University of San Francisco California
North American Primary Care Research Group Annual Meeting
The North American Primary Care Research Group (NAPCRG) invites you to join them for the 46th NAPCRG Annual Meeting November 9-13 in Chicago.
More than 1,100 primary care researchers from around the world attend NAPCRG's Annual Meeting. The conference allows attendees to receive high-quality educational content, network with their colleagues, and discover innovative advancements the primary care research. Conference attendees experience over 800 educational sessions including oral presentations, workshops, forums, posters, plenary sessions. and networking at the largest primary care research meeting of its kind.
Below is a selection of NAPCRG pre-conferences, oral presentations and workshops that may be of interest to you (download as a Word document):
Friday, November 9, 2018
PR1 Place Matters: Mapping and Data Tools for Doing Population Health
Michael Topmiller, PhD; Mark Carrozza; Jené Grandmont; Jennifer Rankin, PhD; Andrew Bazemore, MD, MPH
11/9/18 8:30 AM - 12:30 PM Stevens Salon C2
Objectives: This preconference session will enhance participants’ understanding about the importance of geography to population health, give a practical understanding of the tools, methods, and data available to do population health research and practice, and consider ways in which care providers can use these resources to inform their practice. Content: Place matters to personal and population health. Understanding the community context of patients has become increasingly important in the primary care research domain. In light of the growing interest in this area of research, multiple tools have been developed to help physicians use these concepts at both the research and practice level. This hands-on workshop will introduce participants to a variety of geographic information analysis and data dissemination tools, as well as discuss ways in which community-level data can help inform research and care. Participants will review the existing primary care research highlighting population health and the importance of Social Determinants of Health, access hundreds of community-level data points, and consider how they can begin to use the combination of data and geography to positively affect health outcomes by making changes both at the community level and at the point of care. The workshop will include real-world examples of spatial primary care research and application. Method: Didactics, discussion, and hands-on computer workshop using GIS software and web-based mapping applications. We will provide sample data to use in applying concepts taught in the session and incorporate examples from a variety of primary care domains. Participants are encouraged to bring their own examples. Prerequisite Knowledge: None
Saturday, November 10, 2018
Emily Abramsohn; Megan DePumpo; Kelly Boyd; Tiffany Brown; Milton Garrett III; Abel Kho; Chenab Navalkha; Kelsey Paradise; Stacy Lindau, MD
11/10/18 9:30 AM - 10:30 AM Stevens Salon B
Context: Healthy Hearts in the Heartland (H3) is an AHRQ EvidenceNOW initiative to evaluate small, Midwest primary care practices’ capacity to implement evidence-based strategies to prevent cardiovascular disease (CVD). The Chronic Care Model identifies community support as important for self-management of CVD risk factors, but little is known about practices’ use of community resource referral systems. Objective: Describe practices’ implementation of CommunityRx, a community resource referral system developed and previously tested in large Federally Qualified Health Centers and academic practices through a 2012-15 CMMI Health Care Innovation Award. Study Design: Qualitative study of H3 practice facilitators (PFs) as expert informants. Setting: Focus groups. Participants: 14 of all 19 H3 PFs. Intervention: A referral list (HealtheRx) with community resource information for patients with a diagnosis of hypertension or diabetes. Each practice-specific HealtheRx was populated with resources from an inventory generated by practices with PF support. Main and Secondary Outcome Measures: Barriers to and facilitators of connecting patients to community resources and providers’ use of and experiences with the HealtheRx. Results: Facilitators of HealtheRx uptake included larger clinic staff size, urban (vs. rural) setting and practices where healthcare providers embraced a population health management strategy. Clinical sites with either physician or practice manager “champions” were more consistent in disseminating the HealtheRx; 31/84 (37%) practices proactively requested iterations of their HealtheRx over time, indicating engagement. Barriers included integrating CommunityRx into existing workflows, capacity to generate the resource inventory, and print the HealtheRx. Some practices experienced communication difficulties with community resource providers, leading to skepticism that patients would utilize referred resources. Conclusions: H3 practices varied in their ability to implement a community resource referral solution to support self-management of patients with CVD risks. More than a third of practices demonstrated engagement. Integration into routine workflow and resource inventory support would likely increase uptake.
P172 Evaluating RHC Effectiveness Increasing Primary Care's Connections With Their Communities
Benjamin Robb; Paige Backlund Jarquin, MPH; Rebecca Rapport
11/10/18 9:30 AM - 10:30 AM Stevens Salon B
Context: Colorado has launched a Regional Health Connector (RHC) workforce to promote upstream connections among primary care, community organizations, public health, human services, and other partners. With the understanding that a better-connected system will result in health improvement, the RHC program is using Social Network Analysis to evaluate the connectedness of RHC networks. Objective: The RHC workforce increases clinical-community linkages to improve services and supports between primary care, their communities, and the RHCs themselves. Study Design: Survey using bidirectional social network analysis methods. Setting or Dataset: Regional, community-based clusters in each of the 21 RHC networks, across the state. Patients or Other Participants: 822 partners within the RHC network. Selection was based on documented stakeholder engagement from the pilot year of the RHC workforce. Participants represented primary care, community organizations, and government agencies. RHCs were limited to 75 total participants each and could exclude participants if connections were too infrequent to measure. Intervention/Instrument: Survey instrument used: PARTNER. This was not an intervention study. Main and Secondary Outcome Measures: Outcome measures: if RHCs were attributed as facilitators to a more connected system; to increase knowledge and access to resources for primary care providers and community organizations; and to improve coordination of services/referrals. Results: Preliminary results demonstrate that the RHCs workforce has facilitated new and improved connections, they have led to an increased exchange of resources, and improved services and supports. Conclusions: The evaluation provides evidence that RHCs are improving clinical-community linkages and systems connections. PCPs and community partners attribute RHCs for supporting population health improvement and increasing services/referrals. This progress is relevant to primary care practices who are supporting patients through the health neighborhood by strengthening clinical-community connections.
Ranit Mishori, MD, MHS, FAAFP; Robert Baillieu, MD, MPH; Matthew Pazderka
11/10/18 9:30 AM - 10:30 AM Stevens Salon B
Context: The social determinants of health (SDoH) are linked to health disparities, and include housing, food insecurity, employment, and poverty. Experts believe clinicians should screen for the SDoH, but critics worry that physicians may lack the confidence, time and guidance to screen, feel powerless to address them, and that screening may contribute to patient harm. Objectives: To assess the available evidence in order to understand the benefits and potential harms of screening for the SDoH. Design: Scoping literature review to map and synthesize existing literature. Approach: Using OVID, searches were limited to: 1. Food insecurity AND screening; Hunger AND screening; 2. Homelessness AND Screening; Housing AND Screening; 3. Employment AND screening; 4. Poverty AND screening; and 5. SDoH AND screening. Inclusion criteria: all ages; all populations; all geographical locations; All disease states; all clinical settings; all dates. Exclusion criteria: not tool evaluation; Not commentary; Limit to US. Main Outcomes: Assessment of available evidence to determine the harms and benefits associated with screening for the SDoH. Results: Literature on quantifying the benefits and/or harms of screening is very limited. The defined search terms and criteria produced approximately 30 articles. Manuscripts yielded a variety of texts describing programs, offering toolkits and rationales for screening; fewer addressed specific outcomes. When outcomes were addressed they focused on: reductions in healthcare utilization; physician satisfaction and empowerment; and how patients are empowered by discussions about adverse circumstances. Conclusions: Screening for specific SDoH may have the potential to address health more comprehensively, but studies are small and of low quality. A research agenda should be developed.
