Codesigning Online Continuing Medical Education on Social Health Integration and Social Risk-Informed Care for Primary Care Providers.

INTRODUCTION: Adapting clinical care decisions for patient-reported social risks is essential to social health integration and patient-centered care. Most research in this area focuses on awareness and assistance (social-needs-targeted care), such as screening and referral to food, financial, and other resources. Limited evidence for adjustment strategies (social risk-informed care) or adapting care for social risks made it difficult for Kaiser Permanente to implement new initiatives. This article describes a co-design process to build a novel, adjustment-focused continuing medical education course. METHODS: The authors co-developed the online continuing medical education course with patients and clinicians using user-centered design. Transcripts from co-design activities were coded and analyzed by thematic analysis to identify major themes, including perceptions of social risk-informed care and barriers to care adjustment. RESULTS: Practical hurdles for implementing social risk-informed care emerged, including clinicians' concerns about the ethics of adjustment as substandard care, particularly without robust assistance activities. However, patients expressed a desire for their care to be adapted to their social circumstances, to allow for more realistic care plans. DISCUSSION: Implementation barriers identified from the co-design were addressed through an interactive, case-study approach. Existing evidence on contextualized care and shared decision making informed a general framework for primary care providers to engage in awareness and adjustment activities, paired with 3 interactive case studies based on real-world, clinician-supplied scenarios. CONCLUSION: The authors recommend that multiple stakeholder perspectives be incorporated during the development of social health integration initiatives, particularly adjustment. Education complemented by active, nuanced, flexible implementation strategies may be necessary for the successful uptake of care-delivery-based social health integration activities.

"I really had somebody in my corner." Patient experiences with a pharmacist-led opioid tapering program.

BACKGROUND: Opioid tapering has been identified as an effective strategy to prevent the dangers associated with long-term opioid therapy for patients with chronic pain. However, many patients are resistant to tapering, and conversations about tapering can be challenging for health care providers. Pharmacists can play a role in supporting both providers and patients with the process of opioid tapering. OBJECTIVE: Qualitatively describe patient experiences with a unique phone-based and pharmacy-led opioid tapering program implemented within an integrated health care system. METHODS: In-depth telephone interviews with patients who completed the program were recorded, transcribed, and analyzed. Themes were identified through a constant comparative approach. RESULTS: We completed 25 interviews; 80% of patients were women (20), with a mean age of 58 years, and 72% (18) had been using opioids for pain management for 10 or more years. Most (60%) described a positive and satisfying experience with the tapering program. Strengths of the program reported by patients included a patient-centered and compassionate taper approach, flexible taper pace, easy access to knowledgeable pharmacist advocates, and resultant improvements in quality of life (e.g., increased energy). Challenges reported included: unhelpful or difficult-to-access nonpharmacological pain management options, negative quality of life impacts (e.g., inability to exercise), and lack of choice in the taper process. At the end of tapering, most patients (72%) described their pain as reduced or manageable rather than worse and expressed willingness to use the program in the future if a need should arise. CONCLUSIONS: Patients in a pharmacist-led opioid tapering program appreciated the program's individualized approach to care and access to pharmacist' expertise. Most interviewed patients successfully reduced their opioid use and recommended that the program should continue as an offered service. To improve the program, patients suggested increased personalization of the taper process and additional support for withdrawal symptoms and nonpharmacological pain management.

Bridge to Health/Puente a la Salud: a pilot randomized trial to address diabetes self-management and social needs among high-risk patients.

Social needs contribute to persistent diabetes disparities; thus, it is imperative to address social needs to optimize diabetes management. The purpose of this study was to determine determine the feasibility and acceptability of health system-based social care versus social care + behavioral intervention to address social needs and improve diabetes self-management among patients with type 2 diabetes. Black/African American, Hispanic/Latino, and low-income White patients with recent hemoglobin A1C (A1C) ≥ 8%, and ≥1 social need were recruited from an integrated health system. Patients were randomized to one-of-two 6-month interventions: (a) navigation to resources (NAV) facilitated by a Patient Navigator; or (b) NAV + evidence-based nine-session diabetes self-management support (DSMS) program facilitated by a community health worker (CHW). A1C was extracted from the electronic health record. We successfully recruited 110 eligible patients (54 NAV; 56 NAV + DSMS). During the trial, 78% NAV and 80% NAV + DSMS participants successfully connected to a navigator; 84% NAV + DSMS connected to a CHW. At 6-month follow-up, 33% of NAV and 34% of NAV + DSMS participants had an A1C < 8%. Mean reduction in A1C was clinically significant in NAV (-0.65%) and NAV + DSMS (-0.72%). By follow-up, 89% of NAV and 87% of NAV + DSMS were successfully connected to resources to address at least one need. Findings suggest that it is feasible to implement a health system-based social care intervention, separately or in combination, with a behavioral intervention to improve diabetes management among a high-risk, socially complex patient population. A larger, pragmatic trial is needed to test the comparative effectiveness of each approach on diabetes-related outcomes.

