Implementation of Social Isolation Screening and an Integrated Community Resource Referral Platform.

BACKGROUND: Screening and referral programs for social isolation and loneliness in older patients increased during the COVID-19 pandemic in primary care settings to mitigate associated adverse health outcomes. This study explores community health centers' experiences implementing a social isolation and loneliness screening program involving a community resource referral platform integrated into the electronic health record to support referrals. METHODS: A formative mixed methods evaluation in 4 community health centers. Semistructured interviews, observation of implementation meetings, facilitated group discussions, surveys, and utilization data extracted from the electronic health record and community resource referral platform were collected and analyzed concurrently. RESULTS: Screening for social isolation and loneliness can heighten health center staff knowledge and prioritization of socially isolated older patients. Participants indicate using an integrated community resource referral platform may only be useful in certain circumstances, particularly for those located outside urban areas. The experiences of these health centers indicate that when implementing interventions to mitigate patients' social isolation and loneliness, it is necessary to consider other resource directories, needed adjustments to referral and documentation workflows, and potential impacts on patients and care teams. CONCLUSION: Screening older patients for social isolation could increase care team awareness of social risk; assistance related referral options should be considered carefully.

Partner-developed electronic health record tools to facilitate social risk-informed care planning.

OBJECTIVE: Increased social risk data collection in health care settings presents new opportunities to apply this information to improve patient outcomes. Clinical decision support (CDS) tools can support these applications. We conducted a participatory engagement process to develop electronic health record (EHR)-based CDS tools to facilitate social risk-informed care plan adjustments in community health centers (CHCs). MATERIALS AND METHODS: We identified potential care plan adaptations through systematic reviews of hypertension and diabetes clinical guidelines. The results were used to inform an engagement process in which CHC staff and patients provided feedback on potential adjustments identified in the guideline reviews and on tool form and functions that could help CHC teams implement these suggested adjustments for patients with social risks. RESULTS: Partners universally prioritized tools for social risk screening and documentation. Additional high-priority content included adjusting medication costs and changing follow-up plans based on reported social risks. Most content recommendations reflected partners' interests in encouraging provider-patient dialogue about care plan adaptations specific to patients' social needs. Partners recommended CDS tool functions such as alerts and shortcuts to facilitate and efficiently document social risk-informed care plan adjustments. DISCUSSION AND CONCLUSION: CDS tools were designed to support CHC providers and staff to more consistently tailor care based on information about patients' social context and thereby enhance patients' ability to adhere to care plans. While such adjustments occur on an ad hoc basis in many care settings, these are among the first tools designed both to systematize and document these activities.

Social Care Recommendations in National Diabetes Treatment Guidelines.

PURPOSE OF REVIEW: An expanding body of research documents associations between socioeconomic circumstances and health outcomes, which has led health care institutions to invest in new activities to identify and address patients' social circumstances in the context of care delivery. Despite growing national investment in these "social care" initiatives, the extent to which social care activities are routinely incorporated into care for patients with type II diabetes mellitus (T2D), specifically, is unknown. We conducted a scoping review of existing T2D treatment and management guidelines to explore whether and how these guidelines incorporate recommendations that reflect social care practice categories. RECENT FINDINGS: We applied search terms to locate all T2D treatment and management guidelines for adults published in the US from 1977 to 2021. The search captured 158 national guidelines. We subsequently applied the National Academies of Science, Engineering, and Medicine framework to search each guideline for recommendations related to five social care activities: Awareness, Adjustment, Assistance, Advocacy, and Alignment. The majority of guidelines (122; 77%) did not recommend any social care activities. The remainder (36; 23%) referred to one or more social care activities. In the guidelines that referred to at least one type of social care activity, adjustments to medical treatment based on social risk were most common [34/36 (94%)]. Recommended adjustments included decreasing medication costs to accommodate financial strain, changing literacy level or language of handouts, and providing virtual visits to accommodate transportation insecurity. Ensuring that practice guidelines more consistently reflect social care best practices may improve outcomes for patients living with T2D.

Adjusting for Patient Economic/Access Issues in a Hypertension Quality Measure.

