Community-engaged Research Partnerships as Healing Spaces for Health Professionals and Researchers.

Drawing from collective experiences in our capacity building project: Health Equity Activation Research Team for Inclusion Health, we argue that while community-engaged partnerships tend to focus on understanding health inequities and developing solutions, they can be healing spaces for health professionals and researchers. Data were obtained from a 15-month participatory ethnography, including focus groups and interviews. Ethnographic notes and transcripts were coded and analyzed using both deductive and inductive coding. Practices of radical welcome, vulnerability, valuing the whole person, acknowledging how partnerships can cause harm, and centering lived experience expertise in knowledge creation processes were identified as key characteristics of healing spaces. Ultimately, health professionals and researchers work within the same social, political and economic contexts of populations with the worst health outcomes. Their own healing is critical for tackling larger systemic changes aimed at improving the well-being of communities harmed by legacies of exclusion.

Prospective Validation of a Simple Risk Score to Predict Hospitalization during the Omicron Phase of COVID-19.

INTRODUCTION: We previously developed a simple risk score with 3 items (age, patient report of dyspnea, and any relevant comorbidity), and in this report validate it in a prospective sample of patients, stratified by vaccination status. METHODS: Data were abstracted from a structured electronic health record of primary care and urgent care 8 patients with COVID-19 in the Lehigh Valley Health Network from 11/21/2021 and 10/31/2022 9 (Omicron variant). Our previously derived risk score was calculated for each of 19,456 patients, 10 and the likelihood of hospitalization was determined. Area under the ROC curve was calculated. RESULTS: We were able to place 13,239 patients (68%) in a low-risk group with only a 0.16% risk of 13 hospitalization. The moderate risk group with 5622 patients had a 2.2% risk of hospitalization 14 and might benefit from close outpatient follow-up, whereas the high-risk group with only 574 15 patients (2.9% of all patients) had an 8.9% risk of hospitalization and may require further 16 evaluation. Area under the curve was 0.844. DISCUSSION: We prospectively validated a simple risk score for primary and urgent care patients with COVID1919 that can support outpatient triage decisions around COVID-19.

Storylines of family medicine VI: ways of being-in the office with patients.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'VI: ways of being-in the office with patients', authors address the following themes: 'Patient-centred care-cultivating deep listening skills', 'Doctor as witness', 'Words matter', 'Understanding others-metaphor and its use in medicine', 'Communicating with patients-making good use of time', 'The patient-centred medical home-aspirations for the future', 'Routine, ceremony or drama?' and 'The life course'. May readers better appreciate the nuances of patient care through these essays.

The Radical Welcome Engagement Restoration Model and Assessment Tool for Community-Engaged Partnerships.

People experiencing addiction, houselessness, or who have a history of incarceration have worse health outcomes compared with the general population. This is due, in part, to practices and policies of historically White institutions that exclude the voices, perspectives, and contributions of communities of color in leadership, socio-economic development, and decision-making that matters for their wellbeing. Community-based participatory research (CBPR) approaches hold promise for addressing health inequities. However, full engagement of people harmed by systemic injustices in CBPR partnerships is challenging due to inequities in power and access to resources. We describe how an Allentown-based CBPR partnership-the Health Equity Activation Research Team of clinicians, researchers, and persons with histories of incarceration, addiction, and houselessness-uses the Radical Welcome Engagement Restoration Model (RWERM) to facilitate full engagement by all partners. Data were collected through participatory ethnography, focus groups, and individual interviews. Analyses were performed using deductive coding in a series of iterative meaning-making processes that involved all partners. Findings highlighted six defining phases of the radical welcome framework: (a) passionate invitation, (b) radical welcome, (c) authentic sense of belonging, (d) co-creation of roles, (e) prioritization of issues, and (f) individual and collective action. A guide to assessing progression across these phases, as well as a 32-item radical welcome instrument to help CBPR partners anticipate and overcome challenges to engagement are introduced and discussed.