Dental providers' perceptions of the feasibility and acceptability of implementing vaccine administration programs in dental settings: A qualitative study.

OBJECTIVES: Involving dental offices in routine vaccinations could have a positive impact on public health. In this study, we assessed dental providers' attitudes and perceptions regarding implementing vaccination in dental settings. METHODS: We performed semi-structured interviews with 31 dental providers (25 dentists and 6 dental hygienists) enrolled in the Western region of the National Dental Practice-Based Research Network as of June 28, 2021. Interviews were recorded and transcribed. We analyzed transcripts using deductive and inductive coding approaches. RESULTS: We identified three main themes that captured the perceptions of dental practitioners regarding the feasibility of implementing vaccine administration in a dental setting: (1) dental practitioners perceive contributing to the public health mission of disease prevention as having high value, (2) dental practitioners face considerable complexity when deciding whether to implement vaccine administration, and (3) dental practitioners do not understand current laws and associated reimbursement models related to vaccine administration. CONCLUSIONS: To make vaccination commonplace in dental practices, legal changes to allow dental practitioners to administer vaccines should be followed by concrete guidance and relevant trainings to help interested dental practitioners successfully implement vaccination programs in their clinical settings.

Challenges with implementing the Diabetes Prevention Program for Medicare beneficiaries in an integrated health system.

OBJECTIVES: In April 2018, CMS began reimbursing both clinical and community settings for providing the CDC-recognized Diabetes Prevention Program (DPP) to eligible Medicare beneficiaries. To better understand the process of offering the program to Medicare beneficiaries, we interviewed relevant stakeholders in a large, integrated health care delivery system. STUDY DESIGN: Qualitative interview study. METHODS: We conducted semistructured interviews with 12 delivery system stakeholders. Data were analyzed following a thematic analysis approach. RESULTS: Stakeholders described systemic challenges to the implementation of Medicare DPP (MDPP), including inadequate reimbursement for the health care system, low awareness of MDPP among patients and providers, and challenges with utilizing third-party vendors to connect patients to CDC-recognized MDPPs. CONCLUSIONS: Although the reimbursement of DPP for Medicare beneficiaries was a landmark decision, the current structure and requirements make it difficult for health systems and community-based providers to implement and promote this benefit. This study highlights the challenges that even integrated health systems are facing to implement MDPP, as well as potential strategies to overcome these barriers and expand the reach of the program. Medicare should seek ways to increase the financial incentives and decrease the barriers associated with implementing MDPP.

Bridge to Health/ Puente a la Salud: Rationale and design of a pilot feasibility randomized trial to address diabetes self-management and unmet basic needs among racial/ethnic minority and low-income patients.

INTRODUCTION: Racial/ethnic and socioeconomic disparities in diabetes prevalence and management persist. Unmet basic needs such as food insecurity and unstable housing interfere with optimal diabetes self-management. Bridge to Health/Puente a la Salud is a randomized pilot trial designed to examine the feasibility of testing the effectiveness of addressing unmet basic needs via navigation services versus navigation plus diabetes self-management support (DSMS) on improving diabetes-related outcomes among racial/ethnic minority and low-income patients with uncontrolled diabetes. MATERIAL AND METHODS: We recruited and randomized 110 African American, Hispanic, and Medicaid patients (any race/ethnicity) with diabetes and recent hemoglobin A1C ≥ 8% to one of two 6-month interventions: 1) Navigation only; or 2) Navigation + DSMS. In both arms, practice-embedded patient navigators help participants navigate social services and community-based resources to address unmet basic needs. In Navigation + DSMS, participants are also assigned to a community health worker (CHW) embedded in a local community-based organization who provides additional navigation support and delivers DSMS. A1C and unmet basic needs data are collected via routine lab and survey, respectively, at baseline and 6-month follow-up. Qualitative interviews with participants, health system leaders, CHWs, and patient navigators are conducted to explore intervention acceptability and determinants of implementation in a health care setting. DISCUSSION: Findings from this pilot feasibility study will enhance understanding about acceptability, preliminary clinical effectiveness, and facilitators and barriers to implementation of the Navigation only and Navigation + DSMS interventions and inform refinements of the overall study design for the larger, randomized clinical trial.