INTRODUCTION: The American Heart Association and American College of Cardiology have proposed adjusting hypertension-related care quality measures by excluding patients with economic/access issues from the denominator of rate calculations. No research to date has explored the methods to operationalize this recommendation or how to measure economic/access issues. This study applied and compared different approaches to populating these denominator exceptions. METHODS: Electronic health record data from 2019 were used in 2021 to calculate hypertension control rates in 84 community health centers. A total of 10 different indicators of patient economic/access barriers to care were used as denominator exclusions to calculate and then compare adjusted quality measure performance. Data came from a nonprofit health center‒controlled network that hosts a shared electronic health record for community health centers located in 22 states. RESULTS: A total of 5 of 10 measures yielded an increase in adjusted hypertension control rates in ≥50% of clinics (average rate increases of 0.7-3.71 percentage points). A total of 3 of 10 measures yielded a decrease in adjusted hypertension control rates in >50% of clinics (average rate decreases of 1.33-13.82 percentage points). A total of 5 measures resulted in excluding >50% of the clinic's patient population from quality measure assessments. CONCLUSIONS: Changes in clinic-level hypertension control rates after adjustment differed depending on the measure of economic/access issue. Regardless of the exclusion method, changes between baseline and adjusted rates were small. Removing community health center patients experiencing economic/access barriers from a hypertension control quality measure resulted in excluding a large proportion of patients, raising concerns about whether this calculation can be a meaningful measure of clinical performance.

Reduction of Long-Term Opioid Prescribing for Back Pain in Community Health Centers After a Medicaid Policy Change.

INTRODUCTION: Beginning around 2011, innumerable policies have aimed to improve pain treatment while minimizing harms from excessive use of opioids. It is not known whether changing insurance coverage for specific conditions is an effective strategy. We describe and assess the effect of an innovative Oregon Medicaid back/neck pain coverage policy on opioid prescribing patterns. METHODS: This retrospective cohort study uses electronic health record data from a network of community health centers (CHCs) in Oregon to analyze prescription opioid dose changes among patients on long-term opioid treatment (LOT) affected by the policy. RESULTS: Of the 1,789 patients on LOT at baseline, 41.6% had an average daily dose of <20 morphine milligram equivalents (MME), 32.3% had ≥20 to <50 MME, 14.5% had ≥50 to <90 MME, and 11.6% ≥90 MME. Around half of each group discontinued opioids within the 18-month policy period. Those who discontinued did so gradually (average of 11 months) regardless of starting dosage. Predictors of discontinuation included: diagnosis of opioid use disorder, older, non-Hispanic white, and less medical complexity. CONCLUSIONS: Regardless of starting opioid dose, nearly half of patients affected by the 2016 Oregon Medicaid back/neck pain treatment policy no longer received opioid prescriptions by the end of the 18-month study period; another 30% decreased their dose. Gradual dose reduction was typical. These outcomes suggest that the policy impacted opioid prescribing. Understanding patient experiences resulting from such policies could help clinicians and policy makers navigate the complex balance between potential harms and benefits of LOT.

Using Electronic Health Record-Based Clinical Decision Support to Provide Social Risk-Informed Care in Community Health Centers: Protocol for the Design and Assessment of a Clinical Decision Support Tool.

