Identifying COVID-19 Mortality and Social Deprivation Hot Spots and Exploring Opportunities for Health Center Response
CP22 - Identifying COVID-19 Mortality and Social Deprivation Hot Spots and Exploring Opportunities for Health Center Response
CP22 - Identifying COVID-19 Mortality and Social Deprivation Hot Spots and Exploring Opportunities for Health Center Response
Poster Type: Research
Track/Topic: Expanding Access to Care and Other Services; Public Health Crises; Social Determinants of Health
Research Objectives: This research has two aims: (1) to identify priority areas based on high levels of social deprivation and COVID-19 mortality and COVID-19 mortality “hot spots” – which are clusters of high rates of COVID-19 mortality; and (2) to identify health centers located in priority areas.
Research Study Design/Methods: Data sources include COVID-19 mortality from USA Facts, social deprivation from the Robert Graham Center, and health center awardee patient characteristics from UDS. Bayesian smoothing of COVID-19 mortality was used to identify counties in the top quintile for COVID-19 mortality per capita. Local Moran’s I analysis was then used to identify counties within geographic “hot spots.” Priority areas were defined as counties in the top quintile for COVID-19 mortality rates and social deprivation, or those identified as COVID-19 mortality “hot spots.” Geographic Information Systems (GIS) were then used to overlay health center service delivery sites on priority counties.
Research Principal Findings and Quantitative/Qualitative Results: We identified 504 priority counties that had high rates of COVID-19 mortality and social deprivation, or were part of COVID-19 mortality “hot spot.” Most priority counties are located in rural areas in Texas, the Southeast (MS, GA, AL, LA), and Great Plains States (KS, IA, ND, SD), while several are within large urban centers (New York City). Priority counties include more than 250 Health Center Program awardees, 1,660 service delivery sites, and 6.5 million patients. Health centers in priority counties have higher percentages of patients that are Black, uninsured, homeless, and in public housing.
Research Conclusions on Impact on Health Centers: The impact of COVID-19 has been significant for health centers across the U.S. However, health centers located in the hardest hit areas would likely benefit most from having increased access to COVID-19 vaccinations via health centers and may have experienced the largest declines in “routine” health care utilization, including having large numbers of patients forgo critical preventive care such as cancer screenings. This research identifies health centers located in areas most impacted by COVID-19 and identifies opportunities to target resources to these health centers regarding preventive care, COVID-19 immunizations, and other patient outreach.
Authors:
Michael Topmiller, PhD, Health GIS Research Specialist, American Academy of Family Physicians
Jennifer Rankin, PhD, Sr. Manager Research & Product Services, American Academy of Family Physicians
Jessica McCann, MA, User Engagement Specialist, American Academy of Family Physicians
Jene Grandmont, MA, Sr. Manager Application & Data Services, American Academy of Family Physicians
David Grolling, MS, GIS Strategist, American Academy of Family Physicians
Mark Carrozza, MA, Director, American Academy of Family Physicians
Speaker(s):
Poster Type: Research
Track/Topic: Expanding Access to Care and Other Services; Public Health Crises; Social Determinants of Health
Research Objectives: This research has two aims: (1) to identify priority areas based on high levels of social deprivation and COVID-19 mortality and COVID-19 mortality “hot spots” – which are clusters of high rates of COVID-19 mortality; and (2) to identify health centers located in priority areas.
Research Study Design/Methods: Data sources include COVID-19 mortality from USA Facts, social deprivation from the Robert Graham Center, and health center awardee patient characteristics from UDS. Bayesian smoothing of COVID-19 mortality was used to identify counties in the top quintile for COVID-19 mortality per capita. Local Moran’s I analysis was then used to identify counties within geographic “hot spots.” Priority areas were defined as counties in the top quintile for COVID-19 mortality rates and social deprivation, or those identified as COVID-19 mortality “hot spots.” Geographic Information Systems (GIS) were then used to overlay health center service delivery sites on priority counties.
Research Principal Findings and Quantitative/Qualitative Results: We identified 504 priority counties that had high rates of COVID-19 mortality and social deprivation, or were part of COVID-19 mortality “hot spot.” Most priority counties are located in rural areas in Texas, the Southeast (MS, GA, AL, LA), and Great Plains States (KS, IA, ND, SD), while several are within large urban centers (New York City). Priority counties include more than 250 Health Center Program awardees, 1,660 service delivery sites, and 6.5 million patients. Health centers in priority counties have higher percentages of patients that are Black, uninsured, homeless, and in public housing.
Research Conclusions on Impact on Health Centers: The impact of COVID-19 has been significant for health centers across the U.S. However, health centers located in the hardest hit areas would likely benefit most from having increased access to COVID-19 vaccinations via health centers and may have experienced the largest declines in “routine” health care utilization, including having large numbers of patients forgo critical preventive care such as cancer screenings. This research identifies health centers located in areas most impacted by COVID-19 and identifies opportunities to target resources to these health centers regarding preventive care, COVID-19 immunizations, and other patient outreach.
Authors:
Michael Topmiller, PhD, Health GIS Research Specialist, American Academy of Family Physicians
Jennifer Rankin, PhD, Sr. Manager Research & Product Services, American Academy of Family Physicians
Jessica McCann, MA, User Engagement Specialist, American Academy of Family Physicians
Jene Grandmont, MA, Sr. Manager Application & Data Services, American Academy of Family Physicians
David Grolling, MS, GIS Strategist, American Academy of Family Physicians
Mark Carrozza, MA, Director, American Academy of Family Physicians
Speaker(s):
Quality Improvement Network for Contraceptive Access (QINCA) 2.0: Integrating Reproductive Justice Through a Contraceptive Access Quality Improvement Program
CP23 - Quality Improvement Network for Contraceptive Access (QINCA) 2.0: Integrating Reproductive Justice Through a Contraceptive Access Quality Improvement Program
CP23 - Quality Improvement Network for Contraceptive Access (QINCA) 2.0: Integrating Reproductive Justice Through a Contraceptive Access Quality Improvement Program
Poster Type: Innovation
Category: Expanding Access to Care and Other Services; Improving Care for Special Populations; Quality of Care and Quality Improvement; Workforce
Issue or Challenge: Access to high-quality, patient-centered contraceptive care is key to supporting individuals’ human right to make informed and autonomous decisions about their reproductive health. However, communities of color, LGBTQ+ and low-income communities frequently report receiving coercive or biased contraceptive counseling and reproductive health care. It is critical that clinical care settings address these inequities by intentionally implementing care practices that center contraceptive choice and reproductive autonomy. To this end, QINCA 2.0 supported NYC-based health care setting in implementing clinical and operational improvements to increase contraceptive access for all, specifically those at highest risk for reproductive coercion and/or discrimination.
