Offering transportation services to economically disadvantaged patients at a family health center: a case study.

It has been established that high no-show rates of publicly supported health systems in economically depressed areas are largely due to a lack of inexpensive, reliable transportation. The purpose of this paper is to determine the financial feasibility of offering transportation and investigate the net cost savings by reducing no-show rates. The approach starts with a data analysis on 636 patients at the Family Health Center (FHC) in San Antonio, Texas, followed by logistic regression to determine the impact of various transportation factors on cancellations/no-shows and late arrivals. We then investigate the costs savings that could be realised by reducing the no-show rate from 24.3% by up to 60%. Finally, we analyse the expenses that would be incurred should the FHC provide transportation. The full analysis indicates a cost reduction of more than $15,000 per month can be achieved when the no-show rate is reduced by 25% down to 18.2%.

Community Health Workers as Trust Builders and Healers: A Cohort Study in Primary Care.

PURPOSE: Improving patients' self-care for chronic disease is often elusive in the context of social deprivation. We evaluated whether a practice-integrated community health worker (CHW) intervention could encourage effective long-term self-management of type 2 diabetes mellitus (T2DM). METHODS: This cohort study, in a safety-net primary care practice, enrolled patients with uncontrolled T2DM and psychosocial risk factors. Patients were identified through a practice diabetes registry or by clinicians' referrals. The CHWs engaged patients in trust building and sensemaking to understand their social context, identify goals, navigate health care, and connect to community resources. Primary outcome was progress through 3 prospectively defined stages of self-care: outreach (meeting face-to-face); stabilization (collaborating to address patients' life circumstances); and self-care generativity (achieving self-care competencies). Secondary outcomes were change in hemoglobin A1c (HbA1c) and need for urgent care, emergency department, or hospital visits. RESULTS: Of 986 participating patients, 27% remained in outreach, 41% progressed to stabilization, and 33% achieved self-care generativity. Repeated measures ANOVA demonstrates an overall decline in HbA1c, without group differences, through the 4th HbA1c measurement (mean follow-up 703 days). Beginning at the 5th HbA1c measurement (mean 859 days), the self-care generativity group achieved greater declines in HbA1c, which widened through the 10th measurement (mean 1,365 days) to an average of 8.5% compared with an average of 8.8% in the outreach group and 9.0% in the stabilization group (P = .003). Rates of emergency department and hospital visits were lower in the self-care generativity group. CONCLUSIONS: Practice-linked CHWs can sustainably engage vulnerable patients, helping them advance self-management goals in the context of formidable social disadvantage.

Telephone or Visit-Based Community Health Worker Care Management for Uncontrolled Diabetes Mellitus: A Longitudinal Study.

Community health workers (CHWs) can reduce health disparities for low income patients but type of contact and outcomes has had limited study. Low-income Hispanic primary care patients with hemoglobin A1c [HbA1c] ≥ 9% received care managment (CM) over 6 months classified as: (CM1) telephone only; (CM2) clinic visit but no calls; (CM3) clinic visit with calls; and (CM4) ≥ 2 visits ± calls. Type of CM delivery and time to DM control (HbA1c < 9%) examined in Cox proportional hazards model and more rapid control within 6 months using logistic regression. Models adjusted for demographics, clinical, and health care variables. At baseline, 523 patients had mean HbA1c 10.9% (SD = 1.7%), mean age 57.9 years (SD = 10), 58.5% women, 87.6% Hispanic, and 55.5% uninsured. CM types for patients: 51 (9.8%) CM1; 192 (36.7%) CM2; 44 (8.4%) CM3; and 236 (45.4%) CM4. Median time to HbA1c control was 197 days (95% CI [71, 548]) and 41.5% achieved control within 6 months. Compared with CM1, control was more rapid for CM2 (Hazard ratio [HR] 1.45, 95% CI [1.01, 2.09], p = 0.043) and CM4 but not significant (HR [95% CI] 1.29 [0.91, 1.83], p = 0.15). Adjusted odds of more rapid control within 6 months were twofold higher for CM2 (p = 0.04) and CM4 (p = 0.055), respectively, versus CM1. CM2 did not differ from CM1. DM control was less likely for CM by telephone only than face-to-face in clinic. To benefit vulnerable patients with uncontrolled DM, in-person engagement may be required.

Implementation of the Chronic Care Model to Reduce Disparities in Hypertension Control: Benefits Take Time.

