Implementing and monitoring high-quality community health worker care in adult primary care at New York City Health + Hospitals.

BACKGROUND: This study describes how New York City (NYC) Health + Hospitals implemented a large-scale Community Health Worker (CHW) program in adult primary care clinics between January 2022 and December 2023 and established metrics to monitor program implementation. This study is timely as healthcare systems consider how to scale high-quality CHW programs. METHODS: We collected metrics in the following areas: (1) Workforce demographics, team structure, and training; (2) Enrolled patient demographics; (3) Patient-centered metrics, such as patient counts (e.g. patients outreached and enrolled) and engagement (e.g. median time in program, caseloads per CHW), and goals (e.g. median number of goals identified and completed). Metrics are based on standard data elements captured through CHW documentation in the electronic health record collected during program implementation. Data cleaning is completed using SQL queries and R scripts. RESULTS: In June 2023, there were a total of 97 CHW and 22 CHW Supervisor staff lines in adult primary care across 17 healthcare sites. There were 4.6 CHWs to 1 CHW supervisor on average though this ranged by facility from 1:1 to 1:6. Compared to the population that receives primary care at NYC H + H, CHWs served more African American/Black patients (40% vs. 32%) and an older patient population (35% older than 65 vs. 21% older than 65). From January 2022 to December 2023, 13,812 patients were outreached by CHWs. Of these, 9,069 (66%) were referred by clinicians, 7,331 (53%) were enrolled, and 5,044 (37%) successfully graduated. The median number of goals identified by patients was four, and the median number of goals completed with a CHW per patient was three. The top three goals were primary care engagement (47%), specialty care engagement (46%), and food insecurity (45%). CONCLUSION: Establishing clear implementation and process metrics helps to ensure that CHWs embedded in health systems can meaningfully engage adult patients in health care, address patient-centered goals, and connect patients to community and government services.

Acquisitions of safety-net hospitals from 2016-2021: a case series.

Safety-net hospitals have recently become targets of acquisition by health systems with the stated purpose of improving their financial solvency and preserving access to safety-net services. Whether acquisition achieves these goals is unknown. In this descriptive case series, we sought to determine the factors that contribute to safety-net hospital acquisition, and identify whether safety-net services are preserved after acquisition. We examined 22 acquisitions of safety-net hospitals from 2016 to 2021 and described characteristics of the acquired safety-net hospitals, their acquiring systems, and the operational fate of acquired hospitals. Relative to other hospitals in the same Hospital Referral Region in the year prior to acquisition, acquired safety-net hospitals tended to be smaller and have lower occupancy rates. Acquiring systems were geographically concentrated, with only 6 of 20 systems operating in more than 1 state. Safety-net hospitals frequently offered typical safety-net services prior to acquisition. However, after acquisition, 2 of the 22 acquired safety-net hospitals lost safety-net services, 3 hospitals ceased inpatient services, and 1 hospital closed entirely. These findings suggest that acquisition of safety-net hospitals may be associated with trade-offs related to the provision of safety-net services for the communities that stand to benefit from them most.

Assessing breast cancer-related lymphedema screening and treatment gaps in a safety-net hospital.

BACKGROUND AND OBJECTIVES: We evaluated the unmet breast cancer-related lymphedema (BCRL) treatment and education needs at New England's largest safety-net hospital serving a diverse population by assessing prevalence, risk factors, and treatment. METHODS: This was a retrospective cohort study examining breast cancer surgery patients from September 2016 to September 2021. The primary outcome was BCRL diagnosis. Secondary outcomes included BCRL risk factors, and physical and occupational therapy (PT/OT) referral frequency and completion. RESULTS: Of 639 patients, 17% of patients had documented BCRL, which was significantly associated with axillary lymph node dissection (ALND). There were no racial, insurance, breast radiation, or BMI category differences between patients with and without a BCRL diagnosis. Of those with BCRL, 58% received a PT/OT referral, and 56% completed their referral. There were no racial, insurance, or BMI category differences between those who received a PT/OT referral and those who did not. CONCLUSION: In our high-risk population, rates of documented BCRL were higher than expected, approaching rates of ALND, despite the majority undergoing sentinel lymph node biopsy (SLNB). PT/OT referral and completion rates were low, concerning for an unmet BCRL treatment and education need. No disparities in care delivery were seen, but a program that addresses treatment gaps and ensures accessible and patient-centered BCRL care is urgently needed.

