Assessing the Feasibility of an Empathic Inquiry Approach to Social Needs Screening in 10 Federally Qualified Health Centers.

OBJECTIVES: Despite an increasing emphasis from health care organizations on patients' social health, there is debate about how best to screen patients for social health needs in practice. Empathic Inquiry is a patient-centered approach to asking about patients' social needs that incorporates motivational interviewing and trauma-informed care techniques to increase patient experience of trustworthiness and safety with their care teams. The purpose of this brief report is to describe the feasibility and acceptability of implementing an Empathic Inquiry-informed approach to social needs screening in 10 federally qualified health centers. METHODS: Clinical staff at community health centers implemented Empathic Inquiry as part of an 8-month learning collaborative. Patients completed surveys about their experience with Empathic Inquiry after screening conversations took place. Qualitative data on organizational implementation experience were collected monthly during 2018. FINDINGS: Eight of 10 organizations completed the learning collaborative and implemented Empathic Inquiry in practice. Of 132 patient surveys received, patients agreed (64% strongly agree, 28% somewhat agree) that being screened for social needs strengthened their relationship with their care team and 83% strongly agreed the conversation was a good use of time. Most patients (54%) indicated social health screening was appropriate at every visit, and 27% answered once every 6 months. CONCLUSIONS: The Empathic Inquiry approach to understanding patients' social needs was feasible for implementation in community settings. Patients said the conversations were worthwhile, built trust with their care teams, and should be conducted every 6 months or more frequently.

Understanding the Relationship Between Social Risk Factors and COVID-19 Contacts.

Introduction Social risks are associated with increased risk of COVID-19 transmission by limiting patients' ability to practice precautions and access care. Researchers need to understand the prevalence of patients' social risk factors during the pandemic and recognize how social risks may exacerbate COVID-19. Methods The authors conducted a national survey among Kaiser Permanente members between January and September 2020 and restricted analyses to those who responded to a set of COVID-19 items. The survey asked if they experienced social risks, knew of people with COVID-19, and if COVID-19 affected their emotional and mental health, and their preferred type of assistance. Results Social risks were reported by 62% of respondents, with 38% reporting having 2 or more social risks. Respondents most commonly reported financial strain (45%). One or more contact types with COVID-19 were reported by one-third of the respondents. Those with 2 or more COVID-19 contact types reported higher housing instability, financial strain, food insecurity, and social isolation than those with fewer contacts. Overall, 50% of respondents reported that COVID-19 negatively affected their emotional, mental health, and 19% noted that it affected their ability to maintain a job. Discussion People with any COVID-19 contacts reported more social risks compared to those who did not know anyone with COVID-19. This suggests that those with higher social risks during this time may have faced higher risk for COVID-19, or the converse may be true. Conclusion These findings highlight patients' social health during the pandemic and suggest that health systems develop interventions to assess social health and link patients to appropriate resources.

Discussing measurement-based care with patients: An analysis of clinician-patient dyads.

Abstract Measurement-based care (MBC) refers to the use of three integrated strategies to improve effectiveness of behavioral health care: routine outcomes monitoring using symptom measures; regularly sharing these data with patients; and using these data to inform treatment decisions. This study examined how clinicians discuss MBC data with patients, including identifying what aspects of these discussions contribute to clinician-patient agreement on the value of MBC, and how clinicians use MBC data to inform treatment decisions. Twenty-six clinician-patient dyads participated in semi-structured interviews and provided a treatment session recording in which MBC data were discussed. Qualitative data analyses revealed four subtypes of dyads: clinician and patient both valued MBC; clinician valued MBC, patient passively participated in MBC; clinician valued MBC, patient had mixed perceptions of MBC; clinician and patient reported moderate or low value for MBC. In dyads for whom both the clinician and patient valued MBC, the clinician provided clear and repeated rationale for MBC, discussed data with patients at every administration, and connected observed scores to patient skills or strategies. Emerging best practices for discussing MBC include providing a strong rationale, discussing results frequently, actively engaging patients in discussions, and using graphs to visualize progress.

Association of Primary and Specialty Care Integration on Physician Communication and Cancer Screening in Safety-Net Clinics.

