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Jacobs JC, Greene L, Rao M, Smith VA, Van Houtven CH, Maciejewski ML, Zulman DM. The association between social risks and days at home for older veterans. J Am Geriatr Soc 2024. [PMID: 38997214 DOI: 10.1111/jgs.19064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 06/07/2024] [Accepted: 06/12/2024] [Indexed: 07/14/2024]
Abstract
BACKGROUND Many health systems are trying to support the ability of older adults to remain in their homes for as long as possible. Little is known about the relationship between patient-reported social risks and length of time spent at home. We assessed how social risks were associated with days at home for a cohort of older Veterans at high risk for hospitalization and mortality. METHODS A prospective cross-sectional study using a 2018 survey of 3479 high-risk Veterans aged ≥65 linked to Veterans Health Administration data. Social risks included measures of social resources (i.e., no partner present, low social support), material resources (i.e., not employed, financial strain, medication insecurity, food insecurity, and transportation barriers), and personal resources (i.e., low medical literacy and less than high school education). We estimated how social risks were associated with days at home, defined as the number of days spent outside inpatient, long-term care, observation, or emergency department settings over a 12-month period, using a negative binomial regression model. RESULTS Not having a partner, not being employed, experiencing transportation barriers, and low medical literacy were respectively associated with 2.57, 3.18, 3.39, and 6.14 fewer days at home (i.e., 27% more facility days, 95% confidence interval [CI] 8%-50%; 42% more facility days, 95% CI 7%-89%; 34% more facility days, 95% CI 7%-68%; and 63% more facility days, 95% CI 27%-109%). Experiencing food insecurity was associated with 2.62 more days at home (i.e., 24% fewer facility days, 95% CI 3%-59%). CONCLUSIONS Findings suggest that screening older Veterans at high risk of community exit for social risks (i.e., social support, material resources, and medical literacy) may help identify patients likely to benefit from home- and community-based health and social services that facilitate remaining in home settings. Future research should focus on understanding the mechanisms by which these associations occur.
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Affiliation(s)
- Josephine C Jacobs
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, USA
- Department of Health Policy, Stanford University School of Medicine, Stanford, California, USA
| | - Liberty Greene
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
| | - Mayuree Rao
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, USA
- General Medicine Service, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, Washington, USA
- Department of Medicine, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Valerie A Smith
- Center for Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Courtney H Van Houtven
- Center for Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
| | - Matthew L Maciejewski
- Center for Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Donna M Zulman
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
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Cornell PY, Hua CL, Buchalksi ZM, Chmelka GR, Cohen AJ, Daus MM, Halladay CW, Harmon A, Silva JW, Rudolph JL. Using social risks to predict unplanned hospital readmission and emergency care among hospitalized Veterans. Health Serv Res 2024. [PMID: 38972911 DOI: 10.1111/1475-6773.14353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2024] Open
Abstract
OBJECTIVES (1) To estimate the association of social risk factors with unplanned readmission and emergency care after a hospital stay. (2) To create a social risk scoring index. DATA SOURCES AND SETTING We analyzed administrative data from the Department of Veterans Affairs (VA) Corporate Data Warehouse. Settings were VA medical centers that participated in a national social work staffing program. STUDY DESIGN We grouped socially relevant diagnoses, screenings, assessments, and procedure codes into nine social risk domains. We used logistic regression to examine the extent to which domains predicted unplanned hospital readmission and emergency department (ED) use in 30 days after hospital discharge. Covariates were age, sex, and medical readmission risk score. We used model estimates to create a percentile score signaling Veterans' health-related social risk. DATA EXTRACTION We included 156,690 Veterans' admissions to a VA hospital with discharged to home from 1 October, 2016 to 30 September, 2022. PRINCIPAL FINDINGS The 30-day rate of unplanned readmission was 0.074 and of ED use was 0.240. After adjustment, the social risks with greatest probability of readmission were food insecurity (adjusted probability = 0.091 [95% confidence interval: 0.082, 0.101]), legal need (0.090 [0.079, 0.102]), and neighborhood deprivation (0.081 [0.081, 0.108]); versus no social risk (0.052). The greatest adjusted probabilities of ED use were among those who had experienced food insecurity (adjusted probability 0.28 [0.26, 0.30]), legal problems (0.28 [0.26, 0.30]), and violence (0.27 [0.25, 0.29]), versus no social risk (0.21). Veterans with social risk scores in the 95th percentile had greater rates of unplanned care than those with 95th percentile Care Assessment Needs score, a clinical prediction tool used in the VA. CONCLUSIONS Veterans with social risks may need specialized interventions and targeted resources after a hospital stay. We propose a scoring method to rate social risk for use in clinical practice and future research.
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Affiliation(s)
- Portia Y Cornell
- Center of Innovation for Long Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
- Centre for the Digital Transformation of Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Cassandra L Hua
- Department of Public Health, Zuckerberg College of Health Sciences, University of Massachusetts, Lowell, Massachusetts, USA
| | - Zachary M Buchalksi
- Center of Innovation for Long Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
| | - Gina R Chmelka
- National Social Work Program, Care Management and Social Work, Patient Care Services, Department of Veterans Affairs, Washington, DC, USA
- Tomah VA Medical Center, Tomah, Wisconsin, USA
| | - Alicia J Cohen
- Department of Health Services, Policy and Practice, Brown University, Providence, Rhode Island, USA
- Department of Family Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | | | - Christopher W Halladay
- Center of Innovation for Long Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
| | - Alita Harmon
- National Social Work Program, Care Management and Social Work, Patient Care Services, Department of Veterans Affairs, Washington, DC, USA
- Gulf Coast Veterans Health Care System, Biloxi, Mississippi, USA
| | - Jennifer W Silva
- National Social Work Program, Care Management and Social Work, Patient Care Services, Department of Veterans Affairs, Washington, DC, USA
| | - James L Rudolph
- Center of Innovation for Long Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
- Department of Health Services, Policy and Practice, Brown University, Providence, Rhode Island, USA
- Department of Family Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Wang PR, Anand A, Bena JF, Morrison S, Weleff J. Changes in Emergency Department Utilization in Vulnerable Populations After COVID-19 Shelter-in-Place Orders. Cureus 2024; 16:e60556. [PMID: 38887338 PMCID: PMC11182374 DOI: 10.7759/cureus.60556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2024] [Indexed: 06/20/2024] Open
Abstract
OBJECTIVES This study aims to compare emergency department (ED) utilization and admission rates for patients with a history of mental health (MH) disorders, substance use disorders (SUDs), and social determinants of health (SDOH) before and after implementing COVID-19 shelter-in-place (SIP) orders. METHODS This was a retrospective, multicenter study leveraging electronic medical record (EMR) data from 20 EDs across a large Midwest integrated healthcare system from 5/2/2019 to 12/31/2019 (pre-SIP) and from 5/2/2020 to 12/31/2020 (post-SIP). Diagnoses were documented in the patient's medical records. Poisson and logistic regression models were used to evaluate ED utilization and admission rate changes. RESULTS A total of 871,020 ED encounters from 487,028 unique patients were captured. Overall, 2,572 (0.53%) patients had a documented Z code for SDOH. Patients with previously diagnosed MH disorders or SUDs were more likely to seek ED care after the SIP orders were implemented (risk ratio (RR): 1.20, 95% confidence interval (CI): 1.18-1.22, p<0.001), as were patients with SDOH (RR: 2.37, 95% CI: 2.19-2.55, p<0.001). Patients with both previously diagnosed MH disorders or SUDs and a documented SDOH had even higher ED utilization (RR: 3.31, 95% CI: 2.83-3.88, p<0.001) than those with either condition alone. Patients with MH disorders and SUDs (OR: 0.89, 95% CI: 0.86-0.92, p<0.001) or SDOH (OR: 0.67, 95% CI: 0.54-0.83, p<0.001) were less likely to be admitted post-SIP orders, while patients with a history of diseases of physiologic systems were more likely to be admitted. CONCLUSION Vulnerable populations with a history of MH disorders, SUDs, and SDOH experienced increased ED utilization but a lower rate of hospital admissions after the implementation of SIP orders. The findings highlight the importance of addressing these needs to mitigate the impact of public health crises on these populations.
