Learning in real world practice: Identifying implementation strategies to integrate health-related social needs screening within a large health system.

Introduction: Health systems have many incentives to screen patients for health-related social needs (HRSNs) due to growing evidence that social determinants of health impact outcomes and a new regulatory context that requires health equity measures. This study describes the experience of one large urban health system in scaling HRSN screening by implementing improvement strategies over five years, from 2018 to 2023. Methods: In 2018, the health system adapted a 10-item HRSN screening tool from a widely used, validated instrument. Implementation strategies aimed to foster screening were retrospectively reviewed and categorized according to the Expert Recommendations for Implementing Change (ERIC) study. Statistical process control methods were utilized to determine whether implementation strategies contributed to improvements in HRSN screening activities. Results: There were 280,757 HRSN screens administered across 311 clinical teams in the health system between April 2018 and March 2023. Implementation strategies linked to increased screening included integrating screening within an online patient portal (ERIC strategy: involve patients/consumers and family members), expansion to discrete clinical teams (ERIC strategy: change service sites), providing data feedback loops (ERIC strategy: facilitate relay of clinical data to providers), and deploying Community Health Workers to address HRSNs (ERIC strategy: create new clinical teams). Conclusion: Implementation strategies designed to promote efficiency, foster universal screening, link patients to resources, and provide clinical teams with an easy-to-integrate tool appear to have the greatest impact on HRSN screening uptake. Sustained increases in screening demonstrate the cumulative effects of implementation strategies and the health system's commitment toward universal screening.

Interdisciplinary Care and Preparedness for Kidney Failure Management in a High-Risk Population.

Rationale & Objective: Interdisciplinary care may improve health outcomes in patients with chronic kidney disease (CKD). Few studies have evaluated this model of health care delivery in racial and ethnic minorities. Study Design: Retrospective cohort study. Setting & Participants: Incident end-stage kidney disease (ESKD) patients at Montefiore Medical Center from October 1, 2013, to October 31, 2019. Exposure: Pre-ESKD interdisciplinary care. Outcomes: Pre-ESKD transplant listing and optimal kidney replacement therapy (KRT) start (use of arteriovenous access at hemodialysis initiation, outpatient hemodialysis start, preemptive transplant, or peritoneal dialysis as the first modality). Analytical Approach: We constructed multivariable logistic regression models adjusted for sociodemographic and clinical factors to determine the odds of transplant listing and optimal KRT start between interdisciplinary versus the usual care group. Results: Of the 295 incident ESKD patients included in our study, 84 received interdisciplinary care and 211 received usual nephrology care. The mean age was 59.9 years (standard deviation, 13.9 years), 47% were women, and 87% were African American or Hispanic. Baseline characteristics were similar between the groups, except that the interdisciplinary care group had a lower prevalence of hypertension (60% vs 75%). Compared with usual care, a higher proportion of patients in the interdisciplinary care group were listed for kidney transplant (44% vs 16%) and had an optimal KRT start (53% vs 44%). Receipt of interdisciplinary care was associated with a higher odds (OR, 5.73; 95% CI, 2.78-11.80; P < 0.001) of transplant listing compared with usual care after adjusting for important sociodemographic and clinical factors. The odds of an optimal KRT start also favored interdisciplinary care (OR, 1.60; 95% CI, 0.88-2.89; P = 0.12) but did not achieve statistical significance. Limitations: The study was non-randomized and had a small sample size. Conclusions: Interdisciplinary care is associated with better ESKD preparedness compared with usual nephrology care alone in racial and ethnic minorities. Larger studies are needed to determine the effectiveness of interdisciplinary care in patients with advanced CKD.

Feasibility of Problem Adaption Therapy in a Diverse, Frail Older Adult Population (PATH-MHS).

The purpose of the Problem Adaptation Therapy - Montefiore Health System (PATH-MHS) pilot program was to demonstrate the feasibility and effectiveness of PATH across a culturally, educationally, and functionally diverse cohort of older adults. METHODS: Clinicians referred 145 participants with depression and cognitive impairment to PATH-MHS. We completed analyses of the change in depression, disability and the association between baseline characteristics and remission of depression. RESULTS: Most participants were Hispanic or Non-Hispanic Black and 54.7% (76) were primary Spanish speakers. Overall, there were significant decreases in the mean PHQ-9 and WHODAS 2.0 scores. In logistic regression models, neither age, education, gender, race/ethnicity, language nor long-term care status was significantly associated with remission of depression. CONCLUSIONS: This study demonstrates that we were able to engage a diverse, cognitively impaired, and frail cohort of older adults in PATH-MHS with significant reductions in depression and disability.

"I was not able to keep myself away from tending to her immediate needs": Primary Care Physicians' Perspectives of Serious Illness Conversations at Community Health Centers.

PURPOSE: Seriously ill patients in low-income and minority populations have lower rates of advance care planning. Initiatives that promote serious illness (SI) conversations in community health centers (CHCs) can reach broad, diverse patient populations. This qualitative study explored the experiences of primary care physicians in conducting SI conversations at CHCs in order to understand challenges and needs in this setting. METHODS: An initiative to increase SI conversations was implemented at two CHCs in the Bronx, NY. Eleven participating family physicians who together conducted 37 SI conversations underwent semi-structured in-depth interviews. The 11 interviews were analyzed using inductive thematic analysis. RESULTS: Eight themes emerged: (1) Structured approaches to SI conversations are useful even in longstanding patient-doctor relationships; (2) Discussion of prognosis is meaningful but difficult; (3) Emotional work is humanizing but draining; (4) Poverty and underinsurance are high priorities; (5) Social context affects patient readiness; (6) Communication barriers take multiple forms; (7) Patient characteristics make it "easier" or "harder" to initiate the SI conversation; (8) Time constraints limit the ability to meet multiple patient needs. CONCLUSIONS: Physicians at CHCs identified challenges in SI conversations at personal, interpersonal, organizational, and societal levels. These challenges should be addressed by initiatives that aim to increase SI conversations in primary care, and especially at CHCs.

Real-world insights from launching remote peer-to-peer mentoring in a safety net healthcare delivery setting.

Peer mentors have been proven to improve diabetes outcomes, especially among diverse patients. Delivering peer mentoring via remote strategies (phone, text, mobile applications) is critical, especially in light of the recent pandemic. We conducted a real-world evaluation of a remote diabetes intervention in a safety-net delivery system in New York. We summarized the uptake, content, and pre-post clinical effectiveness for English- and Spanish-speaking participants. Of patients who could be reached, 71% (n = 690/974) were enrolled, and 90% of those (n = 618/690) participated in coaching. Patients and mentors had a mean of 32 check-ins, and each patient set an average of 10 goals. 29% of the participants accessed the program via the smartphone application. Among participants with complete hemoglobin A1c data (n = 179), there was an absolute 1.71% reduction (P < .01). There are multiple lessons for successful implementation of remote peer coaching into settings serving diverse patients, including meaningful patient-mentor matching and addressing social determinants.