Development and Validation of Simple Risk Scores to Predict Hospitalization in Outpatients with COVID-19 Including the Omicron Variant.

INTRODUCTION: Outpatient physicians need guidance to support decisions regarding hospitalization of COVID-19 patients and how closely to follow outpatients. Thus, we sought to develop and validate simple risk scores to predict hospitalization for outpatients with COVID-19 that do not require laboratory testing or imaging. METHODS: We identified outpatients 12 years and older who had a positive polymerase chain reaction test for SARS-CoV-2. Logistic regression was used to derive a risk score in patients presenting before March, 2021, and it was validated in a cohort presenting from March to September 2021 and an Omicron cohort from December, 2021 to January, 2022. RESULTS: Overall, 4.0% of 5843 outpatients in the early derivation cohort (before 3/1/21), 4.2% of 3806 outpatients in the late validation cohort, and 1.2% in an Omicron cohort were hospitalized. The base risk score included age, dyspnea, and any comorbidity. Other scores added fever, respiratory rate and/or oxygen saturation. All had very good overall accuracy (AUC 0.85-0.87) and classified about half of patients into a low-risk group with < 1% hospitalization risk. Hospitalization rates in the Omicron cohort were 0.22%, 1.3% and 8.7% for the base score. Two externally derived risk scores identified more low risk patients, but with a higher overall risk of hospitalization than our novel risk scores. CONCLUSIONS: A simple risk score suitable for outpatient and telehealth settings can classify over half of COVID-19 outpatients into a very low risk group with a 0.22% hospitalization risk in the Omicron cohort. The Lehigh Outpatient COVID Hospitalization (LOCH) risk score is available online as a free app: https://ebell-projects.shinyapps.io/LehighRiskScore/.

Implementation of a Virtual Asynchronous Scribe Program to Reduce Physician Burnout.

GOAL: Administrative burden is one of many potential root causes of physician burnout. Scribe documentation assistance can reduce this burden. However, traditional in-person scribe services are challenged by consistent staffing because the model requires the physical presence of a scribe and limits the team to a single individual. In addition, in-person scribes cannot provide the flexible support required for virtual care encounters, which can now pivot geographically and temporally. To respond to these challenges, our health network implemented an asynchronous virtual scribe model and evaluated the program's impact on clinician perceptions of burnout across multiple outpatient specialties. METHODS: Using a mixed-methods, pre-/postdesign, this evaluation measured the impact of an asynchronous virtual scribe program on physician burnout. Physicians were given the Professional Fulfillment Index tool (to self-assess their mental state) and free-text comment surveys before virtual scribe initiation and again at 3-, 6-, and 12-month intervals after program implementation. Descriptive statistics of survey results and qualitative review of free-text entries were analyzed for themes of facilitation and barriers to virtual scribe use. PRINCIPAL FINDINGS: Of 50 physician participants in this study, 42 (84%) completed the preintervention survey and 15 (36%) completed all 4 surveys; 25 participants (50%) discontinued scribe use after 12 months. Burnout levels-as defined by dread, exhaustion, lack of enthusiasm, decrease in empathy, and decrease in colleague connection-all trended toward improvement during this study. Importantly, quality, time savings, burnout, and productivity moved in positive directions as well. PRACTICAL APPLICATION: The cost burden to physicians and the COVID-19 pandemic inhibited the continued use of asynchronous virtual medical scribes. Nevertheless, those who continued in the program have reported positive outcomes, which indicates that the service can be a viable and effective tool to reduce physician burnout.

Qualitative Exploration of Geospatially Identified Bright Spots and Priority Areas to Improve Diabetes Management.

