Building the Infrastructure to Integrate Social Care in a Safety Net Health System.

A recent National Academies report recommended that health systems invest in new infrastructure to integrate social and medical care. Although many health systems routinely screen patients for social concerns, few health systems achieve the recommended model of integration. In this critical case study in an urban safety net health system, we describe the human capital, operational redesign, and financial investment needed to implement the National Academy recommendations. Using data from this case study, we estimate that other health systems seeking to build and maintain this infrastructure would need to invest $1 million to $3 million per year. While health systems with robust existing resources may be able to bootstrap short-term funding to initiate this work, we conclude that long-term investments by insurers and other payers will be necessary for most health systems to achieve the recommended integration of medical and social care. Researchers seeking to test whether integrating social and medical care leads to better patient and population outcomes require access to health systems and communities who have already invested in this model infrastructure. (Am J Public Health. 2024;114(6):619-625. https://doi.org/10.2105/AJPH.2024.307602).

Poverty, Comorbidity, and Ethnicity: COVID-19 Outcomes in a Safety Net Health System.

Objective: To determine if race-ethnicity is correlated with case-fatality rates among low-income patients hospitalized for COVID-19. Research Design: Observational cohort study using electronic health record data. Patients: All patients assessed for COVID-19 from March 2020 to January 2021 at one safety net health system. Measures: Patient demographic and clinical characteristics, and hospital care processes and outcomes. Results: Among 25,253 patients assessed for COVID-19, 6,357 (25.2%) were COVID-19 positive: 1,480 (23.3%) hospitalized; 334 (22.6%) required intensive care; and 106 (7.3%) died. More Hispanic patients tested positive (51.8%) than non-Hispanic Black (31.4%) and White patients (16.7%, P<.001]. Hospitalized Hispanic patients were younger, more often uninsured, and less likely to have comorbid conditions. Non-Hispanic Black patients had significantly more diabetes, hypertension, obesity, chronic kidney disease, and asthma (P<.05). Non-Hispanic White patients were older and had more cigarette smoking history, COPD, and cancer. Non-Hispanic White patients were more likely to receive intensive care (29.6% vs 21.1% vs 20.8%, P=.007) and more likely to die (12% vs 7.3% vs 3.5%, P<.001) compared with non-Hispanic Black and Hispanic patients, respectively. Length of stay was similar for all groups. In logistic regression models, Medicaid insurance status independently correlated with hospitalization (OR 3.67, P<.001) while only age (OR 1.076, P<.001) and cerebrovascular disease independently correlated with in-hospital mortality (OR 2.887, P=.002). Conclusions: Observed COVID-19 in-hospital mortality rate was lower than most published rates. Age, but not race-ethnicity, was independently correlated with in-hospital mortality. Safety net health systems are foundational in the care of vulnerable patients suffering from COVID-19, including patients from under-represented and low-income groups.

Indianapolis Provider's Use Of Wraparound Services Associated With Reduced Hospitalizations And Emergency Department Visits.

Recent changes to US reimbursement policies are increasingly holding providers financially accountable for patients' health. Providing nonmedical services in conjunction with primary care-known as wraparound services-is one strategy to improve patient outcomes and reduce overall health care spending. These services leverage additional providers to address patients' social determinants of health. Eskenazi Health-an Indianapolis, Indiana, safety-net provider-introduced wraparound services at its federally qualified health center sites. Behavioral health, social work, dietetics, patient navigation, and other services that address patients' social and behavioral needs are co-located with primary care services. In an eleven-year panel of primary care patients, receipt of any wraparound service was negatively associated with subsequent hospitalizations and emergency department visits. The estimated cost savings from potentially avoided hospitalizations alone was $1.4 million annually. Under value-based payment, wraparound services may be one part of a portfolio of strategies to address the social, behavioral, and environmental factors that drive poor patient health and increase costs.

Fostering Local Health Department and Health System Collaboration Through Case Conferences for At-Risk and Vulnerable Populations.

In case conferences, health care providers work together to identify and address patients' complex social and medical needs. Public health nurses from the local health department joined case conference teams at federally qualified health center primary care sites to foster cross-sector collaboration, integration, and mutual learning. Public health nurse participation resulted in frequent referrals to local health department services, greater awareness of public health capabilities, and potential policy interventions to address social determinants of health.

An Assessment of SBIRT Prescreening and Screening Outcomes by Medical Setting and Administration Methodology.

