Language-Specific Challenges and Solutions for Equitable Telemedicine Implementation in the Primary Care Safety Net During COVID-19.

PURPOSE: Telemedicine care dramatically expanded during the COVID-19 pandemic. We characterized facilitators and barriers to telemedicine implementation among safety-net primary care clinics serving patients with limited English proficiency (LEP). METHODS: We collected data on telemedicine volume and patient demographics among safety-net clinics participating in a telemedicine learning collaborative. Data on various metrics were reported to the collaborative from February 2019 through August 2021. We conducted semi-structured interviews with clinical and quality leaders, purposively sampling clinics serving high proportions of patients with LEP. We analyzed interviews with a mixed inductive-deductive approach applying the Consolidated Framework for Implementation Research. RESULTS: By September 2020, the 23 sites served 121,589 unique patients with in-person and 120,338 with telephone visits; 47% of these patients had LEP. Of 10,897 unique patients served by video visits, 38% had LEP. As a proportion of total visits, telemedicine (telephone and video) visits increased from 0-17% in October 2019-March 2020 to 10-98% in March-August 2020. We conducted 14 interviews at 11 sites. Themes included (1) existing telemedicine platforms and interpreter services were not optimized to support patients with LEP; (2) clinics invested significant labor iterating workflows; (3) sites with technological infrastructure and language-concordant staff were best suited to serve patients; (4) patients speaking less-represented languages or experiencing intersecting literacy barriers were underserved with telemedicine. Interviewees recommended innovations in telemedicine platforms and community-based access. CONCLUSIONS: Safety-net sites relied on existing resources to accommodate patients with LEP, but struggled providing access for the most marginalized. Proactive, data-driven strategies to address patient and community barriers as well as optimize clinical workflows with high-quality, certified medical interpreters are needed to ensure equitable access.

Frightened of giants: fear responses to elephants approach that of predators.

Animals are faced with a variety of dangers or threats, which are increasing in frequency with ongoing environmental change. While our understanding of fearfulness of such dangers is growing in the context of predation and parasitism risk, the extent to which non-trophic, interspecific dangers elicit fear in animals remains less appreciated. We provide an experimental test for fear responses of savannah ungulates to a dominant and aggressive megaherbivore, the African bush elephant (Loxodonta africana), and contrast responses to an apex predator known to elicit fear in this system. Using an automated behavioural response system, we contrast vigilance and run responses of ungulates to elephant, leopard (Panthera pardus), and control (red-chested cuckoo Cuculus solitarius) vocalizations. Overall, we find that ungulates responded to elephant calls, both in terms of an increase in run and vigilance responses relative to controls. The magnitude of most behavioural responses (four of six considered) to elephant vocalizations were not significantly different than responses to leopards. These results suggest that megaherbivores can elicit strong non-trophic fear responses by ungulates and call to broaden frameworks on fear to consider dominant species, such as megaherbivores, as key modifiers of fear-induced interactions.

Building Public Health Competencies for Cross-Sector Leadership: Results From the National Leadership Academy for the Public's Health.

Context. The public health workforce is increasingly being asked to provide leadership in addressing complex community health needs. Effective leadership requires adaptiveness and cross-sector collaboration in developing solutions to address community needs. Program. An annual yearlong public health leadership development program, which engages cross-sector teams and uses an iterative design to build competencies for adaptive and collaborative leadership across sectors (e.g., public health, business, education, nonprofits). Implementation. The program engages cross-sector teams through a national retreat, coaching, site visits, interactive webinars, readings, and a community-based action learning project. As of 2020, the program was offered to nine cohorts, serving more than 100 communities across the United States. Results. Results from a mixed-methods evaluation found that high proportions of participants reported increased leadership skills, cross-sector collaboration, continued use of tools and concepts, and positive impact on their communities after participating in the program. Across all cohorts, participants rated themselves on five leadership domains and 17 leadership competencies focused on by the program. All domains and all competencies had statistically significant improvements from the beginning to the end of their program year. Discussion. The improvements in leadership skills were seen across all cohorts, geographies, roles, and sectors. The success of the program suggests the need for leadership programs that emphasize adaptive and collaborative leadership to advance community health and equity.

