Addressing Housing-Related Social Needs Through Medicaid: Lessons From North Carolina's Healthy Opportunities Pilots Program.

North Carolina Medicaid's Healthy Opportunities Pilots program is the country's first comprehensive program to evaluate the impact of paying community-based organizations to provide eligible Medicaid enrollees with an array of evidence-based services to address four domains of health-related social needs, one of which is housing. Using a mixed-methods approach, we mapped the distribution of severe housing problems and then examined the design and implementation of Healthy Opportunities Pilots housing services in the three program regions. Four cross-cutting implementation and policy themes emerged: accounting for variation in housing resources and needs to address housing insecurity, defining and pricing housing services in Medicaid, engaging diverse stakeholders across sectors to facilitate successful implementation, and developing sustainable financial models for delivery. The lessons learned and actionable insights can help inform the efforts of stakeholders elsewhere, particularly other state Medicaid programs, to design and implement cross-sectoral programs that address housing-related social needs by leveraging multiple policy-based resources. These lessons can also be useful for federal policy makers developing guidance on addressing housing-related needs in Medicaid.

Residential Structural Racism and Prevalence of Chronic Health Conditions.

Importance: Studies elucidating determinants of residential neighborhood-level health inequities are needed. Objective: To quantify associations of structural racism indicators with neighborhood prevalence of chronic kidney disease (CKD), diabetes, and hypertension. Design, Setting, and Participants: This cross-sectional study used public data (2012-2018) and deidentified electronic health records (2017-2018) to describe the burden of structural racism and the prevalence of CKD, diabetes, and hypertension in 150 residential neighborhoods in Durham County, North Carolina, from US census block groups and quantified their associations using bayesian models accounting for spatial correlations and residents' age. Data were analyzed from January 2021 to May 2023. Exposures: Global (neighborhood percentage of White residents, economic-racial segregation, and area deprivation) and discrete (neighborhood child care centers, bus stops, tree cover, reported violent crime, impervious areas, evictions, election participation, income, poverty, education, unemployment, health insurance coverage, and police shootings) indicators of structural racism. Main Outcomes and Measures: Outcomes of interest were neighborhood prevalence of CKD, diabetes, and hypertension. Results: A total of 150 neighborhoods with a median (IQR) of 1708 (1109-2489) residents; median (IQR) of 2% (0%-6%) Asian residents, 30% (16%-56%) Black residents, 10% (4%-20%) Hispanic or Latino residents, 0% (0%-1%) Indigenous residents, and 44% (18%-70%) White residents; and median (IQR) residential income of $54 531 ($37 729.25-$78 895.25) were included in analyses. In models evaluating global indicators, greater burden of structural racism was associated with greater prevalence of CKD, diabetes, and hypertension (eg, per 1-SD decrease in neighborhood White population percentage: CKD prevalence ratio [PR], 1.27; 95% highest density interval [HDI], 1.18-1.35; diabetes PR, 1.43; 95% HDI, 1.37-1.52; hypertension PR, 1.19; 95% HDI, 1.14-1.25). Similarly in models evaluating discrete indicators, greater burden of structural racism was associated with greater neighborhood prevalence of CKD, diabetes, and hypertension (eg, per 1-SD increase in reported violent crime: CKD PR, 1.15; 95% HDI, 1.07-1.23; diabetes PR, 1.20; 95% HDI, 1.13-1.28; hypertension PR, 1.08; 95% HDI, 1.02-1.14). Conclusions and Relevance: This cross-sectional study found several global and discrete structural racism indicators associated with increased prevalence of health conditions in residential neighborhoods. Although inferences from this cross-sectional and ecological study warrant caution, they may help guide the development of future community health interventions.

Community-based organizations' perspectives on piloting health and social care integration in North Carolina.

BACKGROUND: Community-based organizations (CBOs) are key players in health and social care integration initiatives, yet little is known about CBO perspectives and experiences in these pilot programs. Understanding CBO perspectives is vital to identifying best practices for successful medical and social care integration. METHODS: From February 2021 to March 2021, we conducted surveys with 12 CBOs that participated in the North Carolina COVID-19 Social Support Program, a pre-pilot for North Carolina's Medicaid Sect. 1115 demonstration waiver program that addresses social drivers of health. RESULTS: CBO participants preferred communication strategies that involved direct communication and felt clear communication was vital to the program's success. Participants expressed varied experiences regarding their ability to handle a changing volume of referrals. Participants identified their organizations' strengths as: strong organizational operations, past experiences with and understanding of the community, and coordination across organizations. Participants identified challenges as: difficulty communicating with clients, coping with capacity demands for scaling services, and lack of clear processes from external organizations. Almost all CBO participants expressed enthusiasm for participating in similar social care transformation programs in the future. CONCLUSIONS: CBO participants in our study had broadly positive experiences in the pilot program and almost all would participate in a similar program in the future. Participants provided perspectives that can inform health and social care integration initiatives, including strengths and challenges in such programs. To build and sustain health and social care integration programs, it is important to: (1) support CBOs through regular, direct communication that builds trust and power-sharing between CBO and health care entities; (2) leverage CBO community expertise; and (3) pursue an individualized assessment of CBO capacity and identify CBO capacity-building strategies that ensure program success and sustainability.

