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1.
Popul Health Manag ; 25(6): 721-728, 2022 12.
Artigo em Inglês | MEDLINE | ID: mdl-36576384

RESUMO

Behavioral health integration (BHI) within primary care settings is shown to improve outcomes. However, achieving BHI requires identifying best practices and a reliable tool that can be used to measure existing levels and progress toward BHI. The objective of this study was to develop and apply a conceptual framework to measure BHI, test the approach, and examine challenges to achieving BHI. Surveys and interviews were conducted with key informants within 17 designated public hospitals in California at the midpoint of participating in a 5-year project to establish BHI. A framework and coding methodology were developed to assess BHI best practices at each hospital. BHI status was assessed in the domains of infrastructure and process. Each domain included 5 themes such as electronic health record integration and functionality (infrastructure) and interprovider communication (process). Themes were assessed using a 6-point scale for various activities under a theme and associated weights. Theme-specific values were standardized from 0% to 100% to compare BHI scores between hospitals. Overall progress toward BHI ranged from scores of 52% to 83% (mean 63%) and indicated greater contribution of infrastructure versus process implementation. Within the infrastructure domain, scores were higher for having institutional and provider support, but lagged in establishing provider proximity. Within the process domain, scores were highest for implementation of behavioral health screening, but were frequently lower for other themes such as use of care coordination and referral processes. Further research is needed to test the robustness of this approach in other settings.


Assuntos
Hospitais Públicos , Atenção Primária à Saúde , Humanos , Inquéritos e Questionários
2.
J Nerv Ment Dis ; 210(8): 596-606, 2022 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-35184128

RESUMO

ABSTRACT: The long-term course of depression is not well-understood among minority women. We assessed depression trajectory, barriers to depression care, and life difficulties among minority women accessing health and social service programs as part of the Community Partners in Care study. Data include surveys ( N = 339) and interviews ( n = 58) administered at 3-year follow-up with African American and Latina women with improved versus persistent depression. The majority of the sample reported persistent depression (224/339, 66.1%), ≥1 barrier to mental health care (226/339, 72.4%), and multiple life difficulties (mean, 2.7; SD, 2.3). Many barriers to care ( i.e. , related to stigma and care experience, finances, and logistics) and life difficulties ( i.e. , related to finances, trauma, and relationships) were more common among individuals reporting persistent depression. Results suggest the importance of past experiences with depression treatment, ongoing barriers to care, and negative life events as contributors to inequities in depression outcomes experienced by minority women.


Assuntos
Depressão , Estigma Social , Depressão/epidemiologia , Depressão/terapia , Feminino , Acessibilidade aos Serviços de Saúde , Hispânico ou Latino , Humanos , Inquéritos e Questionários
3.
Vaccine ; 39(25): 3435-3444, 2021 06 08.
Artigo em Inglês | MEDLINE | ID: mdl-33992435

RESUMO

PURPOSE: Young adulthood is characterized by changes in health care decision-making, insurance coverage, and sexual risk. Although the human papillomavirus (HPV) vaccine is now approved for adults up to age 45, and catch-up vaccination is currently recommended up through age 26, vaccination rates remain low in young adults. This study explored perspectives on HPV vaccination among young adults receiving care at the student health center of a large public university. METHODS: We conducted semi-structured interviews (n = 27) and four focus groups with female and male undergraduate and graduate students (n = 18) and semi-structured interviews with health care providers (n = 6). Interviews and focus groups explored perceived risk of HPV infection, benefits of the HPV vaccine, and motivations for and barriers to HPV vaccination. RESULTS: Many young adults cited their parents' views and recommendations from medical providers as influential on their decision-making process. Students perceived that cervical cancer prevention was a main benefit of the HPV vaccine and sexual activity was a risk factor for HPV infection. Students often lacked knowledge about the vaccine's benefits for males and expressed some concerns about the safety and side effects of a vaccine perceived as new. Logistical barriers to vaccination included uncertainty over vaccination status and insurance coverage for the vaccine, and concerns about balancing the vaccine schedule with school obligations. Providers' vaccine recommendations were impacted by health system factors, including clinical infrastructure, processes for recommending and documenting vaccination, and office visit priorities. Suggested vaccination promotion strategies included improving the timing and messaging of outreach efforts on campus and bolstering clinical infrastructure. CONCLUSIONS: Although college may be an opportune time to reach young adults for HPV vaccination, obstacles including navigating parental influence and independent decision-making, lack of awareness of vaccination status, and numerous logistical and system-level barriers may impede vaccination during this time.