Prevalence of Unmet Basic Needs and Association with Diabetes Control and Care Utilization Among Insured Persons with Diabetes.

Unmet basic needs (eg, food insecurity, inadequate housing) are major barriers to diabetes self-management. The purpose of this study was to identify the prevalence of unmet basic needs and examine the association with diabetes control and care utilization among insured persons with diabetes. A total of 4043 adult patients with diabetes were screened for unmet basic needs using Your Current Life Situation, a screener for unmet basic needs, during a clinical encounter or as an online survey, during the study period (January 1, 2016-August 31, 2017). Hemoglobin A1c and care utilization (outpatient, emergency department [ED], hospitalization, diabetes-related prescription refills) were extracted from the electronic health record 12 months prior to screening. The authors compared patients with unmet basic needs to those with no needs on poor diabetes control (ie, A1c ≥8%) and care utilization using multivariable regression models. Of the 4043 patients screened, 25% endorsed ≥1 unmet basic need. In adjusted analyses, the presence of unmet basic needs was associated with an increased likelihood of having an A1c ≥8% (OR = 1.77; 95% CI 1.47, 2.13), more outpatient visits (incidence rate ratio [IRR] = 1.3; 1.2, 1.4), more ED visits (IRR = 2.3; 2.0, 2.6), more hospitalizations (IRR = 1.8; 1.5, 2.2), and more delays in refilling diabetes medication (IRR = 1.21; 1.13, 1.30). Findings indicate that unmet basic needs are highly prevalent, even among an insured patient population, and are associated with poor diabetes-related clinical outcomes and excess utilization. Future studies to determine best strategies to integrate this information into treatment planning are warranted.

"We Need to Taper." Interviews with Clinicians and Pharmacists About Use of a Pharmacy-Led Opioid Tapering Program.

OBJECTIVE: To identify factors that influence or interfere with referrals by primary care providers (PCPs) to a pharmacist-led telephone-based program to assist patients undergoing opioid tapering. The Support Team Onsite Resource for Management of Pain (STORM) program provides individualized patient care and supports PCPs in managing opioid tapers. DESIGN: Qualitative interviews were conducted with referring PCPs and STORM staff. Interview guides addressed concepts from the RE-AIM framework, focusing on issues affecting referral to the STORM program. SETTING: An integrated healthcare system (HCS) in the Northwest United States. SUBJECTS: Thirty-five interviews were conducted with 20 PCPs and 15 STORM staff. METHODS: Constant comparative analysis was used to identify key themes from interviews. A codebook was developed based on interview data and a qualitative software program was used for coding, iterative review, and content analysis. Representative quotes illustrate identified themes. RESULTS: Use of the STORM opioid tapering program was influenced by PCP, patient, and HCS considerations. Factors motivating use of STORM included lack of PCP time to support chronic pain patients requiring opioid tapering and the perception that STORM is a valued partner in patient care. Impediments to referral included PCP confidence in managing opioid tapering, patient resistance to tapering, forgetting about program availability, and PCP resistance to evolving guidelines regarding opioid tapering goals. CONCLUSIONS: PCPs recognized that STORM supported patient safety and reduced clinician burden. Utilization of the program could be improved through ongoing PCP education about the service and consistent co-location of STORM pharmacists within primary care clinics.

Factors associated with opioid-tapering success: A mixed methods study.

