Implementing an advanced team-based care model in a federally qualified health center (FQHC): Assessing implementation facilitators and challenges.

OBJECTIVE: The objective of this paper is to assess implementation facilitators and challenges for advanced team-based care (aTBC) in a federally qualified health center (FQHC). In aTBC, care team coordinators room patients, perform vitals and agenda setting during patient intake, and remain present alongside providers during patient visits. METHODS: The authors conducted a qualitative post-hoc analysis of the aTBC implementation using data from several sources. They used content analysis to code items as facilitators or challenges and thematic analysis to group those into larger themes. Finally, they applied a priori codes from the revised consolidated framework for implementation research (CFIR) to organize the facilitators and barriers into subdomains. RESULTS: The existing evidence-base around aTBC, the FQHC's ability to pilot and adapt it, and strong implementation leads were key facilitating factors. Challenges included an external shock (i.e., the COVID-19 pandemic), aTBC complexity, and uncertainty about whether success required implementation of the full model versus easier-to-integrate smaller components. CONCLUSIONS: FQHCs that wish to implement aTBC models need strong champions and internal structures for piloting, adapting, and disseminating interventions. FQHC leaders must think strategically about how to build support and demonstrate success to improve an FQHC's chances of expanding and sustaining aTBC.

Erratum: 292 Activating community health workers: A community-academic partnership to understand vaccine hesitancy - CORRIGENDUM.

[This corrects the article DOI: 10.1017/cts.2024.267.].

Beyond minimum wage: Broader employment policies can significantly affect food insecurity.

Although many have investigated the impacts of minimum wage on a broad array of health outcomes, innovative policies surrounding broader employment policies have largely not been studied. To that end, this paper contributes in three ways. First, it discusses the rise in precarious employment. Then, it turns to the current federal framework of employment policies, namely minimum wage. Finally, it explores what a broader definition of employment policies could include and how future studies could use state, county, and municipal policymaking in this space to investigate ways in which they might contribute to reducing food insecurity and in turn, improve health outcomes.

About 30% of low-income households experienced food insecurity in 2023. Given that food security is strongly tied to employment conditions, there is potential to reduce food insecurity through innovative employment-focused policy changes. Minimum wage is often studied as an indicator of employment quality. However, employment policies now stretch beyond hourly rate, as several jurisdictions have adopted innovative, broader approaches to improving employment. More research is needed to determine whether these broader employment policies, such as secure scheduling, paid leave, and collective bargaining, may mitigate food insecurity.

Why Don't Employees Participate in Well-being Programs? A Research-Informed Systems-Based Model.

OBJECTIVE: Employee nonparticipation in well-being programs is common, but not well understood. Development of a systems-based framework to characterize reasons for nonparticipation can inform efforts to enhance engagement. METHODS: Following literature review and building on previous research, a systems-based model was developed to contextualize participation barriers. RESULTS: Well-being program nonparticipation is more frequent among low-wage workers as well as minority subpopulations. Contributors include employer factors, such as inequitable benefits design, and employee factors, such as lack of perceived relevance, barriers to access, and lower prioritization of personal health needs. CONCLUSIONS: A systems-based approach to evaluating well-being program nonparticipation can help identify factors contributing to employee nonparticipation and lead to targeted policy and practice changes that encourage greater employee engagement.

COVID-19 Vaccine Policy Implementation and Differential Vaccine Uptake Trajectories in Chicago Communities.

BACKGROUND: Since the onset of the COVID-19 pandemic, multiple public health interventions have been implemented to respond to the rapidly evolving pandemic and community needs. This article describes the scope, timing, and impact of coordinated strategies for COVID-19 vaccine uptake in Chicago for the first year of vaccine distribution. METHODS: Using a series of interviews with public health officials and leaders of community-based organizations (CBOs) who participated in the implementation of the citywide COVID-19 vaccine outreach initiatives, we constructed a timeline of vaccine outreach initiatives. The timeline was matched to the vaccine uptake rates to explore the impact of the vaccine outreach initiatives by community area. Finally, we discussed the nature of policy initiatives and the level of vaccine uptake in relation to community characteristics. RESULTS: The Chicago Department of Public Health (CDPH) implemented myriad vaccine outreach strategies, including mass vaccination sites, improved access, and community-level vaccine campaigns. Protect Chicago+ was the primary vaccine outreach effort initiated by the CDPH, which identified 15 highly vulnerable community areas. More than 2.7 million (67%) Chicagoans completed the vaccine regimen by December 2021. Black (51.3%) Chicagoans were considerably less likely to be vaccinated than Asian (77.6%), White (69.8%), and Hispanic (63.6%) Chicago residents. In addition, there were significant spatial differences in the rate of COVID-19 vaccine completion: predominantly White and Hispanic communities, compared with Black communities, had higher rates of vaccine completion. CONCLUSIONS: The community outreach efforts to improve COVID-19 vaccine uptake in Chicago have shown the importance of community-engaged approaches in pandemic responses. Despite citywide efforts to build community infrastructure, Black communities had relatively lower levels of vaccine uptake than other communities. Broader social restructuring to mitigate disinvestment and residential segregation and to ameliorate medical mistrust will be needed to prepare for future pandemics and disasters.