BACKGROUND: Type 2 diabetes (T2DM) results in significant morbidity and mortality and is associated with disparities in prevalence, treatment, and outcomes. GIS can identify geographically based disparities. In the focused Rapid Assessment Process (fRAP)-a novel mixed-method study design-GIS is combined with qualitative inquiry to inform practice interventions and policy changes. METHODS: Using fRAP, areas with poor T2DM outcomes (priority areas) as well as areas with positive T2DM outcomes (bright spots) were identified, focus groups were conducted, and responses analyzed for intervention opportunities. Focus group participants were English- and Spanish-speaking patients with T2DM living in one of the identified areas. Qualitative analysis consisted of initial coding with a priori themes from the focus group question guide, followed by identification of emergent themes within each defined category. RESULTS: The a priori categories included Facilitators, Barriers, Strategies, and Impact of Diabetes Diagnosis. Emerging recurrent themes were Interactions with Medical Professionals, Medications, Lifestyle Management, Family Motivators and Support, Self-Efficacy, and Social Needs and Community Resources. CONCLUSIONS: Thematic results from focus groups can be used by practices to improve T2DM care through educating patients about chronic disease and nutrition, connecting them to diabetes-specific services, learning how diabetes fits in the context of patient lives, and eliciting patient values and motivations to improve diabetes self-management. Findings also may be used by health care professionals to inform community-based advocacy efforts, interventions, and future research.

Development and Validation of Simple Risk Scores to Predict Hospitalization in Outpatients with COVID-19 Including the Omicron Variant.

INTRODUCTION: Outpatient physicians need guidance to support decisions regarding hospitalization of COVID-19 patients and how closely to follow outpatients. Thus, we sought to develop and validate simple risk scores to predict hospitalization for outpatients with COVID-19 that do not require laboratory testing or imaging. METHODS: We identified outpatients 12 years and older who had a positive polymerase chain reaction test for SARS-CoV-2. Logistic regression was used to derive a risk score in patients presenting before March, 2021, and it was validated in a cohort presenting from March to September 2021 and an Omicron cohort from December, 2021 to January, 2022. RESULTS: Overall, 4.0% of 5843 outpatients in the early derivation cohort (before 3/1/21), 4.2% of 3806 outpatients in the late validation cohort, and 1.2% in an Omicron cohort were hospitalized. The base risk score included age, dyspnea, and any comorbidity. Other scores added fever, respiratory rate and/or oxygen saturation. All had very good overall accuracy (AUC 0.85-0.87) and classified about half of patients into a low-risk group with < 1% hospitalization risk. Hospitalization rates in the Omicron cohort were 0.22%, 1.3% and 8.7% for the base score. Two externally derived risk scores identified more low risk patients, but with a higher overall risk of hospitalization than our novel risk scores. CONCLUSIONS: A simple risk score suitable for outpatient and telehealth settings can classify over half of COVID-19 outpatients into a very low risk group with a 0.22% hospitalization risk in the Omicron cohort. The Lehigh Outpatient COVID Hospitalization (LOCH) risk score is available online as a free app: https://ebell-projects.shinyapps.io/LehighRiskScore/.

A Novel Mixed Methods Approach Combining Geospatial Mapping and Qualitative Inquiry to Identify Multilevel Policy Targets: The Focused Rapid Assessment Process (fRAP) Applied to Cancer Survivorship.

Multi-level perspectives across communities, medical systems and policy environments are needed, but few methods are available for health services researchers with limited resources. We developed a mixed method health policy approach, the focused Rapid Assessment Process (fRAP), that is designed to uncover multi-level modifiable barriers and facilitators contributing to public health issues. We illustrate with a study applying fRAP to the issue of cancer survivorship care. Through this multi-level investigation we identified two major modifiable areas impacting high-quality cancer survivorship care: 1) the importance of cancer survivorship guidelines/data, 2) the need for improved oncology-primary care relationships. This article contributes to the mixed methods literature by coupling geospatial mapping to qualitative rapid assessment to efficiently identify policy change targets.

Substance use disorder approaches in US primary care clinics with national reputations as workforce innovators.