INTRODUCTION: Primary care providers who lack reliable referral relationships with specialists may be less likely than those who do have such relationships to conduct cancer screenings. Community health centers (CHCs), which provide primary care to disadvantaged populations, have historically reported difficulty accessing specialty care for their patients. This study aimed to describe strategies CHCs use to integrate care with specialists and examine whether more strongly integrated CHCs have higher rates of screening for colorectal and cervical cancers and report better communication with specialists. METHODS: Using a 2017 survey of CHCs in 12 states and the District of Columbia and administrative data, we estimated the association between a composite measure of CHC/specialist integration and 1) colorectal and cervical cancer screening rates, and 2) 4 measures of CHC/specialist communication using multivariate regression models. RESULTS: Integration strategies commonly reported by CHCs included having specialists deliver care on-site (80%) and establishing referral agreements with specialists (70%). CHCs that were most integrated with specialists had 5.6 and 6.8 percentage-point higher colorectal and cervical cancer screening rates, respectively, than the least integrated CHCs (P < .05). They also had significantly higher rates of knowing that specialist visits happened (67% vs 42%), knowing visit outcomes (65% vs 42%), receiving information after visits (47% vs 21%), and timely receipt of information (44% vs 27%). CONCLUSION: CHCs use various strategies to integrate primary and specialty care. Efforts to promote CHC/specialist integration may help increase rates of cancer screening.

Integrating Department of Defense and Department of Veterans Affairs Purchased Care: Preliminary Feasibility Assessment.

The U.S. Department of Defense (DoD) and U.S. Department of Veterans Affairs (VA) health systems provide services through a mix of direct care, delivered at government facilities, and purchased care, provided through the private sector, mainly by community-based providers who have entered into contracts with third-party administrators (TPAs). In the interest of expanding DoD-VA resource sharing that may lead to greater efficiencies and cost savings, the DoD/VA Joint Executive Committee is exploring options to integrate DoD and VA's purchased care programs. This preliminary feasibility assessment examined how an integrated approach to purchasing care could affect access, quality, and costs for beneficiaries, DoD, and VA and identified general legislative, policy, and contractual challenges to implementing an integrated purchased care program. An integrated approach to purchasing care is feasible under current legal and regulatory authorities, but policy changes may be needed-and the practicality of such an approach depends on the contract and network design. For example, legal/regulatory changes in how contracts are established would be required to achieve any real savings to the government. There are also differences in the populations served by TRICARE (DoD health care) and VA, particularly in terms of age and geographic location. Implementation would be further complicated by contractual differences in the TPA contracts for VA and DoD as they relate to network standards, provider payments, network participation requirements, and reporting requirements and incentive structures. As a result, there are significant uncertainties with respect to increased efficiency or cost savings for the government.

Provision of Social Services and Health Care Quality in US Community Health Centers, 2017.

Objectives. To describe the types of social services provided at community health centers (CHCs), characteristics of CHCs providing these services, and the association between on-site provision and health care quality.Methods. We surveyed CHCs in 12 US states and the District of Columbia during summer 2017 (n = 208) to identify referral to and provision of services to address 8 social needs. Regression models estimated factors associated with the provision of social services by CHCs and the association between providing services and health care quality (an 8-item composite).Results. CHCs most often offered on-site assistance for needs related to food or nutrition (43%), interpersonal violence (32%), and housing (30%). Participation in projects with community-based organizations was associated with providing services on-site (odds ratio = 2.48; P = .018). On-site provision was associated with better performance on measures of health care quality (e.g., each additional social service was associated with a 4.3 percentage point increase in colorectal cancer screenings).Conclusions. Some CHCs provide social services on-site, and this was associated with better performance on measures of health care quality.Public Health Implications. Health care providers are increasingly seeking to identify and address patients' unmet social needs, and on-site provision of services is 1 strategy to consider.

Access, Quality, And Financial Performance Of Rural Hospitals Following Health System Affiliation.

More than 100 rural hospitals have closed since 2010. Some rural hospitals have affiliated with health systems to improve their financial performance and potentially avoid closure, but the effects of affiliation on rural hospitals and their patients are unclear. To examine the relationship between affiliation and performance, we compared rural hospitals that affiliated with a health system in the period 2008-17 and a propensity score-weighted set of nonaffiliating rural hospitals on twelve measures of structure, utilization, financial performance, and quality. Following health system affiliation, rural hospitals experienced a significant reduction in on-site diagnostic imaging technologies, the availability of obstetric and primary care services, and outpatient nonemergency visits, as well as a significant increase in operating margins (by 1.6-3.6 percentage points from a baseline of -1.6 percent). Changes in patient experience scores, readmissions, and emergency department visits were similar for affiliating and nonaffiliating hospitals. While joining health systems may improve rural hospitals' financial performance, affiliation may reduce access to services for patients in rural areas.

Federally Qualified Health Center Strategies for Integrating Care with Hospitals and Their Association with Measures of Communication.