BACKGROUND: Screening, brief intervention, and referral to treatment (SBIRT) is an efficacious prevention practice. However, little research has assessed differences in prescreening outcomes between inpatient and outpatient primary care or among different prescreening administration methods. This study tested whether administration method (self-administered vs interview) and setting (inpatient versus outpatient) predicted prescreening outcomes in a large sample of primary care patients. Then, among patients who prescreened positive, it tested whether full screening scores differed by administration method and setting. METHODS: Researchers used binomial logistic regression to assess predicted prescreening outcomes and analysis of variance to assess differences in SBIRT screening scores across a total of 14 447 unique patient visits in 10 outpatient sites and 1 centrally located hospital. RESULTS: Controlling for gender, depression, and other substance use, both medical setting and method of prescreening, predicted prescreening results. Among patients who prescreened positive for alcohol, setting also was associated with mean screening scores. However, outcomes were not uniform by substance (eg, alcohol vs other drugs). CONCLUSION: The results support previous studies on this topic that had utilized cross-study comparison or that were not specific to SBIRT prescreening/screening mechanisms. At the same time, nuanced findings were observed that had not previously been reported and suggest the need for further research in this area.

Preparing for an aging population and improving chronic disease management.

New models of health care delivery are inevitable. There is likely to be increasing emphasis on patient self-monitoring, health care delivery at patient homes, interdisciplinary treatment plans, a greater percentage of medical care delivered by non-physician health professionals, targeted health educational materials, and greater involvement and training of informal caregivers. The Information Technologies (IT) infrastructure of health systems will need to adapt. We have begun sorting out the implications of this future within a County public hospital system: defining the desirable features, relevant technologies, necessary modifications to the network, and additional data elements to be captured. We seek to build an infrastructure that will support new patient-focused technologies designed to more efficiently and effectively support older individuals. We hypothesize utility to further exploring the impact that new health care delivery models will have on health systems' IT infrastructures.

Managing primary care using patient satisfaction measures.

Our study aimed to identify which attributes of a primary healthcare experience have the most impact on patient satisfaction as well as which aspects of each attribute are most significant in patients' response to the services they receive. The three attributes examined in this study were access, staff care, and physician care. Analyses of the aspects of each attribute controlled for age, gender, and race. Data used in this study were obtained through a survey questionnaire with random sampling, resulting in the sample size of 8,465. The psychometric properties of the questionnaire were also examined and showed appropriate reliability and validity. The multiple regression analysis showed that among the three attributes, physician care was most influential, closely followed by staff care, with access having much less influence. Further analyses revealed that specific aspects of each attribute were more influential on patient satisfaction. Within the physician care attribute, patients were found to be rational consumers who were looking for surrogate indicators of correct diagnosis and treatment options among the measures available to them. They were much less likely to be influenced by so-called bedside manner. Within the staff care attribute, willingness and compassionate behaviors of staff and prompt service were most important. Within the access attribute, patients sought caring interaction with appointment personnel. After considering the findings, we discuss possible actions for healthcare managers.

Can computer-generated evidence-based care suggestions enhance evidence-based management of asthma and chronic obstructive pulmonary disease? A randomized, controlled trial.

OBJECTIVE: Translation of evidence-based guidelines into clinical practice has been inconsistent. We performed a randomized, controlled trial of guideline-based care suggestions delivered to physicians when writing orders on computer workstations. STUDY SETTING: Inner-city academic general internal medicine practice. STUDY DESIGN: Randomized, controlled trial of 246 physicians (25 percent faculty general internists, 75 percent internal medicine residents) and 20 outpatient pharmacists. We enrolled 706 of their primary care patients with asthma or chronic obstructive pulmonary disease. Care suggestions concerning drugs and monitoring were delivered to a random half of the physicians and pharmacists when writing orders or filling prescriptions using computer workstations. A 2 x 2 factorial randomization of practice sessions and pharmacists resulted in four groups of patients: physician intervention, pharmacist intervention, both interventions, and controls. DATA EXTRACTION/COLLECTION METHODS: Adherence to the guidelines and clinical activity was assessed using patients' electronic medical records. Health-related quality of life, medication adherence, and satisfaction with care were assessed using telephone questionnaires. PRINCIPAL FINDINGS: During their year in the study, patients made an average of five scheduled primary care visits. There were no differences between groups in adherence to the care suggestions, generic or condition-specific quality of life, satisfaction with physicians or pharmacists, medication compliance, emergency department visits, or hospitalizations. Physicians receiving the intervention had significantly higher total health care costs. Physician attitudes toward guidelines were mixed. CONCLUSIONS: Care suggestions shown to physicians and pharmacists on computer workstations had no effect on the delivery or outcomes of care for patients with reactive airways disease.