Resilience and Value: Pediatric Trauma Care in Safety Net Hospitals.

Background: In the setting of limited funding and high expectations for quality care, safety net hospitals play a crucial role in treating pediatric trauma patients. This study aimed to compare outcomes and hospitalization costs of pediatric trauma patients in safety net hospitals across the United States. Methods: The Nationwide Readmissions Database for 2016-2020 was queried for all patients under the age of 18 years hospitalized for traumatic injury. Patients admitted to safety net hospitals were propensity matched 1:1 to all other patients. The primary outcome was mortality. The secondary outcomes were readmission within 1-year, mean length of stay (LOS), total charges, and total hospitalization costs including readmissions. Results: There were 176,325 patients meeting inclusion criteria, and 30,869 were admitted to safety net hospitals. All safety net patients were successfully matched across predictors, and 61,738 patients were included. The overall mortality rate was 1.4% (n = 834), and the mortality risk was similar in safety net hospitals (OR 1.11 [.96-1.27] P = .15). The overall readmission rate, mean LOS, and mean total cost were similar for safety net hospitals when compared to all hospitals. However, the overall mean total charge was $78,724 (±$224,884) and was lower in safety net hospitals ($76,575 [±$198,342], P = .02). Discussion: Safety net hospitals deliver comparable outcomes as other health care facilities when caring for pediatric trauma patients. Notably, these hospitals appear to undercharge for their services, despite incurring similar costs in the process. These results shed light on the resilience of safety net hospitals in delivering quality and cost-effective care.

Association of Safety-Net Hospital Status With Outcomes Following Head and Neck Cancer Operations.

OBJECTIVE: To assess perioperative and readmission outcomes of patients undergoing head and neck cancer (HNCA) surgery at safety-net hospitals (SNHs) in a modern cohort. STUDY DESIGN: Retrospective cohort study. SETTING: Nationwide Readmissions Database (NRD), 2010 to 2019. METHODS: All elective adult (≥18 years) admissions involving HNCA resection were identified from the NRD. To calculate safety-net burden, the proportion of Medicaid or uninsured patients admitted to each hospital for any indication was tabulated annually, with centers in the highest quartile defined as SNHs. To perform risk adjustment in assessing perioperative and readmission outcomes, multivariable regression models were developed. RESULTS: Of an estimated 133,018 head and neck surgical patients, 26.5% (n = 35,268) received treatment at a SNH. Utilization of SNHs increased over the decade-long study period, with 29.8% of individuals treated at these sites in 2019. After multivariable adjustment, several patient factors were noted to be associated with SNHs, including younger age, lower comorbidity burden, and income within the lowest quartile. Although incidence of adverse events decreased at both SNHs and non-SNHs during the study period, treatment at SNHs remained associated with these events after risk adjustment (adjusted odds ratio: 1.17, 95% confidence interval: 1.08-1.28, P < .001). CONCLUSION: SNHs continue to provide valuable specialty care to underserved populations, often with limited financial resources. Despite promising results from prior decades demonstrating comparable perioperative outcomes, the present study noted increased adverse events following HNCA surgery at these sites. Such findings underscore the need for continued advocacy to secure necessary funding for these centers.

Disparities in clinical trial enrollment among patients with gastrointestinal cancer relative to minority-serving and safety-netting hospitals.

