Behavioral Health Care Delivery Through Street Medicine Programs in California.

Mental health and substance use disorders are prevalent among people experiencing homelessness. Street Medicine can reach unhoused people who face barriers to accessing healthcare in more traditional medical settings including shelter-based clinics. However, there is little guidance on best practices for mental health and substance use treatment through Street Medicine. The aim of the study was to describe behavioral health care through Street Medicine by analyzing data from the California Street Medicine Landscape survey and follow-up qualitative interviews. Most street medicine programs utilize non-psychiatrists to diagnose and treat mental health and substance use disorders, though the capacity to provide the level of care needed varies. There is a lack of street-based psychiatric clinicians and programs have difficulty making referrals to mental health and addiction services. This report shows that Street Medicine could serve as a strategy to expand access to behavioral health care for the unhoused.

Alleviating Financial Hardships Associated with High-Deductible Health Plans for Adults with Chronic Conditions Through Health Savings Accounts.

BACKGROUND: High-deductible health plans (HDHPs) are becoming increasingly common, but their financial implications for enrollees with and without chronic conditions and the mitigating effects of health savings accounts (HSAs) are relatively unknown. OBJECTIVE: Our aim was to compare financial hardship between non-HDHPs and HDHPs with and without HSAs, stratified by enrollees' number of chronic conditions. DESIGN: We used data from 2015 to 2018 Medical Expenditure Panels Surveys (MEPS) to compare rates of financial hardship across individuals with HDHPs and non-HDHPs using linear and logistic regression models. PARTICIPANTS: A nationally representative sample of 30,981 adults aged 18-64 enrolled in HDHPs and non-HDHPs. MAIN MEASURES: We examined several measures of financial hardship, including total yearly out-of-pocket medical spending as well as rates of delaying medical care or prescriptions in the past year due to cost, forgoing medical care or prescriptions in the past year due to cost, paying medical bills over time, or having problems paying medical bills. We compared rates using the non-HDHP as the control. KEY RESULTS: On most measures, HDHPs are associated with greater financial hardship compared to non-HDHPs, including average annual out-of-pocket spending of $637 for non-HDHPs, $939 for HDHPs with HSAs, and $825 for HDHPs without HSAs (p < 0.01). However, for HDHP enrollees with multiple chronic conditions, having an HSA was associated with less financial hardship (p < 0.05). CONCLUSIONS: Our findings suggest that HSAs may be most beneficial for those with chronic conditions, in part due to the tax benefits they offer as well as the fact that those with chronic conditions are more likely to take advantage of their HSAs than their younger, healthier counterparts. However, as HDHPs are more likely to be correlated with worse financial outcomes regardless of health status, recent trends of increasing participation may be a reason for concern.

Preventing Financial Strain for Low- and Moderate-Income Adults: a Comparison of Medicaid, Marketplace, and Employer-Sponsored Insurance.

BACKGROUND: Medicaid expansion and subsidized private plans purchased on the Affordable Care Act's (ACA) Marketplaces accounted for most of the ACA's coverage gains. OBJECTIVE: Compare access to care and financial strain between Medicaid and Marketplace plans, and benchmark these against employer-sponsored insurance (ESI) plans. DESIGN: Cross-sectional survey PARTICIPANTS: A nationally representative, non-institutionalized sample of 37,219 non-elderly adults with incomes up to 400% of the federal poverty level between 2015 and 2018, and a sub-group of individuals with chronic diseases. MAIN MEASURES: Self-reported barriers to accessing care, cost-related medication non-adherence, and financial strain. KEY RESULTS: Marketplace enrollees were more likely than Medicaid enrollees to delay or avoid care due to cost (19.3% vs 10.0%; adjusted difference (AD), 8.6 [95% CI, 6.8 to 10.4]) and report difficulties affording specialty care (7.7% vs 6.6%; AD, 1.8% [95% CI, 0.3% to 3.3%]), while there were no differences in having insurance accepted by a doctor or ability to afford dental care. Marketplace enrollees were also more likely to report cost-related medication non-adherence (21.5% vs 20.0%; AD, 4.0 [CI, 1.5 to 6.4]), be very worried about not being able to pay medical costs in case of a serious accident (32.3% vs 25.8%; AD, 6.4 [CI, 4.2 to 8.6]), have expenses exceeding $2000 (22.4% vs 5.4%; AD, 8.3 [CI, 6.2 to 10.3]), and have problems paying medical bills (18.4% vs 15.6%; AD, 1.8 [CI, 0.3 to 3.9]). Marketplace-Medicaid differences were larger among persons with a chronic disease. Individuals in ESI plans fared better for most, but not all, outcomes. CONCLUSION: Medicaid offers better protections than Marketplace plans on most measures of access and financial strain.