Description of Innovation: QINCA 2.0, a 12-month quality improvement learning collaborative (QILC), was launched in 2019 in partnership between the New York City (NYC) Department of Health and Mental Hygiene (DOHMH) and Public Health Solutions (PHS) to improve the quality of contraceptive care in primary care, post-abortion, and postpartum settings in NYC. QINCA 2.0 is based on the Institute for Healthcare Improvement (IHI) Breakthrough Series (BTS) model and guided by the sexual and reproductive justice (SRJ) framework, developed by women of color, which prioritizes individual choice and bodily autonomy within the context of historical events, lived experiences, sexualities, and social conditions.To support site-based improvements in contraceptive care, PHS and NYC DOHMH developed a quality improvement (QI) toolkit, including a set of SRJ-informed best practices called the Four Steps to Contraceptive Access. The Four Steps include assessing contraceptive need, ensuring same-day access, reducing cost as a barrier, and documenting care. QINCA 2.0 also applied a set of SRJ-aligned performance measures adapted from existing validated measures of contraceptive care, including the Person-Centered Contraceptive Counseling (PCCC) measure, that support monitoring of progress across the Four Steps. Throughout the collaborative, participating sites were provided targeted training, coaching and technical assistance on the Four Steps, the SRJ framework, patient-centered care strategies, and fiscal best practices to ensure sustainability of contraceptive care programs. Participating sites tested and implemented improvements using Plan-Do-Study-Act cycles, data collection on key measures, and collaboration with other teams at learning sessions. Following the start of COVID-19, activities were adapted to integrate a telehealth focus.
Impact or Result: Participants improved their setting’s contraceptive care practices through collaborative activities and site-based QI initiatives. Successes included: the introduction of new contraceptive services, integration of SRJ principles into care practices, optimization of contraceptive workflows, and implementation of a contraceptive counseling patient experience survey including the PCCC measure. Additionally, a total of 247 staff across seven health care organizations participated in an introductory training on SRH services and the SRJ framework, among other collaborative trainings.Results of participants’ pre-post self-assessment, which measured implementation of the Four Steps, revealed that average scores among the six completing teams increased by 27%, with the greatest improvements seen in sub-elements related to staff training, on-site stocking of contraceptives, updating policies and procedures, electronic health record (EHR) configuration, and standardized measure reports. Findings from the PCCC measure are inconclusive due to the impact of COVID-19 on service provision and challenges related to data collection from telehealth visits.
Replicating this Innovation: QINCA 2.0 materials are available upon request. Health care organizations can apply the QI framework used in QINCA 2.0 to design and implement similar quality improvements. Review of SRJ literature and engagement of local SRJ experts is foundational to this work and should inform all stages of planning and implementation. QI resources are available to support the application of this model, through IHI for example, and many health care organizations retain QI staff that can guide improvement efforts. Key first steps include assessing current clinical and operational practices, identifying specific areas for improvement, addressing gaps in staff knowledge and skill through training, and establishing infrastructure to support ongoing improvements, such as EHR re-configuration to document care and the adoption of key indicators of contraceptive care quality, including the PCCC measure. Early engagement of senior leadership and establishing a strong improvement team are also critical to the success of QI initiatives.
Author(s):
Julia Keegan, MPH, Collaborative Manager, Sexual and Reproductive Health Capacity Building, Public Health Solutions
Dayana Bermudez, Program Manager, Sexual and Reproductive Health Capacity Building, Public Health Solutions
Hestia Rojas, MPH, Quality Improvement Specialist, Public Health Solutions
Christina Ortiz, MPH, Training Manager, Sexual and Reproductive Health Capacity Building, Public Health Solutions
Allyna Steinberg, MPH, MAmSAT, Deputy Director, Sexual and Reproductive Health (SRH) Initiatives, NYC Department of Health and Mental Hygiene
Lindsey Gibson, MPH, Sexual and Reproductive Health Analyst, NYC Department of Health and Mental Hygiene
Kathryn Iglehart, MPH, Assistant Director, Sexual and Reproductive Health Capacity Building, Public Health Solutions
Joslyn Levy, MPH, President, Joslyn Levy & Associates, LLC
Natalie Tobier, MPH, LCSW, Senior Director, Sexual and Reproductive Health, Public Health Solutions
Speaker(s):
Poster Type: Innovation
Category: Expanding Access to Care and Other Services; Improving Care for Special Populations; Quality of Care and Quality Improvement; Workforce
Issue or Challenge: Access to high-quality, patient-centered contraceptive care is key to supporting individuals’ human right to make informed and autonomous decisions about their reproductive health. However, communities of color, LGBTQ+ and low-income communities frequently report receiving coercive or biased contraceptive counseling and reproductive health care. It is critical that clinical care settings address these inequities by intentionally implementing care practices that center contraceptive choice and reproductive autonomy. To this end, QINCA 2.0 supported NYC-based health care setting in implementing clinical and operational improvements to increase contraceptive access for all, specifically those at highest risk for reproductive coercion and/or discrimination.
Description of Innovation: QINCA 2.0, a 12-month quality improvement learning collaborative (QILC), was launched in 2019 in partnership between the New York City (NYC) Department of Health and Mental Hygiene (DOHMH) and Public Health Solutions (PHS) to improve the quality of contraceptive care in primary care, post-abortion, and postpartum settings in NYC. QINCA 2.0 is based on the Institute for Healthcare Improvement (IHI) Breakthrough Series (BTS) model and guided by the sexual and reproductive justice (SRJ) framework, developed by women of color, which prioritizes individual choice and bodily autonomy within the context of historical events, lived experiences, sexualities, and social conditions.To support site-based improvements in contraceptive care, PHS and NYC DOHMH developed a quality improvement (QI) toolkit, including a set of SRJ-informed best practices called the Four Steps to Contraceptive Access. The Four Steps include assessing contraceptive need, ensuring same-day access, reducing cost as a barrier, and documenting care. QINCA 2.0 also applied a set of SRJ-aligned performance measures adapted from existing validated measures of contraceptive care, including the Person-Centered Contraceptive Counseling (PCCC) measure, that support monitoring of progress across the Four Steps. Throughout the collaborative, participating sites were provided targeted training, coaching and technical assistance on the Four Steps, the SRJ framework, patient-centered care strategies, and fiscal best practices to ensure sustainability of contraceptive care programs. Participating sites tested and implemented improvements using Plan-Do-Study-Act cycles, data collection on key measures, and collaboration with other teams at learning sessions. Following the start of COVID-19, activities were adapted to integrate a telehealth focus.
Impact or Result: Participants improved their setting’s contraceptive care practices through collaborative activities and site-based QI initiatives. Successes included: the introduction of new contraceptive services, integration of SRJ principles into care practices, optimization of contraceptive workflows, and implementation of a contraceptive counseling patient experience survey including the PCCC measure. Additionally, a total of 247 staff across seven health care organizations participated in an introductory training on SRH services and the SRJ framework, among other collaborative trainings.Results of participants’ pre-post self-assessment, which measured implementation of the Four Steps, revealed that average scores among the six completing teams increased by 27%, with the greatest improvements seen in sub-elements related to staff training, on-site stocking of contraceptives, updating policies and procedures, electronic health record (EHR) configuration, and standardized measure reports. Findings from the PCCC measure are inconclusive due to the impact of COVID-19 on service provision and challenges related to data collection from telehealth visits.
Replicating this Innovation: QINCA 2.0 materials are available upon request. Health care organizations can apply the QI framework used in QINCA 2.0 to design and implement similar quality improvements. Review of SRJ literature and engagement of local SRJ experts is foundational to this work and should inform all stages of planning and implementation. QI resources are available to support the application of this model, through IHI for example, and many health care organizations retain QI staff that can guide improvement efforts. Key first steps include assessing current clinical and operational practices, identifying specific areas for improvement, addressing gaps in staff knowledge and skill through training, and establishing infrastructure to support ongoing improvements, such as EHR re-configuration to document care and the adoption of key indicators of contraceptive care quality, including the PCCC measure. Early engagement of senior leadership and establishing a strong improvement team are also critical to the success of QI initiatives.