BACKGROUND: For results to be generalizable to all patients with cancer, clinical trials need to include a diverse patient demographic that is representative of the general population. We sought to characterize the effect of receiving care at a minority-serving hospital (MSH) and/or safety-net hospital on clinical trial enrollment among patients with gastrointestinal (GI) malignancies. METHODS: Adult patients with GI cancer who underwent oncologic surgery and were enrolled in institutional-/National Cancer Institute-funded clinical trials between 2012 and 2019 were identified in the National Cancer Database. Multivariable regression was used to assess the relationship between MSH and safety-net status relative to clinical trial enrollment. RESULTS: Among 1,112,594 patients, 994,598 (89.4%) were treated at a non-MSH, whereas 117,996 (10.6%) were treated at an MSH. Only 1857 patients (0.2%) were enrolled in a clinical trial; most patients received care at a non-MSH (1794 [96.6%]). On multivariable analysis, the odds of enrollment in a clinical trial were markedly lower among patients treated at an MSH vs non-MSH (odds ratio [OR], 0.32; 95% CI, 0.22-0.46). In addition, even after controlling for receipt of care at MSH, Black patients remained at lower odds of enrollment in a clinical trial than White patients (OR, 0.57; 95% CI, 0.45-0.73; both P < .05). CONCLUSION: Overall, clinical trial participation among patients with GI cancer was extremely low. Patients treated at an MSH and high safety-net burden hospitals and Black individuals were much less likely to be enrolled in a clinical trial. Efforts should be made to improve trial enrollment and address disparities in trial representation.

Disparities in Care for Low-Income Patients with Cirrhosis: Implementing an Innovative Outpatient Clinic for Refractory Ascites in a Safety Net Hospital.

BACKGROUND: Disparities in life-saving interventions for low-income patients with cirrhosis necessitate innovative models of care. AIM: To implement a novel generalist-led FLuid ASPiration (FLASP) clinic to reduce emergency department (ED) care for refractory ascites. SETTING: A large safety net hospital in Los Angeles. PARTICIPANTS: MediCal patients with paracentesis in the ED from 6/1/2020 to 1/31/2021 or in FLASP clinic or the ED from 3/1/2021 to 4/30/2022. PROGRAM DESCRIPTION: According to RE-AIM, adoption obtained administrative endorsement and oriented ED staff. Reach engaged ED staff and eligible patients with timely access to FLASP. Implementation trained FLASP clinicians in safer, guideline-based paracentesis, facilitated timely access, and offered patient education and support. PROGRAM EVALUATION: After FLASP clinic opened, significantly fewer ED visits were made by patients discharged after paracentesis [rate ratio (RR) of 0.33 (95% CI 0.28, 0.40, p < 0.0001)] but not if subsequently hospitalized (RR = 0.88, 95% CI 0.70, 1.11). Among 2685 paracenteses in 225 FLASP patients, complications were infrequent: 39 (1.5%) spontaneous bacterial peritonitis, 265 (9.9%) acute kidney injury, and 2 (< 0.001%) hypotension. FLASP patients rated satisfaction highly on a Likert-type question. DISCUSSION: Patients with refractory ascites in large safety net hospitals may benefit from an outpatient procedure clinic instead of ED care.

The Role of Preoperative Antibiotics in Surgical Site Infection (SSI) Rate after Class I/Clean Gynaecologic Surgery at an Academic Safety Net Hospital.

