Building a Community Partnership for the Development of Health Ministries Within the African American Community: The Triad Pastors Network

African Americans continue to have worse health outcomes despite attempts to reduce health disparities. This is due, in part, to inadequate access to healthcare, but also to the health care and medical mistrust experienced by communities of color. Churches and worship centers have historically served as cultural centers of trusted resources for educational, financial, and health information within African American communities and a growing number of collaborations have developed between academic institutions and community/faith entities. Herein, we describe the infrastructure of a true and sustainable partnership developed with > 100 prominent faith leaders within the Piedmont Triad region of North Carolina for the purpose of developing or expanding existing health ministries within houses of worship, to improve health literacy and overall health long-term. The Triad Pastors Network is an asset-based partnership between the Maya Angelou Center for Health Equity at Wake Forest University School of Medicine and faith leaders in the Piedmont Triad region of North Carolina that was created under the guiding principles of community engagement to improve health equity and decrease health disparities experienced by African American communities. A partnership in which co-equality and shared governance are the core of the framework provides an effective means of achieving health-related goals in a productive and efficient manner. Faith-based partnerships are reliable approaches for improving the health literacy needed to address health disparities and inequities in communities of color.

Providing medication for opioid use disorder and HIV pre-exposure prophylaxis at syringe services programs via telemedicine: a pilot study

BACKGROUND

People who inject drugs (PWID) are at high risk for opioid overdose and infectious diseases including HIV. We piloted PARTNER UP, a telemedicine-based program to provide PWID with medication for opioid use disorder (MOUD) with buprenorphine/naloxone (bup/nx) and oral pre-exposure prophylaxis (PrEP) with tenofovir disoproxil fumarate/emtricitabine through two syringe services programs (SSP) in North Carolina. We present overall results from this project, including participant retention rates and self-reported medication adherence.

METHODS

Study participants met with a provider for an initial in-person visit at the SSP, followed by weekly telemedicine visits in month 1 and then monthly until program end at month 6. Participants were asked to start both MOUD and PrEP at initiation but could choose to discontinue either at any point during the study. Demographics and health history including substance use, sexual behaviors, and prior use of MOUD/PrEP were collected at baseline. Follow-up surveys were conducted at 3- and 6-months to assess attitudes towards MOUD and PrEP, change in opioid use and sexual behaviors, and for self-reported medication adherence. Participant retention was measured by completion of visits; provider notes were used to assess whether the participant reported continuation of medication.

RESULTS

Overall, 17 persons were enrolled and started on both bup/nx and PrEP; the majority self-identified as white and male. At 3 months, 13 (76%) remained on study; 10 (77%) reported continuing with both MOUD and PrEP, 2 (15%) with bup/nx only, and 1 (8%) with PrEP only. At 6 months, 12 (71%) remained on study; 8 (67%) reported taking both bup/nx and PrEP, and 4 (33%) bup/nx only. Among survey participants, opioid use and HIV risk behaviors decreased. Nearly all reported taking bup/nx daily; however, self-reported daily adherence to PrEP was lower and declined over time. The most common reason for not continuing PrEP was feeling not at risk for acquiring HIV.

CONCLUSIONS

Our study results show that MOUD and PrEP can be successfully administered via telemedicine in SSPs. PrEP appears to be a lower priority for participants with decreased continuation and adherence. Low perception of HIV risk was a reason for not continuing PrEP, possibly mitigated by MOUD use. Future studies including helping identify PWID at highest need for PrEP are needed.

TRIAL REGISTRATION

Providing Suboxone and PrEP Using Telemedicine, NCT04521920. Registered 18 August 2020. https://clinicaltrials.gov/study/NCT04521920?term=mehri%20mckellar&rank=2 .

The Association of Frailty and Neighborhood Disadvantage with Emergency Department Visits and Hospitalizations in Older Adults

BACKGROUND

Risk stratification and population management strategies are critical for providing effective and equitable care for the growing population of older adults in the USA. Both frailty and neighborhood disadvantage are constructs that independently identify populations with higher healthcare utilization and risk of adverse outcomes.

OBJECTIVE

To examine the joint association of these factors on acute healthcare utilization using two pragmatic measures based on structured data available in the electronic health record (EHR).

