Effects of the COVID-19 Pandemic on Patient Navigation for Health-Related Social Needs: Reflections From the Accountable Health Communities Model.

BACKGROUND AND OBJECTIVES: This paper uses data from the Center for Medicare & Medicaid Innovation's Accountable Health Communities (AHC) Model to assess the effects of the COVID-19 pandemic on patient navigation (PN) for health-related social needs. METHODS: We analyzed evaluation data from 28 organizations implementing the Center for Medicare & Medicaid Innovation's AHC Model. We first distilled themes from 81 stakeholder interviews conducted in 2021. We then analyzed quantitative beneficiary-level data on acceptance of navigation among 133,173 unique Medicare and Medicaid beneficiaries who were eligible for navigation between January 2019 and March 2021. RESULTS: During the pandemic, interview participants described greater complexity of patients' cases and uncertainty regarding community service availability. Changes to navigation staffing and mode led to improvements in navigation quality and efficiency, but also challenges such as reduced rapport with patients. The pandemic increased navigator stress and burnout but also deepened appreciation for navigation among navigators and their patients. Beneficiaries were more likely to accept navigation during the pandemic than before the pandemic ( P < .05). CONCLUSIONS: Changes in PN during the pandemic were perceived as both good and bad. Future work is needed to assess the long-term implications of pandemic-related changes to navigation for patients and navigators.

Addressing Health-Related Social Needs Via Community Resources: Lessons From Accountable Health Communities.

The Center for Medicare and Medicaid Innovation launched the Accountable Health Communities (AHC) Model in 2017 to assess whether identifying and addressing Medicare and Medicaid beneficiaries' health-related social needs reduced health care use and spending. We surveyed a subset of AHC Model beneficiaries with one or more health-related social needs and two or more emergency department visits in the prior twelve months to assess their use of community services and whether their needs were resolved. Survey findings indicated that navigation-connecting eligible patients with community services-did not significantly increase the rate of community service provider connections or the rate of needs resolution, relative to a randomized control group. Findings from interviews with AHC Model staff, community service providers, and beneficiaries identified challenges connecting beneficiaries to community services. When connections were made, resources often were insufficient to resolve beneficiaries' needs. For navigation to be successful, investments in additional resources to assist beneficiaries in their communities may be required.

Disparities in care by insurance status for individuals with rheumatoid arthritis: analysis of the medical expenditure panel survey, 2006-2009.

OBJECTIVE: Treatment guidelines for rheumatoid arthritis (RA) recommend early, aggressive treatment with nonbiologic and biologic disease-modifying antirheumatic drugs (DMARDs) to minimize long-term disability. We aimed to assess differences in medical resource utilization, drug therapy, and health outcomes among RA patients by insurance type in the United States. METHODS: Individuals with a self-reported diagnosis of RA were identified in the Medical Expenditure Panel Survey (MEPS) database, 2006-2009. Data regarding sociodemographic characteristics, insurance type and status, and outcomes (including health care resource utilization, prescription medication use, health status, and patient-reported barriers to health care) were extracted. Multivariable regression analyses were used to examine the impact of insurance type (private, Medicare, Medicaid, or uninsured) on outcome measures while controlling for age group, sex, and race/ethnicity. RESULTS: A total of 693 individuals with a self-reported diagnosis of RA during the study period were identified; 423 were aged 18-64 years and 270 were aged ≥65 years. Among patients aged 18-64, those with Medicaid or who were uninsured were less likely than those with private insurance to visit a rheumatologist (adjusted odds ratio [aOR] 0.13 and 0.17, respectively; p < .001) and to receive biologic DMARDS (aOR 0.09 [p < .001] and 0.16 [p < .01], respectively); those with Medicaid were also less likely to receive nonbiologic DMARDS (aOR 0.26 [p < .01]). Those with Medicaid were more likely than those with private insurance to be unable/delayed in getting prescription drugs (aOR 2.9 [p < .05]), to experience cognitive, social, and physical limitations (aOR 8.7 [p < .001], 4.7 [p < .001], and 2.5 [p < .05], respectively); they also reported significantly lower general health and health-related quality of life. Patients aged ≥65 experienced greater equity in care and outcomes. CONCLUSIONS: Younger RA patients with Medicaid (including those who receive coverage under the Medicaid expansion component of the Affordable Care Act) may be at risk for inadequate treatment.

