Common pots in Chile. Understanding a social phenomenon of organization to face hunger during the COVID-19 pandemic.

Background: The COVID-19 pandemic has led to a socioeconomic crisis, increasing food insecurity. Government measures have not been enough, and the community has organized itself to solve its food needs. In Chile, the "Ollas Comunes" (OC) have re-emerged: self-managed social organizations whose purpose is to feed community members in a situation of hunger. The study aims to describe the characteristic elements of the operation of the OC in Chile during the COVID-19 pandemic. Method(s): This is a cross-sectional and descriptive study, which uses quantitative and qualitative data. Through an online form, information was collected from 117 OC nationwide. Result(s): On average, nine people work in the OC, with different tasks. The OC operated mainly three days a week in community spaces and in the more vulnerable neighborhoods. The volunteers recognized that the OC arose from a community need that the government could not attend to;the OC promoted social participation and helped the vulnerable population. Conclusion(s): This research could help develop public policies that consider these community organizations and their role in food insecurity and take advantage of the community capacity.Copyright © 2022 Sociedad Espanola de Nutricion Comunitaria. All rights reserved.

Developing a Community Standard of Care for Individuals Diagnosed with Breast Cancer Patients Across Oregon

Early in the pandemic, cancer centers across the nation and Oregon canceled their cancer support programs as non-essential medical care. Breast cancer patients were forced to look elsewhere for essential assistance and community support to move along their cancer journeys. Pink Lemonade Project (PLP), a Vancouver, WA based community based nonprofit, helped fill the gaps and expanded its local support for breast cancer patients. A virtual format allowed PLP to serve more individuals with our psychological, emotional and financial support programs. Next, PLP convened an informal coalition of all the local breast cancer support organizations including those that offer breast cancer support programs, community including dragon boating and rowing, and others that serve broader communities and more people of color. Then, as Komen National announced its restructuring, and closed the Oregon-Southwest Washington affiliate in Spring 2021, Pink Lemonade Project stepped up again to maintain two locally-grown Komen programs that met critical community need-the MBC Dinner Series and the Treatment Access Program (TAP), a transportation assistance program that served all of Oregon and reduced the geographic barrier to care. Through the coalition, PLP heard patients express concern that they were receiving outdated information and were struggling more to find needed support and resources from their providers. Understandably, nurse navigators and social workers could not maintain and/or update patient resources while they assisted COVID patients. The goal of the coalition was to increase communication across the organizations and to share more event schedules for the ease of patients to understand what support programs are available. This session, delivered by an all breast cancer patient panel, will give an overview of Pink Lemonade Project;its programs that helps with psychological, emotional, community and financial support for breast cancer patients, survivors and those living with metastatic breast cancer;and will highlight the results from the patient point of view of the systematic review of the contents of 6 regional health systems new patient binders and present recommendations for consistent, community-wide content for all future breast cancer patients. The project's main strength was that Pink Lemonade Project could draw upon on an existing coalition of local, community-based breast cancer organizations to help update and standardize breast cancer support information from the patient point of view. Then by acting as a neutral convener, PLP could request and receive the binders from all the region's healthcare providers to help standardize and update the community resources across all the region's cancer centers. The result is that any new breast cancer patient, regardless of where their access to care is, can receive consistent community-based information and resources. Another result of this project showed the importance of the partnership of healthcare and human service agencies, especially in a post-pandemic world. As the pandemic continues to strain healthcare, community-based nonprofits have a unique role to help coordinate community resources and improve the quality of life for those affected by breast cancer.

Expanding current decentralized research model concepts for targeted community health interventions

Background: Inclusion of historically underrepresented populations in research has been a problem existing for many years. The recent Covid pandemic has exposed the significant cost of gaps in access to care. There remains a need to reevaluate current research paradigm frameworks to consider tailored approaches that accommodate any location that would ease participant burden and maintain retention. Current decentralized research models include home and mobile options. However, barriers exist, and certain demographics remain elusive to recruitment into research studies. Aim(s): In this paper, we aim to identify a theoretical framework that will allow for more inclusivity in research. Methodology: Current utilized community-based decentralized research models are compared, barriers in recruitment and retention of interested participants are examined, and a framework individualized to study participants is offered. Result(s): The proposed framework expands upon the complex adaptive systems theory to incorporate community-based research which considers dividing studies into individual study visit components that may differ in location. It allows for ease of research participant access to care and mutual collaboration among providers and institutions. This new theoretical model expansion outlines a novel approach to communitybased participatory research for increased representation and inclusion. Conclusion(s): Investigators should carefully consider creative and effective solutions to overcome barriers to research participation access, increase diversity and representation, and provide tailored public health interventions. Minimally risk study intervention visits may occur in multiple community-driven locations such as: community resource centers, local physician offices, mobile research units, remote electronic visits, home settings, and a combination of the above (hybrid model). Breaking studies into individual study visit components expands the reach of science into the communities that have long been difficult to reach.