BACKGROUND: Consistent and compelling evidence demonstrates that social and economic adversity has an impact on health outcomes. In response, many health care professional organizations recommend screening patients for experiences of social and economic adversity or social risks-for example, food, housing, and transportation insecurity-in the context of care. Guidance on how health care providers can act on documented social risk data to improve health outcomes is nascent. A strategy recommended by the National Academy of Medicine involves using social risk data to adapt care plans in ways that accommodate patients' social risks. OBJECTIVE: This study's aims are to develop electronic health record (EHR)-based clinical decision support (CDS) tools that suggest social risk-informed care plan adaptations for patients with diabetes or hypertension, assess tool adoption and its impact on selected clinical quality measures in community health centers, and examine perceptions of tool usability and impact on care quality. METHODS: A systematic scoping review and several stakeholder activities will be conducted to inform development of the CDS tools. The tools will be pilot-tested to obtain user input, and their content and form will be revised based on this input. A randomized quasi-experimental design will then be used to assess the impact of the revised tools. Eligible clinics will be randomized to a control group or potential intervention group; clinics will be recruited from the potential intervention group in random order until 6 are enrolled in the study. Intervention clinics will have access to the CDS tools in their EHR, will receive minimal implementation support, and will be followed for 18 months to evaluate tool adoption and the impact of tool use on patient blood pressure and glucose control. RESULTS: This study was funded in January 2020 by the National Institute on Minority Health and Health Disparities of the National Institutes of Health. Formative activities will take place from April 2020 to July 2021, the CDS tools will be developed between May 2021 and November 2022, the pilot study will be conducted from August 2021 to July 2022, and the main trial will occur from December 2022 to May 2024. Study data will be analyzed, and the results will be disseminated in 2024. CONCLUSIONS: Patients' social risk information must be presented to care teams in a way that facilitates social risk-informed care. To our knowledge, this study is the first to develop and test EHR-embedded CDS tools designed to support the provision of social risk-informed care. The study results will add a needed understanding of how to use social risk data to improve health outcomes and reduce disparities. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/31733.

Impacts of a Web-Based Course on Mental Health Clinicians' Attitudes and Communication Behaviors Related to Use of OpenNotes.

OBJECTIVE: The OpenNotes initiative encourages health care systems to provide patients online access to clinical notes. Some individuals have expressed concerns about use of OpenNotes in mental health care. This study evaluated changes in mental health clinicians' attitudes and communications with patients after participation in a Web-based course designed to reduce potential for unintended consequences and enhance likelihood of positive outcomes of OpenNotes. METHODS: All 251 mental health clinicians (physicians, nurse practitioners, psychologists, and social workers) of a large U.S. Department of Veterans Affairs facility were invited to participate. Clinicians completed surveys at baseline and 3 months after course participation. Ten items were examined that addressed clinicians' concerns and communication behaviors with patients. Mixed-effects models with repeated measures were used to compare pre-post data. RESULTS: Of the 251 clinicians, 141 (56%) completed baseline surveys, and 113 (80%) completed baseline and postcourse surveys. Of the 141 clinicians, 63% were female, 46% were social workers, 34% were psychologists, 16% were psychiatrists, and 4% were nurse practitioners. In final adjusted models, pre-post item scores indicated significant increases in clinicians' ability to communicate with and educate patients (p<.01) and in the frequency with which clinicians educated patients about OpenNotes access (p<.001), advised patients to access and read notes (p<.01), and asked patients about questions or concerns they have with notes (p=.04). There was also a significant reduction in clinicians' worry about negative consequences (p=.05). CONCLUSIONS: A Web-based course for mental health clinicians on use of OpenNotes resulted in self-reported improvements in some concerns and in aspects of patient-clinician communication.

Providing mental health care in the context of online mental health notes: advice from patients and mental health clinicians.

BACKGROUND: The OpenNotes initiative provides patients online access to their clinical notes. Mental health clinicians in the Veterans Health Administration report a need for guidance on how to provide care, write notes, and discuss them in the context of OpenNotes. AIM: To provide mental health clinicians recommendations identified by patients and clinicians that help them effectively practice in the context of OpenNotes. METHOD: Twenty-eight mental health clinicians and 28 patients in mental health care participated in semi-structured interviews about their experiences and perceptions with OpenNotes. A rapid review approach was used to analyze transcripts. RESULTS: Analysis of interviews identified three domains of advice for mental health clinicians: writing notes that maintain the therapeutic relationship, communicating with patients about their notes and utilizing clinical notes as a patient resource to enhance care. Specific recommendations are provided. CONCLUSION: Findings provide mental health clinicians with guidance from service users and clinicians on how to leverage clinical notes to maintain - and potentially enhance -therapeutic relationships in a healthcare system in which patients are able to read their mental health notes online.

Impacts of a web-based educational program for veterans who read their mental health notes online.