Advocacy for Health Justice: An Innovative Pilot Course for MD and Master of Public Policy Students.

Problem: U.S. medical schools are searching for ways to address issues of health justice in undergraduate medical education. Physicians have not typically received training in how to be effective advocates for systemic change and individuals in policy fields are not usually equipped to understand the complex issues of health science and their intersection with the health system and society. To address this gap, medical school faculty partnered with school of public policy faculty on a collaborative learning model that engaged MD and Master of Public Policy students together to strengthen their collective knowledge of the healthcare landscape, and to build skills to work for health justice. Intervention: We hypothesized that pairing medical students with public policy students to learn about the intersections of health justice and advocacy could enhance the efficacy of each group and provide a new model of collaboration between medical and policy professionals. The students collaborated on a health justice advocacy project through which they provided consultation to an established community organization. Context: The 8-week course took place in the spring of 2021 in Los Angeles, California. Due to Covid-19 the course was taught online and included asynchronous learning modules and live Zoom sessions. The project also served as a pilot for the post-clerkship phase of a new longitudinal health justice curriculum for MD students that launched in August 2021. Impact: Analysis of student work products, course evaluations, partner interviews, and student focus groups showed that students valued learning through their interdisciplinary collaborative work which gave them new perspectives on health justice issues. The community partners indicated that the students consultative work products were useful for their initiatives, and that they found working with MD and MPP students to be a valuable way to think about how to build stronger and more inclusive coalitions to advocate for health justice. This project has the potential for national impact as it aligns with the Association of American Medical Colleges' renewed focus on the responsibility of academic medicine to partner with communities for health justice. The project also contributed to the national conversation on how to align health systems science education with the aims of health justice through our participation in the American Medical Association Accelerating Change in Medical Education Consortium. Lessons Learned: Leveraging faculty relationships with community partners was crucial for developing meaningful projects for students. Cultivating and expanding community partner networks is necessary to sustain and scale up this type of intervention. Centering the needs of communities and supporting their on-going work for health justice is essential for becoming an effective advocate. Learning communities that bring interdisciplinary students, healthcare providers, policy professionals, and community partners together to learn from one another can create key opportunities for ameliorating health inequities.

Primary Care: the New Frontier for Reducing Readmissions.

To date, efforts to reduce hospital readmissions have centered largely on hospitals. In a recently published environmental scan, we examined the literature focusing on primary care-based efforts to reduce readmissions. While rigorous studies on interventions arising from primary care are limited, we found that multi-component care transitions programs that are initiated early in the hospitalization and are part of broader primary care practice transformation appear most promising. However, policy changes are necessary to spur innovation and support effective primary care-led transitions interventions. Though more rigorous research is needed, our findings suggest that primary care can and should lead future efforts for reducing hospital readmissions.

Support for National Health Insurance Seven Years Into Massachusetts Healthcare Reform: Views of Populations Targeted by the Reform.

