Lost and found, safe and sound: a case report surrounding the stabilization of a medically complex young adult patient with opioid use disorder through an acute wrapround care approach.

Background: Hospitalization can be a critical time to stabilize chronically ill patients across levels that transcend medical and social determinants of health. The use of the biopsychosocial model can be instrumental in understanding both medically and psychosocially complex patient cases. An acute inpatient hospitalization provides an opportunity to mediate both intrinsic and extrinsic risk factors for both substance use disorder and suicide risk in the context of achieving medical stabilization and crisis mobilization. Case Presentation: Inpatient care of a 22-year-old African American female patient who was chronically ill involved tapping into existing resources within the larger academic hospital inclusive of both adult and pediatric expertise. This patient's care and treatment was multidisciplinary and involved a range of consults that further expanded both the depth and breadth of care and optimized stability from both medical and psychosocial standpoints. In fact, this patient's hospitalization presented a window of opportunity to facilitate a time of transition in chronic disease management and mobilize resources as part of securing wraparound care for her within a one-week timespan. Her care involved the integration of pediatrics (hematology, adolescent medicine), adult medicine (hematology, addiction medicine), and psychiatry. In addition to treating acute symptomology, underlying sources of pain stemming from her opioid use disorder were also alleviated. Furthermore, her care embodied the interface of chronic illness with opioid use, as her reported pain crises were determined to be motivated by intrinsic factors (e.g. poor coping skills from cumulative stressors) supporting her opioid use disorder. Conclusions: The biopsychosocial treatment approach taken for this patient also clearly delineated that physiological and mental health domains are interrelated aspects of chronic pain in chronic illness. Furthermore, this case also emphasized that chronically ill patients are at elevated risk of developing substance use disorders. This case study lends itself nicely to elucidating parity in physiological and mental health domains as crucial elements in promoting health and safety in patient care.

A Case for Comprehensive Transitional Care for Formerly Incarcerated Individuals.

People released from prison are at risk of adverse health outcomes in the weeks after release. This article describes cases that illustrate the complexity of caring for this population. It is important to address medical and psychological needs as well as factors that contribute to social determinants of health.

The Paradox of Readmission Prevention Interventions: Missing Those Most in Need.

BACKGROUND: Post-hospitalization transition interventions remain a priority in preventing rehospitalization. However, not all patients referred for readmission prevention interventions receive them. We sought to 1) define patient characteristics associated with non-receipt of readmission prevention interventions (among those eligible for them), and 2) determine whether these same patient characteristics are associated with hospital readmission at the state level. METHODS: We used state-wide data from the Maryland Health Services Cost Review Commission to determine patient-level factors associated with state-wide readmissions. Concurrently, we conducted a retrospective analysis of discharged patients referred to receive 1 of 3 post-discharge interventions between January 2013 and July 2019-a nurse transition guide, post-discharge phone call, or follow-up appointment in our post-discharge clinic-to determine patient-level factors associated with not receiving the intervention. Multivariable generalized estimating equation logistic regression models were used to calculate the odds of not accepting or not receiving the interventions. RESULTS: Older age, male gender, black race, higher expected readmission rate, and lower socioeconomic status were significantly associated with 30-day readmission in hospitalized Maryland patients. Most of these variables (age, sex, race, payer type [Medicaid or non-Medicaid], and socioeconomic status) were also associated with non-receipt of intervention. CONCLUSIONS: We found that many of the same patient-level characteristics associated with the highest readmission risk are also associated with non-receipt of readmission reduction interventions. This highlights the paradox that patients at high risk of readmission are least likely to accept or receive interventions for preventing readmission. Identifying strategies to engage hard-to-reach high-risk patients continues to be an unmet challenge in readmission prevention.

Examining black and white racial disparities in emergency department consultations by age and gender.

BACKGROUND: While significant racial inequities in health outcomes exist in the United States, these inequities may also exist in healthcare processes, including the Emergency Department (ED). Additionally, gender has emerged in assessing racial healthcare disparity research. This study seeks to determine the association between race and the number and type of ED consultations given to patients presenting at a safety-net, academic hospital, which includes a level-one trauma center. METHOD: Retrospective data was collected on the first 2000 patients who arrived at the ED from 1/1/2015-1/7/2015, with 532 patients being excluded. Of the eligible patients, 77% (74.6% adults and 80.7% pediatric patients) were black and 23% (25.4% adults and 19.3% pediatric patients) were white. RESULTS: White and black adult patients receive similar numbers of ED consultations and remained after gender stratification. White pediatric males have a 91% higher incidence of receiving an ED consultation in comparison to their white counterparts. No difference was found between black and white adult patients when assessing the risk of receiving consultations. White adult females have a 260% higher risk of receiving both types of consultations than their black counterparts. Black and white pediatric patients had the same risk of receiving consultations, however, white pediatric males have a 194% higher risk of receiving a specialty consultation as compared to their white counterparts. DISCUSSION: Future work should focus on both healthcare practice improvements, as well as explanatory and preventive research practices. Healthcare practice improvements can encompass development of appropriate racial bias trainings and institutionalization of conversations about race in medicine.

