Intensity and Variation of Health Navigator Support: Addressing Medical and Social Needs of Diabetes Patients in East Oakland.

BACKGROUND: Healthcare systems are increasingly screening and referring patients for unmet social needs (e.g., food insecurity). Little is known about the intensity of support necessary to address unmet needs, how this support may vary by circumstance or time (duration), or the factors that may contribute to this variation. OBJECTIVE: Describe health navigator services and the effort required to support patients with complex needs at a community health center in East Oakland, CA. DESIGN: Retrospective analysis of de-identified patient contact notes (e.g., progress notes). PARTICIPANTS: Convenience sample of patients (n = 27) enrolled in diabetes education and referred to health navigators. INTERVENTIONS: Navigators provide education on managing conditions (e.g., diabetes), initiate and track medical and social needs referrals, and navigate patients to medical and social care organizations. MAIN MEASURES: Descriptive statistics for prevalence, mean, median, and range values of patient contacts and navigation services. We described patterns and variation in navigation utilization (both contacts and navigation services) based on types of need. KEY RESULTS: We identified 811 unmet social and medical needs that occurred over 710 contacts with health navigators; 722 navigation services were used to address these needs. Patients were supported by navigators for a median of 9 months; approximately 25% of patients received support for > 1 year. We categorized patients into 3 different levels of social risk, accounting for patient complexity and resource needs. The top tertile (n = 9; 33%) accounted for the majority of resource utilization, based on health navigator contacts (68%) and navigation services (75%). CONCLUSIONS: The required intensity and support given to meet patients' medical and social needs is substantial and has significant variation. Meeting the needs of complex patients will require considerable investments in human capital, and a risk stratification system to help identify those most in need of services.

Integrated Interventions to Bridge Medical and Social Care for People Living with Diabetes.

Social drivers of health impact health outcomes for patients with diabetes, and are areas of interest to health systems, researchers, and policymakers. To improve population health and health outcomes, organizations are integrating medical and social care, collaborating with community partners, and seeking sustainable financing with payors. We summarize promising examples of integrated medical and social care from the Merck Foundation Bridging the Gap: Reducing Disparities in Diabetes Care initiative. The initiative funded eight organizations to implement and evaluate integrated medical and social care models, aiming to build a value case for services that are traditionally not eligible for reimbursement (e.g., community health workers, food prescriptions, patient navigation). This article summarizes promising examples and future opportunities for integrated medical and social care across three themes: (1) primary care transformation (e.g., social risk stratification) and workforce capacity (e.g., lay health worker interventions), (2) addressing individual social needs and structural changes, and (3) payment reform. Integrated medical and social care that advances health equity requires a significant paradigm shift in healthcare financing and delivery.

"Everything in One Place": Stakeholder Perceptions of Integrated Medical and Social Care for Diabetes Patients in Western Maryland.

BACKGROUND: Patients with type 2 diabetes frequently have both medical- and health-related social needs that must be addressed for optimal disease management. Growing evidence suggests that intersectoral partnerships between health systems and community-based organizations may effectively support improved health outcomes for patients with diabetes. OBJECTIVE: The purpose of this study was to describe stakeholders' perceptions of the implementation factors associated with a diabetes management program, an intervention involving coordinated clinical and social services supports to address both medical- and health-related social needs. This intervention delivers proactive care alongside community partnerships, and leverages innovative financing mechanisms. DESIGN: Qualitative study with semi-structured interviews. PARTICIPANTS: Study participants included adults (18 years or older) who were patients with diabetes and essential staff (e.g., members of a diabetes care team, health care administrators) and leaders of community-based organizations. APPROACH: We used the Consolidated Framework for Implementation Research (CFIR) to develop a semi-structured interview guide designed to elicit perspectives from patients and essential staff on their experiences within an outpatient center to support patients with chronic conditions (the CCR) as a part of an intervention to improve care for patients with diabetes. KEY RESULTS: Interviews illuminated three key takeaways: (1) team-based care held an important role in promoting accountability across stakeholders motivating patient engagement and positive perceptions, (2) mission-driven alignment across the health care and community sectors was needed to synergize a broad range of efforts, and (3) global payment models allowing for flexible resource allocation can invaluably support the appropriate care being directed where it is needed the most whether medical or social services. CONCLUSIONS: The views and experiences of patient and essential staff stakeholder groups reported here thematically according to CFIR domains may inform the development of other chronic disease interventions that address medical- and health-related social needs in additional settings.

New Frontiers in Diabetes Care: Quality Improvement Study of a Population Health Team in Rural Critical Access Hospitals.

