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Pourat N, Tieu L, Martinez AE. Measuring Behavioral Health Integration in Primary Care. Popul Health Manag 2022; 25:721-728. [PMID: 36576384 PMCID: PMC10024064 DOI: 10.1089/pop.2022.0160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Behavioral health integration (BHI) within primary care settings is shown to improve outcomes. However, achieving BHI requires identifying best practices and a reliable tool that can be used to measure existing levels and progress toward BHI. The objective of this study was to develop and apply a conceptual framework to measure BHI, test the approach, and examine challenges to achieving BHI. Surveys and interviews were conducted with key informants within 17 designated public hospitals in California at the midpoint of participating in a 5-year project to establish BHI. A framework and coding methodology were developed to assess BHI best practices at each hospital. BHI status was assessed in the domains of infrastructure and process. Each domain included 5 themes such as electronic health record integration and functionality (infrastructure) and interprovider communication (process). Themes were assessed using a 6-point scale for various activities under a theme and associated weights. Theme-specific values were standardized from 0% to 100% to compare BHI scores between hospitals. Overall progress toward BHI ranged from scores of 52% to 83% (mean 63%) and indicated greater contribution of infrastructure versus process implementation. Within the infrastructure domain, scores were higher for having institutional and provider support, but lagged in establishing provider proximity. Within the process domain, scores were highest for implementation of behavioral health screening, but were frequently lower for other themes such as use of care coordination and referral processes. Further research is needed to test the robustness of this approach in other settings.
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Affiliation(s)
- Nadereh Pourat
- Health Economics and Evaluation Research Program, UCLA Center for Health Policy Research, Los Angeles, California, USA
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA
| | - Lina Tieu
- Health Economics and Evaluation Research Program, UCLA Center for Health Policy Research, Los Angeles, California, USA
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA
| | - Ana E. Martinez
- Health Economics and Evaluation Research Program, UCLA Center for Health Policy Research, Los Angeles, California, USA
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Tieu L, Walton QL, Sherbourne CD, Miranda JM, Wells KB, Tang L, Williams P, Anderson GL, Booker-Vaughns J, Pulido E, Carr T, Heller SM, Bromley E. Life Events, Barriers to Care, and Outcomes Among Minority Women Experiencing Depression: A Longitudinal, Mixed-Method Examination. J Nerv Ment Dis 2022; 210:596-606. [PMID: 35184128 PMCID: PMC9338920 DOI: 10.1097/nmd.0000000000001496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
ABSTRACT The long-term course of depression is not well-understood among minority women. We assessed depression trajectory, barriers to depression care, and life difficulties among minority women accessing health and social service programs as part of the Community Partners in Care study. Data include surveys ( N = 339) and interviews ( n = 58) administered at 3-year follow-up with African American and Latina women with improved versus persistent depression. The majority of the sample reported persistent depression (224/339, 66.1%), ≥1 barrier to mental health care (226/339, 72.4%), and multiple life difficulties (mean, 2.7; SD, 2.3). Many barriers to care ( i.e. , related to stigma and care experience, finances, and logistics) and life difficulties ( i.e. , related to finances, trauma, and relationships) were more common among individuals reporting persistent depression. Results suggest the importance of past experiences with depression treatment, ongoing barriers to care, and negative life events as contributors to inequities in depression outcomes experienced by minority women.
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Affiliation(s)
- Lina Tieu
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, 650 Charles Young Drive South, A2-125 CHS, Los Angeles, CA, USA
| | - Quenette L. Walton
- Graduate College of Social Work, University of Houston, 3511 Cullen Blvd Room 110HA, Houston, TX, USA
| | | | - Jeanne M. Miranda
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, 650 Charles Young Drive South, A2-125 CHS, Los Angeles, CA, USA
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, 760 Westwood Plaza, Los Angeles, CA, USA
- Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, 10920 Wilshire Blvd., Suite 300, Los Angeles, CA, USA
| | - Kenneth B. Wells
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, 650 Charles Young Drive South, A2-125 CHS, Los Angeles, CA, USA
- RAND Corporation, 1776 Main St, Santa Monica, CA, USA
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, 760 Westwood Plaza, Los Angeles, CA, USA
- Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, 10920 Wilshire Blvd., Suite 300, Los Angeles, CA, USA
| | - Lingqi Tang
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, 760 Westwood Plaza, Los Angeles, CA, USA
- Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, 10920 Wilshire Blvd., Suite 300, Los Angeles, CA, USA
| | - Pluscedia Williams
- Department of Social and Preventive Medicine: Community Engagement, Charles R. Drew University of Medicine & Science,1731 E. 120th St, Los Angeles, CA, USA
| | - Gera L. Anderson
- Asian Americans for Community Involvement, 2400 Moorpark Ave, San Jose, CA, USA
| | - Juanita Booker-Vaughns
- Department of Social and Preventive Medicine: Community Engagement, Charles R. Drew University of Medicine & Science,1731 E. 120th St, Los Angeles, CA, USA
| | - Esmeralda Pulido
- University of Washington Medical Center, 1959 N.W. Pacific St, Seattle, WA, USA
| | - Themba Carr
- Autism Discovery Institute, Rady Children’s Hospital San Diego, 3020 Children’s Way, San Diego, CA, USA
| | - S. Megan Heller
- Department of Anthropology, University of California, Los Angeles, 375 Portola Plaza, Los Angeles, CA, USA
| | - Elizabeth Bromley
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, 760 Westwood Plaza, Los Angeles, CA, USA
- Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, 10920 Wilshire Blvd., Suite 300, Los Angeles, CA, USA
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Glenn BA, Nonzee NJ, Tieu L, Pedone B, Cowgill BO, Bastani R. Human papillomavirus (HPV) vaccination in the transition between adolescence and adulthood. Vaccine 2021; 39:3435-3444. [PMID: 33992435 DOI: 10.1016/j.vaccine.2021.04.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 01/27/2021] [Accepted: 04/09/2021] [Indexed: 12/19/2022]
Abstract
PURPOSE Young adulthood is characterized by changes in health care decision-making, insurance coverage, and sexual risk. Although the human papillomavirus (HPV) vaccine is now approved for adults up to age 45, and catch-up vaccination is currently recommended up through age 26, vaccination rates remain low in young adults. This study explored perspectives on HPV vaccination among young adults receiving care at the student health center of a large public university. METHODS We conducted semi-structured interviews (n = 27) and four focus groups with female and male undergraduate and graduate students (n = 18) and semi-structured interviews with health care providers (n = 6). Interviews and focus groups explored perceived risk of HPV infection, benefits of the HPV vaccine, and motivations for and barriers to HPV vaccination. RESULTS Many young adults cited their parents' views and recommendations from medical providers as influential on their decision-making process. Students perceived that cervical cancer prevention was a main benefit of the HPV vaccine and sexual activity was a risk factor for HPV infection. Students often lacked knowledge about the vaccine's benefits for males and expressed some concerns about the safety and side effects of a vaccine perceived as new. Logistical barriers to vaccination included uncertainty over vaccination status and insurance coverage for the vaccine, and concerns about balancing the vaccine schedule with school obligations. Providers' vaccine recommendations were impacted by health system factors, including clinical infrastructure, processes for recommending and documenting vaccination, and office visit priorities. Suggested vaccination promotion strategies included improving the timing and messaging of outreach efforts on campus and bolstering clinical infrastructure. CONCLUSIONS Although college may be an opportune time to reach young adults for HPV vaccination, obstacles including navigating parental influence and independent decision-making, lack of awareness of vaccination status, and numerous logistical and system-level barriers may impede vaccination during this time.
