A Community Health Worker-Led Rotation to Train Medical Students in the Social Determinants of Health.

Medical students often lack training in understanding and addressing the social determinants that shape the health of high-risk populations. We describe a novel clinical elective rotation in which fourth-year medical students served as apprentices to community health workers in order to develop community engagement skills and cultural humility.

Community Health Worker Support for Disadvantaged Patients With Multiple Chronic Diseases: A Randomized Clinical Trial.

OBJECTIVES: To determine whether a community health worker (CHW) intervention improved outcomes in a low-income population with multiple chronic conditions. METHODS: We conducted a single-blind, randomized clinical trial in Philadelphia, Pennsylvania (2013-2014). Participants (n = 302) were high-poverty neighborhood residents, uninsured or publicly insured, and diagnosed with 2 or more chronic diseases (diabetes, obesity, tobacco dependence, hypertension). All patients set a disease-management goal. Patients randomly assigned to CHWs also received 6 months of support tailored to their goals and preferences. RESULTS: Support from CHWs (vs goal-setting alone) led to improvements in several chronic diseases (changes in glycosylated hemoglobin: -0.4 vs 0.0; body mass index: -0.3 vs -0.1; cigarettes per day: -5.5 vs -1.3; systolic blood pressure: -1.8 vs -11.2; overall P = .08), self-rated mental health (12-item Short Form survey; 2.3 vs -0.2; P = .008), and quality of care (Consumer Assessment of Healthcare Providers and Systems; 62.9% vs 38%; P < .001), while reducing hospitalization at 1 year by 28% (P = .11). There were no differences in patient activation or self-rated physical health. CONCLUSIONS: A standardized CHW intervention improved chronic disease control, mental health, quality of care, and hospitalizations and could be a useful population health management tool for health care systems. TRIAL REGISTRATION: clinicaltrials.gov identifier: NCT01900470.

Decision-making and goal-setting in chronic disease management: Baseline findings of a randomized controlled trial.

OBJECTIVE: Growing interest in collaborative goal-setting has raised questions. First, are patients making the 'right choices' from a biomedical perspective? Second, are patients and providers setting goals of appropriate difficulty? Finally, what types of support will patients need to accomplish their goals? We analyzed goals and action plans from a trial of collaborative goal-setting among 302 residents of a high-poverty urban region who had multiple chronic conditions. METHODS: Patients used a low-literacy aid to prioritize one of their chronic conditions and then set a goal for that condition with their primary care provider. Patients created patient-driven action plans for reaching these goals. RESULTS: Patients chose to focus on conditions that were in poor control and set ambitious chronic disease management goals. The mean goal weight loss -16.8lbs (SD 19.5), goal HbA1C reduction was -1.3% (SD 1.7%) and goal blood pressure reduction was -9.8mmHg (SD 19.2mmHg). Patient-driven action plans spanned domains including health behavior (58.9%) and psychosocial (23.5%). CONCLUSIONS: High-risk, low-SES patients identified high priority conditions, set ambitious goals and generate individualized action plans for chronic disease management. PRACTICE IMPLICATIONS: Practices may require flexible personnel who can support patients using a blend of coaching, social support and navigation.

Toward A Scalable, Patient-Centered Community Health Worker Model: Adapting the IMPaCT Intervention for Use in the Outpatient Setting.

Community health worker (CHW) programs are an increasingly popular strategy for patient-centered care. Many health care organizations are building CHW programs through trial and error, rather than implementing or adapting evidence-based interventions. This study used a qualitative design-mapping process to adapt an evidence-based CHW intervention, originally developed and tested in the hospital setting, for use among outpatients with multiple chronic conditions. The study involved qualitative in-depth, semi-structured interviews with chronically ill, uninsured, or Medicaid outpatients from low-income zip codes (n = 21) and their primary care practice staff (n = 30). Three key themes informed adaptation of the original intervention for outpatients with multiple conditions. First, outpatients were overwhelmed by their multiple conditions and wished they could focus on 1 at a time. Thus, the first major revision was to design a low-literacy decision aid that patients and providers could use to select a condition to focus on during the intervention. Second, motivation for health behavior change was a more prominent theme than in the original intervention. It was decided that in addition to providing tailored social support as in the original intervention, CHWs would help patients track progress toward their chronic disease management goals to motivate health behavior change. Third, patients were already connected to primary care; yet they still needed additional support to navigate their clinic once the intervention ended. The intervention was revised to include a weekly clinic-based support group. Structured adaptation using qualitative design mapping may allow for rapid adaptation and scale-up of evidence-based CHW interventions across new settings and populations.

Patient financial responsibility for observation care.

BACKGROUND: As observation care grows, Medicare beneficiaries are increasingly likely to revisit observation care instead of being readmitted. This trend has potential financial implications for Medicare beneficiaries because observation care-although typically hospital based-is classified as an outpatient service. Beneficiaries who are readmitted pay the inpatient deductible only once per benefit period. In contrast, beneficiaries who have multiple care episodes under observations status are subject to coinsurance at every stay and could accrue higher cumulative costs. OBJECTIVES: We were interested in answering the question: Do Medicare beneficiaries who revisit observation care pay more than they would have had they been readmitted? DESIGN: We used a 20% sample of the Medicare Outpatient Standard Analytic File (2010-2012) to determine the total cumulative financial liability for Medicare beneficiaries who revisit observation care multiple times within a 60-day period. PARTICIPANTS: Participants were fee-for-service Medicare beneficiaries who had Part A and Part B coverage for a full calendar year (or until death) during the study period. MEASUREMENTS: Our primary measure was beneficiary financial responsibility for facilities fees. RESULTS: On average, beneficiaries with multiple observation stays in a 60-day period had a cumulative financial liability of $947.40 (803.62), which is significantly lower than the $1100 inpatient deductible (P < 0.01). However, 26.6% of these beneficiaries had a cumulative financial liability that exceeded the inpatient deductible. CONCLUSIONS: More than a quarter of Medicare beneficiaries with multiple observation stays in a 60-day time period have a higher financial liability than they would have had under Part A benefits.