Kevin Pottie, MD, MClSc, CCFP; David Ponka, MSc, MDCM, CCFP; Olivia Magwood; Vanessa Ymele Leki
11/10/18 9:30 AM - 10:30 AM Stevens Salon B
Context: Homeless and vulnerably housed individuals have significantly worse health outcomes than people in stable housing. Their perceptions can affect participation, engagement, and retention in social and health services. Understanding service perceptions may guide primary care practitioners and ensure that services provided are inclusive, equitable, and effective. Objective: To understand the experiences and factors influencing the acceptability and accessibility of social and health interventions targeted towards homeless and vulnerably housed individuals. Study Design: Systematic review of qualitative studies. Dataset: Electronic searches of MEDLINE, EMBASE, PsycINFO, ERIC via Ovid, ProQuest Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts and Sociology Database for studies published from 1994 to 2018. Participants: Homeless and vulnerably housed populations found in high income countries. Interventions: Housing, mental health, addictions, income assistance, and care coordination interventions, as well as interventions for women and youth, occuring in primary care settings. Main Outcome Measures: (1) Identification of biomedical, behavioural, and structural enabling factors, (2) valuation of positive and negative outcomes of interventions, (3) acceptability of interventions, and (4) accessibility of interventions. Results: Out of 8938 studies retrieved, 32 were identified for qualitative synthesis. The evidence synthesis shows that people experiencing homelessness value trust and safety. Often, self-identity is a factor linked to the development of trust and acceptance for long-term and integrated services, peer-support, and patient-centered engagement. Their perceptions is also affected by depression and low self-esteem. Conclusions: The experience of homeless and vulnerably housed individuals related to health and social services varied based on self identity, self esteem, trust and depression. Identifying and finding innovative ways to address these service use determinants may improve the inclusiveness, equitability, and ultimately effectiveness of primary care targeting this population.
Andrew Pinto, MD, MSc, CCFP, FRCPC; Rose Wang; Marcella Jones; Gary Bloch
11/10/18 10:45 AM - 11:45 AM Stevens Salon C4
CONTEXT: Income is a key social determinant, with numerous studies documenting that poorer individuals have worse health outcomes and less access to health services than the wealthy. Income influences who has access to basic necessities, such as healthy food and adequate housing, but also determines our status in society and how we relate to others. Over the past decade a growing number of primary care organizations, associations and frontline providers have become interested in addressing the social determinants of health, including income. OBJECTIVE: To evaluate the short-term impact of a novel Income Security Health Promotion (ISHP) service in operation in a primary care organization. STUDY DESIGN: Survey administered by a trained research coordinator via telephone to all patients discharged from the ISHP service between March 1, 2017 and January 31, 2018 at one month. The questions focused on if the ISHP service was helpful to patients, how it was helpful, and what improvements in financial situation occurred. SETTING AND PARTICIPANTS: A large, patient centred medical home primary care organization in Toronto, Canada serving over 45,000 patients at six clinics, approximately 30% who live below the Canadian poverty line. The ISHP service consists of two social workers who have received additional training, who focus solely on increasing income, reducing expenses and improving financial literacy of patients they are referred. RESULTS: Of 131 patients discharged during the study period, 79 (60%) gave permission to be contacted, and 56 (43% of total) could be reached. The majority were struggling with a combination of health and financial challenges, and 13% reported they were in a significant crisis. 95% found the service to be helpful and would recommend it to others. 57% reported an increase in their income. The median increase in recurring income was $248/month (range $30-$4000), and the median one-time increase was $475 (range $45-$1,500). 34% reported a decrease in expenses, and 71% had an increase in their financial literacy. CONCLUSIONS: Our findings suggest that this novel ISHP service succeeds in increasing income, reducing expenses and improving financial literacy. Participants that agreed to participate and who could be reached by telephone likely represent a bias sample. Future work includes an ongoing randomized controlled trial and a qualitative study to better understand how this service works.
OT13 Should SDH Data Influence Clinical Decision Making?
Arwen Bunce, MA; Inga Gruss; Rachel Gold, PhD, MPH; James Davis; Katie Dambrun, MPH; Erika Cottrell, PhD, MPP; Nadia Yosuf, MPH
11/10/18 10:45 AM - 11:45 AM Mobley
Context: While the role of social determinants of health (SDH) data collection in primary care is gaining prominence, most discussions of how to use this data focus on connecting patients with SDH needs to community resources. Though likely equally important, the potential impact / utility of SDH information in clinical decision-making has received far less consideration. Objective: Explore staff perspectives on the role SDH data should play in clinical care. Design: Transcripts from 60 in-depth interviews; analyzed using the constant comparative method. Setting: Eleven community health centers (CHCs) across the US. Participants: CHC staff. Intervention: EHR-based SDH documentation tools provided to CHCs in 2016. Results: Across a variety of staff roles, perspectives on the appropriate influence of SDH data on treatment plans fell into three groups: 1) Some saw a clear distinction between medical and psychosocial care, and thought a clinician’s obligation is to make the best possible medical decisions for the patient regardless of SDH barriers; it is then the responsibility of care team members to support the patient in following the treatment plan. 2) Some felt that SDH should play a role in clinical decisions under limited circumstances – e.g., if it affected a patients’ ability to pay for medications they could prescribe less costly options, or if SDH was affecting treatment adherence. 3) Some considered psychosocial and traditional medical factors so intertwined that SDH knowledge is critical to clinical decision-making. Conclusion: The proper role of SDH information in a clinician’s ability to provide high-quality care to vulnerable patients is a point of debate: does good patient care necessitate accounting for SDH when formulating treatment plans, or might it be more appropriate to base clinical decisions on standard of care regardless of social situation? These questions must be carefully considered as SDH screening is increasingly incorporated into primary care.
Pablo Buitron de la Vega; Stephanie Losi; Linda Sprague Martinez; Allison Bovell-Ammon; Arvin Garg; Thea James; Alana Ewen, MPH; Marna Stack; Heloisa DeCarvalho; Megan Sandel; Rebecca Mishuris; Stella Deych; Patrick Pelletier; Nancy Kressin
11/10/18 1:15 PM - 2:15 PM Stevens Salon B
Context: Despite the recognized impact of social factors on individual health, there are few, systematic clinical strategies in primary care for addressing Social Determinants of Health (SDOH), while fewer illustrate strategies to leverage EMR automation to facilitate screening and resource referrals. At Boston Medical Center (BMC), population-based strategies for helping patients address social needs are urgently needed as the institution transitions to a value-based accountable care model. Objective: Develop a systematic clinical strategy to screen primary care patients for SDOH. Secondary objectives: Utilize the EMR to generate ICD-10 codes from screening responses. Provide language-appropriate referrals to available community and hospital-based resources. Study Design: Observational study. Evaluated the feasibility of implementing a SDOH strategy. Setting or Dataset: Primary care patients at a large safety-net hospital in Boston, MA. Patients or Other Participants: All new English, Spanish, Haitian Creole, and Portuguese speaking adult patients presenting to General Internal Medicine Primary Care. Sociodemographic features: Information available for 1,522/1,696 screened patients. Mean age: 40 years (s.d. 15). Male: 51.9%. Black/African American: 39%, White: 31.7%, Asian: 4%. Primary language – English: 77%; Spanish: 11%; Haitian Creole: 8%. Main and Secondary Outcome Measures: Main: Patients screened vs. eligible patients. Secondary: Provider orders signed vs. positive patient screens. Secondary: Provider orders signed vs. patient requests for help connecting to resources. Results: 1696/2420 (70%) eligible patients were screened. 215/255 (84%) patients with ≥1 identified need had the appropriate ICD-10 code added to their visit diagnoses. 158/204 (77%) patients who requested resources received a resource guide. Conclusions: Integrating a systematic clinical strategy using EMR workflows to address SDOH is feasible in primary care clinics. The researchers attribute their success to alignment with hospital strategic priorities; involving key stakeholders in developing a streamlined, standard workflow; leveraging EMR automation to minimize time burden on clinic staff; piloting and improving the initial program design before scaling; and incorporating staff feedback and ideas to continuously improve the program.