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Affiliation(s)
- Beth A Glenn
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, 650 Charles Young Drive South, A2-125 CHS, Los Angeles, CA 90095-6900, USA; UCLA Center for Cancer Prevention and Control Research, UCLA Kaiser Permanente Center for Health Equity, Fielding School of Public Health and Jonsson Comprehensive Cancer Center, University of California, 650 Charles Young Drive South Drive, A2-125 CHS, Los Angeles, CA 90095-6900, USA.
| | - Narissa J Nonzee
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, 650 Charles Young Drive South, A2-125 CHS, Los Angeles, CA 90095-6900, USA; UCLA Center for Cancer Prevention and Control Research, UCLA Kaiser Permanente Center for Health Equity, Fielding School of Public Health and Jonsson Comprehensive Cancer Center, University of California, 650 Charles Young Drive South Drive, A2-125 CHS, Los Angeles, CA 90095-6900, USA.
| | - Lina Tieu
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, 650 Charles Young Drive South, A2-125 CHS, Los Angeles, CA 90095-6900, USA; UCLA Center for Cancer Prevention and Control Research, UCLA Kaiser Permanente Center for Health Equity, Fielding School of Public Health and Jonsson Comprehensive Cancer Center, University of California, 650 Charles Young Drive South Drive, A2-125 CHS, Los Angeles, CA 90095-6900, USA.
| | - Bettina Pedone
- UCLA Arthur Ashe Student Health & Wellness Center, University of California, Los Angeles, 221 Westwood Plaza, Los Angeles, CA 90095, USA.
| | - Burt O Cowgill
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, 650 Charles Young Drive South, A2-125 CHS, Los Angeles, CA 90095-6900, USA; UCLA Center for Cancer Prevention and Control Research, UCLA Kaiser Permanente Center for Health Equity, Fielding School of Public Health and Jonsson Comprehensive Cancer Center, University of California, 650 Charles Young Drive South Drive, A2-125 CHS, Los Angeles, CA 90095-6900, USA.
| | - Roshan Bastani
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, 650 Charles Young Drive South, A2-125 CHS, Los Angeles, CA 90095-6900, USA; UCLA Center for Cancer Prevention and Control Research, UCLA Kaiser Permanente Center for Health Equity, Fielding School of Public Health and Jonsson Comprehensive Cancer Center, University of California, 650 Charles Young Drive South Drive, A2-125 CHS, Los Angeles, CA 90095-6900, USA.
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Kaplan LM, Vella L, Cabral E, Tieu L, Ponath C, Guzman D, Kushel MB. Unmet mental health and substance use treatment needs among older homeless adults: Results from the HOPE HOME Study. J Community Psychol 2019; 47:1893-1908. [PMID: 31424102 PMCID: PMC7046319 DOI: 10.1002/jcop.22233] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 06/19/2019] [Accepted: 07/25/2019] [Indexed: 05/04/2023]
Abstract
AIMS To examine the prevalence of and factors associated with unmet need for mental health and substance use treatment in older homeless adults. METHODS Among 350 homeless adults aged ≥50, we examined prevalence of mental health and substance use problems and treatment. Using logistic regression, we examined factors associated with unmet treatment need. RESULTS Among those with a mental health problem, being aged ≥65 was associated with an increased odds, while having a regular healthcare provider and case manager were associated with a decreased odds of having unmet need for mental health treatment. A first homelessness episode at age ≥50 was associated with increased, while spending time in jail/prison or having a case manager was associated with decreased odds of unmet needs for substance use treatment. CONCLUSION Older homeless adults have a high prevalence of unmet behavioral health treatment need. There is a need for targeted services for this population.
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Affiliation(s)
- Lauren M Kaplan
- Division of General Internal Medicine, University of California, San Francisco, CA Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California
| | - Lea Vella
- San Francisco Veteran Affairs Medical Center, San Francisco, California and Division of Geriatrics, University of California, San Francisco, California
- Department of Quality, University of California San Francisco Medical Center, San Francisco, California
| | - Elise Cabral
- Department of Medicine, School of Medicine, University of California, San Francisco, California
| | - Lina Tieu
- Division of General Internal Medicine, University of California, San Francisco, CA Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California
| | - Claudia Ponath
- Division of General Internal Medicine, University of California, San Francisco, CA Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California
| | - David Guzman
- Division of General Internal Medicine, University of California, San Francisco, CA Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California
| | - Margot B Kushel
- Division of General Internal Medicine, University of California, San Francisco, CA Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California
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Tieu L, Hobbs A, Sarkar U, Nacev EC, Lyles CR. Adapting Patient Experience Data Collection Processes for Lower Literacy Patient Populations Using Tablets at the Point of Care. Med Care 2019; 57 Suppl 6 Suppl 2:S140-S148. [PMID: 31095053 PMCID: PMC6527129 DOI: 10.1097/mlr.0000000000001030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patient experience surveys are widely used to capture the patient-reported quality of care and are increasingly being used for formal reporting purposes. There is evidence that certain patient subgroups are less likely to respond to traditional CAHPS surveys. As patient-facing technologies become more common, it is important to examine whether tablet-based patient experience surveys have the potential to promote responses from more diverse populations. OBJECTIVES To develop, gain perspectives about, and pilot an English and Spanish low-literacy adaptation of the Consumer Assessment of Healthcare Providers & Systems Clinician & Group Survey (CG-CAHPS) administered on a tablet device at the point of care. RESEARCH DESIGN Cognitive testing and evaluation of a quality improvement pilot comparing a tablet-based adaptation and traditional paper-based versions of the CG-CAHPS survey. SUBJECTS English-speaking and Spanish-speaking patients receiving primary care in an urban community clinic. MEASURES To compare the acceptability of low-literacy tablet-based and traditional paper-based patient experience surveys, we examined the concordance of responses between survey modes and preferences for modality, as well as perspectives on usability and reporting care experiences. We examined demographic differences in responses to tablet-based versus mailed surveys from a quality improvement pilot. RESULTS The majority of cognitive interview participants preferred a low-literacy, tablet-based survey over a paper-based survey with traditional wording. In a quality improvement pilot comparing tablet-based administration at the point of care versus mailed surveys, respondents to the tablet-based survey were more likely to be younger and Latino. CONCLUSIONS If designed with patient input, tablet-based surveys have the potential to improve the collection of patient experience data among diverse populations.
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Affiliation(s)
- Lina Tieu
- Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, United States
- Center for Vulnerable Populations, University of California, San Francisco, San Francisco, CA, United States
- Division of General Internal Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Alicia Hobbs
- Center for Vulnerable Populations, University of California, San Francisco, San Francisco, CA, United States
- Silver Avenue Family Health Center, San Francisco Health Network, San Francisco, San Francisco, CA, United States
- UC Davis School of Medicine, Sacramento, CA, United States
| | - Urmimala Sarkar
- Center for Vulnerable Populations, University of California, San Francisco, San Francisco, CA, United States
- Division of General Internal Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Erin C. Nacev
- Silver Avenue Family Health Center, San Francisco Health Network, San Francisco, San Francisco, CA, United States
- School of Medicine and Public Health, University of Wisconsin, Madison, WI, United States
| | - Courtney R. Lyles
- Center for Vulnerable Populations, University of California, San Francisco, San Francisco, CA, United States
- Division of General Internal Medicine, University of California, San Francisco, San Francisco, CA, United States
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Tong M, Tieu L, Lee CT, Ponath C, Guzman D, Kushel M. Factors associated with food insecurity among older homeless adults: results from the HOPE HOME study. J Public Health (Oxf) 2019; 41:240-249. [PMID: 29617886 PMCID: PMC6636692 DOI: 10.1093/pubmed/fdy063] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 02/09/2018] [Accepted: 03/15/2018] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND The US homeless population is aging. Older adults and those living in poverty are at a high risk of food insecurity. METHODS We conducted a cross-sectional analysis of baseline data from a population-based study of 350 homeless adults aged ≥50. We assessed food security and receipt of food assistance. We used multivariable logistic regression to examine factors associated with very low food security. RESULTS The majority of the cohort was male and African American. Over half (55.4%) met criteria for food insecurity, 24.3% reported very low food security. Half (51.7%) reported receiving monetary food assistance. In the multivariable model, those who were primarily sheltered in the prior 6 months, (multi-institution users [AOR = 0.44, 95% CI: 0.22-0.86]) had less than half the odds of very low food security compared with those who were unsheltered. Depressive symptoms (AOR = 3.01, 1.69-5.38), oral pain (AOR = 2.15, 1.24-3.74) and cognitive impairment (AOR = 2.21, 1.12-4.35) were associated with increased odds of very low food security. CONCLUSIONS Older homeless adults experience a high prevalence of food insecurity. To alleviate food insecurity in this population, targeted interventions must address specific risk groups.
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Affiliation(s)
- M Tong
- School of Public Health, University of California, Berkeley, USA
| | - L Tieu
- Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, UCSF Box 1364, San Francisco, CA, USA
- Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, USA
| | - C T Lee
- Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, UCSF Box 1364, San Francisco, CA, USA
| | - C Ponath
- Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, UCSF Box 1364, San Francisco, CA, USA
- Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, USA
| | - D Guzman
- Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, UCSF Box 1364, San Francisco, CA, USA
- Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, USA
| | - M Kushel
- Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, UCSF Box 1364, San Francisco, CA, USA
- Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, USA
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Lyles CR, Gupta R, Tieu L, Fernandez A. After-visit summaries in primary care: mixed methods results from a literature review and stakeholder interviews. Fam Pract 2019; 36:206-213. [PMID: 29846584 DOI: 10.1093/fampra/cmy045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND After-visit summary (AVS) documents presenting key information from each medical encounter have become standard in the USA due to federal health care reform. Little is known about how they are used or whether they improve patient care. METHODS First, we completed a literature review and described the totality of the literature on AVS by article type and major outcome measures. Next, we used reputational sampling from large-scale US studies on primary care to identify and interview nine stakeholders on their perceptions of AVS across high-performing primary care practices. Interviews were transcribed and coded for AVS use in practice, perceptions of the best/worst features and recommendations for improving AVS utility in routine care. RESULTS The literature review resulted in 17 studies; patients reported higher perceived value of AVS compared with providers, despite poor recall of specific AVS content and varied post-visit use. In key informant interviews, key informants expressed enthusiasm for the potential of using AVS to reinforce key information with patients, especially if AVS were customizable. Despite this potential, key informants found that AVS included incorrect information and did not feel that patients or their practices were using AVS to enhance care. CONCLUSIONS There is a gap between the potential of AVS and how providers and patients are using it in routine care. Suggestions for improved use of AVS include increasing customization, establishing care team responsibilities and workflows and ensuring patients with communication barriers have dedicated support to review AVS during visits.
