Transforming a traditional safety net into a coordinated care system: lessons from healthy San Francisco

Surgical Cancer Care in Safety-Net Hospitals: a Systematic Review

BACKGROUND

Tertiary medical centers in the USA provide specialized, high-volume surgical cancer care, contributing standards for quality and outcomes. For the most vulnerable populations, safety-net hospitals (SNHs) remain the predominant provider of both complex and routine healthcare needs. The objective of this study was to evaluate access to and quality of surgical oncology care within SNHs.

METHODS

A comprehensive and systematic review of the literature was conducted using PubMed, EMBASE, and Cochrane Library databases to identify all studies (January 2000-October 2021) reporting the delivery of surgical cancer care at SNHs in the USA (PROSPERO #CRD42021290092). These studies describe the process and/or outcomes of surgical care for gastrointestinal, hepatopancreatobiliary, or breast cancer patients seeking treatment at SNHs.

RESULTS

Of 3753 records, 37 studies met the inclusion criteria. Surgical care for breast cancer (43%) was the most represented, followed by colorectal (30%) and hepatopancreatobiliary (16%) cancers. Financial constraints, cultural and language barriers, and limitations to insurance coverage were cited as common reasons for disparities in care within SNHs. Advanced disease at presentation was common among cancer patients seeking care at SNHs (range, 24-61% of patients). Though reports comparing cancer survival between SNHs and non-SNHs were few, results were mixed, underscoring the variability in care seen across SNHs.

CONCLUSIONS

These findings highlight barriers in care facing many cancer patients. Continued efforts should address improving both access and quality of care for SNH patients. Future models include a transition away from a two-tiered system of resourced and under-resourced hospitals toward an integrated cancer system.

Cancer screening and breast cancer family history in Spanish-speaking Hispanic/Latina women in California

Background

Breast cancer is the most common cancer among women in the U.S. and the leading cause of cancer death among Hispanics/Latinas (H/L). H/L are less likely than Non-H/L White (NHW) women to be diagnosed in the early stages of this disease. Approximately 5-10% of breast cancer can be attributed to inherited genetic mutations in high penetrance genes such as BRCA1/2. Women with pathogenic variants in these genes have a 40-80% lifetime risk of breast cancer. Past studies have shown that genetic counseling can help women and their families make informed decisions about genetic testing and early cancer detection or risk-reduction strategies. However, H/L are 3.9-4.8 times less likely to undergo genetic testing than NHW women. We developed a program to outreach and educate the H/L community about hereditary breast cancer, targeting monolingual Spanish-speaking individuals in California. Through this program, we have assessed cancer screening behavior and identified women who might benefit from genetic counseling in a population that is usually excluded from cancer research and care.

Materials and Methods

The "Tu Historia Cuenta" program is a promotores-based virtual outreach and education program including the cities of San Francisco, Sacramento, and Los Angeles. Participants responded to three surveys: a demographic survey, a breast cancer family history survey, and a feedback survey. Survey responses were described for participants and compared by area where the program took place using chi-square, Fisher exact tests, and t tests. Multinomial logistic regression models were used for multivariate analyses.

Results and Conclusion

We enrolled 1042 women, 892 completed the cancer family history survey and 62 (7%) provided responses compatible with referral to genetic counseling. We identified 272 women (42.8% ages 40 to 74 years) who were due for mammograms, 250 women (24.7% ages 25 to 65 years) due for Papanicolaou test, and 189 women (71.6% ages 50+) due for colorectal cancer screening. These results highlight the need of additional support for programs that spread awareness about cancer risk and facilitate access to resources, specifically within the H/L community.

Barriers and Facilitators to Accessing Health Services for People Without Documentation Status in an Anti-Immigrant Era: A Socioecological Model

Purpose: This qualitative study explores the barriers and facilitators to health care from the perspective of providers who care for patients without documentation status in the San Francisco Bay Area.

Methods: Twenty-four direct providers were interviewed using semi-structured in-depth interviews. Participants included health care providers and community-based organization leaders. Interviews were independently coded using grounded theory analysis. The socioecological framework was used to develop the interview guide, analyze findings, and guide the discussion.

Results: Participants identified fear as a barrier that transcended multiple levels of influence. At the public policy level, national policies, such as public charge and anti-immigration rhetoric, limited access to services. Local expansion of health care coverage, such as Healthy San Francisco, facilitated access to care. At the organizational level, law enforcement presence generated fear. This was countered by a welcoming environment, described as culturally concordant clinical sites, representation of the community in the provider pool, and resources to address social needs. Individual-level fear, rooted in trauma and economic insecurity, was eased by trauma-informed care and health navigators. Community engagement and sustained partnerships built trust and credibility to transcend the fear that hindered access to care.

