>>MY NAME IS TANIA STROUT, I'M
HAPPY TO BE HERE AGAIN TODAY ON
BEHALF OF THE EMERGENCY NURSES
ASSOCIATION.
AND THE ANA RESEARCH ADVISORY
COUNCIL.
WE HAD A WONDERFUL OPENING
SESSION YESTERDAY, WHERE DR.
RENEE HSIA GET US STARTED ON
STRUCTURAL INEQUITIES WITHIN OUR
EMERGENCY CARE SYSTEM.
WE HAVE A FANTASTIC SERIES OF
SPEAKERS WHO WILL CONTINUE TO
EXPLORE THE IMPACT OF SOCIAL
DETERMINANTS OF HEALTH AND HOW
WE MIGHT BETTER ADDRESS THOSE
SOCIAL DETERMINANTS IN OUR
NATION'S EMERGENCY DEPARTMENTS.
THANK YOU VERY MUCH FOR JOINING
US AGAIN TODAY.
AS WE BEGIN I'D LOVE TO
ACKNOWLEDGE THAT THE TERRITORY
THAT I'M SITUATED ON TODAY IS
THE TRADITIONAL AND MODERN HOME
OF THE WABANAKI PEOPLE.
AS WE WORK TOGETHER ON
ADDRESSING SOCIAL DETERMINANTS
AND THEIR CONNECTION TO HEALTH
WE ACKNOWLEDGE AND SUPPORT
WABANAKI EFFORTS AND ALL
INDIGENOUS PEOPLES TOWARD LAND
PROTECTION, CULTURAL HEARING,
RECONCILIATION.
I ENCOURAGE EVERYONE TO CONSIDER
THE LAND YOU'RE SITUATED ON
TODAY AND THE INDIGENOUS PEOPLES
WHO INHABITED THAT SPACE BEFORE
YOU AND TODAY.
AS WE BEGIN, I'D LOVE TO INVINE
DR. SHANNON ZENK TO SHARE
COMMENTS AND UPDATES WITH THE
GROUP.
DR. ZENK?
>> THANK YOU, DR. STROUT.
AND WELCOME
TO THE DAY 2 OF THE 2022
NATIONAL NURSING RESEARCH
ROUNDTABLE.
SO TODAY THIS MORNING I'LL SHARE
WITH YOU A BRIEF UPDATE ON NINR
ACTIVITY INCLUDING OVERVIEW OF
OUR STRATEGIC DIRECTION, SOME OF
THE PARTNERSHIPS AND
COLLABORATIONS WE'RE PART OF AND
NEWS FROM NINR.
SO LET'S START WITH A BIT ABOUT
OUR SOON TO BE RELEASED
STRATEGIC PLAN THAT WILL PROVIDE
A BIG PICTURE VIEW OF THE
DIRECTIONS WE'LL BE HEADING
NEXT.
THOUGH THE PLAN HASN'T BEEN
RELEASED YET I CAN SHARE SOME
INFORMATION ON FRAMEWORK.
THREADED THROUGHOUT THE GUIDING
PRINCIPLES FOR RESEARCH AND
STRATEGIC PLAN FRAMEWORK IS A
FOCUS ON HEALTH EQUITY.
WE BELIEVE THIS IS NECESSARY TO
RIGHT SYSTEMIC WRONGS THAT LED
TO UNEQUAL ACCESS TO RESOURCES
NEEDED FOR EACH PERSON TO LIVE
THEIR HEALTHIEST LIFE AND ALSO
BECAUSE IT'S THE ROOT OF MANY
OUR NATION'S MOST PRESSING
HEALTH CHALLENGES.
BEFORE I GO INTO A BIT MORE
DETAIL ON THE STRATEGIC PLAN'S
FRAMEWORK I WANT TO SHARE SOME
OF THE WAYS THAT WE ENGAGED OUR
RESEARCH COMMUNITY AS WE
DEVELOPED AND REFINED THE
FRAMEWORK.
20 EXTERNAL EXPERTS PARTICIPATED
IN A WORKING GROUP THAT PROVIDED
RECOMMENDATIONS THROUGH THE
NATIONAL ADVISORY COUNCIL FOR
NURSING RESEARCH.
WE RECEIVED 385 ONLINE RESPONSES
TO OUR TELL US WHAT NURSING
RESEARCH MEANS TO YOU CAMPAIGN.
WE RECEIVED OVER 100 E-MAILS IN
RESPONSE TO AN OPEN CALL FOR
INPUT ON THE DEVELOPMENT OF THE
STRATEGIC PLAN.
I PERSONALLY PARTICIPATED IN 80
MEETINGS AND PRESENTATIONS WITH
EXTERNAL GROUPS, AND OUR REQUEST
FOR INFORMATION ON THE DRAFT
STRATEGIC PLAN RESEARCH
FRAMEWORK GENERATED OVER 130
PUBLIC COMMENTS.
WE CAREFULLY STUDIED THE INPUT
AND THE FEEDBACK WE RECEIVED.
THE MAJORITY OF RESPONDENTS TO
OUR CALL FOR INPUT ON THE
DEVELOPMENT OF THE STRATEGIC
PLAN EXPLICITLY SUPPORTED A
STRATEGIC DIRECTION AND RESEARCH
TOPICS ALIGNED WITH SOCIAL
DETERMINANTS OF HEALTH, HEALTH
EQUITY, AND COMMUNITY AND
POPULATION HEALTH.
REGARDING OUR REQUEST FOR
INFORMATION ON THE DRAFT
FRAMEWORK, OVERALL NEARLY 2/3 OF
RESPONDENTS SUPPORTED THE
STRATEGIC PLAN FRAMEWORK.
AS PART OF THE STRATEGIC PLAN
EFFORT WE RECENTLY UPDATED THE
INSTITUTE'S MISSION STATEMENT.
AS YOU CAN SEE HERE WE'RE
COMMITTED TO SOLVING PRESSING
HEALTH CHALLENGES AND INFORMING
PRACTICE AND POLICY TO OPTIMIZE
HEALTH AND ADVANCE HEALTH
EQUITY.
A BIG PART OF ACHIEVING THIS
MISSION WILL INVOLVE ADDRESSING
THE IMPACT OF SOCIAL
DETERMINANTS OF HEALTH.
OUR STRATEGIC PLAN FRAMEWORK
INCLUDES A SET OF GUIDING
PRINCIPLES THAT WE BELIEVE
SHOULD DRIVE ALL AREAS OF
NINR-SUPPORTED SCIENCE, AND FIVE
RESEARCH LENSES THAT DESCRIBE
BROAD PERSPECTIVES BY WHICH TO
EXAMINE HEALTH CHALLENGES.
AFTER THE PLAN IS IMPLEMENTED
WE'LL ALSO DESCRIBE OUR
INTENTION TO DEVELOP STRATEGIC
IMPERATIVES AS NEW HEALTH
CHALLENGES AND NEW OPPORTUNITIES
ARE IDENTIFIED.
SO FIRST I'LL DESCRIBE OUR
GUIDING PRINCIPLES.
NINR'S GUIDING PRINCIPLES
DESCRIBE IMPORTANT POLICIES WE
SHOULD HAVE AS WE MOVE TO THE
TOWARD.
IN CONSIDERING AWARDS, EXTENT TO
WHICH STUDIES REFLECT THESE
PRINCIPLES WILL BE A FACTOR.
WE NEED TO SUPPORT RESEARCH
THAT'S INNOVATIVE, APPLIES
RIGOROUS RESEARCH METHODS, HAS
THE POTENTIAL FOR SIGNIFICANT
IMPACT ON HEALTH AND WELLNESS,
WELL BEYOND THE STUDY STUDY
SAMPLE, ADDRESSES TODAY'S
CHALLENGES AND PROVIDES
SOLUTIONS TO OPTIMIZE HEALTH
ACROSS CLINICAL, COMMUNITY, AND
POLICY SETTINGS.
NOW LET ME EXPLAIN WHAT WE MEAN
BY A RESEARCH LENS.
SIMPLY PUT, WHAT WE'RE CALLING A
RESEARCH LENS IS PERSPECTIVE BY
WHICH TO EXAMINE IDENTIFIED
HEALTH CHALLENGE.
AS WE KNOW THE FIELD OF NURSING
SCIENCE IS COMPRISED OF MANY,
MANY DIFFERENT PERSPECTIVES ON
TOPIC AND HOW TO DO SO.
IN DEVELOPING THE STRATEGIC
PLAN, NINR IDENTIFIED FIVE
LENSES THAT WE THINK BEST LEVER
YANG THE STRENGTHS OF NURSING
SCIENCE AND POSITION THE FIELD
TO INNOVATE AND THINK EVEN
BIGGER THAN WE HAVE IN THE PAST,
TO INCREASE OUR IMPACT, SO LET'S
TAKE A CLOSER LOOK AT EACH OF
THESE LENSES.
HEALTH EQUITY INCLUDES STUDIES
AIMED AT PRODUCING EVIDENCE
NEEDED TO REDUCE AND ULTIMATELY
ELIMINATE SYSTEMIC AND
STRUCTURAL INEQUALITIES THAT
PLACE POPULATION GROUPS AT A
DISADVANTAGE.
SOCIAL DETERMINANTS OF HEALTH
ARE THE CONDITIONS PEOPLE ARE
BORN, LIVE, LEARN, WORK, PLAY,
AGE.
BECAUSE THESE DETERMINANTS
IMPACT SO MANY FACETS OF OUR
HEALTH AND WELL-BEING WE BELIEVE
IT'S VITAL TO SUPPORT RESEARCH
THAT WILL EXAMINE THEM AND
IDENTIFY EFFECTIVE APPROACHES TO
ADDRESS SOCIAL FACTORS, POSITIVE
AND NEGATIVE, AND SOCIAL NEEDS
TO IMPROVE HEALTH OUTCOMES.
POPULATION AND COMMUNITY HEALTH
INCLUDE STUDIES THAT ADDRESS
CRITICAL HEALTH CHALLENGES AT
THE MACRO LEVEL, BY FOCUSING ON
INTERVENTIONS THAT AFFECT GROUPS
OF PEOPLE WITH SHARED
CHARACTERISTICS, OR WHO LIVE
WITHIN A SHARED AREA.
PREVENTION AND HEALTH PROMOTION
INCLUDE PROJECTS STUDYING HOW TO
PREVENT DISEASE AND PROMOTE
HEALTH THROUGH THE CONTINUUM OF
PREVENTION.
FROM PRIMORDIAL PREVENTION THAT
TARGETS UNDERLYING FACTORS THAT
INCREASE RISK OF ILLNESS TO
TERTIARY PREVENTION TO REDUCE
SYMPTOMS, PROGRESSION, WITH
EMPHASIS ON ELIMINATING HEALTH
DISPARITIES.
SYSTEMS ADDRESS ORGANIZATIONAL
AND POLICY CHALLENGES THROUGH
DEVELOPMENT, DISSEMINATION AND
IMPLEMENTATION OF SYSTEMS OF
CARE BRIDGING COMMUNITY CARE
WITH SOCIAL FACTORS AND
ASSOCIATE NEEDS.
HERE'S WHAT YOU CAN EXPECT OVER
THE NEXT FEW MONTHS.
THE STRATEGIC PLAN WILL BE
FINALIZED AND PUBLISHED ON OUR
WEBSITE.
WE'LL BEGIN THE HARD WORK OF
IMPLEMENTING THE NEW PLAN.
AND RESEARCH WE FUND AND CONDUCT
AND IN THE WAY WE MANAGE OUR
INSTITUTE.
WE'RE CONSIDERING HOSTING
SEMINARS AND OTHER EVENTS THAT
WILL HIGHLIGHT IMPORTANT
RESEARCH IN THESE NEW AREAS OF
EMPHASIS.
THE BOTTOM LINE IS PLEASE STAY
TUNED TO OUR WEBSITE, TWITTER
FEED, NEWS NEED FOR THE VERY
LATEST.
AS YOU ALL KNOW THE PERSPECTIVE
THAT NURSING BRINGS TO RESEARCH
IS UNIQUE IN THAT WE APPROACH
PREVENTION, TREATMENT, AND CARE
HOLISTICALLY AND IN CONTEXT.
AND THE SCOPE OF OUR PRACTICE
AND DISCIPLINE EXTENDS FROM
IMPROVING THE HEALTH OF
INDIVIDUALS TO THAT OF ENTIRE
POPULATIONS.
WHAT SETS NINR APART FROM THE
OTHER NIH INSTITUTES IS THAT OUR
RESEARCH IS FOCUSED ON PEOPLE IN
THE CONTEXT OF THEIR LIVES AND
LIVING CONDITIONS.
IT'S OUR UNIQUE PERSPECTIVE THAT
MAKES OUR SCIENTIFIC DISCIPLINE
SO WELL-POSITIONED TO LEAD
RESEARCH FOCUSED ON THE WHOLE
PICTURE OF HEALTH, FROM THE
BIOLOGY OF A PERSON'S CELLS AND
GENES TO THEIR WHOLE SELF,
FAMILY AND RESOURCES, THE
COMMUNITY AND SOCIETY IN WHICH
THEY LIVE.
IT'S VITAL THAT WE BRING THAT
PERSPECTIVE TO THE TABLE
WHEREVER DECISIONS ARE MADE THAT
IMPACT HUMAN HEALTH AND WE'RE
DOING JUST THAT.
SO I'M EXCITED TO SHARE THAT
NINR IS EXPANDING OUR
INVOLVEMENT IN NIH-WIDE
INITIATIVES.
