"It Made Me Feel like Things Are Starting to Change in Society:" A Qualitative Study to Foster Positive Patient Experiences during Phone-Based Social Needs Interventions.

Many healthcare organizations are screening patients for health-related social needs (HRSN) to improve healthcare quality and outcomes. Due to both the COVID-19 pandemic and limited time during clinical visits, much of this screening is now happening by phone. To promote healing and avoid harm, it is vital to understand patient experiences and recommendations regarding these activities. We conducted a pragmatic qualitative study with patients who had participated in a HRSN intervention. We applied maximum variation sampling, completed recruitment and interviews by phone, and carried out an inductive reflexive thematic analysis. From August to November 2021 we interviewed 34 patients, developed 6 themes, and used these themes to create a framework for generating positive patient experiences during phone-based HRSN interventions. First, we found patients were likely to have initial skepticism or reservations about the intervention. Second, we identified 4 positive intervention components regarding patient experience: transparency and respect for patient autonomy; kind demeanor; genuine intention to help; and attentiveness and responsiveness to patients' situations. Finally, we found patients could be left with feelings of appreciation or hope, regardless of whether they connected with HRSN resources. Healthcare organizations can incorporate our framework into trainings for team members carrying out phone-based HRSN interventions.

Implementing health-related social needs screening in western Colorado primary care practices: Qualitative research to inform improved communication with patients.

Social determinants profoundly impact health. Many primary care practices now seek to screen their patients for health-related social needs (HRSN) and refer them to resources in the community. However, there is little empirical evidence to guide communication with patients in order to ensure their comfort with the process and increase the likelihood that it results in positive outcomes. This paper describes the first phase of the Improving Messaging Around Gaps in Needs and rEfferals (IMAGINE) study-a multi-phase study aiming to develop and test patient-centred messages about screening and referral for HRSN. In this initial qualitative phase, our objective was to identify communication strategies that might make western Colorado primary care patients more comfortable with the HRSN screening and referral process. From May to July 2020 we interviewed 10 staff members responsible for HRSN screening from primary care practices participating in the western Colorado Accountable Health Communities (AHC) initiative and 20 patients from 2 of these practices. We used a rapid qualitative analysis process that involved summarising interview transcripts across key domains of interest and then identifying emergent themes within each domain using a data matrix. Through this process, we examined current communication about HRSN screening, as well as suggestions for messages and other strategies that could improve communication. In most practices, the AHC Screening Tool was handed to patients by front desk staff at check-in with little explanation as to its purpose. Patients and staff alike recommended that patients be provided with information that: normalises the screening and referral process; assures privacy; clarifies that the purpose is to help and support rather than judge or report; emphasises community benefits; and respects patient autonomy. Interviewees also suggested broader strategies to support more effective communication, such as practice staff and clinicians building trusting relationships with patients and understanding and acknowledging the complex structural barriers that often prevent patients from accessing meaningful assistance. These findings provide actionable suggestions for improving communication about HRSN screening and referral in primary care settings. The next steps include developing specific messages based on these findings and testing their impact on screening tool completion rate, referral uptake, and patient-reported comfort with the process.

COVID-19 stressors and one-year changes in depression and anxiety in a longitudinal cohort of low-income adults in the United States.

Emerging data suggest that adults with low income are at highest risk for COVID-19-related stressors and mental health disorders. This study aimed to determine if COVID-19-related stressors were associated with worsening depression and anxiety in a cohort of low-income adults one year after the start of the pandemic. Participants included 253 Medicaid and commercial accountable care organization recipients from 5 community health centers around Boston, MA who enrolled December 2019-March 2020 in a larger longitudinal study of a Medicaid program. Participants completed surveys at baseline and one-year follow-up that measured depression (Patient Health Questionnaire-8 [PHQ-8]) and anxiety (Generalized Anxiety Disorder-7 [GAD-7]) symptoms. Follow-up surveys assessed COVID-19-related stressors experienced over the prior 12 months. A stressor score included COVID-19-related infectious, social, and economic stressors categorized into tertiles (low, 0-3; medium, 4-6; high, 7-19). Mean age (SD) was 45.2 (11.5) years; 71.2% were female, 42.3% Hispanic and 14.6% Black. At baseline, 126 (49.8%) had moderate or severe depression (PHQ-8 ≥ 10), and 109 (43.1%) had moderate or severe anxiety (GAD-7 ≥ 10). The mean (SD) number of COVID-19 stressors was 4.9 (3.1); the most frequent were food insecurity (52.2%) and job or income loss (43.9%). Compared to the low tertile, those in high and medium tertiles had significantly greater one-year increases in depression and anxiety symptoms. Low-income adults facing multiple COVID-19-related stressors, particularly health-related social needs, had worsening mental health symptoms over one year. Interventions are urgently needed to address the dual burden of health-related social needs and poor mental health exacerbated by COVID-19.

