Integrating Community Health Workers into Community-Based Primary Care Practice Settings to Improve Blood Pressure Control Among South Asian Immigrants in New York City: Results from a Randomized Control Trial.

BACKGROUND: Blood pressure (BP) control is suboptimal in minority communities, including Asian populations. We evaluate the feasibility, adoption, and effectiveness of an integrated CHW-led health coaching and practice-level intervention to improve hypertension control among South Asian patients in New York City, Project IMPACT (Integrating Million Hearts for Provider and Community Transformation). The primary outcome was BP control, and secondary outcomes were systolic BP and diastolic BP at 6-month follow-up. METHODS: A randomized-controlled trial took place within community-based primary care practices that primarily serve South Asian patients in New York City between 2017 and 2019. A total of 303 South Asian patients aged 18-85 with diagnosed hypertension and uncontrolled BP (systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg) within the previous 6 months at 14 clinic sites consented to participate. After completing 1 education session, individuals were randomized into treatment (n=159) or control (n=144) groups. Treatment participants received 4 additional group education sessions and individualized health coaching over a 6-month period. A mixed effect generalized linear model with a logit link function was used to assess intervention effectiveness for controlled hypertension (Yes/No), adjusting for practice level random effect, age, sex, baseline systolic BP, and days between BP measurements. RESULTS: Among the total enrolled population, mean age was 56.8±11.2 years, and 54.1% were women. At 6 months among individuals with follow-up BP data (treatment, n=154; control, n=137), 68.2% of the treatment group and 41.6% of the control group had controlled BP (P<0.001). In final adjusted analysis, treatment group participants had 3.7 [95% CI, 2.1-6.5] times the odds of achieving BP control at follow-up compared with the control group. CONCLUSIONS: A CHW-led health coaching intervention was effective in achieving BP control among South Asian Americans in New York City primary care practices. Findings can guide translation and dissemination of this model across other communities experiencing hypertension disparities. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT03159533.

Building and Sustaining Community Partnerships: An Organizational Network Analysis in a Low-resource Neighborhood.

BACKGROUND: Launched in 2012, the Claremont Healthy Village Initiative (CHVI) is a partnership focused on fostering community collaboration, addressing the social determinants of health, and reducing health disparities. Partners include local community centers, schools, after-school programs, health care providers, a health insurer, city agencies, tenant associations, resident leaders, elected officials, and other stakeholders. OBJECTIVES: To understand the development and value of collaboration within the CHVI from the perspective of multiple partners. METHODS: Using a community-based participatory research approach, we worked collaboratively with the CHVI leaders, we used paper-and web-based surveys grounded in social network theory were administered in 2017 and 2018. Questions focused on relationships between organizations that are part of the coalition. Our analysis included responses from organizations that participated in the survey at both points in time. Network measures such as density, degree centrality, and node characteristics were used to understand information sharing, referral, and collaboration among the participating organizations. Additional data included stake-holder interviews. RESULTS: Coalition partners increased connectedness with one another over the course of the study, with significantly greater density of relationship and bi-directional partnerships in the follow-up survey. Of the three types of interactions, referrals showed a trend for highest density change. Trust levels were highest among organizations with a local physical presence. CONCLUSIONS: Social network analysis provided visual and quantitative information that helped reinforce relationships and identify opportunities to improve connectedness and collaboration among diverse community partners, helping to support the coalition's goals and objectives.

"Hey, We Can Do This Together": Findings from an Evaluation of a Multi-sectoral Community Coalition.

Multi-sectoral coalitions focused on systemic health inequities are commonly promoted as important mechanisms to facilitate changes with lasting impacts on population health. However, the development and implementation of such initiatives present significant challenges, and evaluation results are commonly inconclusive. In an effort to add to the evidence base, we conducted a mixed-methods evaluation of the Claremont Healthy Village Initiative, a multi-sectoral partnership based in the Bronx, New York City. At an organizational level, there were positive outcomes with respect to expanded services, increased access to resources for programs, improved linkages, better coordination, and empowerment of local leaders-all consistent with a systemic, community building approach to change. Direct impacts on community members were more difficult to assess: perceived access to health and other services improved, while community violence and poor sanitation, which were also priorities for community members, remained important challenges. Findings suggest significant progress, as well as continued need.

Timely Postpartum Visits for Low-Income Women: A Health System and Medicaid Payer Partnership.