I'M EXCITED TO HIGHLIGHT NINR'S
PARTICIPATION IN SOME OF THESE
PARTNERSHIPS AND COLLABORATIONS,
INCLUDING THE MATERNAL MORTALITY
TASK FORCE ADVISORY CABINET.
THE NIH CMS JOINT COUNCIL, THE
"ALL OF US" BRAIN TRUST AND
EXECUTIVE COMMITTEE FOR
ADVANCING NIH-WIDE BASIC
BEHAVIORAL AND SOCIAL SCIENCES
RESEARCH.
AND AS YOU KNOW WE'VE BEEN
INVITED TO SERVE ON LEADERSHIP
ROLES IN THE CLIMATE CHANGE AND
HEALTH INITIATIVE, COVID SOCIAL
BEHAVIORAL AND ECONOMIC HEALTH
IMPACTS INITIATIVE, AND
EXECUTIVE COMMITTEE OF HELPING
TO END ADDICTION LONG TERM, OR
HEAL INITIATIVE, AND SPEARHEADED
NIH-WIDE SOCIAL DETERMINANTS OF
HEALTH RESEARCH COORDINATING
COMMITTEE WITH SEVERAL OTHER
INSTITUTES AND CENTERS.
AS WELL AS OFFICES.
GIVEN OUR NATION'S PRESSING
HEALTH CHALLENGES, THE
IMPORTANCE OF STRUCTURAL AND
SOCIAL FACTORS FOR HEALTH AND
HEALTH DISPARITIES AND THEIR
PRIORITIZATION IN THE NIH-WIDE
STRATEGIC PLAN, THE GOAL OF THE
RESEARCH COORDINATING COMMITTEE
IS TO ACCELERATE SOCIAL
DETERMINANTS OF HEALTH RESEARCH
ACROSS NIH.
TOWARDS THIS GOAL, THE RESEARCH
COORDINATING COMMITTEE WILL SEEK
TO FACILITATE INFORMATION
SHARING ABOUT SOCIAL
DETERMINANTS OF HEALTH RESEARCH
ACROSS NIH AND WITH FEDERAL
PARTNERS, DEVELOP SOCIAL
DETERMINANTS OF HEALTH
EXPERTISE, CAPACITY AND A
LEARNING SYSTEM IN THIS
SCIENTIFIC FIELD, BUILD
COMMUNITY AND COLLABORATION IN
SOCIAL DETERMINANTS OF HEALTH
RESEARCH ACROSS NIH AND WITH
FEDERAL PARTNERS, AND IDENTIFY
GAPS AND PROMISING RESEARCH
DIRECTIONS IN THIS FIELD.
THE RESEARCH COORDINATING
COMMITTEE WAS APPROVED JUST A
WEEK AGO, AND WE LOOK FORWARD TO
SHARING MORE INFORMATION AS THE
COMMITTEE IS ESTABLISHED AND
MOVES FORWARD.
WE THINK OUR LEADERSHIP AND
PARTICIPATION IN THESE
ACTIVITIES MAKE CLEAR THAT
NURSING RESEARCH IS BEING
RECOGNIZED FOR ITS VITAL ROLE IN
THE BIOMEDICAL RESEARCH
ENTERPRISE.
AT NIH I'M ALSO EXCITED TO SHARE
THAT NINR IS HELPING TO LEAD TWO
COMMON FUND PROGRAMS TO ADVANCE
HEALTH EQUITY, AS BACKGROUND THE
THEY ADDRESS EMERGING
OPPORTUNITIES AND PRESSING
HEALTH CHALLENGES IN BIOMEDICAL
RESEARCH, BUT NO SINGLE NIH
INSTITUTE OR CENTER CAN ADDRESS
ON ITS OWN.
BUT ARE OF HIGH PRIORITY FOR NIH
AS A WHOLE.
THE COMMON FUND IS A UNIQUE
RESOURCE AT NIH, HIGH RISK
INNOVATIVE ENDEAVORS WITH THE
POTENTIAL FOR EXTRAORDINARY
IMPACT ARE SUPPORTED.
LAUNCHED IN 2021, THE FIRST
PROGRAM WAS THE TRANSFORMATIVE
RESEARCH TO ADDRESS HEALTH
DISPARITIES AND ADVANCE HEALTH
EQUITY COMMON FUND PROGRAM,
SUPPORTING INNOVATIVE
TRANSLATIONAL RESEARCH PROJECTS
TO PREVENT, REDUCE, OR ELIMINATE
HEALTH DISPARITIES AND ADVANCE
HEALTH EQUITY.
SO FAR, 11 GRANTS HAVE BEEN
FUNDED THROUGH THIS PROGRAM,
WITH ADDITIONAL GRANTS
CONSIDERED.
TWO FUNDING ANNOUNCEMENTS
RELEASED IN 2021 ULTIMATELY
PROVIDED $58 MILLION OVER THE
NEXT FIVE YEARS.
SO YOU CAN LEARN MORE ABOUT THAT
PROGRAM AND FUNDED GRANTS AT THE
WEB ADDRESS SHOWN ON THE SLIDE.
AND I WANT TO POINT OUT THAT THE
RFA FOR MINORITY-SERVING
INSTITUTIONS WAS RECENTLY
REISSUED FOR THE PROGRAM WITH A
MAY 23 DUE DATE.
I'M ALSO EXCITED TO SHARE OUR
INVOLVEMENT IN A SECOND OR NEW
COMMON FUND PROGRAM RECOGNIZING
URGENCY OF HEALTH EQUITY
RESEARCH, NINNR WITH COLLEAGUES
IS CO-CHAIRING A SECOND NEW
10-YEAR $397 MILLION NIH COMMON
FUND PROGRAM, COMPASS, IT WILL
BE TRANSFORMATIVE AND HELP MAKE
REAL PROGRESS IN ELIMINATING
HEALTH INEQUITIES AND ACHIEVING
HEALTH EQUITY.
BY LOOKING UPSTREAM AT THE
SYSTEMS AND STRUCTURES THAT ARE
CAUSING SOCIALLY AND
ECONOMICALLY DISADVANTAGED
POPULATIONS TO BECOME SICK IN
THE FIRST PLACE.
COMPASS HAS TWO OVERARCHING
GOALS.
FIRST THE PROGRAM WILL
FACILITATE AND IMPLEMENT A
CROSS-I.C. FRAMEWORK FOR
RESEARCH.
SECOND, IT WILL DEPLOY AND
EVALUATE COMMUNITY-DRIVEN
STRUCTURAL HEALTH EQUITY
INTERVENTIONS THAT LEVERAGE
INTERSECTORIAL PARTNERSHIPS,
GENERATING NEW EVIDENCE ON WHAT
STRUCTURAL INTERVENTIONS ARE
EFFECTIVE IN ADVANCING HEALTH
EQUITY.
AND IT WILL SHED LIGHT ON THE
MECHANISMS BY WHICH THESE
INTERVENTIONS WORK.
IN ADDITION IT WILL INCREASE
RESEARCH CAPACITY AMONG ALL
PARTNERS IN HEALTH EQUITY
INTERVENTION RESEARCH, AND
INCREASE COMPETITIVENESS FOR
INSTITUTE AND CENTER FUNDING,
CONTRIBUTING TO GREATER
DIVERSITY AND INCLUSION OF
INVESTIGATORS AND PARTICIPANTS
ACROSS THE NIH.
IT WILL RESULT IN COMMON DATA
AND TOOLS, SHARED FRAMEWORK FOR
RESEARCH ACROSS PARTNERS, AND
EXCITINGLY A DISEASE AGNOSTIC
NETWORK AT THE NATIONAL LEVEL AS
WELL AS AT-RISK COMMUNITIES.
IT WILL PROVIDE REPOSITORIES OF
EVIDENCE-BASED HEALTH EQUITY
INTERVENTIONS, YIELD CAPACITY
BUILDING AND TRAINING CURRICULA,
AND INFORM HEALTH EQUITY
ENHANCING POLICIES AND PROGRAMS.
SO I CERTAINLY LOOK FORWARD TO
NURSING SCIENCE'S CONTINUED
INVOLVEMENT IN THIS IMPORTANT
PROGRAM.
IN ADDITION TO NINR
PARTICIPATION IN THESE IMPORTANT
NIH-WIDE PROGRAMS WE'RE ALSO
PARTICIPATING IN SEVERAL
INTERAGENCY AND HHS-WIDE
INITIATIVES.
THESE INCLUDE SOCIAL
DETERMINANTS OF HEALTH
INTERAGENCY POLICY COMMITTEE,
THE INTERAGENCY WORKING GROUP
FOR THE NATIONAL HEALTHCARE
QUALITY AND DISPARITIES REPORT,
THE HHS INTERDEPARTMENTAL HEALTH
EQUITY COLLABORATIVE, THE HHS
SOCIAL DETERMINANTS OF HEALTH
WORKGROUP, AND THE HHS
INITIATIVE TO STRENGTHEN PRIMARY
HEALTH CARE, AND WE'RE
REPRESENTED ON THE CLIMATE
CHANGE FOOD SYSTEMS AND
NUTRITION SECURITY WORKING GROUP
OF THE U.S. GLOBAL CHANGE
RESEARCH PROGRAM.
I AM REALLY EXCITED TO HAVE
NURSING SCIENCE'S PERSPECTIVE ON
THESE, ACROSS ALL THESE
IMPORTANT COMMITTEES.
SO NOW LET ME SHARE A LITTLE BIT
MORE NEWS FROM NINR.
AT NINR WE ACKNOWLEDGE THAT OUR
EFFORTS TOWARDS ACHIEVING HEALTH
EQUITY DEPEND AT LEAST IN PART
ON OUR EFFORTS TOWARDS
DIVERSITY.
QUITE SIMPLY, GREATER DIVERSITY
AND INCLUSION IN OUR SCIENCE
GREATLY IMPACTS, ENHANCES
QUALITY AND IMPACT OF OUR
SCIENCE.
WE'RE ADDRESSING THE ISSUE OF
DIVERSITY AND NURSING SCIENCE
WORKFORCE BY PARTICIPATING IN
TWO IMPORTANT NIH INITIATIVES
THAT AIM TO BUILD DIVERSITY
AMONG EARLY CAREER SCIENTISTS,
THE FIRST IS THE FIRST
INITIATIVE, THE SECOND, THE
MOSAIC POSTDOCTORAL CAREER
TRANSITION AWARD TO PROMOTE
DIVERSITY.
THROUGH FIRST, NIH AIMS TO
FACILITATE INSTITUTIONS AND
BUILDING A SELF-REINFORCING
COMMUNITY OF SCIENTISTS, THROUGH
RECRUITMENT OF A CRITICAL MASS
OF EARLY CAREER FACULTY WITH
DEMONSTRATED COMMITMENT TO
INCLUSIVE EXCELLENCE.
THE FIRST PROGRAM WILL SOON
BEGIN ACCEPTING APPLICATIONS FOR
NEW COHORT SO PLEASE SHARE THIS
OPPORTUNITY BROADLY ACROSS YOUR
NETWORKS.
MOSAIC AIMS TO SUPPORT A COHORT
OF EARLY CAREER INDEPENDENT
INVESTIGATORS FROM DIVERSE
BACKGROUNDS WITH A LONG-TERM
GOAL OF ENHANCING DIVERSITY IN
THE BIOMEDICAL RESEARCH
WORKFORCE, AGAIN PLEASE SHARE
ACROSS YOUR NETWORKS, FOR MORE
INFORMATION THOUGH ON ALL
TRAINING OPPORTUNITIES AVAILABLE
THROUGH NINR PLEASE CHECK OUR
WEBSITE.
OF COURSE, ALWAYS FEEL FREE TO
REACH OUT TO OUR PROGRAM STAFF.
AND WE ENCOURAGE ALL
INVESTIGATORS WITH AN ELIGIBLE
GRANT SUCH AS R01 TO SUBMIT A
DIVERSITY SUPPLEMENT AND HELP
ENSURE OUR WORK IS INCLUSIVE OF
EVERYONE.
DIVERSITY SUPPLEMENTS HAVE BEEN
SHOWN TO LAUNCH SUCCESSFUL AND
PROTECTIVE RESEARCH CAREERS OF
SCIENTISTS OF DIVERSITY
BACKGROUNDS.
NINR SUPPORTS DIVERSITY
SUPPLEMENTS TO ENHANCE THE
DIVERSITY OF THE RESEARCH, AND
ENTREPRENEURIAL WORK FORCE BY
RECRUITING AND SUPPORTING
STUDENTS, POSTDOCTORAL FELLOWS,
AND ELIGIBLE INVESTIGATORS FROM
DIVERSE BACKGROUNDS.
THIS INCLUDES THOSE FROM GROUPS
THAT HAVE BEEN SHOWN TO BE
UNDERREPRESENTED IN
HEALTH-RELATED RESEARCH, OR IN
THE SMALL BUSINESS PROGRAMS.
AN INTERESTING OPPORTUNITY TOYED
LIKE TO DRAW -- I'D LIKE TO DRAW
YOUR ATTENTION TO, SUPPLEMENTS
TO RECOGNIZE EXCELLENCE IN
MENTORSHIP RECOGNIZING THE
CRUCIAL ROLE GREAT MENTORS PLAY
IN DEVELOPMENT OF FUTURE LEADERS
IN THE SCIENTIFIC RESEARCH
ENTERPRISE.