The Health and Social Needs of Patients Discharged From the Emergency Department With Suspected COVID-19.

Health-related social needs (HRSNs), such as food or housing insecurity, are important drivers of disparities in outcomes during public health emergencies. We describe the development of a telehealth follow-up program in Boston, Massachusetts, for patients discharged from the emergency department after coronavirus disease 2019 (COVID-19) testing to identify patients with worsening clinical symptoms, to screen for unmet HRSNs, and to deliver self-isolation counseling and risk-reduction strategies for socially vulnerable people. We prioritized telephone calls to patients with public health insurance and patients without primary care physicians. In the first 43 days of operation, March 30-May 12, 2020, our intervention reached 509 patients, with 209 (41.1%) patients reporting an HRSN, most commonly related to food, housing, or utilities. Thirty-one (6.1%) patients required assessment by a clinician for clinical worsening. This public health intervention may be useful for other institutions developing programs to address the social and health needs of patients discharged with suspected COVID-19.

Patient Experiences with Screening and Assistance for Social Isolation in Primary Care Settings.

BACKGROUND: Social isolation is a known predictor of mortality that disproportionately affects vulnerable populations in the USA. Although experts began to recognize it as a public health crisis prior to 2020, the novel coronavirus pandemic has accelerated recognition of social isolation as a serious threat to health and well-being. OBJECTIVE: Examine patient experiences with screening and assistance for social isolation in primary care settings, and whether patient experiences with these activities are associated with the severity of reported social isolation. DESIGN: Cross-sectional survey conducted in 2018. PARTICIPANTS: Adults (N = 251) were recruited from 3 primary care clinics in Boston, Chicago, and San Francisco. MAIN MEASURES: A modified version of the Berkman-Syme Social Network Index (SNI), endorsed by the National Academies of Sciences, Engineering, and Medicine; items to assess for prior experiences with screening and assistance for social isolation. KEY RESULTS: In the sample population, 12.4% reported the highest levels of social isolation (SNI = 0/1), compared to 36.7%, 34.7%, and 16.3% (SNI = 2-4, respectively). Most patients had not been asked about social isolation in a healthcare setting (87.3%), despite reporting no discomfort with social isolation screening (93.9%). Neither discomfort with nor participation in prior screening for social isolation was associated with social isolation levels. Desire for assistance with social isolation (3.2%) was associated with a higher level of social isolation (AOR = 6.0, 95% CI, 1.3-28.8), as well as poor or fair health status (AOR = 9.1; 95% CI, 1.3-64.1). CONCLUSIONS: In this study, few patients reported being screened previously for social isolation in a primary care setting, despite low levels of discomfort with screening. Providers should consider broadening social isolation screening and referral practices in healthcare settings, especially among sicker and more isolated patients who express higher levels of interest in assistance with social isolation.

Rapid-Cycle Community Assessment of Health-Related Social Needs of Children and Families During Coronavirus Disease 2019.

OBJECTIVE: To identify unmet health and social resource needs during a county-wide coronavirus disease 19 (COVID-19) stay-at-home order and phased re-opening in Western Pennsylvania. METHODS: With public health, social service, and community partners connected through an ongoing academic-community collaborative, we developed and fielded a weekly repeated cross-sectional electronic survey assessing usage of and unmet need for health and social service resources. Using 10 weeks of surveys (April 3-June 11, 2020) by Allegheny County residents, we examined variation in responses by week and by sociodemographic characteristics using chi-square tests. We shared written reports weekly and discussed emerging trends with community partners. RESULTS: Participants ranged from 229 to 1001 per week. Unmet need for at least 1 health or health-related social need resource varied by week, ranging from 55% (95% confidence interval [CI] 50%-59%) of participants in week 2 to 43% (95% CI 37%-49%) of participants in week 9 (P = .006). Increased use of at least 1 resource ranged from 53% (95% CI 47%-58%) of participants in week 3 to 36% (95% CI 31%-42%) in week 9 (P < .001). Unmet need for food and financial assistance peaked early during the stay-at-home order, while unmet need for mental health care rose later. Unmet need for food assistance varied significantly by race and ethnicity and by household prepandemic income. CONCLUSIONS: Over half of families with children reported unmet health or social service needs during the first month of a county-wide COVID-19 stay-at-home order. Unmet needs varied with race, ethnicity, and income and with duration of the stay-at-home order.