Before the Affordable Care Act (ACA), many surveys showed majority support for national health insurance (NHI), also known as single payer; however, little is currently known about views of the ACA's targeted population. Massachusetts residents have had seven years of experience with state health care reform that became the model for the ACA. We surveyed 1,151 adults visiting safety-net emergency departments in Massachusetts in late 2013 on their preference for NHI or the Massachusetts reform and on their experiences with insurance. Most of the patients surveyed were low-income and non-white. The majority of patients (72.0%) preferred NHI to the Massachusetts reform. Support for NHI among those with public insurance, commercial insurance, and no insurance was 68.9%, 70.3%, and 86.3%, respectively (p < .001). Support for NHI was higher among patients dissatisfied with their insurance plan (83.3% vs. 68.9%, p = .014), who delayed medical care (81.2% vs. 69.6%, p < .001) or avoided purchasing medications due to cost (87.3% vs. 71.4%; p = .01). Majority support for NHI was observed in every demographic subgroup. Given the strong support for NHI among disadvantaged Massachusetts patients seven years after state health reform, a reappraisal of the ACA's ability to meet the needs of underserved patients is warranted.

Disparities in access to COVID-19 testing in Los Angeles County.

COVID-19 has disparately impacted low-income persons and racial and ethnic minorities-primarily Black and Hispanic populations. Our objective is to quantify disparities in access to COVID-19 testing and identify barriers to testing during the winter 2020-2021 surge in COVID-19 infections in Los Angeles County. An online survey was administered between December 2020 and January 2021 through which respondents were asked about their use of COVID testing and the barriers to testing they experienced. Our sample of 1,984 was reweighted to match the demographics of Los Angeles County. Despite similar testing rates to White residents, Hispanic residents were more likely to report testing positive. Persons with an annual income of $20,000 or less were less likely to receive a test than those with an income of $100,000 or more. Barriers to testing were more prevalent among racial/ethnic minorities and low-income persons. White respondents and high-income persons were more likely to report the ability to take time off work to await test results. Rates of testing were not commensurate with the rates of infection across racial/ethnic groups, which may be explained by higher rates of reported barriers to testing among Black and Hispanic residents. These findings may inform policies that address structural barriers to testing that disproportionately impact racial/ethnic minorities and low-income populations.

Health Justice and Systems of Care: A Required Longitudinal Course for MD Students.

Problem & Background: Medical education has acknowledged the impact of structural societal factors on health, prompting the need for curricula seeking to eliminate health inequities upstream while simultaneously caring for downstream effects of existing inequities. The Keck School of Medicine of USC (KSOM) implemented one such comprehensive curriculum, Health Justice and Systems of Care (HJSC), integrating health systems science, structural competency, and service-learning in a required course spanning the pre-clerkship and clerkship phases with an optional post clerkship elective. Approach: The HJSC course addresses topics including racism in medicine, health inequities, and health systems science. Using transformative learning theory, it fosters critical consciousness and structural competency. Assessments include case analyses, reflections, team-based learning sessions, and group projects related to social justice in healthcare. The program aims to instill cultural humility and practical application, fostering a holistic approach to medical education that implores physicians to become advocates for health justice. Outcomes of the Innovation: Feedback from students indicated generally positive perceptions of the curriculum. Students provided overall positive comments about discussions with guest speakers. However, students expressed a desire for more concrete examples of how health inequities can be remedied. Some found small-group activities less engaging. Other challenges included providing students of different readiness levels with tailored experiences and seamlessly integrating HJSC content within basic and clinical sciences courses. Critical Reflection: Next steps include continuing to integrate content into the science curriculum and clerkships, improving opportunities for meaningful student interactions, and enhancing faculty development to address health justice concerns in clinical settings.

Partners in vaccination: A community-based intervention to promote COVID-19 vaccination among low-income homebound and disabled adults.