Author(s):
Julia Keegan, MPH, Collaborative Manager, Sexual and Reproductive Health Capacity Building, Public Health Solutions
Dayana Bermudez, Program Manager, Sexual and Reproductive Health Capacity Building, Public Health Solutions
Hestia Rojas, MPH, Quality Improvement Specialist, Public Health Solutions
Christina Ortiz, MPH, Training Manager, Sexual and Reproductive Health Capacity Building, Public Health Solutions
Allyna Steinberg, MPH, MAmSAT, Deputy Director, Sexual and Reproductive Health (SRH) Initiatives, NYC Department of Health and Mental Hygiene
Lindsey Gibson, MPH, Sexual and Reproductive Health Analyst, NYC Department of Health and Mental Hygiene
Kathryn Iglehart, MPH, Assistant Director, Sexual and Reproductive Health Capacity Building, Public Health Solutions
Joslyn Levy, MPH, President, Joslyn Levy & Associates, LLC
Natalie Tobier, MPH, LCSW, Senior Director, Sexual and Reproductive Health, Public Health Solutions
Speaker(s):
The Influence of Meal Delivery on Engagement in a Digital Health Coaching Program
CP24 - The Influence of Meal Delivery on Engagement in a Digital Health Coaching Program
CP24 - The Influence of Meal Delivery on Engagement in a Digital Health Coaching Program
Poster Type: Research
Track/Topic: Expanding Access to Care and Other Services
Research Objectives: Digital health coaching (DHC) demonstrates positive outcomes among adults with type 2 diabetes (T2DM), yet engagement rates are often low, particularly among underserved populations with health-related barriers including food insecurity. This retrospective review explored how inclusion of meal delivery influences DHC engagement, focusing on transition from enrollment to program participation.
Research Study Design/Methods: We compared participant data from two payer-provided 12-week T2DM DHC programs. Group 1 (n=597) includes adults with T2DM, largely recruited from financially- and food-insecure communities, who were provided DHC + biweekly meal delivery; Group 2 (n=448) includes adults with T2DM who received DHC only. Both programs provide behavioral and psychosocial support delivered by phone, text and/or email. This analysis focuses on retention between enrollment and the first DHC call. Descriptive statistics were used to analyze data including participant retention, demographics and baseline patient reported outcomes (diet, mental health, overall physical health, financial toxicity).
Research Principal Findings and Quantitative/Qualitative Results: Groups 1 and 2 had similar mean age (53 vs. 58), racial/ethnic backgrounds (44% vs. 41% nonwhite) and baseline A1cs (7.23% vs. 7.64%). Diabetes distress (2.80 vs. 2.68), depression (1.43 vs. 0.97), stress (5.32 vs. 5.04), and financial toxicity (20.21 vs. 24.60) were higher in Group 1. Group 1 also reported poorer overall physical health (41.57 vs. 44.46) and consumed fewer weekly healthy meals (5.72 vs. 7.09). Retention from enrollment to the first call was significantly higher in Group 1 compared with Group 2 (93% vs. 75%; pxtagstartz.0001), representing improved engagement from DHC orientation to participation.
Speaker(s):
Poster Type: Research
Track/Topic: Expanding Access to Care and Other Services
Research Objectives: Digital health coaching (DHC) demonstrates positive outcomes among adults with type 2 diabetes (T2DM), yet engagement rates are often low, particularly among underserved populations with health-related barriers including food insecurity. This retrospective review explored how inclusion of meal delivery influences DHC engagement, focusing on transition from enrollment to program participation.
Research Study Design/Methods: We compared participant data from two payer-provided 12-week T2DM DHC programs. Group 1 (n=597) includes adults with T2DM, largely recruited from financially- and food-insecure communities, who were provided DHC + biweekly meal delivery; Group 2 (n=448) includes adults with T2DM who received DHC only. Both programs provide behavioral and psychosocial support delivered by phone, text and/or email. This analysis focuses on retention between enrollment and the first DHC call. Descriptive statistics were used to analyze data including participant retention, demographics and baseline patient reported outcomes (diet, mental health, overall physical health, financial toxicity).
Research Principal Findings and Quantitative/Qualitative Results: Groups 1 and 2 had similar mean age (53 vs. 58), racial/ethnic backgrounds (44% vs. 41% nonwhite) and baseline A1cs (7.23% vs. 7.64%). Diabetes distress (2.80 vs. 2.68), depression (1.43 vs. 0.97), stress (5.32 vs. 5.04), and financial toxicity (20.21 vs. 24.60) were higher in Group 1. Group 1 also reported poorer overall physical health (41.57 vs. 44.46) and consumed fewer weekly healthy meals (5.72 vs. 7.09). Retention from enrollment to the first call was significantly higher in Group 1 compared with Group 2 (93% vs. 75%; pxtagstartz.0001), representing improved engagement from DHC orientation to participation.
Speaker(s):
CareSouth Carolina MOBYs - Mobile Vehicles to Provide and Enhance Services for Our Patients
CP25 - CareSouth Carolina MOBYs - Mobile Vehicles to Provide and Enhance Services for Our Patients
CP25 - CareSouth Carolina MOBYs - Mobile Vehicles to Provide and Enhance Services for Our Patients
Poster Type: Innovation
Category: Expanding Access to Care and Other Services
Issue or Challenge: We saw the COVID-19 Testing need facing us with a rural population in our 5 county service area with a total population of 185,693. We heard about using mobile vehicles that could be outfitted for testing. After choosing one, we designed the vehicle to not only be used for COVID-19 testing but though these could be used to bring needed services to our patients outside of the existing medical centers we have. We purchased 5 units, one for each of our 5 counties in rural SC that we serve.
Description of Innovation: The MOBY vehicles are designed to offer direct patient outreach, lab testing and collection, vaccine administration, and future closing of patient medical gaps in care. Direct patient outreach is offered by the quick setup at almost any location. The vehicle is similar to an ambulance but its inside configuration was designed to maximize space. There is a side window that pops out and a step included that allows patients to step up outside the vehicle and have certain lab tests collected while standing. The inside of the vehicle is equipped with 2 seats for staffing, one of which is at the back with a laboratory workstation. There are numerous cabinets on both sides to allow for storage of all supplies. There is both a vaccine-grade refrigerator and freezer on board to store both vaccines, medications, and lab reagents. The vehicle has internet access onboard for EMR access. The outside of the vehicle includes a canopy that automatically rolls out to provide shade and shelter for patients and staff while working. The vehicle is staffed with a phlebotomist and a Community Health Worker, and have included nurses and providers to see patients in the parking lots where the MOBY is setup when these staff are available.
Impact or Result: Our MOBY vehicles started providing services with 1 MOBY starting in October of 2020. 3 additional MOBY vehicles started providing services in November and the 5th MOBY arrived in January. Our sites include Division of Social Services, City Chambers of Commerce, Coker College Athletic Department, Churches, Libraries, YMCAs, Community Colleges, Dollar Generals, Grocery Stores, Community Centers, Convenient Stores, Free Medical Clinics, Apartment Complexes, and Schools. To date, we have administered over 7900 COVID-19 tests in our communities. We have just started offering vaccines in the last week on our MOBY vehicles and given over 200 vaccines in our communities.