Race Matters: Income Shares, Income Inequality, and Income Mobility for All U.S. Races.

Using unique linked data, we examine income inequality and mobility across racial and ethnic groups in the United States. Our data encompass the universe of income tax filers in the United States for the period 2000-2014, matched with individual-level race and ethnicity information from multiple censuses and American Community Survey data. We document both income inequality and mobility trends over the period. We find significant stratification in terms of average incomes by racial/ethnic group and distinct differences in within-group income inequality. The groups with the highest incomes-whites and Asians-also have the highest levels of within-group inequality and the lowest levels of within-group mobility. The reverse is true for the lowest-income groups: blacks, American Indians, and Hispanics have lower within-group inequality and immobility. On the other hand, low-income groups are also highly immobile in terms of overall, rather than within-group, mobility. These same groups also have a higher probability of experiencing downward mobility compared with whites and Asians. We also find that within-group income inequality increased for all groups between 2000 and 2014, and the increase was especially large for whites. The picture that emerges from our analysis is of a rigid income structure, with mainly whites and Asians positioned at the top and blacks, American Indians, and Hispanics confined to the bottom.

A Community-Wide Collaboration to Reduce Cardiovascular Disease Risk: The Hearts of Sonoma County Initiative.

PURPOSE AND OBJECTIVES: Collaboration across multiple sectors is needed to bring about health system transformation, but creating effective and sustainable collaboratives is challenging. We describe outcomes and lessons learned from the Hearts of Sonoma County (HSC) initiative, a successful multi-sector collaborative effort to reduce cardiovascular disease (CVD) risk in Sonoma County, California. INTERVENTION APPROACH: HSC works in both clinical systems and communities to reduce CVD risk. The initiative grew out of a longer-term county-wide collaborative effort known as Health Action. The clinical component involves activating primary care providers around management of CVD risk factors; community activities include community health workers conducting blood pressure screenings and a local heart disease prevention campaign. EVALUATION METHODS: The impact of the clinical improvement efforts was tracked using blood pressure data from the 4 health systems participating in HSC. Descriptive information on the community-engagement efforts was obtained from program records. Lessons learned in developing and maintaining the collaborative were gathered through document review and interviews with key informants. RESULTS: Favorable trends were seen in blood pressure control among patients with hypertension in the participating health systems: patients with controlled blood pressure increased from 58% in 2014 to 67% in 2016 (P < .001). Between 2017 and 2019, the community engagement effort conducted 99 outreach events, reaching 1,751 individuals, and conducted 1,729 blood pressure screenings, with 441 individuals referred to clinical providers for follow-up care. HSC scored highly on 6 essential elements of an effective coalition and achieved a degree of sustainability that has eluded many other collaboratives. IMPLICATIONS FOR PUBLIC HEALTH: Factors contributing to the success of HSC include 1) starting small and focused to build trust among participants and demonstrate value, 2) working within the framework of a larger effort, and 3) providing long-term, open-ended backbone support.

Clinic Readiness for Trauma-Informed Health Care Is Associated With Uptake of Screening for Adverse Childhood Experiences.

INTRODUCTION: Adverse childhood experiences (ACEs) are strongly correlated with many of the most common causes of preventable illness, preventable death, and health disparities. In January 2020, California launched the first statewide initiative to integrate ACE screening throughout its Medicaid system. A key element of the initiative was the California ACEs Learning and Quality Improvement Collaborative, a 48-clinic, 16-month learning collaborative. This evaluation aimed to determine whether developing a trauma-informed environment of care was associated with uptake of ACE screening. METHODS: Participants included 40 of 48 clinics that participated in the statewide learning collaborative. Clinics completed an assessment of progress in 5 essential components of trauma-informed health care at baseline and 1-year follow-up. Clinics tracked data on ACE screens completed on an ongoing basis and submitted data quarterly. A hierarchical linear model was used to examine the association between change in readiness for trauma-informed health care and change in quarterly screens. RESULTS: Readiness for trauma-informed health care increased for all participating clinics over the course of the learning collaborative. The average number of quarterly screens also increased, with considerable variability among clinics. Clinics with larger increases in readiness for trauma-informed health care had larger increases in quarterly screens. DISCUSSION: The findings align with long-standing recommendations for trauma screening to occur in the context of trauma-informed environments of care. CONCLUSION: A trauma-informed clinic is the foundation for successful adoption of ACE screening. ACE screening initiatives should include education and sufficient support for clinics to embrace a trauma-informed systems change process.