DESIGN

In this retrospective observational study, we used EHR data to identify patients aged ≥ 65 years at Atrium Health Wake Forest Baptist on January 1, 2019, who were attributed to affiliated Accountable Care Organizations. Frailty was categorized through an EHR-derived electronic Frailty Index (eFI), while neighborhood disadvantage was quantified through linkage to the area deprivation index (ADI). We used a recurrent time-to-event model within a Cox proportional hazards framework to examine the joint association of eFI and ADI categories with healthcare utilization comprising emergency visits, observation stays, and inpatient hospitalizations over one year of follow-up.

KEY RESULTS

We identified a cohort of 47,566 older adults (median age = 73, 60% female, 12% Black). There was an interaction between frailty and area disadvantage (P = 0.023). Each factor was associated with utilization across categories of the other. The magnitude of frailty's association was larger than living in a disadvantaged area. The highest-risk group comprised frail adults living in areas of high disadvantage (HR 3.23, 95% CI 2.99-3.49; P < 0.001). We observed additive effects between frailty and living in areas of mid- (RERI 0.29; 95% CI 0.13-0.45; P < 0.001) and high (RERI 0.62, 95% CI 0.41-0.83; P < 0.001) neighborhood disadvantage.

CONCLUSIONS

Considering both frailty and neighborhood disadvantage may assist healthcare organizations in effectively risk-stratifying vulnerable older adults and informing population management strategies. These constructs can be readily assessed at-scale using routinely collected structured EHR data.

Establishing and sustaining an acute care for elders unit: An incremental journey to success

Acute Care for Elders (ACE) units reduce hospital-associated delirium, functional decline, and lengths of stay. However, establishing and sustaining such units have proven difficult. There are only 43 ACE units among the >3500 hospitals in the United States. This study describes an iterative quality improvement process, which allowed us to establish and sustain an ACE unit care model in a modern academic hospital. This continuous process was centered on implementing the key principles of the ACE unit model of care: patient-centered care assessments, medical care review, specialized prepared environment, early mobilization, physical therapy, and early planning for discharge to home. Quality of care and patient outcomes data for older adults admitted to our ACE unit includes mortality index (observed/expected) consistently <1 (FY22 = 0.86), 30-day readmission rate of <10% (FY22 9.31%), and length of stay index of ~1 (FY22 1.07). We describe how work on our ACE unit has led to hospital-wide initiatives, including dementia-friendly hospital certification. Our hope is that others can use this process to enhance the dissemination of the ACE unit model of care.

Home visiting impacts during the pandemic: Evidence from a randomized controlled trial of child first

Existing research has found that home visiting programs for families with young children can improve children's development and strengthen caregiver and family well-being. However, the pandemic created numerous challenges for home visiting programs, forcing them to deliver services online or in a hybrid format to respond to pandemic-related challenges. Questions remain about the impacts of these programs when delivered at-scale via a hybrid model, especially during this uniquely challenging time. The present study reports 12-month impacts from a randomized controlled trial of Child First-an evidence-based home visiting program that provides psychotherapeutic, parent-child intervention (children ages 0-5) embedded in a coordinated system of care-when implemented as a hybrid service. This study estimates impacts within four domains: families' receipt of services, caregiver psychological well-being and parenting, child behavior, and family economic well-being. After randomly assigning families (N = 226) to receive Child First or typical community services, the research team surveyed caregivers (N = 183) about a year after study enrollment. Results from regression models with site fixed effects revealed suggestive evidence that Child First reduced caregivers' job loss, residential mobility, and self-reported substance abuse, and increased receipt of virtual services during the pandemic. There were null impacts on caregivers' psychological well-being, families' involvement with the child welfare system, children's behaviors, and other indicators of economic well-being. Implications for future research and policy are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Mechanisms of change in external implementation support: A conceptual model and case examples to guide research and practice

Background

External implementation support (EIS) is a well-recognized feature of implementation science and practice, often under related terms such as technical assistance and implementation facilitation. Existing models of EIS have gaps related to addressing practice outcomes at both individual and organizational levels, connecting practice activities to intended outcomes, or grounding in well-established theories of behavior and organization change. Moreover, there have been calls to clarify the mechanisms of change through which EIS influences related outcomes.