Conclusion: In a region with expansive policies for improved health care access, barriers are rooted in fear and span individual, organizational, and public policy levels of access to care. Richer community engagement may lessen the national and systemic barriers that this vulnerable population continues to face. Developing an understanding of this topic improves health care providers' ability to meet the needs of this growing and vulnerable population.

Breast Cancer in San Francisco: Disentangling Disparities at the Neighborhood Level

BACKGROUND

This study uses a novel geographic approach to summarize the distribution of breast cancer in San Francisco and aims to identify the neighborhoods and racial/ethnic groups that are disproportionately affected by this disease.

METHODS

Nine geographic groupings were newly defined on the basis of racial/ethnic composition and neighborhood socioeconomic status. Distribution of breast cancer cases from the Greater Bay Area Cancer Registry in these zones were examined. Multivariable logistic regression models were used to determine neighborhood associations with stage IIB⁺ breast cancer at diagnosis. Cox proportional hazards regression was used to estimate the hazard ratios for all-cause and breast cancer-specific mortality.

RESULTS

A total of 5,595 invasive primary breast cancers were diagnosed between January 1, 2006 and December 31, 2015. We found neighborhood and racial/ethnic differences in stage of diagnosis, molecular subtype, survival, and mortality. Patients in the Southeast (Bayview/Hunter's Point) and Northeast (Downtown, Civic Center, Chinatown, Nob Hill, Western Addition) areas were more likely to have stage IIB⁺ breast cancer at diagnosis, and those in the East (North Beach, Financial District, South of Market, Mission Bay, Potrero Hill) and Southeast were more likely to be diagnosed with triple-negative breast cancers (TNBC). Compared with other racial/ethnic groups, Blacks/African Americans (B/AA) experienced the greatest disparities in breast cancer-related outcomes across geographic areas.

CONCLUSIONS

San Francisco neighborhoods with lower socioeconomic status and larger minority populations experience worse breast cancer outcomes.

IMPACT

Our findings, which reveal breast cancer disparities at sub-county geographic levels, have implications for population-level health interventions.

Low Literacy Level Instructions and Reminder Calls Improve Patient Handling of Fecal Immunochemical Test Samples

BACKGROUND & AIMS

The fecal immunochemical test (FIT) is an alternative to colonoscopy and can increase overall screening for colorectal cancer (CRC). However, little is known about the frequency of and reasons for mishandled FIT samples.

METHODS

We performed a prospective study, nested within a randomized controlled trial of patients, recruited from December 2015 through August 2017, who were not up to date with colorectal cancer screening (50-75 years old). The patients were randomly assigned to usual care or outreach groups that received a mailed FIT with low literacy level instructions or a reminder call, or both. We examined frequency of and reasons for mishandled FIT samples, including absence of collection date; time from collection to laboratory receipt of more than 14 days; or mishandling of stool, buffer, or cap. The outcomes were the frequency of mishandled FIT samples, effects of outreach on mishandling, and positive results from the FIT among proper and mishandled samples.

RESULTS

FIT samples were returned from 1871 patients assigned to usual care and 3045 who received the low literacy level instructions and a reminder call. In total, 19.8% of samples were mishandled; most of these (93.7%) had not labeled the date of stool collection but were still processed. Of the received samples, 1.2% of were not processed because the time from patient collection to laboratory receipt was more than 14 days. Outreach was associated with a lower proportion of mishandled samples (16.5% vs 25.0% for usual care; P < .0001). The proportion of mishandled samples was lowest among patients who received the low literacy level instruction and a reminder call (12.8%, P < .0001). There was no significant difference in proportions of positive results between properly processed samples (7.5%) and improperly processed samples (6.2%) (P = .14).

CONCLUSION

In a prospective study of patients who were not up to date with colorectal cancer screening, we found that almost 20% of FIT samples were mishandled, with most patients missing the stool collection date. Patient outreach was associated with a lower proportion of mishandled samples, but there was no difference in proportions of positive results between properly and improperly handled samples. Our findings indicate that routine processing of undated FIT samples is associated with similar rates of positive results. There are limited data on test characteristics for FIT samples beyond the 14 days of stool acquisition. The inclusion of low literacy level instructions with reminder calls was associated with improved patient handling of the FIT sample. ClincialTrials.gov no: NCT02613260.