Grace Kyoon-Achan, PhD; Kathi Avery Kinew; Wanda Phillips-Beck, MSc, RN; Josee Lavoie; Alan Katz, MSc, MBChB
11/10/18 1:15 PM - 2:15 PM Stevens Salon B
Context: Recognizing the right of self-determination of indigenous peoples is essential to improve the state of health of First Nations, Inuit and Metis peoples in Canada. Understanding communities’ priorities and community-based health agendas is critical for community-based primary healthcare transformation. Objectives: To understand existing strengths supporting primary healthcare in Manitoba First Nations communities. To elaborate a First Nation vision for optimal community-based healthcare system. Human subjects review: Ethics approvals were obtained from the University of Manitoba Research Ethics Board and the Health Information Research Governance Committee at Nanaandawewigamig, the First Nations Health and Social Secretariat of Manitoba. Design: Qualitative study using community-based participatory approach to engage 8 First Nations communities. Interview questions were co-developed by university-based researchers, First Nations Health and Social Secretariat of Manitoba and community partners. Interviews were conducted by community-based local research assistants of First Nations ancestry. Data is collaboratively analyzed with community partners. Setting: Rural and Remote First Nations communities in Manitoba. Results: Key emerging themes likely to transform community-based primary healthcare include: primary prevention focused on health determinants affecting various communities (housing, water, employment, education), an integrated healthcare system providing access to both mainstream and First Nations traditional health practices and land based activities, expanded and upgraded infrastructure improvements, continuity of care, investing in community-based human resources, increased mental health services including appropriate addictions counseling. Specific roles were identified at four levels; individual, community, local leadership and government. Conclusion: Optimal community-based primary healthcare for First Nations, would empower local leaders to implement culturally responsive, geographically sensitive, and outcomes-oriented solutions. This could be achieved by acknowledging and supporting local health champions and community health priorities rather than imposing contextually irrelevant solutions.
P287 Complex Care Program Effectiveness at an Urban Community Health Center
Helen Jin, MBA, MD; James Gill, MD, MPH; Jennifer Lo, MD
11/10/18 1:15 PM - 2:15 PM Stevens Salon B
Context: Complex case management (CCM) for patients with high healthcare utilization and disease burden may be beneficial to reduce healthcare utilization. However, few studies have evaluated the effectiveness of CCM developed within community health centers (CHCs), especially for Medicaid patients. CCM developed by CHCs may be more effective due to increased knowledge of local community resources and closer communication with primary care providers. Objective: To evaluate if a complex case management program developed within a community health center is effective in reducing acute healthcare utilization. Study Design: Retrospective cohort study. Setting: Urban community health center. Patients: From 06/01/2014-01/31/2018, 82 patients were included due to qualifying scores from a local scoring tool. 8 patients were excluded due to less than one year of primary care at the CHC, death or switching to specialty case management within the year before and after program assessment. 84% of patients had Medicaid. Patients of any age were included and median age was 58. Intervention: A nurse case manager and patient navigator coordinated skilled home services, provided healthcare and social services navigation, and local community resource referral. Main and Secondary Outcome Measures: The annual hospitalization and emergency room rate of program participants and program decliners before program participation was compared to one year after accepting or declining the program. Results: Compared to program decliners, annual emergency room visits for program participants decreased 0.84 visits, from 1.77 to 0.80, p=0.04. However, annual hospitalizations of program participants were stable compared to annual hospitalizations of program decliners, which decreased 0.89 visits annually from 1.83 to 0.76, p=0.004. Conclusions: CCM developed within CHCs may be beneficial for complex Medicaid patients by reducing the annual rate of emergency department visits. Future studies should fully control for patient complexity in order to more rigorously analyze CCM effectiveness.
Raman Nohria, MD; Julia Tse, MD; Elise A Carpenter, MD, PhD; Keith Nokes, MD, MPH
11/10/18 1:15 PM - 2:15 PM Stevens Salon B
Context Over the past 12 months, the Greater Lawrence Family Health Center has used the Hunger Vital Signs to screen 1600 of the clinic's patients and has found that 67%, or over two-thirds, screened positive for food insecurity. This is a surprisingly large portion of the clinic's patients, so it is imperative for the clinic to address this issue. To ensure the desired effectiveness and widespread impact of a clinic-wide intervention, the clinic needs a patient-centered framework built upon the experiences and perspectives of patients. If proven effective, this framework could provide a unique and refreshing perspective that other primary care clinics can use to address their respective social determinants of health challenges. Objective Learn about patients' experiences with food insecurity to inform appropriate clinic and community interventions. Human Subjects Review Study was exempt from formal review as names and personal protected information were not used. Design Qualitative study using thematic analysis. Setting Patients aged 18 and older enrolled at the resident clinic of the Greater Lawrence Family Health Center and who screened positive for food insecurity using the 2-question Hunger Vital Sign screening questionnaire. Total of 9 participants were recruited with mean age 58 all born in the Dominican Republic. Instrument 3 focus group facilitated by 2 resident physicians conducted in Spanish. Interviews were transcribed into English and then analyzed via coded thematic analysis. Main and Secondary Outcome Measures Main outcome: themes generated from coded thematic analysis Anticipated Results We anticipate identifying several major themes from the coded analysis, such as mental health, lack of transportation, and economic challenges, from which to build a collective patient-centered experience Conclusions Addressing food insecurity is a priority for the clinic. The challenge is that the intervention must be personalized to each patient and also widely adopted by the community. Focus groups can be a central tool to solve this challenge by promoting patient engagement and creating a patient-centered framework as the foundation of the clinical intervention. Learning Objectives 1) Define food insecurity and describe how to screen for food insecurity using evidence-based guidelines 2) Describe how to conduct a focus group and its appropriate use
Michael Klinkman, MD, MS; Donald Nease Jr, MD; Beth Careyva, MD
11/10/18 2:30 PM - 5:30 PM Mobley
Objectives: This Forum seeks to bring together researchers interested in partnering with communities to co-develop interventions to reduce fragmentation and inequities in health care. We will briefly describe collaborative efforts to date in 3 communities (Jackson MI, Longmont CO, and Allentown PA) to stimulate deeper discussion on effective methods to develop sustainable long-term partnerships to carry out this work. Our objectives for participants are threefold: (1) to understand how sociotechnical design principles can inform cross-sector work on complex community problems; (2) to develop a shared ‘methods toolbox’ to guide this work; (3) to build collaborative relationships with the community of researchers actively working in this area. Rationale: In most communities, information related to individuals’ health is distributed across the multiple unconnected care siloes created to support medical, behavioral, and community service providers. While progress has been made toward EHR interoperability for the medical enterprise, community-side information remains highly fragmented and sequestered. The result is that community care providers too often work with incomplete information, cannot connect to the broader system of care, and unintentionally create complex pathways of care that fail to effectively address health disparities. It is unlikely that this classic ‘wicked problem’ will be solved by entering more social data into the EHR. Developing active partnerships with local community stakeholders to address this problem is very important - and incredibly challenging. Participation: After presenting brief descriptions of work in each community, we will open the floor for facilitated group discussion. Participants can share their own experiences and learnings in this area – for example, participatory design work with communities, addressing social determinants of health in community practice, or community-partnered work on integrated care. Participants will be encouraged to question assumptions, provide additional perspectives, and propose new approaches for developing effective partnerships in this space. Prerequisite Knowledge: None.
DB11 Hypoglycemia and the Social Determinants of Health: The Perspectives of Healthcare Providers
Judith Brown, PhD; Sonja Reichert, MD, MSc; Yashoda Valliere; Susan Webster-Bogaert, MA; Alexandria Ratzki-Leewing; Stewart Harris, MD, MPH, CM, FACPM
11/10/18 4:15 PM - 5:45 PM Stevens Salon A5
Context: The impact of the social determinants of health (SDoH) on general diabetes care is relatively well-understood. Less is known, however, about healthcare practitioners’ (HCPs) perceptions of the impact of SDoH on how their patients’ with type 1 and type 2 diabetes mellitus manage hypoglycemia, a common adverse event associated with certain antihyperglycemic medications. Objective: To explore HCPs’ perspectives and experiences regarding the impact of SDoH in the prevention and treatment of hypoglycemia. Design: A descriptive qualitative study from the InHypo-DM (Canada) mixed methods research program. A purposive sampling technique was used to recruit participants for a 30-45 minute semi-structured interview. Individual and team analysis of interviews was conducted to identify themes and sub-themes. NVivo10 software was used for coding of themes. Setting: Southwestern Ontario, Canada. Participants: Twenty HCPs participated including family physicians, endocrinologists, and allied HCPs. Results: Participants described two overarching components of the SDoH impacting patients with type 1 and type 2 diabetes who experience hypoglycemia: patients’ socioeconomic issues and psychosocial issues. Specifically, two socioeconomic issues were noted: 1. occupation type (e.g. pilot, cook), including the impact of shift work and the number of workdays missed due to hypoglycemia; and 2. poverty, including food insecurity and the inability to purchase test strips. With regard to psychosocial issues, participants emphasized three areas: 1. stage in the life cycle (e.g. elderly); 2. social isolation (e.g. lack of family support); and 3. mental health issues (e.g. schizophrenia). Conclusions: This study highlights the importance of conducting detailed and comprehensive social histories to optimize the clinical management of hypoglycemia. Furthermore, strategies that ensure HCPs have adequate time as well as the necessary resources to address patients’ SDOH are imperative in reducing patients’ risk of hypoglycemia.