OBJECTIVES: Examine whether preoperative antibiotics in class I/clean abdominal gynaecologic surgery decrease the incidence of surgical site infections (SSI). METHODS: Retrospective cohort study at academic safety net hospital of patients undergoing class I laparoscopic or open gynaecologic surgery between November 2013 and September 2017. Performance improvement initiative to administer preoperative antibiotics to all surgical patients starting July 2016. RESULTS: In total, 510 patients were included: 283 in the antibiotic group and 227 in the no-antibiotic group. PRIMARY OUTCOME: incidence of SSI. Baseline characteristics were similar between groups once balanced by propensity score method. In unweighted analysis, incidence of SSI decreased from 9.3% (21/227) in the no-antibiotics group to 4.9% (14/283) in antibiotics group, but this was not statistically significant (odds ratio (OR) 0.51 CI 0.25-1.03, P = 0.0598). Following of inverse probability of treatment weighting adjustments in weighted analysis, incidence of SSI was found to be significantly lower in patients who received antibiotics compared to patients who did not receive antibiotics across entry types (4.6% vs. 9.8%, OR 0.45; CI 0.22-0.90, P = 0.023). Weighted analysis demonstrated in the exploratory laparotomy group patients who received antibiotics had a lower incidence of SSI compared to patients who did not receive antibiotics (5.1% vs. 18.7%, OR 0.23; CI 0.08-0.68, P = 0.008). In the laparoscopy group, there was no difference between groups (4.4% vs. 5.4%, OR 0.81; CI 0.3-2.16, P = 0.675). CONCLUSIONS: There is limited literature on SSI prevention/preoperative antibiotic use in class I gynaecologic surgeries. This study demonstrates antibiotics in class I procedures decrease SSI rates, specifically in open procedures. There was a lack of demonstrated benefit in laparoscopy.

Hospital Finances During the First Two Years of the COVID-19 Pandemic: Evidence From Washington State Hospitals.

The COVID-19 pandemic created a broad array of challenges for hospitals. These challenges included restrictions on admissions and procedures, patient surges, rising costs of labor and supplies, and a disparate impact on already disadvantaged populations. Many of these intersecting challenges put pressure on hospitals' finances. There was concern that financial pressure would be particularly acute for hospitals serving vulnerable populations, including safety-net (SN) hospitals and critical access hospitals (CAHs). Using data from hospitals in Washington State, we examined changes in operating margins for SN hospitals, CAHs, and other acute care hospitals in 2020 and 2021. We found that the operating margins for all three categories of hospitals fell from 2019 to 2020, with SNs and CAHs sustaining the largest declines. During 2021, operating margins improved for all three hospital categories but SN operating margins still remained negative. Both changes in revenue and changes in expenses contributed to observed changes in operating margins. Our study is one of the first to describe how the financial effects of COVID-19 differed for SNs, CAHs, and other acute care hospitals over the first two years of the pandemic. Our results highlight the continuing financial vulnerability of SNs and demonstrate how the factors that contribute to profitability can shift over time.

Impact of safety-net hospital burden on achievement of textbook oncologic outcomes following resection in for stage I-IV colorectal cancer.

BACKGROUND AND OBJECTIVES: Textbook oncologic outcome (TOO) is a benchmark for high-quality surgical cancer care but has not been studied at safety-net hospitals (SNH). The study sought to understand how SNH burden affects TOO achievement in colorectal cancer. METHODS: The National Cancer Database was queried for colorectal cancer patients who underwent resection for stage I-III plus stage IV with liver-only metastases (2010-2019). TOO was defined as R0 resection, AJCC-compliant lymphadenectomy (>12 nodes), no prolonged LOS, no 30-day mortality/readmission, and receipt of stage-appropriate adjuvant chemotherapy. RESULTS: Of 487,195 patients, 66.7% achieved TOO. Lower achievement was explained by adequate lymphadenectomy (87.3%), non-prolonged LOS (76.3%), and receipt of adjuvant chemotherapy in stage III (60.3%) and IV (54.1%). Treatment at high burden hospitals (HBH, >10% Medicaid/uninsured) was a predictor of non-TOO (Stage I/II: OR 0.83, III: OR 0.86, IV: OR 0.83; all p < 0.001). Achieving TOO was associated with decreased mortality (Stage I/II: HR 0.49, III: HR 0.48, IV: HR 0.57; all p < 0.001), and HBH treatment was a predictor of mortality (Stage I/II: HR 1.09, III: HR 1.05, IV: HR 1.07; all p < 0.05). CONCLUSIONS: Treatment at higher SNH burden hospitals was associated with less frequent TOO achievement and increased mortality. Quality improvement targets include receipt of adjuvant chemotherapy and avoidance of prolonged LOS.