COVID Collaborations: A Physician Assistant Program and Health Department Partnership.

ABSTRACT: The onset of the COVID-19 pandemic resulted in the displacement of clinical-phase medical learners across the country. Physician assistant (PA) and other health professions programs were challenged to innovate and offer alternate learning experiences that would meet students' needs as future health care professionals. At the same time, local and state health departments were faced with quickly increasing their capacity for contact tracing and case investigation in response to the growing number of COVID-19 infections. Through a collaborative partnership based on the needs of the local health department and clinical-phase PA students, the Duke PA program developed an elective in which students served as contact tracers and case investigators. PA students provided over 1500 hours of contact tracing and case investigation support to the local health department. Qualitative review showed students gained a greater appreciation of the impact of social determinants of health, saw first-hand how the pandemic disproportionately affected communities of color, and increased their knowledge about the role of public health. The partnership between the PA program and the health department was mutually beneficial and established a foundation for future collaborative experiences that support both the community and the needs of health professions' learners.

Perceived Benefits of Training Clinicians in Community Engagement for a Leadership Development Program.

BACKGROUND AND OBJECTIVES: Community engagement (CE), including community-engaged research, is a critical tool for improving the health of patients and communities, but is not taught in most medical curricula, and is even rarer in leadership training for practicing clinicians. With the growth of value-based care and increasing concern for health equity, we need to turn our attention to the benefits of working with communities to improve health and health care. The objective of this brief report is to increase understanding of the perceived benefits of CE training for primary care clinicians, specifically those already working. METHODS: We assessed perceived benefits of CE training for primary care clinicians participating in health care transformation leadership training through analysis of learner reflection papers. RESULTS: Clinicians (n=12) reported transformational learning and critical shifts of perspective. Not only did they come to value and understand CE, but the training changed their perception of their roles as clinicians and leaders. CONCLUSIONS: Educating primary care clinicians in CE as a foundational principle can orient them to the criticality of stakeholder engagement for daily practice, practice transformation, and population health improvement, and provides them with a new understanding of their roles as clinicians and leaders.

Partnerships to Care for Our Patients and Communities During COVID-19.

The Coronavirus disease 2019 (COVID-19) pandemic forced not only rapid changes in how clinical care and educational programs are delivered but also challenged academic medical centers (AMCs) like never before. The pandemic made clear the need to have coordinated action based on shared data and shared resources to meet the needs of patients, learners, and communities. Family medicine departments across the country have been key partners in AMCs' responses. The Duke Department of Family Medicine and Community Health (FMCH) was involved in many aspects of Duke University's and Health System's responses, including leadership contributions in delivering employee health and student health services. The pandemic also surfaced the biological and social interactions that reveal underlying socioeconomic inequalities, for which family medicine has advocated since its inception. Key to success was the department's ability to integrate "horizontally" with the broader community, thereby accelerating the institution's response to the pandemic.

Utilizing a Behavioral Health Bundle to Improve Patient and Clinician Safety for Hospitalized Children.

Due to limited psychiatric hospital availability, increasing numbers of pediatric patients with behavioral health (BH) needs are hospitalized in medical units in the US Patients and staff are at increased risk for safety events like self-harm or aggression. Our study aimed to decrease safety events by 25% over a year among hospitalized children with BH diagnoses by implementing an intervention bundle. METHODS: A multidisciplinary team developed and implemented a BH intervention bundle that included a BH equipment cart, an electronic medical record tool for BH patient identification/stratification, a de-escalation team, daily operational BH phone call, and staff training with a safety checklist. The primary outcome measure was the number of reported safety events in BH patients. Process measure was "medically avoidable days", wherein a medically cleared patient remained hospitalized awaiting transfer to inpatient psychiatric units; balance measure was staff perception of the workflow. RESULTS: Although not statistically significant, we noted a downward trend in safety events per 1,000 patient days from 0.47 preintervention to 0.34 postintervention (28% decrease). Special cause variation was not achieved for BH safety events or medically avoidable days. Although one-third of staff members felt the BH bundle was helpful, many reported it as impeding workflow and expressed ongoing discomfort caring for BH patients. CONCLUSIONS: The implementation of a BH intervention bundle requires significant institutional support and interdisciplinary coordination. Despite additional training, equipment, and staff support, we did not achieve measurable improvements in patient safety and care coordination. Additional studies to measure impact and improve care for this population are needed.