BACKGROUND: Federally qualified health centers have aligned clinical services and systems with local hospitals, but little is known about the specific care integration strategies health centers use or their impact on care. A research team examined the use of strategies by health centers to integrate care with hospitals and emergency departments (EDs) and their association with performance on measures of health center-hospital communication. METHODS: A Web-based survey was administered to health center medical directors in 12 states and Washington, DC, in 2017. The survey collected 10 self-reported measures of communication between health centers and hospitals/EDs and the extent to which health centers used different strategies to improve care integration. Health center and market characteristics that predict higher vs. lower integration activity were examined, and logistic regression was used to assess the relationship between integration activity and communication. RESULTS: Between 56% and 81% of health centers participated in quality improvement projects, health promotion initiatives, guideline alignment, or executive meetings with hospitals; far fewer established notification agreements regarding hospital/ED utilization. Health centers that were larger, were located in rural areas or states with Accountable Care Organization programs, reported fewer staff shortages, and had fewer minority patients were associated with greater integration activity. Higher levels of integration activity were associated with better performance on most communication measures in both inpatient and ED settings (p < 0.05). Integration activity was not associated with health centers' receipt of notifications after patients' ED visits. CONCLUSION: Health centers differ in the use of strategies to integrate care with hospitals. Overall, integration activity is associated with better communication.

Specialty care access for Medicaid enrollees in expansion states.

OBJECTIVES: Community health centers (CHCs) historically have reported challenges obtaining specialty care for their patients, but recent policy changes, including Medicaid eligibility expansions under the Affordable Care Act, may have improved access to specialty care. The objective of this study was to assess current levels of difficulty accessing specialty care for CHC patients, by insurance type, and to identify specific barriers and strategies that CHCs are using to overcome these barriers. STUDY DESIGN: Cross-sectional survey, administered during summer 2017, of medical directors at CHCs in 9 states and the District of Columbia, all of which expanded Medicaid. METHODS: Surveys were administered to medical directors at 361 CHCs (response rate, 55%) to assess the difficulty of accessing specialty care by insurance type and to identify the specialties for which it was most difficult to obtain new patient visits. The survey also elicited ratings of commonly reported barriers to obtaining specialty care and identified strategies used by CHCs to access specialty care for patients. Descriptive results are presented. RESULTS: Nearly 60% of CHCs reported difficulty obtaining new patient specialty visits for their Medicaid patients, most often for orthopedists. Barriers to specialty care reported by CHCs included that few specialists in Medicaid managed care organization (MCO) networks were accepting new patients (69.4%) and MCO administrative requirements for obtaining specialist consults (49.0%). To enhance access to specialists, CHCs reported that they entered into referral agreements, developed appointment reminder systems, and participated in data exchange and other community-based initiatives. CONCLUSIONS: Medicaid patients at CHCs face many barriers to accessing specialty care. Payment policies and network adequacy rules may need to be reexamined to address these challenges.

Development and preliminary evaluation of a self-guided, internet-based tool for coping with stress and trauma: Life Improvement for Teens (LIFT).

Implementation issues often interfere with delivery of evidence-based interventions for students exposed to trauma. To improve uptake of evidence-based techniques for such students, a partnership of interventionist scientists, research and development experts, and students created a self-paced, confidential, online curriculum. This article describes the program and results of an open trial in 5 schools that serve primarily ethnic minority youth in urban settings. Fifty-one middle and high school students completed surveys before and after the program, as well as within the program, to assess emotional and behavioral symptoms (depressive, anxiety, posttraumatic stress disorder [PTSD] symptoms and behavior) and purported mechanisms of action (coping, cognitions, emotional self-efficacy). Results indicated the program was feasible and acceptable, with moderate satisfaction. Despite low power in this study, we observed changes in several hypothesized mechanisms of action. In addition, we observed promising improvements in PTSD symptoms, emotional problems, and total behavioral difficulties. These findings offer the promise of using a self-help web-based tool to augment and enhance usual school support services. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Patient-Centered Medical Home Implementation in Indian Health Service Direct Service Facilities.