Interprofessional relationships and their impact on resident hospitalizations in nursing homes: A qualitative study.

AIM: The aim of this study is to explore experiences and perspectives of nurses and providers (e.g., physicians, medical directors, fellows, and nurse practitioners) on reducing preventable hospitalizations of nursing home (NH) residents in relation to interprofessional relationship and hospitalization decision-making process. BACKGROUND: Preventable NH resident hospitalization continues to be a pressing public health issue. Studies show that improved interprofessional relationship may help reduce hospitalization, yet research on communication processes and interactions among different NH staff remains limited. METHODS: This is a qualitative descriptive study. Two focus groups were held with fourteen nurses and thirteen in-depth, qualitative interviews were conducted with providers from two Chicagoland NHs. Focus group sessions and interviews were transcribed, coded, and analyzed for common themes based on qualitative description method. RESULTS: All study participants agreed that providers have the ultimate responsibility for hospitalization decisions. However, nurses believed they could influence those decisions, depending on provider characteristics, trust, and resident conditions. Nurses and providers differed in the way they experienced and conveyed emotions, and differed in key elements affecting hospitalization decisions such as structural or environmental factors (e.g., lacking staff and equipment at the facility, poor communication between the NH and hospitals) and interpersonal factors (e.g., characteristics of effective nurses or providers and the effective interactions between them). CONCLUSIONS: Interpersonal factors, including perceived competence, respect, and trust, may influence NH hospitalization decisions and be targeted for reducing preventable hospitalizations of residents.

Actualising power sharing in community-led initiatives: Insights from community-based organisation leaders in Chicago, USA.

There is an increasing call for a governmental organisations such as local health departments and federal health and human service agencies to partner with community based organisations (CBOs) for health promotion. There is a large body of literature suggesting that CBOs need capacity building or empowerment to do this work, but less literature about the necessary culture shift at governmental organisations who fund public health work. This study aimed to examine the knowledge, attitudes, and beliefs of CBO leadership who do not want to partner with state funders, and understand which structures and practices demonstrate power-sharing in a community-led approach. We conducted six interviews with community-based organisation leaders and conducted a thematic analysis and a secondary, inductive discourse analysis of the transcripts to analyse why organisations chose not to apply for a government funded initiative and how they talked about power-sharing for community-led public health. Themes about the decision for CBOs to apply to the public health funding initiative: how it related to the CBO's scope of work, meeting the needs of the community, having the technical capacity, and cross-cutting themes of putting the community first and having a long-term positive impact. Organisations rejected the opportunity for this funding due to poor fit, even if they could fulfil the scope of work. A community-led approach was described as one that includes the government giving up control, creating spaces for meaningful participation and power-sharing, and systems demonstrating trust in CBOs. These findings reiterate that in order for public health to be community-led, there needs to be system-wide transformation and intentional investment that supports an infrastructure for community-led public health. State funders can learn from practices in trust-based philanthropy, such as flexible funding and reporting requirements. The results of this study can support the wider participation of CBOs in collaboration with state actors, maximising the transformative potential of collaboration, ultimately transforming power structures and advancing health equity.

Employee Sources of Stress and Their Associations With Absenteeism: Differences by Wage Category.

OBJECTIVE: The aim of this study was to examine the association between sources of stress and self-reported illness- or injury-related absenteeism (SRIRA) across three wage categories among participants in an employee health and well-being program. METHODS: In multivariate analyses, linear regression models were analyzed separately by wage bands (low, <$46,100; moderate, $46,100 to $62,800; high, >$62,800). RESULTS: In the low-wage category, child care concerns are positively associated ( b = 0.5, P = ≤0.05), whereas illness or injury of a loved one is negatively associated ( b = -0.6, P = 0.05) with SRIRA. Personal illness/injury is positively associated with SRIRA across all wage bands (in ascending order of wage bands: b = 4.2, P < 0.001; b = 4.4, P < 0.001; b = 4.1, P < 0.001). CONCLUSION: Results provide evidence that employees in different wage categories experience different home-based stressors, which may impact SRIRA. Employers collecting SRIRA data may be better able to respond to the needs of employees in different wage categories.

