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Over a third of US adults carry a diagnosis of prediabetes, 70% of whom may progress to type 2 diabetes mellitus (\"diabetes\"). Community health workers (CHWs) can help patients undertake healthy behavior to prevent diabetes. However, there is limited guidance to integrate CHWs in primary care, specifically to address CHWs' dual clinic-based and community-oriented role. Using evidence from CHWs' adaptations of a diabetes-prevention intervention in safety-net hospitals in New York City, we examine the nature, intent, and possible consequences of CHWs' actions on program fidelity. We propose strategies for integrating CHWs in primary care. Case study drawing on the Model for Adaptation Design and Impact (MADI) to analyze CHWs' actions during implementation of CHORD (Community Health Outreach to Reduce Diabetes), a cluster-randomized pragmatic trial (2017-2022) at Manhattan VA and Bellevue Hospital. CHWs and clinicians in the CHORD study, with a focus in this analysis on CHWs. Semi-structured interviews and focus group discussion with CHWs (n=4); semi-structured interviews with clinicians (n=17). Interpretivist approach to explain CHWs' adaptations using a mix of inductive and deductive analysis. CHWs' adaptations extended the intervention in three ways: by extending social assistance, healthcare access, and operational tasks. The adaptations were intended to improve fit, reach, and retention, but likely had ripple effects on implementation outcomes. CHWs' focus on patients' complex social needs could divert them from judiciously managing their caseload. CHWs' community knowledge can support patient engagement, but overextension of social assistance may detract from protocolized health-coaching goals. CHW programs in primary care should explicitly delineate CHWs' non-health support to patients, include multiprofessional teams or partnerships with community-based organizations, establish formal communication between CHWs and clinicians, and institute mechanisms to review and iterate CHWs' work to resolve challenges in their community-oriented role.

OBJECTIVE:US hospitals that care for vulnerable populations, “safety-net hospitals” (SNHs), are more likely to incur penalties under the Hospital Readmissions Reduction Program, which penalizes hospitals with higher-than-expected readmissions. Understanding whether SNHs face unique barriers to reducing readmissions or whether they underuse readmission-prevention strategies is important. DESIGN:We surveyed leadership at 1600 US acute care hospitals, of whom 980 participated, between June 2013 and January 2014. Responses on 28 questions on readmission-related barriers and strategies were compared between SNHs and non-SNHs, adjusting for nonresponse and sampling strategy. We further compared responses between high-performing SNHs and low-performing SNHs. RESULTS:We achieved a 62% response rate. SNHs were more likely to report patient-related barriers, including lack of transportation, homelessness, and language barriers compared with non-SNHs (P-values<0.001). Despite reporting more barriers, SNHs were less likely to use e-tools to share discharge summaries (70.1% vs. 73.7%, P<0.04) or verbally communicate (31.5% vs. 39.8%, P<0.001) with outpatient providers, track readmissions by race/ethnicity (23.9% vs. 28.6%, P<0.001), or enroll patients in postdischarge programs (13.3% vs. 17.2%, P<0.001). SNHs were also less likely to use discharge coordinators, pharmacists, and postdischarge programs. When we examined the use of strategies within SNHs, we found trends to suggest that high-performing SNHs were more likely to use several readmission strategies. CONCLUSIONS:Despite reporting more barriers to reducing readmissions, SNHs were less likely to use readmission-reduction strategies. This combination of higher barriers and lower use of strategies may explain why SNHs have higher rates of readmissions and penalties under the Hospital Readmissions Reduction Program.

BackgroundThere is a need for new strategies to improve the success of obesity treatment within the primary care setting.ObjectiveTo determine if patients offered low out-of-pocket cost weight management tools achieved more weight loss compared to usual care.DesignTwelve-month pragmatic clinical weight loss trial with a registry-based comparator group performed in primary care clinics of an urban safety-net hospital.ParticipantsFrom a large clinical registry, we randomly selected 428 patients to have the opportunity to receive the intervention.InterventionsMedical weight management tools—partial meal replacements, recreation center vouchers, pharmacotherapy, commercial weight loss program vouchers, and a group behavioral weight loss program—for $5 or $10 monthly. Patients chose their tools, could switch tools, and could add a second tool at 6 months.Main MeasuresThe primary outcome was the proportion of intervention-eligible patients who achieved ≥ 5% weight loss. The main secondary outcome was the proportion of on-treatment patients who achieved ≥ 5% weight loss.Key ResultsOverall, 71.3% (305 of 428) had available weight measurement data/PCP visit data to observe the primary outcome. At 12 months, 23.3% (71 of 305) of intervention-eligible participants and 15.7% (415 of 2640) of registry-based comparators had achieved 5% weight loss (p < 0.001). Of the on-treatment participants, 34.5% (39 of 113) achieved 5% weight loss. Mean percentage weight loss was − 3.15% ± 6.41% for on-treatment participants and − 0.30% ± 6.10% for comparators (p < 0.001). The initially preferred tools were meal replacements, pharmacotherapy, and recreation center passes.ConclusionsAccess to a variety of low out-of-pocket cost weight management tools within primary care resulted in ≥ 5% body weight loss in approximately one quarter of low-income patients with obesity.Trial Registrationhttps://clinicaltrials.gov/ct2/show/NCT01922934

