Technology, data, people, and partnerships in addressing unmet social needs within Medicaid Managed Care.

BACKGROUND: Individuals with unmet social needs experience adverse health outcomes and are subject to greater inequities in health and social outcomes. Given the high prevalence of unmet needs among Medicaid enrollees, many Medicaid managed care organizations (MCOs) are now screening enrollees for unmet social needs and connecting them to community-based organizations (CBOs) with knowledge and resources to address identified needs. The use of screening and referral technology and data sharing are often considered key components in programs integrating health and social services. Despite this emphasis on technology and data collection, research suggests substantial barriers exist in operationalizing effective systems. METHODS: We used qualitative methods to examine cross-sector perspectives on the use of data and technology to facilitate MCO and CBO partnerships in Kentucky, a state with high Medicaid enrollment, to address enrollee social needs. We recruited participants through targeted sampling, and conducted 46 in-depth interviews with 26 representatives from all six Kentucky MCOs and 20 CBO leaders. Qualitative descriptive analysis, an inductive approach, was used to identify salient themes. RESULTS: We found that MCOs and CBOs have differing levels of need for data, varying incentives for collecting and sharing data, and differing valuations of what data can or should do. Four themes emerged from interviewees' descriptions of how they use data, including 1) to screen for patient needs, 2) to case manage, 3) to evaluate the effectiveness of programs, and 4) to partner with each other. Underlying these data use themes were areas of alignment between MCOs/CBOs, areas of incongruence, and areas of tension (both practical and ideological). The inability to interface with community partners for data privacy and ownership concerns contributes to division. Our findings suggest a disconnect between MCOs and CBOs regarding terms of their technology interfacing despite their shared mission of meeting the unmet social needs of enrollees. CONCLUSIONS: While data and technology can be used to identify enrollee needs and determine the most critical need, it is not sufficient in resolving challenges. People and relationships across sectors are vital in connecting enrollees with the community resources to resolve unmet needs.

Examining the communication work of women who have tested BRCA-positive: "I feel this responsibility to let people know".

Inheriting a pathogenic variant in the BRCA1 or BRCA2 gene considerably increases a woman's risk levels for developing breast and ovarian cancer. In addition to serious physical health implications, women with a BRCA pathogenic variant may face psychosocial challenges, including those related to navigating the often demanding process of communicating about topics regarding BRCA with family and other social network members. Based on in-depth interviews with 24 women who tested BRCA-positive, we found that-consistent with the conceptualization of communication work articulated by Donovan-Kicken et al. (2012) as an extension of the theory of illness trajectories (Corbin & Strauss, 1988)-the labor of communicating about BRCA genetic risk entails (a) duties, (b) challenges, (c) strategies, and (d) shared work. Within each category, our results illuminate particular characteristics of communication work for women who have tested BRCA-positive, which are commonly tied to the profound health consequences that a pathogenic variant may have for them and, potentially, for their genetic relatives. Our findings offer useful theoretical implications regarding communication work in this context. Furthermore, our results yield valuable practical insight for genetic counselors and other health care professionals regarding the struggles that can accompany communication work for women who have tested BRCA-positive as well as the strategies that participants reported using to manage or avoid these challenges.

Women's Metaphors About BRCA Gene Testing and How They Can Inform Health Communication Theory and Practice.

Genetic testing can detect whether an individual carries a harmful variant in the BRCA1 or BRCA2 (Breast Cancer 1 or 2) gene which, if present, drastically increases a woman's risk for breast and ovarian cancer. The experience of BRCA gene testing can be an emotionally laden process yielding significant uncertainty. In this study, we examined women's experiences of BRCA gene testing by exploring how participants communicatively framed and made sense of this process through the use of metaphors. Comparing uncertain and unfamiliar experiences to familiar references through metaphor can help people in challenging health-related situations with sense-making and communicating complex emotions. Furthermore, metaphors can be employed as a therapeutic tool by health care professionals, but their use has not often been studied regarding experiences of genetic testing, including BRCA gene testing. We conducted in-depth interviews with 42 women who have undergone BRCA gene testing (regardless of results), and analyzed data using constant comparative techniques. Eight categories of metaphors that women used surrounding BRCA gene testing were evident in the data, including those related to (a) knowledge is power; (b) gambling; (c) a journey; (d) a rollercoaster; (e) battle, disaster, or wreckage; (f) Pandora's box or a can of worms; (g) doom and gloom; and (h) the release or placing of a weight. Results enhance our understanding of women's experiences related to the uncertainty-inducing process of BRCA gene testing and lead to valuable theoretical implications and practical recommendations, including regarding the potential use of metaphors in patient-provider communication about BRCA genetic risk.

