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1.
AJPM Focus ; 2(3): 100102, 2023 Sep.
Article in English | MEDLINE | ID: mdl-37790667

ABSTRACT

Introduction: There were more than 100,000 fatal drug overdoses in the U.S. in 2021 alone. In recent years, there has been a shift in opioid mortality from predominantly White rural communities to Black urban communities. This study aimed to identify the Virginia communities disproportionately affected by the overdose crisis and to better understand the systemic factors contributing to disparities in opioid mortality. Methods: Using the state all-payer claims database, state mortality records, and census data, we created a multivariate model to examine the community-level factors contributing to racial disparities in opioid mortality. We used generalized linear mixed models to examine the associations between socioecologic factors and fatal opioid overdoses, opioid use disorder diagnoses, opioid-related emergency department visits, and mental health diagnoses. Results: Between 2015 and 2020, racial disparities in mortality widened. In 2020, Black males were 1.5 times more likely to die of an opioid overdose than White males (47.3 vs 31.6 per 100,000; p<0.001). The rate of mental health disorders strongly correlated with mortality (ß=0.53, p<0.001). Black individuals are not more likely to be diagnosed with opioid use disorder (ß=0.01, p=0.002) or with mental health disorders (ß= -0.12, p<0.001), despite higher fatal opioid overdoses. Conclusions: There are widening racial disparities in opioid mortality. Untreated mental health disorders are a major risk factor for opioid mortality. Findings show pathways to address inequities, including early linkage to care for mental health and opioid use disorders. This analysis shows the use of comprehensive socioecologic data to identify the precursors to fatal overdoses, which could allow earlier intervention and reallocation of resources in high-risk communities.

2.
Ann Fam Med ; 21(Suppl 1)2023 Jan 01.
Article in English | MEDLINE | ID: mdl-38226950

ABSTRACT

Context: Patients with multiple chronic conditions (MCC) may have unmet behavioral, mental, and social needs which can be difficult to address in primary care. Care planning provides a framework for patients to be screened, collaborate on a care plan, and access a patient navigator who can support them achieving their personal health goals. Objective: To compare patients' progress and confidence in addressing personal care plans for different topics. Study Design and Analysis: Clinician level randomized control trial and descriptive analyses. Dataset: My Own Health Report (MOHR) study and navigator field notes. Population Studied: As part of a randomized controlled trial (RCT) to evaluate a feasible approach to patient care planning, 24 clinicians from 12 practices in the Virginia Ambulatory Care Outcomes Research Network (ACORN) in the Greater Richmond metro and the Northern Virginia areas participated in a care planning intervention. 91 patients in the intervention arm received support from a patient navigator for making and working on a goal. We focused on patients with uncontrolled chronic conditions that have complex needs. Intervention/Instrument: Community-clinical linkage support and navigator field notes in My Own Health Report (MOHR). Outcome Measures: We determined confidence and progress ratings (ranked by patients on 1-10 point scale), health risk assessment responses, and care plan topics selected by patients. Results: Patients feel more confident addressing nutrition than weight loss (mean = 8.07 vs 6.31, p=0.0031). Patients tended to report better prior progress on nutrition care plans (mean = 3.80) than physical activity (mean =2.95, p=0.0024) and weight loss (mean=2.93, p=0.004). Conclusions: Helping patients create care plans on topics they feel most comfortable addressing may better address root causes of poor health associated with chronic conditions. Connecting them with a patient navigator for the short-term may have long-term benefits for patients and care teams.


Subject(s)
Emotions , Multiple Chronic Conditions , Humans , Ambulatory Care , Weight Loss , Primary Health Care
3.
J Prim Care Community Health ; 13: 21501319221134754, 2022.
Article in English | MEDLINE | ID: mdl-36348571

ABSTRACT

OBJECTIVES: To help better control chronic conditions we need to address root causes of poor health like unhealthy behaviors, mental health, and social needs. However, addressing these needs in primary care is difficult. One solution may be connecting patients with a navigator for support creating a personal care goal. METHODS: As part of an RCT to evaluate a feasible approach to care planning, 24 clinicians from 12 practices in the Virginia Ambulatory Care Outcomes Research Network (ACORN) and 87 intervention patients with uncontrolled chronic conditions participated in a care planning intervention. We had a structured process to guide patients, train navigators, and adapt the navigation process to meet the needs of each practice. RESULTS: Only 1 practice had bandwidth for staff to serve as a patient navigator, even for extra pay. For the other 11 practices, a research team member needed to provide navigation services. On average, patients wanted 25 weeks of support to complete care plans. The average time patients needed to speak with navigators on the phone was 7 min and 3 s. In exit interviews, patients consistently shared how motivational it was to have a caring person check in on them, offer help, and hold them accountable. CONCLUSION: Patient navigation to address care plans should be feasible. The time commitment is minimal. It does not require intensive training, and primary care is already doing much of this work. Yet, given the burden and competing demands in primary care, this help cannot be offered without additional resources.