Method

In this article, we theorize about mechanisms of change within EIS. Our theorizing process aligns with the approach advocated by Kislov et al. We aim to consolidate prior EIS literature, combining related constructs from previous empirical and conceptual work while drawing on our extensive EIS experience to develop a higher-order, midrange theory of change.

Results

Our theory of change is empirically and practically informed, conceptually situated within an established grand theory of change, and guided by eight practice principles and social cognitive theory. The theory of change proposes 10 core practice components as mechanisms of change within EIS. When used according to underlying theory and principles, they are believed to contribute to favorable practice outcomes at individual, team, organizational, and system levels. The model offers flexibility by recognizing the need for sequential support processes and the demand to practice in dynamic and responsive ways. Case examples are presented to illustrate major themes and patterns of the model in action.

Conclusions

The proposed model is intended to support prospective EIS studies by conceptualizing discernable practice components with hypothesized relationships to proximal and distal practice outcomes. The model can be behaviorally operationalized to compliment and extend competency-based approaches to implementation support practitioner (ISP) training and coaching. Over time, the model should be refined based on new empirical findings and contributions from ISPs across the field.

Trajectory of external implementation support activities across two states in the United States: A descriptive study

Background

Reporting on strategies to advance implementation outcomes is imperative. The current study reports descriptive information about external implementation support (EIS) provided over 5 years to 13 regions in North Carolina and South Carolina scaling an evidence-based system of parenting and family supports. Regional support teams operating through the Implementation Capacity for Triple P (ICTP) projects employed core practice components (CPCs) for EIS as proposed by Aldridge et al. and further operationalized by members of The Impact Center at FPG Child Development Institute, UNC-Chapel Hill.

Method

Practice activities associated with CPCs were developed and iteratively refined across the study period. ICTP regional support teams systematically tracked their use of CPCs and related activities following each substantive support interaction. Tracking included the duration of time a CPC was employed and the use of specific practice activities associated with that CPC. Data were aggregated by month of the relationship to account for differential start dates across regions.

Results

From November 2016 through December 2021, ICTP support teams tracked 749 support interactions with Triple P regions in North Carolina and South Carolina. Monthly support decreased year over year, though dose varied considerably. Patterns of CPC use indicated a high dose of "foundational" and "co-design" CPCs early, followed by a blended and more diverse use thereafter, with some notable trends. Practice activities considered essential to influencing intended practice outcomes were characterized by higher rates of use. Like CPCs, practice activities were used dynamically across the study period.

Conclusions

This descriptive study offers a case study for how EIS might be operationalized, tracked, and employed. Findings suggest several interpretations that might refine our understanding and use of EIS. Although the nature of this practical report precludes generalizability of findings, directions for future research and practice are discussed.

Acupuncture for acute musculoskeletal pain management in the emergency department and continuity clinic: a protocol for an adaptive pragmatic randomised controlled trial

INTRODUCTION

Chronic musculoskeletal pain causes a significant burden on health and quality of life and may result from inadequate treatment of acute musculoskeletal pain. The emergency department (ED) represents a novel setting in which to test non-pharmacological interventions early in the pain trajectory to prevent the transition from acute to chronic pain. Acupuncture is increasingly recognised as a safe, affordable and effective treatment for pain and anxiety in the clinic setting, but it has yet to be established as a primary treatment option in the ED.

METHODS AND ANALYSIS

This pragmatic clinical trial uses a two-stage adaptive randomised design to determine the feasibility, acceptability and effectiveness of acupuncture initiated in the ED and continued in outpatient clinic for treating acute musculoskeletal pain. The objective of the first (treatment selection) stage is to determine the more effective style of ED-based acupuncture, auricular acupuncture or peripheral acupuncture, as compared with no acupuncture. All arms will receive usual care at the discretion of the ED provider blinded to treatment arm. The objective of the second (effectiveness confirmation) stage is to confirm the impact of the selected acupuncture arm on pain reduction. An interim analysis is planned at the end of stage 1 based on probability of being the best treatment, after which adaptations will be considered including dropping the less effective arm, sample size re-estimation and unequal treatment allocation ratio (eg, 1:2) for stage 2. Acupuncture treatments will be delivered by licensed acupuncturists in the ED and twice weekly for 1 month afterward in an outpatient clinic.