Universal Health Care: Lessons From San Francisco

The San Francisco Health Care Security Ordinance is the country's only local law designed to promote universal health care. It provides access to health services for the uninsured while requiring employers to contribute financially toward employees' health care costs. Enrollment in Healthy San Francisco, a program for the uninsured that is one component of the ordinance, fell significantly after the Affordable Care Act extended other types of coverage. Healthy San Francisco continues as a major source of care for undocumented people. Many other California counties have programs that provide at least some nonemergency care to undocumented residents, which demonstrates the versatility of this approach for localities. San Francisco employer contributions also fund medical reimbursement accounts that help insured people pay their health costs, including through a program added in 2016 to make Marketplace insurance more affordable. The city's experiences show that programs to help people pay for private coverage should be simple and include strong outreach and education and that the affordability of Marketplace coverage would be most easily addressed at the state level.

Inadequate Utilization of Diagnostic Colonoscopy Following Abnormal FIT Results in an Integrated Safety-Net System

OBJECTIVES

The effectiveness of stool-based colorectal cancer (CRC) screening is contingent on colonoscopy completion in patients with an abnormal fecal immunochemical test (FIT). Understanding system and patient factors affecting follow-up of abnormal screening tests is essential to optimize care for high-risk cohorts.

METHODS

This retrospective cohort study was conducted in an integrated safety-net system comprised of 11 primary-care clinics and one Gastroenterology referral unit and included patients 50-75 years, with a positive FIT between April 2012 and February 2015.

RESULTS

Of the 2,238 patients identified, 1,245 (55.6%) completed their colonoscopy within 1-year of the positive FIT. The median time from positive FIT to colonoscopy was 184 days (interquartile range 140-232). Of the 13% of FIT positive patients not referred to gastroenterology, 49% lacked documentation addressing their abnormal result or counseling on the increased risk of CRC. Of the patients referred but who missed their appointments, 62% lacked documentation following up on the abnormal result in the absence of a completed colonoscopy. FIT positive patients never referred to gastroenterology or who missed their appointment after referrals were more likely to have comorbid conditions and documented illicit substance use compared with patients who completed a colonoscopy.

CONCLUSIONS

Despite access to colonoscopy and a shared electronic health record system, colonoscopy completion after an abnormal FIT is inadequate within this safety-net system. Inadequate follow-up is in part explained by inappropriate screening, but there is an absence of clear documentation and systematic workflow within both primary care and GI specialty care addressing abnormal FIT results.

Assessing health care services used by California's undocumented immigrant population in 2010

Undocumented immigrants were excluded from the health benefit Marketplaces created by the Affordable Care Act partly because of claims that they contribute to problems such as high costs and emergency department (ED) crowding. This article examines the likely health care use and costs of undocumented immigrants in California in 2009-10. Using data from the 2009 California Health Interview Survey (CHIS), we developed a model that estimated the state's adult and child undocumented immigrant population, since the survey does not explicitly inquire about undocumented status. The survey also provided information on insurance status, doctor visits, and ED visits in the previous year. We found that undocumented immigrants in California, and the uninsured among them, had fewer or similar numbers of doctor visits, ED visits, and preventive services use compared to US citizens and other immigrant groups. Allowing undocumented immigrants to purchase insurance in the Marketplaces and ensuring receipt of low-cost preventive services can contribute to lower premiums and reduce resource strains on safety-net providers.

Barriers to Homeless Persons Acquiring Health Insurance Through the Affordable Care Act

BACKGROUND

Medicaid expansion under the Affordable Care Act (ACA) is intended to provide a framework for increasing health care access for vulnerable populations, including the 1.2 million who experience homelessness each year in the United States.

OBJECTIVE

We sought to characterize homeless persons' knowledge of the ACA, identify barriers to their ACA enrollment, and determine access to various forms of communication that could be used to facilitate enrollment.

METHODS

At an urban county Level I trauma center, we interviewed all noncritically ill adults who presented to the emergency department (ED) during daytime hours and were able to provide consent. We assessed access to communication, awareness of the ACA, insurance status, and barriers preventing subjects from enrolling in health insurance and compared homeless persons' responses with concomitantly enrolled housed individuals.

RESULTS

Of the 650 enrolled subjects, 134 (20.2%) were homeless. Homeless subjects were more likely to have never heard of the ACA (26% vs. 10%). "Not being aware if they qualify for Medicaid" was the most common (70%) and most significant (30%) barrier to enrollment reported by uninsured homeless persons. Of homeless subjects who were unsure if they qualified for Medicaid, 91% reported an income < 138% of the federal poverty level, likely qualifying them for enrollment. Although 99% of housed subjects reported access to either phone or internet, only 74% of homeless subjects reported access.

CONCLUSIONS

Homeless persons report having less knowledge of the ACA than their housed counterparts, poor understanding of ACA qualification criteria, and limited access to phone and internet. ED-based outreach and education regarding ACA eligibility may increase their enrollment.

Supporting health insurance expansion: do electronic health records have valid insurance verification and enrollment data?