Geauxhealth.org - A technological approach to addressing social determinants of health in New Orleans

Purpose of Study: GeauxHealth! is a multi-institutional, multi-disciplinary collaboration designed to create an easy-to-use guide for community health resources based on significant need in the Greater New Orleans area. The 2019 New Orleans Community Health Assessment found that New Orleanians identified mental health, substance use, women's health and chronic medical diagnosis management as areas of concern. Health barriers identified include crime and violence, infrastructure, environmental factors, healthy food, housing and income Additionally, the COVID-19 pandemic has further highlighted health inequity in communities across the United States. In an effort to address these findings and to promote awareness of social determinants of health among providers, Geauxhealth.org was created with a vision to be an updated, user-friendly website created by medical trainees for medical trainees and patients. Methods Used: 139 residents and fellows across multiple specialties within Tulane School of Medicine and LSUHSC School of Medicine were surveyed before and after the introduction of Geauxhealth.org. Summary of Results: When asked about confidence in referring patients to community resources when needed, 27% of trainees answered "Definitely not confident" and 31% answered "Somewhat confident." Nearly all respondents noted that barriers to referring patients to resources included: "Lack of Time" and "Lack of Knowledge." 96% of trainees noted they would use a website or app if available for referring patients to community resources. Post-intervention results are currently being analyzed. Conclusion(s): Awareness of social determinants of health is the first step in addressing health inequity experienced by the patients we serve. GeauxHealth! is designed to bridge the gap between awareness and action. Over time, the hope is for GeauxHealth! to serve as education for [Table presented] incoming residents, to be a utilized tool by providers, hospital employees and patients and to create a framework for the development of health resource guides in other cities. Copyright © 2023 Southern Society for Clinical Investigation.

Content Analysis of the Recommendations from Project Echo Ontario Autism

BACKGROUND: The rising prevalence of autism spectrum disorder (ASD) diagnoses has caused an increased number of community practitioners to care for this population. However, community practitioners report a lack of knowledge and confidence in treating these patients, resulting in unmet healthcare needs. The Extension of Community Healthcare Outcomes (ECHO) Autism model aims to address this through case-based and didactic learning to help guide community practitioners in providing comprehensive, best-practice care for ASD screening, diagnosis, and management of co-occurring conditions. Each ECHO session involves a case presentation followed by a list of recommendations generated by community participants and an interdisciplinary 'hub' team. While ECHO Autism has been shown to improve physicians' abilities to care for children with ASD in their practices, recommendations stemming from ECHO cases have yet to be characterized and may help guide future care. OBJECTIVE(S): To quantify and characterize the common categories within ECHO Autism Ontario case recommendations. DESIGN/METHODS: A content analysis of 422 recommendations from 61 ECHO cases was conducted to identify categories of recommendations and their frequencies. Three researchers independently coded recommendations from five ECHO cases, from which an original coding guide was developed. The researchers then independently coded the remaining cases and met regularly with the ECHO lead to modify and consolidate the codes and coding guide. From there, categories and sub-categories from the various codes were identified. Finally, the frequencies of each code and category were calculated. RESULT(S): Fifty-seven codes were included in the final coding guide and grouped into eight broad categories. Categories included: 1) diagnosis;2) concurrent mental and physical health conditions;3) referrals to allied health providers and other specialists;4) accessing community resources, such as parent and sibling support groups;5) providing education and guidance to physicians, patients, and families;6) management strategies such as nutrition, physical activity, and social skills;and 7) patient and family-centered care. A COVID-19 category was added, as many of the later recommendations were adapted to online service delivery. An analysis of the frequency of codes found that 1,384 total in-text codes were distributed amongst the various categories. The three highest frequencies of categories were providing general guidance and education (22%), accessing resources (16%), and referrals (15%). CONCLUSION(S): This is the first time recommendations from ECHO Autism have been characterized and quantified. Our results, particularly the most common category of providing general guidance and education about ASD, show there is still important work to be done with educating clinicians and families about aspects of ASD. Furthermore, findings from this study should inform Pediatrics residency programs about real-world knowledge gaps in ASD care, and may help create more tailored ASD training programs and educational materials.

The Creation of a Rapid Psychiatric Stabilization Team for Psychiatric Surge Volumes

Background: The COVID-19 pandemic has impacted our community in many ways, with negative downstream effects on the mental health system. Greater limitations on community resources have resulted in increased emergency room visits for acute mental health treatment. The increase in patients, along with limited resources, has led to patients boarding for hours to days in emergency rooms and medical floors. Method(s): Given the need for acute psychiatric treatment in the ED and medical floor, a rapid psychiatric stabilization (RPS) team was created. This team consists of 2 complex case BH managers, ED BH case managers, advanced practice clinicians, and psychiatrists;they meet virtually each morning to deploy resources where needed. The goal is to start active psychiatric treatment at time of presentation. Result(s): Examples of cases treated by the RPS team: Example #1: J.R. is a 10 yr. old who presented to the ED for increasing aggressive behaviors. Initial recommendation was for inpatient psychiatric admission;however, no bed was able to be secured. A psychiatrist met with J.R. daily and started medication for his aggression. After 4 days in the ED, J.R was stable for discharge, with an aftercare plan arranged by the complex BH case manager. Additionally, the team collaborated with his pediatrician to obtain prior authorization for psychotropic medication until an outpatient psychiatric appointment was secured. Example #2: H.B. is a 28 yr. old who presented to the ED with SI, however, was medically admitted due to being COVID positive. She was treated psychiatrically on the medical floor. As a result, she was discharged prior to her 10-day quarantine was completed, due to her positive response to treatment, and with psychiatric follow up arranged by the complex BH case manager. Prior to establishing the RPS team, discharges from the medical floor would have been difficult due to the inability to set up aftercare. Discussion(s): The American Academy of Child and Adolescent Psychiatry and Children's Hospital Association have declared a national emergency in children's mental health (1). Data from Mental Health America showed that any mental illness has increased 5% nationally, with a 7.6% increase in Pennsylvania (2). Additionally, adults with serious thoughts of suicide have increased 6% nationally and 16% in Pennsylvania. At LVHN-Lehigh Valley, psychiatric emergency room presentations have increased 1,401 (20%) compared to last year and are projected at 8,398. Clearly, demand for psychiatric treatment has grown, creating strain on the limited recourses available. Conclusion(s): The increased need for psychiatric treatment, coupled with the reduction of community resources, will cause psychiatric providers to rethink and redesign care in the post-pandemic world. The deployment of a RPS team to actively treat patients in non-traditional psychiatric settings is just one attempt at dealing with the psychiatric crises. Copyright © 2022