Assuntos
Alphapapillomavirus , Infecções por Papillomavirus , Vacinas contra Papillomavirus , Neoplasias do Colo do Útero , Adolescente , Adulto , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Infecções por Papillomavirus/prevenção & controle , Aceitação pelo Paciente de Cuidados de Saúde , Vacinação , Adulto Jovem
4.
J Cancer Surviv ; 15(2): 213-223, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-32794009

RESUMO

PURPOSE: Cancer survivors diagnosed at an early age remain at risk for cancer recurrence and other chronic diseases. This study assessed engagement in surveillance for recurrence, cancer screening, and other recommended preventive health services among breast and colorectal cancer survivors with early-onset disease (≤ 50 years) who were diagnosed in California. METHODS: Breast and colorectal cancer survivors diagnosed with early-onset cancer between 1999 and 2009 were identified through the California Cancer Registry, the state-based cancer registry, and surveyed. Multivariable regression analyses were used to assess correlates of receipt of cancer surveillance, cancer screening, and other preventive health services. RESULTS: Of the 497 survivors that were invited to participate in the study, 156 completed the survey for a response rate of 31%. The sample was 50 years of age on average (range 32-69 years) with a mean time since diagnosis of 9 years. The majority of the sample (71%) was a racial/ethnic minority (24% Latino, 15% African American, 29% Asian). Overall, 80% received appropriate surveillance for recurrence, and 72% received recommended screening for early detection of other cancers (breast, cervical, colorectal). Increasing age was associated with lower likelihood of early detection screening (adjusted odds ratio (aOR) 0.28, 95% confidence interval (CI) 0.11-0.69), and higher income was associated with a greater likelihood (aOR 4.89, 95% CI 1.62-14.81). Screening rates were highest for blood pressure (96%), cholesterol (86%), and diabetes (81%), followed by dental visits (64%) and flu vaccination (35%). Greater use of recommended preventive health services was associated with increasing age, female sex, higher education level, and having health insurance. CONCLUSIONS: Although the majority of survivors received appropriate surveillance for recurrence, engagement in other preventive health services varied substantially. IMPLICATIONS FOR CANCER SURVIVORS: Efforts are needed to address gaps in the use of recommended cancer screening and preventive health services among cancer survivors, particularly survivors with early-onset disease who may be at increased risk for additional cancers and common chronic conditions over their lifetime.


Assuntos
Sobreviventes de Câncer , Neoplasias Colorretais , Adulto , Idoso , Etnicidade , Feminino , Humanos , Pessoa de Meia-Idade , Grupos Minoritários , Serviços Preventivos de Saúde , Sobreviventes
5.
J Community Psychol ; 47(8): 1893-1908, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31424102

RESUMO

AIMS: To examine the prevalence of and factors associated with unmet need for mental health and substance use treatment in older homeless adults. METHODS: Among 350 homeless adults aged ≥50, we examined prevalence of mental health and substance use problems and treatment. Using logistic regression, we examined factors associated with unmet treatment need. RESULTS: Among those with a mental health problem, being aged ≥65 was associated with an increased odds, while having a regular healthcare provider and case manager were associated with a decreased odds of having unmet need for mental health treatment. A first homelessness episode at age ≥50 was associated with increased, while spending time in jail/prison or having a case manager was associated with decreased odds of unmet needs for substance use treatment. CONCLUSION: Older homeless adults have a high prevalence of unmet behavioral health treatment need. There is a need for targeted services for this population.


Assuntos
Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Pessoas Mal Alojadas/psicologia , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Envelhecimento/psicologia , California/epidemiologia , Humanos , Acontecimentos que Mudam a Vida , Modelos Logísticos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Prevalência
6.
Med Care ; 57 Suppl 6 Suppl 2: S140-S148, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31095053

RESUMO

BACKGROUND: Patient experience surveys are widely used to capture the patient-reported quality of care and are increasingly being used for formal reporting purposes. There is evidence that certain patient subgroups are less likely to respond to traditional CAHPS surveys. As patient-facing technologies become more common, it is important to examine whether tablet-based patient experience surveys have the potential to promote responses from more diverse populations. OBJECTIVES: To develop, gain perspectives about, and pilot an English and Spanish low-literacy adaptation of the Consumer Assessment of Healthcare Providers & Systems Clinician & Group Survey (CG-CAHPS) administered on a tablet device at the point of care. RESEARCH DESIGN: Cognitive testing and evaluation of a quality improvement pilot comparing a tablet-based adaptation and traditional paper-based versions of the CG-CAHPS survey. SUBJECTS: English-speaking and Spanish-speaking patients receiving primary care in an urban community clinic. MEASURES: To compare the acceptability of low-literacy tablet-based and traditional paper-based patient experience surveys, we examined the concordance of responses between survey modes and preferences for modality, as well as perspectives on usability and reporting care experiences. We examined demographic differences in responses to tablet-based versus mailed surveys from a quality improvement pilot. RESULTS: The majority of cognitive interview participants preferred a low-literacy, tablet-based survey over a paper-based survey with traditional wording. In a quality improvement pilot comparing tablet-based administration at the point of care versus mailed surveys, respondents to the tablet-based survey were more likely to be younger and Latino. CONCLUSIONS: If designed with patient input, tablet-based surveys have the potential to improve the collection of patient experience data among diverse populations.