THIS IS FOR SCIENTIST WHO IS ARE
OUTSTANDING MENTORS AND WHO HAVE
DEMONSTRATED COMPELLING
COMMITMENT AND CONTRIBUTIONS TO
ENHANCING DIVERSITY, EQUITY,
INCLUSION, AND ACCESSIBILITY IN
THE BIOMEDICAL SCIENCES.
NOW, PART OF INCREASING
DIVERSITY AMONG NINR-SUPPORTED
SCIENTISTS INCLUDING ENSURING
OPPORTUNITIES ARE AVAILABLE TO
SCIENTISTS AN STUDENTS AT A
RANGE OF INSTITUTIONS.
AS SUCH WE'RE PARTICIPATING IN
THE NIH SEARCH ENHANCEMENT AWARD
PROGRAM DESIGNED TO STIMULATE
BASIC AND CLINICAL RESEARCH IN
EDUCATIONAL INSTITUTIONS THAT
PROVIDE BACCALAUREATE OR
ADVANCED DEGREES, FOR
SIGNIFICANT NUMBER OF THE
NATION'S RESEARCH SCIENTISTS,
BUT THAT HAVE NOT BEEN MAJOR
RECIPIENTS OF NIH SUPPORT.
IT'S HOPED THIS PROGRAM WILL
EXPOSE STUDENTS IN THESE
ENVIRONMENTS TO MERITORIOUS
RESEARCH.
ELIGIBLE INSTITUTIONS MUST AWARD
NIH-RELEVANT BACCALAUREATE OR
ADVANCED DEGREES IN HEALTH
PROFESSIONS AND HAVE RECEIVED
LESS THAN $6 MILLION A YEAR IN
NIH SUPPORT, MA GEORGE OF THE
LAST SEVEN PHYSICAL EQUAL YEARS.
A LOT TO REMEMBER, CHECK OUT THE
WEBSITE.
I ENCOURAGE YOU TO CONSIDER
APPLYING FOR THIS AND, YOU KNOW,
HOPE THAT YOU'LL SHARE THIS
INFORMATION AGAIN IN YOUR
NETWORKS.
AND WE'RE EAGER TO LEARN MORE
ABOUT WHAT WE CAN DO TO
SIGNIFICANTLY STRENGTHEN
DIVERSITY AND INCLUSION.
TOWARDS THAT END, TWO NEW
WORKING GROUPS OF THE NINR
ADVISORY COUNCIL RECENTLY
LAUNCHED THEIR FIRST MEETINGS,
THESE WORKING GROUPS ARE
ADDRESSING DIVERSITY AND
INCLUSION IN OUR RESEARCH
WORKFORCE AND IN THE WORK WE
SUPPORT.
I LOOK FORWARD TO HEARING FROM
THESE GROUPS AS THEY EXAMINE
THESE ISSUES.
WE HAVE SEVERAL ACTIVE FUNDING
OPPORTUNITIES THAT I'D LIKE TO
HIGHLIGHT.
NINR RELEASED AN RFA TO EVALUATE
THE IMPACT OF PANDEMIC-RELATED
FOOD AND HOUSING POLICIES AND
PROGRAMS ON HEALTH OUTCOMES AND
HEALTH DISPARITY POPULATIONS.
OUR PROGRAM OFFICE, FOR THOSE
INTERESTED IN APPLYING FOR THIS
RFA, YOU CAN FIND MORE
INFORMATIONING ON OUR WEBSITE AS
WELL AS OTHER DETAILS ABOUT THIS
OPPORTUNITY ON NIH'S GRANT
WEBSITE.
APPLICATIONS FOR THIS RFA ARE
DUE APRIL 7.
WE ALSO RECENTLY POSTED AN R01
AND R21 FOR ADVANCING INTEGRATED
MODELS OF CARE TO IMPROVE
MATERNAL HEALTH OUTCOMES AMONG
DISPROPORTIONATELY IMPACTED
POPULATIONS, AND, AGAIN, THE DUE
DATE IS APRIL 7.
WE ARE ALSO SIGNED ON TO MANY
ADDITIONAL FUNDING OPPORTUNITY
ANNOUNCEMENTS.
SOME EXAMPLES ARE SHOWN HERE.
I ENCOURAGE YOU TO LEARN MORE
ABOUT THESE AT THE ADDRESSES
SHOWN HERE.
OF COURSE, WE WELCOME
INVESTIGATOR-INITIATED
APPLICATION SO IT DOESN'T JUST
TO -- YOU DON'T JUST HAVE TO
APPLY THROUGH ONE OF THESE
MECHANISMS.
CLOSER TO HOME, WE ARE LOOKING
FOR NURSING SCIENTISTS TO JOIN
OUR TEAM.
ONE EXCITING OPPORTUNITY IS TO
JOIN AS A PROGRAM OFFICER.
IN THIS ROLE YOU'LL HAVE THE
OPPORTUNITY TO HELP SHAPE THE
NINR RESEARCH PORTFOLIO TO
SUPPORT STRONGEST HIGHEST IMPACT
SCIENCE WITH THE GREATEST
POTENTIAL TO SOLVE THE NATION'S
MOST PRESSING HEALTH CHALLENGES.
THIS IS AN EXCITING TIME TO JOIN
AND CONTRIBUTE TO OUR NEW VISION
AND STRATEGIC DIRECTION.
PROGRAM OFFICERS INITIATE,
DEVELOP, MANAGE, AND PROVIDE
INSIGHT FOR THE INSTITUTE'S
EXTRAMURAL RESEARCH PORTFOLIO.
WE'RE SPECIFICALLY INTERESTED IN
EXPERTISE ALIGNED WITH RESEARCH
LENSES, IDENTIFIED IN THE DRAFT
FRAMEWORK.
AGAIN, THOSE ARE SOCIAL
DETERMINANTS OF HEALTH, HEALTH
EQUITY, COMMUNITY AND POPULATION
HEALTH, PREVENTION AND HEALTH
PROMOTION, AND SYSTEMS AND
MODELS OF CARE.
THESE POSITIONS ARE FILLED VIA
NIH'S GLOBAL HEALTH SCIENCE
ADMINISTRATOR, IT'S A LONG TERM,
JOB ANNOUNCEMENT, A NEW
ANNOUNCEMENT WILL BE POSTED ON
MARCH 14 WITH APPLICATIONS DUE
BY MARCH 18.
SO YOU CAN FIND THE
ANNOUNCEMENTS ON USA JOBS, AND
CAN ALSO WATCH FOR ANNOUNCEMENT
ON OUR WEBSITE.
PLEASE FEEL FREE TO REACH OUT TO
OUR ACTING EXTRAMURAL DIRECTOR,
DR. REBEKAH RASOOLY, WITH ANY
QUESTIONS.
FINALLY, ONE MORE UPDATE FROM
NINR, I AM VERY THANKFUL TO DR.
JOHN GRAYSON FOR AGREEING TO
SERVE AS NINR ACTING DEPUTY
DIRECTOR WHILE WE CONTINUE OUR
SEARCH FOR OUR NEXT PERMANENT
DEPUTY.
DR. GRASON SERVED IN OFFICE OF
SCIENCE POLICY AND LEGISLATION
FOR MORE THAN 15 YEARS, RECENTLY
AS ACTING DIRECTOR OF THE
DIVISION.
HE BEGAN HIS NIH CAREER AS AN
AMERICAN ASSOCIATION FOR THE
ADVANCEMENT OF SCIENCE FELLOW,
HE WAS ALSO AN HHS EMERGING
LEADER FELLOW, HAS A Ph.D. IN
BIOCHEMISTRY FROM UNIVERSITY OF
MARYLAND, AND HE HAS BEEN
INSTRUMENTAL IN NINR STRATEGIC
PLANNING PROCESS AS WELL AS A
SOURCE OF COUNSEL FOR ME AND
LEADERS ACROSS THE INSTITUTE.
I'M SO THRILLED TO HAVE DR.
GRASON IN THIS IMPORTANT ROLE AS
WE MOVE NINR INTO THE FUTURE.
SO TURNING TO THE REASON WE'RE
ALL HERE TODAY, THE NATIONAL
NURSING RESEARCH ROUNDTABLE,
THIS YEAR'S THEME AS YOU ALL
KNOW IS FROM CONTEXT TO CARE,
UNDERSTANDING THE CONVERGENCE OF
SOCIAL FACTORS AND EMERGENCY
DEPARTMENT CARE.
AND WE CERTAINLY UNDERSTAND THE
IMPORTANCE OF SOCIAL
DETERMINANTS OF HEALTH.
MANY OF THE INITIATIVES AND
FUNDING OPPORTUNITIES I SHARED
EARLIER FOCUS ON OR INCLUDE
SOCIAL DETERMINANTS.
AS EXPERTS IN EMERGENCY
MEDICINE, OUR ENA COLLEAGUES SEE
EVERY DAY THE IMPACT OF UPSTREAM
FACTORS THAT LEAD TO HEALTH
INEQUITIES BASED ON SOCIAL
NEEDS.
AND OUR COLLEAGUES ACROSS THE
MANY FIELDS THAT ARE REPRESENTED
HERE TODAY ARE CERTAINLY WELL
VERSED IN THESE ISSUES.
I MENTIONED EARLIER THAT AS
NURSES WE HAVE A UNIQUE
PERSPECTIVE THAT VIEWS THE
INDIVIDUAL HOLISTICALLY AND IN
CONTEXT.
WE KNOW THERE ARE FACTORS THAT
INFLUENCE PEOPLE'S HEALTH AND
THAT OF THEIR COMMUNITIES, LONG
BEFORE WE PROVIDE CARE.
AND WE KNOW THAT FOR SOME PEOPLE
WE CARE FOR HAVE MANY IF NOT ALL
THE RESOURCES, SOME PEOPLE
DON'T, NEEDED TO MAINTAIN
THROUGH NO FAULT OF OUR THINK
BUT IT'S OUR RESPONSIBILITY AS
CLINICIANS AND RESEARCHERS TO
ENSURE WE DO EVERYTHING AND IN
OUR POWER TO HELP BRIDGE THAT
DIVIDE.
I'M SO EXCITED THAT WE'RE HERE
AT THIS ROUNDTABLE TO SHARE
EXPERIENCE AND KNOWLEDGE ON
TOPICS FROM INEQUITY IN THE
EMERGENCY CARE SYSTEM TO
ADDRESSING SOCIAL DETERMINANTS
OF HEALTH IN EMERGENCY
DEPARTMENTS TO THE ROLE OF
HOUSING IN PATIENTS' HEALTH AND
SO MUCH MORE.
I HOPE THAT BY BRINGING SO MANY
EXPERTS AND SO MANY FIELDS
TOGETHER IN THIS ROUNDTABLE,
MANY OF YOU WILL MAKE
CONNECTIONS WITH OTHERS WHO ARE
PASSIONATE ABOUT THESE ISSUES
AND I'M CONFIDENT THOSE
CONNECTIONS WILL LEAD TO
RESEARCH THAT WILL INFORM
POLICIES AND SYSTEMS TO ADDRESS
THE INEQUITIES AND INJUSTICES
THAT PREVENT SO MANY FROM
ACHIEVING AND REACHING THEIR
HEALTHIEST LIVES.
WE HAVE A PACKED AGENDA.
BEFORE I TURN THE MEETING OVER
TO DR. STROUT I WANT TO MAKE A
MOMENT TO THANK ENA COLLEAGUES
AGAIN FOR PARTNERING WITH US ON
THE ROUNDTABLE.
I THINK EVERYONE WHO HELPED -- I
THANK EVERYONE WHO BROUGHT THIS
TOGETHER.
EVERYONE WHO HAS JOINED US FORT
MEET -- FOR THE MEETING,
LEARNING HOW WE IMPLEMENT THE
LESSONS WE TAKE AWAY FROM OUR
DISCUSSION.
AND NOW BACK TO YOU, DR. STROUT.
>> THANK YOU SO VERY MUCH.
IT'S FANTASTIC TO HEAR ABOUT
THESE IMPORTANT UPDATES AND I'M
SO PLEASED TO HEAR ABOUT THE
INCORPORATION OF DIVERSITY,
HEALTH EQUITY, SOCIAL
DETERMINANTS INTO THE WORK OF
THE INSTITUTE GOING FORWARD.
FABULOUS STUFF AND GREAT
OPPORTUNITIES.
LOOK FORWARD TO READING THE
WHOLE STRATEGIC PLAN.
NOW I WOULD LIKE TO INTRODUCE
DR. SARAH YOON, PLANNING
COMMITTEE MEMBER AND NINR
PROGRAM DIRECTOR OVERSEEING
PORTFOLIO FOCUSED ON WOMEN'S
HEALTH AND DATA SCIENCE, AND SHE
WILL BE INTRODUCING THE NEXT
SPEAKER.
IN THE INTEREST OF TIME I'D LIKE
TO SHARE THE BIOS WILL BE SHORT.
I'LL REMIND YOU THAT THE FULL
BIOS CAN BE FOUND IN THE
ELECTRONIC PROGRAM.
I'LL PLACE THAT IN THE CHAT IN
CASE YOU HAVEN'T HAD A CHANCE TO
DOWNLOAD THAT YET.
I'LL REMIND YOU THERE IS A
SUGGESTED READING LIST FOR MANY
SPEAKERS THAT WAS ATTACHED TO
YOUR INVITATION, I'LL INVITE YOU
TO PERUSER THAT AND TAKE
ADVANTAGE OF THOSE RESOURCES TO
CONTINUE OUR LEARNING TOGETHER.
