Behavioral Health Care Delivery Through Street Medicine Programs in California.

Mental health and substance use disorders are prevalent among people experiencing homelessness. Street Medicine can reach unhoused people who face barriers to accessing healthcare in more traditional medical settings including shelter-based clinics. However, there is little guidance on best practices for mental health and substance use treatment through Street Medicine. The aim of the study was to describe behavioral health care through Street Medicine by analyzing data from the California Street Medicine Landscape survey and follow-up qualitative interviews. Most street medicine programs utilize non-psychiatrists to diagnose and treat mental health and substance use disorders, though the capacity to provide the level of care needed varies. There is a lack of street-based psychiatric clinicians and programs have difficulty making referrals to mental health and addiction services. This report shows that Street Medicine could serve as a strategy to expand access to behavioral health care for the unhoused.

Advocacy for Health Justice: An Innovative Pilot Course for MD and Master of Public Policy Students.

Problem: U.S. medical schools are searching for ways to address issues of health justice in undergraduate medical education. Physicians have not typically received training in how to be effective advocates for systemic change and individuals in policy fields are not usually equipped to understand the complex issues of health science and their intersection with the health system and society. To address this gap, medical school faculty partnered with school of public policy faculty on a collaborative learning model that engaged MD and Master of Public Policy students together to strengthen their collective knowledge of the healthcare landscape, and to build skills to work for health justice. Intervention: We hypothesized that pairing medical students with public policy students to learn about the intersections of health justice and advocacy could enhance the efficacy of each group and provide a new model of collaboration between medical and policy professionals. The students collaborated on a health justice advocacy project through which they provided consultation to an established community organization. Context: The 8-week course took place in the spring of 2021 in Los Angeles, California. Due to Covid-19 the course was taught online and included asynchronous learning modules and live Zoom sessions. The project also served as a pilot for the post-clerkship phase of a new longitudinal health justice curriculum for MD students that launched in August 2021. Impact: Analysis of student work products, course evaluations, partner interviews, and student focus groups showed that students valued learning through their interdisciplinary collaborative work which gave them new perspectives on health justice issues. The community partners indicated that the students consultative work products were useful for their initiatives, and that they found working with MD and MPP students to be a valuable way to think about how to build stronger and more inclusive coalitions to advocate for health justice. This project has the potential for national impact as it aligns with the Association of American Medical Colleges' renewed focus on the responsibility of academic medicine to partner with communities for health justice. The project also contributed to the national conversation on how to align health systems science education with the aims of health justice through our participation in the American Medical Association Accelerating Change in Medical Education Consortium. Lessons Learned: Leveraging faculty relationships with community partners was crucial for developing meaningful projects for students. Cultivating and expanding community partner networks is necessary to sustain and scale up this type of intervention. Centering the needs of communities and supporting their on-going work for health justice is essential for becoming an effective advocate. Learning communities that bring interdisciplinary students, healthcare providers, policy professionals, and community partners together to learn from one another can create key opportunities for ameliorating health inequities.

A Tobacco Control Framework for Regulating Public Consumption of Cannabis: Multistate Analysis and Policy Implications.

Eleven US states and Washington, DC, legalized recreational (adult use) cannabis. Seven states-Alaska, California, Colorado, Massachusetts, Nevada, Oregon, and Washington-allow cannabis sales. A public health concern is that exemptions in state or local smoke-free laws for public cannabis smoking or vaping will weaken smoke-free laws, expose the public to secondhand cannabis, and renormalize smoking.We describe the experience of the seven states and challenges faced in maintaining smoke-free laws. Using elements of a tobacco control framework, we identify best practices in cannabis regulation by comparing each state's smoke-free laws and allowances for public cannabis use. All states prohibit public cannabis use; two lack 100% smoke-free protections; one lacks vaping devices in its smoke-free law; three allow cannabis use in retailers; two allow cannabis use in social consumption lounges; and two allow cannabis use in tourism venues.States should close gaps in smoke-free laws and not expand where cannabis use is permitted to ensure public health.

Evaluation of a Digital Diabetes Prevention Program Adapted for Low-Income Patients, 2016-2018.