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Affiliation(s)
- Philip R Wang
- Department of Psychiatry, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, USA
| | - Akhil Anand
- Department of Psychiatry and Psychology, Neurological Institute, Cleveland Clinic, Cleveland, USA
| | - James F Bena
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, USA
| | - Shannon Morrison
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, USA
| | - Jeremy Weleff
- Department of Psychiatry, Yale School of Medicine, New Haven, USA
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Singh K, Timko C, Yu M, Taylor E, Blue-Howells J, Finlay AK. Scoping review of military veterans involved in the criminal legal system and their health and healthcare: 5-year update and map to the Veterans-Sequential Intercept Model. HEALTH & JUSTICE 2024; 12:18. [PMID: 38639813 PMCID: PMC11027330 DOI: 10.1186/s40352-024-00274-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 04/07/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND A previous scoping review of legal-involved veterans' health and healthcare (1947-2017) identified studies and their limitations. Given the influx of literature published recently, this study aimed to update the previous review and map articles to the Veterans-Sequential Intercept Model (V-SIM) - a conceptual model used by key partners, including Veterans Health Administration, veteran advocates, criminal justice practitioners, and local governments to identify intercept points in the criminal legal system where resources and programming can be provided. Developing an updated resource of literature is essential to inform current research, discover gaps, and highlight areas for future research. METHODS A systematic search of 5 databases identified articles related to legal-involved veterans' health and healthcare published between December 2017 through December 2022. The first and senior authors conducted abstract reviews, full-text reviews, and data extraction of study characteristics. Finally, each article was sorted by the various intercept points from the V-SIM. RESULTS Of 903 potentially relevant articles, 107 peer-reviewed publications were included in this review, most related to mental health (66/107, 62%) and used an observational quantitative study design (95/107, 89%). Although most articles did not explicitly use the V-SIM to guide data collection, analyses, or interpretation, all could be mapped to this conceptual model. Half of the articles (54/107, 50%) collected data from intercept 5 (Community Corrections and Support Intercept) of the V-SIM. No articles gathered data from intercepts 0 (Community and Emergency Services Intercept), 1 (Law Enforcement Intercept), or 2 (Initial Detention and Court Hearings Intercept). CONCLUSIONS There were 107 articles published in the last five years compared to 190 articles published in 70 years covered in the last review, illustrating the growing interest in legal-involved veterans. The V-SIM is widely used by front-line providers and clinical leadership, but not by researchers to guide their work. By clearly tying their research to the V-SIM, researchers could generate results to help guide policy and practice at specific intercept points. Despite the large number of publications, research on prevention and early intervention for legal-involved veterans is lacking, indicating areas of great need for future studies.
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Affiliation(s)
- Kreeti Singh
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA, 94025, USA.
| | - Christine Timko
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA, 94025, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 291 Campus Drive, Li Ka Shing Building, Stanford, CA, 94305, USA
| | - Mengfei Yu
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA, 94025, USA
| | - Emmeline Taylor
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA, 94025, USA
- Department of Psychology, University of Colorado, Columbine Hall 4th Floor, 1420 Austin Bluffs Pkwy, Colorado Springs, CO, 80918, USA
| | - Jessica Blue-Howells
- Department of Veterans Affairs, Veterans Justice Programs, 810 Vermont Avenue, Washington DC, NW, 20420, USA
| | - Andrea K Finlay
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA, 94025, USA
- Department of Veterans Affairs, National Center on Homelessness Among Veterans, 795 Willow Road, Menlo Park, CA, 94025, USA
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Li C, Mowery DL, Ma X, Yang R, Vurgun U, Hwang S, Donnelly HK, Bandhey H, Akhtar Z, Senathirajah Y, Sadhu EM, Getzen E, Freda PJ, Long Q, Becich MJ. Realizing the Potential of Social Determinants Data: A Scoping Review of Approaches for Screening, Linkage, Extraction, Analysis and Interventions. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.02.04.24302242. [PMID: 38370703 PMCID: PMC10871446 DOI: 10.1101/2024.02.04.24302242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
Background Social determinants of health (SDoH) like socioeconomics and neighborhoods strongly influence outcomes, yet standardized SDoH data is lacking in electronic health records (EHR), limiting research and care quality. Methods We searched PubMed using keywords "SDOH" and "EHR", underwent title/abstract and full-text screening. Included records were analyzed under five domains: 1) SDoH screening and assessment approaches, 2) SDoH data collection and documentation, 3) Use of natural language processing (NLP) for extracting SDoH, 4) SDoH data and health outcomes, and 5) SDoH-driven interventions. Results We identified 685 articles, of which 324 underwent full review. Key findings include tailored screening instruments implemented across settings, census and claims data linkage providing contextual SDoH profiles, rule-based and neural network systems extracting SDoH from notes using NLP, connections found between SDoH data and healthcare utilization/chronic disease control, and integrated care management programs executed. However, considerable variability persists across data sources, tools, and outcomes. Discussion Despite progress identifying patient social needs, further development of standards, predictive models, and coordinated interventions is critical to fulfill the potential of SDoH-EHR integration. Additional database searches could strengthen this scoping review. Ultimately widespread capture, analysis, and translation of multidimensional SDoH data into clinical care is essential for promoting health equity.