Assuntos
Computadores de Mão , Coleta de Dados , Alfabetização , Sistemas Automatizados de Assistência Junto ao Leito , Fatores Etários , Etnicidade/psicologia , Etnicidade/estatística & dados numéricos , Feminino , Humanos , Proficiência Limitada em Inglês , Masculino , Pessoa de Meia-Idade , Melhoria de Qualidade , Inquéritos e Questionários
7.
J Am Board Fam Med ; 32(2): 248-258, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30850461

RESUMO

BACKGROUND: Patient portals are becoming ubiquitous. Previous research has documented substantial barriers, especially among vulnerable patient subgroups such as those with lower socioeconomic status or limited health literacy (LHL). We tested the effectiveness of delivering online, video-based portal training to patients in a safety net setting. METHODS: We created an online video curriculum about accessing the San Francisco Health Network portal, and then randomized 93 English-speaking patients with 1+ chronic diseases to receive 1) an in-person tutorial with a research assistant, or 2) a link to view the videos on their own. We also examined a third, nonrandomized usual care comparison group. The primary outcome was portal log-in (yes/no) 3 to 6 months post-training, assessed via the electronic health record. Secondary outcomes were self-reported attitudes and skills collected via baseline and follow-up surveys. RESULTS: Mean age was 54 years, 51% had LHL, 60% were nonwhite, 52% were female, 45% reported fair/poor health, and 76% reported daily Internet use. At followup, 21% logged into the portal, with no differences by arm (P = .41), but this was higher than the overall clinic rate of 9% (P < .01) during the same time period. We found significant prepost improvements in self-rated portal skills (P = .03) and eHealth literacy (P < .01). Those with LHL were less likely to log in post-training (P < .01). CONCLUSIONS: Both modalities of online training were comparable, and neither mode enabled a majority of vulnerable patients to use portals, especially those with LHL. This suggests that portal training will need to be more intensive or portals need improved usability to meaningfully increase use among diverse patients.


Assuntos
Letramento em Saúde/estatística & dados numéricos , Portais do Paciente/estatística & dados numéricos , Adulto , Idoso , Alfabetização Digital/estatística & dados numéricos , Feminino , Humanos , Internet , Masculino , Pessoa de Meia-Idade , Educação de Pacientes como Assunto/métodos , Atenção Primária à Saúde/métodos , São Francisco , Populações Vulneráveis/estatística & dados numéricos
8.
Fam Pract ; 36(2): 206-213, 2019 03 20.
Artigo em Inglês | MEDLINE | ID: mdl-29846584

RESUMO

BACKGROUND: After-visit summary (AVS) documents presenting key information from each medical encounter have become standard in the USA due to federal health care reform. Little is known about how they are used or whether they improve patient care. METHODS: First, we completed a literature review and described the totality of the literature on AVS by article type and major outcome measures. Next, we used reputational sampling from large-scale US studies on primary care to identify and interview nine stakeholders on their perceptions of AVS across high-performing primary care practices. Interviews were transcribed and coded for AVS use in practice, perceptions of the best/worst features and recommendations for improving AVS utility in routine care. RESULTS: The literature review resulted in 17 studies; patients reported higher perceived value of AVS compared with providers, despite poor recall of specific AVS content and varied post-visit use. In key informant interviews, key informants expressed enthusiasm for the potential of using AVS to reinforce key information with patients, especially if AVS were customizable. Despite this potential, key informants found that AVS included incorrect information and did not feel that patients or their practices were using AVS to enhance care. CONCLUSIONS: There is a gap between the potential of AVS and how providers and patients are using it in routine care. Suggestions for improved use of AVS include increasing customization, establishing care team responsibilities and workflows and ensuring patients with communication barriers have dedicated support to review AVS during visits.


Assuntos
Registros Eletrônicos de Saúde , Atenção Primária à Saúde/métodos , Literatura de Revisão como Assunto , Participação dos Interessados , Atitude do Pessoal de Saúde , Humanos , Entrevistas como Assunto , Uso Significativo , Assistência Centrada no Paciente , Pesquisa Qualitativa , Estados Unidos
9.
J Public Health Dent ; 79(1): 3-9, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-30295922