The Social Emergency Medicine Mini- Curriculum: A Novel, Multifaceted Immersive Approach to Resident Education in Social EM

Learning Objectives: 1) To design, implement and evaluate the feasibility of a replicable multifaceted Social EM curriculum for EM residents 2) To increase EM residents' level of awareness related to Social EM and increase their ability to identify/intervene on social determinants of health in clinical practice Background: Emergency Medicine (EM) physicians are in a unique position to impact both individual and population health needs. Despite this, EM residency training lacks a formalized education on social determinants of health (SDoH) and social EM (SEM). The need for such a curriculum has been previously recognized, however there is a gap in the literature related to the feasibility of such a curriculum addition. This innovation seeks to address this need. Curricular Design: A taskforce of EM clinicianeducators with expertise in SEM developed a 4.5-hour educational curriculum for use during a single Emergency Medicine resident didactic block (1/2-day session). The curriculum (Table 1) included asynchronous learning via a podcast, four SEM subtopic lecture didactics, guest speakers from ED social work and a community outreach partner representative, and a poverty simulation with interdisciplinary debrief. The curriculum was delivered via videoconference due to COVID-19 restrictions. Pre- and post-curricular intervention participant surveys were obtained. Impact: Post-survey results (Table 2) demonstrated improved awareness of SEM concepts and increased confidence in participant's knowledge of community resources and ability to connect patients to these resources following the curricular intervention. In addition, post-survey assessment demonstrated significantly heightened awareness and clinical consideration of SDoH among participants and increased comfort in identifying social risk in the ED. Overall, all components of the curriculum were evaluated as meaningful and specifically beneficial for EM training. The community partner presentation and subtopic lectures were ranked highest, followed closely by the poverty simulation, ED social services presentation, and asynchronous podcast component. This pilot curricular integration study demonstrates the feasibility and perceived participant value of incorporating a SEM curriculum into residency training.

Mental health and addiction diagnoses are linked to increased violent injuries and gaps in provision of resources during the COVID-19 pandemic

Background: The COVID-19 pandemic has been linked to increased mental health issues and interpersonal violence. Both psychiatric diagnoses and young males are overrepresented in the trauma population. Our objective was to characterize injury characteristics and their relationship to psychiatric diagnoses after the COVID-19 lockdown at a trauma centre in Edmonton, Alberta. Specifically, we queried relationships between gender, age, length of stay and intentionally violent injuries, and we reviewed access to inpatient and outpatient mental health and addiction resources. Method(s): We performed a retrospective chart audit for trauma patients aged 18-64 years admitted to the University of Alberta Hospital Trauma Service from June 1 to Aug. 31, 2020. Variables included demographics, injury characteristics, psychiatric history, substance use disorder history and presence of psychiatry and addictions consultations. Treatment plans and follow-up were assessed. Frequencies and basic descriptives were calculated. Univariate analyses were performed to identify relationships between psychiatric or addiction diagnosis (or both) and injury patterns. Result(s): A total of 176 patients met the inclusion criteria. Patients were young (mean age 39.7 yr) and male (73%), and blunt injury was most common (82%). Sixty-three patients (36%) had a psychiatric (29 patients) or addiction (59 patients) history. Twenty-eight patients (15%) received consults to the psychiatry service. At discharge, follow-up included mental health team (10 patients, 36%), family physician (2 patients, 7%) or self-referral resources (8 patients, 29%). Eight patients were not provided follow-up. Fifty-nine patients (34%) had 1 or more addictions history. Nineteen patients (32%) received consultations to psychiatry (18 patients) or addictions (1 patient). Otherwise, 6 patients (10%) were provided community resources at tertiary survey, 6 patients (10%) declined offered resources and 6 patients (10%) had traumatic brain injury (addiction resources deferred). Twenty-five patients (42%) either were not offered resources or documentation was unclear. On univariate analysis of patients with psychiatry consult, age was similar, but females were more likely to be represented (42% v. 24%, p = 0.06). Average length of stay was 17 days versus 9.7 days (p = 0.05). Having a psychiatric consultation or addictions history (or both) was associated with a violent mechanism of injury (35% v. 18%, p < 0.02). Conclusion(s): Over one-third of trauma patients aged 18-64 years had a psychiatric or addiction history (or both) and were significantly more likely to have a violent injury mechanism. Psychiatric consultation was common, more so in female patients, and linked to increased length of stay. Community follow-up was suboptimal, especially for patients with addiction history. Resource access and provision must be optimized to improve care, reduce recidivism and target interpersonal violence during this time of increased individual and system stress..