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Affiliation(s)
- Courtney R Lyles
- Division of General Internal Medicine, University of California, San Francisco, CA, USA.,Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, University of California, San Francisco, CA, USA
| | - Reena Gupta
- Division of General Internal Medicine, University of California, San Francisco, CA, USA
| | - Lina Tieu
- Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Alicia Fernandez
- Division of General Internal Medicine, University of California, San Francisco, CA, USA.,Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, University of California, San Francisco, CA, USA
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Raven MC, Kaplan LM, Rosenberg M, Tieu L, Guzman D, Kushel M. Mobile Phone, Computer, and Internet Use Among Older Homeless Adults: Results from the HOPE HOME Cohort Study. JMIR Mhealth Uhealth 2018; 6:e10049. [PMID: 30530464 PMCID: PMC6305882 DOI: 10.2196/10049] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 09/20/2018] [Accepted: 09/25/2018] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The median age of single homeless adults is approximately 50 years. Older homeless adults have poor social support and experience a high prevalence of chronic disease, depression, and substance use disorders. Access to mobile phones and the internet could help lower the barriers to social support, social services, and medical care; however, little is known about access to and use of these by older homeless adults. OBJECTIVE This study aimed to describe the access to and use of mobile phones, computers, and internet among a cohort of 350 homeless adults over the age of 50 years. METHODS We recruited 350 participants who were homeless and older than 50 years in Oakland, California. We interviewed participants at 6-month intervals about their health status, residential history, social support, substance use, depressive symptomology, and activities of daily living (ADLs) using validated tools. We performed clinical assessments of cognitive function. During the 6-month follow-up interview, study staff administered questions about internet and mobile technology use. We assessed participants' comfort with and use of multiple functions associated with these technologies. RESULTS Of the 343 participants alive at the 6-month follow-up, 87.5% (300/343) completed the mobile phone and internet questionnaire. The median age of participants was 57.5 years (interquartile range 54-61). Of these, 74.7% (224/300) were male, and 81.0% (243/300) were black. Approximately one-fourth (24.3%, 73/300) of the participants had cognitive impairment and slightly over one-third (33.6%, 100/300) had impairments in executive function. Most (72.3%, 217/300) participants currently owned or had access to a mobile phone. Of those, most had feature phones, rather than smartphones (89, 32.1%), and did not hold annual contracts (261, 94.2%). Just over half (164, 55%) had ever accessed the internet. Participants used phones and internet to communicate with medical personnel (179, 64.6%), search for housing and employment (85, 30.7%), and to contact their families (228, 82.3%). Those who regained housing were significantly more likely to have mobile phone access (adjusted odds ratio [AOR] 3.81, 95% CI 1.77-8.21). Those with ADL (AOR 0.53, 95% CI 0.31-0.92) and executive function impairment (AOR 0.49; 95% CI 0.28-0.86) were significantly less likely to have mobile phones. Moderate to high risk amphetamine use was associated with reduced access to mobile phones (AOR 0.27, 95% CI 0.10-0.72). CONCLUSIONS Older homeless adults could benefit from portable internet and phone access. However, participants had a lower prevalence of smartphone and internet access than adults aged over 65 years in the general public or low-income adults. Participants faced barriers to mobile phone and internet use, including financial barriers and functional and cognitive impairments. Expanding access to these basic technologies could result in improved outcomes.
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Affiliation(s)
- Maria C Raven
- Department of Emergency Medicine, School of Medicine, University of California, San Francisco, San Francisco, CA, United States.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, United States
| | - Lauren M Kaplan
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, United States.,Division of General Internal Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, United States
| | - Marina Rosenberg
- School of Public Health, University of California, Berkeley, Berkeley, CA, United States
| | - Lina Tieu
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, United States.,Division of General Internal Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, United States
| | - David Guzman
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, United States.,Division of General Internal Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, United States
| | - Margot Kushel
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, United States.,Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, United States.,Division of General Internal Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, United States
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Freitas DJ, Kaplan LM, Tieu L, Ponath C, Guzman D, Kushel M. Oral health and access to dental care among older homeless adults: results from the HOPE HOME study. J Public Health Dent 2018; 79:3-9. [PMID: 30295922 DOI: 10.1111/jphd.12288] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 06/01/2018] [Accepted: 08/10/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To describe the prevalence of and factors associated with oral health measures in a sample of older homeless adults in Oakland, CA. METHODS We conducted a cross-sectional analysis of data from a population-based study of 350 homeless adults aged ≥50 in which trained researchers conducted structured interviews using validated questions regarding sociodemographics, health-related behaviors, healthcare utilization, and health status. We assessed self-reported tooth loss, oral pain, and unmet need for dental care. We used multivariable logistic regression to examine factors associated with missing half or more teeth. RESULTS Over half 201/350 (57.4 percent) of participants were missing at least half of their teeth. Half 191/350 (54.6 percent) reported oral pain in the past 6 months; 101/350 (28.9 percent) reported that oral pain prevented them from eating and 73/350 (20.9 percent) reported that pain prevented sleeping. Almost half, 141/350 (40.3 percent), had not seen a dentist in over 5 years, and over half 190/350 (54.3 percent) reported being unable to obtain needed dental care. In multivariate models, increased age (AOR = 1.09, 95 percent CI 1.04-1.14), moderate-to-high risk alcohol use (AOR = 2.17, CI = 1.23-3.84), moderate-to-high risk cocaine use (AOR = 1.72, CI = 1.03-2.88), and ever smoking (AOR = 2.87, CI = 1.59-5.18) were associated with an increased odds of having lost half or more teeth. CONCLUSIONS Tooth loss and oral pain are highly prevalent in older homeless adults. Increasing age, alcohol, drug, and tobacco use are associated with tooth loss.
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Affiliation(s)
- Daniel J Freitas
- Department of Family and Community Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Lauren M Kaplan
- Division of General Internal Medicine, Center for Vulnerable Populations, University of California, San Francisco, San Francisco, CA, USA.,Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, USA
| | - Lina Tieu
- Division of General Internal Medicine, Center for Vulnerable Populations, University of California, San Francisco, San Francisco, CA, USA.,Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, USA
| | - Claudia Ponath
- Division of General Internal Medicine, Center for Vulnerable Populations, University of California, San Francisco, San Francisco, CA, USA.,Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, USA
| | - David Guzman
- Division of General Internal Medicine, Center for Vulnerable Populations, University of California, San Francisco, San Francisco, CA, USA.,Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, USA
| | - Margot Kushel
- Division of General Internal Medicine, Center for Vulnerable Populations, University of California, San Francisco, San Francisco, CA, USA.,Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, USA
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Brown RT, Hemati K, Riley ED, Lee CT, Ponath C, Tieu L, Guzman D, Kushel MB. Geriatric Conditions in a Population-Based Sample of Older Homeless Adults. Gerontologist 2018; 57:757-766. [PMID: 26920935 DOI: 10.1093/geront/gnw011] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 11/17/2015] [Indexed: 01/23/2023] Open
Abstract
Purpose of the Study Older homeless adults living in shelters have high rates of geriatric conditions, which may increase their risk for acute care use and nursing home placement. However, a minority of homeless adults stay in shelters and the prevalence of geriatric conditions among homeless adults living in other environments is unknown. We determined the prevalence of common geriatric conditions in a cohort of older homeless adults, and whether the prevalence of these conditions differs across living environments. Design and Methods We interviewed 350 homeless adults, aged 50 and older, recruited via population-based sampling in Oakland, CA. We evaluated participants for common geriatric conditions. We assessed living environment using a 6-month follow-back residential calendar, and used cluster analysis to identify participants' primary living environment over the prior 6 months. Results Participants stayed in 4 primary environments: unsheltered locations (n = 162), multiple locations including shelters and hotels (n = 88), intermittently with family/friends (n = 57), and, in a recently homeless group, rental housing (n = 43). Overall, 38.9% of participants reported difficulty performing 1 or more activities of daily living, 33.7% reported any falls in the past 6 months, 25.8% had cognitive impairment, 45.1% had vision impairment, and 48.0% screened positive for urinary incontinence. The prevalence of geriatric conditions did not differ significantly across living environments. Implications Geriatric conditions were common among older homeless adults living in diverse environments, and the prevalence of these conditions was higher than that seen in housed adults 20 years older. Services that address geriatric conditions are needed for older homeless adults living across varied environments.
