Patient-Centered Care Through Nurse Practitioner-Led Integrated Behavioral Health: A Case Study.

Integrated behavioral health can improve primary care and mental health outcomes. Access to behavioral health and primary care services in Texas is in crisis because of high uninsurance rates, regulatory restrictions, and lack of workforce. To address gaps in access to care, a partnership formed among a large local mental health authority in central Texas, a federally designated rural health clinic, and the Texas A&M University School of Nursing to create an interprofessional team-based health care delivery model led by nurse practitioners in rural and medically underserved areas of central Texas. Academic-practice partners identified 5 clinics for an integrated behavioral health care delivery model. From July 1, 2020, through December 31, 2021, a total of 3183 patient visits were completed. Patients were predominantly female (n = 1719, 54%) and Hispanic (n = 1750, 55%); 1050 (33%) were living at or below the federal poverty level; and 1400 (44%) were uninsured. The purpose of this case study was to describe the first year of implementation of the integrated health care delivery model, barriers to implementation, challenges to sustainability, and successes. We analyzed data from multiple sources, including meeting minutes and agendas, grant reports, direct observations of clinic flow, and interviews with clinic staff, and identified common qualitative themes (eg, challenges to integration, sustainability of integration, outcome successes). Results revealed implementation challenges with the electronic health record, service integration, low staffing levels during a global pandemic, and effective communication. We also examined 2 patient cases to illustrate the success of integrated behavioral health and highlighted lessons learned from the implementation process, including the need for a robust electronic health record and organizational flexibility.

Expanding Access to Psychiatric Care: Implementation of Psychiatric e-Consultation and Tele-consultation for Primary Care in a Safety-net Health System.

Technology can expand access to specialty health services for disadvantaged and underserved populations. A novel psychiatric consultation service involving both electronic consultations (e-consultations) and telephonic consultations (tele-consultations) was implemented by hospital-based staff and trainee psychiatrists in 12 primary care sites within a public safety-net health system. Utilization data were collected over a three-year period. A brief provider satisfaction survey was distributed to primary care providers. Over the three-year study period, 490 technology-enabled consultations were provided, of which three-fifths were e-consultations and two-fifths were tele-consultations. Most addressed medication questions (81%). Average time spent by the consulting psychiatrist was 30 minutes. Four-fifths (80%) of primary care providers reported being extremely or moderately satisfied with the service. The model represents multimodal support for primary care providers in providing community-level mental health care, including the provision of same-day consultation. This report demonstrates the feasibility of such a service in lowresource settings.

Broadband access within Medically Underserved Areas and its implication for telehealth utilization.

PURPOSE: There is little information as to how America's broadband infrastructure might impact recent efforts to expand access to virtual care for underserved communities. OBJECTIVE: To examine potential and realized access to broadband internet services within Medically Underserved Areas (MUAs) that rely on community health care service providers for primary care. METHODS: This cross-sectional study included 214,946 US Census Block Group estimates from the 2017 and 2019 American Community Survey and the corresponding Federal Communications Commission database. Changes in household broadband subscription rates and Healthy People 2020 access thresholds within MUAs were assessed. FINDINGS: In 2019, 24,304 MUA households (31.9%) met Healthy People 2020 targets for broadband subscription rates, compared to 64.4% of non-MUA households (n = 89,285). On average, 74.7% of MUA households had a broadband internet subscription compared to 85.2% of non-MUA households, whereas 61.1% (n = 46,635) of MUA households had access to broadband speeds of at least 25.0 Mbps, compared to 75.6% (n = 104,696) of non-MUA households. Within urban households, there was a 0.8 to 1.3 to 1.6 annual percentage point convergence in MUA versus non-MUA broadband disparities between across quintiles (P < .05). Rural MUA households showed little improvement in broadband access between 2017 and 2019. CONCLUSIONS: There has been an overall convergence of broadband access disparities between MUA and non-MUA households over time, but less improvements in access among the most rural households. Reimbursement for audio-only telehealth visits by state Medicaid agencies would help drive down barriers to virtual health care options for populations residing in MUAs.

COVID-19 Testing, Vaccine Perceptions, and Trust among Hispanics Residing in an Underserved Community.