DR. YOON, I'LL TURN IT OVER TO
YOU AT THIS POINT.
>> THANK YOU, DR. STROUT.
GOOD MORNING, EVERYONE.
TODAY WE'LL START WITH THE
SESSION OVERVIEW OF EMERGENCY
DEPARTMENT VISITS AND THE
SPEAKER WILL BE DR. CAROL
DEFRANCES, CURRENTLY THE ACTING
DIRECTOR AT CDC CENTER FOR HELD
STATISTICIAN, MODERNIZING TO
ELECTRONIC DATA CHECK, WAS DHCS
DEPUTY DIRECTOR AND DHCS CHIEF
OF AMBULATORY AND HOSPITAL CARE
STATISTIC BRANCH.
PLEASE JOIN ME IN WELCOMING DR.
DEFRANCES WHO WILL SPEAK FOR 15
MINUTES AND JUST PLEASE NOTE
WE'RE REQUESTING THAT YOU HOLD
YOUR QUESTIONS FOR THE PANEL
DISCUSSION.
HOWEVER, PLEASE USE THE CHAT
FUNCTION TO BEGIN SUBMITTING
YOUR QUESTIONS AT ANY TIME
DURING THE PRESENTATION, SO
DURING THE BREAK WE WILL BEGIN
TO CURATE YOUR QUESTIONS FOR THE
PANEL MODERATOR.
DR. FRANCES, PLEASE SHARE YOUR
PRESENTATION.
>> THANK YOU.
THANK YOU, DR. YOON, GOOD
MORNING.
I'M TRULY PLEASED TO BE HERE
TODAY AND TO ACTUALLY START OFF
THIS ROUND OF PRESENTATIONS FOR
TODAY.
THE GOAL OF MY PRESENTATION
TODAY IS TWO-FOLD.
I WILL PROVIDE OVERVIEW OF
EMERGENCY DEPARTMENT OR E.D.
VISITS IN THE UNITED STATES
USING DATA FROM NATIONAL
HOSPITAL AMBULATORY MEDICAL CARE
SURVEY, AND DISCUSS NCHS EFFORTS
TO ENHANCE COLLECTION OF DATA
THROUGH NATIONAL HOSPITAL CARE
SURVEY WITH AN CREASED DATA THAT
HAMCS DOES NOT.
I'M GOING TO BE PRESENTING DATA
FROM HAMCS TODAY BUT I WANT TO
POINT OUT THERE ARE OTHER E.D.
DATASETS OUT THERE.
THE AGENCY FOR HEALTH CARE
QUALITY AND RESEARCH, AMERICAN
HOSPITAL ASSOCIATION, CONSUMER
PRICE SAFETY COMMISSION HAVE
DATASETS.
AND THERE ARE OTHERS.
NEEDLESS TO SAY, ALL OF THESE
DATASETS INCLUDING HAMCS HAVE
ADVANTAGES AND DISADVANTAGES TO
KEEP IN MIND WHEN WE EXAMINE
PATTERNS OF E.D. CARE.
WHAT DOES HAMCS HAVE TO TELL US?
VISIT RATES IN E.D.s REMAINED
STABLE OVER THE DECADE FROM 2007
THROUGH 2018.
VARIATIONS EXIST IN E.D. VISITS
BY VARIOUS PATIENT
CHARACTERISTICS, AND MEASUREMENT
OF THESE VARIATIONS IS POSSIBLE
IF DATA ON CHARACTERISTICS OF
INTEREST HAVE BEEN COLLECTED IN
THE MEDICAL RECORD.
SEVERAL PATIENT CHARACTERISTICS
ARE ROUTINELY COLLECTED, SOME
ARE RELATED TO SOCIAL
DETERMINANTS OF HEALTH MAY AT
TIMES BE MISSING FROM MEDICAL
RECORDS.
BEFORE I BEGIN AND SHOW DATA I
WANT TO TALK BRIEFLY ABOUT
HAMCS.
IT WAS DESIGNED TO COLLECT DATA
ON THE PROVISION AND ALLS OF
AMBULATORY CARE SERVICES IN
HOSPITAL EDs, OUTPATIENT
DEPARTMENTS, AND AMBULATORY
SURGERY LOCATIONS.
SINCE 2018 WE'VE COLLECTED ONLY
E.D. DATA A, 400 HOSPITALS, WE
COLLECTED SAMPLE OF E.D. VISITS.
THE DATA ARE COLLECTED ANNUALLY,
NHMCS IN THE FIELD SINCE 1992.
PRE-COVID, THE DATA WERE
COLLECTED WITH IN-PERSON
INDUCTION INTERVIEWS, ON-SITE,
CONDUCTED BY U.S. BUREAU OF
CENSUS FIELD REPRESENTATIVES.
PARTICIPATION IN NHMCS IS
VOLUNTARY.
AS YOU CAN IMAGINE WITH COVID-19
PANDEMIC, IT'S BEEN VERY HARD TO
COLLECT THESE DATA.
HOSPITALS HAVE BEEN SERIOUSLY
BURDENED WITH THE PANDEMIC, AND
IT'S BEEN VERY DIFFICULT FOR US
TO GET ON SITE.
SO WE'VE HAD TO SWITCH TO
ADMINISTRATION OF HOSPITAL
INDUCTION INTERVIEW TO
TELEPHONE.
WE SWITCHED FROM IN-PERSON
ABSTRACTION TO REMOTE
ABSTRACTION FOR HOSPITALS THAT
WERE ABLE TO DO SO, AND WE ALSO
DELAYED THE DATA COLLECTION AND
LOOKING AT HOT SPOTS IN 2021.
CONSEQUENTLY, OUR DATA ARE
DELAYED FOR 2020 AND 2021, SO
I'LL ONLY BE ABLE TO PRESENT
DATA THROUGH 2019 TODAY.
SO LET'S LOOK AT SOME DATA.
AND, AGAIN, I SHOULD POINT OUT
IN THE NEXT SERIES OF SLIDES I'M
ONLY GOING TO BE HIGHLIGHTING
STATISTICALLY SIGNIFICANT
RESULTS.
IN FIGURE 1 HERE WE HAVE E.D.
VISITS PER THOUSAND PERSONS BY
PATIENT AGE.
IN 2016 AND 2017, ENCOUNTERS OF
PATIENTS WHO WERE 18-44 HAD
SIGNIFICANT HIGHER E.D. RATES
THAN THOSE AGE 45-64.
2018 AND 19 ENCOUNTERS FOR THOSE
65 AND OVER WERE SIGNIFICANTLY
HIGHER THAN RATES FOR THOSE
45-64.
HERE IN FIGURE 2 WE SHOW E.D.
RATES PER THOUSAND BY PATIENT
RACE AND ETHNICITY.
DURING 2016 AND 2019, ENCOUNTERS
OF NON-HISPANIC OTHER PERSONS
HAD THE LOWEST E.D. RATES DURING
THESE FOUR YEARS.
IN FIGURE 3 WE SHOW E.D. VISIT
RATES PER THOUSAND BY SOURCE OF
PAYMENT.
ENCOUNTERS WITH MEDICAID HAD
HIGHEST RATE OF E.D. VISITS FROM
2016 TO 2019.
THE LOWEST RATE OF E.D. VISITS
WAS CONSISTENTLY OBSERVED FOR
PATIENTS WITH PRIVATE INSURANCE.
FIGURE 4 DEPICTS E.D. RATES PER
THOUSAND BY METROPOLITAN
STATISTICAL AREA OR MSA, NO
SIGNIFICANT DIFFERENCES OBSERVED
BY MSA STATUS FOR E.D.
ENCOUNTERS IN ANY YEAR
2016-2019.
THE NEXT FOUR BAR GRAPHS DEPICT
RATES PER THOUSAND PERSONS BY
FIVE MOST COMMON REASONS FOR
VISIT FOR PRIMARY DIAGNOSIS FOR
ONLY 2019.
HERE IN FIGURE 5 ENCOUNTERS FOR
E D VISITS FOR THE FIVE MOST
COMMON ARE SHOWN.
OVERALL, THE FIVE MOST COMMON
REASONS FOR E.D. VISITS INCLUDE
STOMACH AND ABDOMINAL PAIN,
CRAMP, AND SPASMS; CHEST PAIN
AND RELATED SYMPTOMS, FEVER,
COUGH, SHORTNESS OF BREATH.
FOR STOMACH PAIN, CHEST PAIN AND
COUGH, NON-HISPANIC BLACKS HAD
THE HIGHEST RATES OF E.D.
VISITS.
FOR SHORTNESS OF BREATH,
NON-HISPANIC WHITES AND
NON-HISPANIC BLACKS HAD HIGHER
VISIT RATES THAN COMPARED TO
HISPANICS.
FIGURE 6 HERE SHOWS E.D. RATES
PER THOUSAND PERSONS FOR FIVE
MOST COMMON REASONS FOR VISIT BY
PRIMARY EXPECTED SOURCE OF
PAYMENT.
FOR STOMACH PAIN, FEVER AND
COUGH, ENCOUNTERS OF PATIENTS
WITH MEDICAID HAD THE HIGHEST
E.D. VISIT RATES.
CHEST PAIN, RATES OF ENCOUNTER
WITH MEDICAID AND MEDICARE WERE
SIGNIFICANTLY HIGHER THAN RATES
FOR PRIVATE INSURANCE AND
UNINSURED.
SHORTNESS OF BREATH MEDICARE HAD
HIGHEST VISIT RATES.
HERE IN FIGURE 7 WE ILLUSTRATE
E.D. RATES PER THOUSAND PERSONS
FOR THE FIVE MOST COMMON PRIMARY
DIAGNOSIS BY RACE AND ETHNICITY
FOR 2019.
FIVE MOST COMMON DIAGNOSES
REPORTED IN 2019 WERE SYMPTOMS,
SIGNS, ABNORMAL CLINICAL LAB
FINDINGS, INJURY POISONING,
DISEASES OF THE RESPIRATORY
SYSTEM, DISEASES OF THE
MUSCULOSKELETAL SYSTEM,
CONNECTIVE TISSUE, DISEASES OF
DIGESTIVE SYSTEM.
FOR ENCOUNTERS FOR ALL FIVE OF
THESE PRIMARY DIAGNOSES,
NON-HISPANIC BLACKS HAD THE
HIGHEST RATE OF E.D. VISITS,
NON-HISPANIC OTHER PERSONS HAD
LOWEST RATE OF E.D. VISITS.
FIGURE 8 SHOWS E.D. RATES PER
THOUSAND PERSONS FOR FIVE MOST
COMMON PRIMARY DIAGNOSES,
PRIMARY EXPECTED SOURCE OF
PAYMENT FOR 2019.
FOR SYMPTOMS AND SIGNS, INJURY
AND POISONINGS, MEDICAID HAD
HIGHEST, PRIVATE INSURANCE HAD
LOWEST.
DISEASES OF THE MUSCULOSKELETAL
SYSTEM, PATIENTS WITH MEDICARE
AND MEDICAID HAD HIGHER E.D.
VISIT RATES THAN UNINSURED,
AGAIN THOSE WITH PRIVATE
INSURANCE HAD THE LOWEST E.D.
VISIT RATES.
SINCE THE THEME OF OUR
ROUNDTABLE TODAY IS LOOKING AT
SOCIAL FACTORS, SOCIAL
DETERMINANTS OF HEALTH, I ALSO
WANTED TO INCLUDE A SLIDE ON THE
HOMELESS.
HERE IN FIGURE 9 WE SHOW E.D.
RATES HER 100 PERSONS AMONG
HOMELESS PERSONS BY PATIENT SEX,
FOR FOUR-YEAR PERIOD 2016
THROUGH 2019.
ONLY SIGNIFICANT DIFFERENCE,
HIGHER RATE OF E.D. VISITS AMONG
HOMELESS MALES VERSUS FEMALES.
OUR ESTIMATES OF E.D. VISITS BY
HOMELESS PERSONS ARE LOWER THAN
OTHER DATA SOURCES.
THIS IS A LIMITATION OR
DISADVANTAGE OF NHMCS.
THEY ARE HARDER FOR US TO SELECT
GIVEN OUR CURRENT SAMPLING
METHODS.
ALSO NHMCS DAD DATA RELY ON
WHAT'S REPORTED IN MEDICAL
RECORD FOR RESIDENCE AND
SOMETIMES DIFFICULT, WE DON'T
KNOW WHERE THAT DATA COME FROM,
AND BECAUSE THERE ARE MANY
PLACES WHERE IT COULD BE STORED
AND PLACED IN THE RECORD.
ALSO SOME PATIENTS MAY
UNDERREPORT HOMELESSNESS DUE TO
SOCIAL DESIRABILITY BIAS.
AND THIS IS A GOOD SEGUE TO TALK
ABOUT SOME EFFORTS WE'RE DOING
AT NCHS TO ENHANCE OUR E.D. DATA
THROUGH THE NATIONAL HOSPITAL
CARE SURVEY.
AND QUICKLY LET ME JUST TELL YOU
ABOUT HOSPITAL CARE.
HOSPITAL CARE PROVIDES RELIABLE
AND TIMELY HEALTH CARE
UTILIZATION DATA FOR ENCOUNTERS
IN HOSPITAL-BASED SETTINGS,
UNLIKE NHMCS THE HOSPITAL CARE
IS ALL ELECTRONIC DATA
COLLECTION, ADMINISTRATIVE
CLAIMS DATA AND ELECTRONIC
HEALTH RECORD DATA TRANSMITTED
ELECTRONICALLY.