SOCIAL PRESCRIBING: FACILITATING THE INTEGRATION OF HOSPICE, PRIMARY CARE AND COMMUNITY DEVELOPMENT

Social prescribing is a fundamental aspect of the NHS Long Term Plan. The roll-out of social prescribing is underpinned by the belief that individuals have the capacity to define and solve their own problems and that local communities are rich in social assets, skills and talents which can be tapped into to enhance and improve health and wellbeing. Social Prescribing Link Workers (SPLWs) aim to focus on what matters to each client holistically, looking at social, economic and environmental factors and creating personalised care plans to improve wellbeing linking in to local community resources and assets. This philosophy aligns with both the person centred ethos of hospice care and the Public Health model of Palliative Care. Aims To adopt a partnership approach to develop and deliver social prescribing through hospice partnerships with local VCSE organisations and local PCNs to develop and deliver social prescribing. Commitment to learning and developing together rather than 'doing' social prescribing through service provision, drawing on the strengths of the local community and the partner organisations. Actions•Social prescribers in post fully funded through PCN with commitment for five years - links built with GPs, hospice and other services.•Partnership approach embedded, service launch in March 2020 - impacted by COVID-19 pandemic, an opportunity and a threat. Outcomes•Social prescribing now embedded in local community and GP practices. Over 500 referrals received in year 1: bereavement, end-of-life care plans, carers support identified as some of the key challenges people face.•Data and case studies support difference Social Prescribing is making on individual and system perspective.•NHS Graduate evaluation report completed. Conclusion Involvement in a partnership approach to social prescribing is supporting the hospice in facilitating a public health model to palliative and end-of-life care being adopted as part of the wider system change.

IMPACT OF THE COVID-19 PANDEMIC IN IBD PATIENT CARE

Background: The COVID-19 pandemic is affecting patients and healthcare providers worldwide. During the first wave of the pandemic, healthcare delivery shifted from in-person to virtual clinics. Non-urgent and some emergent procedures, including endoscopies, surgeries, and imaging, were delayed to limit the spread and divert resources to COVID-19. Aims: To assess the impact of the COVID-19 pandemic in care to IBD patients Methods: A survey study was conducted to assess the impact of the COVID-19 pandemic on IBD care. All patients had a virtual clinic appointment between March to July 2020 at either: University of Alberta Hospital or the University of Calgary Clinic. A section of the survey assessed patient experience of virtual clinics and delays in access to IBD care during the COVID-19 pandemic. Results: A total of 1581 patients were contacted to complete the survey. 628 patients agreed to participate in the survey, however not all patients completed each component. The mean age of patients who participated in the survey was 48 years (SD = 15.19). 408 patients responded to satisfaction/future use questions: 84.3% (344) patients agree/strongly agree they were comfortable communicating to the physician using the remote system, 77.5% (316) of patients agree/strongly agree that virtual clinic is an acceptable way to receive healthcare services, 84.8% (346) of patients agree/strongly agree they would use virtual care services again, and 82.6% (337) agree/strongly agree they were satisfied with the telehealth system. Additional challenges were reported by 228 patients. Fear and stress (infection risk/mental health concerns/unemployment) was reported by 57.4% (131) patients. Access to healthcare services, PPE, and community resources was a challenge experienced by 26.3% (60) patients. Additionally, 16.2% (37) patients experienced uncertainty around IBD-specific care, including procedures, treatments, labs, and medications. Overall, 17.3% of patients reported some type of delay in care by July 2020. Table 1 shows the proportion of patients with a delay by type of care and the median delay: 5.7% of patients with IBD had surgery delayed by a median of 10 weeks (8-16 weeks). Conclusions: While some delays in healthcare delivery occurred during the first wave of the pandemic, overall 82.7% of patients with IBD maintained their care without disruption. Sustaining healthcare delivery to the IBD community required adaptation to virtual care;however, patient satisfaction was overwhelming positive among patients with IBD.

Preference and Utilization of Food Resources by Refugee and Immigrant Populations

Purpose/Objectives: Cultural values are often cited as important influences on an individual, family or communities' health decisions. However, culture as a positive predictor of healthy food behavior may be less significant than structural and economic barriers such as documentation status and access to healthy food. This is particularly true for refugee and immigrant children living in districts that are considered food deserts. The 2018 Roanoke City Community Health Assessment reports that 5% of survey respondents indicated their unhealthy behavior is due to lack of cultural value of health. Food preference, however, is seldom reported. Additionally, resources such as food banks/pantries (FBP) can be highly variable in access and requirements of proof of residency, legal documentation, or age. Preliminary attestations from local food banks also indicate additional barriers due to lack of language interpreters and limited hours, particularly during the COVID-19 pandemic. This may suggest these factors play a larger role for refugee and immigrant populations on healthy food behaviors. This study seeks to explore challenges to achieving food health for refugees and immigrants by assessing food preferences and utilization of community resources. Demographic and geographic information are analyzed in order to better understand contributing factors. Design/Methods: A 10-question survey was administered to 132 refugee and immigrant households with assistance of an interpreter as needed. The survey asked about food resources used within the last year, food and household item preferences, and deidentified demographics. The Hunger Vital Sign questionnaire, a validated tool, was used to screen for Food Insecurity. Results: 86.2% of survey respondents reported having at least one child at home. 46.8% of households with children reported to be food-insecure. Figure 1 shows resources used by households with children. Figure 2 shows food preferences among respondents. Only 20.5% of respondents from a food desert area, despite a high density of FBP, reported utilizing FBP in the last year. Respondents are represented by 25 countries. Conclusion/Discussion: Households with children, especially those screening positive for food insecurity, primarily utilized community organizations over food pantries and schools for their food help during COVID-19 pandemic. The primary utilization of community organizations includes those living in identified food desert areas. These food desert areas have a higher density of FBP, but rates of utilization are the same compared to all respondents regardless of geographic location. Additionally, milk/eggs and vegetables were the highest requested foods. This provides evidence of preference for healthier foods suggesting culture plays little role in achieving food health. More influential factors to consider are access, availability and awareness of these resources, which may be addressed by interventions that bolster community relationships in order to bridge these gaps.