BACKGROUND: Over the last decade, primary care clinics in the United States have responded both to national policies encouraging clinics to support substance use disorders (SUD) service expansion and to regulations aiming to curb the opioid epidemic. OBJECTIVE: To characterize approaches to SUD service expansion in primary care clinics with national reputations as workforce innovators. METHODS: Comparative case studies were conducted to characterize different approaches among 12 primary care clinics purposively and iteratively recruited from a national registry of workforce innovators. Observational field notes and qualitative interviews from site visits were coded and analysed to identify and characterize clinic attributes. RESULTS: Codes describing clinic SUD expansion approaches emerged from our analysis. Clinics were characterized as: avoidant (n = 3), contemplative (n = 5) and responsive (n = 4). Avoidant clinics were resistant to planning SUD service expansion; had no or few on-site behavioural health staff; and lacked on-site medication treatment (previously termed medication-assisted therapy) waivered providers. Contemplative clinics were planning or had partially implemented SUD services; members expressed uncertainties about expansion; had co-located behavioural healthcare providers, but no on-site medication treatment waivered and prescribing providers. Responsive clinics had fully implemented SUD; members used non-judgmental language about SUD services; had both co-located SUD behavioural health staff trained in SUD service provision and waivered medication treatment physicians and/or a coordinated referral pathway. CONCLUSIONS: Efforts to support SUD service expansion should tailor implementation supports based on specific clinic training and capacity building needs. Future work should inform the adaption of evidence-based practices that are responsive to resource constraints to optimize SUD treatment access.

Primary care clinics in the US have been encouraged to expand addiction services to increase treatment access and respond to the opioid epidemic. This study uses structured observations and depth interviews to assess and compare how primary care clinics with innovative workforces have responded to the growing need for substance use disorder treatment. Each of the clinics studied represents a 'case.' We systematically compared cases to understand how and if addiction services were expanded. Twelve clinic 'cases' were coded and characterized based on a continuum of receptivity ranging from avoidant (i.e., resistant), contemplative (i.e., organization members plan to implement change) and responsive (i.e. expansions implemented). Our analysis characterized three clinics as avoidant to expanding addiction services reporting no plans to respond to calls to expand addiction services. Five clinics were characterized as contemplative, meaning they recognized the need but still had reservations and concerns about the expansion. Four clinics were characterized as responsive to addiction service expansion and had several organizational-wide strategies to assess, intervene and treat patients with addictions. Despite national and state-based policies to entice clinics to expand addiction services there was a diversity of approaches observed in clinics. Avoidant and contemplative clinics may need implementation support to build capacity for this type of delivery expansion.

Community-engaged fRAP: a mixed method approach for policy change and advocacy to reduce cancer disparities in Hispanic women.

Context: Cervical cancer is preventable and curable, yet Hispanic populations in certain areas of the United States have higher mortality rates from invasive cervical cancer than non-Hispanic white women. Objective: Our study aimed to develop community-engaged on-the-ground partnerships between our research team and local stakeholders to identify policy change targets for advocacy and action that could impact cervical cancer disparities in geographic areas of high need. Study Design: This mixed methods study utilized a community-engaged fRAP (focused Rapid Assessment Process) methodology to uncover modifiable differences in cervical cancer survivorship contributing to mortality differences at the county level. This poster highlights the final advocacy for change phase of the fRAP process, where we work in partnership with local community stakeholders to identify actionable steps targeted at local policy change through advocacy. Setting: This American Cancer Society funded project included ZCTA level mapping of cervical cancer cases alongside qualitative data in three Texas counties (Bexar, Dallas and Tarrant) over the last three years. Population studied: This study included data obtained from the Texas Cancer Registry for cervical cancer cases in the three counties from 1995-2015, along with 39 key informant interviews identified during fieldwork visits representing different levels of interest: community, medical systems, policy. Outcome Measures: We examine multi-level community, medical, and policy contextual elements within three counties using quantitative ZCTA level mapping to identify areas of interest for qualitative investigation. Qualitative investigation then proceeds with iterative cycles of community participant observation and mapping until saturation of themes is determined. Results: Through the use of multi-level cross-comparative investigation of community, medical and policy elements in different counties, we identified important contextual/policy differences impacting cervical cancer disparities in certain highest need locales. An online teach-out on immigrant health, a Facebook live "Platicas" workshop on women's health, and a county level disparities taskforce are one county's action steps to improve cervical cancer outcomes. Conclusions: Community-engaged fRAP effectively identifies local policy change targets for advocacy, with the goal for sustained community-engaged action aimed at decreasing cervical cancer disparities.

