Storylines of family medicine II: foundational building blocks-context, community and health.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'II: foundational building blocks-context, community and health', authors address the following themes: 'Context-grounding family medicine in time, place and being', 'Recentring community', 'Community-oriented primary care', 'Embeddedness in practice', 'The meaning of health', 'Disease, illness and sickness-core concepts', 'The biopsychosocial model', 'The biopsychosocial approach' and 'Family medicine as social medicine.' May readers grasp new implications for medical education and practice in these essays.

Medicaid member perspectives on innovation in prenatal care delivery: A call to action from pregnant people using unscheduled care.

BACKGROUND: Low-income women using prenatal care have shared concerns as well as unique needs not met by traditional prenatal care. Our objective was to explore user ideas on addressing unmet needs driving unscheduled care utilization and use findings to inform interventions to improve perinatal outcomes. METHODS: We performed a secondary analysis of qualitative interviews among purposively sampled, Medicaid-insured pregnant women with varied degrees of unscheduled care utilization. Interviews explored barriers and facilitators of health and ideas for improvement in care delivery, with a focus on the potential role of community health workers and social support. We extracted material on participants' perceived gaps and ideas, used modified grounded theory to develop general and subset themes by study group, and then mapped themes to potential intervention features. RESULTS: We identified intervention targets in three thematic domains: social support, care delivery, and access, noting sub-group differences. Participants with four or more unscheduled visits during pregnancy ("Group 1") wanted individualized help navigating resources, coaching, and peer support, while participants with a first unscheduled care visit after 36 weeks of pregnancy ("Group 2) wanted these services to be optional. Group 1 participants wanted flexible appointments, less wait time, discharge education and improved communication with providers, while Group 2 participants sought stable insurance coverage. CONCLUSIONS: Findings suggest acceptable approaches to improve social support, care delivery, and access via stratified, targeted interventions. IMPLICATIONS: Targeted interventions to improve prenatal care that incorporate user ideas and address unique unmet needs of specific subgroups may improve perinatal outcomes. LEVEL OF EVIDENCE: III.

Understanding Why Urban, Low-Income Patients Miss Primary Care Appointments: Insights From Qualitative Interviews of West Philadelphians.

Missed primary care appointments occur frequently among urban, low-income patients-some of the costliest and sickest patients. We conducted semi-structured interviews with 43 patients who reside in West Philadelphia (100% insured by Medicaid, 95% were non-Hispanic African Americans, and 47.1 years old on average) to identify why recent primary care appointments were or might have been missed. Existing transportation options, including public transportation, were considered unreliable and alternative options too costly. In addition, we discovered poor health, family obligations, and work requirements prevented appointment attendance. Intervening on the barriers identified may reduce missed appointment rates among disadvantaged populations.

Effect of Community Health Worker Support on Clinical Outcomes of Low-Income Patients Across Primary Care Facilities: A Randomized Clinical Trial.

Importance: Addressing the social determinants of health has been difficult for health systems to operationalize. Objective: To assess a standardized intervention, Individualized Management for Patient-Centered Targets (IMPaCT), delivered by community health workers (CHWs) across 3 health systems. Design, Setting, and Participants: This 2-armed, single-blind, multicenter randomized clinical trial recruited patients from 3 primary care facilities in Philadelphia, Pennsylvania, between January 28, 2015, and March 28, 2016. Patients who resided in a high-poverty zip code, were uninsured or publicly insured, and who had a diagnosis for 2 or more chronic diseases were recruited, and patients were randomized to either the CHW intervention or the control arm (goal setting only). Follow-up assessments were conducted at 6 and 9 months after enrollment. Data were analyzed using an intention-to-treat approach from June 2017 to March 2018. Intervention: Participants set a chronic disease management goal with their primary care physician; those randomized to the CHW intervention received 6 months of tailored support. Main Outcomes and Measures: The primary outcome was change in self-rated physical health. The secondary outcomes were self-rated mental health, chronic disease control, patient activation, patient-reported quality of primary care, and all-cause hospitalization. Results: Of the 592 participants, 370 (62.5%) were female, with a mean (SD) age of 52.6 (11.1) years. Participants in both arms had similar improvements in self-rated physical health (mean [SD], 1.8 [11.2] vs 1.6 [9.9]; P = .89). Patients in the intervention group were more likely to report the highest quality of care (odds ratio [OR], 1.8; 95% CI, 1.4-2.4; risk difference [RD], 0.12; P < .001) and spent fewer total days in the hospital at 6 months (155 days vs 345 days; absolute event rate reduction, 69%) and 9 months (300 days vs 471 days; absolute event rate reduction, 65%). This reduction was driven by a shorter average length of stay (difference, -3.1 days; 95% CI, -6.33 to 0.22; P = .06) and a lower mean number of hospitalizations (difference, -0.3; 95% CI, -0.6 to 0.0; P = .07) among patients who were hospitalized. Patients in the intervention group had a lower odds of repeat hospitalizations (OR, 0.4; 95% CI, 0.2-0.9; RD, -0.24; P = .02), including 30-day readmissions (OR, 0.3; 95% CI, 0.1-0.9; RD, -0.17; P = .04). Conclusions and Relevance: A standardized intervention did not improve self-rated health but did improve the patient-perceived quality of care while reducing hospitalizations, suggesting that health systems may use a standardized intervention to address the social determinants of health. Trial Registration: ClinicalTrials.gov identifier: NCT02347787.