Increase in Social Determinants of Health related Needs During the COVID-19 Pandemic

Background: Social determinants of health (SDoH) influence the health and psychosocial well-being of children and families. Several national organizations, including the AAP, recommend that primary care practices implement an approach to screening for SDoH at all health supervision visits to identify and address risks. The COVID-19 pandemic has placed additional stress on patients, families, and their communities and has highlighted the challenges we continue to face in efforts to achieve health equity. In our primary care pediatric clinic, we have analyzed our existing SDoH screening and referral process and have found an exponential increase in resource needs for our patients and families in the setting of the COVID-19 pandemic. Methods: We administered SDoH screening forms based on a modified PQ-R to families at every well child visit from 2019-2021 in our pediatric primary care clinic and resident continuity practice. We partnered with the Health Equity Project at Albany Medical College which is a service-learning program that provides public health outreach to families who have screened positive for 1 or more SDoH need. Starting in February 2021, families have been contacted at 1-and 3-month intervals following initial referral to determine if resources were accessed. This follow up has allowed for identification of barriers to connecting with community-based organizations. We analyzed positive screens pre-COVID and during the COVID pandemic to assess the impact of COVID on our patient population. Results: Since August 2019, 507 families in total have screened positive for one or more need based on SDoH screening in our clinic. Out of the 507 families, 70% have been contacted successfully by our public health outreach team to provide resource referrals. During our pre-COVID screening period from August 2019-February 2020 there were 77 positive screens compared to the COVID screening period August 2020-February 2021 during which were 231 positive screens. This represents a 200% increase in positive screens during this time. We have identified several barriers to connecting with community resources as reported by families, such as difficulty finding time to contact the given resources and experiencing long wait times to receive assistance. Conclusion: SDoH screening in primary care has been widely recognized as a method to identify and address targeted risk factors to improve the health and well-being of children. We have identified an increasing need for resources in our patient population since the start of the COVID-19 pandemic. Future study is needed to identify barriers between referral and provision of resources by community-based organizations and to address the impact of our referral process on health outcomes. Our findings do underscore the impact that the COVID-19 pandemic has had on the social wellbeing of children in our community, and this must be considered in the delivery of their health care.

ENRICHING EDUCATION ON SOCIAL DETERMINANTS OF HEALTH: A RESIDENT-DRIVEN, MULTIMODAL CURRICULUM FOR INTERNAL MEDICINE RESIDENTS

SETTING AND PARTICIPANTS: The curriculum was offered to Internal Medicine (IM) residents and took place in Boston and surrounding communities. DESCRIPTION: This program was developed by IM residents in collaboration with clinical education faculty, physician leaders in health equity, and community partners. It identifies and enhances multiple aspects of residency training to reinforce learning on Social Determinants of Health (SDH). Our curriculum offers four key components. 1) Dedicated discussion of health disparities and institutional/community resources incorporated into existing ambulatory curriculum modules. 2) Resident-led walking tours of neighborhoods around Health Centers focused on the history, health disparities, and resources unique to each community. 3) Residency-wide conferences featuring healthcare innovations that address social determinants of health, including a community health van delivering COVID-19 tests and vaccines. 4) A novel resident-designed, two week elective incorporating patient-centered work with community based initiatives to allow identification of social determinants and tangible work to reduce their adverse effects on health. EVALUATION: Quantitative evaluations are assessed via pre- and postinnovation surveys. Sixty-nine of 85 (81%) interns completed the preinnovation survey. Only 56% felt that their prior SDH education was adequate and 25% felt that they had a good understanding of health disparities in Boston. Merely 4% were familiar with resources available in the local healthcare system. Over 98% of responders indicated interest in learning more about health disparities in Boston and available resources to address SDH needs. A post-innovation survey will be distributed after the first year of the curriculum. One of three planned community walking tours has been piloted with positive feedback. Further qualitative feedback will be collected as more walking tours and ambulatory lectures are completed. Feedback on conferences by guest speakers will be collected by the residency via focus groups. DISCUSSION / REFLECTION / LESSONS LEARNED: The environment in which individuals live, work, and build community;access to adequate housing, healthy food, living wages, social support, and healthcare;language and marginalization affect health. Understanding how these social determinants impact health outcomes, leveraging community resources to address them, and advocating for health equity are essential elements of the practice of medicine and residency training. This sentiment is reflected in our survey of interns and in the ACGME Guidelines. An effective way of incorporating SDH education into residency training is via a multimodal resident-led initiative that helps residents identify social determinants and describe programs that reduce their adverse impact on health. This initiative began as two residents' interest in learning more about their community and patients. It now serves as a model for weaving SDH into GME curriculum through didactics, conferences, community focused tours, and a clinical elective.

ADDRESSING SOCIAL NEEDS TO ENABLE SUCCESSFUL CARE TRANSITIONS FOR PATIENTS HOSPITALIZED WITH COVID-19: THE CRITICAL ROLE OF COMMUNITY HEALTH WORKERS

