures to support both practice operations and research. These metrics now provide a foundation for emerging research on how continuity of care relates to care quality, utilization, and patient outcomes, with the goal of informing patient care and targeted quality improvement initiatives.

Cardiovascular Health

Awarded in April 2026 through PCORI HSII, a new system-wide hypertension initiative, led by Geoffrey Mills, MD, PhD, will implement an evidence and team‑based approach to improving hypertension management across the Jefferson Primary Care network. This $1.7 million dollar contract will address current gaps in care by introducing a comprehensive care model that strengthens blood pressure measurement and active management. The program will allow clinical teams to partner with patients to empower them to manage their blood pressure more effectively. Utilizing the RE-AIM evaluation framework, this project will track rates of confirmed hypertension diagnoses and proper documentation, referrals, rates of false positives, staff training, and initiative implementation. This new initiative will scale critical hypertension work across the Jefferson Health system.

Two recent NIH-sponsored trials led by Christopher Chambers, MD, PRE-EMPT and PREVENTABLE, focus on identifying adults at cardiovascular risk and evaluating clinical and pharmacologic strategies to improve prevention. PREVENTABLE is examining whether atorvastatin can reduce death, dementia, persistent disability, cognitive decline, and cardiovascular events in community-dwelling older adults without established cardiovascular disease or dementia, while PRE-EMPT is designed to identify younger and middle-aged adults with subclinical coronary atherosclerosis and test whether early treatment with rosuvastatin and/or colchicine can reduce coronary plaque burden.

Lifestyle Medicine

The Jefferson Lifestyle Program, launched in January 2026 and funded by a $2.1 million PCORI Health Systems Implementation Initiative contract, aims to improve patient health via the pillars of lifestyle medicine - nutrition, physical activity, sleep, social connection, stress management, and avoidance of risky substances. Led by Anna Flattau, MD, MSc, MS and Amy Cunningham, PhD, MPH, this program will evaluate clinical (weight, blood pressure, A1c) and patient-reported (health-related quality of life, diet, physical activity, social connection, satisfaction, etc.) outcomes using the RE-AIM framework. Available to all Jefferson adult patients, the Lifestyle Program supports patient longevity and sustained health and serves as a critical complement to clinical care. Findings will be disseminated as the program advances.  

Geriatrics

Improving Dementia Care in Primary Practice, led by Barry Rovner, MD, and funded by a 2026 Independence Blue Cross Clinical Care Innovation Grant, focuses on supporting primary care clinicians to more easily identify and manage mild cognitive impairment and early Alzheimer’s disease in older adults, while enhancing the experience patients and their families and care givers have when seeking care. Patients receive education and personal support from Community Health Worker. This initiative tests whether adding structured screening tools and additional patient support can improve early detection and care planning. 

A recent pilot study, led by DFCM faculty members Brooke Salzman, MD, Amy Cunningham, PhD, MPH, and Susan Parks, MD, compared clinician’s impression of a patient’s cognitive status (provider gestalt) with a standardized screening tool (Mini-Cog^©) during the Medicare Annual Wellness Visit (AWV).

Cancer Prevention

Led by Ron Myers, PhD, DSW, the “Provider Support and Patient Outreach in Lung Cancer Screening” clinical trial, funded by the National Cancer Institute’s Center to Reduce Cancer Health Disparities tests how well providing education improves screening rates for lung cancer in patients with a history of smoking. These screenings help clinicians identify lung cancer in patients earlier, when it is likely easier to treat.

Lean Into SOAR Initiative (LISI) is a $1.2 million collaboration with Exact Sciences to better understand how patients and providers view multi-cancer early detection (MCED) tests and how these tests might be incorporated into care delivery. The initiative has already produced three publications on patient interest, provider receptivity, and trial participation, helping to inform future research on MCED evaluation and implementation in real-world primary care settings.

Integrated Behavioral Health

A central area of our integrated behavioral health research is the implementation and evaluation of SBIRT (Screening, Brief Intervention, and Referral to Treatment) in primary care. As an evidence-based strategy to identify individuals who use alcohol and other substances at risky levels, SBIRT offers an important framework for early identification and intervention within routine care delivery. Anna Flattau, MD, MSc, MS and Robert Sterling, PhD of Drexel University led a SAMHSA-funded collaboration to implement SBIRT across two sites: Drexel’s Student Health Center and Jefferson Health’s Family Medicine Associates in Center City Philadelphia. Current research builds on this foundation by examining implementation processes, predictors of positive screening outcomes, and clinical workflow strategies to improve the systematic identification of substance use within primary care practice.

Another project, led by Gregory Jaffe, MD, MSEd launched in 2025 and funded by an Independence Blue Cross Clinical Care Innovation Grant, supports patients with opioid use disorder and expands access to medication for opioid use disorder. This study implemented universal screening for opioid use disorder and provided patients with the opportunity to engage in medications for opioid use disorder via telemedicine.

Women’s Health

Access to contraceptive care is critical to supporting women’s health – and a new collaboration between Jefferson’s Internal Medicine, Obstetrics and Gynecology, and Primary Care departments will pilot the implementation of a new screening tool to quickly and comprehensively address this need amongst our patient population. Funded by Upstream USA, this initiative will also focus on enhancing clinician education and training on contraceptive care and reproductive health.