BACKGROUND: Care managers (CM) for low-income disabled clients may address COVID-19 vaccine hesitancy with specific training. OBJECTIVE: To assess the Partners in Vaccination (PIV) that trained CMs of a homecare program for disabled adults to promote COVID-19 vaccination. METHODS: We randomized 78 CMs to PIV intervention (N = 38) or control (N = 40). PIV featured motivational interviewing (MI) skills and educational materials for unvaccinated clients. The primary outcome was first COVID-19 vaccination between December 1, 2021 and June 30, 2022 for clients of intervention CMs versus control CMs. Mixed method analysis included key informant interviews conducted from 5/24/22 to 7/25/22 with CMs, administrators, and clients about the PIV intervention. RESULTS: Among 1939 clients of 78 study CMs, 528 (26.8 %) were unvaccinated by December 1, 2021 (274 clients of intervention CMs; 254 clients of control CMs). These clients' mean age was 62.3 years old (SD = 22.4) and 54 % were Black or Hispanic/Latino. First vaccination rate did not differ for intervention and control groups (6.2 % vs. 5.9 %, p = .89) by 6/30/2022. Barriers to addressing COVID-19 vaccination from interviews with 7 CMs and administrators were competing responsibilities and potentially antagonizing clients. Seven interviewed clients (five vaccinated and two unvaccinated) cited concerns about vaccination they heard from their family/friends and belief that risks of COVID-19 infection may be less than vaccination. Yet, some clients were receptive to physician recommendations. CONCLUSION: Training CMs to promote COVID-19 vaccination for disabled clients did not increase first vaccination rates. CMs preferred their usual role of coordinating care and, even after the training, expressed discomfort with this potentially polarizing topic.

2023 Inaugural Healthcare Delivery Science: Innovation and Partnerships for Health Equity Research (DESCIPHER) Symposium.

Introduction: This article provides an overview of presentations and discussions from the inaugural Healthcare Delivery Science: Innovation and Partnerships for Health Equity Research (DESCIPHER) Symposium. Methods: The symposium brought together esteemed experts from various disciplines to explore models for translating evidence-based interventions into practice. Results: The symposium highlighted the importance of disruptive innovation in healthcare, the need for multi-stakeholder engagement, and the significance of family and community involvement in healthcare interventions. Conclusions: The article concluded with a call to action for advancing healthcare delivery science to achieve health equity.

Care coordination across healthcare systems: development of a research agenda, implications for practice, and recommendations for policy based on a modified Delphi panel.

OBJECTIVE: For large, integrated healthcare delivery systems, coordinating patient care across delivery systems with providers external to the system presents challenges. We explored the domains and requirements for care coordination by professionals across healthcare systems and developed an agenda for research, practice and policy. DESIGN: The modified Delphi approach convened a 2-day stakeholder panel with moderated virtual discussions, preceded and followed by online surveys. SETTING: The work addresses care coordination across healthcare systems. We introduced common care scenarios and differentiated recommendations for a large (main) healthcare organisation and external healthcare professionals that contribute additional care. PARTICIPANTS: The panel composition included health service providers, decision makers, patients and care community, and researchers. Discussions were informed by a rapid review of tested approaches to fostering collaboration, facilitating care coordination and improving communication across healthcare systems. OUTCOME MEASURES: The study planned to formulate a research agenda, implications for practice and recommendations for policy. RESULTS: For research recommendations, we found consensus for developing measures of shared care, exploring healthcare professionals' needs in different care scenarios and evaluating patient experiences. Agreed practice recommendations included educating external professionals about issues specific to the patients in the main healthcare system, educating professionals within the main healthcare system about the roles and responsibilities of all involved parties, and helping patients better understand the pros and cons of within-system and out-of-system care. Policy recommendations included supporting time for professionals with high overlap in patients to engage regularly and sustaining support for care coordination for high-need patients. CONCLUSIONS: Recommendations from the stakeholder panel created an agenda to foster further research, practice and policy innovations in cross-system care coordination.

Relationship between mask wearing, testing, and vaccine willingness among Los Angeles County adults during the peak of the COVID-19 pandemic.