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Affiliation(s)
- Rebecca T Brown
- Division of Geriatrics, University of California, San Francisco.,San Francisco VA Medical Center, California
| | - Kaveh Hemati
- School of Medicine, Stony Brook University, New York
| | - Elise D Riley
- Division of HIV/AIDS, San Francisco General Hospital, University of California
| | - Christopher T Lee
- Division of General Internal Medicine, San Francisco General Hospital, University of California
| | - Claudia Ponath
- Division of General Internal Medicine, San Francisco General Hospital, University of California
| | - Lina Tieu
- Division of General Internal Medicine, San Francisco General Hospital, University of California
| | - David Guzman
- Division of General Internal Medicine, San Francisco General Hospital, University of California
| | - Margot B Kushel
- Division of General Internal Medicine, San Francisco General Hospital, University of California
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11
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Sudore RL, Cuervo IA, Tieu L, Guzman D, Kaplan LM, Kushel M. Advance Care Planning for Older Homeless-Experienced Adults: Results from the Health Outcomes of People Experiencing Homelessness in Older Middle Age Study. J Am Geriatr Soc 2018; 66:1068-1074. [PMID: 29741765 DOI: 10.1111/jgs.15417] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Older homeless-experienced adults have low engagement in advance care planning (ACP) despite high morbidity and mortality. We conducted a cross-sectional analysis of a cohort of 350 homeless-experienced adults aged 50 and older in Oakland, California. We assessed the prevalence of potential surrogate decision-makers, ACP contemplation, discussions, and ACP documentation (surrogate designation, advance directives). We used multivariable logistic regression to examine factors associated with ACP discussions and documentation. The median age of the cohort was 59 (range 52-82), 75.2% were male, and 82.1% were black. Sixty-one percent reported a potential surrogate, 21.5% had discussed ACP, and 19.0% reported ACP documentation. In multivariable models, having 1 to 5 confidants versus none (adjusted odds ratio (aOR)=5.8, 95% confidence interval (CI)=1.7-20.0), 3 or more chronic conditions versus none (aOR=2.3, 95% CI=0.9-5.6), and a recent primary care visit (aOR=2.1, 95% CI=1.0-4.4) were associated with higher odds of ACP discussions and each additional 5 years of homelessness (aOR=0.7, 95% CI=0.5-0.9) with lower odds. Having 1 to 5 confidants (aOR=5.0, 95% CI=1.4-17.5), being black (aOR=5.5, 95% CI=1.5-19.5), and having adequate versus limited literacy (aOR=7.0, 95% CI=1.5-32.4) were associated with higher odds of ACP documentation and illicit drug use (aOR=0.3, 95% CI=0.1-0.9) with lower odds. Although the majority of older homeless-experienced adults have a potential surrogate, few have discussed or documented their ACP wishes; the odds of both were greater with larger social networks. Future interventions must be customized for individuals with limited social networks and address the instability of homelessness, health literacy, and the constraints of safety-net healthcare settings.
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Affiliation(s)
- Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.,Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California Center; University of California, San Francisco, California.,San Francisco Veterans Affairs Medical Center, San Francisco, California
| | | | - Lina Tieu
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California Center; University of California, San Francisco, California.,Department of Medicine, Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General, San Francisco, California
| | - David Guzman
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California Center; University of California, San Francisco, California.,Department of Medicine, Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General, San Francisco, California
| | - Lauren M Kaplan
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California Center; University of California, San Francisco, California.,Department of Medicine, Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General, San Francisco, California
| | - Margot Kushel
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California Center; University of California, San Francisco, California.,Department of Medicine, Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General, San Francisco, California
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12
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Patanwala M, Tieu L, Ponath C, Guzman D, Ritchie CS, Kushel M. Physical, Psychological, Social, and Existential Symptoms in Older Homeless-Experienced Adults: An Observational Study of the Hope Home Cohort. J Gen Intern Med 2018; 33:635-643. [PMID: 29185174 PMCID: PMC5910332 DOI: 10.1007/s11606-017-4229-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 09/14/2017] [Accepted: 11/03/2017] [Indexed: 01/23/2023]
Abstract
BACKGROUND The homeless population in the United States is aging. Aging-associated comorbidities are associated with increased symptoms. OBJECTIVE To describe the prevalence of symptoms among older homeless-experienced adults, analyze factors associated with moderate-high physical symptom burden, and identify symptom clusters. DESIGN Cross-sectional analysis within longitudinal cohort study. PARTICIPANTS Using population-based sampling from shelters, meal programs, encampments, and a recycling center in Oakland, CA, we recruited homeless adults aged ≥ 50 for a longitudinal cohort. This study includes participants who participated in the 18-month follow-up visit. MAIN MEASURES We assessed physical symptoms using the Patient Health Questionnaire-15 (PHQ-15); psychological symptoms using the Center for Epidemiologic Studies Depression Scale (CES-D), Primary Care PTSD Screen (PC-PTSD), and psychiatric section of the Addiction Severity Index (ASI); loneliness using the Three-Item Loneliness Scale; and regret using a six-item regret scale. KEY RESULTS Two hundred eighty-three participants (75.6% men and 82.3% African-Americans) completed symptoms interviews. Over a third (34.0%) had moderate-high physical symptom burden. The most prevalent physical symptoms were joint pain, fatigue, back pain, and sleep trouble. Over half (57.6%) had psychological symptoms; 39.6% exhibited loneliness and 26.5% had high regret. In a multivariate model, being a woman (AOR 2.54, 95% CI 1.28-5.03), childhood abuse (AOR 1.88, 95% CI 1.00-3.50), cannabis use (AOR 2.59, 95% CI 1.38-4.89), multimorbidity (AOR 2.50, 95% CI 1.36-4.58), anxiety (AOR 4.30, 95% CI 2.24-8.26), hallucinations (AOR 3.77, 95% CI 1.36-10.43), and loneliness (AOR 2.32, 95% CI 1.26-4.28) were associated with moderate-high physical symptom burden. We identified four symptom clusters: minimal overall (n = 129), moderate overall (n = 68), high physical and high psychological (n = 67), and high physical and low psychological (n = 17). CONCLUSIONS Older homeless-experienced adults exhibit a high prevalence of symptoms across multiple dimensions. To reduce suffering, clinicians should recognize the interaction between symptoms and address multiple symptom dimensions.
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Affiliation(s)
- M Patanwala
- UCSF School of Medicine, San Francisco, CA, USA
| | - L Tieu
- UCSF Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
- UCSF Center for Vulnerable Populations, San Francisco, CA, USA
| | - C Ponath
- UCSF Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - D Guzman
- UCSF Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
- UCSF Center for Vulnerable Populations, San Francisco, CA, USA
| | - C S Ritchie
- UCSF Division of Geriatrics, Department of Medicine, San Francisco, CA, USA
| | - Margot Kushel
- UCSF Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, San Francisco, CA, USA.
- UCSF Center for Vulnerable Populations, San Francisco, CA, USA.
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13
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Ackerman SL, Sarkar U, Tieu L, Handley MA, Schillinger D, Hahn K, Hoskote M, Gourley G, Lyles C. Meaningful use in the safety net: a rapid ethnography of patient portal implementation at five community health centers in California. J Am Med Inform Assoc 2018; 24:903-912. [PMID: 28340229 DOI: 10.1093/jamia/ocx015] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 02/13/2017] [Indexed: 11/13/2022] Open
Abstract
Objective US health care institutions are implementing secure websites (patient portals) to achieve federal Meaningful Use (MU) certification. We sought to understand efforts to implement portals in "safety net" health care systems that provide services for low-income populations. Materials and Methods Our rapid ethnography involved visits at 4 California safety net health systems and in-depth interviews at a fifth. Visits included interviews with clinicians and executives ( n = 12), informal focus groups with front-line staff ( n = 35), observations of patient portal sign-up procedures and clinic work, review of marketing materials and portal use data, and a brief survey ( n = 45). Results Our findings demonstrate that the health systems devoted considerable effort to enlisting staff support for portal adoption and integrating portal-related work into clinic routines. Although all health systems had achieved, or were close to achieving, MU benchmarks, patients faced numerous barriers to portal use and our participants were uncertain how to achieve and sustain "meaningful use" as defined by and for their patients. Discussion Health systems' efforts to achieve MU certification united clinic staff under a shared ethos of improved quality of care. However, MU's assumptions about patients' demand for electronic access to health information and ability to make use of it directed clinics' attention to enrollment and message routing rather than to the relevance and usability of a tool that is minimally adaptable to the safety net context. Conclusion We found a mismatch between MU-based metrics of patient engagement and the priorities and needs of safety net patient populations.