THE DATA COLLECTION IS ANNUAL.
THE SAMPLE SIZE IS ABOUT 608
NATIONALLY REPRESENTED
HOSPITALS.
WE ASK THESE HOSPITALS TO SEND
US ALL THEIR INPATIENT AND E.D.
ENCOUNTERS.
THE SURVEY AGAIN IS ALL
VOLUNTARY.
A KEY FEATURE IS THAT PERSONALLY
IDENTIFIABLE INFORMATION IS
COLLECTED IN HOSPITAL CARE.
AND THIS ALLOWS US TO LINK
ACROSS HOSPITAL SETTINGS, SO IF
SOMEONE COMES INTO THE EMERGENCY
DEPARTMENT AND IS ADMITTED AS
INPATIENT WE CAN TRACE THAT
CARE.
WE CAN ALSO LOOK AT REPEAT
VISITS.
FINALLY WE CAN ALSO LINK TO
EXTERNAL DATA SOURCES SUCH AS
NATIONAL DEATH INDEX, HOUSED IN
NCHS, AND CMS AND HUD DATA.
WHY MOVE TO ELECTRONIC DATA
COLLECTION?
RELYING ON IN-PERSON AND MANUAL
RECORD ABSTRACTIIN HAS CHANCE,
THERE ARE CHALLENGES,
HIGHLIGHTED DURING THE COVID-19
PANDEMIC.
IT WAS VERY HARD FOR US TO GET
ON SITE, ALSO WE HAD TO BE
REALLY CONCERNED ABOUT THE
SAFETY OF THE HOSPITAL STAFF AS
WELL AS OUR CENSUS FRs.
ELECTRONIC DATA COLLECTION
ALLOWS FOR MORE TIMELY RELEASE.
WE CAN OBTAIN LARGER VOLUME OF
VISITS WITH MORE CLINICAL DEATH
WHEN COLLECTING DATA.
I'LL HIGHLIGHT THREE EXAMPLES
HOW THIS HAS INCLUSIVE CREASED
UTILITY OF OUR E.D. DATA THROUGH
PRELIMINARY RELEASE OF DATA,
DATA LINKAGE, USE OF
UNSTRUCTURED DATA.
THE COLLECTION OF ELECTRONIC
HEALTH DATA HAS ALLOWED FOR
RELEASE OF PRELIMINARY DATA FOR
50 HOSPITALS, ON IMPACT OF
COVID-19, INPATIENT AND E.D.
SETTINGS.
THESE DATA ARE NOT NATIONALLY
REPRESENTATIVE, THEY PROVIDE
IMPORTANT INSIGHT INTO WHAT IS
HAPPENING WITH COVID-19 IN SOME
HOSPITALS ACROSS THE COUNTRY.
THIS SHOWS TYPE OF DATA THAT WE
HAVE AVAILABLE BY WEEK FROM
MARCH 2020 THROUGH SEPTEMBER
2021.
AGAIN, THIS IS SOMETHING THAT WE
CAN'T DO WITH NHMCS.
ON THIS SLIDE THE PRELIMINARY
HOSPITAL AVAILABLE, THIS SLIDE
SHOWS PERCENTAGE OF E.D.
ENCOUNTERS WITH CONFIRMED
COVID-19 STAT FROM US COLLECTED
HOSPITALS BY HOSPITAL URBAN
RURAL LOCATION AND WEEK.
THESE DATA FROM MARCH 2020
THROUGH SEPTEMBER 2021, THE DATA
ARE AVAILABLE FOR DOWNLOAD.
UNLIKE NHMCS DATA, THE HOSPITAL
CARE DATA HAVE BEEN LINKED TO
EXTERNAL SOURCES.
WE'VE LINK LTD TO THE NATIONAL
DEATH INDEX, CENTERS FOR
MEDICARE AND MEDICAID DATASETS,
HOUSING AND URBAN DEVELOPMENT
DATA.
WE'RE LINKING TO MEDICARE AND
VETERANS AFFAIRS DATA.
THIS SHOULD HELP WITH SOCIAL
DETERMINANTS OF HEALTH RESEARCH,
INPATIENT AND E.D. HOSPITAL USE
BY INCREASING NUMBER OF RELEVANT
VARIABLES AVAILABLE TO PROVIDE
CONTEXT.
ALSO, FOR HOSPITALS SUBMITTING
EHR DATA TO THE SURVEY THEY HAVE
INCLUDED UNSTRUCTURED DATA,
THESE HAVE BEEN USED TO ENHANCE
ELEMENTS PROVIDING ADDITIONAL
INFORMATION.
USE OF NATURAL LANGUAGE
PROCESSING HELPS IN DEVELOPMENT
OF ALGORITHMS IN OPIOID AND
CO-OCCURRING DISORDERS, HOPING
SIMILAR APPROACHES MAY BE USED
TO CAPTURE SOCIAL DETERMINANTS
OF HEALTH ELEMENTS WITHIN THESE
STRUCTURED DATA.
I PROVIDED LINKS FOR MORE
INFORMATION ON NHAMCS, AND MORE
ABOUT THE DATA THROUGH THE NCHS
RESEARCH DATA CENTER.
THANK UP FOR YOUR TIME TODAY.
>> THANK YOU.
THERE'S A LOT OF INFORMATION AND
DATA AND NUMBERS.
FASCINATING.
THANK YOU.
NOW I WOULD LIKE TO INTRODUCE
CORYCNE PERHATS WORKING TO
ADVANCE PROFESSION THROUGH
RESEARCH AND EVIDENCE-BASED
POLICIES AND PRACTICE.
SHE WILL INTRODUCE THE NEXT TWO
SPEAKERS.
THANK YOU.
>> THANK YOU, DR. YOON.
GOOD MORNING, EVERYONE.
THIS SECTION IS GOING TO HAVE
SPEAKERS ADDRESSING SPECIFIC
SOCIAL NEEDS TO PROVIDE
CONTEXTUALIZED, PERSON-FOCUSED
CARE IN THE EMERGENCY
DEPARTMENT.
DR. ANDREA WALLACE IS ASSOCIATE
PROFESSOR AND ASSOCIATE DEAN FOR
RESEARCH AT UNIVERSITY OF UTAH
COLLEGE OF NURSING.
A PRIMARY OBJECTIVE OF DR.
WALLACE'S RESEARCH IS DESIGNED
HIGH-QUALITY CHRONIC HEALTH CARE
SERVICE INTERVENTIONS AIMED AT
NARROWS GAPS IN CLINICAL
OUTCOMES WITH EMPHASIS ON
UNDERSTANDING HOW THESE
INTERVENTIONS CAN BE FEASIBLY
ADMINISTERED DURING ROUTINE
SERVICE DELIVERY.
MOST RECENTLY, AHRQ AND
NIH-FUNDED RESEARCH PROGRAM HAS
FOCUSED ON HOW TO BEST COUNT FOR
PATIENT SOCIAL DETERMINANTS OF
HEALTH DURING INPATIENT AND E.D.
DISCHARGE PLANNING.
AS WELL AS PART OF COVID-19
TESTING.
DR. EMELIA DE MARCHIS IS A
FAMILY PHYSICIAN, HEALTH
SERVICES RESEARCHER, UNIVERSITY
OF CALIFORNIA, SAN FRANCISCO.
HER RESEARCH IS BASED OUT OF THE
UCSF SOCIAL INTERVENTION
RESEARCH AND EVALUATION NETWORK,
ALSO KNOWN AS SIREN, SHE WORKS
TO ASSESS AND IMPROVE HOW WE
SCREEN FOR AND ADDRESS SOCIAL
RISK FACTORS WITHIN HEALTH CARE
SETTINGS.
SHE USES IMPLEMENTATION SCIENCE
METHODS, INTO ACTIVITIES IN REAL
WORLD SETTINGS.
THROUGH HER RESEARCH AND
CLINICAL PRACTICE SHE HOPES TO
ADVANCE THE HEALTH CARE SYSTEM'S
INTEGRATION OF PATIENT SOCIAL
RISK DATA TO PROVIDE HIGH
QUALITY PATIENT CENTERED
PREVENTIVE HEALTH CARE TO REDUCE
HEALTH DISPARITIES.
DR. CRAIG POLLACK IS KATY AYRES
ENDOWED PROFESSOR, DEPARTMENT OF
HEALTH POLICY AND MANAGEMENT,
JOHNS HOPKINS BLOOMBERG SCHOOL
OF PUBLIC HEALTH AND SCHOOL OF
NURSING.
HE IS A PRACTICING PRIMARY CARE
PHYSICIAN, RESEARCH FOCUSES ON
SOCIAL DETERMINANTS OF HEALTH
WITH EMPHASIS ON HOUSING POLICY.
IN A CURRENT NIH-FUNDED RESEARCH
STUDY HE'S INVESTIGATING THE
HEALTH EFFECTS OF HOUSING
MOBILITY PROGRAMS THAT HELP
FAMILY MOVE TO RESOURCED
RESOURCED NEIGHBORHOODS,
PART-TIME SENIOR RESEARCH
ADVISER IN OFFICE OF POLICY
DEVELOPMENT AND RESEARCH AT THE
U.S. DEPARTMENT OF HOUSING AND
URBAN DEVELOPMENT.
PLEASE JOIN ME IN WELCOMING
DOCTORS WALLACE, DE MARCHIS AND
POLLACK, WHO WILL SPEAK EACH FOR
15 MINUTES AND AGAIN WE'RE
REQUESTING THAT YOU HOLD
QUESTIONS FOR THE PANEL
DISCUSSION.
PLEASE ENTER THEM IN THE CHAT.
DURING THE BREAK WE'LL MAKE THE
QUESTIONS AVAILABLE FOR THE
PANEL MODERATOR.
DR. WALLACE, WELCOME.
PLEASE BEGIN YOUR PRESENTATION.
>> ALL RIGHT.
HOPEFULLY YOU CAN SEE WHAT I
SEE.
IT'S AN HONOR TO PRESENT THIS
WORK.
NOTHING I PRESENT TODAY IS DONE
WITHOUT HELP FROM COLLABORATORS,
COMMUNITY PARTNERS AT UTAH 211
AND STAFF.
THIS WORK WAS FUNDED BY AHRQ AND
BY NINR.
I HAVE NO CONFLICTS TO DISCLOSE.
I SHOW THIS MAP, WHAT INSPIRES
OUR WORK RELATED TO SOCIAL
DETERMINANTS AT A LOCAL AND
PERSONAL LEVEL.
THIS IS A MAP OF NEIGHBORHOODS
IN URBAN SALT LAKE CITY, UTAH,
WHERE UNIVERSITY OF UTAH IS
LOCATED.
LIFE EXPECTANCY BASED WHERE A
PATIENT RESIDES, MORE HOMOGENOUS
AVENUES HAS A LIFE EXPECTANCY
TEN YEARS LONGER THAN THOSE
LIVING ONLY A FEW BLOCKS
DOWNHILL IN CENTRAL DOWNTOWN
WHERE RESIDENTS EXPERIENCE
HOUSING INSTABILITY AND FOOD
INSECURITY.
WE'VE LONG KNOWN THIS AFFECTS
HEALTH AND WELL BEING.
HOWEVER, THE IDEA THAT SOCIAL
DETERMINANTS CAN AND SHOULD BE
ADDRESSED BY HEALTH SYSTEMS
CAUGHT NATIONAL ATTENTION WITH
AWARENESS OF CAMDEN COALITION
EXPLAINED HERE IN THIS FAMOUS
2011 NEW YORKER PIECE.
THE IDEA WAS THAT BY HOT
SPOTTING HEALTH SERVICE SUPER
UTILIZERS SOME HAD UP TO 100
E.D. VISITS ANNUALLY, ADDRESSING
SOCIAL NEEDS, WE CAN DECREASE
UNNECESSARY HEALTH CARE RESOURCE
USE, REDUCE COST, IMPROVE
OUTCOMES.
IT TOOK A DECADE TO TEST THIS
IDEA WITH RCT, SOCIAL SERVICE
SOLUTIONS WERE OFFERED TO THOSE
IDENTIFIED AS HEALTH CARE
SUPER-UTILIZERS, UNFORTUNATELY
RESULTS WERE DISCOURAGING,
OFFERING SERVICES DID NOT RESULT
IN SIGNIFICANT COST SAVINGS.
SO WHERE DOES THAT LEAVE US?
SHOULD WE ABANDON?
WE SHOULDN'T.
THERE ARE MANY IDEAS WERE IT
CONFLICTED WITH CONVENTIONAL
WISDOM HOW SOCIAL DETERMINANTS
WORK.
I WANT TO USE THESE TO POINT OUT
HOW THIS DISTINGUISHES OUR
WORK.
A KEY REALIZATION IS ALL
PATIENTS COME IN TO HEALTH CARE
SETTINGS WITH SOCIAL FACTORS
IMPACTING HEALTH AND THEY CHANGE
OVER TIME.
ISOLATION CAN AFFECT POPULATIONS
REGARDLESS OF HOW MUCH THEY HAVE
USED SERVICES.
AS WE KNOW SOCIAL NEEDS POSE
BARRIERS TO ACCESSING SERVICES
SO FOCUSING ONLY ON THOSE USING
SERVICES DOESN'T ALLOW US TO
FULLY UNDERSTAND OR ADDRESS
SOCIAL NEEDS AND MAY REINFORCE
INEQUITIES.