Identifying priority and bright spot areas for improving diabetes care: a geospatial approach.

The objective of this study was to describe a novel geospatial methodology for identifying poor-performing (priority) and well-performing (bright spot) communities with respect to diabetes management at the ZIP Code Tabulation Area (ZCTA) level. This research was the first phase of a mixed-methods approach known as the focused rapid assessment process (fRAP). Using data from the Lehigh Valley Health Network in eastern Pennsylvania, geographical information systems mapping and spatial analyses were performed to identify diabetes prevalence and A1c control spatial clusters and outliers. We used a spatial empirical Bayes approach to adjust diabetes-related measures, mapped outliers and used the Local Moran's I to identify spatial clusters and outliers. Patients with diabetes were identified from the Lehigh Valley Practice and Community-Based Research Network (LVPBRN), which comprised primary care practices that included a hospital-owned practice, a regional practice association, independent small groups, clinics, solo practitioners and federally qualified health centres. Using this novel approach, we identified five priority ZCTAs and three bright spot ZCTAs in LVPBRN. Three of the priority ZCTAs were located in the urban core of Lehigh Valley and have large Hispanic populations. The other two bright spot ZCTAs have fewer patients and were located in rural areas. As the first phase of fRAP, this method of identifying high-performing and low-performing areas offers potential to mitigate health disparities related to diabetes through targeted exploration of local factors contributing to diabetes management. This novel approach to identification of populations with diabetes performing well or poor at the local community level may allow practitioners to target focused qualitative assessments where the most can be learnt to improve diabetic management of the community.

Identifying Bright Spot Counties for Appropriate Diabetes Preventive Care: A Geospatial, Positive Deviance Approach.

Positive deviance approaches, which have been used to identify and study high performers (bright spots) and translate their successes to poorer performers, offer great potential for chronic disease management. However, there are few examples of applying positive deviance approaches across different geographic contexts. Building on prior research that developed a new measure for appropriate diabetes preventive care (DMPrevCare) and identified priority counties for this strategy, we introduce a geospatial approach for identifying bright spot counties and case matching them to priority counties that need improvement. We used the Local Moran's I tool to identify DMPrevCare spatial outliers, which are counties with larger percentages of Medicare beneficiaries receiving appropriate diabetes preventive care (DMPrevCare) surrounded by counties with smaller percentages of Medicare beneficiaries receiving DMPrevCare. We define these spatial outliers as bright spots. The Robert Wood Johnson Foundation County Health Rankings Peer Counties tool was used to link bright spot counties to previously identified priority counties. We identified 25 bright spot counties throughout the southern and mountain western United States. Bright spot counties were linked to 45 priority counties, resulting in 23 peer (bright/priority) county groups. A geospatial approach was shown to be effective in identifying peer counties across the United States that had either poor or strong metrics related to DMPrevCare, but were otherwise similar in terms of demographics and socioeconomic characteristics. We describe a framework for the next steps in the positive deviance process, which identifies potential factors in bright spot counties that positively impact diabetes care and how they may be applied to their peer priority counties.

Identifying diabetes management opportunity areas in the USA.

