Primary Care Practice Redesign: Challenges in Improving Behavioral Health Care for a Vulnerable Patient Population.

This study examined a program focused on integrating mental health in a family medicine practice in an economically challenged urban setting. The program included using a behavioral health technology platform, a behavioral health collaborative composed of community mental health agencies, and a community health worker (CHW). Of the 202 patients screened, 196 were used for analysis; 56% were positive for anxiety, 38% had scores consistent with moderate to severe depression, and 34% were positive for post-traumatic stress disorder. There was a statistically significant difference in the diagnosis of depression when comparing the screened group to a control group. Only 27% of patients followed through with behavioral health referrals despite navigational assistance provided by a CHW and assured access to care through a community agency engaged with the Behavioral Health Alliance. Further qualitative analysis revealed that there were complex patient factors that affected patient decision making regarding follow-up with behavioral health care.

Complexities of Addressing Food Insecurity in an Urban Population.

There is an association between food insecurity, poor health outcomes, and increased health care spending. The Temple Food Insecurity Program was initiated to screen patients for food insecurity as part of the post Temple University Hospital discharge process. The community is economically challenged and food insecurity is a significant problem. Food insecure patients were identified and referred to community-based resources, with a 30-day follow-up call. Screening was successful in 3655 patients, 27% (n = 987) of whom reported food insecurity. Of these patients, 66% (n = 647) were already receiving benefits through the Supplemental Nutrition Assistance Program (SNAP), but were still food insecure. All patients with food insecurity were referred to one of 2 resources for help. Despite significant need, less than a quarter of patients connected with these resources. Qualitative data revealed that some patients did not remember the information provided to them, were overwhelmed with poor health or other social determinants of health, had competing priorities, did not perceive the need for food assistance; and experienced system barriers. Health literacy also was an issue. Health care systems addressing food insecurity should consider the high prevalence of food insecurity in impoverished regions, the reality that SNAP benefits may not alleviate food insecurity for many patients, and the need for individualized, custom care plans that address barriers and reflect patient priorities and capabilities. Engaging patients differently may be aided by additional communication from community food resources directly to patients who provide permission for this added service.