EVALUATION OF A TRANSITIONS CLINIC TO BRIDGE EMERGENCY DEPARTMENT AND PRIMARY CARE

BACKGROUND: Suboptimal transitions from emergency department (ED) to ambulatory settings contribute to poor clinical outcomes and unnecessary non-urgent ED utilization. Primary care-staffed care transition clinics (CTCs) are a potential solution to reduce ED crowding by providing ED follow-up care and facilitating the bridge to longer-term primary care. This study is a preliminary evaluation of the initiation of an ED transitions clinic on 30-day ED and hospital readmissions. METHODS: This retrospective cross-sectional study included adults discharged from the ED at UC hicago Medicine referred to the transitions clinic between November 2020 and May 2021. Appointment attendance, frequency of care type provided, and percent contacted with patient advocate were computed to assess clinic utilization. 30-day ED and hospital readmissions were compared between patients who completed their CTC appointment and patients who missed their CTC appointment using a chi-square test. RESULTS: In the first 6 months of program initiation, 116 patients were referred to the CTC from the ED and around half (47%) completed their follow-up appointment. The majority of patients were of black race (90%) and on public insurance (81%). Almost a quarter of referred patients (22%) were contacted by a patient advocate for referral to longer-term care. The most common reasons for referral were wound check (top 3: cellulitis, abscess, suture removal) and clinical problem management (top 3: SOB, chest pain, covid). Wound checks were 20% more likely to be completed compared to clinical appointments (58% show rate vs 38%). Patients who completed their CTC appointment had a lower rate of ED revisits (15% vs 20%) but the effect was not statistically significant (p>0.05). No statistically significant effects were seen for CTC appointment completion on hospital readmission. CONCLUSIONS: Transition clinics may have the potential to help reduce excess ED use for ambulatory care needs, particularly if they can help facilitate patients being connected to more permanent ambulatory care sites and clinicians. In addition to ongoing analysis of this program evaluation regarding ED and hospital utilization, additional research is needed to investigate the factors influencing follow-up completion and identifying effective interventions for increasing appointment attendance.

EXAMINING THE RELATIONSHIP BETWEEN HEALTH LITERACY AND TECHNOLOGY ACCESS AND USAGE IN ADULT INPATIENTS DIAGNOSED WITH TYPE 2 DIABETES MELLITUS

BACKGROUND: Considering the increased reliance on health technology during the COVID-19 Pandemic, Electronic Health (eHealth) interventions have become important for DM self-management (e.g., glucose monitoring). We have previously shown low HL to be a barrier to technology usage in the general inpatient adult population. However, the role of lowHL specifically for DM self-management requires further evaluation. METHODS: This is a sub-analysis of the Hospitalist Study, an observational, ongoing, quality improvement study of adults (age ≥18 years) enrolled from June 2019-March 2021. Patients were eligible for our sub-study if they were English speaking, had a DM diagnosis, and completed the brief health literacy screen. Participants completed questionnaires assessing technology access/use and online capabilities. Descriptive statistics, bivariate chi-squared, and multivariate logistic regression analyses (adjusted for age, race, education, and gender) were performed using STATA version 15.1 (StataCorp). RESULTS: Among 110 participants, the mean age was 61±15 years, most identified as Black (76%) and/or female (51%) and had at least some college education (58%). There were no significant differences in device ownership between low (n=15) and adequate (n=95) HL groups (93% vs. 94%, p=0.96). Those with low vs. adequate HL were less-likely to have previously used the internet (47% vs. 83%, p=0.006) and less-likely to independently use several internet features: use search engine (33% vs. 76% p<0.001), open online attachment (33% vs. 68%, p =0.005), upload images/files to a website (20% vs 54%, p=0.005), print webpages/online information (27% vs. 49%, p=0.04), use a video (47% vs. 72%, p=0.02), and/or use an interactive video (27% vs. 52%, p=0.01). In the multivariate analysis, participants with low HL remained significantly associated with decreased ability to independently perform online tasks (all measures p<0.05). CONCLUSIONS: Our data suggest that low HL may be a barrier to internet access and usage among patients with DM, but not for technology ownership. Future studies are necessary to ensure that at-risk populations can effectively utilize novel eHealth technologies particularly in the rapidly changing landscape of technology use in the clinical setting.

