Patients' Progress and Confidence Addressing Root Causes of Poor Health in Primary Care.

Context: Patients with multiple chronic conditions (MCC) may have unmet behavioral, mental, and social needs which can be difficult to address in primary care. Care planning provides a framework for patients to be screened, collaborate on a care plan, and access a patient navigator who can support them achieving their personal health goals. Objective: To compare patients' progress and confidence in addressing personal care plans for different topics. Study Design and Analysis: Clinician level randomized control trial and descriptive analyses. Dataset: My Own Health Report (MOHR) study and navigator field notes. Population Studied: As part of a randomized controlled trial (RCT) to evaluate a feasible approach to patient care planning, 24 clinicians from 12 practices in the Virginia Ambulatory Care Outcomes Research Network (ACORN) in the Greater Richmond metro and the Northern Virginia areas participated in a care planning intervention. 91 patients in the intervention arm received support from a patient navigator for making and working on a goal. We focused on patients with uncontrolled chronic conditions that have complex needs. Intervention/Instrument: Community-clinical linkage support and navigator field notes in My Own Health Report (MOHR). Outcome Measures: We determined confidence and progress ratings (ranked by patients on 1-10 point scale), health risk assessment responses, and care plan topics selected by patients. Results: Patients feel more confident addressing nutrition than weight loss (mean = 8.07 vs 6.31, p=0.0031). Patients tended to report better prior progress on nutrition care plans (mean = 3.80) than physical activity (mean =2.95, p=0.0024) and weight loss (mean=2.93, p=0.004). Conclusions: Helping patients create care plans on topics they feel most comfortable addressing may better address root causes of poor health associated with chronic conditions. Connecting them with a patient navigator for the short-term may have long-term benefits for patients and care teams.

Exploring the Relationship Between Community Program Location and Community Needs.

INTRODUCTION: Health behaviors, mental health, and social needs impact health, but addressing these needs is difficult. Clinicians can partner with community programs to provide patients support. The relationship between program location and community need is uncertain. METHODS: We identified and geolocated community programs in Richmond, Virginia, that aid with 9 domains of needs (mental health, smoking, unhealthy alcohol use, nutrition, physical activity, transportation, financial, housing, food insecurity). For each census tract, we identified needs from public data sources. We used 2 methods to compare program location and need: (1) hotspot analysis and (2) a negative binomial regression model. RESULTS: We identified 280 community programs that provide aid for the 9 domains. Programs most often provided financial assistance (n = 121) and housing support (n = 73). The regression analysis showed no relationship between the number of community programs and the level of need in census tracts, with 2 exceptions. There was a positive association between financial programs and financial need and a negative association between housing programs and housing need. CONCLUSIONS: Community programs are generally not colocated with need. This poses a barrier for people who need help addressing these domains.

Feasibility of Patient Navigation for Care Planning in Primary Care.

OBJECTIVES: To help better control chronic conditions we need to address root causes of poor health like unhealthy behaviors, mental health, and social needs. However, addressing these needs in primary care is difficult. One solution may be connecting patients with a navigator for support creating a personal care goal. METHODS: As part of an RCT to evaluate a feasible approach to care planning, 24 clinicians from 12 practices in the Virginia Ambulatory Care Outcomes Research Network (ACORN) and 87 intervention patients with uncontrolled chronic conditions participated in a care planning intervention. We had a structured process to guide patients, train navigators, and adapt the navigation process to meet the needs of each practice. RESULTS: Only 1 practice had bandwidth for staff to serve as a patient navigator, even for extra pay. For the other 11 practices, a research team member needed to provide navigation services. On average, patients wanted 25 weeks of support to complete care plans. The average time patients needed to speak with navigators on the phone was 7 min and 3 s. In exit interviews, patients consistently shared how motivational it was to have a caring person check in on them, offer help, and hold them accountable. CONCLUSION: Patient navigation to address care plans should be feasible. The time commitment is minimal. It does not require intensive training, and primary care is already doing much of this work. Yet, given the burden and competing demands in primary care, this help cannot be offered without additional resources.