Unique Barriers to Workplace Health Promotion Programs by Wage Category: A Qualitative Assessment of Secondary Data.

PURPOSE: To understand barriers around accessing or using workplace health promotion (WHP) programs among workers in different wage categories. APPROACH: We conducted qualitative analysis of responses to three open-ended questions about WHP program participation, collected as part of an existing WHP program evaluation. Setting: A large mid-western university. PARTICIPANTS: Of the 20,000 employees emailed an online survey, 3,212 responded (16.1%). The sample was mostly female (75%), white (79%), and comprised of staff members (84%). The average age was 44 years and 67% had annual incomes <$75,001. METHOD: We used NVivo-12 Plus and two coders to apply Grounded Theory on the open-ended questions and identify emergent themes. RESULTS: Although most respondents were happy with the program, differences across wage categories emerged around time, financial incentives, commute, workload, and organizational policies/support. Employees at all wage levels were enthusiastic about creating a culture of health but needed different cultural supports to do so. For instance, higher-wage workers needed to overcome self-made time constraints, while lower-wage workers needed supervisor support to overcome coverage constraints that prevented participation. CONCLUSION: The unique participation challenges experienced by employees in different wage categories provide justification for WHP programs that can better accommodate the participation barriers of all employees. While some programs may simply require more flexible offerings, supervisors may need to be trained to support and foster healthy environments.

Supporting Employee Health at Work: How Perceptions Differ Across Wage Category.

PURPOSE: This study examines the association between sources of stress and perceptions of organizational and supervisor support for health and well-being. DESIGN: Retrospective, cross-sectional analysis. SETTING: Large university in the mid-western United States. SAMPLE: This study focused on university employees with complete data for all variables (organizational support/N = 19,536; supervisor support/N = 20,287). MEASURES: 2019 socioeconomic and demographic characteristics, count of chronic conditions, sources of stress and perceptions of organizational and supervisor support. ANALYSIS: For the multivariate analyzes, linear regression models were analyzed separately by wage bands (low ≤$46,100; middle >$46,100-$62,800; high >$62,800). RESULTS: For all employees, workplace stressors, including problematic relationships at work and heavy job responsibilities, were negatively associated with perceptions of supervisor and organizational support. In comparison, the most salient home-based stressors were negatively associated with perceptions of supervisor support for the lowest-wage band (the death of a loved one, b = -0.13) and middle-wage band (personal illness or injury, b = -0.09), while the one for the highest-wage band (illness or injury of a loved one, b = 0.07) was positively associated with perceptions of supervisor support. CONCLUSION: Stressful job responsibilities and work relationships are associated with lower perceptions of supervisor and organizational support for health and well-being across all wage bands. Favorable perceived support for personal stressors only among high wage earning employees may suggest a need for improved equity of perceived support for these stressors among lower wage workers.

Integration of Primary Care Teams Within the Examination Room: A Qualitative Study of Advanced Team-Based Care.

Multidisciplinary teams deliver high-quality care in complex primary care environments. Using qualitative interviews, we explored the interpersonal dynamics of care team members from 2 models-traditional team-based care and "advanced team-based care" (aTBC). Two differentiating themes emerged-the ways care teams learned and collaborated. aTBC participants described learning from each other and integrating their roles and tasks more so than the traditional model. These differences have implications for patient care and care team member well-being. Our results provide a framework for improving team-based care models and for further research on the impact of adaptive learning and integration in primary care settings.

Certified Nursing Assistants' Barriers and Facilitators to Accessing and Using Worksite Health Promotion Programs.

OBJECTIVE: Certified nursing assistants (CNAs) are low-wage healthcare workers who provide direct care to nursing home residents, yet also experience significant health disparities. However, limited research has been conducted on CNAs' perceived barriers and facilitators to workplace health promotion (WHP) participation. METHOD: Informed by the Consolidated Framework for Implementation Research (CFIR), 24 CNA semi-structured, in-depth interviews were conducted in two Chicagoland nursing homes. RESULTS: Key barriers were time-constraints and lack of staffing, lack of access to WHP programs, and limited organizational and employer support. Facilitators included the availability of WHP programs, breaks, and other workplace benefits, and enhanced leadership and familial support. CONCLUSION: An effective WHP program must attempt to minimize the work-related, organizational, and environmental barriers while supporting high motivation of CNAs in health promotion. We offer some suggestions for enhancing CNAs' WHP access and utilization.