Carol Mulder, MSc, DVM, DBA , CUTL; Sarah Burrows; Brian Clark; Alies Maybee; Nadiya Sunderji, MD, MPH
11/10/18 4:15 PM - 5:45 PM Stevens Salon A3
Context: Incorporating aspects of the patient-provider relationship into mainstream, quantitative primary care performance measurement is difficult. Ontario’s primary care teams worked with patients to ask patients what their measurement priorities are related to this relationship. Objective: Describe patients’ measurement priorities, considering demographics, social determinants of health (SDH), health status, perceived performance on indicators. Study Design: Population-based quantitative online survey. Setting: 184 interdisciplinary primary care teams serving approximately 25% of Ontario, Canada. Patients: Self-selected respondents to email and social media survey invitations. Main Measures: Priority indicators, according to patients’ SDH, health status and perceived performance on indicators. Results: Top 10 priority indicators from the 218 respondents related to: involvement in decisions, quality of life, time spent with patients, attention to feelings, taking concerns seriously, reasonable wait for appointment, patients saying what is important, primary care-hospital record integration (not for lower SDH), collaboration (not for low SDH) and being approachable (not for low SDH, poor health). Patients with lower SDH (17 of 145 complete responses): 7 of top 10 priorities in common with other patients – remaining 3 related to same/next day appointment, referral process and office-staff courtesy. Patients with poor health (49 of 99 complete responses):9 of top 10 priorities in common with other patients, remaining related to medication review. Both patient sub-group prioritized “availability” but otherwise had similar priorities for remaining patient-provider relationship domains: knowledge, trust, sensitivity, commitment and collaboration. Demographics not explored (too homogenous). Generally high correlation between perceived performance and priorities. Some exceptions were immunizations (high performance, low priority) and time spent with patients (low performance, high priority). Conclusions: SDH and health status have limited impact on patients’ priorities with respect to patient-provider relationship. Correlation between performance and priorities questions conventional wisdom that patients deprioritize biomedical indicators because they assume that providers are already performing well on these.
Sunday, November 11, 2018
Sean Lucan, MD, MPH, MS; Alex Bryan, MD, MPH; Hilary Frankel; Zoe Ginsburg, MD; Andrew Maroko; Ellen Rubinstein, PhD; Clyde Schechter
11/11/18 10:45 AM - 12:30 PM Stevens Salon A5
Context: In primary care, there is increasing interest in social determinants of health like food insecurity. Patients who are food insecure may rely on food pantries for basic nutritional needs. But the degree to which food-insecure patients may have ‘access’ to pantry food is not well-described. Objective: To assess ‘access’ to pantry food according to five dimensions: *availability* (variety of food items offered), *accessibility* (eligibility criteria, hours open), *accommodation* (hours relative to personal schedule), *affordability* (cost, even if not strictly monetary), and *acceptability* (e.g., as related to quality). Study Design: Cross-sectional: quantitative data about the five ‘access’ dimensions and qualitative analysis of investigator observations and pantry-worker thoughts. Setting: Bronx, NY. Participants: Convenience sample of 50 food pantries. Outcome Measures: Frequencies for aspects of ‘access’ dimensions and emergent themes from qualitative data. Results: Pantries had restricted ‘access’: Only 50% of pantries (n=25) were open when they were supposed to be. At most pantries, there was different *availability* of items based on persons’ position in line, *accessibility* limited to certain populations having required documentation, and no *accommodation* for hours outside of Mon-Fri 9am-5pm. As for *affordability*, some pantries necessitated waiting in hours-long lines to get food, and some pantries distributed inferior-quality, less-*acceptable*, fare. Restricted provision by pantries was both a cause of and response to limited food supply. Qualitative themes that emerged were rules (pre-planned systems for orderly operation), workarounds (improvisations based on unexpected food deliveries), and exceptions (rule breaking to meet patients’/clients’ perceived needs), all of which applied to different aspects of pantry operation. Conclusions: Food pantries had set hours and rules but rarely adhered to either. Half of all pantries were not open when they were supposed to be. When they were open, realities and rules limited ‘access’ to food but were inconsistent and unpredictable; there were impromptu workarounds and exceptions for unplanned circumstances.
Winston Liaw, MD, MPH; Jennifer Rankin, PhD; Robert Phillips Jr, MD, MSPH; Andrew Bazemore, MD, MPH; Chris Barnett; Yan Barnett
11/11/18 10:45 AM - 12:15 PM Stevens Salon C5
Rationale: There is increasing pressure and interest in understanding how to use social determinant of health (SDH) data to evaluate patient risk and direct interventions. Policy makers point to mounting evidence demonstrating the impact of social determinants on health and have created programs like accountable care organizations that shift payment from volume to value and increase resources to address social needs. While primary care researchers are ideally suited to leverage the intersection of big data and geography, tools for assessing and addressing SDHs remain inadequate. Electronic health records (EHRs) rarely capture social determinants, and geography does not routinely inform care though other countries use neighborhood data to refine individual risk. To address this gap, the American Board of Family Medicine commissioned the Population Health Assessment Engine (PHATE) and related curriculum. PHATE is an online tool that maps EHR data, creates patient-level Community Vital Signs (a composite measure of community deprivation), identifies clinical hot spots and community cold spots (resource poor geographies), and facilitates referrals to community resources. Participation: During the first third of the workshop, the presenters will introduce what users can do with PHATE, provide an overview of the curriculum, and demonstrate how to use the tool. For the remainder, participants will use PHATE to understand their own communities. Using their own devices and in small groups, they will view data about their communities, use PHATE to select census tracts that they think make up their clinic service areas, identify problems plaguing their communities, and use PHATE to identify potential community partners. Finally, participants will generate questions in PICO (Population, Intervention, Comparison, and Outcome) format that use PHATE data or functionality and can be answered as research projects at their home institutions. Prerequisite knowledge: Participants need to know how to use mapping tools such as Google Maps.
Monday, November 12, 2018
SRF111 Screening Tool to Identify Patients with Social Needs
Franklin Niblock, MD, MPH; Alisa Malki, MD; Rebecca Mullen, MD, MPH; William LeBlanc; Kyle Knierim, MD; Heather Bleacher, MD
11/12/18 10:45 AM - 11:45 AM Stevens Salon B
Context: Primary care physicians are increasingly aware of the impact of social factors on the health of patients. Social determinants of health (SDOH) screening tools can identify these needs within patient panels. Application of these tools will allow us to develop precision public health interventions and move towards clinical population management. Objective: To determine patient characteristics associated with self-reported social needs. Design: Retrospective Cohort Study. Setting: Family medicine residency program clinic located in an urban/suburban setting in Denver, CO. Participants: Adult patients who presented for preventive or new patient visits between November 2017 and May 2018. Instruments: The AF Williams SDOH questionnaire assesses social needs including transportation, social isolation, food insecurity, financial strain, housing problems, household violence and health literacy. Main Outcome: Patient characteristics associated with a higher SDOH score. Results: A total of 968 patients completed the questionnaire with 28.3% (274/968) respondents reporting at least one social need, and 13.0% (126/968) respondents reporting two or more needs. SDOH scores were significantly different based upon self-reported race, with black patients more likely to indicate two or more social needs compared to white patients (25.6% vs. 11.1%, p0.001). Patients with Medicaid or Medicare were more likely to indicate two or more social needs compared to patients with private insurance (43.3% Medicaid, 22.7% Medicare, 11.2% Private; p0.001). There were no significant differences in SDOH scores by respondent age, gender, or ethnicity. Conclusion: Patients of diverse backgrounds report social needs. SDOH screening tools can be used to identify populations with these needs. More investigation can be done to understand the variation of social needs within our patient panel and how our medical system can decrease the impact of these needs on patient and population health.
