Adding a Seat at the Table: A Case Study of the Provider's Perspective on Integrating Community Health Workers at Provider Practices in California.

Blue Shield of California's Community Health Advocate Program was created to support whole person-health needs by helping individuals of all socio-economic statuses navigate and access community resources, social services, and medical systems. Blue Shield's Health Reimagined team is partnering with medical providers, community resources centers, and community partners to provide intensive person-centered and technology-enabled care to patients, ensuring social needs are met while promoting health equity. A key aspect of the Health Reimagined initiative embeds Community Health Advocates (CHAs) within physician practices serving patients using a payor-agnostic approach, by which Blue Shield aims to increase access to social services and community resources, improve health outcomes, reduce medical costs, and improve overall patient experience. The purpose of this case study is to understand the provider's perspective of embedding a CHA into the care team and the resulting impact on the practice and patients. Blue Shield also sought to identify best practices and barriers of a CHA program within primary and specialty care practices. As part of an ongoing two-year mixed-methods impact evaluation (2019-2021), 10 semi-structured interviews were conducted with a total of 18 providers and office staff at five primary care and specialty practices where CHAs have been embedded. We also conducted two focus groups with the same five CHAs at different points in time. Several themes emerged from the provider, office staff, and CHA interviews. Provider practices found great value in adding a CHA to their care team as the CHA brings flexibility and continuity to patient care. They also found that having access to a CHA with shared life experiences of the communities they served is a key component to the program's success. Providers and staff reported a new understanding of the social determinants of health that impacts a patient's wellbeing with the embedding of a CHA in the care team. Overall, practitioners expressed high satisfaction with the CHA program. During the COVID-19 pandemic, CHAs have been critically important in care, as social needs have increased, and resources have shifted. The CHA program is constantly adapting to address challenges faced by all stakeholders and applying new knowledge to ensure best practices are implemented within the CHA program.

Nativity, Neighborhoods, and Body Composition in the Sacramento Area Latino Study on Aging.

BACKGROUND AND OBJECTIVES: Globally, obesity influences the risk of many major chronic diseases. Our study examines the association between individual nativity and neighborhood level concentration of immigrants with 10-year changes in weight, body mass index (BMI), and waist circumference (WC) among older Latinos. RESEARCH DESIGN AND METHODS: The Sacramento Area Latino Study on Aging (SALSA) is a population-based prospective study of community-dwelling older adults of Mexican origin (baseline ages 58-101 years). The primary outcome was repeated measures of weight over a 10-year period for 1,628 respondents. Nativity was defined by participants' reported place of birth (US-born or Latin American foreign born). Neighborhood immigrant concentration was measured as the percentage of foreign born at census tract level (2000 US Census). We used linear mixed models with repeated measures of weight, height, BMI, and WC as dependent variables (level 1), clustered within individuals (level 2) and neighborhood migrant concentration (level 3). RESULTS: Foreign born (FB) respondents had lower baseline weight than the US-born (mean, 160 vs. 171 lbs, p < .0001). Over time, weight differences between the FB and the US-born decreased by 1.7 lbs/5 years as US-born weight decreased more rapidly. We observed a significant interaction between individual nativity and neighborhood immigrant concentration (p = .012). We found similar patterns for BMI, but did not find statistically significant differences in WC trajectories. DISCUSSION AND IMPLICATIONS: Our study observed significant differences by foreign born vs. US nativity in baseline weight/BMI and in their trajectories over time. Additionally, we found weight/BMI differences in neighborhood immigrant concentration for the FB, but not for the US-born.

Cumulative psychological stress and cardiovascular disease risk in middle aged and older women: Rationale, design, and baseline characteristics.

Although a growing body of evidence indicates strong links between psychological stress (stress) and untoward cardiovascular disease (CVD) outcomes, comprehensive examination of these effects remains lacking. The "Cumulative Psychological Stress and Cardiovascular Disease Risk in Middle Aged and Older Women" study is embedded within the landmark Women's Health Study (WHS) follow-up cohort and seeks to evaluate the individual and joint effects of stressors (cumulative stress) on incident CVD risk, including myocardial infarction, stroke, coronary revascularization and CVD death. GWAS data will be used for exploratory analyses to identify any genes associated with stress and CVD. This study prospectively follows 25,335 women (mean age 72.2 ± 6.04 years) without CVD who returned a short mailed stress questionnaire at baseline and 3 years of follow-up inquiring about their experiences with stress including perceived stress, work stress, work-family spillover, financial stress, traumatic and major life events, discrimination and neighborhood environment/stressors. Other domains ascertained were sleep, anger, cynical hostility, depression, anxiety, social support, intimate partner relations, and volunteer and social activities. Higher levels of cumulative stress were associated with younger age and black race/ethnicity, divorced or separated marital status, increased prevalence of obesity, smoking, diabetes, depression and anxiety (p<0.001 for each). Findings from this study will provide clinically important, new information about associations of cumulative stress, environmental, lifestyle and genetic factors with incident CVD risk in aging women.

Receptivity to alcohol-related care among U.S. women Veterans with alcohol misuse.

Previous research indicates women Veterans have a potentially large, unmet need for alcohol-related care but are under-represented in treatment settings. The purpose of this study was to identify factors associated with women Veterans' receptivity to a recommendation for alcohol-related care when they present to Veterans Affairs (VA) primary care with alcohol misuse. Semi-structured interviews were conducted from 2012-2013 with 30 women Veterans at two VA facilities who screened positive for alcohol misuse during a primary care visit and discussed their alcohol use with their primary-care provider. Qualitative analyses identified 9 themes women used to describe what affected their receptivity to a recommendation for alcohol-related care (i.e., VA specialty substance use disorder services). The most common themes positively associated with women's receptivity included self-appraisal of their drinking behavior as more severe, the provider's presentation of treatment options, availability of gender-specific services, and worse physical and mental health. The themes identified here may have important implications for the clinical strategies providers can use to present alcohol-related care options to women Veterans to facilitate their use of care. These strategies include educating women about the health effects of alcohol misuse and increasing providers' knowledge about available care options (within the care organization or the community), including the availability of gender-specific services.