INTRODUCTION: We examined the effects of a digitally delivered, type 2 diabetes mellitus prevention program (DPP) for a low-income population. METHODS: We conducted a nonrandomized clinical trial with matched controls. The intervention group was offered a digital DPP, a web-based and mobile-based program including 52 weeks of participation in an educational curriculum, health coaching, and peer support. RESULTS: A total of 227 participants enrolled. At baseline, 34.6 was the mean body mass index, and 5.8 was the mean HbA1c. For the intervention group, mean weight loss was 4.4% at the 12-month follow-up. CONCLUSION: The modified DPP successfully engaged participants and resulted in weight loss. Low-income patients with prediabetes benefitted from a digitally delivered diabetes intervention. This prevention method should be accessible to a low-income population.

Assessment of student interprofessional education (IPE) training for team-based geriatric home care: does IPE training change students' knowledge and attitudes?

Our study assesses changes in students' knowledge and attitudes after participation in an interprofessional, team-based, geriatric home training program. Second-year medical, physician assistant, occupational therapy, social work, and physical therapy students; third-year pharmacy students; and fourth-year dental students were led by interprofessional faculty teams. Student participants were assessed before and after the curriculum using an interprofessional attitudes learning scale. Significant differences and positive data trends were noted at year-end. Our study suggests that early implementation, assessment, and standardization of years of student training is needed for optimal interprofessional geriatric learning. Additionally, alternative student assessment tools should be considered for future studies.

Community health events for enrolling uninsured into public health insurance programs: implications for health reform.

OBJECTIVES: To determine whether enrollment events may serve as a venue to identify eligible individuals, enroll them into health insurance programs, and educate them about the changes the Patient Protection and Affordable Care Act will bring about. METHODS: More than 2900 surveys were administered to attendees of 7 public health insurance enrollment events in California. Surveys were used to identify whether participants had any change in understanding of health reform after participating in the event. RESULTS: More than half of attendees at nearly all events had no knowledge about health reform before attending the event. On average, more than 80% of attendees knew more about health reform following the event and more than 80% believed that the law would benefit their families. CONCLUSIONS: Enrollment events can serve as an effective method to educate the public on health reform. Further research is recommended to explore in greater detail the impact community enrollment events can have on expanding public understanding of health reform.

Investigating the Comparative Effectiveness of Place-Based and Scatter-Site Permanent Supportive Housing for People Experiencing Homelessness During the COVID-19 Pandemic: Protocols for a Mixed Methods, Prospective Longitudinal Study.

BACKGROUND: Permanent supportive housing (PSH) is an evidence-based practice to address homelessness that is implemented using 2 distinct approaches. The first approach is place-based PSH (PB-PSH), or single-site housing placement, in which an entire building with on-site services is designated for people experiencing homelessness. The second approach is scatter-site PSH (SS-PSH), which uses apartments rented from a private landlord while providing mobile case management services. OBJECTIVE: This paper describes the protocols for a mixed methods comparative effectiveness study of 2 distinct approaches to implementing PSH and the patient-centered quality of life, health care use, and health behaviors that reduce COVID-19 risk. METHODS: People experiencing homelessness who are placed in either PB-PSH or SS-PSH completed 6 monthly surveys after move-in using smartphones provided by the study team. A subsample of participants completed 3 qualitative interviews at baseline, 3 months, and 6 months that included photo elicitation interviewing. Two stakeholder advisory groups, including one featuring people with lived experience of homelessness, helped guide study decisions and interpretations of findings. RESULTS: Study recruitment was supposed to occur over 6 months starting in January 2021 but was extended due to delays in recruitment. These delays included COVID-19 delays (eg, recruitment sites shut down due to outbreaks and study team members testing positive) and delays that may have been indirectly related to the COVID-19 pandemic, including high staff turnover or recruitment sites having competing priorities. In end-July 2022, in total, 641 people experiencing homelessness had been referred from 26 partnering recruitment sites, and 563 people experiencing homelessness had enrolled in the study and completed a baseline demographic survey. Of the 563 participants in the study, 452 had recently moved into the housing when they enrolled, with 272 placed in PB-PSH and 180 placed in SS-PSH. Another 111 participants were approved but are still waiting for housing placement. To date, 49 participants have been lost to follow-up, and 12% of phones (70 of the initial 563 distributed) were reported lost by participants. CONCLUSIONS: Recruitment during the pandemic, while successful, was challenging given that in-person contact was not permitted at times either by program sites or the research institutions during COVID-19 surges and high community transmission, which particularly affected homelessness programs in Los Angeles County. To overcome recruitment challenges, flexible strategies were used, which included extending the recruitment period and the distribution of cell phones with paid data plans. Given current recruitment numbers and retention rates that are over 90%, the study will be able to address a gap in the literature by considering the comparative effectiveness of PB-PSH versus SS-PSH on patient-centered quality of life, health care use, and health behaviors that reduce COVID-19 risk, which can influence future public health approaches to homelessness and infectious diseases. TRIAL REGISTRATION: ClinicalTrials.gov NCT04769349; https://clinicaltrials.gov/ct2/show/NCT04769349. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/46782.