The Impact of Health Communication Research on Medical and Health Professional Education and Training.

In this essay, we review how health communication scholarship has been translated into various communication skills trainings (CSTs), we present four case studies of how health communication research informed the development and implementation of specific CSTs, and we reflect on how we can productively define "impact" in looking back as well as looking forward within this line of research.

Michelle P. Medicaid Waivers: Exploring Sources of Uncertainty for Parent Caregivers of Children with Disabilities.

Guided by Brashers's uncertainty management theory, the purpose of this study was to better understand the experience of family caregivers utilizing Medicaid waivers to subsidize health care for children with disabilities. Specifically, the focus of this study was to explore caregivers' experience with Kentucky's Michelle P. Waiver (MPW), a Medicaid waiver that provides robust benefit offerings to children with disabilities. Little is known about how parents come to know about the waiver, and the communication challenges they experience when applying for and navigating their child's health care through Medicaid. Data were gathered by narratively interviewing 31 parents of children who are currently receiving services through the MPW. Data were analyzed using narrative thematic analysis. The analysis focused on the community-level communication that contributes to parent caregivers' uncertainty about the MPW system. Findings show that parents experience unique personal, social, and medical uncertainties related to the MPW when navigating care for their child in the community. This project contributes to the health communication literature theoretically by expanding the conceptualization of the uncertainty in illness framework to include the means of health care (i.e. Medicaid) as a consequential element of an individual's illness experience.

Oncologists' Perceptions of Strategies for Discussing the Cost of Care with Cancer Patients and the Meaning of Those Conversations.

To better understand what makes cost-of-care communication between oncologists and cancer patients more or less successful, we conducted in-depth interviews with 32 oncologists (22 male, 10 female) who were board-certified in medical, surgical, or radiation oncology. Through qualitative descriptive analysis by four coders, we found that oncologists used six broad strategies to discuss cost with patients: open discussion, avoidance, reassurance, warning, outsourcing, and educating. We also found that oncologists invoked certain meanings of cost conversations: cost conversations as holistic care, coercion, a matter of timing, risking patient suspicions, advocacy, unwanted distraction, transparency, bad news delivery, problem-solving, pointless, informed decision making, or irrelevant. These meanings appeared to be linked to oncologists enacting certain strategies (e.g., oncologists who invoked cost conversations as holistic care tended to enact open discussion, those who saw cost conversations as risky tended to use avoidance). Theoretically, our results suggest that the invoked meaning of a difficult conversation may be a key explanatory mechanism for differentiating high-quality from low-quality communication in cost conversations. Practically, our findings suggest that oncologists should consider how well the invoked meaning of the cost conversation is serving their own and their patients' goals.

Identifying Conversational Strategies for Psychiatrists in Discussing Substance Use with Adolescent Patients.

Child and adolescent psychiatrists are uniquely positioned to discuss substance use with high risk patients; however, there has been little research about these conversations and their characteristics. To identify communication strategies for navigating conversations about substance use with adolescent patients, we conducted 21 in-depth interviews with practicing child and adolescent psychiatrists. Findings from this study identify four strategies that child and adolescent psychiatrists reported as being successful: expressing empathy, avoiding resistance, honoring autonomy, and managing family involvement. In addition to describing these strategies, we briefly describe a theoretical framework that might help to explain the perceived success of these strategies, and we offer recommendations for how to apply our findings to improve psychiatric practice.

Primary Care Physicians' Strategic Pursuit of Multiple Goals in Cost-of-Care Conversations with Patients.