Why Effective Interventions Do Not Work for All Patients: Exploring Variation in Response to a Chronic Disease Management Intervention.

BACKGROUND: Half of all Americans have a chronic disease. Promoting healthy behaviors to decrease this burden is a national priority. A number of behavioral interventions have proven efficacy; yet even the most effective of these has high levels of nonresponse. OBJECTIVES: In this study, we explore variation in response to an evidence-based community health worker (CHW) intervention for chronic disease management. RESEARCH DESIGN: We used a convergent parallel design that combined a randomized controlled trial with a qualitative process evaluation that triangulated chart abstraction, in-depth interviews and participant observation. SUBJECTS: Eligible patients lived in a high-poverty region and were diagnosed with 2 or more of the following chronic diseases: diabetes, obesity, hypertension or tobacco dependence. There were 302 patients in the trial, 150 of whom were randomly assigned to the CHW intervention. Twenty patients and their CHWs were included in the qualitative evaluation. RESULTS: We found minimal differences between responders and nonresponders by sociodemographic or clinical characteristics. A qualitative process evaluation revealed that health behavior change was challenging for all patients and most experienced failure (ie, gaining weight or relapsing with cigarettes) along the way. Responders seemed to increase their resolve after failed attempts at health behavior change, while nonresponders became discouraged and "shut down." CONCLUSIONS: Failure is a common and consequential aspect of health behavior change; a deeper understanding of failure should inform chronic disease interventions.

A Community Health Worker-Led Rotation to Train Medical Students in the Social Determinants of Health.

Medical students often lack training in understanding and addressing the social determinants that shape the health of high-risk populations. We describe a novel clinical elective rotation in which fourth-year medical students served as apprentices to community health workers in order to develop community engagement skills and cultural humility.

Understanding High Utilization of Unscheduled Care in Pregnant Women of Low Socioeconomic Status.

BACKGROUND: Pregnant high utilizers of unscheduled care may be at particular risk for poor perinatal outcomes, but the drivers of this association have not been explored from the patient perspective. PURPOSE: We sought to understand maternal preference for unscheduled hospital-based obstetric care to inform interventions and improve value of publicly funded care during pregnancy. METHODS: We conducted a comparative qualitative analysis of in-depth semistructured interviews. Low-income pregnant women presenting to an inner city hospital-based obstetric triage unit were purposively sampled, categorized as either high or low utilizers of unscheduled care, and interviewed about challenges faced in obtaining pregnancy care and reasons for choosing between unscheduled versus scheduled care delivery. RESULTS: Demographically, high utilizers were similar to low utilizers, but were more likely to report adverse childhood experiences (p = .01). All 40 participants reported resource constraints and perceived hospital-based unscheduled obstetric care to be more accessible than outpatient prenatal care. Beyond this, high (n = 20) and low (n = 20) utilizer narratives differed significantly. Two distinct high utilizer profiles emerged. Some high utilizers repetitively used unscheduled hospital-based services owing to psychosocial determinants. Other high utilizing participants were driven by severe experiences of illness insufficiently addressed by outpatient prenatal care. Low utilizer narratives demonstrated high self-efficacy and social support compared with high utilizers. CONCLUSIONS: Low-value, unscheduled, hospital-based care utilization by pregnant women of low socioeconomic status was driven by unmet clinical and psychosocial need. IMPLICATIONS FOR POLICY AND/OR PRACTICE: Tailored community-focused innovations that use unscheduled visits as signals of risk may improve value of both outpatient and inpatient maternity care and better address adverse perinatal outcomes in vulnerable subgroups.

Penn Center for Community Health Workers: Step-by-Step Approach to Sustain an Evidence-Based Community Health Worker Intervention at an Academic Medical Center.