What Is Population Health?

This article defines population health as the health outcomes of a group of individuals, including the distribution of such outcomes within the group. Population health includes health outcomes, patterns of health determinants, and policies and interventions that link these two. Attention to social and environmental, as well as medical, determinants of health is essential. The population health lens can be used at the individual, practice, institutional, and community levels. The need for primary care to engage in population health stems from the importance of social and environmental factors, the nature of primary care, and contextual changes.

Methods and initial findings from the Durham Diabetes Coalition: Integrating geospatial health technology and community interventions to reduce death and disability.

OBJECTIVE: The Durham Diabetes Coalition (DDC) was established in response to escalating rates of disability and death related to type 2 diabetes mellitus, particularly among racial/ethnic minorities and persons of low socioeconomic status in Durham County, North Carolina. We describe a community-based demonstration project, informed by a geographic health information system (GHIS), that aims to improve health and healthcare delivery for Durham County residents with diabetes. MATERIALS AND METHODS: A prospective, population-based study is assessing a community intervention that leverages a GHIS to inform community-based diabetes care programs. The GHIS integrates clinical, social, and environmental data to identify, stratify by risk, and assist selection of interventions at the individual, neighborhood, and population levels. RESULTS: The DDC is using a multifaceted approach facilitated by GHIS to identify the specific risk profiles of patients and neighborhoods across Durham County. A total of 22,982 patients with diabetes in Durham County were identified using a computable phenotype. These patients tended to be older, female, African American, and not covered by private health insurance, compared with the 166,041 persons without diabetes. Predictive models inform decision-making to facilitate care and track outcomes. Interventions include: 1) neighborhood interventions to improve the context of care; 2) intensive team-based care for persons in the top decile of risk for death or hospitalization within the coming year; 3) low-intensity telephone coaching to improve adherence to evidence-based treatments; 4) county-wide communication strategies; and 5) systematic quality improvement in clinical care. CONCLUSIONS: To improve health outcomes and reduce costs associated with type 2 diabetes, the DDC is matching resources with the specific needs of individuals and communities based on their risk characteristics.

Results from a pilot promotora program to reduce depression and stress among immigrant Latinas.

The stressful experiences that Latino immigrants face throughout the migration process to the United States put them at increased risk for poor mental health. Latinas are at heightened risk due to stigma, limited access to mental health resources, domestic violence, and gender role expectations. In addition, for those who live in new immigrant settlement areas, such as the Southeast, these disparities are magnified by even fewer culturally appropriate services and limited social support. This study evaluates the impact of ALMA (Amigas Latinas Motivando el Alma/Latina Friends Motivating the Soul), a pilot promotora intervention offered in three North Carolina counties to improve mental health among Latinas by offering coping skills training. The intervention trained community-based promotoras to conduct outreach to Latina women in their social network (compañeras). Using a pre-post test design, we assessed the mental health outcomes of compañeras. Compañeras improved on the following outcomes: depressive symptoms, attitudes of depression treatment, perceived and acculturative stress, perceived social support, and positive coping responses. Our findings suggest that promotora interventions, such as ALMA, that focus on building self-care strategies can be valuable to reducing preclinical symptoms and addressing health care disparities that are exacerbated by unavailable or underused mental health services.

Evaluation of Amigas Latinas Motivando el Alma (ALMA): a pilot promotora intervention focused on stress and coping among immigrant Latinas.

Recent immigrant Latinas are at increased risk of poor mental health due to stressors associated with adapting to life in the United States. This study evaluated Amigas Latinas Motivando el Alma, a promotora intervention to reduce stress and promote health and coping among recent immigrant Latinas. Using a pre- and post-test design, we evaluated mental health outcomes, specifically, in promotoras. Promotoras' knowledge levels related to role of promotora and stress management increased, depressive symptoms and stress levels decreased, and coping responses and perceived social support increased as well. Results suggest that promotora programs may be an effective way to improve mental health in recent immigrant Latinas.

Amigas Latinas Motivando el ALMA (ALMA): Development and Pilot Implementation of a Stress Reduction Promotora Intervention.

