A Community-Wide Collaboration to Reduce Cardiovascular Disease Risk: The Hearts of Sonoma County Initiative.

PURPOSE AND OBJECTIVES: Collaboration across multiple sectors is needed to bring about health system transformation, but creating effective and sustainable collaboratives is challenging. We describe outcomes and lessons learned from the Hearts of Sonoma County (HSC) initiative, a successful multi-sector collaborative effort to reduce cardiovascular disease (CVD) risk in Sonoma County, California. INTERVENTION APPROACH: HSC works in both clinical systems and communities to reduce CVD risk. The initiative grew out of a longer-term county-wide collaborative effort known as Health Action. The clinical component involves activating primary care providers around management of CVD risk factors; community activities include community health workers conducting blood pressure screenings and a local heart disease prevention campaign. EVALUATION METHODS: The impact of the clinical improvement efforts was tracked using blood pressure data from the 4 health systems participating in HSC. Descriptive information on the community-engagement efforts was obtained from program records. Lessons learned in developing and maintaining the collaborative were gathered through document review and interviews with key informants. RESULTS: Favorable trends were seen in blood pressure control among patients with hypertension in the participating health systems: patients with controlled blood pressure increased from 58% in 2014 to 67% in 2016 (P < .001). Between 2017 and 2019, the community engagement effort conducted 99 outreach events, reaching 1,751 individuals, and conducted 1,729 blood pressure screenings, with 441 individuals referred to clinical providers for follow-up care. HSC scored highly on 6 essential elements of an effective coalition and achieved a degree of sustainability that has eluded many other collaboratives. IMPLICATIONS FOR PUBLIC HEALTH: Factors contributing to the success of HSC include 1) starting small and focused to build trust among participants and demonstrate value, 2) working within the framework of a larger effort, and 3) providing long-term, open-ended backbone support.

Acceptance of a community-based navigator program for cancer control among urban African Americans.

Patient navigation is now a standard component of cancer care in many oncology facilities, but a fundamental question for navigator programs, especially in medically underserved populations, is whether or not individuals will use this service. In this study, we evaluated acceptance of a community-based navigator program for cancer control and identified factors having significant independent associations with navigation acceptance in an urban sample of African Americans. Participants were African American men and women ages 50-75 who were residents in an urban metropolitan city who were referred for navigation. Of 240 participants, 76% completed navigation. Age and perceived risk of developing cancer had a significant independent association with navigation acceptance. Participants who believed that they were at high risk for developing cancer had a lower likelihood of completing navigation compared with those who believed that they had a low risk for developing this disease. The likelihood of completing navigation increased with increases in age. None of the socioeconomic factors or health care variables had a significant association with navigation acceptance. There are few barriers to using community-based navigation for cancer control among urban African Americans. Continued efforts are needed to develop and implement community-based programs for cancer control that are easy to use and address the needs of medically underserved populations.

Feasibility, acceptability and preliminary effectiveness of patient advocates for improving asthma outcomes in adults.

BACKGROUND: Asthmatic adults from low-income urban neighborhoods have inferior health outcomes which in part may be due to barriers accessing care and with patient-provider communication. We adapted a patient advocate (PA) intervention to overcome these barriers. OBJECTIVE: To conduct a pilot study to assess feasibility, acceptability and preliminary evidence of effectiveness. METHODS: A prospective randomized design was employed with mixed methods evaluation. Adults with moderate or severe asthma were randomized to 16 weeks of PA or a minimal intervention (MI) comparison condition. The PA, a non-professional, modeled preparations for a medical visit, attended the visit and confirmed understanding. The PA facilitated scheduling, obtaining insurance coverage and overcoming barriers to implementing medical advice. Outcomes included electronically-monitored inhaled corticosteroid (ICS) adherence, asthma control, quality of life, FEV1, emergency department (ED) visits and hospitalizations. Mixed-effects models guided an intention-to-treat analysis. RESULTS: 100 adults participated: age 47 ± 14 years, 75% female, 71% African-American, 16% white, baseline FEV1 69% ± 18%, 36% experiencing hospitalizations and 56% ED visits for asthma in the prior year. Ninety-three subjects completed all visits; 36 of 53 PA-assigned had a PA visit. Adherence declined significantly in the control (p = 0.001) but not significantly in the PA group (p = 0.30). Both PA and MI groups demonstrated improved asthma control (p = 0.01 in both) and quality of life (p = 0.001, p = 0.004). Hospitalizations and ED visits for asthma did not differ between groups. The observed changes over time tended to favor the PA group, but this study was underpowered to detect differences between groups. CONCLUSION: The PA intervention was feasible and acceptable and demonstrated potential for improving asthma control and quality of life.

Cultural, economic, and psychological predictors of colonoscopy in a national sample.