RESUMO

OBJECTIVES: To describe the prevalence of and factors associated with oral health measures in a sample of older homeless adults in Oakland, CA. METHODS: We conducted a cross-sectional analysis of data from a population-based study of 350 homeless adults aged ≥50 in which trained researchers conducted structured interviews using validated questions regarding sociodemographics, health-related behaviors, healthcare utilization, and health status. We assessed self-reported tooth loss, oral pain, and unmet need for dental care. We used multivariable logistic regression to examine factors associated with missing half or more teeth. RESULTS: Over half 201/350 (57.4 percent) of participants were missing at least half of their teeth. Half 191/350 (54.6 percent) reported oral pain in the past 6 months; 101/350 (28.9 percent) reported that oral pain prevented them from eating and 73/350 (20.9 percent) reported that pain prevented sleeping. Almost half, 141/350 (40.3 percent), had not seen a dentist in over 5 years, and over half 190/350 (54.3 percent) reported being unable to obtain needed dental care. In multivariate models, increased age (AOR = 1.09, 95 percent CI 1.04-1.14), moderate-to-high risk alcohol use (AOR = 2.17, CI = 1.23-3.84), moderate-to-high risk cocaine use (AOR = 1.72, CI = 1.03-2.88), and ever smoking (AOR = 2.87, CI = 1.59-5.18) were associated with an increased odds of having lost half or more teeth. CONCLUSIONS: Tooth loss and oral pain are highly prevalent in older homeless adults. Increasing age, alcohol, drug, and tobacco use are associated with tooth loss.


Assuntos
Pessoas Mal Alojadas , Perda de Dente , Adulto , Idoso , Estudos Transversais , Assistência Odontológica , Humanos , Saúde Bucal
10.
JMIR Mhealth Uhealth ; 6(12): e10049, 2018 Dec 10.
Artigo em Inglês | MEDLINE | ID: mdl-30530464

RESUMO

BACKGROUND: The median age of single homeless adults is approximately 50 years. Older homeless adults have poor social support and experience a high prevalence of chronic disease, depression, and substance use disorders. Access to mobile phones and the internet could help lower the barriers to social support, social services, and medical care; however, little is known about access to and use of these by older homeless adults. OBJECTIVE: This study aimed to describe the access to and use of mobile phones, computers, and internet among a cohort of 350 homeless adults over the age of 50 years. METHODS: We recruited 350 participants who were homeless and older than 50 years in Oakland, California. We interviewed participants at 6-month intervals about their health status, residential history, social support, substance use, depressive symptomology, and activities of daily living (ADLs) using validated tools. We performed clinical assessments of cognitive function. During the 6-month follow-up interview, study staff administered questions about internet and mobile technology use. We assessed participants' comfort with and use of multiple functions associated with these technologies. RESULTS: Of the 343 participants alive at the 6-month follow-up, 87.5% (300/343) completed the mobile phone and internet questionnaire. The median age of participants was 57.5 years (interquartile range 54-61). Of these, 74.7% (224/300) were male, and 81.0% (243/300) were black. Approximately one-fourth (24.3%, 73/300) of the participants had cognitive impairment and slightly over one-third (33.6%, 100/300) had impairments in executive function. Most (72.3%, 217/300) participants currently owned or had access to a mobile phone. Of those, most had feature phones, rather than smartphones (89, 32.1%), and did not hold annual contracts (261, 94.2%). Just over half (164, 55%) had ever accessed the internet. Participants used phones and internet to communicate with medical personnel (179, 64.6%), search for housing and employment (85, 30.7%), and to contact their families (228, 82.3%). Those who regained housing were significantly more likely to have mobile phone access (adjusted odds ratio [AOR] 3.81, 95% CI 1.77-8.21). Those with ADL (AOR 0.53, 95% CI 0.31-0.92) and executive function impairment (AOR 0.49; 95% CI 0.28-0.86) were significantly less likely to have mobile phones. Moderate to high risk amphetamine use was associated with reduced access to mobile phones (AOR 0.27, 95% CI 0.10-0.72). CONCLUSIONS: Older homeless adults could benefit from portable internet and phone access. However, participants had a lower prevalence of smartphone and internet access than adults aged over 65 years in the general public or low-income adults. Participants faced barriers to mobile phone and internet use, including financial barriers and functional and cognitive impairments. Expanding access to these basic technologies could result in improved outcomes.