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Affiliation(s)
- Sara L Ackerman
- Department of Social and Behavioral Sciences, University of California, San Francisco, CA, USA
| | - Urmimala Sarkar
- Department of Medicine, Zuckerberg San Francisco General Hospital and University of California, San Francisco, CA, USA
| | - Lina Tieu
- Department of Medicine, Zuckerberg San Francisco General Hospital and University of California, San Francisco, CA, USA
| | - Margaret A Handley
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Dean Schillinger
- Department of Medicine, Zuckerberg San Francisco General Hospital and University of California, San Francisco, CA, USA
| | - Kenneth Hahn
- Department of Medicine, Zuckerberg San Francisco General Hospital and University of California, San Francisco, CA, USA
| | - Mekhala Hoskote
- Department of Medicine, Zuckerberg San Francisco General Hospital and University of California, San Francisco, CA, USA
| | - Gato Gourley
- Department of Medicine, Zuckerberg San Francisco General Hospital and University of California, San Francisco, CA, USA
| | - Courtney Lyles
- Department of Medicine, Zuckerberg San Francisco General Hospital and University of California, San Francisco, CA, USA
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14
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Tieu L, Schillinger D, Sarkar U, Hoskote M, Hahn KJ, Ratanawongsa N, Ralston JD, Lyles CR. Online patient websites for electronic health record access among vulnerable populations: portals to nowhere? J Am Med Inform Assoc 2018; 24:e47-e54. [PMID: 27402138 DOI: 10.1093/jamia/ocw098] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 05/23/2016] [Indexed: 11/13/2022] Open
Abstract
Objective With the rapid rise in the adoption of patient portals, many patients are gaining access to their personal health information online for the first time. The objective of this study was to examine specific usability barriers to patient portal engagement among a diverse group of patients and caregivers. Materials and Methods We conducted interviews using performance testing and think-aloud methods with 23 patients and 2 caregivers as they first attempted to use features of a newly launched patient portal. Results In navigating the portal, participants experienced basic computer barriers (eg, difficulty using a mouse), routine computer barriers (eg, mistyping, navigation issues), reading/writing barriers, and medical content barriers. Compared to participants with adequate health literacy, participants with limited health literacy required 2 additional minutes to complete each task and were more likely to experience each type of navigational barrier. They also experienced more inaccuracies in interpreting a test result and finding a treatment plan within an after-visit summary. Discussion When using a patient portal for the first time, participants with limited health literacy completed fewer tasks unassisted, had a higher prevalence of encountering barriers, took longer to complete tasks, and had more problems accurately interpreting medical information. Conclusion Our findings suggest a strong need for tailored and accessible training and support to assist all vulnerable patients and/or caregivers with portal registration and use. Measuring the health literacy of a patient population might serve as a strong proxy for identifying patients who need the most support in using health technologies.
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Affiliation(s)
- Lina Tieu
- University of California, San Francisco, Center for Vulnerable Populations
| | - Dean Schillinger
- University of California, San Francisco, Center for Vulnerable Populations
| | - Urmimala Sarkar
- University of California, San Francisco, Center for Vulnerable Populations
| | - Mekhala Hoskote
- College of Letters and Science, University of California, Berkeley
| | - Kenneth J Hahn
- College of Letters and Science, University of California, Berkeley
| | - Neda Ratanawongsa
- University of California, San Francisco, Center for Vulnerable Populations
| | | | - Courtney R Lyles
- University of California, San Francisco, Center for Vulnerable Populations
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15
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Landefeld JC, Miaskowski C, Tieu L, Ponath C, Lee CT, Guzman D, Kushel M. Characteristics and Factors Associated With Pain in Older Homeless Individuals: Results From the Health Outcomes in People Experiencing Homelessness in Older Middle Age (HOPE HOME) Study. J Pain 2017; 18:1036-1045. [PMID: 28412229 PMCID: PMC5581208 DOI: 10.1016/j.jpain.2017.03.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 03/16/2017] [Accepted: 03/28/2017] [Indexed: 12/22/2022]
Abstract
Individuals experiencing homelessness in the United States are aging; little is known about chronic pain in this population. In a cross-sectional, population-based study, we interviewed 350 homeless individuals aged 50 years and older to describe pain experienced by older persons experiencing homelessness and to assess factors associated with chronic moderate to severe pain, defined as pain lasting ≥3 months, with a past week average severity score of 5 to 10 (scale 0-10). The median age of participants was 58 years. Participants were predominantly African American (79.6%) and male (77.3%). Overall, 46.8% reported chronic moderate to severe pain. Almost half of participants reported a diagnosis of arthritis (44.3%) and one-third reported symptoms consistent with post-traumatic stress disorder (PTSD; 32.8%). Three-quarters (75.3%) endorsed a personal history of abuse. In multivariate analyses, PTSD (adjusted odds ratio [AOR]: 2.2, 95% confidence interval [CI], 1.4-3.7), arthritis (AOR: 4.8, 95% CI, 3.0-7.8), and history of experiencing abuse (AOR: 2.4, 95% CI, 1.3-4.3) were associated with chronic moderate to severe pain. HIV status, diabetes, depressive symptoms, and substance use were not associated with pain. Clinicians should consider the management of associated mental health conditions and the sequelae of experiencing abuse in the treatment of chronic pain in older adults experiencing homelessness. PERSPECTIVE This article describes the prevalence and factors associated with chronic pain in older homeless adults. Almost half report chronic pain, which was associated with PTSD, arthritis, and personal history of abuse. Clinicians should address chronic pain, trauma, and the associated mental health conditions in this high-risk population.
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Affiliation(s)
- John C Landefeld
- Division of General Internal Medicine, University of California, San Francisco, California; Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Christine Miaskowski
- Department of Physiological Nursing, University of California, San Francisco, California
| | - Lina Tieu
- Division of General Internal Medicine, University of California, San Francisco, California; Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Claudia Ponath
- Division of General Internal Medicine, University of California, San Francisco, California; Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Christopher T Lee
- Division of General Internal Medicine, University of California, San Francisco, California; Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - David Guzman
- Division of General Internal Medicine, University of California, San Francisco, California; Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Margot Kushel
- Division of General Internal Medicine, University of California, San Francisco, California; Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California.
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16
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Raven MC, Tieu L, Lee CT, Ponath C, Guzman D, Kushel M. Emergency Department Use in a Cohort of Older Homeless Adults: Results From the HOPE HOME Study. Acad Emerg Med 2017; 24:63-74. [PMID: 27520382 DOI: 10.1111/acem.13070] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 07/27/2016] [Accepted: 07/29/2016] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The median age of single homeless adults is over 50, yet little is known about their emergency department (ED) use. We describe use of and factors associated with ED use in a sample of homeless adults 50 and older. METHODS We recruited 350 participants who were homeless and 50 or older in Oakland, California. We interviewed participants about residential history in the prior 6 months, health status, health-related behaviors, and health services use and assessed cognition and mobility. Our primary outcome was the number of ED visits in the prior 6 months based on medical record review. We used negative binomial regression to examine factors associated with ED use. RESULTS In the 6 months prior to enrollment, 46.3% of participants spent the majority of their time unsheltered; 25.1% cycled through multiple institutions including shelters, hospitals, and jails; 16.3% primarily stayed with family or friends; and 12.3% had become homeless recently after spending much of the prior 6 months housed. Half (49.7%) of participants made at least one ED visit in the past 6 months; 6.6% of participants accounted for 49.9% of all visits. Most (71.8%) identified a regular non-ED source of healthcare; 7.3% of visits resulted in hospitalization. In multivariate models, study participants who used multiple institutions (incidence rate ratio [IRR] = 2.27; 95% confidence interval [CI] = 1.08 to 4.77) and who were unsheltered (IRR = 2.29; 95% CI = 1.17 to 4.48) had higher ED use rates than participants who had been housed for most of the prior 6 months. In addition, having health insurance/coverage (IRR = 2.6; CI = 1.5 to 4.4), a history of psychiatric hospitalization (IRR = 1.80; 95% CI = 1.09 to 2.99), and severe pain (IRR = 1.72; 95% CI = 1.07 to 2.76) were associated with higher ED visit rates. CONCLUSIONS A sample of adults aged 50 and older who were homeless at study entry had higher rates of ED use in the prior 6 months than the general U.S. age-matched population. Within the sample, ED use rates varied based on individuals' residential histories, suggesting that individuals' ED use is related to exposure to homelessness.