Neutralization of vascular endothelial growth factor antiangiogenic isoforms is more effective than treatment with proangiogenic isoforms in stimulating vascular development and follicle progression in the perinatal rat ovary.

Inhibition of vascular endothelial growth factor A (VEGFA) signal transduction arrests vascular and follicle development. Because antiangiogenic VEGFA isoforms are proposed to block proangiogenic VEGFA isoforms from binding to their receptors, we hypothesized that proangiogenic isoforms promote and antiangiogenic isoforms inhibit these processes. The antiangiogenic isoforms Vegfa_165b and Vegfa_189b were amplified and sequenced from rat ovaries. The Vegfa_165b sequence was 90% homologous to human VEGFA_165B. Quantitative RT-PCR determined that Vegfa_165b mRNA was more abundant around Embryonic Day 18, but Vegfa_189b lacked a distinct pattern of abundance. Antiangiogenic VEGFA isoforms were localized to pregranulosa and granulosa cells of all follicle stages and to theca cells of advanced-stage follicles. To determine the effects of VEGFA isoforms in developing ovaries, Postnatal Day 3/4 rat ovaries were cultured with VEGFA_164 or an antibody to antiangiogenic isoforms (anti-VEGFAxxxB). Treatment with 50 ng/ml of VEGFA_164 resulted in a 93% increase in vascular density (P < 0.01), and treated ovaries were composed of fewer primordial follicles (stage 0) and more developing follicles (stages 1-4) than controls (P < 0.04). Ovaries treated with 5 ng/ml of VEGFAxxxB antibody had a 93% increase in vascular density (P < 0.02), with fewer primordial and early primary follicles (stage 1) and more primary, transitional, and secondary follicles (stages 2, 3, and 4, respectively) compared with controls (P < 0.005). We conclude that neutralization of antiangiogenic VEGFA isoforms may be a more effective mechanism of enhancing vascular and follicular development in perinatal rat ovaries than treatment with the proangiogenic isoform VEGFA_164.

Inhibition of vascular endothelial growth factor receptor signal transduction blocks follicle progression but does not necessarily disrupt vascular development in perinatal rat ovaries.

We hypothesized that vascular endothelial growth factor A (VEGFA) angiogenic isoforms and their receptors, FLT1 and KDR, regulate follicular progression in the perinatal rat ovary. Each VEGFA angiogenic isoform has unique functions (based on its exons) that affect diffusibility, cell migration, branching, and development of large vessels. The Vegfa angiogenic isoforms (Vegfa_120, Vegfa_164, and Vegfa_188) were detected in developing rat ovaries, and quantitative RT-PCR determined that Vegfa_120 and Vegfa_164 mRNA was more abundant after birth, while Vegfa_188 mRNA was highest at Embryonic Day 16. VEGFA and its receptors were localized to pregranulosa and granulosa cells of all follicle stages and to theca cells of advanced-stage follicles. To determine the role of VEGFA in developing ovaries, Postnatal Day 3/4 rat ovaries were cultured with 8 muM VEGFR-TKI, a tyrosine kinase inhibitor that blocks FLT1 and KDR. Ovaries treated with VEGFR-TKI had vascular development reduced by 94% (P < 0.0001), with more primordial follicles (stage 0), fewer early primary, transitional, and secondary follicles (stages 1, 3, and 4, respectively), and greater total follicle numbers compared with control ovaries (P < 0.005). V1, an inhibitor specific for KDR, was utilized to determine the effects of only KDR inhibition. Treatment with 30 muM V1 had no effect on vascular density; however, treated ovaries had fewer early primary, transitional, and secondary follicles and more primary follicles (stage 2) compared with control ovaries (P < 0.05). We conclude that VEGFA may be involved in primordial follicle activation and in follicle maturation and survival, which are regulated through vascular-dependent and vascular-independent mechanisms.

Interprofessional pre-qualification clinical education: a systematic review.

A search was made of relevant databases and the reference lists of key textbooks and reviews. Of 420 potentially relevant articles, 25 were included in the review. Medicine, nursing, physiotherapy, occupational therapy and social work were the professions most often included. Aims and activities of interprofessional clinical education (IPCE) programs were varied, and there was inconsistency in outcome evaluation approach and tools. The models of IPCE described in the literature are diverse. The major barriers to IPCE were logistical, and the careful planning and negotiation required to overcome these barriers was time consuming. Detailed planning, stakeholder enthusiasm and commitment appear to be essential to the success of IPCE. The literature provides guiding principles for establishing a program; however, there is limited evidence to support a particular approach.

Allied health graduate program - supporting the transition from student to professional in an interdisciplinary program.

The transition from student to professional is challenging. Training programs provide discipline specific skills but do not adequately develop the interprofessional, team focused and work ready clinicians needed for the current workplace. In Australia, a formal graduate year is common in nursing; however, structured programs to support the student to professional transition are uncommon in allied health. This paper reports on the first year of an innovative program designed to address this gap. Fourteen new graduates at Northern Health in Melbourne, Australia from the disciplines of occupational therapy, physical education, physiotherapy, podiatry, social work and speech pathology participated in twelve, 2-hour sessions over a ten-month period during their first year of professional practice. These facilitated sessions aimed to foster reflective practice, peer support, to develop professional characteristics and provide an interdisciplinary forum for sharing experiences and learning. The paper outlines graduates and facilitators experience, together with the impacts for the health service.