11.
J Am Geriatr Soc ; 66(6): 1068-1074, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29741765

RESUMO

Older homeless-experienced adults have low engagement in advance care planning (ACP) despite high morbidity and mortality. We conducted a cross-sectional analysis of a cohort of 350 homeless-experienced adults aged 50 and older in Oakland, California. We assessed the prevalence of potential surrogate decision-makers, ACP contemplation, discussions, and ACP documentation (surrogate designation, advance directives). We used multivariable logistic regression to examine factors associated with ACP discussions and documentation. The median age of the cohort was 59 (range 52-82), 75.2% were male, and 82.1% were black. Sixty-one percent reported a potential surrogate, 21.5% had discussed ACP, and 19.0% reported ACP documentation. In multivariable models, having 1 to 5 confidants versus none (adjusted odds ratio (aOR)=5.8, 95% confidence interval (CI)=1.7-20.0), 3 or more chronic conditions versus none (aOR=2.3, 95% CI=0.9-5.6), and a recent primary care visit (aOR=2.1, 95% CI=1.0-4.4) were associated with higher odds of ACP discussions and each additional 5 years of homelessness (aOR=0.7, 95% CI=0.5-0.9) with lower odds. Having 1 to 5 confidants (aOR=5.0, 95% CI=1.4-17.5), being black (aOR=5.5, 95% CI=1.5-19.5), and having adequate versus limited literacy (aOR=7.0, 95% CI=1.5-32.4) were associated with higher odds of ACP documentation and illicit drug use (aOR=0.3, 95% CI=0.1-0.9) with lower odds. Although the majority of older homeless-experienced adults have a potential surrogate, few have discussed or documented their ACP wishes; the odds of both were greater with larger social networks. Future interventions must be customized for individuals with limited social networks and address the instability of homelessness, health literacy, and the constraints of safety-net healthcare settings.


Assuntos
Planejamento Antecipado de Cuidados , Disparidades em Assistência à Saúde , Pessoas Mal Alojadas , Atenção Primária à Saúde/estatística & dados numéricos , Rede Social , Planejamento Antecipado de Cuidados/organização & administração , Planejamento Antecipado de Cuidados/estatística & dados numéricos , Idoso , California/epidemiologia , Doença Crônica/epidemiologia , Estudos Transversais , Etnicidade , Feminino , Letramento em Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/etnologia , Disparidades em Assistência à Saúde/estatística & dados numéricos , Pessoas Mal Alojadas/psicologia , Pessoas Mal Alojadas/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação das Necessidades , Estatística como Assunto , Veteranos
12.
Drug Alcohol Depend ; 178: 562-570, 2017 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-28738314

RESUMO

BACKGROUND: We evaluated cognitive function and factors associated with cognitive impairment in a cohort of older homeless adults. We hypothesized that substance use and a history of traumatic brain injury would be associated with cognitive impairment. METHODS: We recruited 350 homeless individuals aged ≥50 years using population-based sampling and conducted structured interviews and neuropsychological testing. We evaluated alcohol use with the Alcohol Use Disorder Identification Test, defining high-severity alcohol use as a total score ≥16 or ≥4 on the alcohol dependency sub-scale. We assessed global cognition with the Modified Mini-Mental State Test (3MS) and processing speed and executive function with the Trail Making Test (TMTB), defining impairment as performing 1.5 standard deviations below the standardized mean. We used multivariable logistic regression to examine the association between alcohol use and cognition. RESULTS: Participants had a median age of 58 years [IQR 54-61], 76.7% were men, and 79.9% were African American. A quarter (25.1%) of participants met criteria for impairment on the 3MS; 32.9% met criteria for impairment on TMTB. In models adjusted for sociodemographic variables and health conditions, high-severity alcohol use was associated with global cognitive impairment (AOR 2.39, CI 1.19-4.79) and executive dysfunction (AOR 3.09, CI 1.61-5.92). CONCLUSIONS: Older homeless adults displayed a prevalence of cognitive impairment 3-4 times higher than has been observed in general population adults aged 70 and older. Impaired cognition in older homeless adults could impact access to housing programs and the treatment of health conditions, including the treatment of alcohol use disorders.


Assuntos
Alcoolismo/epidemiologia , Transtornos Cognitivos/epidemiologia , Pessoas Mal Alojadas/psicologia , Testes Neuropsicológicos/normas , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Cognição , Estudos de Coortes , Função Executiva , Humanos , Prevalência , Teste de Sequência Alfanumérica
13.
J Pain ; 18(9): 1036-1045, 2017 09.
Artigo em Inglês | MEDLINE | ID: mdl-28412229

RESUMO

Individuals experiencing homelessness in the United States are aging; little is known about chronic pain in this population. In a cross-sectional, population-based study, we interviewed 350 homeless individuals aged 50 years and older to describe pain experienced by older persons experiencing homelessness and to assess factors associated with chronic moderate to severe pain, defined as pain lasting ≥3 months, with a past week average severity score of 5 to 10 (scale 0-10). The median age of participants was 58 years. Participants were predominantly African American (79.6%) and male (77.3%). Overall, 46.8% reported chronic moderate to severe pain. Almost half of participants reported a diagnosis of arthritis (44.3%) and one-third reported symptoms consistent with post-traumatic stress disorder (PTSD; 32.8%). Three-quarters (75.3%) endorsed a personal history of abuse. In multivariate analyses, PTSD (adjusted odds ratio [AOR]: 2.2, 95% confidence interval [CI], 1.4-3.7), arthritis (AOR: 4.8, 95% CI, 3.0-7.8), and history of experiencing abuse (AOR: 2.4, 95% CI, 1.3-4.3) were associated with chronic moderate to severe pain. HIV status, diabetes, depressive symptoms, and substance use were not associated with pain. Clinicians should consider the management of associated mental health conditions and the sequelae of experiencing abuse in the treatment of chronic pain in older adults experiencing homelessness. PERSPECTIVE: This article describes the prevalence and factors associated with chronic pain in older homeless adults. Almost half report chronic pain, which was associated with PTSD, arthritis, and personal history of abuse. Clinicians should address chronic pain, trauma, and the associated mental health conditions in this high-risk population.