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Affiliation(s)
- Maria C. Raven
- Department of Emergency Medicine University of California at San Francisco San Francisco CA
- Philip R. Lee Institute for Health Policy Studies University of California at San Francisco San Francisco CA
| | - Lina Tieu
- Division of General Internal Medicine University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
- Center for Vulnerable Populations University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
| | - Christopher T. Lee
- Division of General Internal Medicine University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
| | - Claudia Ponath
- Division of General Internal Medicine University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
| | - David Guzman
- Division of General Internal Medicine University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
- Center for Vulnerable Populations University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
| | - Margot Kushel
- Division of General Internal Medicine University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
- Center for Vulnerable Populations University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
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17
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Sarkar U, Gourley GI, Lyles CR, Tieu L, Clarity C, Newmark L, Singh K, Bates DW. Usability of Commercially Available Mobile Applications for Diverse Patients. J Gen Intern Med 2016; 31:1417-1426. [PMID: 27418347 PMCID: PMC5130945 DOI: 10.1007/s11606-016-3771-6] [Citation(s) in RCA: 148] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 05/26/2016] [Accepted: 06/06/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Mobile applications or 'apps' intended to help people manage their health and chronic conditions are widespread and gaining in popularity. However, little is known about their acceptability and usability for low-income, racially/ethnically diverse populations who experience a disproportionate burden of chronic disease and its complications. OBJECTIVE The objective of this study was to investigate the usability of existing mobile health applications ("apps") for diabetes, depression, and caregiving, in order to facilitate development and tailoring of patient-facing apps for diverse populations. DESIGN Usability testing, a mixed-methods approach that includes interviewing and direct observation of participant technology use, was conducted with participants (n = 9 caregivers; n = 10 patients with depression; and n = 10 patients with diabetes) on a total of 11 of the most popular health apps (four diabetes apps, four depression apps, and three caregiver apps) on both iPad and Android tablets. PARTICIPANTS The participants were diverse: 15 (58 %) African Americans, seven (27 %) Whites, two (8 %) Asians, two (8 %) Latinos with either diabetes, depression, or who were caregivers. MAIN MEASURES Participants were given condition-specific tasks, such as entering a blood glucose value into a diabetes app. Participant interviews were video recorded and were coded using standard methods to evaluate attempts and completions of tasks. We performed inductive coding of participant comments to identify emergent themes. KEY RESULTS Participants completed 79 of 185 (43 %) tasks across 11 apps without assistance. Three themes emerged from participant comments: lack of confidence with technology, frustration with design features and navigation, and interest in having technology to support their self-management. CONCLUSIONS App developers should employ participatory design strategies in order to have an impact on chronic conditions such as diabetes and depression that disproportionately affect vulnerable populations. While patients express interest in using technologies for self-management, current tools are not consistently usable for diverse patients.
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Affiliation(s)
- Urmimala Sarkar
- Center for Vulnerable Populations at San Francisco General Hospital, University of California, San Francisco, CA, USA.
- DGIM at SFGH, 1001 Potrero Ave, Bldg 10, Ward 13, Box 1364, San Francisco, CA, 94143, USA.
| | - Gato I Gourley
- Center for Vulnerable Populations at San Francisco General Hospital, University of California, San Francisco, CA, USA
- DGIM at SFGH, 1001 Potrero Ave, Bldg 10, Ward 13, Box 1364, San Francisco, CA, 94143, USA
| | - Courtney R Lyles
- Center for Vulnerable Populations at San Francisco General Hospital, University of California, San Francisco, CA, USA
- DGIM at SFGH, 1001 Potrero Ave, Bldg 10, Ward 13, Box 1364, San Francisco, CA, 94143, USA
| | - Lina Tieu
- Center for Vulnerable Populations at San Francisco General Hospital, University of California, San Francisco, CA, USA
- DGIM at SFGH, 1001 Potrero Ave, Bldg 10, Ward 13, Box 1364, San Francisco, CA, 94143, USA
| | - Cassidy Clarity
- Center for Vulnerable Populations at San Francisco General Hospital, University of California, San Francisco, CA, USA
- DGIM at SFGH, 1001 Potrero Ave, Bldg 10, Ward 13, Box 1364, San Francisco, CA, 94143, USA
| | - Lisa Newmark
- Information Systems, Partners HealthCare System, Wellesley, MA, USA
| | - Karandeep Singh
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | - David W Bates
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, MA, USA
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Spinelli MA, Ponath C, Tieu L, Hurstak EE, Guzman D, Kushel M. Factors associated with substance use in older homeless adults: Results from the HOPE HOME study. Subst Abus 2016; 38:88-94. [PMID: 27897965 DOI: 10.1080/08897077.2016.1264534] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The median age of the single adult homeless population is 50 and rising. Although the prevalence of substance use decreases as individuals age, older adults now have a higher prevalence of substance use than older adults did 10 years ago. Homeless individuals have a higher prevalence of substance use disorders than the general population. However, little is known about substance use in older homeless adults. METHODS The objective of the study was to examine prevalence of and factors associated with substance use in a population-based sample (N = 350) of homeless individuals aged 50 and older in Oakland, California. Dependent variables included moderate or greater severity illicit drug symptoms (Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) score >3) and moderate or greater alcohol symptoms (Alcohol Use Disorders Identification Test (AUDIT) score >7). Independent variables included demographics, mental health problems, and negative life course events such as physical and sexual abuse, school expulsion, and onset of homelessness. RESULTS Almost two thirds of participants, 64.6%, had moderate or greater severity symptoms for at least 1 illicit drug; 25.8% had moderate or greater severity alcohol symptoms. History of psychiatric hospitalization was associated with moderate or greater illicit drug symptoms (adjusted odds ratio [AOR] = 1.9, 1.0-3.6). The presence of major depressive symptoms was associated with moderate or greater severity alcohol symptoms (AOR = 1.8, 1.1-3.0). CONCLUSIONS In this sample of older homeless adults, substance use is common. There is a need for substance use treatment programs, integrated with mental health services, which are targeted towards the needs of older homeless adults.
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Affiliation(s)
- Matthew A Spinelli
- a Division of General Internal Medicine , University of California, San Francisco, San Francisco General Hospital , San Francisco , California , USA
| | - Claudia Ponath
- a Division of General Internal Medicine , University of California, San Francisco, San Francisco General Hospital , San Francisco , California , USA
| | - Lina Tieu
- a Division of General Internal Medicine , University of California, San Francisco, San Francisco General Hospital , San Francisco , California , USA
| | - Emily E Hurstak
- a Division of General Internal Medicine , University of California, San Francisco, San Francisco General Hospital , San Francisco , California , USA
| | - David Guzman
- a Division of General Internal Medicine , University of California, San Francisco, San Francisco General Hospital , San Francisco , California , USA
| | - Margot Kushel
- a Division of General Internal Medicine , University of California, San Francisco, San Francisco General Hospital , San Francisco , California , USA
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Lyles CR, Allen JY, Poole D, Tieu L, Kanter MH, Garrido T. "I Want to Keep the Personal Relationship With My Doctor": Understanding Barriers to Portal Use among African Americans and Latinos. J Med Internet Res 2016; 18:e263. [PMID: 27697748 PMCID: PMC5067358 DOI: 10.2196/jmir.5910] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 08/19/2016] [Accepted: 09/07/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Despite the widespread implementation of electronic health records (EHRs), there is growing evidence that racial/ethnic minority patients do not use portals as frequently as non-Hispanic whites to access their EHR information online. This differential portal use could be problematic for health care disparities since early evidence links portal use to better outcomes. OBJECTIVE We sought to understand specific barriers to portal use among African American and Latino patients at Kaiser Permanente, which has had a portal in place for over a decade, and broad uptake among the patient population at large. METHODS We conducted 10 focus groups with 87 participants in 2012 and 2013 among African American and Latino Kaiser Permanente members in the mid-Atlantic, Georgia, and Southern California regions. Members were eligible to participate if they were not registered for portal access. Focus groups were conducted within each racial/ethnic group, and each included individuals who were older, had a chronic disease, or were parents (as these are the three biggest users of the portal at Kaiser Permanente overall). We videotaped each focus group and transcribed the discussion for analysis. We used general inductive coding to develop themes for major barriers to portal use, overall and separately by racial/ethnic group. RESULTS We found that lack of support was a key barrier to initiating portal use in our sample-both in terms of technical assistance as well as the fear of the portal eroding existing personal relationships with health care providers. This held true across a range of focus groups representing a mix of age, income, health conditions, and geographic regions. CONCLUSIONS Our study was among the first qualitative explorations of barriers to portal use among racial/ethnic subgroups. Our findings suggest that uniform adoption of portal use across diverse patient groups requires more usable and personalized websites, which may be particularly important for reducing health care disparities. This work is particularly important as all health care systems continue to offer and promote more health care features online via portals.