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Affiliation(s)
- Chenyu Li
- University of Pittsburgh School of Medicine Department of Biomedical Informatics
| | - Danielle L. Mowery
- University of Pennsylvania, Institute for Biomedical Informatics
- University of Pennsylvania, Department of Biostatistics, Epidemiology and Informatics
| | - Xiaomeng Ma
- University of Toronto, Institute of Health Policy Management and Evaluations
| | - Rui Yang
- Duke-NUS Medical School, Centre for Quantitative Medicine
| | - Ugurcan Vurgun
- University of Pennsylvania, Institute for Biomedical Informatics
| | - Sy Hwang
- University of Pennsylvania, Institute for Biomedical Informatics
| | | | - Harsh Bandhey
- Cedars-Sinai Medical Center, Department of Computational Biomedicine
| | - Zohaib Akhtar
- Northwestern University, Kellogg School of Management
| | - Yalini Senathirajah
- University of Pittsburgh School of Medicine Department of Biomedical Informatics
| | - Eugene Mathew Sadhu
- University of Pittsburgh School of Medicine Department of Biomedical Informatics
| | - Emily Getzen
- University of Pennsylvania, Department of Biostatistics, Epidemiology and Informatics
| | - Philip J Freda
- Cedars-Sinai Medical Center, Department of Computational Biomedicine
| | - Qi Long
- University of Pennsylvania, Institute for Biomedical Informatics
- University of Pennsylvania, Department of Biostatistics, Epidemiology and Informatics
| | - Michael J. Becich
- University of Pittsburgh School of Medicine Department of Biomedical Informatics
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Maciejewski ML, Greene L, Grubber JM, Blalock DV, Jacobs J, Rao M, Zulman DM, Smith VA. Association between patient-reported social and behavioral risks and health care costs in high-risk Veterans health administration patients. Health Serv Res 2024; 59:e14243. [PMID: 37767603 PMCID: PMC10771909 DOI: 10.1111/1475-6773.14243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023] Open
Abstract
OBJECTIVE Social risks complicate patients' ability to manage their conditions and access healthcare, but their association with health expenditures is not well established. To identify patient-reported social risk, behavioral, and health factors associated with health expenditures in Veterans Affairs (VA) patients at high risk for hospitalization or death. DATA SOURCES, STUDY SETTING, AND STUDY DESIGN Prospective cohort study among high-risk Veterans obtaining VA care. Patient-reported social risk, function, and other measures derived from a 2018 survey sent to 10,000 VA patients were linked to clinical and demographic characteristics extracted from VA data. Response-weighted generalized linear and marginalized two-part models were used to examine VA expenditures (total, outpatient, medication, inpatient) 1 year after survey completion in adjusted models. PRINCIPAL FINDINGS Among 4680 survey respondents, the average age was 70.9 years, 6.3% were female, 16.7% were African American, 20% had body mass index ≥35, 42.4% had difficulty with two or more basic or instrumental activities of daily living, 19.3% reported transportation barriers, 12.5% reported medication insecurity and 21.8% reported food insecurity. Medication insecurity was associated with lower outpatient expenditures (-$1859.51 per patient per year, 95% confidence interval [CI]: -3200.77 to -518.25) and lower total expenditures (-$4304.99 per patient per year, 95% CI: -7564.87 to -1045.10). Transportation barriers were negatively associated with medication expenditures (-$558.42, 95% CI: -1087.93 to -31.91). Patients with one functional impairment had higher outpatient expenditures ($2997.59 per patient year, 95% CI: 1185.81-4809.36) than patients without functional impairments. No social risks were associated with inpatient expenditures. CONCLUSIONS In this study of VA patients at high risk for hospitalization and mortality, few social and functional measures were independently associated with the costs of VA care. Individuals with functional limitations and those with barriers to accessing medications and transportation may benefit from targeted interventions to ensure that they are receiving the services that they need.
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Affiliation(s)
- Matthew L. Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT)Durham Veterans Affairs Health Care SystemDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
- Division of General Internal Medicine, Department of MedicineDuke UniversityDurhamNorth CarolinaUSA
| | - Liberty Greene
- Center for Innovation to ImplementationVA Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
- Division of Primary Care and Population HealthStanford University School of MedicineStanfordCaliforniaUSA
| | - Janet M. Grubber
- Cooperative Studies Program Coordinating CenterBoston Veterans Affairs Health Care SystemBostonMassachusettsUSA
| | - Dan V. Blalock
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT)Durham Veterans Affairs Health Care SystemDurhamNorth CarolinaUSA
- Department of Psychiatry and Behavioral SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Josephine Jacobs
- Center for Innovation to ImplementationVA Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
- Health Economics Resource CenterVA Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
| | - Mayuree Rao
- Seattle‐Denver Center of Innovation for Veteran‐Centered and Value‐Driven CareVA Puget Sound Health Care SystemSeattleWashingtonUSA
| | - Donna M. Zulman
- Center for Innovation to ImplementationVA Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
- Division of Primary Care and Population HealthStanford University School of MedicineStanfordCaliforniaUSA
| | - Valerie A. Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT)Durham Veterans Affairs Health Care SystemDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
- Division of General Internal Medicine, Department of MedicineDuke UniversityDurhamNorth CarolinaUSA
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Msw RET, Warner L, Shy BD, Manikowski C, Roosevelt GE. A descriptive study of screening and navigation on health-related social needs in a safety-net hospital emergency department. Am J Emerg Med 2023; 74:65-72. [PMID: 37778164 DOI: 10.1016/j.ajem.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 09/02/2023] [Accepted: 09/04/2023] [Indexed: 10/03/2023] Open
Abstract
BACKGROUND Health-related social needs (HRSN) have been associated with worse clinical outcomes, increased Emergency Department (ED) utilization and higher healthcare costs. The ED is uniquely positioned to bring HRSN screening to the bedside and develop effective interventions. We evaluated whether navigation services for high-risk patients led to the resolution of HRSN. METHODS Navigators screened a convenience sample of patients for HRSN with the Accountable Health Communities Screening Tool from October 2019 to January 2022. Patients with HRSN were considered high-risk if they had at least two ED visits in the previous 12 months. Patients who were high-risk were eligible for navigation including community referrals and one-on-one close follow-up. The HRSN status (resolved, in-progress, unable to resolve) was queried from the Centers for Medicare and Medicaid database. The state hospital association provided data on ED visits and inpatient hospitalizations within 6 months of the screening visit. RESULTS Of 185,470 ED visits, HRSN screening occurred in 4050 (2%). HRSN were self-reported in 48% (1944) of patient visits, with 71% of these (1379) considered high-risk. 15% of high-risk patients with HRSN opted out of navigation. Food insecurity was the most identified HRSN (35%) followed by housing instability (26%), transportation needs (24%) and utility assistance (15%). Food insecurity was the most resolved HRSN (39%, in-progress 32%) followed by utility assistance (37%, in-progress 26%), transportation needs (35%, in-progress 35%) and housing instability (28%, in-progress 36%). High-risk visits in which the patient or guardian accepted navigation were less likely to be associated with an ED visit within 6 months of the screening visit (51%) compared to high-risk patients in which the patient or guardian opted out of navigation (61%, p < 0.001), but there was no difference in inpatient hospitalizations (p = 0.427). CONCLUSIONS During the study period, one-third of HRSN were successfully resolved with another one-third in-progress. Navigation in high-risk patients was associated with fewer subsequent ED visits.
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Affiliation(s)
- Ruth Ellen Tubbs Msw
- Previous/Main: Denver Regional Council of Governments, 1001 17(th) Street, Suite 700, Denver, CO 80202, USA
| | - Leah Warner
- Department of Emergency Medicine, Denver Health, University of Colorado School of Medicine, 601 Broadway, Denver, CO 80204, USA.
| | - Bradley D Shy
- Department of Emergency Medicine, Denver Health, University of Colorado School of Medicine, 601 Broadway, Denver, CO 80204, USA.
| | - Christine Manikowski
- Previous/Main: Denver Regional Council of Governments, 1001 17(th) Street, Suite 700, Denver, CO 80202, USA
| | - Genie E Roosevelt
- Department of Emergency Medicine, Denver Health, University of Colorado School of Medicine, 601 Broadway, Denver, CO 80204, USA.
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Vest JR, Hinrichs RJ, Hosler H. How legal problems are conceptualized and measured in healthcare settings: a systematic review. HEALTH & JUSTICE 2023; 11:48. [PMID: 37979059 PMCID: PMC10656991 DOI: 10.1186/s40352-023-00246-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 10/22/2023] [Indexed: 11/19/2023]
Abstract
Legal problems encompass issues requiring resolution through the justice system. This social risk factor creates barriers in accessing services and increases risk of poor health outcomes. A systematic review of the peer-reviewed English-language health literature following the PRISMA guidelines sought to answer the question, how has the concept of patients' "legal problems" been operationalized in healthcare settings? Eligible articles reported the measurement or screening of individuals for legal problems in a United States healthcare or clinical setting. We abstracted the prevalence of legal problems, characteristics of the sampled population, and which concepts were included. 58 studies reported a total of 82 different measurements of legal problems. 56.8% of measures reflected a single concept (e.g., incarcerated only). The rest of the measures reflected two or more concepts within a single reported measure (e.g., incarcerations and arrests). Among all measures, the concept of incarceration or being imprisoned appeared the most frequently (57%). The mean of the reported legal problems was 26%. The literature indicates that legal concepts, however operationalized, are very common among patients. The variation in measurement definitions and approaches indicates the potential difficulties for organizations seeking to address these challenges.