Replicating this Innovation: The plans, videos, and pictures for our MOBY vehicles can and will be shared with anyone or any center that would like to see these. The vehicle and the staffing are the two largest challenges with this type of innovation. We also have a YouTube video showing the MOBY in action and a tour of the vehicle. Here is the link to the YouTube video
Author(s):
Randall Carlyle, MPA, Chief Quality Officer, CareSouth Carolina
Speaker(s):
A Model for Patient Outreach to Address Outstanding Preventive and Maintenance Health Care During the COVID-19 Pandemic
CP26 - A Model for Patient Outreach to Address Outstanding Preventive and Maintenance Health Care During the COVID-19 Pandemic
CP26 - A Model for Patient Outreach to Address Outstanding Preventive and Maintenance Health Care During the COVID-19 Pandemic
Poster Type: Innovation
Category: Expanding Access to Care and Other Services
Issue or Challenge: The COVID-19 pandemic limited access to routine healthcare including cancer screenings, blood pressure checks, diabetes exams, and others. Of 8 metrics for preventive and maintenance healthcare tracked by Denver Health for Lowry Family Health Center, decreased scores were noted across the board from January 2020 to May 2020. The challenge was to enhance access to these necessary medical services for an underserved population and to produce better health outcomes by re-engaging patients in their preventive and maintenance healthcare in safe ways during the pandemic.
Description of Innovation: A patient outreach strategy was developed to address patient care gaps based on 8 metrics routinely tracked by Denver Health. These 8 metrics were considered suitable for outreach because they involved completion of a lab or screening test or scheduling an in-person visit with a provider. The metrics address diabetes (A1c and nephropathy), hypertension, breast/colon/cervical cancer screening, pediatric vaccinations, and asthma. A calendar was developed which listed the metric of focus for each week and included clickable links to standard work. The outreaches were done by medical assistants and included accessing a report for overdue health maintenance in the electric record, placing orders for labs or screening exams, and calling or sending a letter to patients with instructions for scheduling a visit or obtaining tests. Progress was evaluated using a tracking function in the electronic record for recent outreaches as well as change in the clinic’s success rates on the metrics over time.
Impact or Result: 752 individual outreaches were completed between June and December 2020. Rates of success for some metrics improved over that period including diabetic nephropathy testing (+1.2%), cervical cancer screening (+1.4%), and asthma control (+2.8%). However, rates of success decreased in some metrics including diabetic A1c control (-2.7%), breast cancer screening (-1.3%), hypertension control (-0.9%), pediatric vaccinations (-0.8%), and colorectal cancer screening (-0.5%).
Replicating this Innovation: The outreach calendar model would easily replicate. After choosing the healthcare gaps to be addressed, one would need a reliable way to determine those patients that require outreach and a way to track who has been outreached and when.
Author(s):
Raeanna Simcoe, MD, Senior Instructor, Denver Health and Hospital Authority
Jessica Bull, MD, Assistant Professor, Denver Health and Hospital Authority
Zita Fenner, RN, Nurse Program Manager, Denver Health and Hospital Authority
Speaker(s):
Poster Type: Innovation
Category: Expanding Access to Care and Other Services
Issue or Challenge: The COVID-19 pandemic limited access to routine healthcare including cancer screenings, blood pressure checks, diabetes exams, and others. Of 8 metrics for preventive and maintenance healthcare tracked by Denver Health for Lowry Family Health Center, decreased scores were noted across the board from January 2020 to May 2020. The challenge was to enhance access to these necessary medical services for an underserved population and to produce better health outcomes by re-engaging patients in their preventive and maintenance healthcare in safe ways during the pandemic.
Description of Innovation: A patient outreach strategy was developed to address patient care gaps based on 8 metrics routinely tracked by Denver Health. These 8 metrics were considered suitable for outreach because they involved completion of a lab or screening test or scheduling an in-person visit with a provider. The metrics address diabetes (A1c and nephropathy), hypertension, breast/colon/cervical cancer screening, pediatric vaccinations, and asthma. A calendar was developed which listed the metric of focus for each week and included clickable links to standard work. The outreaches were done by medical assistants and included accessing a report for overdue health maintenance in the electric record, placing orders for labs or screening exams, and calling or sending a letter to patients with instructions for scheduling a visit or obtaining tests. Progress was evaluated using a tracking function in the electronic record for recent outreaches as well as change in the clinic’s success rates on the metrics over time.
Impact or Result: 752 individual outreaches were completed between June and December 2020. Rates of success for some metrics improved over that period including diabetic nephropathy testing (+1.2%), cervical cancer screening (+1.4%), and asthma control (+2.8%). However, rates of success decreased in some metrics including diabetic A1c control (-2.7%), breast cancer screening (-1.3%), hypertension control (-0.9%), pediatric vaccinations (-0.8%), and colorectal cancer screening (-0.5%).
Replicating this Innovation: The outreach calendar model would easily replicate. After choosing the healthcare gaps to be addressed, one would need a reliable way to determine those patients that require outreach and a way to track who has been outreached and when.
Author(s):
Raeanna Simcoe, MD, Senior Instructor, Denver Health and Hospital Authority
Jessica Bull, MD, Assistant Professor, Denver Health and Hospital Authority
Zita Fenner, RN, Nurse Program Manager, Denver Health and Hospital Authority
Speaker(s):
The Role of Health Equity Navigators in Improving Access to COVID-19 Vaccines in Latinx Communities Through Community Health Centers
CP27 - The Role of Health Equity Navigators in Improving Access to COVID-19 Vaccines in Latinx Communities Through Community Health Centers
CP27 - The Role of Health Equity Navigators in Improving Access to COVID-19 Vaccines in Latinx Communities Through Community Health Centers
Poster Type: Innovation
Category: Expanding Access to Care and Other Services; Patient and Community Engagement
Issue or Challenge: Vaccine hesitancy is one of the most cited reasons to explain low COVID-19 vaccine uptake among Latinx communities in the United States. AltaMed Health Services is one of the nation’s largest Federally Qualified Health Centers, serving more than 300,000 predominantly Latinx patients in medically underserved communities of southern California. Through this program, we addressed challenges associated with access to vaccine information and appointments for working-class Latinx patients and community members in Orange County, California. Through this approach, we successfully removed barriers that presented initial sources of hesitancy among our patient population, including disinformation and misinformation.
Description of Innovation: Starting in February 2021, AltaMed embarked on a demonstration project to test its Health Equity Navigator model’s effectiveness in improving access to COVID-19 vaccines in its service area. The program is part of the AltaMed Institute for Health Equity’s Undergraduate Medical Education department. It is designed to provide clinical experience to pre-med and other aspiring health professionals. Four Health Equity Navigator positions were pivoted to focus on COVID-19 vaccine engagement, to identify challenges related to underlying social determinants of health, and ultimately to help overcome these challenges. The innovation included three phases. Phase 1: Navigator-led inbound and outbound calls to identified panel of patients meeting initial vaccine eligibility of ages 65+.Phase 2: Inbound calls from patients and community members and outbound calls to non-AltaMed patients based on interests lists provided by community partners. Phase 3: Inbound calls and deployment of a partner community program to streamline appointments for non-patients. During these engagements, health navigators provide information, education, and support, as well as direct assistance to individuals in making appointments for their COVID-19 vaccine.