In an effort to provide care that is more accessible, team-based, coordinated, and patient-focused, primary care practices are increasingly adopting patient-centered medical home (PCMH) models of care. In 2008, the Indian Health Service (IHS) launched its own PCMH initiative, Improving Patient Care (IPC), to improve the quality of care for American Indians and Alaska Natives (AI/ANs) who seek care in its clinics. The IHS provides comprehensive health care services to roughly 2.2 million AI/ANs from more than 567 federally recognized tribes across the United States. RAND researchers examine the peer-reviewed and grey literature and identify common PCMH implementation strategies and challenges to better understand the kinds of methods used by clinics across the United States-particularly small clinics and those located in rural or remote locations. The research team then held telephone discussions with representatives from seven IHS clinics that had received PCMH recognition as of July 2017. The discussions with clinic leaders sought to identify how components of the PCMH model had been implemented at their clinics; challenges associated with PCMH implementation; and key lessons and recommendations that could benefit clinics that have not yet received PCMH recognition.

An Evaluation of U.S. Military Non-Medical Counseling Programs.

This study evaluates two programs offered by the U.S. Department of Defense (DoD) that provide short-term, solution-focused counseling for common personal and family issues to members of the U.S. military and their families. These counseling services are collectively called non-medical counseling within the DoD and are offered through the Military and Family Life Counseling (MFLC) and Military OneSource programs. RAND's National Defense Research Institute was asked to evaluate these programs to determine whether they are effective in improving outcomes and whether effectiveness varies by problem type and/or population. Two online surveys were provided to program participants-the first two to three weeks after their initial session and the second three months later. Surveys were designed to gain information on 1) problem severity and overall problem resolution, 2) resolution of stress and anxiety, 3) problem interference with work and daily life, 4) connection to other services and referrals, 5) experiences with MFLC and Military OneSource programs, and 6) perceptions of non-medical counselors. The majority of participants experienced a decrease in problem severity and a reduction in reported frequency of feeling stressed or anxious as a result of their problem following counseling. These improvements were sustained or continued to improve in the three months after initiation of counseling. Non-medical counseling was not universally successful, however, and a small minority expressed dissatisfaction with the program or their counselor. Collectively these findings suggest a number of policy implications and programmatic improvements of interest to program leadership in the Office of the Secretary of Defense.

Informal Caregivers' Experiences and Perceptions of a Web-Based Peer Support Network: Mixed-Methods Study.

BACKGROUND: Web-based peer support interventions have shown promise in reducing social isolation and social support deficits among informal caregivers, but little research has examined how caregivers use and perceive these interventions. OBJECTIVE: In this study, we examined utilization and perceptions of a Web-based social support intervention for informal caregivers of wounded, ill, and injured United States military service members and veterans. METHODS: This was a mixed-methods study that used quantitative survey data and qualitative data from focus groups and interviews with informal caregivers enrolled in a Web-based peer support intervention to explore their use and perceptions of the intervention. The intervention was delivered via a website that featured interest groups organized around specific topics, webinars, webchats, and messaging functionality and was moderated by professionally trained peers. This study occurred in the context of a quasi-experimental outcome evaluation of the intervention, where intervention participants were compared with a group of military caregivers who were not enrolled in the intervention. RESULTS: Survey findings indicated that caregivers used the website infrequently, with 60.7% (128/211) visiting the website once a month or less, and passively, with a minority (32/144, 22.2%) of users (ie, those who had visited the website at least once during the past 3 months, N=144) posting comments or links to the network. Nonetheless, most users (121/144, 84.0%) endorsed moderate or greater satisfaction with the website on the survey, and focus group and interview participants reported benefiting sufficiently from passive use of the website (eg, reading posts). Quantitative and qualitative findings suggested that users viewed the website primarily as a source of informational support. Among 63.2% (91/144) of users who completed the survey, the most commonly reported network-related activity was obtaining information from the network's resource library, and focus group and interview participants viewed the network primarily as an informational resource. Focus group and interview participants expressed an unmet need for emotional support and the desire for a more personal touch in the forms of more active engagement with other caregivers in the network and the creation of local, in-person support groups for caregivers. CONCLUSIONS: These findings suggest that Web-based peer support interventions may lend themselves better to the provision of informational (vs emotional) support and may need to be supplemented by in-person peer support groups to better meet caregivers' needs for emotional support.

Examining differential performance of 3 medical home recognition programs.