Did the Taliban's opium eradication campaign cause a decline in HIV infections in Russia?

We offer a new hypothesis for why HIV infections fell rapidly after 2001 in Russia: the Taliban's opium eradication campaign in Afghanistan reduced the supply of heroin, causing use to fall and, thus, transmission of HIV to fall. We present evidence of the impact of the eradication campaign on the heroin market and show that the fall in HIV infections happened simultaneously in Russia and surrounding countries soon after the eradication campaign. We also show that the decline in HIV infections only occurred in injecting drug users, while other risk groups were unaffected. Limitations to our analysis are discussed.

Laissez-Faire Stallions? Males' Fecal Cortisol Metabolite Concentrations Do Not Vary with Increased Female Turnover in Feral Horses (Equus caballus).

Stress responses can be triggered by several physical and social factors, prompting physiological reactions including increases in glucocorticoid concentrations. In a population of feral horses (Equus caballus) on Shackleford Banks, North Carolina, females previously immunized with the immunocontraceptive agent porcine zona pellucida (PZP) change social groups (bands) more often than unimmunized females, disrupting the social stability within the population. We assessed the effects of increased female group changing behavior (or female turnover) on individual male stress by comparing fecal cortisol metabolite (FCM) concentrations among stallions experiencing varying amounts of female group changing behavior. FCM concentrations did not significantly correlate with female turnover. Similarly, FCM concentrations were not dependent upon the timing of female group changing behavior. These findings suggest that female turnover rate has little influence on physiological measures of stress in associated stallions. That said, Shackleford stallions experiencing increased female turnover do engage in behaviors typically associated with stress (increased vigilance, highly escalated male-male conflicts). Future work should compare FCM concentrations across time within populations and among populations managed under different strategies to better isolate factors influencing stallion stress physiology. Such studies are especially important if we are to determine how changes in female behavior related to immunocontraception impact physiological and behavioral indicators of stress for non-target animals. Finally, our study highlights the importance of considering both physiological and behavioral measures when investigating animal responses to potentially challenging situations.

Out of the stable: Social disruption and concurrent shifts in the feral mare (Equus caballus) fecal microbiota.

The disruption of animals' symbiotic bacterial communities (their microbiota) has been associated with myriad factors including changes to the diet, hormone levels, and various stressors. The maintenance of healthy bacterial communities may be especially challenging for social species as their microbiotas are also affected by group membership, social relationships, microbial transfer between individuals, and social stressors such as increased competition and rank maintenance. We investigated the effects of increased social instability, as determined by the number of group changes made by females, on the microbiota in free-living, feral horses (Equus caballus) on Shackleford Banks, a barrier island off the North Carolina coast. Females leaving their groups to join new ones had fecal microbial communities that were similarly diverse but compositionally different than those of females that did not change groups. Changing groups was also associated with the increased abundance of a several bacterial genera and families. These changes may be significant as horses are heavily dependent upon their microbial communities for nutrient absorption. Though we cannot identify the particular mechanism(s) driving these changes, to the best of our knowledge, ours is the first study to demonstrate an association between acute social perturbations and the microbiota in a free-ranging mammal.

Uniting Experiments and Big Data to advance ecology and conservation.

Many ecologists increasingly advocate for research frameworks centered on the use of 'big data' to address anthropogenic impacts on ecosystems. Yet, experiments are often considered essential for identifying mechanisms and informing conservation interventions. We highlight the complementarity of these research frameworks and expose largely untapped opportunities for combining them to speed advancements in ecology and conservation. With nascent but increasing application of model integration, we argue that there is an urgent need to unite experimental and big data frameworks throughout the scientific process. Such an integrated framework offers potential for capitalizing on the benefits of both frameworks to gain rapid and reliable answers to ecological challenges.