ASSESSMENT OF INPATIENTS' FAMILY TECHNOLOGY OWNERSHIP, USAGE, AND AVAILABILITY OF ASSISTANCE WITH TELEHEALTH TECHNOLOGY

BACKGROUND: As COVID-19 shifted healthcare delivery online, family assistance in accessing care using technology was highlighted, particularly in vaccine appointments and telehealth. While previous literature has characterized factors associated with patients' technology ownership and use, the role of families in assisting with technology access and use is less characterized. METHODS: This is a cross-sectional observational sub-study of a larger study of adult general medicine inpatients at the University of Chicago between 5/2019-8/2021. Patient reported family technology access, use, and assistance were evaluated. Multivariable logistic regressions were conducted to evaluate for association(s) with patient demographics, education level, and health literacy. Health literacy was measured using the Brief Health Literacy Screening Tool. STATA 15.1 was used for analysis, and significance was measured at p<0.05. RESULTS: Of 383 participants, the median age was 57 years, 65%(248/383) were Black, and 53% (204/383) were female. A third were college graduates (32%, 123/383) and had low health literacy (34%, 130/383). Most participants reported that their families owned technology devices (88%, 336/383) and regularly used the internet (once or more per day;72%, 274/383). Cell phones were the most commonly reported way that their families accessed the internet, with 29% (108/369) mostly using a cell phone, and 10% (38/369) using a cell phone and another device equally. 22% (84/383) of participants reported using the internet at a family or friend's house. In the multivariable logistic regression, family technology ownership was negatively correlated with increasing age (p=0.04) and self-identifying as Black (p=0.03). Increasing age (p <0.001) and low health literacy (p= 0.03) had a negative association with family daily internet use. Most participants (89%;233/263) reported having a family member or caretaker who could help them use technology to access telehealth. Increasing age (p= 0.01) and low health literacy (p= 0.03) were negatively associated with having family assistance, while female gender had a positive correlation (p= 0.04). CONCLUSIONS: Although family ownership and usage of technology devices are generally high, family ownership was reported less often among older and Black participants. Lower usage was also reported among those with lower health literacy. While most do have someone to help with telehealth technology, this was less common in older patients and those with low health literacy. Considering the importance of family technology use and assistance in ensuring healthcare, leveraging family networks to access technology-based care can help bridge the technology divide for patients.

A Qualitative Analysis of Barriers to Peri-Discharge Care for Patients with COPD and OSA Overlap

Rationale: Patients with chronic obstructive pulmonary disease (COPD) suffer heightened morbidity, mortality, and readmission rates. COPD is co-prevalent with obstructive sleep apnea (OSA) in 20-60% of patients, and patients with COPD/OSA overlap are at higher risk for hospital readmission and mortality compared to COPD alone. Current COPD readmission reduction programs are focused on decreasing COPD readmissions;however, few explore impactful comorbid conditions. No study has identified peri-discharge barriers in the acute care setting from the perspective of patients with COPD/OSA or healthcare workers to identify areas of improvement. Methods: Semi-structured interviews, conducted via telephone (recorded) of hospitalized patients with COPD/OSA and acute care healthcare workers were conducted at an urban academic medical center (11/2020-1/2021) among a convenience sample of recruited participants. All recordings were transcribed and uploaded to NVivo, which facilitated thematic analysis, using an a priori codebook. Coding was conducted in rounds, and meetings were used to resolve differences and update the codebook as needed. This iterative process continued until all transcripts were analyzed. Results: Thirty-five participants were interviewed, 27 healthcare workers (HCW), 4 nurses, 6 respiratory therapists, 5 physicians, 3 case managers, 4 social workers, and 5 pharmacists, and 8 patients. The HCWs interviewed served an average of 7.5 years, were <50 years old (81.5%), and most were female (74.1%), white (81.5%), and non-Hispanic (100%). HCW respondents identified barriers that mapped to four main levels: patient, team, hospital, and the healthcare system. Select barriers HCWs identified included health literacy, patient cognitive impairments, peri-discharge time management, lack of resources for patients post-discharge, cost, and insurance. All patient interviewees were <50 years old, most were male (62.5%), white (62.5%), and non-Hispanic (87.5%). Select barriers patients identified included current SES status, care team discussions, disease burden (visits to ED/hospital), follow-up care (including transportation), and perceptions of healthcare due to COVID-19. Conclusion: Healthcare workers and COPD/OSA patients report multilevel hospital discharge barriers. To improve barriers to care for these complex patients, multilevel interventions addressing noted barriers are needed.