Assuntos
Dor Crônica/epidemiologia , Pessoas Mal Alojadas , Idoso , Artrite/epidemiologia , Estudos de Coortes , Estudos Transversais , Feminino , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Prevalência , Fatores de Risco , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Estados Unidos
14.
J Am Med Inform Assoc ; 24(5): 903-912, 2017 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-28340229

RESUMO

OBJECTIVE: US health care institutions are implementing secure websites (patient portals) to achieve federal Meaningful Use (MU) certification. We sought to understand efforts to implement portals in "safety net" health care systems that provide services for low-income populations. MATERIALS AND METHODS: Our rapid ethnography involved visits at 4 California safety net health systems and in-depth interviews at a fifth. Visits included interviews with clinicians and executives ( n = 12), informal focus groups with front-line staff ( n = 35), observations of patient portal sign-up procedures and clinic work, review of marketing materials and portal use data, and a brief survey ( n = 45). RESULTS: Our findings demonstrate that the health systems devoted considerable effort to enlisting staff support for portal adoption and integrating portal-related work into clinic routines. Although all health systems had achieved, or were close to achieving, MU benchmarks, patients faced numerous barriers to portal use and our participants were uncertain how to achieve and sustain "meaningful use" as defined by and for their patients. DISCUSSION: Health systems' efforts to achieve MU certification united clinic staff under a shared ethos of improved quality of care. However, MU's assumptions about patients' demand for electronic access to health information and ability to make use of it directed clinics' attention to enrollment and message routing rather than to the relevance and usability of a tool that is minimally adaptable to the safety net context. CONCLUSION: We found a mismatch between MU-based metrics of patient engagement and the priorities and needs of safety net patient populations.


Assuntos
Centros Comunitários de Saúde , Implementação de Plano de Saúde , Uso Significativo , Portais do Paciente , Antropologia Cultural , California , Registros Eletrônicos de Saúde , Humanos , Entrevistas como Assunto , Provedores de Redes de Segurança
15.
Gerontologist ; 57(4): 757-766, 2017 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-26920935

RESUMO

Purpose of the Study: Older homeless adults living in shelters have high rates of geriatric conditions, which may increase their risk for acute care use and nursing home placement. However, a minority of homeless adults stay in shelters and the prevalence of geriatric conditions among homeless adults living in other environments is unknown. We determined the prevalence of common geriatric conditions in a cohort of older homeless adults, and whether the prevalence of these conditions differs across living environments. Design and Methods: We interviewed 350 homeless adults, aged 50 and older, recruited via population-based sampling in Oakland, CA. We evaluated participants for common geriatric conditions. We assessed living environment using a 6-month follow-back residential calendar, and used cluster analysis to identify participants' primary living environment over the prior 6 months. Results: Participants stayed in 4 primary environments: unsheltered locations (n = 162), multiple locations including shelters and hotels (n = 88), intermittently with family/friends (n = 57), and, in a recently homeless group, rental housing (n = 43). Overall, 38.9% of participants reported difficulty performing 1 or more activities of daily living, 33.7% reported any falls in the past 6 months, 25.8% had cognitive impairment, 45.1% had vision impairment, and 48.0% screened positive for urinary incontinence. The prevalence of geriatric conditions did not differ significantly across living environments. Implications: Geriatric conditions were common among older homeless adults living in diverse environments, and the prevalence of these conditions was higher than that seen in housed adults 20 years older. Services that address geriatric conditions are needed for older homeless adults living across varied environments.