Using Participatory Design to Engage Physicians in the Development of a Provider-Level Performance Dashboard and Feedback System.

PROBLEM DEFINITION: Performance feedback, in which clinicians are given data on select metrics, is widely used in the context of quality improvement. However, there is a lack of practical guidance describing the process of developing performance feedback systems. INITIAL APPROACH: This study took place at the University of California, San Francisco (UCSF) with hospitalist physicians. Participatory design methodology was used to develop a performance dashboard and feedback system. Twenty hospitalist physicians participated in a series of six design sessions and two surveys. Each design session and survey systematically addressed key components of the feedback system, including design, metric selection, data delivery, and incentives. The Capability Opportunity Motivation and Behavior (COM-B) model was then used to identify behavior change interventions to facilitate engagement with the dashboard during a pilot implementation. KEY INSIGHTS, LESSONS LEARNED: In regard to performance improvement, physicians preferred collaboration over competition and internal motivation over external incentives. Physicians preferred that the dashboard be used as a tool to aid in clinical practice improvement and not punitively by leadership. Metrics that were clinical or patient-centered were perceived as more meaningful and more likely to motivate behavior change. NEXT STEPS: The performance dashboard has been introduced to the entire hospitalist group, and evaluation of implementation continues by monitoring engagement and physician attitudes. This will be followed by targeted feedback interventions to attempt to improve performance.

Reducing Cardiovascular Risk for Patients With Diabetes: An Evidence-Based, Population Health Management Program.

ABSTRACT: Those with diabetes are at an increased risk of cardiovascular disease (CVD). Safety net clinics serve populations that bear a significant burden of disease and disparities and are a key setting in which to focus on reducing CVD. An integrated health system provided funding and technical assistance (TA) to safety net organizations (community health centers and public hospitals) in Northern California to decrease the risk of cardiovascular events for patients with diabetes. This was a program called Preventing Heart Attacks and Strokes Everyday (PHASE), which combined an evidence-based medication protocol with population health management and team-based care strategies. The TA supported organizations by sharing best practices, providing quality improvement coaching, and facilitating peer learning. A mixed-methods evaluation found that organizations involved in PHASE improved rates of blood pressure control and cardioprotective medication prescriptions for patients with diabetes. They made progress on these measures through strategies such as leveraging team-based care, providing education on evidence-based protocols, and using data to drive improvements. The evaluation concluded that financially supporting and providing focused TA to safety net organizations can help them build capacity and leverage their strengths to improve outcomes and potentially decrease the risk of heart attacks and strokes in communities.

Experiences of Health Centers in Implementing Telehealth Visits for Underserved Patients During the COVID-19 Pandemic: Results from the Connected Care Accelerator Initiative.

In early 2020, as the coronavirus disease 2019 (COVID-19) pandemic emerged, widespread social-distancing efforts suspended much of the delivery of nonurgent health care. Telehealth proved to be a viable alternative to in-person care, at least on a temporary basis, and utilization skyrocketed. Many Federally Qualified Health Centers (FQHCs) serving low-income patients started delivering telehealth visits in high volume in March 2020 to help maintain access to care. This sudden and dramatic change in health care delivery posed numerous challenges. Health centers had to quickly make changes to technology, workflows, and staffing to accommodate telehealth visits. To support health centers in these efforts, the California Health Care Foundation established the Connected Care Accelerator (CCA) program, a quality improvement initiative that was launched in July 2020. RAND researchers evaluated the progress of FQHCs that participated in the CCA initiative by investigating changes in telehealth utilization and health center staff experiences with implementation. In this research, researchers review recent literature on telehealth implementation in safety net settings. They also present new information on the experiences of the 45 CCA health centers, drawing from data on visit trends, interviews with health center leaders, and surveys of health center providers and staff. Telehealth has the potential to increase access to care and deliver care that is more convenient and patient-centered; however, ongoing research is needed to ensure that telehealth is implemented in a way that ensures high-quality care and health equity.

Relationships between local public health agency functions and agency leadership and staffing: a look at nurses.