AND DEMONSTRATING CLINICAL
EFFECTIVENESS AND COST SAVINGS
IS EXTREMELY DIFFICULT TO DO BY
FOCUSING ONLY ON THOSE LABELED
AS HIGH SERVICE UTILIZERS.
AS SUCH WE HAVE FOCUSED ON IDEA
OF UNIVERSALLY SCREENING FOR
SOCIAL NIGHTS, TRANSPORTATION,
HOUSING, FOOD, CHILD CARE,
VERSUS ONLY ON THOSE WHO USE
MANY SERVICES.
SECOND DRIVER FOR US IS WE SEE
THAT OUR HEALTH SYSTEMS ARE IN A
CRITICAL JUNCTURE.
WE HAVE AN OPPORTUNITY IN THIS
WORK, HEALTH SYSTEMS ARE RAPIDLY
ADOPTING PRACTICES AND WE LITTLE
EVIDENCE.
WE'RE PASSIONATE ABOUT BUILDING
EVIDENCE.
A KEY CHALLENGE IS HOW DO WE DO
THIS?
CAROL TALKED EARLIER, IT REALLY
IS DIFFICULT DATA TO COLLECT.
IN ROUTINE CARE WE RELY ON
ELECTRONIC HEALTH RECORDS, WE
KNOW LITTLE ABOUT PATIENT SOCIAL
CIRCUMSTANCES.
WE'RE OFTEN LEFT WITH HAPHAZARD
PROXY SUCH AS INSURANCE STATUS,
RESIDENTIAL ZIP CODE,
AVAILABILITY OF EMERGENCY
CONTACTS.
WE'VE BEEN LEFT WITHOUT
UNDERSTANDING HOW TO ADDRESS
SOCIAL NEEDS AND DON'T HAVE A
FIRM UNDERSTANDING OF THE
MECHANISMS BY WHICH NEEDS AND
SERVICES AFFECT HEALTH OUTCOMES.
OVER THE PAST SEVERAL YEARS THE
CHALLENGE OF UNDERSTANDING
SOCIAL NEEDS STARTED A NATIONAL
CONVERSATION OF HOW TO INTEGRATE
SOCIAL INFORMATION IN E HRs,
ALMOST DAILY WE HAVE NEW MODULES
AVAILABLE.
THOUGHT LEADERS AS IN THIS
PUBLICATION IN 2016 CAUTIONED US
SOCIAL NEEDS SCREENING MAY COME
WITH STIGMA AND COULD REINFORCE
HEALTH INEQUITIES IF
IDENTIFICATION ISN'T ACCOMPANIED
BY INTERVENTION.
SO, WITH THIS, OUR RESEARCH
RECOGNIZES THAT THIS REQUIRES
SCREENING APPROACHES IN CLINICAL
WORK FLOW.
SECOND, REQUIRES MEANS OF
COMMUNICATING INFORMATION TO
CLINICAL TEAMS IN A WAY THAT
INFORMS CLINICAL DECISION
MAKING.
THIRD, REQUIRES LINKING PATIENTS
WITH RESOURCES THAT CAN MEET
NEEDS AT HOME.
WE NEED TO RECOGNIZE WE CAN
START THE PROCESS, ADDRESSING
THOSE NEEDS REQUIRES COMMITMENT
AND CONNECTIONS FAR BEYOND
SCREENING AND CLINICAL
ENCOUNTER.
SO WITH THAT, OUR PURPOSE
STARTED IN 2017, TO DEVELOP
MEANS OF IDENTIFYING SOCIAL
NEEDS THAT CAN BE USED IN
ROUTINE CARE.
WHEN THE WORK ISN'T NECESSARILY
SUPPORTED BY DEDICATED RESEARCH
STAFF, TO FACILITATE ACCESS TO
RESOURCES AND INTEGRATE DATA, TO
DATE WE'VE SCREENED 10,000 E.D.
PATIENTS.
OUR WORK IS GROUNDED IN A
PARTNERSHIP WITH UTAH 211, PART
OF A NATIONAL NETWORK OF
COMMUNITY SERVICE REFERRAL
CENTERS THAT OFFER CONNECTIONS
AND LOW COST ASSISTANCE PROGRAMS
FOR FOOD AND HOUSING, AND TO ALL
THOSE WHO CALL.
OR VIA INTERNET OR TEXT.
OVERVIEW OF HOW WE'VE DONE THIS
IS QUITE SIMPLE.
USING LOW COST READILY AVAILABLE
HIPAA COMPLIANT TOOLS, REDCap
IN THIS CASE, E.D. REGISTRATION
STEMS USE THE VALIDATED TEN ITEM
SCREENER, THE CITATION IS
INCLUDED HERE TO THE RIGHT.
WE REFER THOSE WHO HAVE NEEDS
AND WANT OUTREACH TO 211
SPECIALISTS WHO CONTACT VIA
PHONE, TEXT, E-MAIL WITHIN 48
HOURS OF DISCHARGE AND COMPILE
DATA FROM INSIDE AND OUTSIDE
HEALTH SYSTEM TO UNDERSTAND
NEEDS AND COMMUNITY OUTREACH
PROCESS.
PARTNERSHIP WITH 211 WHICH HAS
ROBUST ENCOUNTER AND RESOURCE
DATABASES ALLOWED US TO DO THIS.
OF COURSE, THIS IS DISPLAYED
DIFFERENTLY ON TOUCH PADS BUT
THIS IS A VISUAL OF WHAT IS
ADMINISTERED.
ON THE LEFT ARE QUESTIONS FROM
THE SCREENER, ON THE RIGHT
INFORMATION GATHERED FROM THOSE
WHO WOULD LIKE TO BE CONTACTED
BY 211 FOR SERVICE CONNECTIONS.
AND WE'VE GATHERED A LOT OF DAFT
ALONG THE WAY AND CONTINUE TO
GATHER DATA.
QUANTITATIVE AND QUALITATIVE
INFORMATION FROM PATIENTS,
STAFF, 211 SPECIALISTS TO
UNDERSTAND THE CHALLENGES AND
IMPLICATIONS OF INTEGRATING
SOCIAL NEEDS SCREENING INTO
CLINICAL SYSTEMS.
SO, LET'S TALK ABOUT NUMBERS OF
WHAT WE'VE SEEN FROM THIS WORK.
IN A STUDY FUNDED BY AHRQ WE
SCREENED PATIENTS FOR SOCIAL
NEEDS OVER 15 MONTHS AND FOCUSED
ON EVALUATING EFFORTS USING
IMPLEMENTATION SCIENCE APPROACH.
WE FOLLOWED THE NUMBER OF
PATIENTS APPROACHED, COMPLETED
SCREENINGS, POSITIVE SCREENINGS
AND REFERRALS TO UNDERSTAND THE
IMPACT.
AND HERE WE SHOW WHAT MIGHT
EXPECTING WITHOUT DEDICATED
STAFF.
ABOUT 10% OF POTENTIAL
DISCHARGES ARE APPROACHED FOR
SCREENING BY STAFF.
THE GOOD NEWS IS THAT THE
SCREENING IS EASY TO COMPLETE,
IT TOOK ONE MINUTE, MOST
FINISHED THE QUESTIONS, WE HAD
FEW TECHNICAL DIFFICULTIES.
NOW FOR THE OTHER NEWS.
WE SAW AND CONTINUE TO SEE OVER
40% OF PATIENTS SCREENED IN OUR
EFFORT E.D. HAVE MORE THAN ONE
NEED.
BUT LESS THAN HALF WANT
OUTREACH.
OF THOSE WHO WANT OUTREACH, ONLY
30% CONNECT WITH 211 FOR HELP.
IN THE END ABOUT 10% OF THOSE
WHO STATED THEY HAVE SOCIAL
NEEDS ENGAGED WITH 211 TO GET
HELP.
AND HERE WE SEE THE BREAKDOWN OF
STATED NEEDS FROM THE MOST TO
LEAST COMMON.
KNOW THESE AREN'T MUTUALLY
EXCLUSIVE.
IN OUR ANALYSIS IT'S IMPORTANT
TO NOTE THE NEEDS AT THE TOP,
UTILITIES, MORTGAGE OR
REPRESENTATIVE, HOUSEHOLD ITEMS
OR FOOD DROVE DESIRE FOR
OUTREACH.
EVEN AFTER THE RESEARCH STUDY
STOPPED, STAFF MAINTAINED
SCREENING AND SAW AVAILABLE
SERVICES AVAILABLE WITH A GREAT
DEGREE OF VARIABILITY.
THIS IS WHY WE CONTINUE DOING
THIS WORK.
HERE'S ONE EXAMPLE OF NOTES
SUMMARIZED FROM THE SPECIALIST.
IN HER INITIAL CALL SHE WROTE, I
SPOKE WITH PATIENT'S DAUGHTER
WHO MENTIONED MOTHER NEEDS HELP
WITH MEALS AND TRANSPORTATION TO
APPOINTMENTS WHEN SHE'S NOT
AVAILABLE.
I PROVIDED A LITS OF RESOURCES
AND WILL FOLLOW UP.
TWO WEEKS LATER, I SPOKE WITH
THE PATIENT.
SHE MENTIONED SHE NOR HER
HUSBAND SPEAK ENGLISH, 83 YEARS
OLD, HER HUSBAND IS 92, DAUGHTER
HELPS BUT IS BUSY JUGGLING
SCHOOL AND WORK BUT BECAUSE OF
THE BUSY SCHEDULE HER DAUGHTER
WAS UNABLE TO CONTACT RESOURCES.
I WAS ABLE TO CONNECT THE
PATIENT WITH AGING AND ADULT
SERVICES, AND HELPED COMPLETE
THE PHONE APPLICATION FOR
PROGRAMS, STARTING NEXT WEEK
THEY WILL RECEIVE MEALS AND
TRANSPORTATION.
THIS IS WHY WE DO THIS WORK.
SO, FROM THE NUMBERS, WE CAN
SCREEN AND MAKE CONNECTIONS IN A
QUICK AND COST EFFECT ITCHIVE
BUT IN ROUTINE CARE HAD DROPS
BETWEEN THOSE WITH NEEDS AND WHO
GET HELP ULTIMATELY.
NOW WHAT DID ALL THE QUALITATIVE
DATA TELL US ABOUT WHERE TO GO
WITH THIS IF WE WANT SOCIAL
NEEDS SCREENING TO BE EFFECTIVE
IN OUR HEALTH SYSTEM.
DESPITE SCRIPTING AND TRAINING,
WE FOUND A LOT OF DISCOMFORT
FROM STAFF ABOUT ASKING WHAT
THEY DO TO STIGMATIZING
QUESTIONS AND PROFILE, DETERMINE
WHO TO SCREEN BAILED ON CLOTHING
OR EMPLOYMENT, THE STAFF WHO SAW
THIS AS A TOOL FOR ENGAGING AND
FELT THEY HAD AN IMPORTANT ROLE
IN THE LARGER CLINICAL TEAM WERE
MORE INCLINED TO SCREEN PATIENTS
FOR SOCIAL NEEDS.
PATIENT FOCUSED GROUPS
UNDERSTAND HEALTH CARE PROVIDER
MAY NOT ADDRESS ALL THEIR NEEDS
AND PREFER NURSES TO DO
SCREENING THEY ARE HOPE TO
SCREENING BY OTHER TEAM MEMBERS
AS LONG AS IT'S DONE WITH
SINCERITY AND UNIVERSALLY.
THEY DON'T WANT TO BE SINGLED
OUT AND ASKED QUESTIONS.
THEY RECOMMEND QUESTIONS BE
ACCOMPANIED WITH CLEAR
EXPLANATION OF WHY THEY ARE
BEING ASKED.
SOMETHING WE DIDN'T FULLY
EXPECT, PATIENTS COMMUNICATED
THEY DID NOT WANT THIS
INFORMATION TO BE IN THEIR EHR
FOR FEAR OF BEING LABELED AND
TREATED DIFFERENTLY AND VOICED
CONCERNS ABOUT PRIVACY.
AS WE CONTINUE EXPLORING ALL
THESE TOOLS TO MAKE IT EASY TO
DOCUMENT CLINTON CAT SETTINGS WE
NEED TO BETTER UNDERSTAND HOW TO
MAKE EFFORTS PATIENT CENTERED
AND REDUCING HEALTH INEQUITIES.
AND WE CONTINUE TO DO MORE WORK.
THESE AREAS ARE ALSO IN REVIEW
BUT DATA SHOWS IT'S AS IMPORTANT
TO FOCUS ON MULTIPLE NEEDS VERSE
U. -- VERSUS ONE AREA.
IF THERE'S ONE QUESTION TO ASK,
MAYBE TO ASK WHAT WHETHER
PATIENT HAS ACCESS TO STABLE
TELEPHONE NUMBER.
MORE ON THAT SOON.
AND FROM WHAT WE'RE SEEING,
EXAMINING ENGAGEMENT IN PATIENT
OUTCOMES, SCREENING LOCATION AND
METHODS MATTER.
HOW WE DO THE SCREENING RESULTS
IN DIFFERENCES IN DESIRE FOR
OUTREACH, THOSE WHO INTERACT VIA
MY CHART WITH DIFFERENT THAN
THOSE WHO SCREEN WELL IN THE
E.D.
WE NEED TO CONSIDER HOW AND
WHERE WE SCREEN.
SO WHERE TO NEXT WITH ALL THIS?