Experience of Chicagoland acute care hospitals in preparing for Ebola virus disease, 2014-2015.

During the 2014-2015 Ebola Virus Disease (EVD) outbreak, hospitals in the United States selected personal protective equipment (PPE) and trained healthcare personnel (HCP) in anticipation of receiving EVD patients. To improve future preparations for high-consequence infectious diseases, it was important to understand factors that affected PPE selection and training in the context of the EVD outbreak. Semistructured interviews were conducted with HCP involved with decision-making during EVD preparations at acute care hospitals in the Chicago, IL area to gather information about the PPE selection and training process. HCP who received training were surveyed about elements of training and their perceived impact and overall experience by email invitation. A total of 28 HCP from 15 hospitals were interviewed, and 55 HCP completed the survey. Factors affecting PPE selection included: changing guidance, vendor supply, performance evaluations, and perceived risk and comfort for HCP. Cost did not affect selection. PPE acquisition challenges were mitigated by: sharing within hospital networks, reusing PPE during training, and improvising with existing PPE stock. Selected PPE ensembles were similar across sites. Training included hands-on activities with trained observers, instructional videos, and simulations/drills, which were felt to increase HCP confidence. Many felt refresher training would be helpful. Hands-on training was perceived to be effective, but there is a need to establish the appropriate frequency of refresher training frequency to maintain competence. Lacking confidence in the CDC guidance, interviewed trainers described turning to other sources of information and developing independent PPE evaluation and selection. Response to emerging and/or high consequence infectious diseases would be enhanced by transparent, risk-based guidance for PPE selection and training that addresses protection level, ease of use, ensembles, and availability.

Utilizing the focused conversation method in qualitative public health research: a team-based approach.

BACKGROUND: Qualitative research studies are becoming increasingly necessary to understand the complex challenges in the healthcare setting. Successfully integrating interdisciplinary teams of investigators can be challenging, as investigators inherently view data through their disciplinary lens. Thus, new methods, such as focused conservation, are needed to facilitate qualitative data analysis by interdisciplinary teams. The purpose of this manuscript is to provide a clear description of how we implemented the focused conversation method to facilitate an organized data-driven discussion that responded to our study objectives and ensured participation of our interdisciplinary team. The focused conversation method has not, to our knowledge, been utilized for this purpose to date. METHODS: To better understand the experience of healthcare personnel (HCP) during preparations for the 2014-2015 Ebola Virus Disease (EVD) outbreak, we interviewed HCP who participated in decision making about EVD preparations and training of workers in the use of enhanced personal protective equipment ensembles in the metropolitan Chicagoland area of Illinois to attain a priori research objectives. We identified a systematic method - the focused conversation method - that enabled our interdisciplinary team to interactively contribute to the framing, analysis and interpretation of the data that would enable us to focus on our research objectives. RESULTS: The focused conversation developed to support our a priori research objective about the training of HCP in preparations included objective, reflective, interpretive and decisional questions. These questions grounded the conversation in the data, while leveraging discipline-specific lenses and professional experience in the analysis and interpretation. Insights from the conversation were reviewed later against interview transcripts to ensure validity. The conversation identified areas for future research directions and deficiencies in the interview instrument. CONCLUSIONS: The focused conversation is an efficient, organized method for analysis of qualitative data by an interdisciplinary team.

Worker well-being in the United States: Finding variation across job categories.

Job categories shape the contexts that contribute to worker well-being, including their health, connectivity, and engagement. Using data from the 2014 Gallup Daily tracking survey, this study documented the distribution of worker well-being across 11 broad job categories among a national sample of employed adults in the United States. Well-being was measured by Gallup-Sharecare Well-Being 5™, a composite measure of five well-being dimensions (purpose, community, physical, financial, and social). Analysis of variance (ANOVA) was used to examine how well-being varied across job categories and the extent to which household income modified that relationship, controlling for demographic factors. Well-being varied significantly across job categories, even after adjusting for household income and demographic factors. Well-being was higher among business owners, professionals, managers, and farming/fishing workers and lower among clerical/office, service, manufacturing/production, and transportation workers. Purpose well-being (e.g., liking what you do and being motivated to achieve your goals) showed the greatest variability across job categories-there were small differences across income levels for business owners, professionals, managers, and farming/fishing workers, and statistically significant gaps between the high income group and the two lower income groups among clerical/office, service, manufacturing/production, and transportation workers. Physical well-being exhibited the smallest gaps across income groups within job categories. The findings suggest that job category is an important component of worker well-being that extends beyond the financial dimension to purpose well-being. Our results suggest well-being inequity across job categories, and highlight areas for future research, policy and practice, including targeted interventions to promote worker and workplace well-being.