How accurate are Americans' perceptions of their own weight?

As obesity/overweight has increased in the United States (Centers for Disease Control and Prevention, 2009 ), studies have found that Americans' perceptions of their own weight often are not aligned with their actual body mass index (BMI; Brener et al., 2004 ; Christakis, 2003; Johnson-Taylor et al., 2008 ). Taylor, Funk, and Craighill ( 2006 ) found that half of Americans whose BMI indicated they were overweight perceived their weight to be just about right. The purpose of this study was to examine factors that influence the accuracy of weight self-perceptions and whether accuracy influences health behaviors. Using data from the 2007 Health Information National Trends Survey, the authors compared respondents' weight self-perceptions to their actual BMI to determine the accuracy of their weight self-perceptions. About 28%of respondents were obese, 35%were overweight, 35%were of normal weight, and 2%were underweight. About three quarters of the sample's self-perceptions of weight were aligned with their BMI. About 10%of the sample had a BMI that indicated they were overweight, but they perceived themselves to be of normal weight; about 10%were of normal weight but perceived themselves to be overweight; and about 5%of respondents were of normal weight but thought they were underweight. Gender, race, and education were associated with the accuracy of respondents' weight perceptions. Results suggest that asking patients about their weight self-perceptions could be useful in clinical settings and that weight perception accuracy could be used to segment audiences and tailor messages.

Communicating risk of hereditary breast and ovarian cancer with an interactive decision support tool.

OBJECTIVE: Women with hereditary breast and ovarian cancer syndrome (HBOC) face a higher risk of earlier, more aggressive cancer. Because of HBOC's rarity, screening is recommended only for women with strong cancer family histories. However, most patients do not have accurate history available and struggle to understand genetic concepts. METHODS: Cancer in the Family, an online clinical decision support tool, calculated women's HBOC risk and promoted shared patient-provider decisions about screening. A pilot evaluation (n=9 providers, n=48 patients) assessed the tool's impact on knowledge, attitudes, and screening decisions. Patients used the tool before wellness exams and completed three surveys. Providers accessed the tool during exams, completed exam checklists, and completed four surveys. RESULTS: Patients entered complete family histories (67%), calculated personal risk (96%), and shared risk printouts with providers (65%). HBOC knowledge increased dramatically for patients and providers, and many patients (75%) perceived tool results as valid. The tool prompted patient-provider discussions about HBOC risk and cancer family history (88%). CONCLUSIONS: The tool was effective in increasing knowledge, collecting family history, and sparking patient-provider discussions about HBOC screening. PRACTICE IMPLICATIONS: Interactive tools can effectively communicate personalized risk and promote shared decisions, but they are not a substitute for patient-provider discussions.

Application of the RE-AIM framework to evaluate the impact of a worksite-based financial incentive intervention for smoking cessation.

OBJECTIVE: To apply the RE-AIM framework to examine factors that may have influenced the impact of a financial incentive smoking cessation intervention delivered at General Electric (GE) worksites. METHODS: Intervention reach and efficacy were examined alone and in combination across worksites. Telephone interviews were conducted with worksite staff to explore organizational-level factors that may have influenced program adoption, implementation, and maintenance. Focus groups were conducted with employees to explore barriers and facilitators to program participation. RESULTS: Intervention impact varied considerably across GE business industries when reach and efficacy both were examined instead of efficacy alone. Barriers that may have hindered program success include time constraints, competing priorities, work stress, and the lack of public visibility. CONCLUSION: Employers considering financial incentive interventions for smoking cessation should examine how organizational context and real-world constraints may influence differential impact across sites.

Impact of insurance status on access to care and out-of-pocket costs for U.S. individuals with epilepsy.