BACKGROUND: Although colorectal cancer (CRC) is the second leading cause of cancer death among adults in the US and colonoscopy is efficacious in reducing morbidity and mortality from CRC, screening rates are sub-optimal. Understanding the socioeconomic, cultural, and health care context within which decisions about colonoscopy are made allows physicians to address patients' most salient beliefs and values and other constraints when making screening recommendations. OBJECTIVE: To evaluate the direct and interactive effects of socioeconomics, health care variables, psychological characteristics, and cultural values on colonoscopy use. DESIGN, SETTING, PARTICIPANTS: National survey completed between January-August 2009 in a random sample of African American, white, and Hispanic adults ages 50-75 without cancer (n = 582). MAIN MEASURE: Self-reported colonoscopy use. KEY RESULTS: Only 59% of respondents reported having a colonoscopy. The likelihood of colonoscopy increased with having health insurance (OR = 2.82, 95% CI = 1.24, 6.43, p = 0.004), and increasing age (OR = 1.40, 95% CI = 1.11, 1.77, p = 0.001). In addition, respondents with greater self-efficacy were more likely to have a colonoscopy (OR = 2.41, 95% CI = 1.35, 4.29, p = 0.003). CONCLUSIONS: Programs that help patients to overcome access and psychological barriers to screening are needed.

Low Health Literacy Predicts Misperceptions of Diabetes Control in Patients With Persistently Elevated A1C.

PURPOSE: The purpose of this study is to identify factors associated with perceived control of diabetes in a group of poorly controlled patients. Identifying factors associated with perceived control in these patients is an important step in improving actual control as measured by A1C. As health literacy is essential for understanding complex medical information, we hypothesized that low health literacy would be associated with inaccurate perceptions of diabetes control. METHODS: A cross-sectional analysis was performed on 280 adults with type 2 diabetes whose last 2 A1C measurements were >8.0%. Participants were recruited primarily from 6 University of Pennsylvania primary care practices. Perceived control and factors potentially associated with this outcome, including health literacy, were assessed during an in-person interview. Health literacy was measured using the Rapid Estimate of Adult Literacy. RESULTS: Thirty-nine percent of patients responded that they were managing to control their diabetes well or very well. However, 57% of those at the seventh to eighth-grade health literacy level and 61% of those at the level of sixth grade and below reported that they were controlling their diabetes well or very well. CONCLUSIONS: In this population of patients with poorly controlled diabetes, a majority of those with low health literacy believed that they were controlling their disease well or very well. Patients who believe that they are already controlling their diabetes well may be less likely to make changes to improve control. Health care providers and educators should consider health literacy when discussing control of diabetes and when setting management goals with patients.

Building a patient-centered medical home: obtaining the patient's voice.

PURPOSE: Many primary care practices are currently attempting to transform into patient-centered medical homes (PCMHs), but little is known about how patients view aspects of the PCMH or how they define patient-centeredness. METHODS: We conducted 3 focus groups with patients from urban academic internal medicine practices. We asked questions about patients' perceptions of what patient-centered care should be; care quality, teams and access; diabetes self-management; and community connections and services. We used a grounded theory approach to the analysis. RESULTS: The global themes that arose in our focus groups included the desire for timely, clear, and courteous communication; a practice that is structured to facilitate an ongoing relationship with a provider who knows the patient; and a relationship that allows the patient both to trust the provider's guidance and to engage more fully in his or her own care. CONCLUSIONS: Our patients want a provider to know them personally and to take time to listen to their issues. They feel that they cannot access their providers in a timely fashion, find our automated phone systems frustrating, and want more time with their provider. Although the technological and structural implementation of the PCMH requires considerable effort and resources, we cannot neglect the relationships we have with our patients. Patients should be involved in this process of change to ensure we address their concerns and preserve the primary care relationships they value.

Cancer survivorship and agency model: implications for patient choice, decision making, and influence.

Relative to other types of health communication research (acute care physician patient communication, communication campaigns, compliance episodes, etc.), investigations of patient communication following the diagnosis of cancer are infrequent. Theoretically driven, empirical research is desperately needed in such postdiagnostic communication processes as survivorship, quality of life, palliative and hospice care, and loss, bereavement, and grief for those millions of people who have been diagnosed with the second leading cause of death in our nation. An organizational model of patient communication is needed that identifies and describes salient issues and processes involved when cancer patients attempt to negotiate the difficult courses of action following the diagnosis of cancer. The cancer survivorship and agency model (CSAM) proposes both general and specific strategies that serve as options for patients seeking to take greater control of the decision-making process related to their treatment and care of cancer. Although seemingly practical in its offering, CSAM is intended to serve as a heuristic springboard for theoretically based, applied communication research focusing exclusively on post diagnostic cancer processes.