Health Management in Commercially Insured Populations: It Is Time to Include Social Determinants of Health.

: Employers have been challenged by low employee participation rates in health-related programs, and have often relied on incentives and other engagement approaches to overcome this difficulty. One of the apparent barriers to employee engagement in health-related activities is represented by social determinants of health. According to some, these factors comprise as much as 40% of an individual's health status, and while they have been the focus of attention in the public health domain, their role in the workplace has not been broadly recognized. In this manuscript, we provide an overview of the significance of social determinants of health in the workplace, addressing their influence on employee involvement in health-related offerings. We also acknowledge the unique role of the workplace as both a physical and social determinant of worker health.

Safety Climate Among Nontraditional Workers in Construction: Arguing for a Focus on Construed External Safety Image.

Safety climate, employees' perceptions of work-related safety, 1 has been promoted as a leading indicator of workplace safety in construction. 2 , 3 While research has primarily examined internal organizational sources (e.g., manager attitudes, formal organizational policies) on these perceptions, external sources of information might be more relevant to construction workers in nontraditional jobs who work for a limited time and/or have limited interaction with other employees. This paper argues for the future development of a construed external safety image scale to measure employees' perceptions about how external groups view their organization's safety. 4 The construed external safety image would capture the external sources that nontraditional workers use to assess safety climate and will allow public health researchers to identify and change dangerous workplaces while more effectively communicating information about safe workplaces to workers. The public health relevance of safety climate and construed external safety image for monitoring and communicating safety to nontraditional workers require examination.

Worksite Health Promotion for Low-Wage Workers: A Scoping Literature Review.

OBJECTIVE: To determine: (1) What research has been done on health promotion interventions for low-wage workers and (2) what factors are associated with effective low-wage workers' health promotion programs. DATA SOURCE: This review includes articles from PubMed and PsychINFO published in or before July 2016. Study Inclusion/Exclusion Criteria: The search yielded 130 unique articles, 35 met the inclusion criteria: (1) being conducted in the United States, (2) including an intervention or empirical data around health promotion among adult low-wage workers, and (3) measuring changes in low-wage worker health. DATA EXTRACTION: Central features of the selected studies were extracted, including the theoretical foundation; study design; health promotion intervention content and delivery format; intervention-targeted outcomes; sample characteristics; and work, occupational, and industry characteristics. DATA ANALYSIS: Consistent with a scoping review, we used a descriptive, content analysis approach to analyze extracted data. All authors agreed upon emergent themes and 2 authors independently coded data extracted from each article. RESULTS: The results suggest that the research on low-wage workers' health promotion is limited, but increasing, and that low-wage workers have limited access to and utilization of worksite health promotion programs. CONCLUSION: Workplace health promotion programs could have a positive effect on low-wage workers, but more work is needed to understand how to expand access, what drives participation, and which delivery mechanisms are most effective.

Dissemination of patient navigation programs across the United States.

OBJECTIVE: To use diffusion and dissemination frameworks to describe how indicators of economic and health care disparity affect the location and type of patient navigation programs. METHODS: A cross-sectional national Web-based survey conducted during 2009-2010 with support from 65 separate national and regional stakeholder organizations. PARTICIPANTS: A total of 1116 self-identified patient navigators across the United States. MAIN OUTCOME MEASURE: The location and characteristics of patient navigation programs according to economic and health care disparity indicators. RESULTS: Patient navigation programs appear to be geographically dispersed across the United States. Program differences were observed in navigator type, population served, and setting by poverty level. Programs in high-poverty versus low-poverty areas were more likely to use lay navigators (P < .001) and to be located in community health centers and agencies with religious affiliations (50.6 vs 36.4%, and 21.5% vs 16.7%. respectively; P ≤ 0.01). CONCLUSION(S): Results suggest that navigation programs have spread beyond initial target inception areas and also serve as a potentially important resource in communities with higher levels of poverty and/or relatively low access to care. In addition, while nurse navigators have emerged as a significant component of the patient navigation workforce, lay health navigators serve a vital role in underserved communities. Other factors from dissemination frameworks may influence the spread of navigation and provide useful insights to support the dissemination of programs to areas of high need.