Community-engaged researchers who work with low-income communities can be reliant on grant funding. We use the illustrative case of the Penn Center for Community Health Workers (PCCHW) to describe a step-by-step framework for achieving financial sustainability for community-engaged research interventions. PCCHW began as a small grant-funded research project but followed an 8-step framework to engage both low-income patients and funders, determine outcomes, and calculate return on investment. PCCHW is now fully funded by Penn Medicine and delivers the Individualized Management for Patient-Centered Targets (IMPaCT) community health worker intervention to 2000 patients annually.

Toward A Scalable, Patient-Centered Community Health Worker Model: Adapting the IMPaCT Intervention for Use in the Outpatient Setting.

Community health worker (CHW) programs are an increasingly popular strategy for patient-centered care. Many health care organizations are building CHW programs through trial and error, rather than implementing or adapting evidence-based interventions. This study used a qualitative design-mapping process to adapt an evidence-based CHW intervention, originally developed and tested in the hospital setting, for use among outpatients with multiple chronic conditions. The study involved qualitative in-depth, semi-structured interviews with chronically ill, uninsured, or Medicaid outpatients from low-income zip codes (n = 21) and their primary care practice staff (n = 30). Three key themes informed adaptation of the original intervention for outpatients with multiple conditions. First, outpatients were overwhelmed by their multiple conditions and wished they could focus on 1 at a time. Thus, the first major revision was to design a low-literacy decision aid that patients and providers could use to select a condition to focus on during the intervention. Second, motivation for health behavior change was a more prominent theme than in the original intervention. It was decided that in addition to providing tailored social support as in the original intervention, CHWs would help patients track progress toward their chronic disease management goals to motivate health behavior change. Third, patients were already connected to primary care; yet they still needed additional support to navigate their clinic once the intervention ended. The intervention was revised to include a weekly clinic-based support group. Structured adaptation using qualitative design mapping may allow for rapid adaptation and scale-up of evidence-based CHW interventions across new settings and populations.

Exploring the Patient and Staff Experience With the Process of Primary Care.

PURPOSE: Previous studies suggest that the highest-risk patients value accessible, coordinated primary care that they perceive to be of high technical quality. We have limited understanding, however, of how low-income, chronically ill patients and the staff who care for them experience each individual step in the primary care process. METHODS: We conducted qualitative interviews with uninsured or Medicaid patients with chronic illnesses, as well as with primary care staff. We interviewed 21 patients and 30 staff members with a variety of job titles from 3 primary care practices (1 federally qualified health center and 2 academically affiliated clinics).] RESULTS: The interviews revealed 3 major issues that were present at all stages of a primary care episode: (1) information flow throughout an episode of care is a frequent challenge, despite systems that are intended to improve communication; (2) misaligned goals and expectations among patients, clinicians, and staff members are often an impediment to providing and obtaining care; and (3) personal relationships are highly valued by both patients and staff. CONCLUSIONS: Vulnerable populations and the primary care staff who work with them perceive some of the same challenges throughout the primary care process. Improving information flow, aligning goals and expectations, and developing personal relationships may improve the experience of both patients and staff.

Perceptions of high-risk patients and their providers on the patient-centered medical home.

To explore perceptions of high-risk patients and their practice staff on the patient-centered medical home, we conducted a multisite qualitative study with chronically ill, low-income patients and their primary care practice staff (N = 51). There were 3 key findings. Both patients and staff described a trade-off: timely care from an unfamiliar provider versus delayed access to their personal physician. Staff were enthusiastic about enhancing access through strategies such as online communication, yet high-risk patients viewed these as access barriers. Practices lacked capacity to manage high-risk patients and therefore frequently referred them to the emergency room.

Perspectives of older adults of low socioeconomic status on the post-hospital transition.

BACKGROUND: Older adults of low socioeconomic status are at high risk for poor post-hospital outcomes. Design. A qualitative researcher, who was also an outreach worker from the West Philadelphia community, conducted in-depth interviews with 25 participants within 30 days of their hospital discharge. PARTICIPANTS: Eligible participants were: 1) residents of high-poverty ZIP codes; 2) dually eligible for Medicare and Medicaid; 3) had capacity or a caregiver who could be interviewed as a proxy; 4) general medicine or cardiology patients. RESULTS: Participants were unable to access the care and accommodations needed to cope with post-hospital frailty. As a result, medical disability was amplified by socioeconomic disability. Participants were ashamed of the resulting loss of control and had difficulty asking for help, particularly from potential supports who were perceived as emotionally controlling or judgmental. CONCLUSION: Strategies that address socioeconomic stressors of hospitalization and provide empathic support may improve the post-hospital transition for these high-risk individuals.