Background The aim of this study was to identify the range of ways that safety net hospitals (SNHs) have been empirically operationalized in the literature and determine the extent to which patterns could be identified in the use of empirical definitions of SNHs. Methods We conducted a PRISMA guided systematic review of studies published between 2009 and 2018 and analyzed 22 articles that met the inclusion criteria of hospital-level analyses with a clear SNH definition. Results Eleven unique SNH definitions were identified, and there were no obvious patterns in the use of a definition category (Medicaid caseload, DSH payment status, uncompensated care, facility characteristics, patient care mix) by the journal type where the article appeared, dataset used, or the year of publication. Conclusions Overall, there is broad variability in the conceptualization of, and variables used to define, SNHs. Our work advances the field toward the development of standards in measuring, operationalizing, and conceptualizing SNHs across research and policy questions.

Current treatment options for chronic pain and depression are largely medication-based, which may cause adverse side effects. Integrative Medical Group Visits (IMGV) combines mindfulness techniques, evidence based integrative medicine, and medical group visits, and is a promising adjunct to medications, especially for diverse underserved patients who have limited access to non-pharmacological therapies. Determine the effectiveness of IMGV compared to a Primary Care Provider (PCP) visit in patients with chronic pain and depression. 9-week single-blind randomized control trial with a 12-week maintenance phase (intervention-medical groups; control-primary care provider visit). Academic tertiary safety-net hospital and 2 affiliated federally-qualified community health centers. 159 predominantly low income racially diverse adults with nonspecific chronic pain and depressive symptoms. IMGV intervention- 9 weekly 2.5 hour in person IMGV sessions, 12 weeks on-line platform access followed by a final IMGV at 21 weeks. Data collected at baseline, 9, and 21 weeks included primary outcomes depressive symptoms (Patient Health Questionnaire 9), pain (Brief Pain Inventory). Secondary outcomes included pain medication use and utilization. There were no differences in pain or depression at any time point. At 9 weeks, the IMGV group had fewer emergency department visits (RR 0.32, 95% CI: 0.12, 0.83) compared to controls. At 21 weeks, the IMGV group reported reduction in pain medication use (Odds Ratio: 0.42, CI: 0.18-0.98) compared to controls. Absence of treatment assignment concealment for patients and disproportionate group attendance in IMGV. Results demonstrate that low-income racially diverse patients will attend medical group visits that focus on non-pharmacological techniques, however, in the attention to treat analysis there was no difference in average pain levels between the intervention and the control group. clinicaltrials.gov NCT02262377.

The COVID-19 crisis has led to spiking unemployment rates with disproportionate impacts on low-income families. School and child-care center closures have also meant lost free and reduced-price school meals. Food prices have increased sharply, leading to reduced purchasing power for families with limited income. The Families First Coronavirus Response Act and the Coronavirus Aid, Relief, and Economic Security Act constituted a robust response, including expansions to unemployment insurance (expansions in eligibility and a $600 per week supplement), a onetime payment of $1,200 per adult and $500 per dependent, an increase in SNAP payments, and the launch of the Pandemic EBT program to replace lost school meals. Despite these efforts, real-time data show significant distress—notably, food insecurity rates have increased almost three times over the pre-COVID-19 rates and food pantry use has also spiked. In this paper, we explore why there is so much unmet need despite a robust policy response. We provide evidence for three explanations: (1) timing—relief came with a substantial delay, due to overwhelmed unemployment insurance (UI) systems and the need to implement new programs; (2) magnitude—payments outside UI are modest; and (3) coverage gaps—access is lower for some groups, and other groups are statutorily excluded.

Introduction The underrepresentation of Black, Indigenous, and People of Color (BIPOC) individuals in healthcare research limits generalizability and contributes to healthcare inequities. Existing barriers and attitudes toward research participation must be addressed to increase the representation of safety net and other underserved populations. Methods We conducted semi‐structured qualitative interviews with patients at an urban safety net hospital, focusing on facilitators, barriers, motivators, and preferences for research participation. We conducted direct content analysis guided by an implementation framework and used rapid analysis methods to generate final themes. Results We completed 38 interviews and identified six major themes related to preferences for engagement in research participation: (1) wide variation in research recruitment preferences; (2) logistical complexity negatively impacts willingness to participate; (3) risk contributes to hesitation toward research participation; (4) personal/community benefit, interest in study topic, and compensation serve as motivators for research participation; (5) continued participation despite reported shortcomings of informed consent process; and (6) mistrust could be overcome by relationship or credibility of information sources. Conclusion Despite barriers to participation in research studies among safety‐net populations, there are also facilitators that can be implemented to increase knowledge and comprehension, ease of participation, and willingness to join research studies. Study teams should vary recruitment and participation methods to ensure equal access to research opportunities. Patient/Public Contribution Our analysis methods and study progress were presented to individuals within the Boston Medical Center healthcare system. Through this process community engagement specialists, clinical experts, research directors, and others with significant experience working with safety‐net populations supported data interpretation and provided recommendations for action following the dissemination of data.