BACKGROUND: Mask wearing mitigates the spread of COVID-19; however, many individuals have not adopted the protective behavior. PURPOSE: We examine mask wearing behavior during the height of the pandemic in Los Angeles County, and its association with COVID-19 testing and willingness to get vaccinated. METHODS: We conducted a cross-sectional survey using representative sampling between December 2020 and January 2021, through an online platform targeting Los Angeles County residents. Survey items include demographic characteristics, health conditions, access to health care, mask wearing, COVID-19 testing, exposure risk factors, and willingness to receive COVID-19 vaccine. We performed logistic regression models to examine factors associated with always mask wearing. RESULTS: Of the analytic sample (n = 1,984), 75.3% reported always wearing a face mask when leaving home. Being a female, Asian or African American, or non-Republican resident, or having higher education, having poor or fair health, having a regular doctor, knowing someone hospitalized for COVID-19, and being willing to receive the COVID-19 vaccine were associated with always wearing a mask. Residents who were younger, had a highest risk health condition, and had ≥2 COVID-19 tests had lower odds of always mask wearing. CONCLUSION: Mask wearing guidelines are easing; however, as vaccination rates plateau and new virus variants emerge, mask wearing remains an important tool to protect vulnerable populations. Encouraging protective measures among younger adults, those with less education, republicans, men, and White residents-groups that are least likely to be vaccinated or wear a mask-may be critical to reducing transmission.

Community-Based Health Care Navigation's Impact on Access to Primary Care for Low-Income Latinos.

INTRODUCTION: Despite the Affordable Care Act's insurance expansion, low-income Latinos are less likely to have a primary care provider compared with other racial/ethnic and income groups. We examined if community-based health care navigation could improve access to primary care in this population. METHODS: We surveyed adult clients of a community-based navigation program serving predominantly low-income Latinos throughout Los Angeles County in 2019. We used multivariable logistic regression models, adjusting for sociodemographic characteristics, to calculate odds ratios for differences in access to primary care and barriers to care between clients who had experienced approximately 1 year of navigation services (intervention group) and clients who were just introduced to navigation (comparison group). RESULTS: Clients in the intervention group were more likely to report having a primary care clinic than the comparison group (Adjusted Odds Ratio [aOR] 3.0, 95%CI: 1.7, 5.4). The intervention group was also significantly less likely to experience several barriers to care, such as not having insurance, not being able to pay for a visit, and not having transportation. CONCLUSIONS: Community-based navigation has the potential to reduce barriers and improve access to primary care for low-income Latinos. In addition to expanding insurance coverage, policymakers should invest in health care navigation to reduce disparities in primary care.

Improving Quality and Safety for Patients After Hospital Discharge: Primary Care as the Lead Integrator in Postdischarge Care Transitions.

To understand current and idealized primary care-based care transition workflow processes for hospitalized patients, we conducted 133 interviews with staff at 9 primary care sites; community agency staff (n = 18); recently discharged patients (n = 33); and primary care thought leaders (n = 9). Current postdischarge workflows in primary care vary widely across settings, are often implemented inconsistently, and rarely involve communications with the patient or inpatient team during hospitalization. Based on these findings, we propose 5 principles for primary care practices to facilitate active involvement in postdischarge care, beginning during the hospital admission and extending until after the initial postdischarge primary care visit.

Disparities in COVID-19 vaccine hesitancy among Los Angeles County adults after vaccine authorization.