Impact or Result: Results of our Health Equity Navigator pilot project to increase access to vaccines are as follows: Providing 2,600+ vaccines to highly-vulnerable community members, approximately 50% of whom did not have a medical home. Development and integration of a model to expedite vaccine access for non-clinic patients who lived in our clinic’s service area through community partnerships. Development of a model that can scale medical education programs into a workforce that is ready to advance health equity for pandemic response and recovery. Effectively overcoming vaccine hesitancy by addressing information gaps through culturally concordant education, information, and direct assistance with access.
Replicating this Innovation: Create a pipeline of health navigators who know the community and also have familiarity with navigating systems. This will make it easier for them to address communities’ concerns, in language and terms that resonate with the community. If it is not possible to create a specific pipeline of health navigators, work within the models that already exist in the clinic: community health workers, other forms of patient navigators, and provide specific training on vaccine access and major questions so they can support community members in their process of scheduling.
Author(s):
Gloria Montiel, PhD, Researcher, AltaMed Health Services Corporation
Erick Leyva, Project Coordinator for Undergraduate Medical Education, AltaMed Health Services Corporation
Speaker(s):
Poster Type: Innovation
Category: Expanding Access to Care and Other Services; Patient and Community Engagement
Issue or Challenge: Vaccine hesitancy is one of the most cited reasons to explain low COVID-19 vaccine uptake among Latinx communities in the United States. AltaMed Health Services is one of the nation’s largest Federally Qualified Health Centers, serving more than 300,000 predominantly Latinx patients in medically underserved communities of southern California. Through this program, we addressed challenges associated with access to vaccine information and appointments for working-class Latinx patients and community members in Orange County, California. Through this approach, we successfully removed barriers that presented initial sources of hesitancy among our patient population, including disinformation and misinformation.
Description of Innovation: Starting in February 2021, AltaMed embarked on a demonstration project to test its Health Equity Navigator model’s effectiveness in improving access to COVID-19 vaccines in its service area. The program is part of the AltaMed Institute for Health Equity’s Undergraduate Medical Education department. It is designed to provide clinical experience to pre-med and other aspiring health professionals. Four Health Equity Navigator positions were pivoted to focus on COVID-19 vaccine engagement, to identify challenges related to underlying social determinants of health, and ultimately to help overcome these challenges. The innovation included three phases. Phase 1: Navigator-led inbound and outbound calls to identified panel of patients meeting initial vaccine eligibility of ages 65+.Phase 2: Inbound calls from patients and community members and outbound calls to non-AltaMed patients based on interests lists provided by community partners. Phase 3: Inbound calls and deployment of a partner community program to streamline appointments for non-patients. During these engagements, health navigators provide information, education, and support, as well as direct assistance to individuals in making appointments for their COVID-19 vaccine.
Impact or Result: Results of our Health Equity Navigator pilot project to increase access to vaccines are as follows: Providing 2,600+ vaccines to highly-vulnerable community members, approximately 50% of whom did not have a medical home. Development and integration of a model to expedite vaccine access for non-clinic patients who lived in our clinic’s service area through community partnerships. Development of a model that can scale medical education programs into a workforce that is ready to advance health equity for pandemic response and recovery. Effectively overcoming vaccine hesitancy by addressing information gaps through culturally concordant education, information, and direct assistance with access.
Replicating this Innovation: Create a pipeline of health navigators who know the community and also have familiarity with navigating systems. This will make it easier for them to address communities’ concerns, in language and terms that resonate with the community. If it is not possible to create a specific pipeline of health navigators, work within the models that already exist in the clinic: community health workers, other forms of patient navigators, and provide specific training on vaccine access and major questions so they can support community members in their process of scheduling.
Author(s):
Gloria Montiel, PhD, Researcher, AltaMed Health Services Corporation
Erick Leyva, Project Coordinator for Undergraduate Medical Education, AltaMed Health Services Corporation
Speaker(s):
Addressing Food Insecurity During the Pandemic
CP28 - Addressing Food Insecurity During the Pandemic
CP28 - Addressing Food Insecurity During the Pandemic
Poster Type: Innovation
Category: Expanding Access to Care and Other Services; Patient and Community Engagement
Issue or Challenge: Bronx Community Health Network’s Community Health Workers (CHWs) help identify and refer clients (in clinical and community settings) with social needs to community resources. Historically, food insecurity has been one of the most urgent and common needs our clients face. 1 in 5 clients screened for social needs are food insecure. Referrals of food insecure clients to food resources increased from 700 (2019) to 1,097 (2020). As the pandemic began and stay at home orders were issued, CBOs struggled to stay open and COVID-19 continued to spread, community members found themselves struggling to meet their basic needs.
Description of Innovation: BCHN health centers systematically screen patients for SDH needs (among which food insecurity) and refer them to CHWs who in turn help address patients’ needs and connect them to resources. At the onset of the Covid-19 pandemic, food insecurity needs sharply increased as community members lost income, were unable to go out to get food, and food resources became overwhelmed. In response to the growing food need, BCHN launched a food delivery initiative, through our mobile van and partnership with a local food pantry. CHWs and other care team members (i.e. providers and social workers) identified food insecure clients. If those community members met the eligibility criteria (i.e. elderly, diagnosed with underlying condition, or homebound), they were enrolled in the food delivery initiative. Once enrolled, families received at least one food delivery, connected to additional food resources to supplement the amount of food received, were screened for additional needs and connected to resources (i.e. diapers), and were provided assistance with navigating the internet and submitting benefit applications through newly launched online application portals.
Impact or Result: BCHN is committed to eliminating health disparities among underserved communities in the Bronx. Our mission is to increase access to quality health care, conduct culturally sensitive health education sessions, spearhead community health initiatives, and connect community members to resources to address social determinants of health (SDH). Specific to food insecurity, our CHWs assisted over 700 Bronx families with SNAP enrollment, food pantry or hot meal referrals; increasing to 1,097 in 2020. We have delivered food to over 200 unique families, totaling to over 1,000 Bronxites (one delivery per month, per family), serving every zip code in the Bronx. Through our program we screen for and connect community members to social support services such as food resources, benefits applications, help with housing and utilities, employment, and legal services; provides chronic disease management and healthy lifestyle education; connects to health insurance and quality primary care.
Replicating this Innovation: The goal of this initiative is to address the increasing food insecurity of vulnerable populations in the Bronx. BCHN will replicate our existing food delivery initiative by increasing partnerships to other local food pantries throughout the Bronx. The replication of our program will allow us to have a broader reach and increase the volume of food and the number of people we serve. Additionally, we will be able to link all food delivery recipients to other food and social service resources that can help address the root causes of food insecurity (i.e. job placement, job skills, benefits access etc.)
Author(s):
Patrizia Bernard, MPH, Community Health Worker Supervisor, Bronx Community Health Network
Tashi Chodon, MPH, BSN, Director, Programs, Bronx Community Health Network, Inc.
