Ambulatory Intensive Care for Medically Complex Patients at a Health Care Clinic for Individuals Experiencing Homelessness: The SUMMIT Randomized Clinical Trial.

Importance: Intensive primary care interventions have been promoted to reduce hospitalization rates and improve health outcomes for medically complex patients, but evidence of their efficacy is limited. Objective: To assess the efficacy of a multidisciplinary ambulatory intensive care unit (A-ICU) intervention on health care utilization and patient-reported outcomes. Design, Setting, and Participants: The Streamlined Unified Meaningfully Managed Interdisciplinary Team (SUMMIT) randomized clinical trial used a wait-list control design and was conducted at a health care clinic for patients experiencing homelessness in Portland, Oregon. The first patient was enrolled in August 2016, and the last patient was enrolled in November 2019. Included patients had 1 or more hospitalizations in the prior 6 months and 2 or more chronic medical conditions, substance use disorder, or mental illness. Data analysis was performed between March and May 2021. Intervention: The A-ICU included a team manager, a pharmacist, a nurse, care coordinators, social workers, and physicians. Activities included comprehensive 90-minute intake, transitional care coordination, and flexible appointments, with reduced panel size. Enhanced usual care (EUC), consisting of team-based primary care with access to community health workers and mental health, addiction treatment, and pharmacy services, served as the comparator. Participants who received EUC joined the A-ICU intervention after 6 months. Main Outcomes and Measures: The main outcome was the difference in rates of hospitalization (primary outcome), emergency department (ED) visits, and primary care physician (PCP) visits per person over 6 months (vs the prior 6 months). Patient-reported outcomes included changes in patient activation, experience, health-related quality of life, and self-rated health at 6 months (vs baseline). We performed an intention-to-treat analysis using a linear mixed-effects model with a random intercept for each patient to examine the association between study group and outcomes. Results: This study randomized 159 participants (mean [SD] age, 54.9 [9.8] years) to the A-ICU SUMMIT intervention (n = 80) or to EUC (n = 79). The majority of participants were men (102 [65.8%]) and most were White (121 [76.1%]). A total of 64 participants (41.0%) reported having unstable housing at baseline. Six-month hospitalizations decreased in both the A-ICU and EUC groups, with no difference between them (mean [SE], -0.6 [0.5] vs -0.9 [0.5]; difference, 0.3 [95% CI, -1.0 to 1.5]). Emergency department use did not differ between groups (mean [SE], -2.0 [1.0] vs 0.9 [1.0] visits per person; difference, -1.1 [95% CI, -3.7 to 1.6]). Primary care physician visits increased in the A-ICU group (mean [SE], 4.2 [1.6] vs -2.0 [1.6] per person; difference, 6.1 [95% CI, 1.8 to 10.4]). Patients in the A-ICU group reported improved social functioning (mean [SE], 4.7 [2.0] vs -1.1 [2.0]; difference, 5.8 [95% CI, 0.3 to 11.2]) and self-rated health (mean [SE], 0.7 [0.3] vs -0.2 [0.3]; difference, 1.0 [95% CI, 0.1 to 1.8]) compared with patients in the EUC group. No differences in patient activation or experience were observed. Conclusions and Relevance: The A-ICU intervention did not change hospital or ED utilization at 6 months but increased PCP visits and improved patient well-being. Longer-term studies are needed to evaluate whether these observed improvements lead to eventual changes in acute care utilization. Trial Registration: ClinicalTrials.gov Identifier: NCT03224858.

Planning and Designing the Improving Addiction Care Team (IMPACT) for Hospitalized Adults with Substance Use Disorder.

