Design and Implementation of the Diabetes Impact Project: A Multisector Partnership to Reduce Diabetes Burden in Indianapolis Communities.

CONTEXT: Community-level health disparities have not arisen suddenly but are the result of long-term systemic inequities. This article describes the design and implementation of a community-engaged multisector partnership to address health disparities by reducing the diabetes burden in 3 Indianapolis communities through the implementation of evidence-based strategies across the prevention continuum. PROGRAM: The project has 5 foundational design principles: engage partners from multiple sectors to address community health, focus on geographic communities most affected by the health disparity, practice authentic community engagement, commit for the long term, and utilize a holistic approach spanning the prevention continuum. IMPLEMENTATION: The design principles are incorporated into the following project components in each community: (1) health system community health workers (hCHWs), (2) neighborhood CHWs (nCHWs), (3) community health promotion initiatives, and (4) resident steering committees, as well as a backbone organization responsible for overall coordination, project communication, evaluation, and partnership coordination. EVALUATION: This complex multilevel intervention is being evaluated using data sources and methodologies suited to each project component and its purpose overall. Each component is being evaluated independently and included holistically to measure the impact of the project on the health and culture of health in the communities. Key Performance Indicators were established upon project initiation as our common metrics for the partnership. Because complex interventions aiming at population-level change take time, we evaluate Diabetes Impact Project-Indianapolis Neighborhoods (DIP-IN), assuming its impact will take many years to achieve. DISCUSSION: Health disparities such as the diabetes prevalence in project communities have not arisen suddenly but are the result of long-term systemic inequities. This complex issue requires a complex holistic solution with long-term commitment, trusted partnerships, and investment from diverse sectors as seen in this project. Implications for policy and practice include the need to identify stable funding mechanisms to support these types of holistic approaches.

Primary Care-Based Case Conferences and Reductions in Health Care Utilization.

Case conferences are collaborative, interdisciplinary team meetings that facilitate consensus on individual patients' health management plans, coordinate services, and initiate referrals. This approach is well-suited to address the social needs and risks of complex patients. Evidence of this approach in primary care settings to change patient outcomes is limited. A panel of 976 patients from an urban, federally qualified health center were included in case conferences. Fixed-effects regression models estimated the effect of case conferences on admissions, emergency department (ED) visits, and missed outpatient appointments. Case conferencing was associated with a 6% reduction in the probability that the patient would have an ED visit in a given month and a 5% lower probability of an inpatient admission. The probability of missed primary care appointments increased. Case conferences are a potential strategy to address the multiple issues facing complex patients.

Primary Care Case Conferences to Mitigate Social Determinants of Health: A Case Study from One FQHC System.

Objective: Given the increasing difficulty healthcare providers face in addressing patients' complex social circumstances and underlying health needs, organizations are considering team-based approaches including case conferences. We sought to document various perspectives on the facilitators and challenges of conducting case conferences in primary care settings. Study Design: Qualitative study using semi-structured telephone interviews. Methods: We conducted 22 qualitative interviews with members of case conferencing teams, including physicians, nurses, and social workers from a Federally Qualified Health Clinic, as well as local county public health nurses. Interviews were recorded, transcribed, and reviewed using thematic coding to identify key themes/subthemes. Results: Participants reported perceived benefits to patients, providers, and healthcare organizations including better care, increased inter-professional communication, and shared knowledge. Perceived challenges related to underlying organizational processes and priorities. Perceived facilitators for successful case conferences included generating and maintaining a list of patients to discuss during case conference sessions and team members being prepared to actively participate in addressing tasks and patient needs during each session. Participants offered recommendations for further improving case conferences for patients, providers, and organizations. Conclusions: Case conferences may be a feasible approach to understanding patient's complex social needs. Participants reported that case conferences may help mitigate the effects of these social issues and that they foster better inter-professional communication and care planning in primary care. The case conference model requires administrative support and organizational resources to be successful. Future research should explore how case conferences fit into a larger population health organizational strategy so that they are resourced commensurately.

Indianapolis Provider's Use Of Wraparound Services Associated With Reduced Hospitalizations And Emergency Department Visits.

Recent changes to US reimbursement policies are increasingly holding providers financially accountable for patients' health. Providing nonmedical services in conjunction with primary care-known as wraparound services-is one strategy to improve patient outcomes and reduce overall health care spending. These services leverage additional providers to address patients' social determinants of health. Eskenazi Health-an Indianapolis, Indiana, safety-net provider-introduced wraparound services at its federally qualified health center sites. Behavioral health, social work, dietetics, patient navigation, and other services that address patients' social and behavioral needs are co-located with primary care services. In an eleven-year panel of primary care patients, receipt of any wraparound service was negatively associated with subsequent hospitalizations and emergency department visits. The estimated cost savings from potentially avoided hospitalizations alone was $1.4 million annually. Under value-based payment, wraparound services may be one part of a portfolio of strategies to address the social, behavioral, and environmental factors that drive poor patient health and increase costs.

Using structured and unstructured data to identify patients' need for services that address the social determinants of health.

INTRODUCTION: Increasingly, health care providers are adopting population health management approaches that address the social determinants of health (SDH). However, effectively identifying patients needing services that address a SDH in primary care settings is challenging. The purpose of the current study is to explore how various data sources can identify adult primary care patients that are in need of services that address SDH. METHODS: A cross-sectional study described patients in need of SDH services offered by a safety-net hospital's federally qualified health center clinics. SDH services of social work, behavioral health, nutrition counseling, respiratory therapy, financial planning, medical-legal partnership assistance, patient navigation, and pharmacist consultation were offered on a co-located basis and were identified using structured billing and scheduling data, and unstructured electronic health record data. We report the prevalence of the eight different SDH service needs and the patient characteristics associated with service need. Moreover, characteristics of patients with SDH services need documented in structured data sources were compared with those documented by unstructured data sources. RESULTS: More than half (53%) of patients needed SDH services. Those in need of such services tended to be female, older, more medically complex, and higher utilizers of services. Structured and unstructured data sources exhibited poor agreement on patient SDH services need. Patients with SDH services need documented by unstructured data tended to be more complex. DISCUSSION: The need for SDH services among a safety-net population is high. Identifying patients in need of such services requires multiple data sources with structured and unstructured data.