Assuntos
Pessoas Mal Alojadas/estatística & dados numéricos , Acidentes por Quedas/estatística & dados numéricos , Atividades Cotidianas , Disfunção Cognitiva/epidemiologia , Feminino , Comportamentos Relacionados com a Saúde , Nível de Saúde , Habitação/estatística & dados numéricos , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Incontinência Urinária/epidemiologia , Transtornos da Visão/epidemiologia
16.
J Am Med Inform Assoc ; 24(e1): e47-e54, 2017 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-27402138

RESUMO

OBJECTIVE: With the rapid rise in the adoption of patient portals, many patients are gaining access to their personal health information online for the first time. The objective of this study was to examine specific usability barriers to patient portal engagement among a diverse group of patients and caregivers. MATERIALS AND METHODS: We conducted interviews using performance testing and think-aloud methods with 23 patients and 2 caregivers as they first attempted to use features of a newly launched patient portal. RESULTS: In navigating the portal, participants experienced basic computer barriers (eg, difficulty using a mouse), routine computer barriers (eg, mistyping, navigation issues), reading/writing barriers, and medical content barriers. Compared to participants with adequate health literacy, participants with limited health literacy required 2 additional minutes to complete each task and were more likely to experience each type of navigational barrier. They also experienced more inaccuracies in interpreting a test result and finding a treatment plan within an after-visit summary. DISCUSSION: When using a patient portal for the first time, participants with limited health literacy completed fewer tasks unassisted, had a higher prevalence of encountering barriers, took longer to complete tasks, and had more problems accurately interpreting medical information. CONCLUSION: Our findings suggest a strong need for tailored and accessible training and support to assist all vulnerable patients and/or caregivers with portal registration and use. Measuring the health literacy of a patient population might serve as a strong proxy for identifying patients who need the most support in using health technologies.


Assuntos
Registros Eletrônicos de Saúde , Letramento em Saúde , Portais do Paciente , Populações Vulneráveis , Doença Crônica , Feminino , Registros de Saúde Pessoal , Humanos , Internet , Masculino , Pessoa de Meia-Idade
17.
Subst Abus ; 38(1): 88-94, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-27897965

RESUMO

BACKGROUND: The median age of the single adult homeless population is 50 and rising. Although the prevalence of substance use decreases as individuals age, older adults now have a higher prevalence of substance use than older adults did 10 years ago. Homeless individuals have a higher prevalence of substance use disorders than the general population. However, little is known about substance use in older homeless adults. METHODS: The objective of the study was to examine prevalence of and factors associated with substance use in a population-based sample (N = 350) of homeless individuals aged 50 and older in Oakland, California. Dependent variables included moderate or greater severity illicit drug symptoms (Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) score >3) and moderate or greater alcohol symptoms (Alcohol Use Disorders Identification Test (AUDIT) score >7). Independent variables included demographics, mental health problems, and negative life course events such as physical and sexual abuse, school expulsion, and onset of homelessness. RESULTS: Almost two thirds of participants, 64.6%, had moderate or greater severity symptoms for at least 1 illicit drug; 25.8% had moderate or greater severity alcohol symptoms. History of psychiatric hospitalization was associated with moderate or greater illicit drug symptoms (adjusted odds ratio [AOR] = 1.9, 1.0-3.6). The presence of major depressive symptoms was associated with moderate or greater severity alcohol symptoms (AOR = 1.8, 1.1-3.0). CONCLUSIONS: In this sample of older homeless adults, substance use is common. There is a need for substance use treatment programs, integrated with mental health services, which are targeted towards the needs of older homeless adults.


Assuntos
Asiático/psicologia , Transtorno Depressivo Maior/epidemiologia , Pessoas Mal Alojadas/psicologia , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , População Branca/psicologia , Idoso , California/epidemiologia , Diagnóstico Duplo (Psiquiatria)/estatística & dados numéricos , Feminino , Nível de Saúde , Humanos , Acontecimentos que Mudam a Vida , Masculino , Transtornos Mentais/epidemiologia , Pessoa de Meia-Idade , Prevalência
18.
Am J Geriatr Psychiatry ; 25(2): 107-117, 2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-27544890

RESUMO

OBJECTIVE: To examine whether childhood adversity is associated with depressive symptoms, suicide attempts, or psychiatric hospitalization. METHODS: History of seven childhood adversities (physical neglect, verbal abuse, physical abuse, sexual abuse, parental death, parental incarceration, and child welfare system placement) was gathered through in-person interviews. Multivariate models examined associations between history of childhood adversities and moderate to severe depressive symptoms, lifetime history of suicide attempt, or lifetime history of psychiatric hospitalization. The study enrolled 350 homeless adults, aged 50 and older, in Oakland, California, using population-based sampling methods. Moderate to severe depressive symptoms were measured on a Center for Epidemiologic Studies-Depression Scale (≥22), self-reported lifetime history of suicide attempt, and self-reported lifetime history of psychiatric hospitalization. RESULTS: Participants with exposure to one childhood adversity had elevated odds of reporting moderate to severe depressive symptoms (adjusted odds ratio [AOR]: 2.0; 95% confidence interval [CI]: 1.1-3.7) and lifetime history of suicide attempt (AOR: 4.6; 95% CI: 1.0-21.6) when compared with those who had none; the odds of these two outcomes increased with exposure to additional childhood adversities. Participants with four or more childhood adversities had higher odds of having a lifetime history of psychiatric hospitalization (AOR: 7.1; 95% CI: 2.8-18.0); no increase with fewer adversities was found. CONCLUSION: Childhood adversities are associated with poor mental health outcomes among older homeless adults. Clinicians should collect information about childhood adversities among this high-risk population to inform risk assessment and treatment recommendations.