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Affiliation(s)
- Joshua R Vest
- Indiana University Richard M Fairbanks School of Public Health, Indianapolis, IN, USA.
- Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, IN, USA.
| | - Rachel J Hinrichs
- University Library, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA
| | - Heidi Hosler
- Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, IN, USA.
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Fiori K, Levano S, Haughton J, Whiskey-LaLanne R, Telzak A, Hodgson S, Spurrell-Huss E, Stark A. Learning in real world practice: Identifying implementation strategies to integrate health-related social needs screening within a large health system. J Clin Transl Sci 2023; 7:e229. [PMID: 38028350 PMCID: PMC10643918 DOI: 10.1017/cts.2023.652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 09/14/2023] [Accepted: 10/09/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Health systems have many incentives to screen patients for health-related social needs (HRSNs) due to growing evidence that social determinants of health impact outcomes and a new regulatory context that requires health equity measures. This study describes the experience of one large urban health system in scaling HRSN screening by implementing improvement strategies over five years, from 2018 to 2023. Methods In 2018, the health system adapted a 10-item HRSN screening tool from a widely used, validated instrument. Implementation strategies aimed to foster screening were retrospectively reviewed and categorized according to the Expert Recommendations for Implementing Change (ERIC) study. Statistical process control methods were utilized to determine whether implementation strategies contributed to improvements in HRSN screening activities. Results There were 280,757 HRSN screens administered across 311 clinical teams in the health system between April 2018 and March 2023. Implementation strategies linked to increased screening included integrating screening within an online patient portal (ERIC strategy: involve patients/consumers and family members), expansion to discrete clinical teams (ERIC strategy: change service sites), providing data feedback loops (ERIC strategy: facilitate relay of clinical data to providers), and deploying Community Health Workers to address HRSNs (ERIC strategy: create new clinical teams). Conclusion Implementation strategies designed to promote efficiency, foster universal screening, link patients to resources, and provide clinical teams with an easy-to-integrate tool appear to have the greatest impact on HRSN screening uptake. Sustained increases in screening demonstrate the cumulative effects of implementation strategies and the health system's commitment toward universal screening.
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Affiliation(s)
- Kevin Fiori
- Department of Family & Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA
- Office of Community & Population Health, Montefiore Health System, Bronx, NY, USA
| | - Samantha Levano
- Department of Family & Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jessica Haughton
- Department of Family & Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Renee Whiskey-LaLanne
- Department of Family & Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Andrew Telzak
- Department of Family & Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sybil Hodgson
- Department of Family & Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
- Montefiore Medical Group, Bronx, NY, USA
| | | | - Allison Stark
- Department of Family & Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
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10
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DeMass R, Gupta D, Self S, Thomas D, Rudisill C. Emergency department use and geospatial variation in social determinants of health: a pilot study from South Carolina. BMC Public Health 2023; 23:1527. [PMID: 37563566 PMCID: PMC10416539 DOI: 10.1186/s12889-023-16136-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 06/16/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND Health systems are increasingly addressing patients' social determinants of health (SDoH)-related needs and investigating their effects on health resource use. SDoH needs vary geographically; however, little is known about how this geographic variation in SDoH needs impacts the relationship between SDoH needs and health resource use. METHODS This study uses data from a SDoH survey administered to a pilot patient population in a single health system and the electronic medical records of the surveyed patients to determine if the impact of SDoH needs on emergency department use varies geospatially at the US Census block group level. A Bayesian zero-inflated negative binomial model was used to determine if emergency department visits after SDoH screening varied across block groups. Additionally, the relationships between the number of emergency department visits and the response to each SDoH screening question was assessed using Bayesian negative binomial hurdle models with spatially varying coefficients following a conditional autoregressive (CAR) model at the census block group level. RESULTS Statistically important differences in emergency department visits after screening were found between block groups. Statistically important spatial variation was found in the association between patient responses to the questions concerning unhealthy home environments (e.g. mold, bugs/rodents, not enough air conditioning/heat) or domestic violence/abuse and the mean number of emergency department visits after the screen. CONCLUSIONS Notable spatial variation was found in the relationships between screening positive for unhealthy home environments or domestic violence/abuse and emergency department use. Despite the limitation of a relatively small sample size, sensitivity analyses suggest spatially varying relationships between other SDoH-related needs and emergency department use.
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Affiliation(s)
- Reid DeMass
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, 915 Greene St., Columbia, SC, 29208, USA
| | - Deeksha Gupta
- Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, 29208, USA
| | - Stella Self
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, 300 E. McBee Ave. Greenville, Columbia, SC, 29601, USA.
| | - Darin Thomas
- Addiction Medicine Center, Prisma Health, 605 Grove Road Greenville, Columbia, SC, 29605, USA
| | - Caroline Rudisill
- Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, 300 E. McBee Ave. Greenville, Columbia, SC, 29601, USA
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11
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Mizrahi J, Marhaba J, Buniak W, Sun E. Transition-of-care program from emergency department to gastroenterology clinics improves follow-up. Am J Emerg Med 2023; 69:154-159. [PMID: 37121064 DOI: 10.1016/j.ajem.2023.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 04/16/2023] [Accepted: 04/20/2023] [Indexed: 05/02/2023] Open
Abstract
OBJECTIVES Patients discharged from the emergency department (ED) with gastrointestinal (GI) symptoms need to appropriately transition their care to a GI outpatient clinic in a timely manner to have their health needs met and avoid significant morbidity. When this transition isn't optimal, patients are lost to follow-up, potentially placing them at risk for adverse events. We sought to study the effectiveness of implementing an electronic medical record (EMR) based transition-of-care (TOC) program from the ED to outpatient GI clinics. METHODS We performed a retrospective single center cohort study of patients discharged from the ED of a tertiary care academic medical center referred to outpatient GI clinic before (Pre-TOC patients) and after implementation of an EMR based TOC program (TOC patients). We further stratified patients based on the Distressed Communities Index (DCI), which is a composite measure of economic well-being. We compared rates of appointment scheduling and appointment attendance between the two groups, as well as 30-day readmission rates to the ED. We also performed a subgroup analysis to determine if socioeconomic status would affect patient follow-up rates. RESULTS We included 380 Pre-TOC and 399 TOC patients in our analysis. TOC patients were found to both schedule appointments (50% vs 27% p-value <0.01) as well as show up to appointments (34% vs 24% p-value <0.01) at significantly higher rates compared to Pre-TOC patients. There was no significant difference between 30-day readmission rates between the two groups. In addition, TOC patients from At-Risk and Distressed Communities were over 22 times more likely to schedule an appointment compared to Pre-TOC patients from similar neighborhoods (OR 22.18, 95% CI 4.23-116.32). CONCLUSION Our study shows that patients who are discharged from the ED with outpatient GI follow-up are more likely to both schedule and show up to appointments with implementation of an EMR-based direct referral program compared to no patient navigation, particularly among patients of lower socioeconomic status.
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Affiliation(s)
- Joseph Mizrahi
- Department of Medicine, Division of Gastroenterology and Hepatology, Stony Brook University Hospital, 101 Nicolls Road, Health Science Tower, Level 17, Room 060, Stony Brook, NY 11794-8173, United States of America.
| | - Jade Marhaba
- Department of Medicine, Division of Gastroenterology and Hepatology, Stony Brook University Hospital, 101 Nicolls Road, Health Science Tower, Level 17, Room 060, Stony Brook, NY 11794-8173, United States of America.
| | - William Buniak
- Division of Gastroenterology, Wright Center for Graduate Medical Education, 501 South Washington Avenue, Scranton, PA 18510, United States of America
| | - Edward Sun
- Division of Gastroenterology and Hepatology, Peconic Bay Medical Center, 1300 Roanoke Ave, Riverhead, NY 11901, United States of America.