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Vijayaraghavan M, Tieu L, Ponath C, Guzman D, Kushel M. Tobacco Cessation Behaviors Among Older Homeless Adults: Results From the HOPE HOME Study. Nicotine Tob Res 2016; 18:1733-9. [PMID: 26920648 PMCID: PMC4941600 DOI: 10.1093/ntr/ntw040] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 02/14/2016] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Tobacco-attributable deaths contribute significantly to the increased mortality observed among homeless adults aged 50 years or more. Little is known about the epidemiology of tobacco use among older homeless individuals. This longitudinal cohort study examines smoking behaviors and factors associated with smoking cessation among homeless individuals aged 50 years or more. METHODS We recruited a prospective cohort of 350 homeless individuals sampled from the community in Oakland, California. At 6 months follow-up, participants reported their cigarette quit attempts and 30-day abstinence. We used multivariable logistic regression to examine factors associated with making a quit attempt at follow-up, hypothesizing that heavier smokers would be less likely to make a quit attempt. RESULTS Of the 272 ever-smokers, 229 (84.2%) were current smokers (quit ratio 15.8). Among current smokers at enrollment who had a follow-up interview at 6 months, 43.6% (n = 71) reported making a quit attempt during the follow-up. Of those who reported making a quit attempt, 14.3% (n = 10) reported 30-day abstinence at follow-up. Among those who had reported making a quit attempt at follow-up, 22.5% had used nicotine replacement therapy (NRT). Staying in shelters (adjusted odds ratio [AOR] = 2.5, 95% confidence interval [CI] = 1.0-5.8) was associated with higher odds of making a quit attempt at follow-up. Higher cigarette consumption was associated with lower odds of making a quit attempt (AOR = 0.9, 95% CI = 0.8-0.9). CONCLUSIONS In this study of tobacco use in older homeless adults, rates of quit attempts were similar to that observed in the general population, but successful quitting was lower. IMPLICATIONS The current study is among the first studies to focus specifically on tobacco use and cessation behaviors among older homeless adults. The high prevalence of smoking and the low rates of successful quitting highlight numerous opportunities to intervene to increase quitting rates among this population. Among these, increasing access to smoke-free living environments and identifying effective cessation therapies will be critical to reducing tobacco-related disease burden among older homeless adults.
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Affiliation(s)
- Maya Vijayaraghavan
- Division of General Internal Medicine, University of California, San Francisco, San Francisco General Hospital, San Francisco, CA
| | - Lina Tieu
- Division of General Internal Medicine, University of California, San Francisco, San Francisco General Hospital, San Francisco, CA
| | - Claudia Ponath
- Division of General Internal Medicine, University of California, San Francisco, San Francisco General Hospital, San Francisco, CA
| | - David Guzman
- Division of General Internal Medicine, University of California, San Francisco, San Francisco General Hospital, San Francisco, CA
| | - Margot Kushel
- Division of General Internal Medicine, University of California, San Francisco, San Francisco General Hospital, San Francisco, CA
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Brown RT, Goodman L, Guzman D, Tieu L, Ponath C, Kushel MB. Pathways to Homelessness among Older Homeless Adults: Results from the HOPE HOME Study. PLoS One 2016; 11:e0155065. [PMID: 27163478 PMCID: PMC4862628 DOI: 10.1371/journal.pone.0155065] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 04/23/2016] [Indexed: 11/19/2022] Open
Abstract
Little is known about pathways to homelessness among older adults. We identified life course experiences associated with earlier versus later onset of homelessness in older homeless adults and examined current health and functional status by age at first homelessness. We interviewed 350 homeless adults, aged 50 and older, recruited via population-based sampling. Participants reported age at first episode of adult homelessness and their life experiences during 3 time periods: childhood (<18 years), young adulthood (ages 18–25), and middle adulthood (ages 26–49). We used a structured modeling approach to identify experiences associated with first adult homelessness before age 50 versus at age 50 or older. Participants reported current health and functional status, including recent mental health and substance use problems. Older homeless adults who first became homeless before 50 had more adverse life experiences (i.e., mental health and substance use problems, imprisonment) and lower attainment of adult milestones (i.e., marriage, full-time employment) compared to individuals with later onset. After multivariable adjustment, adverse experiences were independently associated with experiencing a first episode of homelessness before age 50. Individuals who first became homeless before age 50 had higher prevalence of recent mental health and substance use problems and more difficulty performing instrumental activities of daily living. Life course experiences and current vulnerabilities of older homeless adults with first homelessness before age 50 differed from those with later onset of homelessness. Prevention and service interventions should be adapted to meet different needs.
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Affiliation(s)
- Rebecca T. Brown
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, United States of America
- San Francisco Veterans Affairs Medical Center, San Francisco, California, United States of America
| | - Leah Goodman
- School of Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - David Guzman
- Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, United States of America
- Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California, United States of America
| | - Lina Tieu
- Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, United States of America
- Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California, United States of America
| | - Claudia Ponath
- Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, United States of America
- Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California, United States of America
| | - Margot B. Kushel
- Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, United States of America
- Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California, United States of America
- * E-mail:
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Lee CT, Guzman D, Ponath C, Tieu L, Riley E, Kushel M. Residential patterns in older homeless adults: Results of a cluster analysis. Soc Sci Med 2016; 153:131-40. [PMID: 26896877 DOI: 10.1016/j.socscimed.2016.02.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 11/19/2015] [Accepted: 02/02/2016] [Indexed: 11/19/2022]
Abstract
Adults aged 50 and older make up half of individuals experiencing homelessness and have high rates of morbidity and mortality. They may have different life trajectories and reside in different environments than do younger homeless adults. Although the environmental risks associated with homelessness are substantial, the environments in which older homeless individuals live have not been well characterized. We classified living environments and identified associated factors in a sample of older homeless adults. From July 2013 to June 2014, we recruited a community-based sample of 350 homeless men and women aged fifty and older in Oakland, California. We administered structured interviews including assessments of health, history of homelessness, social support, and life course. Participants used a recall procedure to describe where they stayed in the prior six months. We performed cluster analysis to classify residential venues and used multinomial logistic regression to identify individual factors prior to the onset of homelessness as well as the duration of unstable housing associated with living in them. We generated four residential groups describing those who were unsheltered (n = 162), cohabited unstably with friends and family (n = 57), resided in multiple institutional settings (shelters, jails, transitional housing) (n = 88), or lived primarily in rental housing (recently homeless) (n = 43). Compared to those who were unsheltered, having social support when last stably housed was significantly associated with cohabiting and institution use. Cohabiters and renters were significantly more likely to be women and have experienced a shorter duration of homelessness. Cohabiters were significantly more likely than unsheltered participants to have experienced abuse prior to losing stable housing. Pre-homeless social support appears to protect against street homelessness while low levels of social support may increase the risk for becoming homeless immediately after losing rental housing. Our findings may enable targeted interventions for those with different manifestations of homelessness.
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Affiliation(s)
- Christopher Thomas Lee
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA; Division of General Internal Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA.
| | - David Guzman
- Division of General Internal Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Claudia Ponath
- Division of General Internal Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Lina Tieu
- Division of General Internal Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Elise Riley
- Division of HIV/AIDS, University of California San Francisco, San Francisco General Hospital, San Francisco, CA, USA
| | - Margot Kushel
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA; Division of General Internal Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA
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Fontil V, McDermott K, Tieu L, Rios C, Gibson E, Sweet CC, Payne M, Lyles CR. Adaptation and Feasibility Study of a Digital Health Program to Prevent Diabetes among Low-Income Patients: Results from a Partnership between a Digital Health Company and an Academic Research Team. J Diabetes Res 2016; 2016:8472391. [PMID: 27868070 PMCID: PMC5102733 DOI: 10.1155/2016/8472391] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 08/03/2016] [Accepted: 09/19/2016] [Indexed: 11/18/2022] Open
Abstract
Background. The feasibility of digital health programs to prevent and manage diabetes in low-income patients has not been adequately explored. Methods. Researchers collaborated with a digital health company to adapt a diabetes prevention program for low-income prediabetes patients at a large safety net clinic. We conducted focus groups to assess patient perspectives, revised lessons for improved readability and cultural relevance to low-income and Hispanic patients, conducted a feasibility study of the adapted program in English and Spanish speaking cohorts, and implemented real-time adaptations to the program for commercial use and for a larger trial of in multiple safety net clinics. Results. The majority of focus group participants were receptive to the program. We modified the curriculum to a 5th-grade reading level and adapted content based on patient feedback. In the feasibility study, 54% of eligible contacted patients expressed interest in enrolling (n = 23). Although some participants' computer access and literacy made registration challenging, they were highly satisfied and engaged (80% logged in at least once/week). Conclusions. Underserved prediabetic patients displayed high engagement and satisfaction with a digital diabetes prevention program despite lower digital literacy skills. The collaboration between researchers and a digital health company enabled iterative improvements in technology implementation to address challenges in low-income populations.