Despite the importance of cost-of-care conversations between physicians and patients, such discussions are not well understood. We used multiple goals theory to examine the specific goals that are salient in these discussions and how physicians pursue these goals. We used qualitative descriptive coding to analyze the verbatim transcripts from in-depth interviews with 36 primary care physicians. Our analysis identified a number of goals that are commonly salient in cost conversations, including task goals (reducing the cost of care, making treatment decisions, and promoting patient adherence), identity goals (reinforcing their professional identity as a "good doctor," acting as a steward of medical resources, being an advocate for patients, and preventing patient embarrassment), and relational goals (strengthening the physician-patient relationship and mitigating damage to the physician-patient relationship). In addition, participants articulated a number of ways in which these goals compete with each other, making cost conversations challenging. We found that physicians use a common repertoire of rhetorical strategies to manage these goals, including directly addressing cost, avoiding discussion of cost, and falsely reassuring patients about cost concerns. Our analysis revealed that the meaning of the cost conversation explains the connection between physicians' goals and strategies. Specifically, we found that physicians invoke polysemic meanings of cost conversations to achieve their multiple goals using seemingly contradictory strategies. The results of our analysis have implications for building theory and improving practice.

Promoting Oral Health in Appalachia: Effects of Threat Label and Source Accent on Message Acceptance.

This study examined the effects of threat label (i.e., the name assigned to a health threat) and source accent (i.e., the source's manner of pronunciation) on Appalachian residents' acceptance of oral health promotion messages. Participants (N = 348) listened to an audiotaped oral health promotion message about tooth decay or Mountain Dew Mouth; the message was delivered either in a standard American English or a Southern accent. Compared to the label Mountain Dew Mouth, the label tooth decay elevated perceptions of threat susceptibility, threat severity, and response-efficacy and resulted in higher message acceptance. The effect of threat label on message acceptance was mediated by severity perceptions. Participants attributed more status to the source and agreed more with her message when she spoke in a standard than a Southern accent. The effect of source accent on message acceptance was mediated by status perceptions. These findings suggest that the success of persuasive health messages depends not only on message content (i.e., what is said), but also on how that content is linguistically framed and delivered (i.e., how it is said).

Uncertainty Management and Decision Making: Parents' Experiences During their First Visit to a Multidisciplinary Clinic for their Child's Vascular Anomaly.

PURPOSE: To gain a better understanding of parental decision making in situations of uncertainty and multidisciplinary care, we explored parents' decision-making experiences while seeking care for their child's vascular anomaly at a multidisciplinary clinic at a large Midwestern children's hospital. DESIGN AND METHODS: We collected data using semi-structured interviews with 29 parents after they met with multiple specialists for the care of their child's vascular anomaly. RESULTS: The findings revealed parents' attempts to manage decision-related uncertainty about their child's vascular anomaly included seeking information, avoiding information, and seeking support from the specialists. Parents described how information management both facilitated and obstructed decision making. CONCLUSIONS: Overall, the study reveals several benefits and challenges of making decisions about the management of uncertain childhood conditions, like vascular anomalies, in a multidisciplinary context. The information-rich environment produces information-management dilemmas that challenge parents' decision making efforts. Therefore, parents relied on the support of the team of specialists to make decisions about their child's treatment. PRACTICE IMPLICATIONS: The study offers practical implications concerning the barriers of autonomy in decision making. Healthcare professionals should acknowledge the potential for parents' to have shifting information and decision-making goals and preferences, and should explicitly support parents throughout the decision-making process.

"It Just Kind of Happens": College Students' Rationalizations for Blackout Drinking.

Nearly half of college students engage in binge drinking, and blackouts (i.e., episodes of periodic memory loss) represent one common consequence of this behavior. Although researchers have begun to understand the extent to which students black out, little is known about why they do so. We conducted two studies to further our understanding of this risky health behavior. In Study 1, we conducted face-to-face interviews (N = 19) to explore students' blackout experiences. Our findings suggest that students recognize that blacking out is an unhealthy behavior; however, because such a recognition contradicts group norms about alcohol consumption, it causes them to experience dissonance, which they manage via a variety of rationalization strategies. We investigated these findings more systematically through an online survey in Study 2, in which students (N = 254) reported on their own and others' beliefs and behaviors about blacking out. Our results indicate that many of the rationalization strategies students identified in Study 1 were grounded in fallacious reasoning. We discuss the collective implications of these findings for future interventions addressing students' excessive drinking behaviors.

Communication and the Appraisal of Uncertainty: Exploring Parents' Communication with Credible Authorities in the Context of Chronic Childhood Illness.