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12
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Greene L, Maciejewski ML, Grubber J, Smith VA, Blalock DV, Zulman DM. Association between patient-reported social, behavioral, and health factors and emergency department visits in high-risk VA patients. Health Serv Res 2023; 58:383-391. [PMID: 36310448 PMCID: PMC10012238 DOI: 10.1111/1475-6773.14094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
RESEARCH OBJECTIVE To identify patient-reported social risk, behavioral, and health factors associated with emergency department (ED) utilization in high-risk Veterans Affairs (VA) patients. DATA SOURCES Patient survey, VA, Medicare data. STUDY DESIGN Prospective cohort study using multivariable logistic regression to identify patient-reported factors associated with all-cause and ambulatory care sensitive condition (ACSC)-related ED visits among VA patients at high risk for hospitalization or death. DATA EXTRACTION METHODS Patient-reported measures derived from a 2018 survey sent to 10,000 VA patients; clinical and demographic characteristics derived from VA data; ED visits derived from VA and Medicare claims. PRINCIPAL FINDINGS Among 4680 survey respondents, 52.5% and 16.3% experienced an all-cause or ACSC-related ED visit in the following year, respectively. An ED visit was more likely among individuals with functional status limitations (6.0% points (Confidence Interval [CI] 0.017-0.103)) and transportation barriers (5.2% points [CI 0.005-0.099]). An ACSC-related ED visit was more likely among individuals with functional status limitations (3.2% points [CI 0.003-0.062]) and self-rated poorer health (7.4% points (CI 0.030-0.119) poor; 6.2% points (CI 0.029-0.096) fair; 4.1% points (CI 0.009-0.073) good; compared with excellent/very good). CONCLUSIONS Patient-reported factors not present in most electronic health records were significantly associated with future ED visits in high-risk VA patients.
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Affiliation(s)
- Liberty Greene
- Center for Innovation to ImplementationVA Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
- Division of Primary Care and Population HealthStanford University School of MedicineStanfordCaliforniaUSA
| | - Matthew L. Maciejewski
- Center for Innovation to Accelerate Discovery and Practice Transformation (ADAPT)Durham Veterans Affairs Health Care SystemDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
- Division of General Internal Medicine, Department of MedicineDuke UniversityDurhamNorth CarolinaUSA
| | - Janet Grubber
- Center for Innovation to Accelerate Discovery and Practice Transformation (ADAPT)Durham Veterans Affairs Health Care SystemDurhamNorth CarolinaUSA
- Department of Psychiatry and Behavioral SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Valerie A. Smith
- Center for Innovation to Accelerate Discovery and Practice Transformation (ADAPT)Durham Veterans Affairs Health Care SystemDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
- Division of General Internal Medicine, Department of MedicineDuke UniversityDurhamNorth CarolinaUSA
- Durham VA Medical CenterDurhamNorth CarolinaUSA
| | - Dan V. Blalock
- Center for Innovation to Accelerate Discovery and Practice Transformation (ADAPT)Durham Veterans Affairs Health Care SystemDurhamNorth CarolinaUSA
- Department of Psychiatry and Behavioral SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
- Durham VA Medical CenterDurhamNorth CarolinaUSA
| | - Donna M. Zulman
- Center for Innovation to ImplementationVA Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
- Division of Primary Care and Population HealthStanford University School of MedicineStanfordCaliforniaUSA
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13
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Tenso K, Pizer S, Palani S. Delivery system emergency department capacity and its effect on nonsystem service utilization. Acad Emerg Med 2023; 30:359-367. [PMID: 36797812 DOI: 10.1111/acem.14694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 01/24/2023] [Accepted: 02/03/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND Emergency department (ED) use is often seen as a source of excess health care spending, prompting managers to limit ED capacity in their health systems. However, if limited ED capacity in a delivery system leads patients to seek emergency care elsewhere, then health care quality and efficient management may be compromised within the system. OBJECTIVE The objective of this study was to explore the effect of the Veterans Health Administration (VHA) in-house ED clinician capacity on VHA community care (CC) ED claims. METHODS We used administrative data from the VHA to identify CC ED claims and Department of Veterans Affairs emergency physician (EP) capacity for 2014-2019. We used quasi-experimental instrumental variables approach with two different instruments: percent weekday federal holidays and VHA EP full-time equivalents (FTEs). We controlled for VHA ED variables such as ED wait times (door to triage, door to doctor, and door to admission) and demand variables such as alternative insurance coverage, driving time to VHA care, and demographic variables (employment, age, household income, race, gender, and VHA priority status). RESULTS After instrumenting for capacity with percent weekday federal holidays, we found that one clinic-day capacity (one 8-h ED shift) per 10,000 enrollees increase at the VHA ED will result in a reduction of 61 CC ED claims per 10,000 enrollees. After instrumenting for capacity with EP FTE, we found that one clinic-day capacity (one 8-h ED shift) per 10,000 enrollees increase at the VHA ED will result in a reduction of 48 CC ED claims per 10,000 enrollees. Both of these results are statistically significant at p < 0.001. CONCLUSIONS Our findings imply that offering more in-house ED care, in the form of clinician capacity, can substantially reduce out-of-system ED use. The results may be of interest to integrated health care system managers who prefer their patients to stay within network.
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Affiliation(s)
- Kertu Tenso
- Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Massachusetts, Boston, USA.,Department of Health Law Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Steven Pizer
- Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Massachusetts, Boston, USA.,Department of Health Law Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Sivagaminathan Palani
- Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Massachusetts, Boston, USA.,Department of Health Law Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
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14
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Lowery B, D'Acunto S, Crowe RP, Fishe JN. Using Natural Language Processing to Examine Social Determinants of Health in Prehospital Pediatric Encounters and Associations with EMS Transport Decisions. PREHOSP EMERG CARE 2023; 27:246-251. [PMID: 35500212 DOI: 10.1080/10903127.2022.2072984] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Social determinants of health (SDOH) influence access to health care and are associated with inequities in patient outcomes, yet few studies have explored SDOH among pediatric EMS patients. The objective of this study was to examine the presence of SDOH in EMS clinician free text notes and quantify the association of SDOH with EMS pediatric transport decisions. METHODS This was a retrospective analysis of primary 9-1-1 responses for patients ages 0-17 years from the 2019 ESO Data Collaborative research dataset. We excluded cardiac arrests and patients in law enforcement custody. Using natural language processing (NLP) we extracted the following SDOH categories: income insecurity, food insecurity, housing insecurity, insurance insecurity, poor social support, and child protective services. Univariate and multivariable associations between the presence of SDOH in EMS records and EMS transport decisions were assessed using logistic regression. RESULTS We analyzed 325,847 pediatric EMS encounters, of which 35% resulted in non-transport. The median age was 10 years and 52% were male. Slightly over half (53%) were White, 31% were Black, and 11% were Hispanic. Child protective services (n = 2,620) and housing insecurity (n = 1,136) were the most common SDOH categories found in the EMS free text narratives. In the multivariable model, child protective services involvement (odds ratio (OR)=2.04 [95% confidence interval (CI) 1.84-2.05]), housing insecurity (OR = 1.46 [95% CI 1.26-1.70]), insurance security (OR = 2.44 [95% CI 1.93-3.09]), and poor social support (OR = 10.48 [95% CI 1.42-77.29]) were associated with greater odds of EMS transport. CONCLUSIONS SDOH documentation in the EMS narrative was rare among pediatric encounters; however, children with documented SDOH were more likely to be transported. Additional exploration of the root causes and outcomes associated with SDOH among children encountered by EMS are warranted.