We analyzed data from the 2002-2007 Medical Expenditure Panel Survey (MEPS) to assess whether individuals with epilepsy who are uninsured and those who have Medicaid coverage experience differences in medical resource utilization or out-of-pocket costs compared with those having other types of insurance. With sociodemographic characteristics controlled for, uninsured individuals had significantly fewer outpatient visits, fewer visits with neurologists, and greater antiepileptic drug costs than did those with private insurance. Individuals with Medicaid coverage had similar medical resource utilization rates but lower out-of-pocket costs compared with privately insured individuals. These findings indicate substantial barriers to receipt of appropriate medical care for uninsured individuals with epilepsy, but not for those with Medicaid coverage. Future studies should evaluate whether ongoing changes to the US health care system are able to address the differences in care we found among uninsured individuals with epilepsy and should incorporate measures of disease severity and unmet need.

The public's response to the U.S. Preventive Services Task Force's 2009 recommendations on mammography screening.

BACKGROUND: On November 16, 2009, the U.S. Preventive Services Task Force (USPSTF) released new breast cancer screening recommendations, resulting in considerable controversy. PURPOSE: The purpose of this investigation was to assess the volume and framing of the public discourse around the mammography recommendations and determine if women were knowledgeable about the new recommendations. METHODS: Two different types of data collection methods were used for this study: (1) a content analysis of news stories and social media posts around the time of the USPSTF announcement and (2) a web-based survey of women aged 40-74 years conducted through Knowledge Networks from December 17, 2009, to January 6, 2010. Data were analyzed in 2010. RESULTS: The survey sample included 1221 women aged 40-74 years who had never had breast cancer. The majority of the articles and posts (51.9%) did not support the screening recommendations, and 17.6% were supportive. Less than one quarter of the sample could identify the new recommendations for women aged 40-49 years and 50-74 years. Results from logistic regression analyses identified characteristics associated with correct knowledge of the recommendations for each age group. Level of attention paid to the recommendations was significantly associated with accurate knowledge of the recommendations for each age group. Having a mammogram within the past 2 years, "other" race (i.e., not black or white), and having higher levels of education, confidence that recommendations were based on the latest research, and attention paid to the new guidelines were all significantly and positively associated with correct knowledge of the new recommendation for women aged 40-49 years. CONCLUSIONS: The new recommendations confused women (30.0%) more than they helped them understand when to get a mammogram (6.2%). Confusion was greatest among women aged 40-49 years and women who had never had a mammogram or who had one more than 2 years ago. Communication about future recommendations should be pretested to identify strategies and language that may reduce confusion among providers, consumers, and advocacy groups.

Clinical management of smoking cessation: patient factors affecting a reward-based approach.

Although the majority of current smokers indicate they would like to quit, only about half of smokers make a quit attempt each year. Of those who attempt to quit, only about 5% are successful. Many effective products and programs are available to assist in smoking cessation; however those interested in quitting often do not make use of these resources. To increase use of cessation products in order to improve successful cessation rates, the Consumer Demand Roundtable has argued that smokers need to be viewed as consumers of cessation products rather than as patients needing treatment. With this consumer-based approach in mind, the current review examines how participant characteristics, perceptions, and behavior influence, and are influenced by, contingency management (CM) paradigms in various settings. Findings suggest that participant factors associated with success in these programs include demographic characteristics (eg, gender, marital status), self-efficacy, motivation to quit, and impulsivity. Overall, participants perceive incentives for successful cessation as motivating. However, such programs may involve greater withdrawal symptoms (eg, craving for cigarettes) initially, but these symptoms tend to decrease at a greater rate over time compared with nonincentive group participants. CM programs have also been shown to be successful across a number of settings (eg, communities, schools), including settings in which smokers are often considered difficult to treat (eg, substance abuse treatment centers). Overall, CM programs are perceived positively by participants and can increase rates of successful cessation. Furthermore, CM interventions have the flexibility to adapt to individual preferences and needs, leading to greater participation and likelihood of successful cessation. Thus, CM provides an important framework for addressing the need for consumer-focused smoking cessation interventions.

Systematic review of public health branding.