Objective: This study evaluates whether a web-based educational program for patients who read their mental health notes online improves patient-clinician communication and increases patient activation. Methods: The web-based educational program, developed with end-user input, was designed to educate patients on the content of mental health notes, provide guidance on communicating with clinicians about notes, and facilitate patients' safe and purposeful use of their health information. Eligible patients were engaged in mental health treatment (≥1 visit in the prior 6 months) and had logged into the Veterans Health Administration (VHA) patient portal at least twice. Participants completed measures of patient activation, perceived efficacy in healthcare interactions, patient trust in their clinicians, and patient assessment of the therapeutic relationship before and after participating in the program. A total of 247 participants had complete data and engaged with the program for 5 minutes or more, comprising the analytic sample. Multivariate analysis using mixed effects models were used to examine pre-post changes in outcomes. Results: In bivariate analyses, patient activation, perceived efficacy in healthcare interactions, and trust in clinicians increased significantly between pre- and post-training assessments. In fully adjusted models, changes in patient activation [b = 2.71 (1.41, 4.00), P < 0.01] and perceived efficacy in healthcare interactions [b = 1.27 (0.54, 2.01), P < 0.01)] remained significant. Conclusions: Findings suggest that this educational program may help empower mental health patients who read their notes online to be active participants in their care, while also providing information and tools that may facilitate better relationships with their clinicians.

Patients' Positive and Negative Responses to Reading Mental Health Clinical Notes Online.

OBJECTIVE: This study describes responses to OpenNotes, clinical notes available online, among patients receiving mental health care and explores whether responses vary by patient demographic or clinical characteristics. METHODS: Survey data from 178 veterans receiving mental health treatment at a large Veterans Affairs medical center included patient-reported health self-efficacy, health knowledge, alliance with clinicians, and negative emotional responses after reading OpenNotes. Health care data were extracted from the patient care database. RESULTS: Reading OpenNotes helped many participants feel in control of their health care (49%) and have more trust in clinicians (45%), although a few (8%) frequently felt upset after reading their notes. In multivariate models, posttraumatic stress disorder was associated with increased patient-clinician alliance (p=.046) but also with negative emotional responses (p<.01). CONCLUSIONS: Patients receiving mental health care frequently reported benefits from reading OpenNotes, yet some experienced negative responses.

Predictors of viewing progress notes among users of VA's electronic health portal who receive mental health care.

OBJECTIVE: Consistent with the OpenNotes movement, the Veterans Health Administration (VHA) offers patients online access to their clinical notes through the Blue Button feature in its electronic patient health portal, My HealtheVet. We identified demographic, diagnostic, and knowledge-related predictors of viewing clinical notes among veterans receiving VHA mental health care who recently used My HealtheVet. MATERIALS AND METHODS: Three hundred and thirty-eight patients receiving mental health care from 1 VHA medical center who had logged into My HealtheVet in the prior 6 months completed self-report questionnaires assessing their viewing of clinical notes. Additional data were extracted from VHA's Patient Care Database. Multivariable logistic regression was used to examine predictors of viewing notes. RESULTS: Fifty percent of respondents reported having read their notes. In the final multivariable model, post-traumatic stress disorder (PTSD) diagnosis [odds ratio (OR) = 2.30 (1.31-4.07)], speaking with their mental health clinician about their ability to view notes [OR = 3.84 (1.69-8.72)], and being very or extremely confident in understanding the purpose and uses of Blue Button [OR = 9.80 (2.23-43.07) and OR = 13.36 (2.74-65.20), respectively] were associated with viewing notes. DISCUSSION: Patient recall of mental health clinicians speaking to them about their ability to view notes, and confidence in understanding the use and purposes of Blue Button, were stronger predictors of viewing notes than demographic variables. PTSD diagnosis was the only clinical characteristic associated with viewing notes. CONCLUSION: The findings support the value of mental health clinicians openly discussing the availability of notes with patients if they wish to help them take advantage of their potential benefits.

Barriers to Using Nonpharmacologic Approaches and Reducing Opioid Use in Primary Care.