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Affiliation(s)
- Briauna Lowery
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
| | - Salvatore D'Acunto
- Center for Data Solutions, University of Florida College of Medicine, Jacksonville, Florida
| | | | - Jennifer N Fishe
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida.,Center for Data Solutions, University of Florida College of Medicine, Jacksonville, Florida
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15
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Naimi S, Stryckman B, Liang Y, Seidl K, Harris E, Landi C, Thomas J, Marcozzi D, Gingold DB. Evaluating Social Determinants of Health in a Mobile Integrated Healthcare-Community Paramedicine Program. J Community Health 2023; 48:79-88. [PMID: 36269531 DOI: 10.1007/s10900-022-01148-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2022] [Indexed: 11/26/2022]
Abstract
In 2018, the University of Maryland Medical Center and the Baltimore City Fire Department implemented a community paramedicine program to help medically or socially complex patients transition from hospital to home and avoid hospital utilization. This study describes how patients' social determinants of health (SDoH) needs were identified, and measures the association between needs and hospital utilization. SDoH needs were categorized into ten domains. Multinomial logistic regression was used to measure association between identified SDoH domains and predicted risk of readmission. Poisson regression was used to measure association between SDoH domains and actual 30-day hospital utilization. The most frequently identified SDoH needs were in the Coordination of Healthcare (37.7%), Durable Medical Equipment (18.8%), and Medication (16.3%) domains. Compared with low-risk patients, patients with an intermediate risk of readmission were more likely to have needs within the Coordination of Healthcare (RRR [95% CI] 1.12 [1.01, 1.24], p = 0.032) and Durable Medical Equipment (RRR = 1.13 [1.00, 1.27], p = 0.046) domains. Patients with the highest risk for readmission were more likely to have needs in the Utilities domain (RRR = 1.76 [0.97, 3.19], p = 0.063). Miscellaneous domain needs, such as requiring a social security card, were associated with increased 30-day hospital utilization (IRR = 1.23 [0.96, 1.57], p = 0.095). SDoH needs within the Coordination of Healthcare, Durable Medical Equipment, and Utilities domains were associated with higher predicted 30-day readmission, while identification documentation and social services needs were associated with actual readmission. These results suggest where to allocate resources to effectively diminish hospital utilization.
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Affiliation(s)
- Sean Naimi
- University of Maryland School of Medicine, 620 W Lexington St, Baltimore, MD, 21201, USA.
| | - Benoit Stryckman
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Yuanyuan Liang
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Kristin Seidl
- Department of Quality and Safety, University of Maryland Medical Center, Baltimore, USA
- Department of Organizational Systems and Adult Health, University of Maryland School of Nursing, Baltimore, MD, 21201, USA
| | - Erinn Harris
- Baltimore City Fire Department, Baltimore, MD, 21201, USA
| | - Colleen Landi
- Mobile Integrated Health Community Paramedicine, University of Maryland Medical Center, Baltimore, MD, 21201, USA
| | - Jessica Thomas
- Baltimore City Fire Department, Baltimore, MD, 21201, USA
| | - David Marcozzi
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Daniel B Gingold
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
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16
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Muirhead L, Echt KV, Alexis AM, Mirk A. Social Determinants of Health: Considerations for Care of Older Veterans. Nurs Clin North Am 2022; 57:329-345. [PMID: 35985723 DOI: 10.1016/j.cnur.2022.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Social determinants of health (SDOH), the environments and circumstances in which people are born, grow, live, work and age, are potent drivers of health, health disparities, and health outcomes over the lifespan. Military service affords unique experiences, exposures, and social and health vulnerabilities which impact the life course and may alter health equity and health outcomes for older veterans. Identifying and addressing SDOH, inclusive of the military experience, allows person-centered, more equitable care to this vulnerable population. Nurses and other health professionals should be familiar with how to identify and address health-related social needs and implement interdiciplinary, team-based approaches to connect patients with resources and benefits specifically available to veterans.
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Affiliation(s)
- Lisa Muirhead
- Emory University, Nell Hodgson Woodruff School of Nursing, 1520 Clifton Road, Atlanta, GA 30322, USA.
| | - Katharina V Echt
- Veterans Affairs Birmingham/ Atlanta Geriatric Research, Education and Clinical Center (GRECC), Atlanta VA Health Care System, 3101 Clairmont Road Northeast, Brookhaven, GA 30329-1044, USA; Division of Geriatrics and Gerontology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Andrea M Alexis
- Atlanta VA Health Care System, Nursing Education, 1M-116A, 1670 Clairmont Road, Decatur, GA 30033, USA
| | - Anna Mirk
- Veterans Affairs Birmingham/ Atlanta Geriatric Research, Education and Clinical Center (GRECC), Atlanta VA Health Care System, 3101 Clairmont Road Northeast, Brookhaven, GA 30329-1044, USA; Division of Geriatrics and Gerontology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
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17
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Emergency department utilisation among older adults—Protocol for a systematic review of determinants and conceptual frameworks. PLoS One 2022; 17:e0265423. [PMID: 35661153 PMCID: PMC9166351 DOI: 10.1371/journal.pone.0265423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 03/01/2022] [Indexed: 11/19/2022] Open
Abstract
Background Older adults aged 65 years and above have a disproportionately higher utilization of emergency healthcare, of which Emergency Department (ED) visits are a key component. They experience higher degree of multimorbidity and mobility issues compared to younger patients, and are consequently more likely to experience a health event which requires an ED visit. During their visit, older adults tend to require more extensive workup, therefore spending a greater amount of time in the ED. Compared to the younger population, older adults are more susceptible to adverse events following discharge. Considering these factors, investigating the determinants of ED utilisation would be valuable. In this paper, we present a protocol for a systematic review of the determinants of ED utilisation among communitydwelling older adults aged 65 years and above, applying Andersen and Newman’s model of healthcare utilisation. Furthermore, we aim to present other conceptual frameworks for healthcare utilisation and propose a holistic approach for understanding the determinants of ED utilisation by older persons. Methods The protocol is developed in accordance with the standards of Campbell Collaboration guidelines for systematic reviews, with reference to the Cochrane Handbook for Systematic Review of Interventions. Medline, Embase and Scopus will be searched for studies published from 2000 to 2020. Studies evaluating more than one determinant for ED utilisation among older adults aged 65 years and above will be included. Search process and selection of studies will be presented in a PRISMA flow chart. Statistically significant (p < 0.05) determinants of ED utilisation will be grouped according to individual and societal determinants. Quality of the studies will be assessed using Newcastle Ottawa Scale (NOS). Discussion In Andersen and Newman’s model, individual determinants include predisposing factors, enabling and illness factors, and societal determinants include technology and social norms. Additional conceptual frameworks for healthcare utilisation include Health Belief Model, Social Determinants of Health and Big Five personality traits. By incorporating the concepts of these models, we hope to develop a holistic approach of conceptualizing the factors that influence ED utilisation among older people. Systematic review registration This protocol is registered on 8 May 2021 with PROSPERO’s International Prospective Register of Systematic Reviews (CRD42021253770).