BACKGROUND: Rural populations are older, have higher diabetes prevalence, and have less improvement in diabetes-related mortality rates compared to urban counterparts. Rural communities have limited access to diabetes education and social support services. OBJECTIVE: Determine if an innovative population health program that integrates medical and social care models improves clinical outcomes for patients with type 2 diabetes in a resource-constrained, frontier area. DESIGN/PARTICIPANTS: Quality improvement cohort study of 1764 patients with diabetes (September 2017-December 2021) at St. Mary's Health and Clearwater Valley Health (SMHCVH), an integrated health care delivery system in frontier Idaho. The United States Department of Agriculture's Office of Rural Health defines frontier as sparsely populated areas that are geographically isolated from population centers and services. INTERVENTION: SMHCVH integrated medical and social care through a population health team (PHT), where staff assess medical, behavioral, and social needs with annual health risk assessments and provide core interventions including diabetes self-management education, chronic care management, integrated behavioral health, medical nutritional therapy, and community health worker navigation. We categorized patients with diabetes into three groups: patients with two or more PHT encounters during the study (PHT intervention), one PHT encounter (minimal PHT), and no PHT encounters (no PHT). MAIN MEASURES: HbA1c, blood pressure, and LDL over time for each study group. KEY RESULTS: Of the 1764 patients with diabetes, mean age was 68.3 years, 57% were male, 98% were white, 33% had three or more chronic conditions, and 9% had at least one unmet social need. PHT intervention patients had more chronic conditions and higher medical complexity. Mean HbA1c of PHT intervention patients significantly decreased from baseline to 12 months (7.9 to 7.6%, p < 0.01) and sustained reductions at 18 months, 24 months, 30 months, and 36 months. Minimal PHT patients decreased HbA1c from baseline to 12 months (7.7 to 7.3%, p < 0.05). CONCLUSION: The SMHCVH PHT model was associated with improved hemoglobin A1c among less well-controlled patients with diabetes.

Experiences of Community Violence Among Adults with Chronic Conditions: Qualitative Findings from Chicago.

BACKGROUND: Community violence is an important social determinant of health in many high-poverty, urban communities. OBJECTIVE: The purpose of this study was to explore and characterize self-described experiences of community violence among adults with chronic health conditions. DESIGN: Qualitative study design was implemented in 2017 using in-depth, semi-structured focus groups and interviews; data were collected from two clinical sites located in geographic epicenters of high violent crime in Chicago. PARTICIPANTS: Adult patients, ages 35 years and older, who had at least one chronic condition. APPROACH: Data were analyzed using grounded theory and the constant comparison method. KEY RESULTS: The overall sample (N = 51) was predominantly female (67%) and black non-Hispanic (75%); a large proportion had hypertension (65%), arthritis (55%), obesity (53%), and/or diabetes (45%). The majority reported that a close friend or family member was seriously injured or killed due to community violence (71%); a similar proportion had never discussed their experiences of community violence with a healthcare provider (73%). Several major themes emerged: (1) perceived risk of being targeted, (2) chronic stress and worry, (3) hypervigilance, (4) social breakdown, (5) chronic isolation, (6) constrained choice (loss of freedom), (7) limited access to material resources, and (8) inadequate healthcare responses. CONCLUSIONS: Patients often struggled to balance the challenges imposed by community violence with the demands of living with and managing their chronic conditions. Emergent themes may inform practical targets for addressing community violence as a social determinant of health in vulnerable populations.

Culturally Tailoring a Patient Empowerment and Diabetes Education Curriculum for the African American Church.

Purpose The African American church has long been recognized as a valuable partner for health interventions in the community. While an extensive literature exists documenting the potential efficacy of diabetes education programs in church settings, there has yet to be an effort to leverage spiritual beliefs and practices to promote diabetes self-management and shared decision making within a faith-based framework that is culturally tailored to the African American church. The purpose of this article is to describe the translation of a clinic-based diabetes education program into faith-based education curriculum tailored for use in the African American church. Conclusions Themes extracted from focus groups and input from a faith-based community partner provided a methodical and patient-informed foundation for culturally tailoring and piloting a diabetes self-management curriculum for the African American church setting. This study illustrates how spirituality can be incorporated into interventions to enhance health promotion and behavioral change among African Americans with diabetes. Participants in our study described how religious beliefs play an active role in many aspects of diabetes care, including self-management behaviors, coping strategies, and patient/provider communication. In addition, this intervention can serve as a model for the development of patient-centered health interventions.