WE'RE FOCUSING ON EXPANDING
REFERRALS TO UNDERSTAND HOW TO
REACH THOSE IMPACTED BY COVID-19
AND 19, TESTING METHODS CENTERED
ON PATIENT PROBLEM SOLVING,
MEASURING PATIENT CENTERED
OUTCOMES AND TARGETING
MOTIVATION OF STAFF ENGAGED IN
SCREENING.
I KNOW THIS IS A LOT TO TAKE IN.
THIS WORK HAS MANY COMPONENTS,
BUT THE KEY TAKEAWAYS WE HAVE
AVAILABLE TOOLS, OUR APPROACH OF
WORKING WITH E.D. REGISTRATION
STAFF IS ONE OF MANY APPROACHES
THAT COULD BE USED.
OUR RESEARCH FINDINGS UNCOVER
CAVEATS IF IT IS TO BE A
SOLUTION FOR ADDRESSING HEALTH
INEQUITIES.
THANK YOU VERY MUCH FOR YOUR
TIME TODAY.
>> THANK YOU, DR. WALLACE.
DR. DE MARCHIS, WE'RE READY FOR
YOU.
>> THANK YOU SO MUCH.
CAN EVERYONE SEE MY SCREEN?
THANK YOU FOR THAT INTRODUCTION.
THANK YOU, DR. WALLACE, FOR YOUR
TALK.
IT HAS A LOT OF OVERLAP WITH A
LOT OF WORK WE'RE DOING.
IT WAS EXCITING TO SEE THE WORK
FROM UNIVERSITY OF UTAH.
PSOAS HAS BEEN MENTIONED I'M
ASSISTANT PROFESSOR AT THE
UNIVERSITY OF CALIFORNIA, SAN
FRANCISCO.
AND OVER THE PAST DAY, DAY AND A
HALF WE'VE BEEN HEARING GREAT
TALKS ON INTEGRATION OF SOCIAL
CARE AND IT'S BEEN AMAZING TO
SEE AND LEARN MORE ABOUT EFFORTS
TO REDUCE INEQUITIES.
I'M GOING TO TALK IN THIS
SESSION ABOUT BACKGROUND AND
LITERATURE ON PATIENT INTEREST
AND ASSISTANCE AND WORK AT
SIREN, SOCIAL INTERVENTIONS
RESEARCH AND EVALUATION NETWORK,
ON THIS TOPIC.
NO DISCLOSURES.
I'D LIKE TO ACKNOWLEDGE THE
PRIMARY FUNDER, THE COMMONWEALTH
FUND, AND SIREN, SOME RESEARCH I
DID HAD BEEN DURING UCSF PRIMARY
CARE RESEARCH FELLOWSHIP.
SO WE'VE HEARD THERE'S BEEN
MOUNTING EVIDENCE OF THE IMPACT
OF SOCIAL RISK FACTORS TO HEALTH
AND EMERGENCY CARE.
THERE'S BEEN A POLICY PUSH TO
INTEGRATE SOCIAL RISK SCREENING,
THIS IS SOME ORGANIZATION THAT
HAVE SUPPORTED INTERNAL CARE
INTEGRATION.
IN THE 2019 NASEM REPORT
PROVIDED A FRAMEWORK TO
INTEGRATE SOCIAL AND MEDICAL
CARE, 5A FRAMEWORK, INCLUDING
AWARENESS OF THE SCREENING FOR
SOCIAL RISK, ACCOMMODATING IN
CARE WE DELIVER, ASSISTANCE, THE
PROVISION, AND COMMUNITY FOCUSED
STRATEGIES OF ADVOCACY AND
ALIGNMENT.
THE ENTHUSIASM FOR INTEGRATING
SOCIAL MEDICAL CARE IS BASED ON
THE GROWING EVIDENCE BASE
SUGGESTING AWARENESS AND EFFORTS
TO ADDRESS THEM CAN IMPROVE
HEALTH AND WELLNESS.
AND FROM THAT AWARENESS ONE OF
THE AVENUES FOR INTERVENTION IS
FOCUSED ON THE SYSTEM, THE
ACTUAL INTERVENTION TO ASSIST
WITH SOCIAL RISK FACTORS.
THERE'S GROWING EVIDENCE THAT
STRATEGIES TO ASSIST PATIENTS
WITH SOCIAL RISKS CAN IMPROVE
THEIR HEALTH AND WELLNESS AND
DECREASE UTILIZATION, BUT IMPACT
AS WE'VE BEEN HEARING AS WELL AS
BEST PRACTICESES FOR THEIR
IMPLEMENTATION ARE STILL
ACTIVELY BEING STUDIED.
WE KNOW SCREENING FOR SOCIAL
RISKS IS ONE STEP IN THE PROCESS
TOWARDS ASSISTING PATIENTS WITH
SOCIAL RISKS.
THERE HAVE BEEN DIFFERENT WAYS
RESEARCHERS DESCRIBED CASCADE OF
EVENTS THAT NEED TO OCCUR FROM
AWARENESS TO ACTUAL REDUCTION IN
RISK RESOLUTION, AS DR. WALLACE
MENTIONED REFERRED TO AS VOLTAGE
DROP.
THIS FIGURE IS MEANT TO
REPRESENT STEPS FROM A PATIENT
BEING IDENTIFIED AS HAVING A
SOCIAL RISK FACTOR TO WHETHER
THEY HAVE HAD THAT RISK RESOLVED
OR IMPROVED UPON BAILED ON THE
HIV CASCADE, NOT INTENDED TO
REPRESENT NUMBERS OR LEVELS
WITHIN EACH OF THESE BOXES.
IT SERVES AS VISUAL OF THE
MULTIPLE STEPS WHICH PATIENTS
MAY BE LOST TO FOLLOW-UP, MAYBE
DISINTERESTED IN ASSISTANCE,
UNABLE TO ACCESS SERVICES, NOT
ALL OF THESE STEPS MAY BE
REQUIRED OR REPRESENTED,
DEPENDING ON TYPE OF ASSISTANCE
BEING OFFERED OR ACCESSED AND
STEPS MAY OCCUR IN DIFFERENT
ORDERS.
I'M GOING TO FOCUS ON THIS RED
BOX THAT PATIENTS ACCEPTING AN
OFFER OF ASSISTANCE OR BEING
INTERESTED THROUGH THE HEALTH
CARE TEAM.
THERE'S BEEN INCREASE IN
RESEARCH REPORTING ON PATIENTS
SOCIAL RISK SCREENING, COMMON
FIND BE HAS BEEN AS DR. WALLACE
NOTED LOWER THAN ANTICIPATED
PATIENT INTEREST IN THE
ASSISTANCE WITH SOCIAL RISK
FACTORS.
THIS RANGE IN INTEREST IN
ASSISTANCE IN THOSE WHO SCREEN
POSITIVE AS LOW AS 0% TO 100%
DEPENDING ON THE CONTEXT AND
RISK FACTOR.
SO A BIG CHALLENGE FOR THIS WORK
IS WE'RE NOT ALL REPORTING THE
SAME DENOMINATORS AND THE LEVEL
OF INFORMATION TO COMPARE ACROSS
THE STUDIES.
AND STUDIES AREN'T ALL MEASURING
THE SAME THING.
IT'S HARD TO EXTRAPOLATE.
SOME MIGHT REPORT ON WHETHER
PATIENTS REQUEST OR WHETHER THEY
ACCEPT AFTER ASSISTANCE IS
OFFERED.
AND ONCE A PATIENT KNOWS MORE
ABOUT THE RESOURCE BEING OFFERED
THEY MAY BE MORE OR LEST APT TO
BE INTERESTED BASED ON PRIOR
EXPERIENCES AND COMPETING
DEMANDS AND INTERESTS, WHICH IS
ALSO INFLUENCED BY WHETHER
ASSISTANCE BEING OFFERED IS
INFORMATIONAL SUCH AS HAND
THROUGHOUT OR LIST OF RESOURCES
VERSUS ACTIVE NAVIGATION SUPPORT
OR RESOURCES OFFERED BY THE
HEALTH SYSTEM.
OF 22 ARTICLES WE'VE REVIEWED,
MORE IN A SCOPING REVIEW, THE
BULK DO COME FROM PRIMARY CARE,
ALSO EMERGENCY DEPARTMENTS.
16 STUDIES REPORTED WHETHER
PATIENTS ACCEPTED AN OFFER,
EIGHT WENT TO DISCUSS WHETHER OR
NOT THE PATIENTS CONTACTED OR
CONNECTED, WHETHER A PATIENT
ENROLLED, ONLY ONE WHETHER
PATIENT SOCIAL NEEDS IMPROVED
THROUGH THE PROCESS.
AND THERE'S ALSO CONSIDERABLE
VARIATION IN WHO IS OFFERED
ASSISTANCE, WHETHER ALL-COMERS
VERSUS ONLY THOSE WHO SCREEN
POSITIVE FOR SOCIAL RISK FACTOR,
ONLY THOSE OR ANYONE WHO DID THE
SCREENING TOOL, COMPLETED THE
SCREENING TOOL.
SO IT'S OVERLAPPING AREA THAT'S
PRESENTED CONFUSION FOR
RESEARCHES, RAISING CONCERN
WHETHER THERE'S POTENTIAL TO
WORSEN DISPARITIES IF THERE'S
SPECIFIC PATIENT CHARACTERISTICS
DRIVING INTEREST IN ASSISTANCE
AND ACCEPTANCE OF THE
ASSISTANCE.
SHIFTINGGEARS, YOU MAY BE AWARE
IN 2017 THE CENTER FOR MEDICARE
MEDICAID PUBLISHED A SCREENING
TOOL.
THE PROGRAM REQUIRES SCREENING
FOR FIVE SOCIOECONOMIC DOMAINS,
HOUSING, STABILITY AND QUALITY,
TRANSPORTATION ACCESS,
UTILITIES, FOOD SECURITY, AND
PERSONAL SAFETY.
SO PART OF A LARGE STUDY FOCUSED
ON PATIENT ACCEPTABILITY OF
SCREENING WE ALSO ASK PATIENTS
IF THEY WOULD BE INTERESTED IN
ASSISTANCE WITH ANY OF THE FIVE
SOCIAL RISK DOMAINS REGARDLESS
OF SCREENING RESULTS.
RESPONSE OPTIONS INCLUDED
ASSISTANCE WITH HOUSING, FOOD
ACCESS, MEDICAL OR NON-MEDICAL
TRANSPORTATION, ELECTRIC GAS OIL
OR WATER UTILITY SERVICES OR
SAFETY OR VIOLENCE IN THE
HOUSEHOLD OR NONE OF THESE.
AS A SECONDARY ANALYSIS, AS
RELATED TO RESPONSE TO SOCIAL
RISK SCREENING TOOL.
THE GOAL TO UNDERSTAND THE
CONTRIBUTORS TO INTEREST IN
ASSIST ASSISTANCE IN
CAREGIVERS.
DATA FROM 11 CLINICAL SITES,
INCLUDING FOUR FAMILY MEDICINE,
THREE INTERNAL MEDICINE, TWO
GENERAL EMERGENCY DEPARTMENTS,
TWO PEDIATRIC FOCUSED EMERGENCY
DEPARTMENTS.
BLUE ARE CMMI HEALTH COMMUNITY
SITES, STARS INDICATE OUR SITES,
NONE WERE TAKING PART BY DESIGN
IN THE ACTUAL DEMONSTRATION
PROJECT.
EACH RECRUITED 100 ENGLISH OR
SPANISH SPEAKING PATIENTS OR
CAREGIVERS.
WE HYPOTHESIZE INTEREST WOULD
VARY BASED ON SEVERAL PATIENT
CHARACTERISTICS INCLUDING BURDEN
OF SOCIAL RISKS, PRIOR EXPOSURE
TO SOCIAL RISK SCREENING, TRUST
IN CLINICIAN, BEING SURVEYED IN
A SAFETY NET SETTING, EXPERIENCE
OF DISCRIMINATION WITHIN A
HEALTH CARE SETTING.
THIS TABLE OUTLINES PARTICIPANT
DEMOGRAPHICS, PREDOMINANTLY
FEMALE AND ADULT PATIENT
RESPONDENTS.
PRIMARILY ENGLISH SPEAKERS.
AND THIS IS THE RESPONSE TO THE
SOCIAL RISK SCREENING QUESTIONS.
WE HAD ABOUT 5 2% SCREENING
POSITIVE FOR HOUSING, 40% FOOD
INSECURITY, 20% TRANSPORTATION,
13% UTILITIES, 2% PERSONAL
SAFETY.
AND BOTTOM NUMBER OF SOCIAL
RISKS, 35% WITH NO IDENTIFIED
RISK VERSE U.S. 17% HAVING THREE
OR MORE.
THIS GRAPH SHOWS RATES OF
INTEREST IN ANY ASSISTANCE WITH
ONE OR MORE SOCIAL RISK DOMAINS
BASED ON NUMBER OF DOMAINS
SCREENING POSITIVE FOR.
I WANT TO HIGHLIGHT TWO
FINDINGS.
ONE, WE DO SEE INCREASE IN
INTEREST IN ASSISTANCE AS NUMBER
OF POSITIVE RISK DOMAINS
INCREASES.
AMONG THOSE WHO SCREENED
NEGATIVE FOR ALL FIVE INTEREST
WAS LOW BUT THERE WAS STILL
ALMOST 10% REPORTING INTEREST IN
THE ASSISTANCE.
