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INTRODUCTION: People enrolled in Medicaid managed care who struggle with diabetes control often have complex medical, behavioral, and social needs. Here the authors report the results of a program designed to partner with primary care teams to address those needs. METHODS: A nonprofit organization partnered with a Medicaid managed care plan and a Federally Qualified Health Center in California to enroll people with A1cs >9% in a 12-month program. The program team included a community health worker, certified diabetes care and education specialist/registered dietitian, behavioral health counselor, and registered nurse. They developed patient-led action plans, connected patients to community resources, and supported behavior changes to improve diabetes control. Baseline assessments of behavioral health conditions and social needs were collected. Monthly A1c values were tracked for participants and a comparison group. RESULTS: Of the 51 people enrolled, 83% had at least 1 behavioral health condition. More than 90% reported at least 1 unmet social need. The average monthly A1c among program participants was 0.699 lower than the comparison group post-enrollment (P = .0008), and the disparity in A1c between Hispanic and non-Hispanic White participants at enrollment declined. DISCUSSION: Participants had high levels of unmet medical, behavioral, and social needs. Addressing these needs resulted in a rapid and sustained improvement in A1c control compared to non-enrollees and a reduction in disparity of control among Hispanic participants. CONCLUSION: By partnering with a primary care team, a program external to Federally Qualified Health Center primary care can improve clinical outcomes for people with complex needs living with diabetes.
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Diabetes Mellitus , Medicaid , Estados Unidos , Humanos , Hemoglobinas Glicadas , Programas de Assistência Gerenciada , Diabetes Mellitus/terapia , EscolaridadeRESUMO
BACKGROUND: Virtual patient engagement has become more common in recent years. Emerging research suggests virtual engagement can increase accessibility for patients managing long-term health conditions and those living in larger geographic areas, but it can also be challenging to establish relationships and maintain engagement over time. Little is known about virtual engagement lasting more than two years, nor about the specific contributions of patients to virtual engagement projects. Here we describe a project where virtual engagement was sustained over a long period of time (3.5 years), measure patients' contributions to the work, and describe the facilitators and challenges of the project using the Valuing All Voices (VAV) patient engagement framework. METHODS: Five researchers recruited four patient partners living with persistent pain to work together virtually on a project to improve care for others with long-term pain. Researchers documented engagement activities and patient partner contributions and categorized them using Carman et al.'s 3 types of engagement. They also collected data via semi-structured group interviews with patient partners about the facilitators and challenges of the project using the VAV framework. RESULTS: In 3.5 years, patient partners contributed 487 h to the project, averaging 3.0 h per month, and participated in 40 meetings. They contributed to 17 products for patients, health care teams, and researchers. Most products (12 of 17) were created using the more in-depth engagement approaches of involvement or partnership and shared leadership. The group identified facilitators of the project across the five VAV domains of relationship-building, trust, understanding & acceptance, education & communication, and self-awareness, as well as some specific challenges such as keeping track of products across virtual platforms and managing the high volume of project information. CONCLUSIONS: Long-term virtual patient engagement is feasible and can use more in-depth engagement approaches. Additionally, it can result in substantial contributions from patients in terms of time, effort, and products. These findings can inform future long-term virtual patient engagement efforts and provide insight into how researchers can structure their activities to encourage and maintain deep engagement over time.
BACKGROUND: Virtual patient engagement has become more common in recent years. Virtual engagement can make it easier for people with long-term health conditions and from larger geographic areas to be involved, but it can also be challenging to establish relationships and maintain engagement over time. There are not many examples of virtual engagement projects lasting more than two years, and many projects do not describe patients' specific contributions to the work. Here we describe a 3.5-year project where we measured patients' contributions and described the facilitators and challenges of the project using the Valuing All Voices (VAV) patient engagement framework. METHODS: Five researchers worked with four patient partners living with persistent pain to improve health care for others with long-term pain. We tracked how we worked together and how patient partners contributed to the project. We categorized the products we created together using three types of engagement that range from less to more in-depth. Researchers also interviewed patient partners about the facilitators and challenges of working together virtually. RESULTS: In 3.5 years, patient partners contributed 487 h to the project, averaging 3.0 h per month, and participated in 40 meetings. They contributed to 17 different products. Twelve of the products used more in-depth engagement approaches. The group identified facilitators of the project across the five VAV domains, as well as some specific challenges. CONCLUSIONS: We found that long-term virtual patient engagement is feasible, can use in-depth engagement strategies, and can result in important contributions from patients in terms of time, effort, and products.