The Borderplex region has been profoundly impacted by the COVID-19 pandemic. Borderplex residents live in low socioeconomic (SES) neighborhoods and lack access to COVID-19 testing. The purpose of this study was two-fold: first, to implement a COVID-19 testing program in the Borderplex region to increase the number of residents tested for COVID-19, and second, to administer a community survey to identify trusted sources of COVID-19 information and factors associated with COVID-19 vaccine uptake. A total of 4071 community members were tested for COVID-19, and 502 participants completed the survey. COVID-19 testing resulted in 66.8% (n = 2718) positive cases. The community survey revealed that the most trusted sources of COVID-19 information were doctors or health care providers (67.7%), government websites (e.g., CDC, FDA, etc.) (41.8%), and the World Health Organization (37.8%). Logistic regression models revealed several statistically significant predictors of COVID-19 vaccine uptake such as having a trusted doctor or health care provider, perceiving the COVID-19 vaccine to be effective, and perceiving that the COVID-19 vaccine does not cause side-effects. Findings from the current study highlight the need for utilizing an integrated, multifactorial approach to increase COVID-19 testing and to identify factors associated with COVID-19 vaccine uptake in underserved communities.

Drive-Through Mass Vaccination Center Operations in a Rural, Medically Underserved Area Using Military Civilian Partnership During the COVID-19 Pandemic.

During the coronavirus disease (COVID-19) pandemic, mass vaccination centers became an essential element of the public health response. This drive-through mass vaccination operation was conducted in a rural, medically underserved area of the United States, employing a civilian-military partnership. Operations were conducted without traditional electronic medical record systems or Internet at the point of vaccination. Nevertheless, the mass vaccination center (MVC) achieved throughput of 500 vaccinations per hour (7200 vaccinations in 2 days), which is comparable with the performance of other models in more ideal conditions. Here, the study describes the minimum necessary resources and operational practicalities in detail required to implement a successful mass vaccination event. This has significant implications for the generalizability of our model to other rural, underserved, and international settings.

Methodological Challenges in Web-Based Qualitative Research With Medically Underserved Populations.

Internet- or web-based research is rapidly increasing, offering multiple benefits for researchers. However, various challenges in web-based data collection have been illustrated in prior research, particularly since the onset of the COVID-19 pandemic. To add to the literature on best practices for web-based qualitative data collection, we present 4 case studies in which each research team experienced challenges unique to web-based qualitative research and had to modify their research approaches to preserve data quality or integrity. The first 2 case examples describe issues with using social media to recruit hard-to-reach populations, the third example demonstrates the challenge in engaging adolescents in sensitive conversations on the web, and the final example discusses both the issues in recruitment and the use of different modalities in collecting data to accommodate the medical needs of study participants. Based on these experiences, we provide guidance and future directions for journals and researchers in collecting qualitative data on the web.

Experience and Attitudes Toward Telehealth in Student-Run Free Clinics (SRFC).

INTRODUCTION/OBJECTIVES: Telehealth services expanded during the coronavirus disease 2019 (COVID-19) pandemic. Student-run free clinics (SRFC) deliver important health care services to underserved populations, who may face barriers to telehealth use. This study characterizes telehealth usage, experiences, and attitudes among individuals working in SRFCs. METHODS: In November 2021, a survey adapted from the COVID-19 Healthcare Coalition Telehealth Impact Physician Survey was sent to all registrants who identified themselves as students at the 2020 Society of Student-Run Free Clinics Annual Conference. RESULTS: Thirty-eight individuals of 576 registrants (7%) representing 21 of 88 (24%) SRFCs completed the survey. Twenty-one (58%) individuals reported using telehealth in their clinic. Those that did not cited lack of infrastructure as a barrier (eg, broadband, Internet challenges, technology investments), were more likely to serve homeless (P = .01), and less likely to serve non-English speaking populations (P = .02). There were increases in telehealth and decreases in in-person visits after March 11, 2020 though changes did not reach statistical significance. At least 15 (68%) wanted to continue chronic disease management, preventative care, and mental/behavioral health via telehealth after COVID-19. Most felt that telehealth was easy to use and improved the health, safety, and timeliness of care of patients, but not work satisfaction or access to care. Difficulty accessing physical devices, Internet, and data was the most-cited barrier to maintaining and accessing telehealth. CONCLUSIONS: Nearly all participants cited significant benefits and barriers to telehealth that impacted perceived access to care and sustainability. SRFCs' experiences may be modulated by their underserved populations and role in student education. Addressing barriers, particularly patient- and clinic-level technology challenges, could work to improve inequities in telehealth uptake.