BACKGROUND: Opioid prescribing for chronic pain, including the potential for over-reliance and misuse, is a public health concern. OBJECTIVE: In the context of Veterans Administration (VA) primary care team-based pain management, we aimed to understand providers' perceptions of barriers to reducing opioid use and improving the use of nonpharmacologic pain management therapies (NPTs) for chronic pain. DESIGN: A semistructured interview elucidated provider experiences with assessing and managing pain. Emergent themes were mapped to known dimensions of VA primary care access. SUBJECTS: Informants included 60 primary care providers, registered nurses, licensed practical nurses, clerks, psychologists, and social workers at two VA Medical Centers. METHODS: Nine multidisciplinary focus groups. RESULTS: Provider perceptions of barriers to reducing opioids and improving use of NPTs for patients with chronic pain clustered around availability and access. Barriers to NPT access included the following subthemes: geographical (patient distance from service), financial (out-of-pocket cost to patient), temporal (treatment time delays), cultural (belief that NPTs increased provider workload, perception of insufficient training on NPTs, perceptions of patient resistance to change, confrontation avoidance, and insufficient leadership support), and digital (measure used for pain assessment, older patients hesitant to use technology, providers overwhelmed by information). CONCLUSIONS: Decreasing reliance on opioids for chronic pain requires a commitment to local availability and provider-facing strategies that increase efficacy in prescribing NPTs. Policies and interventions for decreasing utilization of opioids and increasing use of NPTs should comprehensively consider access barriers.

A Qualitative Analysis of How Online Access to Mental Health Notes Is Changing Clinician Perceptions of Power and the Therapeutic Relationship.

BACKGROUND: As part of the national OpenNotes initiative, the Veterans Health Administration (VHA) provides veterans online access to their clinical progress notes, raising concern in mental health settings. OBJECTIVE: The aim of this study was to examine the perspectives and experiences of mental health clinicians with OpenNotes to better understand how OpenNotes may be affecting mental health care. METHODS: We conducted individual semi-structured interviews with 28 VHA mental health clinicians and nurses. Transcripts were analyzed using a thematic analysis approach, which allows for both inductive and deductive themes to be explored using an iterative, constant comparative coding process. RESULTS: OpenNotes is changing VHA mental health care in ways that mental health clinicians perceive as both challenging and beneficial. At the heart of these changes is a shifting power distribution within the patient-clinician relationship. Some clinicians view OpenNotes as an opportunity to better partner with patients, whereas others feel that it has the potential to undo the therapeutic relationship. Many clinicians are uncomfortable with OpenNotes, but acknowledge that this discomfort could both improve and diminish care and documentation practices. Specifically, we found that (1) OpenNotes is empowering patients, (2) OpenNotes is affecting how clinicians build and maintain the therapeutic relationship, and (3) mental health clinicians are adjusting their practices to protect patients and themselves from adverse consequences of OpenNotes. CONCLUSIONS: Our findings suggest that future research should monitor whether OpenNotes notes facilitates stronger patient-clinician relationships, enhancing patient-centered mental health care, or diminishes the quality of mental health care through disruptions in the therapeutic relationship and reduced documentation.

Trust in Mental Health Clinicians Among Patients Who Access Clinical Notes Online.

OBJECTIVE: This study explored patient perspectives of how online access to clinical notes (OpenNotes) within the Veterans Affairs (VA) health care system may affect patients' relationships with their mental health clinicians. METHODS: Semistructured qualitative interviews were conducted with 28 patients receiving VA mental health care who had accessed OpenNotes. Transcripts were coded and analyzed with a constant comparative approach. RESULTS: Respondents consistently reported that patient-clinician relationships-feelings of trust in particular-are critical to the therapeutic process and that reading clinical notes strengthens or strains patients' trust in mental health clinicians. Perceptions of transparency and respect as conveyed in notes were central to maintaining trust. CONCLUSIONS: Findings suggest that ensuring consistency between what occurs during appointments and what appears in clinical notes, as well as highlighting patient individuality and strengths in notes, may help engender patient trust and avoid negative consequences of OpenNotes in mental health care.