STATEMENT OF PROBLEM/QUESTION: The COVID-19 pandemic highlights the disproportionate burden of disease on communities made vulnerable by structural inequities. The pandemic has increased economic hardship, including housing instability, food insecurity and ability to pay bills. Hospitalization for COVID-19 is an opportunity to address unmet healthrelated social needs (HRSNs) and connect patients with community resources. DESCRIPTION OF PROGRAM/INTERVENTION: Community health workers (CHWs) play a critical role in response to public health crises. To address the inequitable burden of COVID-19 on Austin's Latinx population, we implemented a pilot program at an academic hospital where a CHW helps patients navigate care transitions and address unmet HRSNs. The care team referred patients with COVID-19 to the CHW, who met with patients to establish rapport, provide language-concordant communication between the care team and patient/family, deliver health promotion education, and assess HRSNs. MEASURES OF SUCCESS: This includes three typical cases describing key components of the CHW pilot program. CHWs connected patients and families to community resources and facilitated discharge planning and connection with primary care providers. The CHWs continued to follow patients for at least 45 days after discharge to assist with care coordination. We provide qualitative data from patients and healthcare professionals. FINDINGS TO DATE: Patient 1 is a 38-year-old day laborer with hypertension hospitalized with COVID-19 pneumonia. His family of four is undocumented and faced economic insecurity due to loss of work from the pandemic. The CHW assisted with utilities, bills, food and rent through coordination with local organizations to provide direct financial assistance to the family. Patient 2 is a 45-year-old woman with diabetes hospitalized with COVID-19 pneumonia. She is a mother of three children, two with disabilities. In addition to financial insecurity, she identified transportation as a primary HRSN. The CHW arranged financial resources to fix their car, which allowed the family to access school and clinic resources. Patient 3 is a 36-year-old man hospitalized with COVID-19 pneumonia. The CHW connected the family, including three children, with their school social worker, enabling access to financial support for utilities, food and clothes. The CHW arranged free food delivery to their home for four months. The CHW also secured county-based indigent care coverage for the patient, enabling hospital follow-up with a primary care provider. The patient's wife noted, because of the CHW, “We never felt alone” and now feel “capable of navigating a health system that we never felt we had access to.” KEY LESSONS FOR DISSEMINATION: CHWs, as patient advocates and skilled care navigators, build trust, establish longitudinal relationships with patients and address unmet HRSNs that can enable successful care transitions. CHWs can alleviate the disproportionate burden of COVID-19 on individuals with unmet HRSNs. Supporting the work of CHWs within hospital care teams can improve care transitions.

AN INITIATIVE TO DECREASE 30-DAY HOSPITAL READMISSION RATES AT AN URBAN ACADEMIC SAFETY-NET HOSPITAL THROUGH A RESIDENT-LED TRANSITIONS-OF-CARE CLINIC

STATEMENT OF PROBLEM/QUESTION: The transition between hospital discharge and primary care follow-up is a vulnerable period for patients that can result in adverse health outcomes and preventable hospital readmissions. The COVID-19 pandemic has exacerbated this transitional period, as many patients have forgone their routine healthcare visits, lost touch with their primary care providers (PCPs), and lacked a point of contact for their health needs after leaving the hospital. DESCRIPTION OF PROGRAM/INTERVENTION: We launched a postdischarge Transitions in Care Management (TCM) clinic to serve patients discharged from NYU Langone Hospital Brooklyn, an urban safety net academic hospital that serves a racially diverse and socioeconomically vulnerable population in Southwest Brooklyn. From October 2020 to October 2021, TCM visits were offered to patients prior to discharge from the general medicine service at NYU Langone Brooklyn who did not have a primary care provider or who could not get an appointment with their PCP within 10 days of discharge. Patients were given the option of in-person visits or virtual visits. TCM visits were scheduled with residents within 2 weeks of patient discharge. Questions at the TCM visit focused on scheduled speciality appointments, any discrepancy in medications prescribed at discharge, or if the patient was connected to additional community resources. MEASURES OF SUCCESS: The primary outcome was the 30-day readmission rate for patients referred to TCM compared to all patients discharged from the general medicine unit. FINDINGS TO DATE: From October 2020 through October 2021, there were a total of 357 TCM visits out of a total 806 referrals placed (44% completion rate). There was a reduction in 30-day hospital readmission rate for patients who completed a TCM visit compared with those who were not referred (5% vs 15.9%;p < 0.001). There was also a reduction in readmission rate for those who were referred but did not complete their TCM visit compared to those who were not referred (8.4% vs. 15.9%;p < 0.001). Of the completed visits, 172 were in-person, 138 were virtual, and 47 were over the telephone. Patients were also more likely to show up to their virtual visits than their in-person visits (30% no-show rate for in-person vs. 12% no-show rate for virtual). KEY LESSONS FOR DISSEMINATION: Thirty-day hospital readmission rate was lower for patients seen as part of the resident-run TCM clinic at a safety net academic medical center. Interestingly, patients referred but who did not complete TCM visits still had a decreased readmission rate compared to those who were not referred, suggesting that there may be an inherent difference in these two patient groups. Future studies will examine the differences between these groups, and analyze the factors that influence TCM referral and visit completion. Future studies will also analyze how the medium of visit (virtual vs. in-person) and specific interventions during the TCM visits (medication reconciliation, specialty appointments, community resources) influenced patients' transition in care.

TOGETHER FOR THE LONG HAUL: DEVELOPMENT AND UTILIZATION OF A POST-ACUTE COVID- 19 RECOVERY PROGRAM EMBEDDED WITHIN A LARGE, URBAN ACADEMIC GENERAL INTERNAL MEDICINE DIVISION