ETHICS AND DISSEMINATION

This study has been reviewed and approved by the Duke University Health System Institutional Review Board. Informed consent will be obtained from all participants. Results will be disseminated through peer-review publications and public and conference presentations.

TRIAL REGISTRATION NUMBER

NCT04290741.

Examining Social Determinants of Health During a Pandemic: Clinical Application of Z Codes Before and During COVID-19

Recognition of the impact of social determinants of health (SDoH) on healthcare outcomes, healthcare service utilization, and population health has prompted a global shift in focus to patient social needs and lived experiences in assessment and treatment. The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) provides a list of non-billable “Z codes” specific to SDoH for use in electronic health records. Using population-level analysis, this study aims to examine clinical application of Z codes in South Carolina before and during the COVID-19 pandemic. The study population consists of South Carolina residents who had a healthcare visit and had their COVID-19 test result reported to the state's Department of Health and Environmental Control before January 14, 2021. Of the 1,190,531 individuals in the overall sample, Z codes were used only for 14,665 (1.23%) of the patients, including 2,536 (0.97%) COVID-positive patients and 12,129 (1.30%) COVID-negative patients. Compared with hospitals that did not use Z codes, those that did were significantly more likely to have higher bed capacity (p = 0.017) and to be teaching hospitals (p = 0.03), although this was significant only among COVID-19 positive individuals. Those at inpatient visits were most likely to receive Z codes (OR: 5.26; 95% CI: 5.14, 5.38; p < 0.0001) compared to those at outpatient visits (OR: 0.07; 95%CI: 0.06, 0.07; p < 0.0001). There was a slight increase of Z code use from 2019 to 2020 (OR: 1.33, 95% CI: 1.30, 1.36; p < 0.0001), which was still significant when stratified by facility type across time. As one of the first studies to examine Z code use among a large patient population, findings clearly indicate underutilization by providers. Additional study is needed to understand the potentially long-lasting health effects related to SDoH among underserved populations.

Diagnosing and Treating Chronic Pain: Are We Doing This Right?

The diagnosis, treatment, and management of chronic pain is complex, nuanced, and challenging in primary care settings. These challenges often give rise to internal provider conflicts around appropriate management strategies, perhaps avoiding diagnosis all together. Factors that contribute to internal provider conflict include knowledge, responsibility, and uncertainties surrounding chronic pain management. This piece acknowledges the complexity and competing priorities of chronic pain management from a provider perspective. We advocate for coordinated and committed care of patients with chronic pain and a sense of shared responsibility among providers to adequately address patient needs.

Advance care planning for vulnerable older adults within an Accountable Care Organization: study protocol for the IMPACT randomised controlled trial

INTRODUCTION

Patients with multimorbidity plus additional impairments (eg, mobility limitations, disability, cognitive impairments or frailty) are at the highest risk for poor healthcare outcomes. Advanced care planning (ACP) provides patients and their surrogates the opportunity to discuss their goals, values and priorities for healthcare-particularly in the context of end-of-life care. ACP discussions promote more person-centred care; however, it is currently underused. There is a tremendous need for systematic, scalable approaches to individualised ACP that promotes patient and family engagement. Here we describe the study protocol for a randomised effectiveness trial of a nurse navigator and informatics intervention designed to improve the documentation and quality of ACP discussions.

METHODS AND ANALYSIS

This is a randomised, pragmatic, effectiveness trial; patients aged 65 years and older who have multimorbidity plus impairments in either physical function (eg, mobility limitations or disability) or cognition, and/or frailty within an affiliated Accountable Care Organization were eligible. The electronic health record was used to develop an automatic prescreening system for eligible patients (n=765) and participants were randomised in a 1:1 ratio to either the nurse navigator-led ACP pathway or usual care. Our primary outcomes are documentation of ACP discussions within the EHR along with the quality of ACP discussions. Secondary outcomes include a broad range of ACP actions (eg, usage of ACP billing codes, choosing a surrogate decision-maker and advance directive documentation). Outcomes will be measured over 12 months of follow-up.

ETHICS AND DISSEMINATION

This study has been approved by the appropriate Institutional Review Boards and is guided by input from patient and clinical advisory boards. The results of this study will inform a scalable solution to ACP discussions throughout our healthcare system and statewide.

TRIALS REGISTRATION NUMBER

NCT03609658.