A health care system and a Medicaid payer partnered to develop an educational intervention and payment redesign program to improve timely postpartum visits for low-income, high-risk mothers in New York City between April 2015 and October 2016. The timely postpartum visit rate was higher for 363 mothers continuously enrolled in the program than for a control group matched by propensity score (67% [243/363] and 56% [407/726], respectively; P < .001). An innovative partnership between a health care system and Medicaid payer improved access to health care services and community resources for high-risk mothers.

Feasibility and Outcomes of an Electronic Health Record Intervention to Improve Hypertension Management in Immigrant-serving Primary Care Practices.

BACKGROUND: South Asians experience a disproportionate burden of high blood pressure (BP) in the United States, arguably the most preventable risk factor for cardiovascular disease. OBJECTIVE: We report 12-month results of an electronic health record (EHR)-based intervention, as a component of a larger project, "Implementing Million Hearts for Provider and Community Transformation." The EHR intervention included launching hypertension patient registries and implementing culturally tailored alerts and order sets to improve hypertension control among patients treated in 14 New York City practices located in predominantly South Asian immigrant neighborhoods. DESIGN: Using a modified stepped-wedge quasi-experimental study design, practice-level EHR data were extracted, and individual-level data were obtained on a subset of patients insured by a Medicaid insurer via their data warehouse. The primary aggregate outcome was change in proportion of hypertensive patients with controlled BP; individual-level outcomes included average systolic BP (SBP) and diastolic BP (DBP) at last clinic visit. Qualitative interviews were conducted to assess intervention feasibility. MEASURES: Hypertension was defined as having at least 1 hypertension ICD-9/10 code. Well-controlled hypertension was defined as SBP<140 and DBP<90 mm Hg. RESULTS: Postintervention, we observed a significant improvement in hypertension control at the practice level, adjusting for age and sex patient composition (adjusted relative risk, 1.09; 95% confidence interval, 1.04-1.14). Among the subset of Medicaid patients, we observed a significant reduction in average SBP and DBP adjusting for time, age, and sex, by 1.71 and 1.13 mm Hg, respectively (P<0.05). Providers reported feeling supported and satisfied with EHR components. CONCLUSIONS: EHR initiatives in practices serving immigrants and minorities may enhance practice capabilities to improve hypertension control.

Protocol for project IMPACT (improving millions hearts for provider and community transformation): a quasi-experimental evaluation of an integrated electronic health record and community health worker intervention study to improve hypertension management among South Asian patients.

BACKGROUND: The Million Hearts® initiative aims to prevent heart disease and stroke in the United States by mobilizing public and private sectors around a core set of objectives, with particular attention on improving blood pressure control. South Asians in particular have disproportionately high rates of hypertension and face numerous cultural, linguistic, and social barriers to accessing healthcare. Interventions utilizing Health information technology (HIT) and community health worker (CHW)-led patient coaching have each been demonstrated to be effective at advancing Million Hearts® goals, yet few studies have investigated the potential impact of integrating these strategies into a clinical-community linkage initiative. Building upon this initiative, we present the protocol and preliminary results of a research study, Project IMPACT, designed to fill this gap in knowledge. METHODS: Project IMPACT is a stepped wedge quasi-experimental study designed to test the feasibility, adoption, and impact of integrating CHW-led health coaching with electronic health record (EHR)-based interventions to improve hypertension control among South Asian patients in New York City primary care practices. EHR intervention components include the training and implementation of hypertension-specific registry reports, alerts, and order sets. Fidelity to the EHR intervention is assessed by collecting the type, frequency, and utilization of intervention components for each practice. CHW intervention components consist of health coaching sessions on hypertension and related risk factors for uncontrolled hypertensive patients. The outcome, hypertension control (<140 mmHg systolic blood pressure (BP) and <90 mmHg diastolic BP), is collected at the aggregate- and individual-level for all 16 clinical practices enrolled. DISCUSSION: Project IMPACT builds upon the evidence base of the effectiveness of CHW and Million Hearts® initiatives and proposes a unique integration of provider-based EHR and community-based CHW interventions. The project informs the effectiveness of these interventions in team-based care approaches, thereby, helping to develop relevant sustainability strategies for improving hypertension control among targeted racial/ethnic minority populations at small primary care practices. TRIAL REGISTRATION: This study protocol has been approved and is made available on Clinicaltrials.gov by NCT03159533 as of May 17, 2017.