Challenges faced by patients with low socioeconomic status during the post-hospital transition.

BACKGROUND: Patients with low socioeconomic status (low-SES) are at risk for poor outcomes during the post-hospital transition. Few prior studies explore perceived reasons for poor outcomes from the perspectives of these high-risk patients. OBJECTIVE: We explored low-SES patients' perceptions of hospitalization, discharge and post-hospital transition in order to generate hypotheses and identify common experiences during this transition. DESIGN: We conducted a qualitative study using in-depth semi-structured interviewing. PARTICIPANTS: We interviewed 65 patients who were: 1) uninsured, insured by Medicaid or dually eligible for Medicaid and Medicare; 2) residents of five low-income ZIP codes; 3) had capacity or a caregiver who could be interviewed as a proxy; and 4) hospitalized on the general medicine or cardiology services of two academically affiliated urban hospitals. APPROACH: Our interview guide investigated patients' perceptions of hospitalization, discharge and the post-hospital transition, and their performance of recommended post-hospital health behaviors related to: 1) experience of hospitalization and discharge; 2) external constraints on patients' ability to execute discharge instructions; 3) salience of health behaviors; and 4) self-efficacy to execute discharge instructions. We used a modified grounded theory approach to analysis. KEY RESULTS: We identified six themes that low-SES patients shared in their narratives of hospitalization, discharge and post-hospital transition. These were: 1) powerlessness during hospitalization due to illness and socioeconomic factors; 2) misalignment of patient and care team goals; 3) lack of saliency of health behaviors due to competing issues; 4) socioeconomic constraints on patients' ability to perform recommended behaviors; 5) abandonment after discharge; and 6) loss of self-efficacy resulting from failure to perform recommended behaviors. CONCLUSIONS: Low-SES patients describe discharge goals that are confusing, unrealistic in the face of significant socioeconomic constraints, and in conflict with their own immediate goals. We hypothesize that this goal misalignment leads to a cycle of low achievement and loss of self-efficacy that may underlie poor post-hospital outcomes among low-SES patients.

The use of participatory action research to design a patient-centered community health worker care transitions intervention.

BACKGROUND: Policymakers, patients and clinicians are increasingly eager to foster patient involvement in health care innovation. Our objective was to use participatory action research with high-risk hospitalized patients to design a post-hospital transition intervention. METHODS: We conducted qualitative interviews with sixty-five low-income, recently hospitalized patients exploring their perceptions of barriers to post-hospital recovery and ideas for improvement. We then used a modified grounded theory approach to design an intervention that would address each barrier using patients׳ suggestions. RESULTS: Five key themes were translated into design elements. First, patients wished to establish a relationship with healthcare personnel to whom they could relate. The intervention was provided by an empathic community health worker (CHW) who established rapport during hospitalization. Second, patients suggested tailoring support to their needs and goals. CHWs and patients designed individualized action plans for achieving their goals for recovery. Third, patient goals were misaligned with those of the inpatient team. CHW facilitated patient-provider discharge communication to align goals. Fourth, patients lacked post-discharge support for predominantly psychosocial or financial issues that undermined recovery. CHWs provided support tailored to patient needs. Finally, patients faced numerous barriers in obtaining post-hospital primary care. CHWs helped patients to obtain timely care with a suitable provider. CONCLUSIONS: Low-income hospitalized patients voiced needs and suggestions that were directly translated into the design of a scalable patient-centered CHW intervention. IMPLICATIONS: The approach of using participatory action research to tightly mapping patient input into intervention design is rapid and systematic strategy for operationalizing patient involvement in innovation.

Understanding why patients of low socioeconomic status prefer hospitals over ambulatory care.

Patients with low socioeconomic status (SES) use more acute hospital care and less primary care than patients with high socioeconomic status. This low-value pattern of care use is harmful to these patients' health and costly to the health care system. Many current policy initiatives, such as the creation of accountable care organizations, aim to improve both health outcomes and the cost-effectiveness of health services. Achieving those goals requires understanding what drives low-value health care use. We conducted qualitative interviews with forty urban low-SES patients to explore why they prefer to use hospital care. They perceive it as less expensive, more accessible, and of higher quality than ambulatory care. Efforts that focus solely on improving the quality of hospital care to reduce readmissions could, paradoxically, increase hospital use. Two different profile types emerged from our research. Patients in Profile A (five or more acute care episodes in six months) reported social dysfunction and disability. Those in Profile B (fewer than five acute care episodes in six months) reported social stability but found accessing ambulatory care to be difficult. Interventions to improve outcomes and values need to take these differences into account.