OBJECTIVES: We examined differences in patient outcomes associated with 3 patient-centered medical home (PCMH) recognition programs-National Committee for Quality Assurance (NCQA) Level 3, The Joint Commission (TJC), and Accreditation Association for Ambulatory Health Care (AAAHC)-among Medicare beneficiaries receiving care at federally qualified health centers (FQHCs). STUDY DESIGN: We used data from CMS' FQHC Advanced Primary Care Practice Demonstration, in which participating FQHCs received assistance to achieve NCQA Level 3 PCMH recognition. We assessed the impact of the 3 recognition programs on utilization, quality, and Medicare expenditures using a sample of 1108 demonstration and comparison FQHCs. METHODS: Using propensity-weighted difference-in-differences analyses, we compared changes in outcomes over 3 years for beneficiaries attributed to FQHCs that achieved each type of recognition relative to beneficiaries attributed to FQHCs that did not achieve recognition. RESULTS: Recognized FQHCs, compared with nonrecognized FQHCs, were associated with significant 3-year changes in FQHC visits, non-FQHC primary care visits, specialty visits, emergency department (ED) visits, hospitalizations, a composite diabetes process measure, and Medicare expenditures. Changes varied in direction and strength by recognition type. In year 3, compared with nonrecognized sites, NCQA Level 3 sites were associated with greater increases in ambulatory visits and quality and greater reductions in hospitalizations and expenditures (P <.01), TJC sites were associated with significant reductions in ED visits and hospitalizations (P <.01), and AAAHC sites had changes in the opposite direction of what we anticipated. CONCLUSIONS: Heterogeneous changes in beneficiary utilization, quality, and expenditures by recognition type may be explained by differences in recognition criteria, evaluation processes, and documentation requirements.

Improving Outcomes for Children Exposed to Violence: Safe Start Promising Approaches.

Children's exposure to violence is common and can lead to mental health problems and delinquent behaviors. Because many interventions have focused on specific violence types or symptoms and been difficult to implement in real-world settings, the evidence base is still emerging. The Office of Juvenile Justice and Delinquency Prevention's Safe Start Promising Approaches (SSPA) initiative focused on preventing and reducing the impact of children's exposure to violence through interventions in ten diverse communities. The evaluation examined the effectiveness of the SSPA interventions to address issues for children and families exposed to violence. The ten sites were diverse in their intervention approaches, types of violence exposure targeted, and implementation settings. To evaluate each approach's effectiveness in reducing violence's harmful effects, RAND researchers partnered with the community-based sites to develop a rigorous controlled evaluation design for each intervention, with either a randomized control group or a comparison group selected on similar characteristics. The longitudinal analyses found that families in both the intervention and comparison groups had positive gains on many outcomes, but there was no evidence that the intervention groups improved more. Among those who received Safe Start services, one site produced large, significant improvements in posttraumatic stress disorder symptoms, and another site produced medium, significant effects on several outcomes (child self-control, posttraumatic stress disorder, and behavior; caregiver depression; and family conflict). Although the initiative added to knowledge about how to address the problem, there was no clear case for using a particular intervention to help these children and their families.

Implementation of Medical Homes in Federally Qualified Health Centers.

BACKGROUND: From 2011 through 2014, the Federally Qualified Health Center Advanced Primary Care Practice Demonstration provided care management fees and technical assistance to a nationwide sample of 503 federally qualified health centers to help them achieve the highest (level 3) medical-home recognition by the National Committee for Quality Assurance, a designation that requires the implementation of processes to improve access, continuity, and coordination. METHODS: We examined the achievement of medical-home recognition and used Medicare claims and beneficiary surveys to measure utilization of services, quality of care, patients' experiences, and Medicare expenditures in demonstration sites versus comparison sites. Using difference-in-differences analyses, we compared changes in outcomes in the two groups of sites during a 3-year period. RESULTS: Level 3 medical-home recognition was awarded to 70% of demonstration sites and to 11% of comparison sites. Although the number of visits to federally qualified health centers decreased in the two groups, smaller reductions among demonstration sites than among comparison sites led to a relative increase of 83 visits per 1000 beneficiaries per year at demonstration sites (P<0.001). Similar trends explained the higher performance of demonstration sites with respect to annual eye examinations and nephropathy tests (P<0.001 for both comparisons); there were no significant differences with respect to three other process measures. Demonstration sites had larger increases than comparison sites in emergency department visits (30.3 more per 1000 beneficiaries per year, P<0.001), inpatient admissions (5.7 more per 1000 beneficiaries per year, P=0.02), and Medicare Part B expenditures ($37 more per beneficiary per year, P=0.02). Demonstration-site participation was not associated with relative improvements in most measures of patients' experiences. CONCLUSIONS: Demonstration sites had higher rates of medical-home recognition and smaller decreases in the number of patients' visits to federally qualified health centers than did comparison sites, findings that may reflect better access to primary care relative to comparison sites. Demonstration sites had larger increases in emergency department visits, inpatient admissions, and Medicare Part B expenditures. (Funded by the Centers for Medicare and Medicaid Services.).