Healthy Kids insurance and experiences of medical home quality for vulnerable children.

OBJECTIVES: To examine the relationship of enrollment in Healthy Kids insurance (locally funded insurance products for low-income children ineligible for other public insurance) with parent-reported experiences of primary care medical home quality. METHODS: A cross-sectional survey of parents of 4011 children stratified by established enrollees in Healthy Kids (enrolled 1 y or longer), new enrollees (less than 1 y), and children on a waitlist. We examined differences across groups in having an ongoing source of primary care, and experiences of 6 features of a medical home-accessibility, continuity, comprehensiveness, contextual knowledge, communication, and coordination-and a summary medical home measure. RESULTS: Compared with waitlisted children, new and established enrollees were more likely to have a regular source of care [odds ratio (OR)=2.49; 95% confidence interval (CI): 1.74-3.57 and OR=6.51; CI: 4.64-9.13, respectively] and a personal doctor or nurse (OR=3.41; CI: 2.42-4.80 and OR=7.00; CI: 5.07-9.66). Among those with a regular source of care and visit in the past year, new and established enrollees reported better medical home experiences in 4 and 6 of the 7 measures, respectively. CONCLUSIONS: Despite many barriers to care for vulnerable children, Healthy Kids enrollment was positively associated with having an ongoing source of primary care and better medical home experiences. As these children are mostly left out of healthcare reform, Healthy Kids programs may be a good model for other counties and states to help to connect such children to primary care.

Dual MD-MPH Degree Students in the United States: Moving the Medical Workforce Toward Population Health.

OBJECTIVE: A growing need exists to train physicians in population health to meet the increasing need and demand for physicians with leadership, health data management/metrics, and epidemiology skills to better serve the health of the community. This study examines current trends in students pursuing a dual doctor of medicine (MD)-master of public health (MPH) degree (MD-MPH) in the United States. METHODS: We conducted an extensive literature review of existing MD-MPH databases to determine characteristics (eg, sex, race/ethnicity, MPH area of study) of this student cohort in 2019. We examined a trend in the MD community to pursue an MPH career, adding additional public health and health care policy training to the MD workforce. We conducted targeted telephone interviews with 20 admissions personnel and faculty at schools offering MD-MPH degrees in the United States with the highest number of matriculants and graduates. Interviews focused on curricula trends in medical schools that offer an MD-MPH degree. RESULTS: No literature describes the US MD-MPH cohort, and available MD-MPH databases are limited and incomplete. We found a 434% increase in the number of students pursuing an MD-MPH degree from 2010 to 2018. The rate of growth was greater than the increase in either the number of medical students (16%) or the number of MPH students (65%) alone. Moreover, MD-MPH students as a percentage of total MPH students more than tripled, from 1.1% in 2010 to 3.6% in 2018. CONCLUSIONS: As more MD students pursue public health training, the impact of an MPH degree on medical school curricula, MD-MPH graduates, and MD-MPH career pursuits should be studied using accurate and comprehensive databases.

Disparities in COVID-19 vaccine hesitancy among Los Angeles County adults after vaccine authorization.

