A randomized controlled trial of Explore Transplant at Home to improve transplant knowledge and decision-making for CKD 3-5 patients at Kaiser Permanente Southern California.

BACKGROUND: Five-year survival on dialysis is only 40%, compared to 74% with a deceased donor kidney transplant (DDKT) and 87% with a living donor kidney transplant (LDKT). An American Society of Transplantation (AST) Consensus Conference recommended that patients with chronic kidney disease (CKD) Stages 3-5 have the opportunity to learn about and decide which treatment option is right for them, particularly about LDKT. However, early education about LDKT and DDKT outside of transplant centers is inconsistent and often poor, with patients in CKD 3 and 4 and ethnic/racial minorities even less likely to receive it. A new randomized control trial (RCT), in partnership with Kaiser Permanente Southern California (KPSC), will assess knowledge gaps and the effectiveness of a supplementary video-guided, print and technology-based education intervention for English- and Spanish-speaking patients in CKD Stages 3, 4, and 5 to increase LDKT knowledge and decision-making. To date, no published LDKT educational interventions have studied such a large and diverse CKD population. METHODS: In this RCT, 1200 English and Spanish-speaking CKD Stage 3-5 patients will be randomly assigned to one of two education conditions: ET@Home or KPSC standard of care education. Randomization will be stratified by CKD stage and primary language spoken. Those in the ET@Home condition will receive brochures, postcards, DVDs, and text messages delivering educational content in modules over a six-month period. Baseline data collection will measure demographics, transplant derailers, and the amount of previous CKD and transplant education they have received. Changes in CKD and transplant knowledge, ability to make an informed decision about transplant, and self-efficacy to pursue LDKT will be captured with surveys administered at baseline and at six months. DISCUSSION: At the conclusion of the study, investigators will understand key knowledge gaps for patients along the CKD continuum and between patients who speak different languages and have assessed the effectiveness of both English- and Spanish-language supplementary education in increasing KPSC patients' knowledge about the opportunities for and risks and benefits of LDKT. We hope this program will reduce disparities in access to transplant. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03389932; date registered: 12/26/2017.

Developing a Community-Oriented and Place-Based Strategy to Improve COVID-19 Vaccine Accessibility.

Objective To address the challenges of inequitable access to the COVID-19 vaccines, Kaiser Permanente Southern California developed a community-oriented and geographic vaccine strategy combining clinical data, community data, and predictive models to identify ZIP codes requiring increased resources to achieve equitable vaccine receipt. Study Design This is a quality-improvement implementation study. Methods The authors developed hot-spot maps for southern California service areas to assist clinicians in identifying specific ZIP codes to increase vaccination efforts. Data inputs for these hot spots included COVID-19 incidence, hospitalization, ecologic variables of social determinants of health, and predictive models of vaccine penetrance. Partnering with community organizations, vaccine penetrance was improved by targeting hot spots with pop-up clinics, mobile health vehicle visits, extending facility hours, and sending tailored text messages. Results By the end of 2021, Kaiser Permanente Southern California achieved a 70% vaccination rate in 83% of 670 ZIP codes it serves, resulting in a total vaccination rate of 81% in 2021. Further, more than 2 out of 3 individuals receiving a vaccine through the hot-spot guided mobile health vehicle were Hispanic or Black. The hot-spotting approach produced a refreshed monthly dashboard of hot spots in 7 counties covering over 670 ZIP codes to help decision makers better understand and improve vaccination in targeted communities. Conclusion The hot-spot methodology produced monthly lists of ZIP codes requiring additional health-care resources and vaccination strategies. This was a feasible place-based approach to mitigating disparities in vaccine uptake in historically disinvested communities that may be readily applied to other areas of care.

Large-Scale Implementation of Collaborative Care Management for Depression and Diabetes and/or Cardiovascular Disease.

BACKGROUND: Collaborative care models have been shown to improve mental and physical health, but their effectiveness varies. Implementation science frameworks identify measures at the structural (eg, sociocultural context, public policies), organizational, provider, innovation, and patient levels that may facilitate or impede collaborative care effectiveness. OBJECTIVE: To describe commonalities and variation in multilevel measures associated with the implementation of Care of Mental, Physical, and Substance-Use Syndromes (COMPASS), a large-scale collaborative care intervention for depression, diabetes, and cardiovascular disease. DESIGN: Qualitative study using semistructured descriptive data obtained from annual site visit reports and supplemental site surveys. PARTICIPANTS: COMPASS care teams from 8 health care systems serving 3854 patients with active depression and poorly controlled diabetes and/or cardiovascular disease. INTERVENTION: COMPASS included weekly case reviews with a consulting physician and psychiatrist, a patient-tracking registry, and monitoring of hospital and emergency department use. MAIN MEASURES: Site visit reports were analyzed with Atlas.ti software to qualitatively describe implementation measures and their variation across sites. KEY RESULTS: Nine measures were identified that impacted implementation efforts across health systems: (1) challenges in health systems' organizational environments, (2) prior care coordination experience, (3) physician engagement, (4) care team trust and cohesion, (5) care manager training and experience, (6) patient enrollment length, attainment of clinical targets, and frequency/content of care manager contacts, (7) patient-tracking registries, (8) quality improvement and outcomes monitoring reports, and (9) patients' social needs. CONCLUSIONS: Understanding multilevel measures impacting COMPASS implementation could increase the success of future collaborative care implementation efforts.

Completion of an Outpatient Visit After Skilled Nursing Facility Discharge and Readmission Risk.

OBJECTIVES: Examine the association between completion of an outpatient visit with a physician or advanced practice provider (PCP) within 7 days of discharge from a short skilled nursing facility (SNF) stay and 30-day readmission and determine if functional status at discharge moderates visit effectiveness. DESIGN: Retrospective cohort study. SETTING: Large integrated health care system. PARTICIPANTS: Adults 65 years and older, discharged home from a short SNF stay (n = 4073). INTERVENTION: None. MEASUREMENTS: Exposure is completion of an outpatient visit with a PCP within 7 days of discharge from an SNF. Primary outcome is readmission within 30 days of SNF discharge. Covariates included gender, risk score for readmission or early death, medical or surgical hospitalization, SNF facility, SNF length of stay, SNF stay in the previous 12 months, discharge to home or home health, and discharge functional independence measures (FIM). RESULTS: A total of 476 (11.6%) patients were readmitted within 30 days of SNF discharge. Patients who completed an outpatient visit with a PCP within 7 days of SNF discharge had a 23% higher risk of being readmitted compared to patients who did not complete any visit (hazard ratio [HR] 1.23, 95% confidence interval [CI] 1.01-1.50). Patients who had FIM scores ≥80 and completed a visit had an increased readmission risk (HR 1.37, 95% CI 1.04-1.79); the increased risk was not seen for those with worse functional impairment, FIM <80 (HR 1.11, 95% CI 0.85-1.46). CONCLUSION: The finding of increased risk of readmission post SNF discharge with completion of an outpatient visit likely reflects inadequate adjustment for selection bias in this observational study, which strongly argues for the need to design prospective studies to test transitional care services post SNF discharge.