Stakeholder input on a care planning tool to address unhealthy behaviors, mental health needs, and social risks: The value of different stakeholder perspectives.

This report describes how stakeholder groups informed a web-based care planning tool's development for addressing root causes of poor health. Stakeholders included community members (n = 6), researchers (n = 6), community care providers (n = 9), and patients (n = 17). Feedback was solicited through focus groups, semi-structured interviews, and user experience observations and then qualitatively analyzed to identify themes. Each group contributed a unique perspective. Researchers wanted evidence-based content; community members and providers focused on making goals manageable; patients wanted care team support and simple action-oriented language. Our findings highlight the benefits of stakeholder input. Blending perspectives from multiple groups results in a more robust intervention design.

The Lullaby Project: A Musical Intervention for Pregnant Women.

Background: This pilot study investigated the impact of a musical intervention on maternal/fetal attachment, psychiatric symptoms, and perceived stress in two centers. Materials and Methods: Forty-four pregnant women participated from the Virginia Commonwealth University in Richmond, VA, and Jacobi Medical Center in Bronx, NY. Participants were assigned to a lullaby intervention or control group. The Maternal Fetal Attachment Scale, Perceived Stress Scale (PSS), and Symptom Checklist (SCL-27) were completed at baseline and follow-up. Results: Although no significant differences were found in maternal/fetal attachment between control and intervention groups, there were within-group differences in both groups from baseline to follow-up. No statistically significant differences in change from baseline occurred on the SCL-27 and PSS. Conclusions: Exposure to a lullaby intervention was not statistically associated with maternal/fetal attachment, mental health, and perceived stress in this pilot study. Future studies with larger samples and different outcomes are suggested.

Adverse Childhood Experiences, Maternal/Fetal Attachment, and Maternal Mental Health.

Background: This pilot study investigated the potential impact of exposure to childhood adversity on variables known to be related to posttraumatic stress (including attachment, mental health, and perceived stress) in a clinic sample of pregnant women. Materials and Methods: Participants consisted of 101 pregnant women recruited from the Virginia Commonwealth University Health System in Richmond, VA. All participants completed the Adverse Childhood Experience (ACE) questionnaire, Parental Bonding Instrument, Maternal Fetal Attachment Scale, Posttraumatic Stress Disorder (PTSD) Checklist, Symptom Checklist, and the Perceived Stress Scale. Results: Increased exposure to ACEs was negatively associated with retrospective report of viewing one's mother and father as caring and involved. ACE exposure was a statistically significant predictor of viewing one's mother and father as intrusive and controlling. ACEs were positively associated with self-reported PTSD symptoms, depressive and anxious symptomatology, and perceived stress. No direct effect of adverse childhood events on maternal/fetal attachment was found. Conclusions: ACE associations are discussed in terms of study methodology and needs for future research. Providers may consider incorporating the ACE questionnaire to identify exposure to childhood adversity and events that may increase an individual's risk for toxic stress and negative health outcomes.

Enhanced care planning and clinical-community linkages versus usual care to address basic needs of patients with multiple chronic conditions: a clinician-level randomized controlled trial.