Using adherence to diabetes management guidelines as a case study, this paper applied a novel geospatial hot-spot and cold-spot methodology to identify priority counties to target interventions. Data for this study were obtained from the Dartmouth Atlas of Healthcare, the United States Census Bureau's American Community Survey and the University of Wisconsin County Health Rankings. A geospatial approach was used to identify four tiers of priority counties for diabetes preventive and management services: diabetes management cold-spots, clusters of counties with low rates of adherence to diabetes preventive and management services (Tier D); Medicare spending hot-spots, clusters of counties with high rates of spending and were diabetes management cold-spots (Tier C); preventable hospitalisation hot-spots, clusters of counties with high rates of spending and are diabetes management cold-spots (Tier B); and counties that were located in a diabetes management cold-spot cluster, preventable hospitalisation hot-spot cluster and Medicare spending hot-spot cluster (Tier A). The four tiers of priority counties were geographically concentrated in Texas and Oklahoma, the Southeast and central Appalachia. Of these tiers, there were 62 Tier A counties. Rates of preventable hospitalisations and Medicare spending were higher in Tier A counties compared with national averages. These same counties had much lower rates of adherence to diabetes preventive and management services. The novel geospatial mapping approach used in this study may allow practitioners and policy makers to target interventions in areas that have the highest need. Further refinement of this approach is necessary before making policy recommendations.

A mixed-methods analysis of the capacity of the Patient-Centered Medical Home to implement care coordination services for cancer survivors.

There are currently 15.5 million cancer survivors in USA who are increasingly relying on primary care providers for their care. Patient-Centered Medical Homes (PCMHs) have the potential to meet the unique needs of cancer survivors; but, few studies have examined PCMH attributes as potential resources for delivering survivorship care. This study assesses the current care coordination infrastructure in advanced PCMHs, known to be innovative, and explores their capacity to provide cancer survivorship care. We conducted comparative case studies of a purposive sample (n = 9) of PCMHs to examine current care coordination infrastructure and capacity through a mixed- methods analysis. Data included qualitative interviews, quantitative surveys, and fieldnotes collected during 10- to 12-day onsite observations at each practice. Case studies included practices in five states with diverse business models and settings. Eight of the nine practices had National Committee for Quality Assurance Level 3 PCMH recognition. No practices had implemented a systematic approach to cancer survivorship care. We found all practices had a range of electronic population health management tools, care coordinator roles in place for chronic conditions, and strategies or protocols for tracking and managing complex disease groups. We identified potential capacity, as well as barriers, to provide cancer survivorship care using existing care coordination infrastructure developed for other chronic conditions. This existing infrastructure suggests the potential to translate care coordination elements within primary care settings to accelerate the implementation of systematic survivorship care.

The Patient-Centered Medical Home (PCMH) Framing Typology for Understanding the Structure, Function, and Outcomes of PCMHs.

INTRODUCTION: Patient-centered medical homes (PCHMs) aspire to transform today's challenged primary care services. However, it is unclear which PCMH characteristics produce specific outcomes of interest for care delivery. This study tested a novel typology of PCMH practice transformation, the PCMH framing typology, and evaluated measurable outcomes by each type. METHODS: Using the Patient-Centered Primary Care Collaborative 2012 to 2013 Annual Review, this secondary analysis of the published PCMH literature extracted data from publications of 59 PCMHs. Each of the 59 sites was categorized as 1 of 4 PCMH types: add-on, renovated, hybrid, or integrated. Six outcome measures (cost reductions, decreased emergency department/hospital utilization, improved quality, improved access, increased preventive services, and improved patient satisfaction) were independently coded for each site. Practices were combined based on type, and mean outcomes scores for each measure were displayed on radar graphs for comparison. RESULTS: While each type showed a characteristic pattern of success, only the integrated type improved in all 6 outcomes. No type achieved high success in all measures. DISCUSSION: There seem to be 4 types of PCMH, each of which shows a distinctive outcomes profile. Within the PCMH framing typology, direction is emerging for how best to transform primary care to achieve the greatest success.