Role of the National Health Service Corps in Delivering Substance Use Disorder Treatment in Underserved Communities.

OBJECTIVE: To help address the opioid epidemic, the U.S. Health Resources and Services Administration expanded the National Health Service Corps (NHSC) to include two new loan repayment programs (LRPs)-the Substance Use Disorder LRP and the Rural Community LRP-to supplement the existing standard LRP. In this article, the authors aimed to describe the role of these NHSC programs in addressing workforce shortages and providing substance use disorder treatment, including for opioid use disorder, in underserved areas. METHODS: Administrative data on NHSC clinician locations were merged with county-level data to characterize the communities served by NHSC clinicians. Primary data from surveys and key informant interviews with NHSC site administrators (N=9) and clinicians (N=9) were used to describe changes in NHSC clinician service delivery due to the COVID-19 pandemic. RESULTS: The NHSC LRP expansion increased the number of clinicians providing behavioral health treatment in underserved areas, especially rural areas. A majority of NHSC sites surveyed have increased their provision of substance use disorder treatment since the COVID-19 pandemic began. CONCLUSIONS: This article demonstrates the valuable role of these NHSC programs as resources that policy makers can use to mitigate the challenges of health care workforce shortages and burnout.

Using telemedicine interventions during COVID-19 to expand care post COVID-19.

Despite available technology and supportive evidence in the literature, the integration of telemedicine interventions in the US health care system has remained sluggish for decades. The COVID-19 pandemic catalyzed widespread utilization of virtual visits and remote monitoring in urgent, primary, and specialist care settings out of sheer necessity. Specifically, in the rheumatology subspecialty, a lack of available providers and a patient community hindered by mobility and access issues have underscored the value of telemedicine. For these reasons, a solutions-focused, multistakeholder virtual roundtable meeting convened by the Frances Hamburger Institute for Community Rheumatology (FHI) identified telemedicine as a critical area for intervention to improve the quality and cost-effectiveness of patient-centered care. Building upon stakeholder experience and published findings, the Patient-Centered Rheumatology Collaborative identified the continued deregulation of policy barriers and the facilitation of sustainable coverage and reimbursement as critical steps toward establishing a robust infrastructure for telemedicine post pandemic. FHI roundtable attendees acknowledged several remaining telemedicine access barriers concerning traditionally underserved patient populations that will need to be addressed to realize the full potential of telemedicine. These recommendations are in concordance with those of other recent consensus groups, and they legitimize the formation of collaborative frameworks among payers, providers, and other key stakeholders to advance care in rheumatology.

Advancing COVID-19 Vaccination Equity Among the Refugee Community: An Innovative Multi-Sector Collaborative Outreach Program.

INTRODUCTION: Multi-sector outreach collaborations have the potential to improve COVID-19 vaccine access among underserved populations, including refugees. METHODS: Using a four-pronged strategy, we offered the local refugee community COVID-19 vaccine appointments within the next week. RESULTS: Over a thousand (1,327) individuals from more than 20 countries were identified; mean age 36.5 (SD=16.4); 55% female. Initially, 613 (46%) reported being scheduled/vaccinated prior to outreach efforts; 312 (24%) appointments were scheduled that resulted from outreach efforts. By February 2022, 895 (67.4%) of the 1,327 patients had at least one dose; the majority of these were Pfizer (n=750, 84%). Of 895 with first dose, 843 completed two-dose series (94.2%). Overall completion rate of initial series was 63.5%. Reasons for declining (171, 13%) included wanting to speak with a physician or family member first; pregnancy hesitation; postponing until after Ramadan. DISCUSSION: Although lower than local and state rates, this refugee community's COVID-19 vaccine uptake is on par with the overall population in the United States (65.8%). Because of COVID-19's disproportionately negative impact on refugee and other underserved populations, we offer recommendations for future equity-informed efforts.

Community-Based COVID-19 Vaccine Clinics in Medically Underserved Neighborhoods to Improve Access and Equity, Philadelphia, 2021-2022.