Individuals with chronic illnesses must manage long-term uncertainty as they cope with the ways the illness influences their lives. In the context of pediatric illnesses, parents must manage uncertainty during the diagnosis and treatment of their child's illness. It is common for children with complex chronic illnesses to see multiple specialists for the treatment of their condition. While previous research has explored parents' uncertainty during a child's diagnosis and during end-of-life care, less is known about these experiences when the child is referred to a team of specialists for treatment. The aim of the current study was to explore how specialists, as credible authorities, influence parents' uncertainty during parents' first visit to a multidisciplinary clinic for the care of their child's complex chronic illness. Data were collected through semi-structured interviews with 29 parents after their child's first visit to a vascular anomaly clinic at a large Midwestern children's hospital. The results suggest parents' communication with credible authorities facilitates effective uncertainty management primarily through the mechanism of uncertainty reappraisal. The results also suggest that specialists, as credible authorities, are a key mechanism in the appraisal of uncertainty for conditions that are often misdiagnosed and mismanaged.

Care Transitions From Patient and Caregiver Perspectives.

PURPOSE: Despite concerted actions to streamline care transitions, the journey from hospital to home remains hazardous for patients and caregivers. Remarkably little is known about the patient and caregiver experience during care transitions, the services they need, or the outcomes they value. The aims of this study were to (1) describe patient and caregiver experiences during care transitions and (2) characterize patient and caregiver desired outcomes of care transitions and the health services associated with them. METHODS: We interviewed 138 patients and 110 family caregivers recruited from 6 health networks across the United States. We conducted 34 homogenous focus groups (103 patients, 65 caregivers) and 80 key informant interviews (35 patients, 45 caregivers). Audio recordings were transcribed and analyzed using principles of grounded theory to identify themes and the relationship between them. RESULTS: Patients and caregivers identified 3 desired outcomes of care transition services: (1) to feel cared for and cared about by medical providers, (2) to have unambiguous accountability from the health care system, and (3) to feel prepared and capable of implementing care plans. Five care transition services or provider behaviors were linked to achieving these outcomes: (1) using empathic language and gestures, (2) anticipating the patient's needs to support self-care at home, (3) collaborative discharge planning, (4) providing actionable information, and (5) providing uninterrupted care with minimal handoffs. CONCLUSIONS: Clear accountability, care continuity, and caring attitudes across the care continuum are important outcomes for patients and caregivers. When these outcomes are achieved, care is perceived as excellent and trustworthy. Otherwise, the care transition is experienced as transactional and unsafe, and leaves patients and caregivers feeling abandoned by the health care system.

Understanding Facilitators and Barriers to Care Transitions: Insights from Project ACHIEVE Site Visits.

BACKGROUND: Care transitions between clinicians or settings are often fragmented and marked by adverse events. To increase patient safety and deliver more efficient and effective health care, new ways to optimize these transitions need to be identified. A study was conducted to delineate facilitators and barriers to implementation of transitional care services at health systems that may have been adopted or adapted from published evidence-based models. METHODS: From March 2015 through December 2015, site visits were conducted across the United States at 22 health care organizations-community hospitals, academic medical centers, integrated health systems, and broader community partnerships. At each site, direct observation and document review were conducted, as were semistructured interviews with a total of 810 participants (5 to 57 participants per site) representing various stakeholder groups, including management and leadership, transitional care team members, internal stakeholders, community partners, patients, and family caregivers. RESULTS: Facilitators of effective care transitions included collaborating within and beyond the organization, tailoring care to patients and caregivers, and generating buy-in among staff. Commonly reported barriers included poor integration of transitional care services, unmet patient or caregiver needs, underutilized services, and lack of physician buy-in. CONCLUSION: True community partnership, high-quality communication, patient and family engagement, and ongoing evaluation and adaptation of transitional care strategies are ultimately needed to facilitate effective care transitions. Health care organizations can strategically prioritize transitional care service delivery through staffing decisions, by making transitional care part of the organization's formal board agenda, and by incentivizing excellence in providing transitional care services.

Lay Epistemology of Breast Cancer Screening Guidelines Among Appalachian Women.

Recent changes to the U.S. Preventive Services Task Force guidelines for breast cancer screening have contributed to increased patient uncertainty regarding the timing and appropriateness of screening behaviors. To gain insight into the lay epistemology of women regarding breast cancer screening practices, we conducted in-depth, face-to-face interviews with 24 adult women living in a medically underserved Appalachian region. We found that women were unaware of breast cancer screening guidelines (i.e., start age, frequency, stop age). Qualitative analysis revealed two lay epistemological narratives establishing (a) uncertain knowledge and ambiguity about breast cancer screening guidelines but certain knowledge of other women's experiences with breast cancer diagnoses, and (b) feelings of knowing one's own body best and seeing the value in "overscreening" to save even one life. Our findings have theoretical and practical implications for scholars and practitioners seeking to improve knowledge or behavior regarding adherence to breast cancer screening recommendations.