Different integration processes of patient satisfaction among four groups.

We examined integration processes of patient satisfaction among four groups of patients and found that these groups of patients combined their health care attribute reactions differently to form their overall satisfaction. For the study, we used an emerging noncompensatory model in health care and considered an interaction effect in the analysis. We discuss the implication of the different integration processes of patient satisfaction for health care managers and make practical suggestions for more effective and efficient means of increasing patient satisfaction.

Failure of computerized treatment suggestions to improve health outcomes of outpatients with uncomplicated hypertension: results of a randomized controlled trial.

STUDY OBJECTIVE: To assess the effects of evidence-based treatment suggestions for hypertension made to physicians and pharmacists using a comprehensive electronic medical record system. DESIGN: Randomized controlled trial with a 2 x 2 factorial design of physician and pharmacist interventions, which resulted in four groups of patients: physician intervention only, pharmacist intervention only, intervention by physician and pharmacist, and intervention by neither physician nor pharmacist (control). SETTING: Academic primary care internal medicine practice. SUBJECTS: Seven hundred twelve patients with uncomplicated hypertension. MEASUREMENTS AND MAIN RESULTS: Suggestions were displayed to physicians on computer workstations used to write outpatient orders and to pharmacists when filling prescriptions. The primary end point was generic health-related quality of life. Secondary end points were symptom profile and side effects from antihypertensive drugs, number of emergency department visits and hospitalizations, blood pressure measurements, patient satisfaction with physicians and pharmacists, drug therapy compliance, and health care charges. In the control group, implementation of care changes in accordance with treatment suggestions was observed in 26% of patients. In the intervention groups, compliance with suggestions was poor, with treatment suggestions implemented in 25% of patients for whom suggestions were displayed only to pharmacists, 29% of those for whom suggestions were displayed only to physicians, and 35% of the group for whom both physicians and pharmacists received suggestions (p=0.13). Intergroup differences were neither statistically significant nor clinically relevant for generic health-related quality of life, symptom and side-effect profiles, number of emergency department visits and hospitalizations, blood pressure measurements, charges, or drug therapy compliance. CONCLUSION: Computer-based intervention using a sophisticated electronic physician order-entry system failed to improve compliance with treatment suggestions or outcomes of patients with uncomplicated hypertension.

Effects of computerized guidelines for managing heart disease in primary care.

BACKGROUND: Electronic information systems have been proposed as one means to reduce medical errors of commission (doing the wrong thing) and omission (not providing indicated care). OBJECTIVE: To assess the effects of computer-based cardiac care suggestions. DESIGN: A randomized, controlled trial targeting primary care physicians and pharmacists. SUBJECTS: A total of 706 outpatients with heart failure and/or ischemic heart disease. INTERVENTIONS: Evidence-based cardiac care suggestions, approved by a panel of local cardiologists and general internists, were displayed to physicians and pharmacists as they cared for enrolled patients. MEASUREMENTS: Adherence with the care suggestions, generic and condition-specific quality of life, acute exacerbations of their cardiac disease, medication compliance, health care costs, satisfaction with care, and physicians' attitudes toward guidelines. RESULTS: Subjects were followed for 1 year during which they made 3,419 primary care visits and were eligible for 2,609 separate cardiac care suggestions. The intervention had no effect on physicians' adherence to the care suggestions (23% for intervention patients vs 22% for controls). There were no intervention-control differences in quality of life, medication compliance, health care utilization, costs, or satisfaction with care. Physicians viewed guidelines as providing helpful information but constraining their practice and not helpful in making decisions for individual patients. CONCLUSIONS: Care suggestions generated by a sophisticated electronic medical record system failed to improve adherence to accepted practice guidelines or outcomes for patients with heart disease. Future studies must weigh the benefits and costs of different (and perhaps more Draconian) methods of affecting clinician behavior.

A paradigm shift in patient satisfaction assessment.