STATEMENT OF PROBLEM/QUESTION: Post-acute COVID-19 syndrome presents new diagnostic and management challenges for primary care physicians, creating a need for dedicated care for affected patients. DESCRIPTION OF PROGRAM/INTERVENTION: To date, the COVID19 pandemic has infected >300 million people worldwide. It is estimated that more than 50% develop Post-acute COVID-19 syndrome. Symptoms persisting >6 months lead to activity impairment and reduced quality of life. In March 2021, we implemented a Post-acute COVID-19 recovery program embedded in a primary care setting. Using an integrated approach, the program utilizes a patient navigator who performs a standardized intake process and assists with information collection and navigation to specialty care. Social workers assist with mental health/community resource access. Five general internal medicine physicians see referred patients 5 half days a week in multiple locations. Intake visits review patient history, previous testing, and ongoing symptoms, and a standard quality of life evaluation is made with a PROMIS-29 score. Templates use new patient and return visits times of 40 minutes (6 slots) and 20 minutes (2 slots) respectively. Expedited specialty care is achieved through prioritized access within two weeks through collaboration with numerous specialists. Monthly case conferences allow clinicians to connect with specialists, discussing challenging cases and common clinical scenarios (e.g., dysosmia, dysgeusia). Additionally, a support group for patients is being developed, as is an “e-consult” option for primary care physicians to engage with the clinic. MEASURES OF SUCCESS: Referrals to program, patients seen, template fill rate, no show rate, new patient visit lag time, revenue generated, and medical diagnoses treated. Future measures will include interval comparison of PROMIS- 29 scores and utilization of e-consults. FINDINGS TO DATE: There have been 557 formal referrals to the program with 620 total patients seen. 584 (84%) were seen by general internal medicine as first contact. Template utilization: 93% and No-show rate of 7%. Median new patient lag: 28 days. Through December 2021, total charges and payments have been $173,445 and $79,692, respectively. Top 3 procedure codes billed: 99215, 99244, and 99214. Top 5 categories of symptoms by primary diagnostic code billed excluding post viral syndrome (111 patients, 18%): Neurologic (headache, fatigue, inattention, etc) (149 patients, 24%), Respiratory (128, 20%), Cardiac (64, 10%), Psychiatric (59, 9.5%), Loss of taste/smell (24, 4%). Top 5 referrals from program: PT/OT/speech therapy, pulmonary rehab, ENT, sleep medicine, and psychology/psychiatry. KEY LESSONS FOR DISSEMINATION: There is high demand for expertise in treatment of Post-Acute COVID-19 syndrome. Primary care physicians, coupled with dedicated, timely access to specialty care and rehab services can successfully manage patients with post-COVID-19 symptoms.

AN INTERPROFESSIONAL STUDENT-FACULTY COLLABORATIVE TELEHEALTH PROGRAM TO ADDRESS POORLY CONTROLLED DIABETES AND SOCIAL DETERMINANTS OF HEALTH EXACERBATED BY THE COVID-19 PANDEMIC

STATEMENT OF PROBLEM/QUESTION: Will a telehealth initiative improve poorly controlled type 2 diabetes mellitus (DM) and unmet social determinants of health (SDOH) needs exacerbated by the COVID-19 pandemic? DESCRIPTION OF PROGRAM/INTERVENTION: Due to COVID-19, many patients with DM faced challenges accessing healthcare, as well as exacerbations of socioeconomic disparities regarding access to food, affordable housing, and safe places to exercise. To address these challenges, we adapted an existing student-faculty collaborative practice at Beth Israel Deaconess Medical Center, Boston, MA, to a telehealth platform to provide targeted DM management, and referrals to dietitians and community resource specialists. MEASURES OF SUCCESS: We assessed clinical outcomes, such as changes in hemoglobin A1c (HbA1c), LDL, and number of medication adjustments. Measured quality indicators included frequency of HbA1c, LDL, and microalbuminuria measurements, as well as prescription of cardiovascular/diabetic medications such as ACE inhibitors, statins, and aspirin within the year prior to enrollment and within 6 months after the final visit. To measure the role and intervenability of SDOH needs, we tracked the results of SDOH screens to identify key needs, as well as the number of dietitian and community resource specialist (CRS) referrals placed. FINDINGS TO DATE: Of 998 patients with non-insulin-dependent type 2 DM, 60 were enrolled in the program, of whom 42% were white and had a median BMI of 32.0 kg/m2 (IQR 28.3-36.1). Patients endorsed high motivation (8/10) and confidence (7/10) in managing their diabetes, but reported inadequate nutrition education (56.7% of cohort), as well as difficulty maintaining a healthy diet (76.7%) and exercising (78.3%). Analysis of baseline data and for those who completed the program thus far (n = 22, >6 months since last clinic visit), showed a significant decrease in mean HbA1c (mean ±SEM) from 8.72±0.15 to 8.09±0.22 (p = 0.03). LDL levels were not significantly different before and after the program, 90.3±5.4 vs 100.9±10.6 (p = 0.42). Lab draw frequency (HbA1c, LDL) and medication prescription (ACE inhibitors, statin, aspirin) and were not significantly different. Of patients who completed the program, 8 (36.4%) had their diabetes medications adjusted. 2 (9.1%) were referred to a CRS, and 2 (9.1%) were referred to a dietitian. KEY LESSONS FOR DISSEMINATION: Our ongoing study showed that the implementation of a telehealth diabetes program with SDOH screening can be an effective way to assist patients with uncontrolled diabetes. We identified significant patient needs for additional support and clinical care. Assessing socioeconomic burdens faced by patients and understanding the impact and key features of such a collaborative telehealth program can pave the way for the implementation of a similar model of care for other chronic conditions.