OBJECTIVE

To validate electronic health record (EHR) insurance information for low-income pediatric patients at Oregon community health centers (CHCs), compared to reimbursement data and Medicaid coverage data.

MATERIALS AND METHODS

Subjects Children visiting any of 96 CHCs (N = 69 189) from 2011 to 2012. Analysis The authors measured correspondence (whether or not the visit was covered by Medicaid) between EHR coverage data and (i) reimbursement data and (ii) coverage data from Medicaid.

RESULTS

Compared to reimbursement data and Medicaid coverage data, EHR coverage data had high agreement (87% and 95%, respectively), sensitivity (0.97 and 0.96), positive predictive value (0.88 and 0.98), but lower kappa statistics (0.32 and 0.49), specificity (0.27 and 0.60), and negative predictive value (0.66 and 0.45). These varied among clinics.

DISCUSSION/CONCLUSIONS

EHR coverage data for children had a high overall correspondence with Medicaid data and reimbursement data, suggesting that in some systems EHR data could be utilized to promote insurance stability in their patients. Future work should attempt to replicate these analyses in other settings.

The colorectal cancer screening process in community settings: a conceptual model for the population-based research optimizing screening through personalized regimens consortium

Reducing colorectal cancer mortality by promoting screening has been a national goal for two decades. The NCI's Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium is the first federal initiative to foster coordinated, transdisciplinary research evaluating the entire cancer screening process in community settings. PROSPR is creating a central data repository to facilitate research evaluating the breast, cervical, and colorectal cancer screening process across different patient populations, provider types, and delivery systems. Data are being collected and organized at the multiple levels in which individuals are nested (e.g., healthcare systems, facilities, providers, and patients). Here, we describe a conceptual model of the colorectal cancer screening process guiding data collection and highlight critical research questions that will be addressed through pooled data. We also describe the three research centers focused on colorectal cancer screening with respect to study populations, practice settings, and screening policies. PROSPR comprehensively elucidates the complex screening process through observational study, and has potential to improve care delivery beyond the healthcare systems studied. Findings will inform intervention designs and policies to optimize colorectal cancer screening delivery and advance the Institute of Medicine's goals of effective, efficient, coordinated, timely, and safe health care with respect to evidence-based cancer screening.

Early experiences implementing pre-exposure prophylaxis (PrEP) for HIV prevention in San Francisco

Albert Liu and colleagues report early experiences with uptake and delivery of pre-exposure prophylaxis(PrEP)for HIV prevention in three different settings in San Francisco. PrEP can be an important component of a comprehensive HIV prevention program and can complement efforts to increase HIV testing, linkage to care, and early initiation of antiretroviral therapy. Please see later in the article for the Editors' Summary

Safety-net providers in some US communities have increasingly embraced coordinated care models

Safety-net organizations, which provide health services to uninsured and low-income people, increasingly are looking for ways to coordinate services among providers to improve access to and quality of care and to reduce costs. In this analysis, a part of the Community Tracking Study, we examined trends in safety-net coordination activities from 2000 to 2010 within twelve communities in the United States and found a notable increase in such activities. Six of the twelve communities had made formal efforts to link uninsured people to medical homes and coordinate care with specialists in 2010, compared to only two communities in 2000. We also identified key attributes of safety-net coordinated care systems, such as reliance on a medical home for meeting patients' primary care needs, and lingering challenges to safety-net integration, such as competition among hospitals and community health centers for Medicaid patients.

How five leading safety-net hospitals are preparing for the challenges and opportunities of health care reform

Safety-net hospitals will continue to play a critical role in the US health care system, as they will need to care for the more than twenty-three million people who are estimated to remain uninsured after the Affordable Care Act is implemented. Yet such hospitals will probably have less federal and state support for uncompensated care. At the same time, safety-net hospitals will need to reposition themselves in the marketplace to compete effectively for newly insured people who will have a choice of providers. We examine how five leading safety-net hospitals have begun preparing for reform. Building upon strong organizational attributes such as health information technology and system integration, the study hospitals' preparations include improving the efficiency and quality of care delivery, retaining current and attracting new patients, and expanding the medical home model.

The health care home model: primary health care meeting public health goals

In November 2010, the American Public Health Association endorsed the health care home model as an important way that primary care may contribute to meeting the public health goals of increasing access to care, reducing health disparities, and better integrating health care with public health systems. Here we summarize the elements of the health care home (also called the medical home) model, evidence for its clinical and public health efficacy, and its place within the context of health care reform legislation. The model also has limitations, especially with regard to its degree of involvement with the communities in which care is delivered. Several actions could be undertaken to further develop, implement, and sustain the health care home.