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18
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Radic M, Parlier-Ahmad AB, Wills B, Martin CE. Social determinants of health and emergency department utilization among adults receiving buprenorphine for opioid use disorder. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 3:100062. [PMID: 35783992 PMCID: PMC9248991 DOI: 10.1016/j.dadr.2022.100062] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 05/09/2022] [Accepted: 05/09/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Individuals with opioid use disorder (OUD) use the emergency department (ED) at high rates. Medication treatment for OUD (MOUD) is associated with reduced ED utilization. However, individuals receiving MOUD still utilize ED services at higher rates than the general population. The objective of this study is to compare the psychosocial and clinical characteristics of those who do and do not utilize ED services based on the Healthy People 2030 framework regarding social determinants of health (SDoH) among a sample of individuals receiving MOUD. METHODS Participants receiving buprenorphine for OUD at an outpatient addiction clinic completed a cross-sectional survey between July and September 2019. A 6-month prospective medical record review was conducted. The primary outcome was ED visit (yes/no) during the 6-month study period. Demographic, psychosocial, and clinical characteristics were gathered from survey measures and chart abstraction. Chi square and T-tests tested differences by ED utilization. RESULTS Participants (n=142) were 54.9% female and 68.8% Black, with an average age of 43.2 years (SD=12.5). Of the participants, 38.7% visited the ED in the study period, primarily for infectious or musculoskeletal causes. Participants with an ED visit were more likely to be Black (p=.011), have less social support (p=.030), more medical comorbidities (p=.008) including chronic pain (p=.045), and more visits with an addiction provider in the study period (p=.009). CONCLUSIONS Factors associated with ED utilization among individuals receiving buprenorphine for OUD include low social support and medical comorbidities, including chronic pain. More research is needed on modifiable SDoH that influence ED utilization.
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Affiliation(s)
- Maja Radic
- Virginia Commonwealth University School of Medicine, 1201 E Marshall St, Richmond, VA 23298, USA
| | - Anna Beth Parlier-Ahmad
- Department of Psychology, Virginia Commonwealth University, 806 W. Franklin St., Richmond, VA 23284, USA
| | - Brandon Wills
- Department of Emergency Medicine, Virginia Commonwealth University, 1250 E. Marshall St., Richmond, VA 23298, USA
| | - Caitlin E. Martin
- Department of Obstetrics and Gynecology and Institute for Drug and Alcohol Studies, Virginia Commonwealth University School of Medicine, 1250 E. Marshall St., Richmond, VA 23298, USA
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Salhi BA, Zeidan A, Stehman CR, Kleinschmidt S, Liu EL, Bascombe K, Preston‐Suni K, White MH, Druck J, Lopez BL, Samuels‐Kalow ME. Structural competency in emergency medical education: A scoping review and operational framework. AEM EDUCATION AND TRAINING 2022; 6:S13-S22. [PMID: 35783075 PMCID: PMC9222890 DOI: 10.1002/aet2.10754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 12/10/2021] [Accepted: 12/11/2021] [Indexed: 06/15/2023]
Abstract
Objectives Existing curricula and recommendations on the incorporation of structural competency and vulnerability into medical education have not provided clear guidance on how best to do so within emergency medicine (EM). The goal of this scoping review and consensus building process was to provide a comprehensive overview of structural competency, link structural competency to educational and patient care outcomes, and identify existing gaps in the literature to inform curricular implementation and future research in EM. Methods A scoping review focused on structural competency and vulnerability following Arksey and O'Malley's six-step framework was performed in concurrence with a multistep consensus process culminating in the 2021 SAEM Consensus Conference. Feedback was incorporated in developing a framework for a national structural competency curriculum in EM. Results A literature search identified 291 articles that underwent initial screening. Of these, 51 were determined to be relevant to EM education. The papers consistently conceptualized structural competency as an interdisciplinary framework that requires learners and educators to consider historical power and privilege to develop a professional commitment to justice. However, the papers varied in their operationalization, and no consensus existed on how to observe or measure the effects of structural competency on learners or patients. None of the studies examined the structural constraints of the learners studied. Conclusions Findings emphasize the need for training structurally competent physicians via national structural competency curricula focusing on standardized core competency proficiencies. Moreover, the findings highlight the need to assess the impact of such curricula on patient outcomes and learners' knowledge, attitudes, and clinical care delivery. The framework aims to standardize EM education while highlighting the need for further research in how structural competency interventions would translate to an ED setting and affect patient outcomes and experiences.
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Affiliation(s)
- Bisan A. Salhi
- Department of Emergency MedicineEmory UniversityAtlantaGeorgiaUSA
- Department of AnthropologyEmory UniversityAtlantaGeorgiaUSA
| | - Amy Zeidan
- Department of Emergency MedicineEmory UniversityAtlantaGeorgiaUSA
| | - Christine R. Stehman
- Department of Emergency MedicineUniversity of Illinois College of MedicinePeoriaIllinoisUSA
| | - Sarah Kleinschmidt
- Department of Emergency MedicineUniversity of Massachusetts Medical School—BaystateSpringfieldMassachusettsUSA
| | - E. Liang Liu
- Department of Emergency MedicineEmory UniversityAtlantaGeorgiaUSA
| | - Kristen Bascombe
- Department of Emergency MedicineEmory UniversityAtlantaGeorgiaUSA
| | - Kian Preston‐Suni
- Department of Emergency MedicineVA Greater Los Angeles Healthcare SystemUniversity of California at Los AngelesLos AngelesCaliforniaUSA
| | - Melissa H. White
- Department of Emergency MedicineEmory UniversityAtlantaGeorgiaUSA
| | - Jeff Druck
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Bernard L. Lopez
- Department of Emergency MedicineSidney Kimmel Medical CollegePhiladelphiaPennsylvaniaUSA
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Gettel CJ, Voils CI, Bristol AA, Richardson LD, Hogan TM, Brody AA, Gladney MN, Suyama J, Ragsdale LC, Binkley CL, Morano CL, Seidenfeld J, Hammouda N, Ko KJ, Hwang U, Hastings SN. Care transitions and social needs: A Geriatric Emergency care Applied Research (GEAR) Network scoping review and consensus statement. Acad Emerg Med 2021; 28:1430-1439. [PMID: 34328674 PMCID: PMC8725618 DOI: 10.1111/acem.14360] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/05/2021] [Accepted: 07/20/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Individual-level social needs have been shown to substantially impact emergency department (ED) care transitions of older adults. The Geriatric Emergency care Applied Research (GEAR) Network aimed to identify care transition interventions, particularly addressing social needs, and prioritize future research questions. METHODS GEAR engaged 49 interdisciplinary stakeholders, derived clinical questions, and conducted searches of electronic databases to identify ED discharge care transition interventions in older adult populations. Informed by the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) framework, data extraction and synthesis of included studies included the degree that intervention components addressed social needs and their association with patient outcomes. GEAR convened a consensus conference to identify topics of highest priority for future care transitions research. RESULTS Our search identified 248 unique articles addressing care transition interventions in older adult populations. Of these, 17 individual care transition intervention studies were included in the current literature synthesis. Overall, common care transition interventions included coordination efforts, comprehensive geriatric assessments, discharge planning, and telephone or in-person follow-up. Fourteen of the 17 care transition intervention studies in older adults specifically addressed at least one social need within the PRAPARE framework, most commonly related to access to food, medicine, or health care. No care transition intervention addressing social needs in older adult populations consistently reduced subsequent health care utilization or other patient-centered outcomes. GEAR stakeholders identified that determining optimal outcome measures for ED-home transition interventions was the highest priority area for future care transitions research. CONCLUSIONS ED care transition intervention studies in older adults frequently address at least one social need component and exhibit variation in the degree of success on a wide array of health care utilization outcomes.