Brands build relationships between consumers and products, services, or lifestyles by providing beneficial exchanges and adding value to their objects. Brands can be measured through associations that consumers hold for products and services. Public health brands are the associations that individuals hold for health behaviors, or lifestyles that embody multiple health behaviors. We systematically reviewed the literature on public health brands; developed a methodology for describing branded health messages and campaigns; and examined specific branding strategies across a range of topic areas, campaigns, and global settings. We searched the literature for published studies on public health branding available through all relevant, major online publication databases. Public health branding was operationalized as any manuscripts in the health, social science, and business literature on branding or brands in health promotion marketing. We developed formalized decision rules and applied them in identifying articles for review. We initially identified 154 articles and reviewed a final set of 37, 10 from Africa, Australia, and Europe. Branded health campaigns spanned most of the major domains of public health and numerous communication strategies and evaluation methodologies. Most studies provided clear information on planning, development, and evaluation of the branding effort, while some provided minimal information. Branded health messages typically are theory based, and there is a body of evidence on their behavior change effectiveness, especially in nutrition, tobacco control, and HIV/AIDS. More rigorous research is needed, however, on how branded health messages impact specific populations and behaviors.

Changing perceptions of the childhood obesity epidemic.

OBJECTIVES: To examine changes in public attitudes about childhood obesity and support for prevention. METHODS: RTI surveyed US households (N = 1047 and N = 1139) about perceived severity, causes, and support for specific obesity interventions. Logistic regressions examined differences in obesity attitudes and support for prevention. RESULTS: Perceived health threat of childhood obesity increased between the 2 surveys. Support increased for interventions such as regulation of restaurant portions and fast food advertising. Logistic regressions revealed differences among sociodemographic groups. CONCLUSIONS: Public support for childhood obesity prevention is increasing. Policy makers can use these findings to develop appropriate prevention strategies.

The influence of social environment and social image on adolescent smoking.

This purpose of this article is to explore differences by gender and school grade in patterns of association among social influences and tobacco use. Data from the 1999 (N = 15,038) and 2000 (N = 35,828) National Youth Tobacco Survey (American Legacy Foundation, 1999, 2000), a nationally representative, repeated cross-sectional survey, were used in the analysis. The authors compared effects on adolescent smoking. Direct paths from social environment to current smoking increased from middle school to high school. Indirect paths with social image mediating this relationship revealed a smaller increase. The pattern was constant across subsamples. Social image of smokers mediated the influence of social environment on adolescent smoking. Social image had a greater effect on smoking among middle school boys and high school girls.

How I see me depends on how I see we: the role of attachment style in social comparison.

The self-concept is a social, flexible construct that shifts in response to the salience of a relationship partner. Three related experiments found that the tendency to pursue closeness in relationships (as measured by attachment style) served as a moderator of the shift. Specifically, individuals who avoid closeness in relationships became less similar to salient friends via contrast effects, whereas those who pursued closeness in relationships became more similar to salient friends via assimilation effects. Results are discussed in terms of their implications for the nature of the self-concept and the importance of friendships.

Public perceptions of childhood obesity.

BACKGROUND: Obesity has been identified as an epidemic by the Centers for Disease Control and Prevention. Rates of unhealthy body weight among children and adolescents have tripled since the 1980s to 15%. Media coverage of obesity has also increased, and the public is now highly aware of obesity-related health threats facing adults and children. METHODS: RTI International sponsored a representative survey of U.S. households (n =1047) that included detailed questions about perceptions of the severity, causes, and public support for specific intervention strategies to combat childhood obesity. Logistic regressions were calculated to examine differences in support by sociodemographic characteristics. RESULTS: Respondents considered childhood obesity to be as serious as other major childhood health threats, such as tobacco use and violence, but not as serious as drug abuse. They supported most school-, community-, and media-based strategies that involved offering health information, limiting unhealthy food promotion, and increasing healthy nutrition and physical activity choices, but were generally opposed to regulatory and tax- or cost-based interventions. Logistic regressions revealed significantly greater support for some interventions among highly educated individuals and women, and lower support among parents with children at home. CONCLUSIONS: This study demonstrates that there is strong public support for interventions aimed at reducing overweight and obesity among children and adolescents. It also shows specific school, community, and media interventions that the public supports and opposes, and what consequences the public will accept in combating childhood obesity. These findings can help policymakers and public health professionals design and implement appropriate interventions.