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

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.