SRF113 Analyzing Medically Complex Patients With Unmet Social Needs
Alisa Malki, MD; Franklin Niblock, MD, MPH; Rebecca Mullen, MD, MPH; Kyle Knierim, MD
11/12/18 10:45 AM - 11:45 AM Stevens Salon B
Context: As much as 80% of modifiable clinical outcomes are influenced by the social determinants of health (SDOH). Growing evidence shows that individuals with unmet social needs are more likely to be higher utilizers of care. Our current system remains underprepared to identify SDOH and understand the impact of SDOH on an individual’s medical complexity. We seek to better understand how social needs relate to medical complexity and healthcare utilization. Objective: To determine how patients’ self-reported social needs are associated with measures of medical complexity. Design: Retrospective cohort analysis. Setting: A university-based family medicine residency clinic located in an urban/suburban setting in Denver, Colorado. Participants: Adult patients presenting for a new patient visit or an annual exam between 11/3/17 and 5/10/18. Instruments: The Knierim Complexity Index (KCI), a locally developed, automated electronic health record (EHR) risk algorithm that scores patients using medical and mental health diagnoses, medications, demographics, and utilization markers was used to assess medical complexity. The AF Williams SDOH questionnaire assesses various aspects of social needs including financial, transportation, and food insecurity, as well as health literacy. Main Outcomes: Associations between respondents’ KCI scores and SDOH components. Results: 23% (274/968) patients completing the SDOH reported at least one need. SDOH needs were significantly associated with KCI scores (r = 0.21, p 0.001). Respondents with transportation and housing insecurity had significantly higher mean KCI scores than those without (4 vs. 1.6 (p .01) and 2.4 vs. 1.7 (p =.03) respectively). Conclusion: Understanding the relationship between patients’ social needs and their medical outcomes and utilization will help health systems develop more patient-centered, equitable, and effective models of care.
P369 Impact of an Inner City Hospital Team Intervention on Primary Care-Associated Outcomes
Ginetta Salvalaggio, MSc, MD, CCFP; Kathryn Dong, MD, MSc, FRCPC; Elaine Hyshka, PhD; Judith Krajnak, PhD; Lara Nixon, MD, CCFP(COE), FCFP
11/12/18 10:45 AM - 11:45 AM Stevens Salon B
Context: Hospitals provide a 24/7 point of care for inner city patients who experience barriers to accessing traditional primary care. Inner city patients describe unmet chronic social and health needs that primary care is ideally placed to address, but that hospitals could address on an interim basis while working on connecting patients to a primary care home. Hospital teams who approach care needs holistically may impact subsequent health care use by patients. Objective: To determine whether a hospital-embedded inner city complex team intervention impacts access to and continuity with quality primary care. Study Design: Secondary analysis within a controlled pre-post quasi-experimental design. Setting/Dataset: Longitudinal survey data (baseline, 6 months, and 12 months) and administrative health services data (6 months pre-baseline and 12 months post-baseline) were collected for consenting Canadian acute care patients who received the intervention, and a comparable control group. Participants: 572 patients (302 intervention, 270 control) experiencing unstable income, unstable housing, and/or active problematic substance use. Intervention: Patient co-designed, multidisciplinary team offering support for addiction and social stabilization, harm reduction, health promotion, and coordination with community-based care. Services provided are intentionally low-threshold and emphasize continuity of care. Outcome Measures: Self-reported primary care provider; Usual Provider Continuity; Emergency Department Visits for Family Practice Sensitive Conditions. Results: We hypothesize that intervention exposure is associated with primary care access, continuity, and quality. Conclusions: Hospitals play an important role in providing bridging care and service integration for underserved populations. Assessing the impact of hospital-based supports on primary care-relevant outcomes will inform best practice and health system planning for inner city hospital-community transitional care and service integration.
Amy Cunningham, PhD; Denine Crittendon; Colleen Payton, MPH, CHES; Ana Stefancic, PhD; Morgan Dawkins; Sidorela Domi; Lara Weinstein, MD, MPH
11/12/18 1:15 PM - 2:15 PM Stevens Salon B
Context: Housing First is an assistance approach that prioritizes providing permanent supportive housing to people experiencing homelessness. The Integrated Healthcare +Housing (IH+H) program in Philadelphia, funded by the Substance Abuse and Mental Health Services Administration(SAMHSA) is designed to improve the health and healthcare of people with experiences of serious mental illness and homelessness. IH+H is an innovative, on-site partnership between a licensed mental health provider - Pathways to Housing PA - and a federally qualified health center providing integrated health care within a Housing First model. Objective: To examine the IH+H program’s effect on health outcomes, participants’ experiences of care, and emergency department (ED) utilization and hospital admissions. Study Design: Retrospective secondary data analysis. Setting or Dataset: IH+H participant electronic medical records, claims data, and SAMHSA Performance Accountability and Reporting System (SPARS) measures. Patients: Up to 400 patients will be enrolled in the IH+H program. To date, the population (baseline n=181) is largely older (average age 51), minority (66%) male (80%), with a high rate of chronic disease (77%), overweight/obesity (65%), tobacco use (80%), history of substance use (80%) and ED/hospital utilization (average of 1.4 ED visits per person annually). Main and Secondary Outcome Measures: Data collected at baseline (entry to IH+H) and at 6 months and 12 months. Measures include health indicators (e.g., body mass index, blood pressure, waist circumference, breath carbon monoxide, plasma glucose/hemoglobin A1C, and cholesterol), patient experience of care, and ED utilization and hospital admissions. Results: Data abstraction and analysis is in progress. Anticipated results will include descriptive analyses of IH+H participants’ baseline health, patient experience, and ED utilization and hospital admissions, as well as changes in these measures over time. Conclusions: Findings from the study will enhance the evidence base for IH+H care models and identify potential targets for future interventions to improve the health of participants.
Kerry McBrien, MD, MPH; Van Nguyen; Jacob Bailey; Hasham Kamran; Alicia Polachek; Eddy Lang; Ginetta Salvalaggio, MSc, MD, CCFP; Cheryl Barnabe; Patrick McLane; Paul Ronksley, PhD; Tyler Williamson, PhD; Katrina Milaney; Karen Tang; William Ghali; Gabriel Fabreau
11/12/18 1:15 PM - 2:15 PM Stevens Salon B
Context: Socially vulnerable individuals, including those experiencing homelessness, face challenges navigating community health services and have higher rates of acute care use. Connect to Care (C2C) is a mobile outreach team of nurses and health navigators that coordinate care for patients referred from hospitals and community agencies. Objective: To determine if C2C reduces acute care use and improves health and social outcomes, and to explore patient, staff and partner experiences with C2C. Study Design: Longitudinal, pre-post, mixed-methods study according to the Donabedian framework of structure, process and outcome. Setting: C2C has been implemented in Calgary, Canada through a partnership between an urban community health center and an emergency shelter and detoxification facility. Patients: Homeless or unstably housed adults with at least three ED visits or at least two hospital admissions in the previous year. In 2017, C2C received 355 referrals and engaged 225 (63%). Referred patients were 73% male, 46 years on average, 21% self-identified as Indigenous, 70% were homeless and 58% lacked medication insurance. Intervention: A transitional community outreach program that combines intensive case management and patient navigation to bridge acute care, community care, and social services. Main and Secondary Outcome Measures: Main: change in 12-month ED visit and hospital admission rates. Secondary: hospital length of stay, quality of life, housing stability, primary care continuity, and cost. Patient, staff, and partner experience explored qualitatively. Results: 104/248 (42%) of clients without housing were housed; 80/190 (42%) without a primary care provider were attached; and 47/87 (54%) without medication coverage obtained coverage. Ongoing analyses will determine the change in acute care use. Conclusions: C2C effectively engages socially vulnerable patients and coordinates needed resources including housing, primary care attachment and medication coverage. It is hypothesized that acute care use will decrease for C2C patients. Results will inform sustainability and scale.