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Affiliation(s)
- Valy Fontil
- Division of General Internal Medicine, University of California, San Francisco (UCSF) at Zuckerberg San Francisco General Hospital and Trauma Center, P.O. Box 1364, San Francisco, CA 94143, USA
- Center for Vulnerable Populations, University of California, San Francisco (UCSF) at Zuckerberg San Francisco General Hospital and Trauma Center, P.O. Box 1364, San Francisco, CA 94143, USA
| | - Kelly McDermott
- Omada Health, 500 Sansome St., Suite 200, San Francisco, CA 94111, USA
| | - Lina Tieu
- Division of General Internal Medicine, University of California, San Francisco (UCSF) at Zuckerberg San Francisco General Hospital and Trauma Center, P.O. Box 1364, San Francisco, CA 94143, USA
- Center for Vulnerable Populations, University of California, San Francisco (UCSF) at Zuckerberg San Francisco General Hospital and Trauma Center, P.O. Box 1364, San Francisco, CA 94143, USA
| | - Christina Rios
- Division of General Internal Medicine, University of California, San Francisco (UCSF) at Zuckerberg San Francisco General Hospital and Trauma Center, P.O. Box 1364, San Francisco, CA 94143, USA
- Center for Vulnerable Populations, University of California, San Francisco (UCSF) at Zuckerberg San Francisco General Hospital and Trauma Center, P.O. Box 1364, San Francisco, CA 94143, USA
| | - Eliza Gibson
- Omada Health, 500 Sansome St., Suite 200, San Francisco, CA 94111, USA
| | | | - Mike Payne
- Omada Health, 500 Sansome St., Suite 200, San Francisco, CA 94111, USA
| | - Courtney R. Lyles
- Division of General Internal Medicine, University of California, San Francisco (UCSF) at Zuckerberg San Francisco General Hospital and Trauma Center, P.O. Box 1364, San Francisco, CA 94143, USA
- Center for Vulnerable Populations, University of California, San Francisco (UCSF) at Zuckerberg San Francisco General Hospital and Trauma Center, P.O. Box 1364, San Francisco, CA 94143, USA
- *Courtney R. Lyles:
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Mirsky JB, Tieu L, Lyles C, Sarkar U. Readability assessment of patient-provider electronic messages in a primary care setting. J Am Med Inform Assoc 2016; 23:202-6. [PMID: 26177659 PMCID: PMC7814916 DOI: 10.1093/jamia/ocv087] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 05/11/2015] [Accepted: 05/28/2015] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The high prevalence of limited health literacy among patients threatens the success of secure electronic messaging between patients from diverse populations and their providers. OBJECTIVE The purpose of this study is to generate hypotheses about the readability of patient and provider electronic messages. METHODS We collected 31 patient-provider e-mail exchanges (n = 119 total messages) from a safety-net primary care clinic. We compared the messages' mean word count and Flesch-Kincaid Grade Levels (FKGLs), calculated the frequency of provider messages below an FKGL = 8, and assessed readability concordance between patients' and providers' messages. RESULTS Patients used more words in their initial e-mails compared to providers, but the FKGLs were similar, and 68% of provider messages were written below an FKGL = 8. Of 31 exchanges, 9 (29%) contained at least one patient message with an FKGL > 3 grade levels lower than the corresponding provider message(s). CONCLUSION Our study demonstrates that most providers are able to respond to patient electronic messages with a matching reading level.
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Affiliation(s)
- Jacob B Mirsky
- University of California, San Francisco, School of Medicine
| | - Lina Tieu
- Division of General Internal Medicine, University of California, San Francisco, School of Medicine and UCSF Center for Vulnerable Populations at San Francisco General Hospital
| | - Courtney Lyles
- Division of General Internal Medicine, University of California, San Francisco, School of Medicine and UCSF Center for Vulnerable Populations at San Francisco General Hospital
| | - Urmimala Sarkar
- Division of General Internal Medicine, University of California, San Francisco, School of Medicine and UCSF Center for Vulnerable Populations at San Francisco General Hospital
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Tieu L, Sarkar U, Schillinger D, Ralston JD, Ratanawongsa N, Pasick R, Lyles CR. Barriers and Facilitators to Online Portal Use Among Patients and Caregivers in a Safety Net Health Care System: A Qualitative Study. J Med Internet Res 2015; 17:e275. [PMID: 26681155 PMCID: PMC4704882 DOI: 10.2196/jmir.4847] [Citation(s) in RCA: 154] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Revised: 08/14/2015] [Accepted: 10/09/2015] [Indexed: 01/17/2023] Open
Abstract
Background Patient portals have the potential to support self-management for chronic diseases and improve health outcomes. With the rapid rise in adoption of patient portals spurred by meaningful use incentives among safety net health systems (a health system or hospital providing a
significant level of care to low-income, uninsured, and vulnerable populations), it is important to understand the readiness and willingness of patients and caregivers in safety net settings to access their personal health records online. Objective To explore patient and caregiver perspectives on online patient portal use before its implementation at San Francisco General Hospital, a safety net hospital. Methods We conducted 16 in-depth interviews with chronic disease patients and caregivers who expressed interest in using the Internet to manage their health. Discussions focused on health care experiences, technology use, and interest in using an online portal to manage health tasks. We used open coding to categorize all the barriers and facilitators to portal use, followed by a second round of coding that compared the categories to previously published findings. In secondary analyses, we also examined specific barriers among 2 subgroups: those with limited health literacy and caregivers. Results We interviewed 11 patients and 5 caregivers. Patients were predominantly male (82%, 9/11) and African American (45%, 5/11). All patients had been diagnosed with diabetes and the majority had limited health literacy (73%, 8/11). The majority of caregivers were female (80%, 4/5), African American (60%, 3/5), caregivers of individuals with diabetes (60%, 3/5), and had adequate health literacy (60%, 3/5). A total of 88% (14/16) of participants reported interest in using the portal after viewing a prototype. Major perceived barriers included security concerns, lack of technical skills/interest, and preference for in-person communication. Facilitators to portal use included convenience, health monitoring, and improvements in patient-provider communication. Participants with limited health literacy discussed more fundamental barriers to portal use, including challenges with reading and typing, personal experience with online security breaches/viruses, and distrust of potential security measures. Caregivers expressed high interest in portal use to support their roles in interpreting health information, advocating for quality care, and managing health behaviors and medical care. Conclusions Despite concerns about security, difficulty understanding medical information, and satisfaction with current communication processes, respondents generally expressed enthusiasm about portal use. Our findings suggest a strong need for training and support to assist vulnerable patients with portal registration and use, particularly those with limited health literacy. Efforts to encourage portal use among vulnerable patients should directly address health literacy and security/privacy issues and support access for caregivers.
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Affiliation(s)
- Lina Tieu
- Division of General Internal Medicine, University of California, San Francisco, San Francisco, CA, United States.
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Abstract
To explore the content of patient-provider e-mails in a safety-net primary care clinic, we conducted a content analysis using inductive and deductive coding of e-mail exchanges (n = 31) collected from January through November 2013. Participants were English-speaking adult patients with a chronic condition (or their caregivers) cared for at a single publicly funded general internal medicine clinic and their primary care providers (attending general internist physicians, clinical fellows, internal medicine residents, and nurse practitioners). All e-mails were nonurgent. Patients included a medical update in 19% of all e-mails. Patients requested action in 77% of e-mails, and the most common requests overall were for action regarding medications or treatment (29%). Requests for information were less common (45% of e-mails). Patient requests (n = 56) were resolved in 84% of e-mail exchanges, resulting in 63 actions. These results show that patients in safety-net clinics are capable of safely and effectively using electronic messaging for between-visit communication with providers. Safety-net systems should implement electronic communications tools as soon as possible to increase health care access and enhance patients' involvement in their care.
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Affiliation(s)
- Jacob B Mirsky
- a Department of Medicine , University of California, San Francisco , San Francisco , California , USA
| | - Lina Tieu
- a Department of Medicine , University of California, San Francisco , San Francisco , California , USA
| | - Courtney Lyles
- a Department of Medicine , University of California, San Francisco , San Francisco , California , USA
| | - Urmimala Sarkar
- a Department of Medicine , University of California, San Francisco , San Francisco , California , USA
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