Pilot Outcomes of A Multi-component Support Intervention for Caregivers of Persons with Heart Failure

Background: Caregivers of persons with heart failure must manage high levels of patient health care utilization, treatment complexity and often unpredictable stressors associated with intermittent symptom exacerbations and mortality. Interventions have often focused on the needs of the person with HF, not the caregiver. Therefore, we developed an intervention using human-centered design to provide caregiver-targeted support for this population. Objective: Pilot test the feasibility and gauge initial effect size of the Caregiver Support intervention to improve quality of life (mental and physical), caregiver burden, and self-efficacy among family caregivers from baseline to 16 weeks. Methods: The intervention includes five individualized, nurse-led sessions over 10 weeks conducted remotely (due to COVID-19). Intervention components focus on 1) nature of caregiving, 2) life purpose, 3) co-development of an action plan to address caregiver goals to reduce caregiver burden and improve caregiver well-being, 4) exploration of social and community resources to support unmet needs, and 5) building a sustainability plan for addressing future caregiver needs. We tested our approach in a randomized waitlist control pilot trial (N=35) from August 2020 through March 2022. We calculated enrollment and retention rates, described acceptability, and computed intervention effect sizes from baseline to 16 weeks. Results: 35 out of 101 (35%) eligible caregivers enrolled and were majority female (93.3%), White (60%) and spousal caregivers (63.3%). Average age was 59.4 ± 16.6 years. Overall retention was 69%. All intervention participants completed the five core components, reporting high levels of satisfaction and acceptability of activities. Between-group effect sizes (n=21) at 16 weeks suggest improvement in the mental health component of quality of life, caregiver burden, and self-efficacy (effect sizes 0.88, 0.31, and 0.63, respectively). Conclusion: Caregivers found Caregiver Support acceptable and study methods were feasible, despite challenges to engaging during the COVID-19 pandemic. Findings provide foundational evidence that this person-centered behavioral intervention can contribute to enhanced caregiver outcomes.

OVERCOMING OBSTACLES TO RECRUITMENT AND COMMUNITY ENGAGEMENT DURING COVID-19 AND DEVELOPMENT OF A DIGITAL COMMUNITY OUTREACH PROGRAM

Introduction: COVID-19 disrupted traditional research infrastructures and processes most notably in-person community recruitment, especially in underrepresented populations like racial ethnic minorities. To find creative and effective strategies, our group implemented and tested the efficacy of a culturally tailored community outreach plan (COP) developed during the US COVID-19 pandemic. Methods: In February 2021, we developed an 11 step culturallytailored community outreach program to support the implementation of three NIH funded community-based sleep studies. The following steps include: (1) description of the situation statement, 2) definition of goals, 3) engagement of audience/stakeholders, 4) tailoring message, 5) defining incentives, 6) choice of outreach methods, 7) identification of spokesperson, 8) choice of tools to assess progress, 9) identification of media outlets, 10) creation of study timeline, and 11) implementation of the plan. The studies leveraged several recruitment channels: 1) community settings (Place of worship, “community recruiter”, health fairs, word of mouth, & healthcare providers/doctors' clinics), 2) online platforms (Facebook, Twitter, LinkedIn and Research Match), and 3) preexisting datasets in NYC. Results: All three studies successfully met recruitment goals. ESSENTIAL [n= 224, 69% females, mean age= 36], MOSAIC [n=109, 61% females;mean age= 64] and Latinx/Hispanics: DORMIR[n=260, 61.3% of female;32.4]. Among the three NYC cohorts, the most common recruitment channels were: preexisting datasets (74%), community settings (19%), & online platform (7%) for ESSENTIAL;preexisting datasets (85%) & community settings (15%) for MOSAIC, and (71.7%) online platform for DORMIR. However, the Miami cohorts came mostly from community settings 90% for Essential and 97% for MOSAIC. Conclusion: Overall, the TSCS community outreach plan seems to be an effective tool to engage minoritized populations in greater NY and Miami. Our current field experience indicates that recruitment channels must be adapted to age, and community resources. Limited access to technology, particularly among older Blacks seem to be a major barrier for field staff to successfully engage the disenfranchised communities.

Needs For Food, Medicine, and Mental Health Services Among Vulnerable Older Adults During Covid-19 Pandemic

Background: The COVID-19 pandemic has exacerbated multiple barriers to healthcare for vulnerable seniors. They may experience more difficulties in meeting their basic needs for food, medicine, and social support. The objective of the project was to connect with seniors to show our care, to assess food security, medication possession, mental health, and to refer those needing services to appropriate providers. Methods: Using a computer-assisted telephone interview (CATI) approach, we called patients served by our primary care providers from April to December 2020. The CATI assessed their mental health by Personal Health Questionnaire-2 (PHQ2) and General Anxiety Disorder-2 (GAD2). The California Health Place Index (HPI) was used to measure social determinants of health associated with community resources. Descriptive analyses examined the proportion of patients needing follow-up services and being referred to services to address food insecurity (if had <3 days of food), medication needs (if had <30 days of medicine), and mental health services (PHQ2>2 or GAD2>2). Multivariable logistic regression analyses examined demographic and health factors associated with the odds for needing and being referred for follow-up services. Results: Of 1921 respondents, their average age was 76 years (SD11). 52% female and 48% non-female (including male, transgender, and other);74% White, 7% Asian, 7% Hispanic, 3% Black, and 8% other. Medication needs existed among 595 (31%) patients, 196 (10%) faced food insecurity, and 292 (15%) needed mental health services. Regression results suggest, Blacks (OR1.86, p<0.05) had higher odds of being at risk of medication shortage than Whites;Blacks (OR2.30, p<0.05) and Hispanics (OR 2.30, p<0.05) had significantly higher odds of food insecurity than Whites. Higher odds for food insecurity referral were found among non-females (OR7.56, p<0.05) and Blacks (OR10.33, p<0.05). Blacks (OR13.34, p<0.05) and those living in 2nd quartile of HPI (OR2.57, p<0.05) had higher odds for mental health referrals. Conclusions: Significant disparities existed across gender, race, and community resource groups in need for food, medications, and mental health services. Findings underscore the imperatives for health and social services organizations to systematize outreach and follow-up services for vulnerable seniors.