Vaccination remains key to reducing the risk of COVID-19-related severe illness and death. Because of historic medical exclusion and barriers to access, Black communities have had lower rates of COVID-19 vaccination than White communities. We describe the efforts of an academic medical institution to implement community-based COVID-19 vaccine clinics in medically underserved neighborhoods in Philadelphia, Pennsylvania. Over a 13-month period (April 2021-April 2022), the initiative delivered 9038 vaccine doses to community members, a majority of whom (57%) identified as Black. (Am J Public Health. 2022;112(12):1721-1725. https://doi.org/10.2105/AJPH.2022.307030).

Development of an At-Home COVID-19 Test Results-Reporting System for a School District Primarily Serving Underrepresented Minority Groups, San Diego, CA, 2021-2022.

School-sponsored at-home COVID-19 testing benefits users, school administrators, and surveillance efforts, although reporting results remains challenging. Users require simple systems with tailored posttest guidance, and administrators need timely positive test information. We built a system to serve these needs and to collect data for our Rapid Acceleration of Diagnostics-Underserved Populations Return to School Program study in San Diego County, California, from October 2021 through January 2022. We describe this system and our participant outreach strategies and outline a replicable model for at-home results reporting. (Am J Public Health. 2022;112(S9):S883-S886. https://doi.org/10.2105/AJPH.2022.307073).

Mobile Health Services for COVID-19: Counseling, Testing, and Vaccination for Medically Underserved Populations.

Mobile health units can improve access to preventive health services, especially for medically underserved populations. However, there is little published experience of mobile health units being used to expand access to COVID-19 vaccination. In concert with local public health departments and community members, we implemented a mobile COVID-19 health unit and deployed it to 12 predominantly low-income and racial/ethnic minority communities in Massachusetts. We describe the success and challenges of this innovative program in expanding access to COVID-19 vaccination. (Am J Public Health. 2022;112(11):1556-1559. https://doi.org/10.2105/AJPH.2022.307021).

Characterization of US State COVID-19 Vaccine Incentive Programs.

This cross-sectional study describes and compares key characteristics of state COVID-19 vaccine incentive programs in the US.

Use of video-based telehealth services using a mobile app for workers in underserved areas during the COVID-19 pandemic: A prospective observational study.

BACKGROUND: The COVID-19 pandemic has limited face-to-face treatment, triggering a change in the structure of existing healthcare services. Unlike other groups, workers in underserved areas have relatively poor access to healthcare. OBJECTIVE: This study aimed to investigate the effects of video-based telehealth services using a mobile personal health record (PHR) app for vulnerable workers with metabolic risk factors. METHODS: A prospective observational study was conducted with 117 participants and 27 healthcare professionals for 16 weeks. Participants visited the research institution three times (at weeks 1, 8, and 16) and underwent health check-ups and used various features of the mobile PHR app. Healthcare professionals observed the participants's data using the monitoring system and performed appropriate interventions. The primary outcome measures were to evaluate the effects of services on changes in the participants' metabolic risk factors, and secondary outcome measures were to analyze changes in the participants' lifestyle and service satisfaction, and to observe service use through usage logs. One-way repeated measures ANOVA and Scheffé's test were performed to observe changes in participants' health status and lifestyle, and a paired t-test was performed to analyze changes in service satisfaction. Finally, in-depth interviews with healthcare professionals were performed using semi-structured questionnaires to understand service providers' perspectives after the end of the study. RESULTS: Systolic blood pressure (F = 7.32, P <.001), diastolic blood pressure (F = 11.30, P <.001), body weight (F = 29.53, P <.001), BMI (F = 17.31, P <.001), waist circumference (F = 17.33, P <.001), fasting blood glucose (F = 5.11, P =.007), and triglycerides (F = 4.66, P =.01) showed significant improvements with time points, whereas high-density lipoprotein cholesterol (F = 3.35, P =.067) did not. The dietary score (F = 3.26, P =.04) showed a significant improvement with time points, whereas physical activity (F = 1.06, P =.34) did not. In terms of service satisfaction, only lifestyle improvement (P <.001) showed a significant difference. COVID-19 has affected the performance of healthcare professionals, thereby changing the perspectives toward healthcare technology services. CONCLUSIONS: We evaluated the effectiveness of video-based telehealth services supporting workers' health status and lifestyle interventions using healthcare technologies such as the mobile PHR app, tele-monitoring, and video teleconsultation. Our results indicate that as a complementary means, its utility can be expanded in the field of occupational safety and health to overcome the limitations of face-to-face treatment due to COVID-19 in the future.