Subject(s)
Patient Navigation , Humans , Feasibility Studies , Chronic Disease , Self Care , Mental Health
4.
J Prim Care Community Health ; 13: 21501319221115946, 2022.
Article in English | MEDLINE | ID: mdl-35920033

ABSTRACT

BACKGROUND: Addressing social needs, health behaviors, and mental health may help patients more than traditional medical care. However, these root causes of poor health are difficult to address and the role of primary care is unclear. This qualitative study assesses patient's willingness and motivations to discuss and accept assistance for these needs from their primary care team. METHODS: In July and August of 2020, semi-structured virtual interviews were conducted with family medicine patients (n = 6) and residents of low resource neighborhoods (n = 11) in Richmond, Virginia. Interviews were conducted over Zoom. We conducted a qualitative analysis of patient and resident interview transcripts. A rapid qualitative analysis approach and immersion-crystallization processes were used to identify themes and categories. RESULTS: Interviewees reported varying degrees of comfort discussing topics with their health care team. They were less comfortable discussing needs they considered outside the realm of "traditional primary care" including finances, transportation, and housing, but interviewees expressed willingness to discuss these needs under certain conditions. Important factors were a strong patient-clinician relationship to create a trusted and safe space for discussion, adequate time for discussion during visits, communication of practices' ability to provide resources to help patients, and ensuring appropriate high quality referrals. CONCLUSIONS: Primary care provides opportunity for identifying and addressing needs that adversely impact health. Some needs are more sensitive for patients to work with their care team on, though, there was willingness to work on any need when a strong provider relationship and clinic structure for providing support were in place. This study highlights critical care delivery factors which may be used to enhance patient comfort accepting support for their needs and ultimately improve clinical care and chronic disease management.


Subject(s)
Patient Care Team , Patient Preference , Communication , Humans , Primary Health Care , Qualitative Research
5.
J Am Board Fam Med ; 35(1): 55-72, 2022.
Article in English | MEDLINE | ID: mdl-35039412

ABSTRACT

INTRODUCTION: Health behaviors, mental health, and social needs impact health, but addressing these needs is difficult. Clinicians can partner with community programs to provide patients support. The relationship between program location and community need is uncertain. METHODS: We identified and geolocated community programs in Richmond, Virginia, that aid with 9 domains of needs (mental health, smoking, unhealthy alcohol use, nutrition, physical activity, transportation, financial, housing, food insecurity). For each census tract, we identified needs from public data sources. We used 2 methods to compare program location and need: (1) hotspot analysis and (2) a negative binomial regression model. RESULTS: We identified 280 community programs that provide aid for the 9 domains. Programs most often provided financial assistance (n = 121) and housing support (n = 73). The regression analysis showed no relationship between the number of community programs and the level of need in census tracts, with 2 exceptions. There was a positive association between financial programs and financial need and a negative association between housing programs and housing need. CONCLUSIONS: Community programs are generally not colocated with need. This poses a barrier for people who need help addressing these domains.


Subject(s)
Housing , Transportation , Humans , Smoking , Virginia
6.
J Clin Transl Sci ; 5(1): e188, 2021.
Article in English | MEDLINE | ID: mdl-34849263

ABSTRACT

This report describes how stakeholder groups informed a web-based care planning tool's development for addressing root causes of poor health. Stakeholders included community members (n = 6), researchers (n = 6), community care providers (n = 9), and patients (n = 17). Feedback was solicited through focus groups, semi-structured interviews, and user experience observations and then qualitatively analyzed to identify themes. Each group contributed a unique perspective. Researchers wanted evidence-based content; community members and providers focused on making goals manageable; patients wanted care team support and simple action-oriented language. Our findings highlight the benefits of stakeholder input. Blending perspectives from multiple groups results in a more robust intervention design.