Renee Whiskey, MPH, MCHES, AE-C, Community Health Programs Developer, Bronx Community Health Network, Inc.
Damiris Perez, MPA, Grants and Program Developer, Bronx Community Health Network, Inc.
Speaker(s):
Poster Type: Innovation
Category: Expanding Access to Care and Other Services; Patient and Community Engagement
Issue or Challenge: Bronx Community Health Network’s Community Health Workers (CHWs) help identify and refer clients (in clinical and community settings) with social needs to community resources. Historically, food insecurity has been one of the most urgent and common needs our clients face. 1 in 5 clients screened for social needs are food insecure. Referrals of food insecure clients to food resources increased from 700 (2019) to 1,097 (2020). As the pandemic began and stay at home orders were issued, CBOs struggled to stay open and COVID-19 continued to spread, community members found themselves struggling to meet their basic needs.
Description of Innovation: BCHN health centers systematically screen patients for SDH needs (among which food insecurity) and refer them to CHWs who in turn help address patients’ needs and connect them to resources. At the onset of the Covid-19 pandemic, food insecurity needs sharply increased as community members lost income, were unable to go out to get food, and food resources became overwhelmed. In response to the growing food need, BCHN launched a food delivery initiative, through our mobile van and partnership with a local food pantry. CHWs and other care team members (i.e. providers and social workers) identified food insecure clients. If those community members met the eligibility criteria (i.e. elderly, diagnosed with underlying condition, or homebound), they were enrolled in the food delivery initiative. Once enrolled, families received at least one food delivery, connected to additional food resources to supplement the amount of food received, were screened for additional needs and connected to resources (i.e. diapers), and were provided assistance with navigating the internet and submitting benefit applications through newly launched online application portals.
Impact or Result: BCHN is committed to eliminating health disparities among underserved communities in the Bronx. Our mission is to increase access to quality health care, conduct culturally sensitive health education sessions, spearhead community health initiatives, and connect community members to resources to address social determinants of health (SDH). Specific to food insecurity, our CHWs assisted over 700 Bronx families with SNAP enrollment, food pantry or hot meal referrals; increasing to 1,097 in 2020. We have delivered food to over 200 unique families, totaling to over 1,000 Bronxites (one delivery per month, per family), serving every zip code in the Bronx. Through our program we screen for and connect community members to social support services such as food resources, benefits applications, help with housing and utilities, employment, and legal services; provides chronic disease management and healthy lifestyle education; connects to health insurance and quality primary care.
Replicating this Innovation: The goal of this initiative is to address the increasing food insecurity of vulnerable populations in the Bronx. BCHN will replicate our existing food delivery initiative by increasing partnerships to other local food pantries throughout the Bronx. The replication of our program will allow us to have a broader reach and increase the volume of food and the number of people we serve. Additionally, we will be able to link all food delivery recipients to other food and social service resources that can help address the root causes of food insecurity (i.e. job placement, job skills, benefits access etc.)
Author(s):
Patrizia Bernard, MPH, Community Health Worker Supervisor, Bronx Community Health Network
Tashi Chodon, MPH, BSN, Director, Programs, Bronx Community Health Network, Inc.
Renee Whiskey, MPH, MCHES, AE-C, Community Health Programs Developer, Bronx Community Health Network, Inc.
Damiris Perez, MPA, Grants and Program Developer, Bronx Community Health Network, Inc.
Speaker(s):
Innovations to Sustain HIV and Hepatitis C Screening and Linkage to Care Efforts: Point-of-Care Testing Through Street Medicine Teams
CP29 - Innovations to Sustain HIV and Hepatitis C Screening and Linkage to Care Efforts: Point-of-Care Testing Through Street Medicine Teams
CP29 - Innovations to Sustain HIV and Hepatitis C Screening and Linkage to Care Efforts: Point-of-Care Testing Through Street Medicine Teams
Poster Type: Innovation
Primary Funding Source: Gilead FOCUS Grant and LA Christian Health Centers, Street Medicine Funding
Category: Expanding Access to Care and Other Services; Improving Care for Special Populations; Patient and Community Engagement; Quality of Care and Quality Improvement; Social Determinants of Health
Issue or Challenge: Over the course of 2020 we saw a 40% decrease overall in Hepatitis C and HIV screenings as patient visits decreased and the clinic shifted to more telehealth visits. Our linkage to care rates remained stable at 96% for Hep C and 91% for HIV. To sustain our Hep C and HIV screening, diagnosis, and linkage to care efforts during the pandemic, we began testing patients for HIV and HCV in non-traditional settings, offering point-of-care screenings both in and outside the clinic in shelters, through street medicine teams, and a mobile van testing unit in collaboration with LA County DPH.
Description of Innovation: LA Christian Health Centers is a federally qualified health center founded in the 1990’s with 2 full-time and 13 part-time satellite sites. Our mission is to serve and improve access to care for the homeless population and those living in public housing. We have performed upwards of 800 point-of-care tests to date in the community as part of our innovation to sustain Hep C and HIV screenings and linkage to care efforts. Planning involved determining a funding source for testing, collaborating with the Los Angeles County Department of Public Health in order to secure access to the mobile van testing unit, establishing workflows and clinical guidelines for screening and linkage, and supplying to and training street medicine teams for use of rapid test and implementation of screening workflows. The point-of-care tests are performed by roaming street medicine teams throughout the week and weekly testing at different locations in the community using a mobile van unit through Los Angeles County DPH. Upon detection of rapid positives on the mobile van testing unit or by street medicine teams, we draw confirmatory labs same day and schedule patient appointments for linkage to care through our HIV/Hepatitis C Care Coordinator.
Impact or Result: We have detected 50 positive Hepatitis C patients at a 12.6% seropositivity rate and 6 positive HIV patients at a 1.38% positivity rate with 67% linked to care and 2 started on rapid start ART therapy day of. All positive patients are offered confirmatory blood-based screenings in the street medicine, mobile van, or clinic settings and scheduled for linkage to care appointments to discuss diagnosis and further care. 32% of the Hepatitis C positives have been new positives. Of these new positives, we have confirmed 43% and are currently working to link the confirmed positives to care. Testing patients in non-traditional settings has allowed us to uncover both new and known Hep C and HIV positive individuals, engage with patients in a familiar setting, and increase access to healthcare services; this has also has changed the way we outreach to patients, emphasizing meeting patients where they are at.
Replicating this Innovation: Replication of these innovations in other organizations would require a similar expansion of street medicine teams and outreach, utilizing teams of healthcare providers, nurses, medical assistants, and a care coordinator to facilitate screening and linkage to care efforts from street medicine to clinic setting. These efforts would additionally require close community partnerships with organizations providing similar community-based and social service-related resources and engaging regularly with patients in street-based settings, such as case management and housing navigation teams. Finally, a means of processing, tracking, and analyzing through EMR via cooperation with IT specialists in your organization, would be an important development to allow for the successful implementation of this innovation.