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BACKGROUND: Delivering prescription digital therapeutics (ie, evidence-based interventions designed to treat, manage, or prevent disorders via websites or smartphone apps) in primary care could increase patient access to substance use disorder (SUD) treatments. However, the optimal approach to implementing prescription digital therapeutics in primary care remains unknown. OBJECTIVE: This pilot study is a precursor to a larger trial designed to test whether implementation strategies (practice facilitation [PF] and health coaching [HC]) improve the delivery of prescription digital therapeutics for SUDs in primary care. This mixed methods study describes outcomes among patients in the 2 pilot clinics and presents qualitative findings on implementation. METHODS: From February 10 to August 6, 2021, a total of 3 mental health specialists embedded in 2 primary care practices of the same integrated health system were tasked with offering app-based prescription digital therapeutics to patients with SUD. In the first half of the pilot, implementation activities included training and supportive tools. PF (at 1 clinic) and HC (at 2 clinics) were added in the second half. All study analyses relied on secondary data, including electronic health records and digital therapeutic vendor data. Primary outcomes were the proportion of patients reached by the prescription digital therapeutics and fidelity related to ideal use. We used qualitative methods to assess the adherence to planned activities and the barriers and facilitators to implementing prescription digital therapeutics. RESULTS: Of all 18 patients prescribed the apps, 10 (56%) downloaded the app and activated their prescription, and 8 (44%) completed at least 1 module of content. Patients who activated the app completed 1 module per week on average. Ideal use (fidelity) was defined as completing 4 modules per week and having a monthly SUD-related visit; 1 (6%) patient met these criteria for 10 weeks (of the 12-week prescription period). A total of 5 (28%) patients had prescriptions while HC was available, 2 (11%) were successfully contacted, and both declined coaching. Clinicians reported competing clinical priorities, technical challenges, and logistically complex workflows in part because the apps required a prescription. Some pilot activities were impacted by staff turnover that coincided with the COVID-19 pandemic. The facilitators to implementation were high engagement and the perception that the apps could meet patient needs. CONCLUSIONS: The pilot study encountered the barriers to implementing prescription digital therapeutics in a real-world primary care setting, especially staffing shortages, turnover, and competing priorities for clinic teams. The larger randomized trial will clarify the extent to which PF and HC improve the implementation of digital therapeutics. TRIAL REGISTRATION: ClinicalTrials.gov NCT04907045; https://clinicaltrials.gov/study/NCT04907045.
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Aplicativos Móveis , Atenção Primária à Saúde , Transtornos Relacionados ao Uso de Substâncias , Humanos , Projetos Piloto , Transtornos Relacionados ao Uso de Substâncias/terapia , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Telemedicina , Pesquisa QualitativaRESUMO
OBJECTIVES: Despite an increasing emphasis from health care organizations on patients' social health, there is debate about how best to screen patients for social health needs in practice. Empathic Inquiry is a patient-centered approach to asking about patients' social needs that incorporates motivational interviewing and trauma-informed care techniques to increase patient experience of trustworthiness and safety with their care teams. The purpose of this brief report is to describe the feasibility and acceptability of implementing an Empathic Inquiry-informed approach to social needs screening in 10 federally qualified health centers. METHODS: Clinical staff at community health centers implemented Empathic Inquiry as part of an 8-month learning collaborative. Patients completed surveys about their experience with Empathic Inquiry after screening conversations took place. Qualitative data on organizational implementation experience were collected monthly during 2018. FINDINGS: Eight of 10 organizations completed the learning collaborative and implemented Empathic Inquiry in practice. Of 132 patient surveys received, patients agreed (64% strongly agree, 28% somewhat agree) that being screened for social needs strengthened their relationship with their care team and 83% strongly agreed the conversation was a good use of time. Most patients (54%) indicated social health screening was appropriate at every visit, and 27% answered once every 6 months. CONCLUSIONS: The Empathic Inquiry approach to understanding patients' social needs was feasible for implementation in community settings. Patients said the conversations were worthwhile, built trust with their care teams, and should be conducted every 6 months or more frequently.
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Instalações de Saúde , Necessidades e Demandas de Serviços de Saúde , Humanos , Estudos de Viabilidade , EmpatiaRESUMO
BACKGROUND: Experts recommend that treatment for substance use disorder (SUD) be integrated into primary care. The Digital Therapeutics for Opioids and Other SUD (DIGITS) Trial tests strategies for implementing reSET® and reSET-O®, which are prescription digital therapeutics for SUD and opioid use disorder, respectively, that include the community reinforcement approach, contingency management, and fluency training to reinforce concept mastery. This purpose of this trial is to test whether two implementation strategies improve implementation success (Aim 1) and achieve better population-level cost effectiveness (Aim 2) over a standard implementation approach. METHODS/DESIGN: The DIGITS Trial is a hybrid type III cluster-randomized trial. It examines outcomes of implementation strategies, rather than studying clinical outcomes of a digital therapeutic. It includes 22 primary care clinics from a healthcare system in Washington State and patients with unhealthy substance use who visit clinics during an active implementation period (up to one year). Primary care clinics implemented reSET and reSET-O using a multifaceted implementation strategy previously used by clinical leaders to roll-out smartphone apps ("standard implementation" including discrete strategies such as clinician training, electronic health record tools). Clinics were randomized as 21 sites in a 2x2 factorial design to receive up to two added implementation strategies: (1) practice facilitation, and/or (2) health coaching. Outcome data are derived from electronic health records and logs of digital therapeutic usage. Aim 1's primary outcomes include reach of the digital therapeutics to patients and fidelity of patients' use of the digital therapeutics to clinical recommendations. Substance use and engagement in SUD care are additional outcomes. In Aim 2, population-level cost effectiveness analysis will inform the economic benefit of the implementation strategies compared to standard implementation. Implementation is monitored using formative evaluation, and sustainment will be studied for up to one year using qualitative and quantitative research methods. DISCUSSION: The DIGITS Trial uses an experimental design to test whether implementation strategies increase and improve the delivery of digital therapeutics for SUDs when embedded in a large healthcare system. It will provide data on the potential benefits and cost-effectiveness of alternative implementation strategies. CLINICALTRIALS: gov Identifier: NCT05160233 (Submitted 12/3/2021). https://clinicaltrials.gov/ct2/show/NCT05160233.