People with substance use disorders (SUD) have high rates of hospitalization and readmission, long lengths of stay, and skyrocketing healthcare costs. Yet, models for improving care are extremely limited. We performed a needs assessment and then convened academic and community partners, including a hospital, community SUD organizations, and Medicaid accountable care organizations, to design a care model for medically complex hospitalized patients with SUD. Needs assessment showed that 58% to 67% of participants who reported active substance use said they were interested in cutting back or quitting. Many reported interest in medication for addiction treatment (MAT). Participants had high rates of costly readmissions and longer than expected length of stay. Community stakeholders identified long wait times and lack of resources for medically complex patients as key barriers. We developed the Improving Addiction Care Team (IMPACT), which includes an inpatient addiction medicine consultation service, rapid-access pathways to posthospital SUD treatment, and a medically enhanced residential care model that integrates antibiotic infusion and residential addiction care. We developed a business case and secured funding from Medicaid and hospital payers. IMPACT provides one pathway for hospitals, payers, and communities to collaboratively address the SUD epidemic. Journal of Hospital Medicine 2017;12:339-342.

Health and illness in context: a pragmatic, interdisciplinary approach to teaching and learning applied public health within an urban safety net system.

BACKGROUND: Academic centers and community programs are too often separated by institutional and cultural chasms. Such divides weaken our capacity to develop a diverse public health-oriented, community-based workforce. This article describes one bridge designed to connect the academy to local safety net systems and the lessons learned during its construction. PROGRAM DESCRIPTION: "Health & Illness in Context" is an interdisciplinary program developed in 2008 by students at Oregon Health & Science University and staff at Portland's Central City Concern. Over a 7-week period, small cohorts of medical, nursing, and public health students gain an intimate, street-level understanding of the local safety net and the structural forces that shape it. Guided by program faculty, they traverse the maze of urban social services-following clients' pathways from homelessness and addiction to treatment, recovery, and social reintegration. In each 4-hour session, students: (1) apply key concepts from public health to challenging real-world contexts, (2) explore effective, innovative approaches to addressing complex health and social issues, and (3) directly engage members of underserved communities and the diverse professionals that serve them. OUTCOMES: Although too early to formally assess its impact on career choice, Health & Illness in Context is already serving as an incubator for novel public health-oriented experiences, curricula, and activism that are further narrowing the community-university divide. Citing Health & Illness in Context as a primary inspiration, students have developed complementary elective courses, community-outreach activities, and long-term community collaborations. Meanwhile, program faculty members, now formally advise student initiatives, serve as mentors/preceptors, and have expanded their involvement at the university.

Evaluation of a community-based, service-oriented social medicine residency curriculum.

BACKGROUND: Educators can create opportunities for physicians-in-training to learn about the health care needs of the underserved and expose learners to models of care and opportunities for service. OBJECTIVES: We evaluated a community-based, service-oriented Social Medicine curriculum for Internal Medicine interns and residents initiated in 2007. METHODS: Qualitative data were collected through focus groups. CONCLUSIONS: Potent community-based experiential learning with adequate time and encouragement to hear clients' stories allowed residents to gain an understanding of some of the complex factors that contribute to ill health in this population and seemed to influence residents' confidence in their skills in working with an undeserved population, particularly a population struggling with addiction. However, the curriculum did not provide adequate time for facilitated, personal reflection. These data will assist community health partnerships in developing their own curricula to address health needs of the underserved.

Comprehending care in a medical home: a usual source of care and patient perceptions about healthcare communication.

OBJECTIVE: To examine whether having a usual source of care (USC) is associated with positive patient perceptions of health care communication and to identify demographic factors among patients with a USC that are independently associated with differing reports of how patients perceive their involvement in health care decision making. METHODS: Cross-sectional analyses of nationally representative data from the 2002 Medical Expenditure Panel Survey. Among adults with a health care visit in the past year (n = approximately 16,700), we measured independent associations between having a USC and patient perceptions of health care communication. Second, among respondents with a USC (n = approximately 18,000), we assessed the independent association between various demographic factors and indicators of patients' perceptions of their autonomy in making health care decisions. RESULTS: Approximately 78% of adults in the United States reported having a USC. Those with a USC were more likely to report that providers always listened to them, always explained things clearly, always showed respect, and always spent enough time with them. Patients who perceived higher levels of decision-making autonomy were non-Hispanic, had health insurance coverage, lived in rural areas, and had higher incomes. CONCLUSIONS: Patients with a USC were more likely to perceive positive health care interactions. Certain demographic factors among the subgroups of Medical Expenditure Panel Survey respondents with a USC were associated with patient perceptions of greater decision-making autonomy. Efforts to ensure universal access to a USC must be partnered with broader awareness and training of USC providers to engage patients from various demographic backgrounds equally when making health care decisions at the point of care.