BACKGROUND: The Chronic Care Model (CCM) has been endorsed by experts to reduce disparities in chronic disease outcomes but benefits may be slow to appear in low-income populations. OBJECTIVE: To evaluate the effect of CCM implementation on systolic blood pressure (SBP) control in minority patients with diabetes mellitus (DM). DESIGN: Retrospective study from 2012 to 2016 in two primary care clinics with primarily uninsured, Hispanic patients. PATIENTS: Four 2-year cohorts of patients aged 18-75 with DM and SBP ≥ 140 mmHg on HTN drugs in year 1 and SBP measured 1 year later in year 2. INTERVENTION: Implementation of CCM for DM in January 2014 involved: electronic medical record revision, a DM registry, hypertension (HTN) treatment protocol, team education, performance feedback, and case management. MAIN MEASURE: SBP < 140 mmHg in year 2. KEY RESULTS: Of 2354 patients, the mean age was 56.2 (SD 9.5), baseline SBP 153.8 (SD 14.9) mmHg, and 79.8% Hispanic. Last SBP < 140 mmHg was 58.4% for cohort 1 (2012-2013) and 68.5% for cohort 4 (2015-2016). Adjusted odds ratios (AORs) for SBP control versus cohort 1 were 1.35 (95% CI 1.07, 1.69) for cohort 3 (2014-2015) and 2.13 (95% CI 1.60, 2.80) for cohort 4. AORs for SBP control were reduced by 15% per HTN drug at baseline (P = 0.001), 9% per HTN drug added at last SBP (P = 0.024), and 22% for multi-dose HTN drugs (P = 0.004). Among patients with persistent elevated SBP and represented in multiple cohorts, AORs for control were still over 2-fold higher for cohort 4 versus cohort 1. CONCLUSIONS: After adopting the CCM for primarily Hispanic patients with DM, SBP control increased significantly despite treatment with fewer HTN drugs. Yet improvement took 3-4 years, suggesting that financial rewards for using the CCM to achieve improved clinical outcomes for low-income, minority patients may be delayed.

Improving patient flow at a family health clinic.

This paper presents an analysis of a residency primary care clinic whose majority of patients are underserved. The clinic is operated by the health system for Bexar County and staffed primarily with physicians in a three-year Family Medicine residency program at The University of Texas School of Medicine in San Antonio. The objective of the study was to obtain a better understanding of patient flow through the clinic and to investigate changes to current scheduling rules and operating procedures. Discrete event simulation was used to establish a baseline and to evaluate a variety of scenarios associated with appointment scheduling and managing early and late arrivals. The first steps in developing the model were to map the administrative and diagnostic processes and to collect time-stamped data and fit probability distributions to each. In conjunction with the initialization and validation steps, various regressions were performed to determine if any relationships existed between individual providers and patient types, length of stay, and the difference between discharge time and appointment time. The latter two statistics along with resource utilization and closing time were the primary metrics used to evaluate system performance.The results showed that up to an 8.5 % reduction in patient length of stay is achievable without noticeably affecting the other metrics by carefully adjusting appointment times. Reducing the no-show rate from its current value of 21.8 % or overbooking, however, is likely to overwhelm the system's resources and lead to excessive congestion and overtime. Another major finding was that the providers are the limiting factor in improving patient flow. With an average utilization rate above 90 % there is little prospect in shortening the total patient time in the clinic without reducing the providers' average assessment time. Finally, several suggestions are offered to ensure fairness when dealing with out-of-order arrivals.

Association of knowledge, attitudes, and behaviors for colon cancer screening in Hispanic patients.

PURPOSE: The purpose of our cross-sectional study was to examine the association between sociodemographic, knowledge, attitude and behavior factors with colon cancer screening among low-income Hispanic patients from an urban family medicine clinic in San Antonio, Texas. METHODS: Using random stratified sampling, 804 patients were surveyed with 274 Hispanic patients meet the eligibility criteria for colon cancer screening (aged > or = 50 years). A 10-page self-administered questionnaire in Spanish or English completed in the clinic waiting room included self-reported colonoscopy, sociodemographic characteristics, health status, knowledge, attitudes, and behaviors toward colon cancer screening. Associations between colonoscopy and patient characteristics were assessed using logistic regression. RESULTS: 62% of patients reported having been tested for colonoscopy. Older Hispanics (age mean=59 + 6.1 SD) were more likely to have a colonoscopy than younger Hispanics (age mean = 56 +/- 4.8 SD) (P < .001). Bivariate analysis showed that patients who discussed colon cancer risk with their doctor (P = .001), did not smoke (P = .004), or encouraged family members or friends to be tested for colon cancer (P < .001) were more likely to be screened. Multiple variable logistic regression analysis showed that older age, having cancer, discussing the risk factors with their doctor, and encouraging family members or friends to get tested were significant predictors for colonoscopy testing in Hispanics. CONCLUSIONS: Colonoscopy screening in a sample of low-income Hispanic patients differed by age and health experience. Intervention programs that increase colon cancer screening in Hispanics patients should concentrate on those aged < 60. Patient education for knowledge, positive attitude, and behaviors may improve colon cancer screening.

Advanced primary care in San Antonio: linking practice and community strategies to improve health.

Improving health among people living in poverty often transcends narrowly focused illness care. Meaningful success is unlikely without confronting the complex social origins of illness. We describe an emerging community of solution to improve health outcomes for a population of 6000 San Antonio, Texas, residents enrolled in a county health care program. The community of solution comprises a county health system, a family medicine residency program, a metropolitan public health department, and local nonprofit organizations and businesses. Community-based activities responding to the needs of individuals and their neighborhoods are driven by a cohort of promotores (community health workers) whose mission encompasses change at both the individual and community levels. Centered on patients' functional goals, promotores mobilize family and community resources and consider what community-level action will address the social determinants of health. On the clinical side, care teams implement population-based risk assessment and nurse care management with a focus on care transitions as well as other measures to meet the needs of patients with high morbidity and high use of health care. Population-based outcome metrics include reductions in hospitalizations, emergency department and urgent care visits, and the associated charges. Promotores also assess patients' progress along the trajectory of their selected functional goals.