Simone Dahrouge, PhD; Alain Gauthier, PhD; Denis Prud'Homme; Manon Lemonde; Claire Kendall, MD, PhD; Andrea Perna, PhD; Darene Toal-Sullivan, PhD; Amelie Cardinal; Marie-hélène Chomienne, MD; Tanya Karyakina; Patrick Timony; Rose Anne Devlin
11/12/18 1:15 PM - 2:15 PM Stevens Salon B
Context: Health enabling community resources (CR), such as smoking cessation, falls prevention, self-management programs, and caregiving support, are underused. Social factors, such as transportation, language, literacy, and finances pose barriers to their access. Objective: Assess the efficacy of the ARC-navigation model to enhance equitable access to CR amongst PC patients. Study Design: A single arm, prospective, mixed-method feasibility study. Setting: Four PC practices in Ottawa, Ontario. Patients: PC patients with needs that may be addressed by CRs. Intervention: The navigator, a lay individual having received training primarily in navigation and communication, is integrated within the PC practices. PC providers identify patient need(s) and recommend services. The ARC-navigator follows up to elicit and understand patient priorities and potential barriers, then works with the patients to overcome obstacles and find the most appropriate CR that will help them meet their needs and achieve their health goals. Main Outcome: CR utilization at 3-months. Results: Enrolment is closed with 82 patients. To date, 64 patients completed navigation services; 31 completed the 3-month post intervention survey. Patient profile: female (74%), 30-65 years (63%), foreign-born (29%), high school (45%), income $25,000 (32%), living alone (25%), and employed (32%). Most (66%) patients had two or more needs identified. Most commonly recommended resources (%/patients): healthy lifestyle (58%), mental health (58%), and support for social determinants of health (32%). Most common barriers (%/patients): knowledge of resources (82%), finances (53%), confidence (32%). Seventeen patients (55%) accessed at least one resource. Final study results, including measures of access across social groups, will be reported. Conclusions: The ARC-navigation model, an innovative approach to enabling better access to CR among vulnerable populations, appears promising in helping individuals overcome barriers to access resources that can benefit their health and well-being. Navigation services integrated within PC can strengthen patient continuity of care.
Nivedita Nair; Bethany Morehouse Howlett, MD, MHS; William Gilles
11/12/18 1:15 PM - 2:15 PM Stevens Salon B
Context: Vulnerable populations face complex barriers to health care services. For persons experiencing homelessness in Dane County, WI, barriers include transportation, finances, and fear of judgment. Mitigating these barriers demands innovative community-based approaches, such as WisCARES. WisCARES provides veterinary medical care, housing support and advocacy, and social support services to pet owners in Dane County who are experiencing housing insecurity. By leveraging the relationship between humans and their companion animals, WisCARES is uniquely placed to connect clients to human primary care services while providing high quality veterinary medical services. Objective: During the summer of 2018, a UW SMPH Department of Family Medicine and Community Health project conducted a community health needs assessment (CHNA) and staff assets assessment at WisCARES with the goal of identifying and developing novel interdisciplinary community health programming to mitigate health disparities in the WisCARES client population. Human Subjects Review: The project was given IRB exemption by the UW IRB. Design/Setting: For the CHNA, a qualitative survey is being administered to clients visiting WisCARES for veterinary services. Surveys are offered to all clients. Brief, structured interviews were conducted with core staff members to assess assets and capacity for program development. Anticipated Results: Preliminary analysis of CHNA results indicate that while the majority of clients are insured and have primary care physicians, there are a number of health issues that clients still struggle to address, such as physical disability, mental illness, and dental health. Staff assets assessment revealed a strong desire for interprofessional partnerships to meet client primary healthcare needs. Conclusions: By developing interdisciplinary human health services offered at WisCARES, there is an opportunity to leverage the human-animal bond maintained at this clinic and the trust this population has in the clinic to mitigate health disparities in the housing insecure population in the larger Madison area.
HC33 Resource Map for Primary Care Patients Experiencing Homelessness: There’s an App for that.
Saundra Regan, PhD; Brendan Andres; Anthony DeMarco; Joseph Kiesler, MD
11/12/18 2:30 PM - 4:00 PM Stevens Salon A2
Context: Connecting people in a primary care clinic for the homeless with resources such as shelter, meals, and healthcare can be an overwhelming challenge. For primary care and social service providers, it is just as overwhelming connecting clients and patients with other agencies. Objective: The objective of this study was to take an annually updated 4’ x 3’ laminated wall map of resources for persons experiencing homelessness and service providers in a large urban area and create, update and evaluate the usefulness of an app of the map for a smart phone. Design: Qualitative focus groups and surveys. Setting: Primary care clinic for patients experiencing homelessness and agencies that provide services to homeless clients. Participants: 57 primary care patients and 20 primary care and social service providers. Intervention/Instrument: Semi-structured face-to-face focus groups, telephone and mailed surveys. Main outcomes: Participants identified additional services such as specialty healthcare, mental health, substance abuse treatment, transportation and legal assistance, in addition to shelters and food as primary resources needed in the map. Secondary outcome: The app was much more helpful to a transient population and service providers than a stationary map on a wall in an agency. Results: Data was transcribed and analyzed using the editing method. Themes were identified and used to inform the map app. Telephone and mailed surveys with 20 healthcare and service providers were used to evaluate the app from the provider perspective. Persons experiencing homelessness and service providers were enthusiastic about the existence of the phone app versus the paper map. Providers found it very helpful to have an app to use with clients that immediately showed services, location, description of program, and directions to the service. Conclusions: Downloading a phone app is more convenient and efficient for utilizing resources compared to reading a wall map.
Andrew Pinto, MD, MSc, CCFP, FRCPC; Tatiana Aratangy; Samantha Davie; Andree Schuler; Rosane Nisenbaum; Aisha Lofters, MD, PhD; Tara Kiran, MD
11/12/18 2:30 PM - 4:00 PM Stevens Salon A2
CONTEXT: Robust data on the social determinants of health, when routinely collected and integrated with electronic medical records (EMR) can serve multiple purposes. Such data can be used to identify social needs at the point-of-care, for quality improvement, for health system planning, and for research on health inequities. The regional health authority in Toronto, Canada has supported the collection of such data, called the Health Equity Questions (HEQ), covering seven domains (language, immigration status, race/ethnicity, disabilities, gender identity, sexual orientation, income). In 2013, collection was mandated in hospitals, community health centres and other institutions. OBJECTIVE: This study analyzed the implementation of the HEQ at a large primary care organization, evaluated responses against other data in the EMR, and captured the perspectives of patients, providers and leaders. STUDY DESIGN: Mixed-methods. Quantitative: HEQ responses, response rate, and comparator variables extracted from the EMR. Qualitative: interviews with patients, providers, clerical staff, and hospital leadership. SETTING: A large academic patient centred medical home, serving over 40,000 individuals through six clinics in south-east Toronto. Clerical staff were trained to administer the survey to all patients presenting to the clinic. PARTICIPANTS: 42,396 patients who had at least one physician visit between Dec 1, 2013 to Mar 31, 2016. Twenty-seven patients, seven clerical staff and seven leaders were interviewed, and nine physicians and nurse practitioners took part in a focus group. RESULTS: 15,221 (36%) of patients were offered the HEQ. Clerical staff were often too busy to offer it to every patient, and less likely to offer it to the very old or to the parents of the very young. Patients who had multiple visits to the clinic were more likely to be offered the HEQ. If offered the HEQ, 94% completed at least one question. Patients sometimes found questions difficult or uncomfortable, particularly those related to income, disability, and sexual orientation. Patients and providers believed the HEQ should focus more on addressing social needs. Harms identified included the potential for discrimination and privacy concerns. CONCLUSIONS: Implementing data collection is feasible but requires ongoing quality assurance processes. Findings will be used to inform the evolution of the HEQ, with efforts underway to develop a standard for Canadian primary care.
Winston Liaw, MD, MPH; Alissa Chen; Aaron Tracy; Casey Goodman; Thomas Northrup, PhD; Angela Stotts, PhD; Thomas Murphy
11/12/18 4:15 PM - 5:45 PM Stevens Salon A4
Context: In 2018, McGovern Medical School is launching a medical-legal partnership (MLP), which embeds lawyers in clinics to address unmet social needs. The evidence supporting MLPs is promising but has, thus far, been limited to pediatric clinics. Objective: To describe potential health-harming legal needs (HHLNs) within primary care Design: Cross-sectional Setting: Three community-based primary care clinics in Houston, Texas Participants: Patients presenting between March 6-16, 2018. Intervention/Instrument: Since no widely accepted MLP screening tool exists, the authors developed a 17-item instrument (available in English, Spanish, Mandarin, and Vietnamese) that assesses for food, housing, transportation, utility, insurance, income, guardianship, and end-of-life concerns. Measures: Percentage responding positively and percentage not wanting to be referred to the MLP. The authors conducted bivariate analyses to assess the relationship between screening positive and patient age, race/ethnicity, and language. Results: Seven hundred and sixteen had appointments, and 263 (36.7%) responded. Of responders, 52% (95% CI 46.0%, 58.2%) had at least one positive response. Of those with positive screens (137), 10.2% did not want to be referred to the MLP. The mean number of concerns identified was 1.8 (95% CI 1.5, 2.1). The most common positive responses were for food insecurity (18.3%, 95% CI 13.6%, 23.0%), housing instability (16.7%, 95% CI 12.2%, 21.3%), income (14.4%, 95% CI 10.1%, 18.7%), concern for utilities shutting off (10.3%, 6.6%, 14.0%), and insurance (9.9%, 95% CI 6.3%, 13.5%). There were no age, race/ethnicity, or language differences between responders and non-responders and between those with and without positive responses. Conclusions: Over half had at least one positive response on a screen for HHLNs. These responses will be compared to the HHLNs identified by the MLP and will inform a cluster-randomized trial to evaluate the impact of the MLP on emergency department and hospital utilization.