Author(s):
Kathryn Fulton, HIV and Hepatitis C Care Coordinator, Los Angeles Christian Health Centers
Speaker(s):
Poster Type: Innovation
Primary Funding Source: Gilead FOCUS Grant and LA Christian Health Centers, Street Medicine Funding
Category: Expanding Access to Care and Other Services; Improving Care for Special Populations; Patient and Community Engagement; Quality of Care and Quality Improvement; Social Determinants of Health
Issue or Challenge: Over the course of 2020 we saw a 40% decrease overall in Hepatitis C and HIV screenings as patient visits decreased and the clinic shifted to more telehealth visits. Our linkage to care rates remained stable at 96% for Hep C and 91% for HIV. To sustain our Hep C and HIV screening, diagnosis, and linkage to care efforts during the pandemic, we began testing patients for HIV and HCV in non-traditional settings, offering point-of-care screenings both in and outside the clinic in shelters, through street medicine teams, and a mobile van testing unit in collaboration with LA County DPH.
Description of Innovation: LA Christian Health Centers is a federally qualified health center founded in the 1990’s with 2 full-time and 13 part-time satellite sites. Our mission is to serve and improve access to care for the homeless population and those living in public housing. We have performed upwards of 800 point-of-care tests to date in the community as part of our innovation to sustain Hep C and HIV screenings and linkage to care efforts. Planning involved determining a funding source for testing, collaborating with the Los Angeles County Department of Public Health in order to secure access to the mobile van testing unit, establishing workflows and clinical guidelines for screening and linkage, and supplying to and training street medicine teams for use of rapid test and implementation of screening workflows. The point-of-care tests are performed by roaming street medicine teams throughout the week and weekly testing at different locations in the community using a mobile van unit through Los Angeles County DPH. Upon detection of rapid positives on the mobile van testing unit or by street medicine teams, we draw confirmatory labs same day and schedule patient appointments for linkage to care through our HIV/Hepatitis C Care Coordinator.
Impact or Result: We have detected 50 positive Hepatitis C patients at a 12.6% seropositivity rate and 6 positive HIV patients at a 1.38% positivity rate with 67% linked to care and 2 started on rapid start ART therapy day of. All positive patients are offered confirmatory blood-based screenings in the street medicine, mobile van, or clinic settings and scheduled for linkage to care appointments to discuss diagnosis and further care. 32% of the Hepatitis C positives have been new positives. Of these new positives, we have confirmed 43% and are currently working to link the confirmed positives to care. Testing patients in non-traditional settings has allowed us to uncover both new and known Hep C and HIV positive individuals, engage with patients in a familiar setting, and increase access to healthcare services; this has also has changed the way we outreach to patients, emphasizing meeting patients where they are at.
Replicating this Innovation: Replication of these innovations in other organizations would require a similar expansion of street medicine teams and outreach, utilizing teams of healthcare providers, nurses, medical assistants, and a care coordinator to facilitate screening and linkage to care efforts from street medicine to clinic setting. These efforts would additionally require close community partnerships with organizations providing similar community-based and social service-related resources and engaging regularly with patients in street-based settings, such as case management and housing navigation teams. Finally, a means of processing, tracking, and analyzing through EMR via cooperation with IT specialists in your organization, would be an important development to allow for the successful implementation of this innovation.
Author(s):
Kathryn Fulton, HIV and Hepatitis C Care Coordinator, Los Angeles Christian Health Centers
Speaker(s):
Addressing the Maternal Mortality Crisis in the Ambulatory Setting: A Quality Improvement Approach
CP30 - Addressing the Maternal Mortality Crisis in the Ambulatory Setting: A Quality Improvement Approach
CP30 - Addressing the Maternal Mortality Crisis in the Ambulatory Setting: A Quality Improvement Approach
Poster Type: Research
Track/Topic: Patient and Community Engagement; Public Health Crises; Quality of Care and Quality Improvement
Research Objectives: The Chicago Collaborative for Maternal Health, led by AllianceChicago and EverThrive Illinois, aims to improve maternal health via quality improvement in ambulatory care, community engagement, and policy advocacy. AllianceChicago is leading QI, a population health model seeking to increase the percentage of high-risk patients linked to primary care after delivery.
Research Study Design/Methods: The CCMH QI collaborative reflects the Institute for Healthcare Improvement’s (IHI) “Collaborative Model for Achieving Breakthrough Improvement,” which includes the following activities: topic selection; expert recruitment; participating organization recruitment; action periods; and learning sessions. AllianceChicago will conduct pre- and post- comparison of the quality improvement intervention: de-identified, aggregate baseline data collection to compare with deidentified, aggregate post-intervention data collection along with analysis of a small subset of patient level, de-identified data from AllianceChicago participating sites. Each clinic will pilot the intervention with their own designated high-risk criteria based on their patient population.
Research Principal Findings and Quantitative/Qualitative Results: AllianceChicago engaged thirteen partners to inform QI, with seven implementing. We conducted baseline data collection on structure, process, and outcome measures. Structure and process measures include: high-risk criteria defined/implemented; care coordination process identified/implemented; number of staff trained; and number of locations of care implemented. At baseline, three sites had existing high-risk criteria and care coordination processes; no sites had processes linking to primary care. All sites are implementing in at least one location of care with staff trainings in process. The primary outcome measure is the percentage of high-risk patients connected to primary care. The aggregate baseline was 26 percent.
Research Conclusions on Impact on Health Centers: According to the Chicago Department of Public Health’s report, “Maternal Morbidity and Mortality in Chicago,” non-Hispanic Black birthing people have the highest rates of maternal morbidity and mortality in Chicago. This is reflective of data at state/national levels. The baseline data is clear there are opportunities for improvement in linking high-risk prenatal patients to primary care after delivery, a crucial time to impact outcomes. From initial learnings, AllianceChicago has developed an algorithm to define and identify high-risk patients to coordinate care, which supports health center capacity and aims for this pilot to be sustainable, replicable, and scalable.
Authors:
Jena Wallander Gemkow, MPH, BSN, RN, Clinical Research Manager, AllianceChicago
Speaker(s):
Poster Type: Research
Track/Topic: Patient and Community Engagement; Public Health Crises; Quality of Care and Quality Improvement
Research Objectives: The Chicago Collaborative for Maternal Health, led by AllianceChicago and EverThrive Illinois, aims to improve maternal health via quality improvement in ambulatory care, community engagement, and policy advocacy. AllianceChicago is leading QI, a population health model seeking to increase the percentage of high-risk patients linked to primary care after delivery.
Research Study Design/Methods: The CCMH QI collaborative reflects the Institute for Healthcare Improvement’s (IHI) “Collaborative Model for Achieving Breakthrough Improvement,” which includes the following activities: topic selection; expert recruitment; participating organization recruitment; action periods; and learning sessions. AllianceChicago will conduct pre- and post- comparison of the quality improvement intervention: de-identified, aggregate baseline data collection to compare with deidentified, aggregate post-intervention data collection along with analysis of a small subset of patient level, de-identified data from AllianceChicago participating sites. Each clinic will pilot the intervention with their own designated high-risk criteria based on their patient population.
Research Principal Findings and Quantitative/Qualitative Results: AllianceChicago engaged thirteen partners to inform QI, with seven implementing. We conducted baseline data collection on structure, process, and outcome measures. Structure and process measures include: high-risk criteria defined/implemented; care coordination process identified/implemented; number of staff trained; and number of locations of care implemented. At baseline, three sites had existing high-risk criteria and care coordination processes; no sites had processes linking to primary care. All sites are implementing in at least one location of care with staff trainings in process. The primary outcome measure is the percentage of high-risk patients connected to primary care. The aggregate baseline was 26 percent.