The authors investigated the relationships between patients' reactions to health care attributes and their overall satisfaction with primary care. The study found the following: (1) patients' overall satisfaction levels are disproportionately influenced by low levels of their reactions (less satisfied) to the primary care attribute, rather than simply averaged out among attribute reactions. This is a noncompensatory relationship. (2) The marginal impact of primary care attributes on overall satisfaction decreases at higher levels of patients' reactions (more satisfied) to primary care attributes, indicating a nonlinear relationship. Patients combine their reactions to the health care attributes by means of noncompensatory and nonlinear models to form their overall satisfaction. Decision makers should selectively concentrate training resources on those areas of attributes showing high dissatisfaction rather than attempt to improve an attribute that showed the largest parameter estimate. This approach would not only save resources but result in better outcomes of patient satisfaction.

Effectiveness of pharmacist care for patients with reactive airways disease: a randomized controlled trial.

CONTEXT: It is not known whether patient outcomes are enhanced by effective pharmacist-patient interactions. OBJECTIVE: To assess the effectiveness of a pharmaceutical care program for patients with asthma or chronic obstructive pulmonary disease (COPD). DESIGN, SETTING, AND PARTICIPANTS: Randomized controlled trial conducted at 36 community drugstores in Indianapolis, Ind. We enrolled 1113 participants with active COPD or asthma from July 1998 to December 1999. Outcomes were assessed in 947 (85.1%) participants at 6 months and 898 (80.7%) at 12 months. INTERVENTIONS: The pharmaceutical care program (n = 447) provided pharmacists with recent patient-specific clinical data (peak expiratory flow rates [PEFRs], emergency department [ED] visits, hospitalizations, and medication compliance), training, customized patient educational materials, and resources to facilitate program implementation. The PEFR monitoring control group (n = 363) received a peak flow meter, instructions about its use, and monthly calls to elicit PEFRs. However, PEFR data were not provided to the pharmacist. Patients in the usual care group (n = 303) received neither peak flow meters nor instructions in their use; during monthly telephone interviews, PEFR rates were not elicited. Pharmacists in both control groups had a training session but received no components of the pharmaceutical care intervention. MAIN OUTCOME MEASURES: Peak expiratory flow rates, breathing-related ED or hospital visits, health-related quality of life (HRQOL), medication compliance, and patient satisfaction. RESULTS: At 12 months, patients receiving pharmaceutical care had significantly higher peak flow rates than the usual care group (P =.02) but not than PEFR monitoring controls (P =.28). There were no significant between-group differences in medication compliance or HRQOL. Asthma patients receiving pharmaceutical care had significantly more breathing-related ED or hospital visits than the usual care group (odds ratio, 2.16; 95% confidence interval, 1.76-2.63; P<.001). Patients receiving pharmaceutical care were more satisfied with their pharmacist than the usual care group (P =.03) and the PEFR monitoring group (P =.001) and were more satisfied with their health care than the usual care group at 6 months only (P =.01). Despite ample opportunities to implement the program, pharmacists accessed patient-specific data only about half of the time and documented actions about half of the time that records were accessed. CONCLUSIONS: This pharmaceutical care program increased patients' PEFRs compared with usual care but provided little benefit compared with peak flow monitoring alone. Pharmaceutical care increased patient satisfaction but also increased the amount of breathing-related medical care sought.

Issues in conducting randomized controlled trials of health services research interventions in nonacademic practice settings: the case of retail pharmacies.

OBJECTIVE: To describe unexpected challenges and strategies to overcome them when conducting randomized controlled trials (RCT) of health services research interventions in retail pharmacies. STUDY SETTING: Thirty-six retail drug stores in Indianapolis. STUDY DESIGN: We conducted an RCT to evaluate the effectiveness of an intervention to increase pharmacists' involvement in caring for customers. We describe: (1) our RCT as originally designed, (2) unexpected challenges we faced; and (3) how we resolved those challenges. DATA COLLECTION/EXTRACTION METHODS: Randomized controlled trial. PRINCIPAL FINDINGS: Major modifications in research design were necessitated by factors such as corporate restructuring, heightened sensitivity to patient confidentiality, and difficulties altering employees' behavior. We overcame these barriers by conducting research that is consistent with corporate goals, involving appropriate corporate administrators and technical personnel early in the process, and being flexible. CONCLUSIONS: Health services researchers should conduct RCTs in a variety of non-academic practice settings to increase generalizability and better reflect the true impact of interventions. Pragmatic problems, although significant, can be successfully overcome.