OBJECTIVE: Opioid tapering is recommended when risks of chronic opioid use outweigh benefits. Little is known about patient characteristics or factors related to tapering success. We sought to identify characteristics that predict a 50% reduction in opioid use and qualitatively characterize factors that impact tapering success. METHODS: We used multilevel hierarchical modeling to identify predictors of a 50% reduction in opioid use among Kaiser Permanente Northwest patients who underwent pharmacist-led tapering between 2012 and 2017. We conducted qualitative interviews among patients and pharmacists to identify factors influencing tapering success. RESULTS: We identified 1384 patients who, on average, were dispensed 207 milligram morphine equivalents per day at baseline. After 12 months, 56% of patients reduced their opioid use by 50%. Increased odds of 50% reduction were associated with younger age 21-49 years (Odds ratio [OR] 1.32, P = 0.004); previous surgery (OR 2.24, P < 0.001); increased number of Addiction Medicine encounters (OR 1.25, P = 0.011); substance use disorder (OR 1.62, P = 0.001); anxiety (OR 1.32, P = 0.003); non-narcotic analgesic (OR 1.22, P = 0.025) or antipsychotic medication use (OR 1.53, P = 0.006); and opioid days supplied in the previous year (OR 1.08, P < 0.001). Patients and pharmacists noted that success was influenced by patients' willingness or resistance to change opioid use, the level of patient engagement achieved through communication with their provider, aspects of the tapering process such as pace, and external factors including health issues or caregiving responsibilities. CONCLUSIONS: Over one-half of patients who underwent tapering reduced their opioid use by 50%. Patient demographic and clinical characteristics were predictive of tapering success; however, patients and pharmacists noted that patient willingness, motivation, and personal circumstances also influence tapering outcome. Opioid tapering requires an individualized approach. Both clinical factors and personal circumstances should be considered when opioid tapering is being discussed as a possible solution for a patient.

A Pharmacist-Led Program to Taper Opioid Use at Kaiser Permanente Northwest: Rationale, Design, and Evaluation.

INTRODUCTION: Primary care practitioners (PCPs) are concerned about adverse effects and poor outcomes of opioid use but may find opioid tapering difficult because of a lack of pain management training or time constraints limiting patient counseling. In 2010, Kaiser Permanente Northwest implemented a pharmacist-led opioid tapering program-Support Team Onsite Resource for Management of Pain (STORM)-to address high rates of opioid use, alleviate PCPs' workload demands, and improve patient outcomes. OBJECTIVE: To describe the rationale, structure, and delivery of this unique pharmacist-led program, which partners with PCPs and provides individualized care to help patients reduce opioid use, and the Facilitating Lower Opioid Amounts through Tapering study, which examines the program's effectiveness, cost-effectiveness, and implementation. RESULTS: The STORM program includes a pain medicine physician, a social worker or nurse, and pharmacists who have received specialized clinical and communications training. The program has a 2-fold role: 1) to provide PCP education about pain management and opioid use and 2) to offer clinician and patient support with opioid tapering and pain management. After program training, PCPs are equipped to discuss the need for tapering with a patient and to refer to the program. Program pharmacists provide a range of services, including opioid taper plans, nonopioid pain management recommendations, and taper-support outreach to patients. DISCUSSION: The STORM program provides individualized care to assist patients with opioid tapering while reducing the burden on PCPs. CONCLUSION: The STORM program may be a valuable addition to health care systems and settings seeking options to address their patients' opioid tapering needs.

Characteristics of community mental health clinics associated with treatment engagement.

OBJECTIVES: Past literature documents many individual predictors of treatment engagement among mental health clients in community settings, but few studies have examined clinic characteristics that may be associated with treatment engagement. With data from a patient activation and self-management trial, this study examined the variation in demographic and clinic characteristics across community mental health clinics and whether this variation predicted differences in treatment engagement in mental health services. METHODS: Chart reviews were conducted for 638 clients of 12 community mental health clinics. Client attendance records were collected for a one-year period to examine engagement (defined as the ratio of kept versus scheduled appointments). Adjusting for client variability, the investigators examined which clinic-level characteristics were associated with treatment engagement. RESULTS: Clinics varied significantly in their clients' demographic characteristics and engagement in mental health care. Providing case management and offering transportation vouchers or free parking at the clinic were associated with lower engagement. However, offering outreach was associated with greater engagement. CONCLUSIONS: The results of this study suggest that certain clinic characteristics are associated with engagement in mental health services. These results demonstrate the difficulties faced by community mental health clinics in reducing no-show rates even in the face of strong efforts to improve engagement.