BACKGROUND: Many patients with poorly controlled multiple chronic conditions (MCC) also have unhealthy behaviors, mental health challenges, and unmet social needs. Medical management of MCC may have limited benefit if patients are struggling to address their basic life needs. Health systems and communities increasingly recognize the need to address these issues and are experimenting with and investing in new models for connecting patients with needed services. Yet primary care clinicians, whose regular contact with patients makes them more familiar with patients' needs, are often not included in these systems. METHODS: We are starting a clinician-level cluster-randomized controlled trial to evaluate how primary care clinicians can participate in these community and hospital solutions and whether doing so is effective in controlling MCC. Sixty clinicians in the Virginia Ambulatory Care Outcomes Research Network will be matched by age and sex and randomized to usual care (control condition) or enhanced care planning with clinical-community linkage support (intervention). From the electronic health record we will identify all patients with MCC, including cardiovascular disease or risks, diabetes, obesity, or depression. A baseline assessment will be mailed to up to 50 randomly selected patients for each clinician (3000 total). Ten respondents per clinician (600 patients total) with uncontrolled MCC will be randomly selected for study inclusion, with oversampling of minorities. The intervention includes two components. First, we will use an enhanced care planning tool, My Own Health Report (MOHR), to screen patients for health behavior, mental health, and social needs. Patients will be supported by a patient navigator, who will help patients prioritize needs, create care plans, and write a personal narrative to guide the care team. Patients will update care plans every 1 to 2 weeks. Second, we will create community-clinical linkage to help address patients' needs. The linkage will include community resource registries, personnel to span settings (patient navigators and a community health worker), and care team coordination across team members through MOHR. DISCUSSION: This study will help inform efforts by primary care clinicians to help address unhealthy behaviors, mental health needs, and social risks as a strategy to better control MCC. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03885401. Registered on 19 September 2019.

Association of Childhood Trauma Exposure With Adult Psychiatric Disorders and Functional Outcomes.

Importance: Being exposed to trauma is a common childhood experience associated with symptoms and impairments in childhood. Objective: To assess the association between cumulative childhood trauma exposure and adult psychiatric and functional outcomes. Design, Setting, and Participants: Prospective, population-based cohort study of 1420 participants. A community representative sample of participants was assessed with structured Child and Adolescent Psychiatric Assessment interviews up to 8 times in childhood (ages 9-16 years; 6674 observations; 1993-2000) for lifetime trauma exposure as defined by the Diagnostic and Statistical Manual of Mental Disorders. Participants were followed up 4 times in adulthood (ages 19, 21, 25, and 30 years; 4556 observations of 1336 participants; 1999-2015) with the structured Young Adult Psychiatric Assessment Interview for psychiatric outcomes, functional outcomes, and evidence of a disrupted transition to adulthood. Analysis was completed in 2018. Exposure: Participants were assessed with the structured Child and Adolescent Psychiatric Assessment interview (parent and self-report) up to 8 times in childhood for lifetime trauma exposure (ages 9-16 years; 6674 observations; 1993-2000). Main Outcomes and Measures: Participants were assessed up to 4 times with the structured Young Adult Psychiatric Assessment interview (self-report) in adulthood (ages 19, 21, 25, and 30 years; 4556 observations of 1336 participants; 1999-2015) for psychiatric outcomes, functional outcomes, and evidence of a disrupted transition to adulthood. Results: Among the 1420 study participants, 630 (49.0%) were female and 983 (89.4%) were white. By age 16 years, 30.9% of children (n = 451) were exposed to 1 traumatic event, 22.5% (n = 289) were exposed to 2 such events, and 14.8% (n = 267) were exposed to 3 or more. Cumulative childhood trauma exposure to age 16 years was associated with higher rates of adult psychiatric disorders (odds ratio for any disorder, 1.2; 95% CI, 1.0-1.4) and poorer functional outcomes, including key outcomes that indicate a significantly disrupted transition to adulthood (eg, failure to hold a job and social isolation). Childhood trauma exposure continued to be associated with higher rates of adult psychiatric and functional outcomes after adjusting for a broad range of childhood risk factors, including psychiatric functioning and family adversities and hardships (adjusted odds ratio for any disorder, 1.3; 95% CI, 1.0-1.5). Conclusions and Relevance: Cumulative childhood trauma exposure was associated with poor adult outcomes even after accounting for many of the childhood and family factors associated with both trauma exposure and poor adult outcomes. Childhood trauma exposures are common, but often preventable, thus providing a clear target for child-focused public health efforts to ameliorate long-term morbidity.