Normative Social Support in Young Adult Cancer Survivors.

Following a cancer diagnosis, young adults (YAs; that is, 18-39) often experience altered social relationships with family, friends, romantic partners, and peers. In light of the social struggles YA patients and survivors report due to cancer's biographical disruption, we elicited narratives from 30 YA cancer survivors to examine how their normative perceptions of social support functioned to hinder and assist them in coping with the cancer experience. Through thematic narrative analysis of their individual accounts, YA survivors explained why and how they perceived various support attempts from peers and loved ones to be effective (i.e., being treated "normally"), ineffective (i.e., receiving pity, negative stories, rudeness, excessive self-monitoring, and returns from estrangement), and both effective and ineffective (e.g., instrumental and relational support) in integrating cancer into their biographies. Implications for the advancement of interpersonal communication theory and for the development of age-appropriate communication interventions, educational programs, and informational resources are discussed.

Communication nonaccommodation in family conversations about end-of-life health decisions.

Furthering our understanding of how communication can improve end-of-life decision making requires a shift in focus from whether people talk to how people talk about end-of-life health decisions. This study used communication accommodation theory to examine the extent to which communication nonaccommodation distinguished more from less successful end-of-life conversations among family members. We analyzed elicited conversations about end-of-life health decisions from 121 older parent/adult child dyads using outside ratings of communication over- and underaccommodation and self-reported conversational outcomes. Results of multilevel linear modeling revealed that outside ratings of underaccommodation predicted self-reported and partner-reported uncertainty, and ratings of overaccommodation predicted self-reported decision-making efficacy and change in concordance accuracy. We discuss the methodological, theoretical, and practical implications of these findings.

Perceptions of oral health in Appalachian Kentucky: implications for message design.

We conducted three studies to investigate Appalachian college students' perceptions and behavior concerning oral health for the purpose of identifying salient factors to consider in designing persuasive messages to promote oral health. In Study 1, we conducted seven focus groups with 67 college students at a state university in Appalachian Kentucky. Using thematic analysis, we found that students based their oral health behavior on the perception that people living in Appalachia have poor oral health and that students denied, confirmed, reframed, or fulfilled this "misconception." In Study 2, quantitative results from a representative survey of students (N = 587) at the same university indicated that the barriers to enacting good oral health behavior were primarily logistical in nature, whereas the facilitators of good oral health behavior were largely social. In Study 3, results from dental screenings (N = 364) of students at the university demonstrated that about one in five students presented with active, visible decay. We discuss how these results inform our understanding of oral health behavior in Appalachia and the implications of these results for designing messages to promote oral health in the region.

Communication quality predicts patients' colorectal cancer screening behavior.

The purpose of the present study was to investigate the quality of patient/clinician communication as one potential factor that impacts colorectal cancer screening behavior. As part of a larger randomized controlled trial conducted between 2011 and 2016 in the setting of community and academic family medicine or internal medicine practices in Michigan, USA, patients completed a pre-encounter survey, completed their regularly scheduled visit with their primary care clinician (which was audio-recorded), completed a post-encounter survey, and allowed 6-month follow-up chart audit. We trained 10 coders to rate 216 of the audio-recorded conversations between 216 patients and their primary care physicians for 6 specific features of communication quality (using 7-point scales), including the extent to which participants enacted attention to medical content, engagement, emotional expression, relationships, face, and accommodation. At least 3 coders rated each conversation, and intraclass correlations (i.e., reliability assessment) were in the good to excellent range. We found that patient and clinician attention to face (an identity goal) was a significant predictor of colorectal cancer screening at 6 months follow up. Measuring communication in terms of attention to multiple goals reveals unexpected findings about the aspects of communication that impact colorectal cancer screening behavior. The focus of many interventions to improve colorectal cancer screening rates is on the content (i.e., task goals) of clinicians' communication (such as presenting the different options for screening), yet the content of communication was not a significant predictor of screening in the present study. Rather, clinicians' and patients' attention to identity goals predicted screening behavior, which suggests that interventions may not need to be overly complex and that simply improving the quality of attention to identity goals in clinician communication might be one of the most straightforward yet impactful ways to improve colorectal cancer screening uptake among patients.