An equitable COVID-19 vaccine rollout is a necessary piece of the public health strategy to end the current pandemic; however, vaccine hesitancy may present a major hurdle. This study examines racial/ethnic and income-based disparities in vaccine hesitancy in Los Angeles County, a recent epicenter of the pandemic in the US, immediately after the Food and Drug Administration issued its emergency use authorization of a COVID-19 vaccine. We conducted online, stratified cross-sectional surveys of 1,984 adults living in Los Angeles County between December 2020 and January 2021 to assess hesitancy towards getting a COVID-19 vaccine. We used multivariable logistic regression to predict vaccine hesitancy after adjusting for covariates and calculated weighted population level estimates of hesitancy and reasons for hesitancy. Blacks and Hispanics were significantly more likely to be hesitant than Whites (AOR = 3.3, P < 0.001; AOR = 2.1, P = 0.008) as were those in the lowest income group (annual income <$20,000 compared to >$100,000) (AOR = 1.8, P = 0.009). Additionally, those having no confidence in doing things online (AOR = 3.3, P < 0.001) were less likely to accept the vaccine than those who were confident. Compared to hesitant White respondents, Black respondents had higher mistrust of the government (36.1% vs 22.1%, P = 0.03) and Black and Hispanic respondents were more likely to want to wait to see how the vaccine works (41.2% and 42.0% vs 27.3%, P = 0.02 and P = 0.006). Our study suggests that culturally appropriate messaging that addresses concerns for lower income and racial/ethnic minority communities, as well as alternatives to online vaccine appointments, are necessary for improving vaccine rollout.

Coronavirus Disease 2019 and the Case to Cover Undocumented Immigrants in California.

Latinos have been affected at higher rates in California. These include undocumented immigrants who are the largest group of Californians that remains uninsured. This population has limited access to health care services and coverage options. The coronavirus disease 2019 (COVID-19) pandemic has shown that undocumented immigrants are particularly vulnerable during this outbreak as they are more likely to delay seeking medical care and lack a regular source of care. In addition, many work in essential services, have low or moderate incomes, and live in overcrowded conditions increasing their risk for exposure to COVID-19. To reduce the state's COVID-19 burden, California should expand comprehensive Medi-Cal to all eligible individuals regardless of immigration status.

Improvements in access to care for vulnerable children in California between 2001 and 2005.

OBJECTIVE: We examined population changes in access to care for children in California during a period of major efforts to improve access to care for children. METHODS: We used cross-sectional data on 36,010 children aged 0-19 years from the 2001 and 2005 California Health Interview Survey to assess population changes in access to care. We assessed changes in access by individual risk factors and a composite risk profile. RESULTS: In 2005, a smaller proportion of children were uninsured (8.2% vs. 10.9% in 2001), living in poverty (20.7% vs. 23.2% in 2001), and in families without a high school education (20.8% vs. 23.6% in 2001), all p<0.001. Before and after adjusting for these changes in risk, children were more likely in 2005 to have had a physician visit (odds ratio [OR] = 1.09, 95% confidence interval [CI] 1.07, 1.12) and dental visit (OR=1.11, 95% CI 1.08, 1.14). Children were slightly less likely in 2005 to have a regular source of care (OR=0.94, CI 0.91, 0.96). Children who had the highest risk profiles (> or = 4 risk factors) experienced the largest gains in access. For example, children with three and > or = 4 risk factors had gains in dental visits of 11 and 20 percentage points, respectively (p<0.001 for each), compared with < or = 3 percentage points for children with fewer risk factors. CONCLUSIONS: This study found improvements in physician and dental visits between 2001 and 2005 that were not fully explained by changes in insurance coverage or other demographic risk factors. Vulnerable children fared well during this period, suggesting that California may be making important and potentially replicable strides in reducing disparities.

Changes in uncompensated pediatric ambulatory care visits for uninsured children among safety net providers after implementing a health insurance program for children of low-income families.