7.
J Am Board Fam Med ; 34(6): 1189-1202, 2021.
Article in English | MEDLINE | ID: mdl-34772774

ABSTRACT

BACKGROUND: Primary care is crucial to the health of individuals and communities, but it faces numerous structural and systemic challenges. Our study assessed the state of primary care in Virginia to prepare for Medicaid expansion. It also provides insight into the frontline of health care prior to an unprecedented global COVID-19 pandemic. METHODS: We surveyed 1622 primary care practices to understand organizational characteristics, scope of care, capacity, and organizational stress. RESULTS: Practices (484) varied in type, ownership, location, and care for medically underserved and diverse patient populations. Most practices accepted uninsured and Medicaid patients. Practices reported a broad scope of care, including offering behavioral health and medication-assisted therapy for opioid addiction. Over half addressed social needs like transportation and unstable housing. One in three practices experienced a significant stress in 2019, prepandemic, and only 18.8% of practices anticipated a stress in 2020. CONCLUSIONS: Primary care serves as the foundation of our health care system and is an essential service, but it is severely stressed, under-resourced, and overburdened in the best of times. Primary care needs strategic workforce planning, adequate access to resources, and financial investment to sustain its value and innovation.


Subject(s)
COVID-19 , Pandemics , Health Services Accessibility , Humans , Medicaid , Primary Health Care , SARS-CoV-2 , United States , Virginia
8.
Clin J Am Soc Nephrol ; 16(11): 1630-1638, 2021 11.
Article in English | MEDLINE | ID: mdl-34507967

ABSTRACT

BACKGROUND AND OBJECTIVES: People receiving maintenance dialysis must often rely on family members and other close persons to make critical treatment decisions toward the end of life. Contemporary data on family members' understanding of the end-of-life wishes of members of this population are lacking. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Among 172 family members of people undergoing maintenance dialysis, we ascertained their level of involvement in the patient's care and prior discussions about care preferences. We also compared patient and family member responses to questions about end-of-life care using percentage agreement and the κ-statistic. RESULTS: The mean (SD) age of the 172 enrolled family members was 55 (±17) years, 136 (79%) were women, and 43 (25%) were Black individuals. Sixty-seven (39%) family members were spouses or partners of enrolled patients. A total of 137 (80%) family members had spoken with the patient about whom they would want to make medical decisions, 108 (63%) had spoken with the patient about their treatment preferences, 47 (27%) had spoken with the patient about stopping dialysis, and 56 (33%) had spoken with the patient about hospice. Agreement between patient and family member responses was highest for the question about whether the patient would want cardiopulmonary resuscitation (percentage agreement 83%, κ=0.31), and was substantially lower for questions about a range of other aspects of end-of-life care, including preference for mechanical ventilation (62%, 0.21), values around life prolongation versus comfort (45%, 0.13), preferred place of death (58%, 0.07), preferred decisional role (54%, 0.15), and prognostic expectations (38%, 0.15). CONCLUSIONS: Most surveyed family members reported they had spoken with the patient about their end-of-life preferences but not about stopping dialysis or hospice. Although family members had a fair understanding of patients' cardiopulmonary resuscitation preferences, most lacked a detailed understanding of their perspectives on other aspects of end-of-life care.


Subject(s)
Comprehension , Family/psychology , Patient Preference , Terminal Care , Adult , Advance Care Planning , Aged , Cardiopulmonary Resuscitation , Decision Making , Female , Hospice Care , Humans , Life Support Care , Male , Middle Aged , Prognosis , Renal Dialysis , Respiration, Artificial , Resuscitation Orders , Surveys and Questionnaires , Value of Life
9.
Trials ; 21(1): 517, 2020 Jun 11.
Article in English | MEDLINE | ID: mdl-32527322

ABSTRACT

BACKGROUND: Many patients with poorly controlled multiple chronic conditions (MCC) also have unhealthy behaviors, mental health challenges, and unmet social needs. Medical management of MCC may have limited benefit if patients are struggling to address their basic life needs. Health systems and communities increasingly recognize the need to address these issues and are experimenting with and investing in new models for connecting patients with needed services. Yet primary care clinicians, whose regular contact with patients makes them more familiar with patients' needs, are often not included in these systems. METHODS: We are starting a clinician-level cluster-randomized controlled trial to evaluate how primary care clinicians can participate in these community and hospital solutions and whether doing so is effective in controlling MCC. Sixty clinicians in the Virginia Ambulatory Care Outcomes Research Network will be matched by age and sex and randomized to usual care (control condition) or enhanced care planning with clinical-community linkage support (intervention). From the electronic health record we will identify all patients with MCC, including cardiovascular disease or risks, diabetes, obesity, or depression. A baseline assessment will be mailed to up to 50 randomly selected patients for each clinician (3000 total). Ten respondents per clinician (600 patients total) with uncontrolled MCC will be randomly selected for study inclusion, with oversampling of minorities. The intervention includes two components. First, we will use an enhanced care planning tool, My Own Health Report (MOHR), to screen patients for health behavior, mental health, and social needs. Patients will be supported by a patient navigator, who will help patients prioritize needs, create care plans, and write a personal narrative to guide the care team. Patients will update care plans every 1 to 2 weeks. Second, we will create community-clinical linkage to help address patients' needs. The linkage will include community resource registries, personnel to span settings (patient navigators and a community health worker), and care team coordination across team members through MOHR. DISCUSSION: This study will help inform efforts by primary care clinicians to help address unhealthy behaviors, mental health needs, and social risks as a strategy to better control MCC. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03885401. Registered on 19 September 2019.