CH33 Parent Perspectives on Social Determinants Screening in Pediatric Primary Care
Bergen Nelson, MD, MS; Rebecca Etz, PhD
11/12/18 4:15 PM - 5:45 PM Stevens Salon A3
Context: Parent-, family-, and neighborhood-level social factors are key determinants of children's health and development. Screening for social determinants of health is being implemented in pediatric primary care, however understanding of parent perspectives on the acceptability of, approaches and responses to screening is limited. Objective: Explore parent perspectives on acceptability of social needs screening, preferences for screening methods and responses to positive screens. Study Design: Exploratory study using focus groups conducted in English and Spanish. Domains included parent health, mental health, education, and smoking; household factors included income, housing and food security; neighborhood factors included safety. Focus groups were recorded, transcribed, and coded in ATLAS.ti using a combination of a priori codes and grounded theory. Setting: Urban pediatric primary care clinic in Richmond, VA, serving a racially diverse patient population. Participants: Parents of young children who receive pediatric primary care; majority of the children are Medicaid insured. Results: Six groups have been conducted to date, including a total of 14 parents (9 English-speakers and 5 Spanish-speakers). Additional groups are being held to reach a total of 30 participants (15 each in English and Spanish groups). Most parents agreed it is acceptable for the pediatric practice to ask questions about social needs when there is a clear connection to children’s health, and when those factors are modifiable. Parents expressed discomfort answering questions perceived as potentially discriminatory, or when they did not feel the clinic could provide potential solutions. Parents expressed preferences for privacy and respect while responding to questions or discussing risks with providers, and were open to receiving information and resources. Conclusions: In designing and implementing social needs screening approaches in pediatric primary care, it is important to clearly communicate to parents how screening questions relate to child health, and how the clinic intends to respond when concerns are found.
Emilia De Marchis, MD; Caroline Fichtenberg; Laura Gottlieb, MD, MPH
11/12/18 4:15 PM - 5:45 PM Stevens Salon A1
Context: Despite increased interest in addressing patients’ health-related social needs (HRSN) in the health care sector, little is known about the prevalence of these risk factors and activities to address them. Objective: a) Examine the prevalence of social and economic risk factors in Bureau of Primary Health Care-funded clinic patients; b) explore associations between HRSN and receipt of HRSN-related assistance. Design: Cross-sectional data analysis. Dataset: 2014 HRSA Health Center Patient Survey (HCPS). Participants: 3,235 HCPS survey respondents. Measures: HRSN included three employment, four housing instability, and seven poverty indicators. HRSN assistance was divided into two categories: a) medical (assistance paying for medications, transportation to appointments, medical care coordination); and b) non-medical (assistance with government benefits, housing, employment, childcare, food, clothing/shoes). Survey weights utilized to approximate a nationally representative sample. Results: 91.9% of respondents had at least one HRSN; 71.0% had four or more. 61.6% reported receiving assistance from their clinic for at least one HRSN; assistance was higher for medical than non-medical categories (55.2% vs. 24.6%). Respondents endorsing HRSN were more likely to report receiving assistance related to reported needs, though rates varied by domain: 37% of those unable to afford medications received assistance around obtaining free medications (p=0.05); 27.1% of respondents endorsing %gt;/=1 poverty indicators received assistance applying for government benefits (p0.001); 5.5% of respondents endorsing housing instability received housing-related assistance (p0.001). In adjusted analyses, respondents reporting WIC benefits or care at a Migrant Health Center were significantly more likely to receive assistance with any non-medical HSRN (adjusted OR: 2.97, 95% CI 1.09-8.05; 3.71, 95% CI 1.70-8.10, respectively). Conclusions: There is growing interest around supporting health care systems to incorporate interventions around HRSN into care. Results from this study on both the prevalence of HRSN and differences in HRSN assistance can help inform activities to increase HRSN assistance efforts.
HC38 Community Health Worker Integration in Oregon’s Medicaid Accountable Care Organizations
Melinda Davis, PhD; Rani George; Rose Gunn, MA; Ruth Rowland; Kenneth Maes; Noelle Wiggins; Annie Cannon; John McConnell
11/12/18 4:15 PM - 5:45 PM Stevens Salon A1
Context: Community Health Workers (CHWs) traditionally fill important gaps in primary care by providing education, advocacy, and support for patients. However, health systems often struggle with start-up and sustainable funding for CHW programs. Oregon’s Medicaid Accountable Care Organizations (ACOs) provide an opportunity to understand a diverse set of payment models and program approaches to reducing health disparities. Objective: To evaluate how the Oregon Medicaid program integrated community health workers (CHW) into its regional health systems as one of its principal strategies to reduce health disparities. Study Design: Qualitative cross-case study. Setting or Dataset: Medicaid Accountable Care Organizations (ACOs) in Oregon. Patients or Other Participants: 29 key informants, including Population Health Directors and Health Equity Officers, across 16 Oregon ACOs. Results: ACOs varied in how they selected priority populations for reducing health disparities and integrated CHWs into services. The characteristics of CHW programs depended on local needs and resources, community partners, funding mechanisms, the size of the health system, and health leadership goals. Pilot funds from Oregon’s transformation grant awards helped start CHW programs at ACOs, while local training capacity, community partners, and flexible payment mechanisms contributed to sustaining them. CHWs most often worked in the role of care coordination for underserved populations that were: racial, ethnic, and linguistic minorities; lacked provider access in rural areas; had complex physical and behavioral health needs; and needed support with accessing primary care and social services. A drive for short-term cost-savings and better healthcare outcomes may have led health systems to steer CHWs into the role of care coordination rather than more traditional, upstream CHW roles, such as health education and community capacity-building. Conclusions: Health systems can leverage their efforts with CHWs to reduce disparities by having flexible payment mechanisms, engaging CHWs in a broad range of roles, and collaborating with partner organizations.