The role of the safety net has been debated in various proposals for healthcare reform in the United States. Yet little is known about how health coverage expansion affects the use of safety net services. This study uses data from Los Angeles County to analyze how the expansion of health insurance for low-income uninsured children has affected their utilization of ambulatory care services in safety net hospitals and health centers. In the Los Angeles Healthy Kids program, 40 000 mostly immigrant children ineligible for State Children's Health Insurance Program or Medicaid, were enrolled in a new insurance program called Healthy Kids. Coverage expansion was associated with a decrease in the utilization of pediatric services in two county-funded programs for the uninsured: directly operated healthcare services and private contracted programs. Thus, coverage expansion may have saved more than $37 million in compensated care for children. For public hospitals and other safety net clinics, these data and previous studies suggest that insurance not only improves access but also reconfigures where people get care. It also helps reduce uncompensated care and provides new avenues to support and stabilize the healthcare safety net. These data suggest that a state or jointly funded insurance expansion will help offset the growing burden of uncompensated care among safety net providers while improving utilization and health status among children. Universal coverage programs are not only good for children but also help stabilize the fragile healthcare safety net by reducing the demand for uncompensated care at county facilities.

Insurance Coverage, and Having a Regular Provider, and Utilization of Cancer Follow-up and Noncancer Health Care Among Childhood Cancer Survivors.

The objective of this study was to assess the role of health insurance coverage on patterns of health care utilization and access to cancer-related follow-up and non-cancer care among childhood cancer survivors (CCS). Cross-sectional survey design was used. Childhood cancer survivors were from 2 large hospitals in Los Angeles County. In all, 235 were identified through the Los Angeles Cancer Surveillance Program, diagnosed between the ages of 5 and 18 in 2000-2007 with any cancer type except Hodgkin lymphoma. At data collection in 2009-2010, participants were between 15 and 25 years old. Study exposure was health insurance coverage (private, public, and uninsured). Main outcomes and measures were respondents' regular source of care for cancer follow-up, noncancer care, and both; and having a cancer follow-up visit, primary care visit, and hospital emergency department visit in the past 2 years. Compared with those with private insurance, the uninsured were less likely to have a regular source for cancer follow-up (odds ratio [OR] = 4.3, 95% confidence interval [CI] = 1.9-9.4), less likely to have a source for noncancer care (OR = 3.3, 95% CI 1.6-6.9), and less likely to have a source of care for both (OR = 5.3, 95% CI = 2.1-13.5). Furthermore, uninsured CCS were less likely to have made visits to cancer specialists (OR = 4.5, 95% CI = 2.1-9.50) and were less likely to have seen a primary care physician in the past 2 years (OR = 3.9, 95% CI = 1.8-8.2). In addition, those with public (vs private) insurance were less likely to have a regular provider for primary care (OR = 2.5, 95% CI = 1.1-5.4) and less likely to have made a primary care visit in the past year (OR = 2.8, 95% CI = 2.1-13.5). Uninsured CCS are at risk of not obtaining cancer follow-up care, and those with public (vs. private) insurance have less access to primary care. Policies that ensure continuity of coverage for survivors as they age into adulthood may result in fewer barriers to needed care, which may lead to fewer health problems for CCS in the future.

Barriers to Primary Care After the Affordable Care Act: A Qualitative Study of Los Angeles Safety-Net Patients' Experiences.

Purpose: Millions of people gained health care coverage in Los Angeles after the Affordable Care Act (ACA); however, challenges with obtaining and utilizing primary care still persist, particularly in the safety net. In this study, we explore barriers to accessing primary care services among safety-net patients in Los Angeles after Medicaid expansion and implementation of other programs for safety-net patients after the ACA. Methods: We conducted qualitative interviews, in Spanish and English, with 34 nonelderly adult patients in 1 of 3 insurance groups: Medicaid, MyHealthLA (a health care program for low-income undocumented individuals), or uninsured. We recruited participants from three sites in Los Angeles in 2017. We analyzed our interviews using a framework approach and included emerging concepts from participant responses. Results: We identified seven themes regarding barriers to accessing primary care: understanding the concept of primary care, finding a primary care provider (PCP), switching PCPs, getting timely appointments, geography and transportation, perceived cost or coverage barriers, and preferring emergency or urgent care over primary care. Patients with Medicaid were more likely to report barriers compared with other groups. Uninsured patients were less likely to understand the concept of primary care. Patients with MyHealthLA noted getting timely appointments and cost of care to be significant barriers. Conclusion: Despite Medicaid and other coverage expansions for safety-net patients after the ACA, substantial barriers to accessing primary care persist. Addressing such barriers through the development of targeted interventions or broader policy solutions could improve access to primary care for safety-net patients in Los Angeles.