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Affiliation(s)
- Cameron J. Gettel
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- National Clinician Scholars Program, Department of internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Corrine I. Voils
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | | | - Lynne D. Richardson
- Department of Emergency Medicine, icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Population Health Science & Policy, icahn School of Medicine at Mount Sinai, New York, New York, USA
- Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Teresita M. Hogan
- Department of Medicine, Section of Emergency Medicine, The University of Chicago School of Medicine, Chicago, Illinois, USA
| | - Abraham A. Brody
- Hartford Institute for Geriatric Nursing, New York University Rory Meyers College of Nursing, New York, New York, USA
| | - Micaela N. Gladney
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA
| | - Joe Suyama
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Luna C. Ragsdale
- Department of Surgery, Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Emergency Medicine, Durham VA Health Care System, Durham, North Carolina, USA
| | - Christine L. Binkley
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Carmen L. Morano
- School of Social Welfare, University at Albany, State University of New York, Albany, New York, USA
| | - Justine Seidenfeld
- Department of Surgery, Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Nada Hammouda
- Department of Emergency Medicine, icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kelly J. Ko
- West Health Institute, La Jolla, California, USA
| | - Ula Hwang
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Geriatrics Research, Education, and Clinical Center, James J. Peters VAMC, Bronx, New York, USA
| | - Susan N. Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, North Carolina, USA
- Center for the Study of Human Aging and Development, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
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21
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Bechtel N, Jones A, Kue J, Ford JL. Evaluation of the core 5 social determinants of health screening tool. Public Health Nurs 2021; 39:438-445. [PMID: 34628675 DOI: 10.1111/phn.12983] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 09/14/2021] [Accepted: 09/17/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This study evaluated the effects of a social determinants of health (SDH) screening tool and service referral on emergency department (ED) use among patients at a Federally Qualified Health Center primary care clinic. STUDY DESIGN Quasi-experimental. SAMPLE Three-hundred and eleven English-speaking patients 18 years and older. MEASURES The Core 5 SDH screening tool consists of five yes/no items assessing food, housing, utilities, transportation, and safety needs. The number of ED visits 3 months before and after the intervention were collected from electronic health records. INTERVENTION The research team administered the Core 5 SDH screening tool and if desired, referred patients with an identified need for SDH services. RESULTS Approximately 43% of patients reported a SDH need with food insecurity most prevalent (62.2%). The number of ED visits was significantly lower 3 months post-intervention compared to 3 months before for the 125 participants who wanted and received the SDH service referral (IRR = 0.64, 95% CI = 0.41, 0.99) and for the 35 participants who reported receiving some/all of the needed services at the 2-week follow-up (IRR = 0.36, 95% CI = 0.17, 0.76). CONCLUSIONS Addressing patients' SDH needs may reduce ED visits, lower healthcare costs, and ultimately, improve health.
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Affiliation(s)
| | | | - Jennifer Kue
- University of South Florida, College of Nursing, Tampa, Florida
| | - Jodi L Ford
- Martha S. Pitzer Center for Women, Children and Youth, Ohio State University, College of Nursing, Columbus, Ohio
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Lyons PG, Ramsey BA, Welker M, Guinn M, Ernest JK, Kosydor A, Maddox TM. Implementation of a non-emergent medical transportation programme at an integrated health system. BMJ Health Care Inform 2021; 28:bmjhci-2021-100417. [PMID: 34489322 PMCID: PMC8422306 DOI: 10.1136/bmjhci-2021-100417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/25/2021] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To implement a unified non-emergency medical transportation (NEMT) service across a large integrated healthcare delivery network. METHODS We assessed needs among key organisational stakeholders, then reviewed proposals. We selected a single NEMT vendor best aligned with organisational priorities and implemented this solution system-wide. RESULTS Our vendor's hybrid approach combined rideshares with contracted vehicles able to serve patients with equipment and other needs. After 6195 rides in the first year, we observed shorter wait times and lower costs compared with our prior state. DISCUSSION Essential lessons included (1) understanding user and patient needs, (2) obtaining complete, accurate and comprehensive baseline data and (3) adapting existing workflows-rather than designing de novo-whenever possible. CONCLUSIONS Our implementation of a single-vendor NEMT solution validates the need for NEMT at large healthcare organisations, geographical challenges to establishing NEMT organisation-wide, and the importance of baseline data and stakeholder engagement.
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Affiliation(s)
- Patrick G Lyons
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA .,Healthcare Innovation Lab, BJC HealthCare, Saint Louis, Missouri, USA
| | | | - Michael Welker
- Supply Utilization, BJC HealthCare, Saint Louis, Missouri, USA
| | | | - Janice K Ernest
- Integrated Care Systems, BJC HealthCare, Saint Louis, Missouri, USA
| | - Ali Kosydor
- Healthcare Innovation Lab, BJC HealthCare, Saint Louis, Missouri, USA
| | - Thomas M Maddox
- Healthcare Innovation Lab, BJC HealthCare, Saint Louis, Missouri, USA.,Division of Cardiovascular Medicine, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
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23
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Blalock DV, Maciejewski ML, Zulman DM, Smith VA, Grubber J, Rosland AM, Weidenbacher HJ, Greene L, Zullig LL, Whitson HE, Hastings SN, Hung A. Subgroups of High-Risk Veterans Affairs Patients Based on Social Determinants of Health Predict Risk of Future Hospitalization. Med Care 2021; 59:410-417. [PMID: 33821830 PMCID: PMC8034377 DOI: 10.1097/mlr.0000000000001526] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Population segmentation has been recognized as a foundational step to help tailor interventions. Prior studies have predominantly identified subgroups based on diagnoses. In this study, we identify clinically coherent subgroups using social determinants of health (SDH) measures collected from Veterans at high risk of hospitalization or death. STUDY DESIGN AND SETTING SDH measures were obtained for 4684 Veterans at high risk of hospitalization through mail survey. Eleven self-report measures known to impact hospitalization and amenable to intervention were chosen a priori by the study team to identify subgroups through latent class analysis. Associations between subgroups and demographic and comorbidity characteristics were calculated through multinomial logistic regression. Odds of 180-day hospitalization were compared across subgroups through logistic regression. RESULTS Five subgroups of high-risk patients emerged-those with: minimal SDH vulnerabilities (8% hospitalized), poor/fair health with few SDH vulnerabilities (12% hospitalized), social isolation (10% hospitalized), multiple SDH vulnerabilities (12% hospitalized), and multiple SDH vulnerabilities without food or medication insecurity (10% hospitalized). In logistic regression, the "multiple SDH vulnerabilities" subgroup had greater odds of 180-day hospitalization than did the "minimal SDH vulnerabilities" reference subgroup (odds ratio: 1.53, 95% confidence interval: 1.09-2.14). CONCLUSION Self-reported SDH measures can identify meaningful subgroups that may be used to offer tailored interventions to reduce their risk of hospitalization and other adverse events.
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Affiliation(s)
- Dan V. Blalock
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC
| | - Matthew L. Maciejewski
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University, Durham NC
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC
| | - Donna M. Zulman
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford CA
| | - Valerie A. Smith
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University, Durham NC
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC
| | - Janet Grubber
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
| | - Ann-Marie Rosland
- VA Pittsburgh Center for Health Equity Research and Promotion, Pittsburgh PA
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh PA
| | - Hollis J. Weidenbacher
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
| | - Liberty Greene
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford CA
| | - Leah L. Zullig
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University, Durham NC
| | - Heather E. Whitson
- Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, NC
- Center for the Study of Human Aging and Development, Duke University, Durham, NC
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Susan N. Hastings
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University, Durham NC
- Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, NC
- Center for the Study of Human Aging and Development, Duke University, Durham, NC
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Anna Hung
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University, Durham NC
- Duke Clinical Research Institute, Duke University, Durham, NC
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