Use of mental health care services for psychological distress is limited among Latino immigrants. In geographic areas where migration has been rapid, mental health systems possess limited capacity to provide bilingual and bicultural assistance. The development of a bilingual and bicultural workforce is a necessary yet long-term solution. More immediate strategies, however, are needed to meet the needs of immigrant Latinos. This paper describes the development of a stress-reduction focused, lay health advisor training that targets individual behavior change among Latina immigrants. The theoretical foundation, curriculum components, and pilot implementation of the training are discussed. As natural leaders, Latina promotoras disseminated learned strategies and resources within their communities. The lay health advisor model is a salient method for disseminating information regarding mental health and stress reduction among Latinas.

Just for Us: in-home care for frail elderly and disabled individuals with low incomes.

In response to increasing concerns about health care access, cost, and quality, Duke University Medical Center began a community-engaged, iterative, data-driven process in 1998 to develop innovative models to provide care earlier, more effectively, and at a lower cost. This commentary reviews Just for Us, an in-home care program launched in 2002 for low-income, frail elderly and disabled individuals.

Development of an interinstitutional collaboration to support community-partnered research addressing the health of emerging Latino populations.

Collaborative and participatory research approaches have received considerable attention as means to understanding and addressing disparities in health and health care. In this article, the authors describe the process of building a three-way partnership among two academic health centers-Duke University and the University of North Carolina-and members of the Latino community in North Carolina to develop and pilot test a lay health advisor program to improve Latina immigrants' mental health and coping skills. The authors applied the principles of participatory research to engage community and academic partners, to select the health topic and population, and to develop program goals and objectives. Key challenges were negotiating administrative structures and learning institutional cultures, as well as dealing with contextual issues such as mental health reform and antiimmigrant sentiment in the state.Some important lessons learned are to seek opportunities for taking advantage of existing relationships and expertise at each academic institution, to be respectful of the burden of research on vulnerable communities, and to involve community partners at all stages of the process.

Defining high-performance teams and physician leadership.

Beset with complex reimbursement and regulatory structures, rapidly advancing technology and a population that is growing increasingly older, sicker, and more obese, the U.S. medical environment needs coordinated interdisciplinary teamwork now more than ever.

Improving the health of the community: Duke's experience with community engagement.

Evidence is accumulating that the United States is falling behind in its potential to translate biomedical advances into practical applications for the population. Societal forces, increased awareness of health disparities, and the direction of clinical and translational research are producing a compelling case for AHCs to bridge the gaps between scientific knowledge and medical advancement and between medical advancement and health. The Duke University Health System, the city and county of Durham, North Carolina, and multiple local nonprofit and civic organizations are actively engaged in addressing this need. More than a decade ago, Duke and its community partners began collaborating on projects to meet specific, locally defined community health needs. In 2005, Duke and Durham jointly developed a set of Principles of Community Engagement reflecting the key elements of the partnership and crafted an educational infrastructure to train health professionals in the principles and practice of community engagement. And, most recently, Duke has worked to establish the Duke Translational Medicine Institute, funded in part by a National Institutes of Health Clinical Translational Science Award, to improve health through innovative behavioral, social, and medical knowledge, matched with community engagement and the information sciences.

Lichen sclerosus in the differential diagnosis of suspected child abuse cases.

Lichen sclerosus in young females can present as traumatic injuries on the vulva which can mimic sexual abuse. The case of an unconscious 6-year-old girl presenting in a reported inflicted drug overdose and with a clinical picture of ecchymosis and abrasions of the anogenital area is presented and discussed. The following case underscores the need for clinicians evaluating children for suspected abuse, to consider alternate conditions and causes that may not be related to sexual abuse.

Just for Us: an academic medical center-community partnership to maintain the health of a frail low-income senior population.

PURPOSE: To promote health and maintain independence, Just for Us provides financially sustainable, in-home, integrated care to medically fragile, low-income seniors and disabled adults living in subsidized housing. DESIGN AND METHODS: The program provides primary care, care management, and mental health services delivered in patient's homes by a multidisciplinary, multiagency team. RESULTS: After 2 years of operation, Just for Us is serving nearly 300 individuals in 10 buildings. The program is demonstrating improvement in individual indices of health. Medicaid expenditures for enrollees are shifting from ambulances and hospital services to pharmacy, personal care, and outpatient visits. The program is not breaking even, but it is moving toward that goal. The program's success is based on a partnership involving an academic medical center, a community health center, county social and mental health agencies, and a city housing authority to coordinate and leverage services. IMPLICATIONS: Just for Us is becoming a financially sustainable way of creating a "system within a nonsystem" for low-income elderly persons in clustered housing.