Joseph LeMaster, MD, MPH; Kim Kimminau, PhD; Anne MacFarlane, PhD, MA; Ginetta Salvalaggio, MSc, MD, CCFP; Michele Allen, MD, MS; Jon Salsberg, PhD
11/12/18 4:15 PM - 5:45 PM Stevens Salon C4
Objectives: By the end of the session, learners will: 1) Identify and describe 3 participatory methods to engage community partners to describe their collective experience regarding issues of concern, such as systemic justice 2) Briefly describe a plan to implement one of these methods within a community seeking help advocating. 3) Have considered deeply how to incorporate these methods in advocating for communities, regardless of the issue tackled. Rationale: While participatory methods effectively engage marginalized communities when developing healthcare evidence, their effectiveness at addressing social justice and community self-determination suggests they would be valuable tools to advocate for community-identified needs and/or priorities. This workshop, which will be conducted by members of the CASFM Working Group on Participatory Health Research, will explore how best to impart to partnering community members skills in the use of participatory research methods so they may document their experiences/stories (both positive and negative), collectively and systematically. We will further discuss the role of researchers, whether as consultants or co-advocates, in assisting communities by advocating personally for changes in health or social policy to address community needs. Participation: To motivate the session, we will initially present scenarios in which 3 of our communities used different participatory research methods to identify their collective experience, and how the communities subsequently used these methods to advocate for their community (30 min). The 3 methods will be: Participatory Learning in Action, World Cafe, and Future Search. We will then conduct a brief participatory exercise in which workshop participants discuss and prioritize the methods which have been presented (30 min). Finally, we will brainstorm potential uses for these methods by communities with which the workshop participants are currently engaged, and for which advocacy efforts are under consideration, planned or underway (30 min). Pre-requisite knowledge/experience: lived experience working with community partners
Tuesday, November 13, 2018
HC46 Measuring the Prevalence of Health Care-Based Social Screening and Related Interventions
Yuri Cartier; Emilia De Marchis, MD; Angeli Bueno; Caroline Fichtenberg; Laura Gottlieb, MD, MPH
11/13/18 9:30 AM - 10:30 AM Stevens Salon A1
Context: Despite rapidly growing interest in patients’ social needs in the US healthcare sector, little is known about the prevalence of related clinical activities. Objective: This study aimed to document the prevalence of social needs screening and interventions (“social prescribing”) in US healthcare; secondary objectives included understanding a) how stakeholders might use such prevalence data; and b) existing barriers to collecting valid data in this field. Study design: Key informant interviews and review of survey findings. Setting or Dataset: 27 interviews conducted with 39 key informants; findings from 18 surveys. Main and Secondary Outcome Measures: Primary study outcome: prevalence of social prescribing activities. Secondary outcomes: informants’ descriptions of use cases for social prescribing prevalence data; barriers to prevalence data collection. Results: The 18 surveys identified included participants from five categories: states, payers (MCOs/ACOs), delivery system leaders, providers, and patients. Findings from 6/18 surveys have been published in publicly-available reports. 93% of Medicaid managed care organizations, 42% of private payers, 79% of hospital leaders, and 89% of primary care providers report connecting members with social services, though no detailed data indicate whether activities are systematically incorporated into care delivery. Informants shared that prevalence data could be used for a) benchmarking intramural social screening and intervention activities; and b) information-sharing and normalization of social needs interventions. Major barriers included: a) variability in definitions of social screening and intervention; b) lack of intervention quality measurement; c) participant reporting biases; and d) limitations to respondents’ awareness of clinical activities. Conclusions: A single point prevalence estimate of social prescribing practices in the US health care system is not feasible based on existing survey data, though some information is available in state, payer, health system, provider, and patient categories. Improved prevalence data could be used for both benchmarking and national policy-making in this rapidly expanding field.
HC50 Developing a Social Determinants of Health Screening and Referral Process
Pablo Buitron de la Vega; Linda Sprague Martinez; Nancy Kressin; Stephanie Losi; Alana Ewen, MPH; Marna Stack; Angela Hu; Sophia Gill; Arvin Garg
11/13/18 10:45 AM - 12:15 PM Stevens Salon C8
Context: The last decade has seen a shift in healthcare from a narrow focus of an individual-level biomedical complexities to a broader one that recognizes how social determinants of health (SDOH) affect patient health. To date, there are few systematic, sustained clinical strategies implemented in adult General Internal Medicine (GIM) for addressing SDOH. Objective: Develop a screening and referral process to identify and address social needs. Design: Mixed-methods study. Setting: GIM outpatient clinic at Boston Medical Center, a 567-bed safety-net hospital and academic medical center. Patients: 149 English and Spanish speaking adult patients new to our clinic. Intervention: A SDOH adult screening and referral process adapted from pediatrics WE CARE model. The screening tool identified housing instability, inability to pay for medications, lack of transportation to medical appointments, food insecurity, unemployment, utility needs and low literacy. The tool was vetted with patients (n=22) and subsequently implemented over the course of 6 weeks. Based on screening results, patients were provided with resources to help with their socials needs or referred to a care coordinator who assisted with the referral process. Main Outcome Measures: Feasibility (percent of completed screeners and percent of completed survey items) and acceptability (patient and staff perceptions) of the screening and referral process. Results: 91% of eligible patients went through the screening and referral process. Patients needing help paying for their medications made up the largest group (32%). From a total of 46 subsequently surveyed patients, 72% felt the process was very useful. Thirty percent were transferred to a care coordinator when needed. Staff also described the pilot favorably but reported a gap in the referral process. Conclusion: It was feasible and acceptable to implement a systematic screening and referral process to address SDOH in GIM clinics. Population-based strategies as the one proposed have the potential to address SDOH in the context of the value-based payment environment.
Andrew Pinto, MD, MSc, CCFP, FRCPC; Danielle Hessler, PhD; Erika Cottrell, PhD, MPP; Alex Krist, MPH, MD; Alicia Cohen, MD, MSc; Laura Gottlieb, MD, MPH
11/13/18 10:45 AM - 12:15 PM Stevens Salon C3
OBJECTIVES: There is growing interest in the role that primary care can play in addressing the social determinants of health. A series of studies over the past decade have focused on intervening at the individual and household level, through routine screening for social needs, with positive responses leading to intervention in the form of information, system navigation and support. However, across studies there is no common outcome or set of outcomes, limiting comparison of the effectiveness of various interventions. During this workshop, presenters will share the thought process that went into identifying outcomes for their studies of interventions to tackle the social determinants of health, and discuss next steps in defining common outcome measures for future work. RATIONALE: An enormous body of evidence supports the important role that social factors and processes play in determining our individual and collective health. While studies are emerging that demonstrate the effectiveness of intervention, the field is still being established and the evidence base is limited. Addressing the social determinants of health remains uncommon in most primary care settings. CONTENT AND PARTICIPATION: Presenters from the University of Toronto, OCHIN, Virginia Commonwealth University, University of Michigan and University of California (San Francisco) will share examples of studies of interventions that have addressed social determinants, including income, precarious employment, social isolation, or a number of needs simultaneously. The audience will then be organized into facilitated groups to discuss next steps and how it applies to research studies that they are planning: What are the principles that should guide the identification of outcomes for intervention studies? How can patients and the broader community be engaged in identifying outcomes for intervention studies? How can the social determinants of health interventions community move forward with a plan to achieve consensus on a suite of common outcomes? METHODS: Presentations from five centers, small group discussions and report-backs, and group discussion. PREREQUISITE KNOWLEDGE: None, although a basic understanding of social determinants is an asset. AUDIENCE: Those interested in social determinants and health equity. SCHEDULE: Introductions - 5 min. Case study presentations - 40 min. Facilitated small group discussions - 30 min. Report-backs and synthesis - 10 min. Conclusion - 5 min.
WH44 Community Partnership to Improve Women's Health Screening in Primary Care
Kathleen Foley, MHS, PhD; Julie Shelton, MPH; Ruth Richardson, MSN, RN; Daniel Davis; Daniel Frayne, MD
11/13/18 10:45 AM - 12:15 PM Stevens Salon A3
Context: Routine and comprehensive women’s preventive health screening can be difficult to achieve in primary care. Incorporating evidence-based screenings (e.g. intimate partner violence (IPV), depression, substance use, and nutrition) faces additional barriers including lack of time, resources, training, and patient/provider question fatigue. Objective: To design the screening process and tools promoting a safe and effective environment for women to discuss their health. Study Design: Three human centered design (HCD) sessions to design a women’s health screening tool and process; and implementation across family medicine (FM) clinics. Setting: A multi-site FM residency program. Participants: Clinic staff, providers, administrators, and 4-6 community women. Instrument: Women’s health screening tool with standard health assessments for weight, physical activity, tobacco/alcohol/drug use, depression, pregnancy intention, contraception, multivitamin use, sexual health, and IPV. Main and Secondary Outcome Measures: Performance of IPV and sexuality screening, and increases in standard assessment documentation. Results: HCD sessions with community women highlighted the current check-box feel of screenings, over-emphasis on weight, and lack of time for promoting patient-provider trust. The new screening tool has a colorful graphic background and accompanying educational engagement tool with facts promoting women’s health needs. The screening process encouraged privacy for IPV screening, and response. Implementation of the new tools and processes increased documented screening of IPV (0% to 53%), sexuality (0% to 55%), pregnancy intention (11% to 59%) and multivitamin use (11% to 57%), alcohol/drug/family planning (20-24% to 56-59%), exercise (45% to 54%) and depression (59% to 90%) in the first 3 months following implementation. Conclusions: Including community participants as end-users led to an innovative and patient-centered approach to a comprehensive list of health screenings. Creation of a combined screening tool and standard worklfow led to substantial improvements documentation.