Health and disease in context: a community-based social medicine curriculum.

Despite the increasing attention paid to the role of social forces in determining health, most physicians finish their training ill-prepared to address these issues. The authors describe their efforts to fill that training gap for internal medicine residents at Oregon Health and Science University through a community-based social medicine curriculum, designed in 2006 in conjunction with community partners at Central City Concern (CCC), an organization addressing homelessness, poverty, and addiction in downtown Portland, Oregon. The challenge was to develop a curriculum that would (1) fit within the scheduling constraints of an established categorical internal medicine residency program, (2) give all internal medicine residents a chance to better understand how social forces affect health, and (3) help show how they, as health professionals, might intervene to improve health and health care. The authors maintain that by developing this curriculum with community partners--who took the lead in deciding what residents should learn about their community and how they should learn it--the residency program is providing a relatively brief but extremely rich opportunity for residents to engage the personal, social, and health-related issues experienced by clients served by CCC. The authors first provide a brief overview of the curriculum and describe how the principles and practices of community-based participatory research were used in its development. They then discuss the challenges involved in teaching medical residents about social determinants of health, how their academic-community partnership approaches those challenges, and the recently established methods of evaluating the curriculum.

Are preventable hospitalizations sensitive to changes in access to primary care? The case of the Oregon Health Plan.

OBJECTIVE: To examine whether preventable hospitalization (PH) rates are sensitive to the impact of policies aimed at improving access, such as the Oregon Health Plan (OHP), which expanded Medicaid coverage to all adults with incomes under the federal poverty level. STUDY DESIGN: We conducted a retrospective, time series analysis of PH rates in Oregon from 1990 to 2000. We calculated hospitalization rates for ambulatory-care sensitive conditions for the Medicaid + uninsured population and compared average annual rates from 1990 to 1993 (pre-OHP implementation) to those from 1995 to 2000 (post-OHP implementation). We compared changes in PH rates over time in the Medicaid + uninsured group to changes in the non-Medicaid insured population. We standardized rates by age and sex and used logistic regression models to compare rates. RESULTS: Contrary to our hypothesis, annual PH rates in the Medicaid + uninsured population increased after the eligibility expansion, from an average of 46.1 to 54.9 per 10,000 persons. This rise was significant compared with the non-Medicaid insured population, who experienced a slight decline in annual PH rates, from 26.9 to 26.1 per 10,000 (P < 0.001, after adjusting for age, sex, and rates of unpreventable hospitalizations). The increase in overall PH rates for the Medicaid + uninsured population can be explained by an increase in PH rates for the newly insured group. CONCLUSIONS: Our results suggest that PH rates may vary not only with access to primary care (inversely) but also with access to hospital care (directly). The use of PH rates as a marker of health care access should take into account these dual influences. Limitations in available data may also contribute to perceived variation in PH rates unrelated to health care access.

Medicaid programme changes and the chronically ill: early results from a prospective cohort study of the Oregon Health Plan.

OBJECTIVE: To describe the impacts of recent Oregon Health Plan (OHP) policy changes on individuals living with chronic illness in Oregon. METHODS: A mail survey was conducted of 1374 OHP beneficiaries who were directly affected by the new policies. The analyses reported in this article represent baseline findings from the first of three survey waves in an ongoing prospective cohort study. RESULTS: A significant association was found between Medicaid policy changes and high rates of disenrolment from the OHP. Compared to the non-chronically ill, the chronically ill were more likely to report inability to pay for medications, higher medical debt, more unmet health needs, and poorer health status. Among the chronically ill, those who lost insurance reported decreased access to and utilization of healthcare, more medical debt, and more restriction of medications. DISCUSSION: As policy-makers restructure public programmes to accommodate tight budgets and rising healthcare costs, people with chronic illness can easily be overlooked. Chronically ill individuals face disproportionate financial and health burdens. Small cost-saving policy changes can lead to widespread disenrolment that cascades into reduced access to healthcare services, altered utilization patterns, and financial strain.