Building access to care in adult sickle cell disease: defining models of care, essential components, and economic aspects.

Sickle cell disease (SCD) is the most common inherited blood disorder in the United States. It is a medically and socially complex, multisystem illness that affects individuals throughout the lifespan. Given improvements in care, most children with SCD survive into adulthood. However, access to adult sickle cell care is poor in many parts of the United States, resulting in increased acute care utilization, disjointed care delivery, and early mortality for patients. A dearth of nonmalignant hematology providers, the lack of a national SCD registry, and the absence of a centralized infrastructure to facilitate comparative quality assessment compounds these issues. As part of a workshop designed to train health care professionals in the skills necessary to establish clinical centers focused on the management of adults living with SCD, we defined an SCD center, elucidated required elements of a comprehensive adult SCD center, and discussed different models of care. There are also important economic impacts of these centers at an institutional and health system level. As more clinicians are trained in providing adult-focused SCD care, center designation will enhance the ability to undertake quality improvement and compare outcomes between SCD centers. Activities will include an assessment of the clinical effectiveness of expanded access to care, the implementation of SCD guidelines, and the efficacy of newly approved targeted medications. Details of this effort are provided.

An Examination of Racial Disparities in Inpatient Consultations.

OBJECTIVE: To determine whether racial disparities occurred among specialty and allied health inpatient consultations for patients admitted to adult hospital services at an academic hospital. METHODS: A retrospective data analysis of the first 2000 patients, ages 18 years or older, admitted to an academic hospital. RESULTS: No regression model demonstrated any statistically significant relation between race and type of inpatient consultation received. No statistically significant difference in the number of inpatient consultations was found. CONCLUSIONS: Processes within the healthcare setting studied did not contribute to racial differences in consultation services. Our findings suggest that implicit racial bias may not be a factor when ordering consultations, but the findings are more likely affected by more appropriate factors such as the patient's age, length of stay, and complexity/severity of illness score.

Adult Head and Neck Health Care Needs for Individuals with Complex Chronic Conditions of Childhood.

Millions of adults in the United States are currently living with what is termed chronic childhood conditions-childhood-onset conditions, about which adult providers often receive minimal training-and another half million youths with special health care needs enter adulthood each year and will undergo transition from pediatric to adult care. Here, the authors review the important otolaryngologic manifestations of several of these chronic childhood conditions, including autism spectrum disorder, cerebral palsy, and Down syndrome, as well as the primary care providers' role in caring for transitioning tracheostomy-dependent patients.

Provider Perceptions of the Organization's Cultural Competence Climate and Their Skills and Behaviors Targeting Patient-Centered Care for Socially At-Risk Populations.

As part of a cultural competence needs assessment study at a large academic health care system, we conducted a survey among 1,220 practicing physicians to assess their perceptions of the organization's cultural competence climate and their skills and behaviors targeting patient-centered care for culturally and socially diverse patients. Less than half of providers reported engaging in behaviors to address cultural and social barriers more than 75% of the time. In multivariable logistic regression models, providers who reported moderate or major structural problems were more likely to report low skillfulness in identifying patient mistrust (aOR: 2.01; 95% CI: 1.23-3.28, p<0.01), how well patients read and write English (aOR: 1.63; 95% CI: 1.03-2.57, p=0.03), and socioeconomic barriers (aOR: 2.14; 95% CI: 1.14-4.01, p=0.01), than providers who reported only small or no structural problems. Improved structural support for socially and culturally complex medical encounters is needed to enhance care for socially at-risk patients.

Two Novel Urban Health Primary Care Residency Tracks That Focus On Community-Level Structural Vulnerabilities.

BACKGROUND: Although residency programs are well situated for developing a physician workforce with knowledge, skills, and attitudes that incorporate the strengths and reflect the priorities of community organizations, few curricula explicitly do so. AIM: To develop urban health primary care tracks for internal medicine and combined internal medicine-pediatrics residents. SETTING: Academic hospital, community health center, and community-based organizations. PARTICIPANTS: Internal medicine and combined internal medicine-pediatrics residents. PROGRAM DESCRIPTION: The program integrates community-based experiences with a focus on stakeholder engagement into its curriculum. A significant portion of the training (28 weeks out of 3 years for internal medicine and 34 weeks out of 4 years for medicine-pediatrics) occurs outside the hospital and continuity clinic to support residents' understanding of structural vulnerabilities. PROGRAM EVALUATION: Sixteen internal medicine and 14 medicine-pediatrics residents have graduated from our programs. Fifty-six percent of internal medicine graduates and 79% of medicine-pediatrics graduates are seeking primary care careers, and eight overall (27%) have been placed in community organizations. Seven (23%) hold leadership positions. DISCUSSION: We implemented two novel residency tracks that successfully placed graduates in community-based primary care settings. Integrating primary care training with experiences in community organizations can create primary care leaders and may foster collective efficacy among medical centers and community organizations.

Screening for colorectal cancer.