Research Conclusions on Impact on Health Centers: According to the Chicago Department of Public Health’s report, “Maternal Morbidity and Mortality in Chicago,” non-Hispanic Black birthing people have the highest rates of maternal morbidity and mortality in Chicago. This is reflective of data at state/national levels. The baseline data is clear there are opportunities for improvement in linking high-risk prenatal patients to primary care after delivery, a crucial time to impact outcomes. From initial learnings, AllianceChicago has developed an algorithm to define and identify high-risk patients to coordinate care, which supports health center capacity and aims for this pilot to be sustainable, replicable, and scalable.
Authors:
Jena Wallander Gemkow, MPH, BSN, RN, Clinical Research Manager, AllianceChicago
Speaker(s):
Improving Health Outcomes in Vulnerable Populations: The Medical-Legal-Partnership Colorado’s (MLP-CO’s) Experience
CP31 - Improving Health Outcomes in Vulnerable Populations: The Medical-Legal-Partnership Colorado’s (MLP-CO’s) Experience
CP31 - Improving Health Outcomes in Vulnerable Populations: The Medical-Legal-Partnership Colorados (MLP-CO’s) Experience
Poster Type: Innovation
Category: Patient and Community Engagement; Social Determinants of Health
Issue or Challenge: Social determinants of health(SDH) may have a greater effect on health outcomes than medical interventions, yet healthcare providers are not adequately equipped to address them. Medical legal partnerships (MLPs) add legal professionals, trained specifically to tackle these issues, to the healthcare team. The latest reviews of the evidence document how the MLP addresses the quadruple aim (patient and provider experience, costs, health outcomes). However, evaluations on health outcomes and healthcare utilization remain scarce hampering the wide adoption of this strategy. We describe the pre and post evaluation of the MLP-CO’s impact on health outcomes, healthcare utilization, legal needs and satisfaction.
Description of Innovation: Unlike other civil legal aid organizations MLP Colorado operates on-site and in coordination with Salud Family Health Center in Commerce City, CO. Under this fully-integrated model, MLP attorneys act as one piece of the care team alongside services like primary care, behavioral health, dental, pharmacy, and care management. Patients are then screened by the MLP-CO lawyers for I-HELP legal needs (Income, Housing, Employment, Legal status, Personal needs). Clients with needs other than I-HELP are referred to local organizations providing legal aid. From 2015-2020, the MLP-CO completed 223 legal cases while 185 cases remained open (average 68 clients/year). Since its inception, evaluation of health outcomes and healthcare utilization (especially emergency department visits) of the MLP-CO clients was a priority. Upon MLP-CO enrollment (BASELINE), clients are assessed for: 1)overall mental and physical health, using validated questions from SF-36; 2)healthcare utilization; 3)legal needs. Six months post-enrollment (FOLLOW-UP), clients are contacted by phone to assess the same items, as well as satisfaction with MLP-CO services, and perception of the MLP-CO’s impact on their healthcare experience. Interviews were conducted in the client’s preferred language.
Impact or Result: Overall, 115 clients (115/193, 59.6%) responded the surveys. Most were low-income women. Reasons for legal assistance were: immigration status(48.7%), income/benefits(28.7%), personal/family stability(16.7%), housing(5.3%), and education(0.7%). Legal success rate was 84.5%. Over 86% of clients reported that their lawyer explained well, listened carefully, treated them with respect and spent enough time with them, and rated their lawyer as 4-5 (scale 0-5, 5=best lawyer).Sixty-nine (69/193, 35.7%) clients had complete data on health outcomes at the BASELINE and FOLLOW-UP periods to allow a paired analysis (Table).Days with poor physical/mental health in the past month, as well as in feelings of stress and worry in the past 2 weeks improved significantly. Self-reported overall health and days with no usual activities due to poor physical or mental health in the past month also improved, albeit not significantly. Missed appointments reduced significantly. There were also reductions, albeit not significant, in the emergency department.
Replicating this Innovation: According to data from the National Center for Medical Legal Partnerships, MLPs have expanded across the nation, with programs in 450 health centers and hospitals, which has increased by over 100 locations from 2019.
Author(s):
Marc Scanlon, JD, Executive Direct, Salud Family Health Centers
Poster Type: Innovation
Category: Patient and Community Engagement; Social Determinants of Health
Issue or Challenge: Social determinants of health(SDH) may have a greater effect on health outcomes than medical interventions, yet healthcare providers are not adequately equipped to address them. Medical legal partnerships (MLPs) add legal professionals, trained specifically to tackle these issues, to the healthcare team. The latest reviews of the evidence document how the MLP addresses the quadruple aim (patient and provider experience, costs, health outcomes). However, evaluations on health outcomes and healthcare utilization remain scarce hampering the wide adoption of this strategy. We describe the pre and post evaluation of the MLP-CO’s impact on health outcomes, healthcare utilization, legal needs and satisfaction.
Description of Innovation: Unlike other civil legal aid organizations MLP Colorado operates on-site and in coordination with Salud Family Health Center in Commerce City, CO. Under this fully-integrated model, MLP attorneys act as one piece of the care team alongside services like primary care, behavioral health, dental, pharmacy, and care management. Patients are then screened by the MLP-CO lawyers for I-HELP legal needs (Income, Housing, Employment, Legal status, Personal needs). Clients with needs other than I-HELP are referred to local organizations providing legal aid. From 2015-2020, the MLP-CO completed 223 legal cases while 185 cases remained open (average 68 clients/year). Since its inception, evaluation of health outcomes and healthcare utilization (especially emergency department visits) of the MLP-CO clients was a priority. Upon MLP-CO enrollment (BASELINE), clients are assessed for: 1)overall mental and physical health, using validated questions from SF-36; 2)healthcare utilization; 3)legal needs. Six months post-enrollment (FOLLOW-UP), clients are contacted by phone to assess the same items, as well as satisfaction with MLP-CO services, and perception of the MLP-CO’s impact on their healthcare experience. Interviews were conducted in the client’s preferred language.
Impact or Result: Overall, 115 clients (115/193, 59.6%) responded the surveys. Most were low-income women. Reasons for legal assistance were: immigration status(48.7%), income/benefits(28.7%), personal/family stability(16.7%), housing(5.3%), and education(0.7%). Legal success rate was 84.5%. Over 86% of clients reported that their lawyer explained well, listened carefully, treated them with respect and spent enough time with them, and rated their lawyer as 4-5 (scale 0-5, 5=best lawyer).Sixty-nine (69/193, 35.7%) clients had complete data on health outcomes at the BASELINE and FOLLOW-UP periods to allow a paired analysis (Table).Days with poor physical/mental health in the past month, as well as in feelings of stress and worry in the past 2 weeks improved significantly. Self-reported overall health and days with no usual activities due to poor physical or mental health in the past month also improved, albeit not significantly. Missed appointments reduced significantly. There were also reductions, albeit not significant, in the emergency department.
Replicating this Innovation: According to data from the National Center for Medical Legal Partnerships, MLPs have expanded across the nation, with programs in 450 health centers and hospitals, which has increased by over 100 locations from 2019.
Author(s):
Marc Scanlon, JD, Executive Direct, Salud Family Health Centers