Delivery and Payment Redesign to Reduce Disparities in High Risk Postpartum Care.

Purpose This paper describes the implementation of an innovative program that aims to improve postpartum care through a set of coordinated delivery and payment system changes designed to use postpartum care as an opportunity to impact the current and future health of vulnerable women and reduce disparities in health outcomes among minority women. Description A large health care system, a Medicaid managed care organization, and a multidisciplinary team of experts in obstetrics, health economics, and health disparities designed an intervention to improve postpartum care for women identified as high-risk. The program includes a social work/care management component and a payment system redesign with a cost-sharing arrangement between the health system and the Medicaid managed care plan to cover the cost of staff, clinician education, performance feedback, and clinic/clinician financial incentives. The goal is to enroll 510 high-risk postpartum mothers. Assessment The primary outcome of interest is a timely postpartum visit in accordance with NCQA healthcare effectiveness data and information set guidelines. Secondary outcomes include care process measures for women with specific high-risk conditions, emergency room visits, postpartum readmissions, depression screens, and health care costs. Conclusion Our evidence-based program focuses on an important area of maternal health, targets racial/ethnic disparities in postpartum care, utilizes an innovative payment reform strategy, and brings together insurers, researchers, clinicians, and policy experts to work together to foster health and wellness for postpartum women and reduce disparities.

Predicting complications after bariatric surgery using obesity-related co-morbidities.

BACKGROUND: To determine which (if any) pre-surgery obesity-related co-morbidities predict complications after bariatric surgery. METHODS: Claims data are analyzed for 1,760 patients aged 18-62 who were covered by one of seven New York State health plans and underwent bariatric surgery during 2002-2005. Data covered 6 months before to 18 months after surgery. Pre-surgery obesity-related comorbidities studied include: diabetes, hyperlipidemia, hypertension, asthma, arthritis, sleep apnea, GERD, and depression. Specific post-surgery complications examined are: stenosis, complications associated with the anastomosis, dumping syndrome, and sepsis. RESULTS: Obesity-related co-morbidities prior to surgery are significantly correlated with the probability of developing complications up to 180 days after bariatric surgery. For example, sepsis was significantly more likely in patients who had diabetes, arthritis, or sleep apnea prior to surgery. An additional pre-surgery comorbidity is associated with a 27.5% higher likelihood of dumping syndrome, 24.5% higher likelihood of complications associated with the anastomosis, and 23.5% higher probability of sepsis in the first 180 days after surgery. Among the individual co-morbidities studied, sleep apnea and GERD are most predictive of complications. CONCLUSION: Patients who exhibit multiple obesity-related co-morbidities prior to bariatric surgery are at significantly elevated risk of post-surgery complications and merit closer monitoring by health care professionals after bariatric surgery. Limitations of this study include nonexperimental data and an unknown degree of under-reporting of pre-surgery co-morbidities in claims data.

Health insurance claims data as a means of assessing reduction in co-morbidities 6 months after bariatric surgery.

BACKGROUND: We measured the very short-term change in obesity-related co-morbidities following bariatric surgery. METHODS: Claims data were analyzed for 933 patients aged 18-62 who were covered by one of 11 New York State health plans and underwent bariatric surgery during calendar year 2002. Data covered 6 months before to 6 months after surgery. Logit regression and fixed effects logit regressions were estimated, to analyze change in the following co-morbidities after bariatric surgery: diabetes, hyperlipidemia, hypertension, asthma, sleep apnea, degenerative joint disease, gastroesophageal reflux, and depression. RESULTS: There were statistically significant post-surgery decreases in each outcome studied. Controlling for individual fixed effects, the probability of a diabetes diagnosis fell by 20% after bariatric surgery. The probability of sleep apnea fell by 33%, and the probability of the other obesity-related co-morbidities fell by 11 to 19% at 6 months. CONCLUSION: Claims data are useful for assessing changes in a wide range of co-morbidities following bariatric surgery. The data indicate significant decreases in obesity-related co-morbidities after bariatric surgery, although considerably smaller than those found in previous studies, which underscores the need for randomized controlled trials of bariatric surgery. Limitations of this study include: follow-up only at 6 months, non-experimental data, and an unknown degree of under-reporting of co-morbidities in claims data.