Tamala Carter

Challenges Faced by Patients with Low Socioeconomic Status During the Post-Hospital Transition

ABSTRACTBACKGROUNDPatients with low socioeconomic status (low-SES) are at risk for poor outcomes during the post-hospital transition. Few prior studies explore perceived reasons for poor outcomes from the perspectives of these high-risk patients.OBJECTIVEWe explored low-SES patients’ perceptions of hospitalization, discharge and post-hospital transition in order to generate hypotheses and identify common experiences during this transition.DESIGNWe conducted a qualitative study using in-depth semi-structured interviewing.PARTICIPANTSWe interviewed 65 patients who were: 1) uninsured, insured by Medicaid or dually eligible for Medicaid and Medicare; 2) residents of five low-income ZIP codes; 3) had capacity or a caregiver who could be interviewed as a proxy; and 4) hospitalized on the general medicine or cardiology services of two academically affiliated urban hospitals.APPROACHOur interview guide investigated patients’ perceptions of hospitalization, discharge and the post-hospital transition, and their performance of recommended post-hospital health behaviors related to: 1) experience of hospitalization and discharge; 2) external constraints on patients’ ability to execute discharge instructions; 3) salience of health behaviors; and 4) self-efficacy to execute discharge instructions. We used a modified grounded theory approach to analysis.KEY RESULTSWe identified six themes that low-SES patients shared in their narratives of hospitalization, discharge and post-hospital transition. These were: 1) powerlessness during hospitalization due to illness and socioeconomic factors; 2) misalignment of patient and care team goals; 3) lack of saliency of health behaviors due to competing issues; 4) socioeconomic constraints on patients’ ability to perform recommended behaviors; 5) abandonment after discharge; and 6) loss of self-efficacy resulting from failure to perform recommended behaviors.CONCLUSIONSLow-SES patients describe discharge goals that are confusing, unrealistic in the face of significant socioeconomic constraints, and in conflict with their own immediate goals. We hypothesize that this goal misalignment leads to a cycle of low achievement and loss of self-efficacy that may underlie poor post-hospital outcomes among low-SES patients.

The use of participatory action research to design a patient-centered community health worker care transitions intervention.

BACKGROUND Policymakers, patients and clinicians are increasingly eager to foster patient involvement in health care innovation. Our objective was to use participatory action research with high-risk hospitalized patients to design a post-hospital transition intervention. METHODS We conducted qualitative interviews with sixty-five low-income, recently hospitalized patients exploring their perceptions of barriers to post-hospital recovery and ideas for improvement. We then used a modified grounded theory approach to design an intervention that would address each barrier using patients׳ suggestions. RESULTS Five key themes were translated into design elements. First, patients wished to establish a relationship with healthcare personnel to whom they could relate. The intervention was provided by an empathic community health worker (CHW) who established rapport during hospitalization. Second, patients suggested tailoring support to their needs and goals. CHWs and patients designed individualized action plans for achieving their goals for recovery. Third, patient goals were misaligned with those of the inpatient team. CHW facilitated patient-provider discharge communication to align goals. Fourth, patients lacked post-discharge support for predominantly psychosocial or financial issues that undermined recovery. CHWs provided support tailored to patient needs. Finally, patients faced numerous barriers in obtaining post-hospital primary care. CHWs helped patients to obtain timely care with a suitable provider. CONCLUSIONS Low-income hospitalized patients voiced needs and suggestions that were directly translated into the design of a scalable patient-centered CHW intervention. IMPLICATIONS The approach of using participatory action research to tightly mapping patient input into intervention design is rapid and systematic strategy for operationalizing patient involvement in innovation.

Perspectives of Older Adults of Low Socioeconomic Status on the Post- hospital Transition

Background. Older adults of low socioeconomic status are at high risk for poor post-hospital outcomes. Design. A qualitative researcher, who was also an outreach worker from the West Philadelphia community, conducted in-depth interviews with 25 participants within 30 days of their hospital discharge. Participants. Eligible participants were: 1) residents of high-poverty ZIP codes; 2) dually eligible for Medicare and Medicaid; 3) had capacity or a caregiver who could be interviewed as a proxy; 4) general medicine or cardiology patients. Results. Participants were unable to access the care and accommodations needed to cope with post-hospital frailty. As a result, medical disability was amplified by socioeconomic disability. Participants were ashamed of the resulting loss of control and had difficulty asking for help, particularly from potential supports who were perceived as emotionally controlling or judgmental. Conclusion. Strategies that address socioeconomic stressors of hospitalization and provide empathic support may improve the post-hospital transition for these high-risk individuals.

Exploring the Patient and Staff Experience With the Process of Primary Care

PURPOSE Previous studies suggest that the highest-risk patients value accessible, coordinated primary care that they perceive to be of high technical quality. We have limited understanding, however, of how low-income, chronically ill patients and the staff who care for them experience each individual step in the primary care process. METHODS We conducted qualitative interviews with uninsured or Medicaid patients with chronic illnesses, as well as with primary care staff. We interviewed 21 patients and 30 staff members with a variety of job titles from 3 primary care practices (1 federally qualified health center and 2 academically affiliated clinics).] RESULTS The interviews revealed 3 major issues that were present at all stages of a primary care episode: (1) information flow throughout an episode of care is a frequent challenge, despite systems that are intended to improve communication; (2) misaligned goals and expectations among patients, clinicians, and staff members are often an impediment to providing and obtaining care; and (3) personal relationships are highly valued by both patients and staff. CONCLUSIONS Vulnerable populations and the primary care staff who work with them perceive some of the same challenges throughout the primary care process. Improving information flow, aligning goals and expectations, and developing personal relationships may improve the experience of both patients and staff.