This review will comprise a general overview of colorectal cancer (CRC) screening. We will cover the impact of CRC, CRC risk factors, screening modalities, and guideline recommendations for screening in average-risk and high-risk individuals. Based on this data, we will summarize our approach to CRC screening.

Effect of Free Dental Services on Individuals with Sickle Cell Disease.

OBJECTIVES: Poor oral health can have a negative impact on overall health. This is especially concerning for individuals with sickle cell disease (SCD), an inherited blood disorder that affects hemoglobin and can lead to an increased risk of infection and hyperalgesia. Because the majority of individuals with SCD have Medicaid insurance and no dental coverage, we provided free basic dental care to individuals with SCD to determine whether it decreased overall healthcare utilization. METHODS: Through a contract with a private dental office, we provided free basic dental care (eg, cleanings, fillings, x-rays) to individuals with SCD. We reviewed medical records for the 12 months before and after their initial dental visit to determine whether there were any changes in acute care visits (defined as a visit to the emergency department, sickle cell infusion center, or visits to both in the same day), hospitalizations, and total days hospitalized. We conducted a negative binomial regression to determine any differences in the pre-post periods. RESULTS: In our multivariable analysis, there was a statistically significant decrease in hospital admissions. In addition, there was a significant decrease in total days hospitalized if dental work was completed, but an increase in days hospitalized in men. CONCLUSIONS: Providing dental care to individuals with SCD who did not have dental insurance did not greatly alter acute care visits. A larger sample size may be necessary to observe an effect.

Community Health Workers as Support for Sickle Cell Care.

Community health workers are increasingly recognized as useful for improving health care and health outcomes for a variety of chronic conditions. Community health workers can provide social support, navigation of health systems and resources, and lay counseling. Social and cultural alignment of community health workers with the population they serve is an important aspect of community health worker intervention. Although community health worker interventions have been shown to improve patient-centered outcomes in underserved communities, these interventions have not been evaluated with sickle cell disease. Evidence from other disease areas suggests that community health worker intervention also would be effective for these patients. Sickle cell disease is complex, with a range of barriers to multifaceted care needs at the individual, family/friend, clinical organization, and community levels. Care delivery is complicated by disparities in health care: access, delivery, services, and cultural mismatches between providers and families. Current practices inadequately address or provide incomplete control of symptoms, especially pain, resulting in decreased quality of life and high medical expense. The authors propose that care and care outcomes for people with sickle cell disease could be improved through community health worker case management, social support, and health system navigation. This paper outlines implementation strategies in current use to test community health workers for sickle cell disease management in a variety of settings. National medical and advocacy efforts to develop the community health workforce for sickle cell disease management may enhance the progress and development of "best practices" for this area of community-based care.

Ethical concerns related to grateful patient philanthropy: the physician's perspective.

BACKGROUND: Philanthropic contributions to academic medical centers from grateful patients support research, patient care, education, and capital projects. The goal of this study was to identify the ethical concerns associated with philanthropic gifts from grateful patients. METHODS: A qualitative study design was selected. Investigators conducted in-depth semi-structured interviews with 20 Department of Medicine physicians at Johns Hopkins who were identified by Development Office staff as experienced and successful in this realm-those having relationships with multiple patients who have made philanthropic contributions. Interview transcripts were independently coded by two investigators. Content analysis identified several themes related to ethical concerns. RESULTS: Eighteen informants (90 %) were Associate Professors or Professors; two (10 %) were females. Four thematic domains emerged related to ethical concerns associated with philanthropy from grateful patients: (i) impact of gift on the doctor-patient relationship; (ii) gift acquisition considered beyond the physician's professional role; (iii) justice and fairness; and (iv) vulnerability of patients. Despite acknowledging at least one of the aforementioned concerns, eleven physician informants (55 %) expressed the view that there were no ethical issues involved with grateful patient philanthropy. CONCLUSIONS: In this paper, we report that physicians involved in grateful patient philanthropy are aware of, and in some cases troubled by, the ethical concerns related to this activity. Further studies could examine how best to prepare faculty for the challenges that may accompany these gifts so as to help them maintain expected professional and ethical standards when accepting grateful patient philanthropy.

Urban health and primary care at Johns Hopkins: urban primary care medical home resident training programs.

Johns Hopkins University recently implemented two novel urban health residency training programs (UHR). The programs include increased access programs, community health worker-delivered care, substance abuse screening and treatment, community psychiatry/ mental health programs, case and disease management teams, and interprofessional training. These programs are designed to create well-trained physicians who competently provide care for the underserved inner-city patient.

Supporting irrational suicide.

In this essay, we present three case studies which suggest that sometimes we are better off supporting a so-called irrational suicide, and that emotional or psychological distress--even if medically controllable--might justify a suicide. We underscore how complicated these decisions are and how murky a physician's moral role can be. We advocate a more individualized route to end-of-life care, eschewing well-meaning, principled, generalizations in favor of highly contextualized, patient-centered approach. We conclude that our Western traditions of promoting reasoned behavior and life themselves may at times be counter-productive.