Evaluation of a digital diabetes prevention program adapted for the Medicaid population: Study design and methods for a non-randomized, controlled trial.

Previous studies have shown that lifestyle modification can successfully prevent or delay development of type 2 diabetes. This trial aimed to test if an underserved, low-income population would engage in a digital diabetes prevention program and successfully achieve lifestyle changes to reduce their risk of type 2 diabetes. Participants were recruited from three health care facilities serving low-income populations. The inclusion criteria were: a recent blood test indicating prediabetes, body mass index (BMI) > 24 kg/m2, age 18-75 years, not pregnant, not insured, Medicaid insured or Medicaid-eligible, internet or smartphone access, and comfort reading and writing in English or Spanish. A total of 230 participants were enrolled and started the intervention. Participants' average age was 48 years, average BMI = 34.8, average initial HbA1c = 5.8, 81% were female, and 45% were Spanish speaking. Eighty percent had Medicaid insurance, 18% were uninsured, and 2% were insured by a medical safety net plan. Participants completed a health assessment including measured anthropometrics, HbA1c test, and self-report questionnaires at baseline, 6 and 12 months. The 52-week digital diabetes prevention program included weekly educational curriculum, human health coaching, connected tracking tools, and peer support from a virtual group. Qualitative data on implementation was collected with semi-structured interviews with key informants to understand the barriers, keys to success, and best practices in the adoption of the program within the clinical setting. This paper describes the study design and methodology of a digital diabetes prevention program and early lessons learned related to recruitment, enrollment, and data collection.

Crisis & commitment: 150 years of service by Los Angeles county public hospitals.

The Los Angeles County University of Southern California Medical Center will open soon, replacing the county's current 74-year-old facility with a modern, although smaller, facility. Los Angeles County has provided hospital care to the indigent since 1858, during which time, the operation of public hospitals has shifted from a state-mandated welfare responsibility to a preeminent part of the county's public health mission. As this shift occurred, the financing of Los Angeles County hospitals changed from primarily county support to state and federal government sources, particularly Medicaid. The success of the new hospital will depend on whether government leaders at all levels provide the reforms needed to help the county and its partners stabilize its funding base.

Children's Health Initiatives in California: the experiences of local coalitions pursuing universal coverage for children.

OBJECTIVES: Many county coalitions throughout California have created local health insurance programs known as Healthy Kids to cover uninsured children ineligible for public programs as a result of family income level or undocumented immigrant status. We sought to gain an understanding of the experiences of these coalitions as they pursue the goal of universal coverage for children. METHODS: We conducted semistructured telephone-based or in-person interviews with coalition leaders from 28 counties or regions engaged in expansion activities. RESULTS: Children's Health Initiative coalitions have emerged in 31 counties (17 are operational and 14 are planned) and have enrolled more than 85000 children in their health insurance program, Healthy Kids. Respondents attributed the success of these programs to strong leadership, diverse coalitions of stakeholders, and the generosity of local and statewide contributors. Because Healthy Kids programs face major sustainability challenges and difficulties with provider capacity, most are cautiously looking toward statewide legislative solutions. CONCLUSIONS: The expansion of Healthy Kids programs demonstrates the ability of local coalitions to reduce the number of uninsured children through local health reform. Such local programs may become important models as other states struggle with declines in employer-based coverage and increasing immigration and poverty rates.

Enrolling in Medicaid through the National School Lunch Program: outcome of a pilot project in California schools.

California has several health insurance programs for children. However, the system for enrolling into these programs is complex and difficult to manage for many families. Express Lane Eligibility is designed to streamline the Medicaid (called Medi-Cal in California) enrollment process by linking it to the National School Lunch Program. If a child is eligible for free lunch and the parents consent, the program provides two months of presumptive eligibility for Medi-Cal and a simplified application process for continuation in Medi-Cal. For those who are ineligible, it provides a referral to other programs. An evaluation of Express Lane shows that while many children were presumptively enrolled, nearly half of the applicants were already enrolled in Medi-Cal. Many Express Enrolled children failed to complete the full Medi-Cal enrollment process. Few were referred to the State Children's Health Insurance Program or county programs. Express Lane is less useful as a broad screening strategy, but can be one of many tools that communities use to enroll children in health insurance.