Factors Affecting Women's Disclosure of Alcohol Misuse in Primary Care: A Qualitative Study with U.S. Military Veterans.

BACKGROUND: One in five women veterans screens positive for alcohol misuse. Women may be less likely than men to disclose alcohol use to a primary care provider (PCP), resulting in women being less likely to receive effective interventions. We sought to qualitatively examine factors that may affect women veterans' willingness to disclose alcohol use to a PCP. METHODS: Between October 2012 and May 2013, in-depth interviews were conducted with 30 women veterans at two Department of Veterans Affairs (VA) medical facilities. Qualitative data analyses identified common themes representing factors that influence women's decision to disclose alcohol use to a PCP. FINDINGS: Nine themes were endorsed by women veterans as influencing their willingness to disclose alcohol use to their PCP. Themes included provider behaviors perceived as encouraging or discouraging disclosure of alcohol misuse, perceived positive relationship with provider, negative emotions such as concerns about being judged or labeled an "alcoholic," health concerns about drinking, non-health-related concerns about drinking, self-appraisal of drinking behavior, social support, and clinic factors. CONCLUSIONS: Our findings demonstrate the importance of social relationships, comfort with one's provider, and education on the potential harms (especially health related) associated with alcohol in encouraging disclosure of alcohol use in women veterans. Our results also support VA national health care efforts, including the provision of brief alcohol counseling and the use of primary care clinics specializing in the care of women veterans.

Ethnicity and alcohol consumption among US adults with diabetes.

PURPOSE: The drinking practices of a nationally representative sample of white, black, Mexican American, and other Hispanic adult diabetics are described and compared. METHODS: Combined years (2005/2006-2011/2012) of the National Health and Nutrition Examination Survey provided home interview data from 2220 adults with self-reported diabetes of white (n = 875), black (n = 720), Mexican American (n = 402), and other Hispanic (n = 223) ethnicity. Current drinking status, the number of drinks consumed per week, and binge drinking were compared across ethnicity. RESULTS: The multivariate findings for both diabetic men and women showed no statistically significant ethnic differences in current drinking status, and among women, there were no statistically significant ethnic differences in binge drinking. Among male diabetics, Mexican Americans consumed more drinks per week than whites (b = 0.35; 95% confidence interval, 0.13-0.58; P = .002) and were at increased risk for binge drinking (odds ratio, 2.04; 95% confidence interval, 1.30-3.21; P = .002). CONCLUSIONS: Binge drinking is prevalent among Mexican American male diabetics. This pattern of drinking may put them at risk for poor diabetes management and control. It is important that health care providers routinely assess their patients' drinking practices and address the health risks associated with alcohol consumption.

A portrait of older californians with disabilities who rely on public services to remain independent.

Low-income older adults with disabilities in California depend on a variety of public programs to help them remain in their own homes. The availability of those services has been in flux since 2009 because of cuts caused by the recession. This article reports on a qualitative study of 33 California seniors who depend on fragile arrangements of paid and unpaid assistance. Thematic analyses of in-depth interviews conducted with these older adults and their caregivers indicate that the disability needs of these individuals are often unstable, with both physical and mental health status sometimes changing day to day. Most have nowhere else to turn for help if their public services are cut. All share the common goal of staying at home and maintaining their independence. Public services serve as a crucial link in the support networks of these individuals.

The health status and unique health challenges of rural older adults in California.

Despite living in the countryside where open space is plentiful and there is often significant agricultural production, rural older adults have higher rates of overweight/obesity, physical inactivity and food insecurity than older adults living in suburban areas. All three conditions are risk factors for heart disease, diabetes and repeated falls. This policy brief examines the health of rural elders and, by contrast, their urban counterparts, and finds that both groups are more likely to be unhealthy than suburban older adults. Yet rural elders, because of their geographical isolation and lack of proximity to health care providers, experience unique environmental and other risk factors that require context-specific solutions to these health issues. In both policies and programs that impact health, policymakers need to take into account the distinctive environmental and social context of older adults living in California's countryside.

The health of aging lesbian, gay and bisexual adults in California.

Research on the health of lesbian, gay and bisexual (LGB) adults generally overlooks the chronic conditions that are the most common health concerns of older adults. This brief presents unique population-level data on aging LGB adults (ages 50-70) documenting that they have higher rates of several serious chronic physical and mental health conditions compared to similar heterosexual adults. Although access to care appears similar for aging LGB and heterosexual adults, aging LGB adults generally have higher levels of mental health services use and lesbian/bisexual women report greater delays in getting needed care. These data indicate a need for general health care and aging services to develop programs targeted to the specific needs of aging LGB adults, and for LGB-specific programs to increase attention to the chronic conditions that are common among all older adults.

Independence at risk: older Californians with disabilities struggle to remain at home as public supports shrink.

This policy brief presents findings from a yearlong study that closely followed a small but typical set of older Californians with disabilities who depend on fragile arrangements of paid public programs and unpaid help to live safely and independently at home. Many of these older adults have physical and mental health needs that can rise or fall with little warning; most are struggling with increasing disability as they age. In spite of these challenges, most display resilience and fortitude, and all share a common determination to maintain their independence at almost any cost. Declines in health status and other personal circumstances among aging Californians have been exacerbated by recent reductions in public support, and will be made even worse by significant additional cuts that are pending. Policy recommendations include consolidating long-term care programs and enhancing support for caregivers.