UNLABELLED: The United States is facing a severe shortage of well-trained public health workers, and public health nursing is the discipline with the greatest shortage. A local public health agency's (LPHA's) staffing and leadership characteristics are critical in determining its programs, performance, and capacity. A better understanding of the relationship between specific staffing and leadership characteristics and public health programs is needed to address this capacity challenge. METHOD: Data from the 2005 National Profile of Local Health Departments, were examined to identify associations between an LPHA's nursing workforce and the specific activities performed by LPHAs. RESULTS: LPHAs with a nurse as senior executive had a greater breadth of immunization, maternal/child health, and prevention activities than their nonnurse-led counterpart LPHAs, particularly in rural areas. Nurse-led LPHAs were less likely, however, to have a broad level of environmental health and regulation activities or to have recently conducted community assessment and planning activities. CONCLUSIONS: Both LPHA nurse leaders and nursing staff play an important role in the provision of LPHA services, and a shortage of LPHA nursing leaders and staff, particularly in rural areas, will likely have a major impact on certain LPHA programs unless steps are taken to address these challenges.

Fostering Partnerships with the Safety Net: An Evaluation of Kaiser Permanente's Community Ambassador Program in the Mid-Atlantic States.

INTRODUCTION: Kaiser Permanente (KP) Mid-Atlantic States has partnered with communities in its service area since 2011 to provide health services to underserved individuals. As part of KP's Community Benefit investment, the Community Ambassador Program places KP advanced-practice clinicians in safety-net clinics to share best practices and to improve access and quality of care. OBJECTIVE: To report program outcomes and disseminate lessons learned. METHODS: Using data from participating clinics, we retrospectively evaluated the program and estimated Community Ambassadors' contributions to clinic capacity, patient access, evidence-based care, and clinical quality measures. Furthermore, we conducted 29 semistructured phone interviews with stakeholders. Questions focused on program benefits, challenges, learning, and sustainability. RESULTS: From 2013 to 2017, Community Ambassadors filled up to 32.8 full-time equivalent positions and conducted 294,436 patient encounters in 19 clinics. In certain years and for subsets of clinics, Community Ambassadors performed above average on 2 high-priority quality measures: Cervical cancer screening for women aged 21 to 64 years and diabetes (blood glucose) control. Interviews with 15 Community Ambassadors, 15 health centers leaders, and 7 KP Mid-Atlantic States staff members revealed that Community Ambassadors improved patient access, clinic capacity, and care quality. Ambassadors also exported KP best practices and supported KP's community relations. Challenges included patient acuity, clinic resources, staff turnover, and long-term sustainability. CONCLUSION: The Community Ambassador Program achieved its goals and had clear benefits, offering a model for large health care systems wanting to collaborate with community-based clinics. Careful planning is needed to ensure that positive results are sustained.

Assessing regional public health preparedness: a new tool for considering cross-border issues.

OBJECTIVE: To provide regional, state, and local public health officials a conceptual framework and checklist for assessing regional public health emergency preparedness, specifically in regard to cross-border public health preparedness needs. METHODS: The project had four phases that are as follows: defining the scope, conducting a literature review, soliciting expert opinion, and creating the assessment framework and checklist. A conceptual framework was developed to define the scope of the project on the basis of the kinds of resources likely to be shared across borders in a public health response (eg, data, supplies, staff), in support of the public health functions likely to be important in a health emergency (eg, epidemiology, laboratory). A literature review was then conducted to identify key articles and tools addressing regional preparedness. Key informant interviews (n = 23) were conducted with public health and emergency management professionals in the Pacific Northwest to identify a set of systems, agreements, and protocols that should be systematically considered in assessing regional public health preparedness. Using the literature review and themes from interviews, a checklist was developed. RESULTS: A checklist was developed for use by public health leaders, which recommends 24 specific agreements, protocols, systems, and management structures that should be considered to foster cross-border public health preparedness. CONCLUSIONS: Regional public health preparedness represents not only the sum of state-level preparedness of the states in a region but also the capacity of those states to collaborate across state and international borders during a public health emergency. This checklist provides a tool to systematically consider cross-border preparedness issues.