Assuntos
Sobreviventes Adultos de Maus-Tratos Infantis/psicologia , Depressão/epidemiologia , Pessoas Mal Alojadas/psicologia , Tentativa de Suicídio/estatística & dados numéricos , Idoso , California/epidemiologia , Estudos Transversais , Feminino , Nível de Saúde , Humanos , Acontecimentos que Mudam a Vida , Modelos Logísticos , Masculino , Serviços de Saúde Mental/estatística & dados numéricos , Pessoa de Meia-Idade , Análise Multivariada , Escalas de Graduação Psiquiátrica , Fatores de Risco , Autorrelato
19.
Acad Emerg Med ; 24(1): 63-74, 2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-27520382

RESUMO

OBJECTIVE: The median age of single homeless adults is over 50, yet little is known about their emergency department (ED) use. We describe use of and factors associated with ED use in a sample of homeless adults 50 and older. METHODS: We recruited 350 participants who were homeless and 50 or older in Oakland, California. We interviewed participants about residential history in the prior 6 months, health status, health-related behaviors, and health services use and assessed cognition and mobility. Our primary outcome was the number of ED visits in the prior 6 months based on medical record review. We used negative binomial regression to examine factors associated with ED use. RESULTS: In the 6 months prior to enrollment, 46.3% of participants spent the majority of their time unsheltered; 25.1% cycled through multiple institutions including shelters, hospitals, and jails; 16.3% primarily stayed with family or friends; and 12.3% had become homeless recently after spending much of the prior 6 months housed. Half (49.7%) of participants made at least one ED visit in the past 6 months; 6.6% of participants accounted for 49.9% of all visits. Most (71.8%) identified a regular non-ED source of healthcare; 7.3% of visits resulted in hospitalization. In multivariate models, study participants who used multiple institutions (incidence rate ratio [IRR] = 2.27; 95% confidence interval [CI] = 1.08 to 4.77) and who were unsheltered (IRR = 2.29; 95% CI = 1.17 to 4.48) had higher ED use rates than participants who had been housed for most of the prior 6 months. In addition, having health insurance/coverage (IRR = 2.6; CI = 1.5 to 4.4), a history of psychiatric hospitalization (IRR = 1.80; 95% CI = 1.09 to 2.99), and severe pain (IRR = 1.72; 95% CI = 1.07 to 2.76) were associated with higher ED visit rates. CONCLUSIONS: A sample of adults aged 50 and older who were homeless at study entry had higher rates of ED use in the prior 6 months than the general U.S. age-matched population. Within the sample, ED use rates varied based on individuals' residential histories, suggesting that individuals' ED use is related to exposure to homelessness.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Pessoas Mal Alojadas/estatística & dados numéricos , Idoso , California , Feminino , Nível de Saúde , Pessoas Mal Alojadas/psicologia , Humanos , Masculino , Prontuários Médicos/estatística & dados numéricos , Pessoa de Meia-Idade , Estados Unidos
20.
J Diabetes Res ; 2016: 8472391, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27868070

RESUMO

Background. The feasibility of digital health programs to prevent and manage diabetes in low-income patients has not been adequately explored. Methods. Researchers collaborated with a digital health company to adapt a diabetes prevention program for low-income prediabetes patients at a large safety net clinic. We conducted focus groups to assess patient perspectives, revised lessons for improved readability and cultural relevance to low-income and Hispanic patients, conducted a feasibility study of the adapted program in English and Spanish speaking cohorts, and implemented real-time adaptations to the program for commercial use and for a larger trial of in multiple safety net clinics. Results. The majority of focus group participants were receptive to the program. We modified the curriculum to a 5th-grade reading level and adapted content based on patient feedback. In the feasibility study, 54% of eligible contacted patients expressed interest in enrolling (n = 23). Although some participants' computer access and literacy made registration challenging, they were highly satisfied and engaged (80% logged in at least once/week). Conclusions. Underserved prediabetic patients displayed high engagement and satisfaction with a digital diabetes prevention program despite lower digital literacy skills. The collaboration between researchers and a digital health company enabled iterative improvements in technology implementation to address challenges in low-income populations.


Assuntos
Diabetes Mellitus Tipo 2/prevenção & controle , Promoção da Saúde , Adolescente , Adulto , Idoso , Estudos de Viabilidade , Feminino , Grupos Focais , Hispânico ou Latino , Humanos , Masculino , Pessoa de Meia-Idade , Satisfação Pessoal , Pobreza , Avaliação de Programas e Projetos de Saúde , Adulto Jovem
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