An equitable COVID-19 vaccine rollout is a necessary piece of the public health strategy to end the current pandemic; however, vaccine hesitancy may present a major hurdle. This study examines racial/ethnic and income-based disparities in vaccine hesitancy in Los Angeles County, a recent epicenter of the pandemic in the US, immediately after the Food and Drug Administration issued its emergency use authorization of a COVID-19 vaccine. We conducted online, stratified cross-sectional surveys of 1,984 adults living in Los Angeles County between December 2020 and January 2021 to assess hesitancy towards getting a COVID-19 vaccine. We used multivariable logistic regression to predict vaccine hesitancy after adjusting for covariates and calculated weighted population level estimates of hesitancy and reasons for hesitancy. Blacks and Hispanics were significantly more likely to be hesitant than Whites (AOR = 3.3, P < 0.001; AOR = 2.1, P = 0.008) as were those in the lowest income group (annual income <$20,000 compared to >$100,000) (AOR = 1.8, P = 0.009). Additionally, those having no confidence in doing things online (AOR = 3.3, P < 0.001) were less likely to accept the vaccine than those who were confident. Compared to hesitant White respondents, Black respondents had higher mistrust of the government (36.1% vs 22.1%, P = 0.03) and Black and Hispanic respondents were more likely to want to wait to see how the vaccine works (41.2% and 42.0% vs 27.3%, P = 0.02 and P = 0.006). Our study suggests that culturally appropriate messaging that addresses concerns for lower income and racial/ethnic minority communities, as well as alternatives to online vaccine appointments, are necessary for improving vaccine rollout.

The impact of a new curriculum on medical students' interest in and knowledge of health systems science.

In this analysis, we describe medical student interest in and knowledge of health systems science (HSS) during the launching of a new curriculum. We surveyed first year students (MS1s) before and after exposure to a new HSS curriculum. MS1s demonstrated a 16% increase in HSS knowledge post-curriculum. Interest in HSS was high in MS1s before (90%) and after (88%) the curriculum when compared to MS3s (72%). The implementation of a longitudinal HSS curriculum may increase knowledge and maintain interest in the subject.

Barriers to Primary Care After the Affordable Care Act: A Qualitative Study of Los Angeles Safety-Net Patients' Experiences.

Purpose: Millions of people gained health care coverage in Los Angeles after the Affordable Care Act (ACA); however, challenges with obtaining and utilizing primary care still persist, particularly in the safety net. In this study, we explore barriers to accessing primary care services among safety-net patients in Los Angeles after Medicaid expansion and implementation of other programs for safety-net patients after the ACA. Methods: We conducted qualitative interviews, in Spanish and English, with 34 nonelderly adult patients in 1 of 3 insurance groups: Medicaid, MyHealthLA (a health care program for low-income undocumented individuals), or uninsured. We recruited participants from three sites in Los Angeles in 2017. We analyzed our interviews using a framework approach and included emerging concepts from participant responses. Results: We identified seven themes regarding barriers to accessing primary care: understanding the concept of primary care, finding a primary care provider (PCP), switching PCPs, getting timely appointments, geography and transportation, perceived cost or coverage barriers, and preferring emergency or urgent care over primary care. Patients with Medicaid were more likely to report barriers compared with other groups. Uninsured patients were less likely to understand the concept of primary care. Patients with MyHealthLA noted getting timely appointments and cost of care to be significant barriers. Conclusion: Despite Medicaid and other coverage expansions for safety-net patients after the ACA, substantial barriers to accessing primary care persist. Addressing such barriers through the development of targeted interventions or broader policy solutions could improve access to primary care for safety-net patients in Los Angeles.

Unsafe Drugs Were Prescribed More Than One Hundred Million Times in the United States Before Being Recalled.

For some drugs, safety concerns are only discovered after they have been on the market, sometimes for several years. The U.S. Food and Drug Administration (FDA) has adopted several policies that could increase the likelihood of approving a potentially unsafe medication. We attempted to quantify the number of exposures in the United States to drugs that were newly approved but later withdrawn from the market. We obtained a list of all drugs approved and subsequently withdrawn from the U.S. market due to safety concerns between 1993 and 2010. Using a representative sample of outpatient physician office visits in the National Ambulatory Medical Care Survey, we estimated the number of visits in the United States at which these unsafe drugs were prescribed. Seventeen drugs were approved and later withdrawn during this 18-year period and were prescribed at 112 million physician office visits in the United States. Nine of these drugs were prescribed more than 1 million times before their market withdrawal. New drugs that are later withdrawn due to being unsafe are frequently prescribed in the United States. To minimize the negative health consequences of prescribing potentially unsafe medications, we should reconsider some of the FDA policies that encourage the rapid approval and dissemination of new drugs.