Safety-net hospitals provide essential care to patients regardless of their insurance coverage, financial circumstances, or immigration status, and they often operate with thin margins. But the lack of a clear definition for safety-net hospitals presents challenges.

Although readmission rates are declining under Medicare's Hospital Readmissions Reduction Program (HRRP), concerns remain that the HRRP will harm quality at safety-net hospitals because they are penalized more often. Disparities between white and black patients might widen because more black patients receive care at safety-net hospitals. Disparities may be particularly worse for clinical conditions not targeted by the HRRP because hospitals might reallocate resources toward targeted conditions (acute myocardial infarction, pneumonia, and heart failure) at the expense of nontargeted conditions. To examine disparities in readmission rates between white and black patients discharged from safety-net or non-safety-net hospitals after the HRRP began, evaluating discharges for any clinical condition and the subsets of targeted and nontargeted conditions. Cohort study conducting quasi-experimental analyses of patient hospital discharges for any clinical condition among fee-for-service Medicare beneficiaries from 2007 to 2015 after controlling for patient and hospital characteristics. Changes in disparities were measured within safety-net and non-safety-net hospitals after the HRRP penalties were enforced and compared with prior trends. These analyses were then stratified by targeted and nontargeted conditions. Analyses were conducted from October 1, 2017, through August 31, 2018. Trends in 30-day readmission rates among white and black patients by quarter and differences in trends across periods. The study sample included 58 237 056 patient discharges (black patients, 9.8%; female, 57.7%; mean age [SD] age, 78.8 [7.9] years; nontargeted conditions, 50 372 806 [86.5%]). Within safety-net hospitals, disparities in readmission rates for all clinical conditions widened between black and white patients by 0.04 percentage point per quarter in the HRRP penalty period (95% CI, 0.01 to 0.07; P = .01). This widening was driven by nontargeted conditions (0.05 percentage point per quarter [95% CI, 0.01 to 0.08]; P = .006), whereas disparities for the HRRP-targeted conditions did not change (with an increase of 0.01 percentage point per quarter [95% CI, -0.07 to 0.10]; P = .74). Within non-safety-net hospitals, racial disparities remained stable in the HRRP penalty period across all conditions, whether the conditions were HRRP-targeted or nontargeted. Findings from this study suggest that disparities are widening within safety-net hospitals, specifically for non-HRRP-targeted conditions. Although increases in racial disparities for nontargeted conditions were modest, they represent 6 times more discharges in our cohort than targeted conditions.

Background Over the past decade, many well-resourced health plans and systems surpassed the 80% colorectal cancer screening rate goal, while lower resource environments such as federally qualified health centers (FQHCs) lag behind. FQHCs in rural areas are especially challenged with limited resources to reach diverse patients who often lack consistent engagement with clinical care. mHealth solutions, like mPATH ® CRC, can address these challenges by automating tasks and expanding patient outreach. This platform identifies patients due for CRC screening, educates them on the commonly used screening tests, and helps them select their best option. This paper describes protocols for a study that will implement mPATH ® CRC in FQHCs using a novel outreach strategy that engages patients outside of regular appointments. Methods Following a type 1 hybrid effectiveness-implementation design, we will conduct a patient-level randomized controlled trial (RCT) to assess the effectiveness of mPATH ® -CRC over a three-year period. Embedded within the RCT, we will utilize a convergent, mixed methods design for evaluation of the implementation process. The planned trial sample will include 1000 patients who are at average CRC risk and due for screening. Participants will be randomized 1:1 to receive either usual care or outreach through mPATH ® -CRC that includes text messages about screening, multi-media education on screening options, and either mailed FIT or assistance to schedule a colonoscopy. The primary outcome is completion of any CRC screening test within six months of randomization. We will also use surveys and interviews with FQHC personnel to explore integration of mPATH ® -CRC into clinical workflows and sustainability challenges. Discussion This trial will generate insights into the effectiveness and implementation of a digital CRC screening intervention in resource-limited FQHCs. Findings will inform strategies for optimizing outreach components and scaling implementation in similar settings. Trial registration This trial was registered on June 4, 2024, at ClinicalTrials.gov (identifier NCT06441487).