Subject(s)
Community Mental Health Services/organization & administration , Multiple Chronic Conditions/therapy , Patient Care Planning/organization & administration , Primary Health Care/organization & administration , Community Mental Health Services/economics , Goals , Health Behavior , Health Promotion , Humans , Mental Health , Multiple Chronic Conditions/psychology , Randomized Controlled Trials as Topic , Risk Assessment , Social Determinants of Health
10.
Internet Interv ; 15: 110-115, 2019 Mar.
Article in English | MEDLINE | ID: mdl-30792962

ABSTRACT

BACKGROUND: Mobile apps have become popular resources for mental health support. Availability of information about developers' data security procedures for health apps, specifically those targeting mental health, has not been thoroughly investigated. If people are to use and trust these tools for their mental health, it is crucial we evaluate the transparency and quality around the data practices of these apps. The present study reviewed data security and privacy policies of mobile apps for depression. METHODS: We reviewed mobile apps retrieved from iTunes and Google Play stores in October 2017, using the term "depression", and evaluated the transparency of data handling procedures of those apps. RESULTS: We identified 116 eligible mobile phone apps. Of those, 4% (5/116) received a transparency score of acceptable, 28% (32/116) questionable, and 68% (79/116) unacceptable. Only a minority of the apps (49%) had a privacy policy. The availability of policies differed significantly by platform, with apps from iTunes more likely to have a policy than from the Google Play store. Mobile apps collecting identifiable information were significantly more likely to have a privacy policy (79%) compared to those collecting only non-identifiable information (34%). CONCLUSION: The majority of apps reviewed were not sufficiently transparent with information regarding data security. Apps have great potential to scale mental health resources, providing resources to people unable or reluctant to access traditional face-to-face care, or as an adjunct to treatment. However, if they are to be a reasonable resource, they must be safe, secure, and responsible.

11.
J Med Internet Res ; 20(6): e10141, 2018 06 11.
Article in English | MEDLINE | ID: mdl-29891468

ABSTRACT

BACKGROUND: A large number of health apps are available directly to consumers through app marketplaces. Little information is known, however, about how consumers search for these apps and which factors influence their uptake, adoption, and long-term use. OBJECTIVE: The aim of this study was to understand what people look for when they search for health apps and the aspects and features of those apps that consumers find appealing. METHODS: Participants were recruited from Northwestern University's Center for Behavioral Intervention Technologies' research registry of individuals with mental health needs. Most participants (n=811) completed a survey asking about their use and interest in health and mental health apps. Local participants were also invited to participate in focus groups. A total of 7 focus groups were conducted with 30 participants that collected more detailed information about their use and interest in health and mental health apps. RESULTS: Survey participants commonly found health apps through social media (45.1%, 366/811), personal searches (42.7%, 346/811), or word of mouth (36.9%, 299/811), as opposed to professional sources such as medical providers (24.6%, 200/811). From the focus groups, common themes related to uptake and use of health apps included the importance of personal use before adoption, specific features that users found desirable, and trusted sources either developing or promoting the apps. CONCLUSIONS: As the number of mental health and health apps continue to increase, it is imperative to better understand the factors that impact people's adoption and use of such technologies. Our findings indicated that a number of factors-ease of use, aesthetics, and individual experience-drove adoption and use and highlighted areas of focus for app developers and disseminators.


Subject(s)
Mental Health Services/trends , Mobile Applications/trends , Social Media/trends , Adolescent , Adult , Aged , Aged, 80 and over , Female , Focus Groups , Humans , Male , Middle Aged , Surveys and Questionnaires , Young Adult
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