Discrepancies in Predictive Factors of Inhaler Technique vs. Adherence

Background: Inhaled medications effectively treat Chronic Obstructive Lung Disease (COPD) through reduction of symptoms and improvement in patient outcomes, however inhaler misuse and nonadherence to treatment plans remain significant barriers to achieving optimal disease control. We investigated predictors for completion of a novel at-home self-management support program to better understand factors that promote treatment adherence and retention of inhaler technique. Methods:Hospitalized adults with COPD were enrolled in this study. Participants received inhospital inhaler education in the form of Virtual Teach-to-Goal (V-TTG). Inhaler technique was assessed using a validated checklist where inhaler misuse was categorized as getting less than or equal to 9 steps out of 12 correct. A validated questionnaire assessed the participants' quality of life (QoL) regarding their respiratory health. Upon discharge, participants were instructed to complete the V-TTG assessment at home and return for a 30-day follow up. Amendments were made to the IRB as the study progressed to further investigate the low completion rates of the VTTG module at home and to facilitate virtual follow-up options due to COVID-19 restrictions. Binary and multivariable logistic regression models were used to predict correct pre-intervention inhaler technique given external factors such as participant zip code, type of housing, and whether they had a caregiver. Results:The majority of participants were Black (97%) and female (57%), with an average age of 63 years (range: 43-79, S.D. ± 8.4). Of 70 participants, 24 completed the study by attending the 30-day follow-up (34%), and there was no significant change in inhaler misuse rates from baseline to 30-day follow up (p = 0.09). No predictors for program completion, external factors, and/or QoL measures were found to be predictive of maintained inhaler technique at the 30-day follow-up or for attending the 30-day follow-up in either binary or multi-variable logistic regression. Conclusions: These findings highlight the challenge of maintaining inhaler skills and adherence to treatment plans through self-supported, home-based interventions. There was no single parameter, or combination of parameters, predictive of attending the 30-day follow-up or adequate inhaler technique at follow-up. Research that further explores the role that personal and societal characteristics play in both treatment adherence and retention of inhaler technique is needed to improve our understanding of how to effectively engage patients in complex self-management.

A National Partnership with the COPD Foundation to Implement the COPD Virtual Medication Reconciliation and Education: COPD V-M(ED) Pilot

Rationale: COPD is the fourth leading cause of US hospitalizations. The majority of hospitalized patients misuse inhalers, a factor unrecognized by many patients and clinicians. COVID-related distancing requirements and decreased in-person care has further challenged the quality and modality of care-delivery, including opportunities for inhaler education. There is a critical need for innovation to deliver this critical aspect of COPD care. This study aims to improve clinician-patient communication and access to care for patients with COPD by developing and implementing a telehealth education platform to augment the clinic visit. Methods: This mixed-methods study utilized semi-structured patient interviews and clinician survey data to obtain diverse perspectives about facilitators and barriers to our “V-M(ED)” intervention. Patients participated in the COPD V-M(ED), pharmacy-led video visits with patients to conduct inhaler technique education using teach-to-goal, during clinic visits. Eligible patients were consented to participate in semi-structured interviews assessing their experiences with prior telehealth visits, inhaler education, and feedback on V-M(ED). Clinicians recruited via email completed brief surveys focusing on barriers, facilitators, and opportunities for incorporating multi-disciplinary teams to deliver telehealth-based educational teaching for patients. Demographic and Likert-scale data were analyzed with descriptive statistics. Themes were coded for open-ended questions. Results: Of 15 clinic patients who received inhaler education, 10 were enrolled in the study. Participants were on average 73.7 years of age, 80% were female, and 90% self-identified as Black. Three major themes emerged regarding patient telehealth experience (Table): 1) the pros and cons of technology-based visits (e.g., convenience);2) setting preference for clinical visits (e.g., in-person);and 3) effectiveness of virtual inhaler education (e.g., most reported benefiting). Thirteen clinicians completed the care team perspectives survey. While the majority felt incorporating virtual teaching from clinician team-members would be beneficial to patients, only 31% reported that the benefits would outweigh barriers to use. However, of clinicians who did not have prior experience incorporating virtual education into patient encounters, nearly half reported they would use a program if it were in place. Conclusions: This study provides important insights into both patient and clinician perspectives on integrating virtual telehealth education into patient care. Despite a preference for in-person clinical encounters, using a telehealth modality for inhaler education was well-received by our patient cohort. This feedback, along with the positive attitudes of clinicians in the usefulness and desire to offer virtual video platforms for patient education, suggests virtual education can be an effective modality for disease self-management. (Table Presented).