Penn Center for Community Health Workers: Step-by-Step Approach to Sustain an Evidence-Based Community Health Worker Intervention at an Academic Medical Center

Community-engaged researchers who work with low-income communities can be reliant on grant funding. We use the illustrative case of the Penn Center for Community Health Workers (PCCHW) to describe a step-by-step framework for achieving financial sustainability for community-engaged research interventions. PCCHW began as a small grant-funded research project but followed an 8-step framework to engage both low-income patients and funders, determine outcomes, and calculate return on investment. PCCHW is now fully funded by Penn Medicine and delivers the Individualized Management for Patient-Centered Targets (IMPaCT) community health worker intervention to 2000 patients annually.

Perceptions of High-Risk Patients and Their Providers on the Patient-Centered Medical Home

To explore perceptions of high-risk patients and their practice staff on the patient-centered medical home, we conducted a multisite qualitative study with chronically ill, low-income patients and their primary care practice staff (N = 51). There were 3 key findings. Both patients and staff described a trade-off: timely care from an unfamiliar provider versus delayed access to their personal physician. Staff were enthusiastic about enhancing access through strategies such as online communication, yet high-risk patients viewed these as access barriers. Practices lacked capacity to manage high-risk patients and therefore frequently referred them to the emergency room.

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

Summary: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.

Effect of Community Health Worker Support on Clinical Outcomes of Low-Income Patients Across Primary Care Facilities: A Randomized Clinical Trial

Importance Addressing the social determinants of health has been difficult for health systems to operationalize. Objective To assess a standardized intervention, Individualized Management for Patient-Centered Targets (IMPaCT), delivered by community health workers (CHWs) across 3 health systems. Design, Setting, and Participants This 2-armed, single-blind, multicenter randomized clinical trial recruited patients from 3 primary care facilities in Philadelphia, Pennsylvania, between January 28, 2015, and March 28, 2016. Patients who resided in a high-poverty zip code, were uninsured or publicly insured, and who had a diagnosis for 2 or more chronic diseases were recruited, and patients were randomized to either the CHW intervention or the control arm (goal setting only). Follow-up assessments were conducted at 6 and 9 months after enrollment. Data were analyzed using an intention-to-treat approach from June 2017 to March 2018. Intervention Participants set a chronic disease management goal with their primary care physician; those randomized to the CHW intervention received 6 months of tailored support. Main Outcomes and Measures The primary outcome was change in self-rated physical health. The secondary outcomes were self-rated mental health, chronic disease control, patient activation, patient-reported quality of primary care, and all-cause hospitalization. Results Of the 592 participants, 370 (62.5%) were female, with a mean (SD) age of 52.6 (11.1) years. Participants in both arms had similar improvements in self-rated physical health (mean [SD], 1.8 [11.2] vs 1.6 [9.9]; P = .89). Patients in the intervention group were more likely to report the highest quality of care (odds ratio [OR], 1.8; 95% CI, 1.4-2.4; risk difference [RD], 0.12; P < .001) and spent fewer total days in the hospital at 6 months (155 days vs 345 days; absolute event rate reduction, 69%) and 9 months (300 days vs 471 days; absolute event rate reduction, 65%). This reduction was driven by a shorter average length of stay (difference, –3.1 days; 95% CI, –6.33 to 0.22; P = .06) and a lower mean number of hospitalizations (difference, –0.3; 95% CI, –0.6 to 0.0; P = .07) among patients who were hospitalized. Patients in the intervention group had a lower odds of repeat hospitalizations (OR, 0.4; 95% CI, 0.2-0.9; RD, –0.24; P = .02), including 30-day readmissions (OR, 0.3; 95% CI, 0.1-0.9; RD, –0.17; P = .04). Conclusions and Relevance A standardized intervention did not improve self-rated health but did improve the patient-perceived quality of care while reducing hospitalizations, suggesting that health systems may use a standardized intervention to address the social determinants of health. Trial Registration ClinicalTrials.gov identifier: NCT02347787

Understanding High Utilization of Emergency Obstetric Care in Pregnant Women of Low Socioeconomic Status [170].

INTRODUCTION: Drivers and impact of low-value care use in pregnant women with high levels of emergency care utilization are poorly understood. METHODS: Deidentified records of all obstetric triage visits from October 2013 to August 2014 at an urban academic medical center were analyzed for utilization trends and clinical outcome. We conducted semistructured interviews with 40 low-income women presenting to obstetric triage after 16 weeks of gestation, purposively sampling those presenting for a fourth or higher visit (high utilizers) or a first visit at term (low utilizers). Interviews were recorded and coded by theme. RESULTS: Six thousand seven hundred and ninety-four triage visits representing 3,539 patients occurred during the study period with 1.9 mean visits per patient. High utilizers made up 10.9% of the sample and were more likely than other triage users to report prior psychosocial trauma (17.8% compared with 7.7%, P<.001) and medical illness (64.0% compared with 47.5%, P<.001). High utilizers were less likely than other triage users to deliver at our center (16% compared with 42%, P<.001); those who did were more likely to deliver preterm (22.6% compared with 12.3%, P=.02). Interview participants perceived triage care to be of higher quality and more accessible than outpatient prenatal care. High utilizers reported social dysfunction and difficulty coping with pregnancy. Low utilizers reported social stability and self-efficacy. CONCLUSION: High emergency utilization can be a signal of unmet need. Interventions targeting perinatal disparities should incorporate low-income patient perspectives by leveraging emergency visits, addressing social determinants, and promoting access to quality prenatal care.