OVERALL THOSE SCREENING POSITIVE
FOR ONE OR MORE RISK FACTORS,
53% INTERESTED IN THE
ASSISTANCE, ONE OR MORE OF
SOCIAL RISK DOMAINS.
THIS NEXT GRAPH SHOWS DOMAIN
SPECIFIC INTEREST IN ASSISTANCE,
STRATIFIED BY WHETHER THEY
SCREENED POSITIVE OR NEGATIVE
WITH BLUE BEING PERCENTAGES WHO
REPORTED INTEREST FROM HEALTH
CARE TEAM AND SCREENED POSITIVE
IN THOSE DOMAINS AND GREEN IS
INTEREST AND ASSISTANCE AMONG
THOSE WHO SCREENED NEGATIVE IN
THOSE DOMAINS.
DRAWING YOUR ATTENTION TO WHO
FINDINGS ON THIS GRAPH.
FIRST ON INDIVIDUAL DOMAIN,
CONSISTENCY AMONG HOUSING, FOOD,
UTILITIES AND TRANSPORTATION,
WITH 35 TO 40% OF PARTICIPANTS
INTERESTED IN DOMAIN-SPECIFIC
ASSISTANCE IF THEY SCREENED
POSITIVE IN THAT DOMAIN BUT
PERSONAL SAFETY STANDS OUT WITH
MUCH LOWER INTEREST IN
ASSISTANCE, AND THERE'S STILL A
PERCENTAGE OF PEOPLE WHO WANTED
ASSISTANCE.
FINALLY WE EXPLORED WHAT FACTORS
WERE ASSOCIATED WITH INTEREST IN
THE ASSISTANCE, RESULTS FROM
MULTI-VARIABLE MODEL SHOWING
ADJUSTED ODDS RATIOS.
THE STARS IN BOLDING INDICATE
STATISTICALLY SIGNIFICANT
RESULT.
ON THE LEFT IS THE RESULT OF THE
MODEL FOR THOSE WHO DID REPORT
OR SCREEN POSITIVE FOR ONE OR
MORE SOCIAL RISK FACTORS, ON THE
RIGHT ARE RESULTS OF THE MODEL
FOR THOSE WITH NO SOCIAL RISK
FACTORS REPORTED.
AND SO AMONG THOSE WHO SCREENED
POSITIVE, CENTER COLUMN, THE
NUMBER OF SOCIAL RISKS
INCREASED, AND PARTICIPANTS WHO
SELF-IDENTIFIED AS NON-HISPANIC
OR LOW VERSUS HIGH, INCREASED
ODDS OF INTEREST, PARTICIPANTS
WITH LOWER ODDS OF INTEREST IF
THEY REPORTED EXPERIENCING
DISCRIMINATION WITHIN HEALTH
CARE IN THE PAST, THOUGH THIS
WAS NOT STATISTICALLY
SIGNIFICANT.
AND AMONG THOSE WHO SCREENED
NEGATIVE FOR ALL RISKS, INTEREST
IN ASSISTANCE FOR 9% OF THIS
POPULATION, LOWER INCOME BUT
ALSO SELF-REPORTED WERE
ASSOCIATE FAIR/POOR HEALTH.
I THINK I MENTIONED THIS BUT WE
FLIPPED THE ORDER OF THE
QUESTIONS FOR ASSISTANCE, IF
PATIENTS ANSWERED IF THEY WERE
INTERESTED IN ASSISTANCE BEFORE
ACTUALLY BEING SCREENED FOR
SOCIAL RISKS, THEY HAD HIGHER
ODDS OF BEING INTERESTED IN THE
ASSISTANCE.
AND SO THERE ARE SOME
LIMITATIONS.
I LIKE TO IDENTIFY, IT WAS
CROSS-SECTIONAL SURVEY, HE WE
EXCLUDED PATIENTS WHO DID NOT
SPEAK OR READ ENGLISH OR
SPANISH, NOT REPRESENTATIVE OF
ALL HEALTH CARE SETTINGS, AND
INTEREST IN ASSISTANCE WAS ASKED
THEORETICALLY AS PART OF
RESEARCH SURVEY, THERE MAY BE
OTHER FACTORS THAT INFLUENCE
INTEREST BUT OUR STUDY WASN'T
DESIGNED TO TEST FOR DIFFERENT
WAYS INTEREST IN ASSISTANCE IS
ASKED.
IN CONCLUSION THERE HAVE BEEN
CONCERNS RAISED ABOUT HOW
PATIENTS WILL REACT TO SCREENING
AND WHETHER THEY COULD WORSEN
INEQUITIES.
FROM THIS WE SEE PEOPLE WHO MAY
BE THE MOST AT RISK OR MOST
MARGINALIZED ARE MOST INTERESTED
IN ASSISTANCE, AND WHETHER WE
ASK ABOUT INTEREST AND
ASSISTANCE FIRST OR SCREEN FOR
SOCIAL RISK FACTORS FIRST SEEMS
TO INFLUENCE WHETHER OR NOT
PEOPLE MIGHT WANT ASSISTANCE SO
WE NEED TO THINK ABOUT HOW
ASSISTANCE IS OFFERED AND BETTER
UNDERSTAND PATIENT PER
PERSPECTIVES TO ENSURE
SUCCESSFUL IMPLEMENTATION.
THERE'S THE POSITION --
POSSIBILITY WE SHOULD OFFER ALL,
UNCLEAR IF THAT MAKES
INTERVENTION MORE OR LESS
FEASIBLE FOR HEALTH CARE
SETTINGS.
PUTTING THESE RESULTS INTO THE
CONTEXT OF OTHER LITERATURE,
OVERALL THERE'S A NEED TO BETTER
URNS PSYCHOMETRIC PROPERTIES OF
SCREENING TOOLS ESPECIALLY IF
ASSISTANCE IS TIED.
WE NEED TO KNOW WHAT TOOLS ARE
MEASURING, HOW TO INTERPRET
RESULTS, AND ARE THERE
LINGUISTICALLY AND CULTURALLY
ACCEPTABLE TO PATIENTS WHO HAVE
BEEN FACED CURRENT AND PRIOR
RACISM AND DISCRIMINATION WITHIN
AND OUTSIDE THE HEALTH CARE
SYSTEM.
WE ALSO NEED TO BETTER
UNDERSTAND PATIENT PREFERENCE
AND PRIORITIES AROUND THE WAY
THEY WANT THE HEALTH CARE TEAM
TO INTEGRATE SOCIAL CARE INTO
THE HEALTH CARE SYSTEM AND EARLY
IMPLEMENTATION EFFORTS SUGGEST
THERE ARE BENEFITS TO ALIGNING
EFFORTS ACROSS HEALTH CARE
SETTINGS, E.D.s AND PRIMARY
HEALTH BUT COMMUNITY
ORGANIZATIONS AND HEALTH CARE AS
DUPLICATION CAN BE RESOURCE
INTENSIVE AND CONTRIBUTE TO
PATIENT SURVEY FATIGUE AND
DISINTEREST IF THEY ARE GETTING
REPEAT OFFERS OF SAME
ASSISTANCE.
FINALLY PERHAPS MOST IMPORTANTLY
WE NEED TO MAKE SURE THAT WE'RE
EVALUATING SOCIAL CARE
INTERVENTION WAS EQUITY LENS.
WE NEED TO BE STUDYING WHO IS
GETTING OR NOT GETTING SCREENED,
WHO IS GETTING OFFERED OR NOT
OFFERED ASSISTANCE, WHO IS
ACCEPTING OR NOT ACCEPTING AND
WHY.
THESE ALL HAVE IMPLICATIONS FOR
WHO WILL AND WON'T BENEFIT FROM
INTEGRATION EFFORTS.
IF ONE GOAL IS TO REDUCE
INEQUITIES, WE NEED TO MINDFULLY
MONITOR HOW WE'RE IMPACTING
EQUITY ALONG THE WAY.
UNDERSTANDING EFFORTS AND
FACTORS CONTRIBUTING TO INTEREST
IN ASSISTANCE WILL INFORM
INTERVENTION SUCCESS AND
EQUITABLE IMPLEMENTATION.
I WANT TO HIGHLY, STAY TUNED.
SIREN FUNDED A NUMBER OF STUDIES
TO BETTER UNDERSTAND WHAT TYPES
OF INTERVENTIONS WILL MAKE
PEOPLE MORE OR LESS LIKELY TO
ACCEPT ASSISTANCE.
AND IN OCTOBER 2022 THERE WILL
BE A SPECIAL ISSUE REPORTING ON
THESE RESULTS, IN ADDITION THE
EVALUATION FOR THE CMMI, HEALTH
COMMUNITIES MODEL, WILL
HOPEFULLY ADD TO KNOWLEDGE BASE
OF NAVIGATION SUPPORT AND
DEMONSTRATION PROJECT COMING TO
A CLOSE AT MAYBE SITES.
MUCH OF THE WORK WAS AT
EMERGENCY DEPARTMENTS.
AND I WANT TO CLOSE BY THANKING
THE RESEARCH TEAM FOR THE STUDY,
AS WELL AS RESEARCH SITES AND
PATIENTS WHO PARTICIPATED AND
HAPPY TO ANSWER QUESTIONS DURING
THE PANEL OR AT ANOTHER TIME AS
WELL.
THANK YOU SO MUCH FOR HAVING ME.
>> THANK YOU, DR. DE MARCHIS.
WE'RE READY FOR YOU, DR.
POLLACK.
>> ARE YOU ABLE TO SEE THE
SLIDES?
>> YES.
>> GREAT.
OKAY.
I WANT TO THANK YOU FOR THE
CHANCE TO TALK ABOUT THE
CONNECTION BETWEEN SOCIAL
FACTORS AND HEALTH.
IMPORTANTLY I APPRECIATE NINR'S
LEADERSHIP IN RAISING AWARENESS
ABOUT UPSTREAM DETERMINANTS OF
HEALTH WITHIN NIH AND BEYOND,
ALSO THANK THE EMERGENCY NURSES
ASSOCIATION FOR THEIR
PARTNERSHIP AND MAKING TODAY
POSSIBLE.
WITH MANY WONDERFUL
PRESENTATIONS, TALKING ABOUT
SCREENING AND CONNECTING PEOPLE
TO SOCIAL NEEDS, HERE I WANT TO
TAKE A STEP BACK.
I'LL DESCRIBE THE PROBLEM OF
UNAFFORDABLE HOUSING BEFORE
TURNING TO TWO SECTIONS.
FIRST WILL BE ABOUT WHAT WE CAN
LEARN FROM COVID-19 AND SECOND
PART WILL TALK ABOUT HOUSING AND
ITS NEIGHBORHOOD LOCATION AND
RELATE BOTH TO EMERGENCY FUND
USE.
AS A BRIEF DISCLAIMER I WORK ON
A PART-TIME BASIS OF HUD'S
OFFICE OF POLICY ON RESEARCH, MY
VIEWS DO NOT NECESSARILY REFLECT
THOSE OF HUD.
AS WE'RE ALL AWARE WE'VE REACHED
A HOUSING AFFORDABLE CRISIS IN
THE UNITED STATES WITH WAGES
INEFFICIENT TO MATCH HOUSING
COSTS.
THIS IS A SLIDE FROM THE
NATIONAL LOW INCOME HOUSING
COALITION THAT MAPS HOW MUCH OF
THE MINIMUM WAGE WOULD NEED TO
BE FOR INDIVIDUAL WORKING 40
HOURS A WEEK, 52 WEEKS A YEAR TO
AFFORD A TWO BEDROOM APARTMENT.
IN NONE OF THE 50 STATES IS THE
MINIMUM WAGE HIGH ENOUGH TO MAKE
HOUSING AFFORDABLE.
IN MARYLAND, THE MINIMUM HOUSING
WAGE IS $28 PER HOUR, ACTUAL
MINIMUM WAGE WAS INCREASED ON
JANUARY 1 TO $12.50.
AND PAYING HIGH HOUSING COSTS
MATTERS IN WAYS WE'RE BEGINNING
TO UNPACK.
AS MATTHEW DESMOND HAS WRITTEN
IN HIS BOOK, THE RENT EATS
FIRST.
THIS FIGURE FROM HARVARD MAKES
THAT CASE.
YOU CAN SEE WHAT HAPPENS TO LOW
INCOME HOUSEHOLDS AS THEY SPENT
MORE OF THEIR HOUSEHOLD INCOME
ON RENT AND UTILITIES.
THE FIRST BAR REPRESENTS THOSE
PAYING 30% OR LESS THAN 30% OF
INCOME ON RENT AND UTILITIES.
SECOND THOSE PAYING 30 TO 50%,
AND THAT FINAL BAR SHOWING THOSE
THAT PAY MORE THAN 50%.
AND YOU CAN SEE THOSE WHO SPEND
MORE ON THEIR RENT HAVE LESS
MONEY LEFT OVER TO PAY FOR FOOD,
TRANSPORTATION, RETIREMENT,
HEALTH CARE.
IMPORTANTLY THESE HOUSEHOLDS ARE
NOT LESS HUNGRY, THEY JUST HAVE
LESS LEFT OVER AFTER THE RENT
EATS.
AS MANY OF US KNOW FROM TRYING
TO REFER PATIENTS TO SUBSIDIZED
HOUSING, THE WAITLISTS ARE LONG
AND CLOSED.
THIS IS A SCREEN SHOT FROM THE
BALTIMORE SUN, WHAT HAPPENED
LAST TIME HOUSING AUTHORITY OF
BALTIMORE CITY OPENED ITS
WAITLIST.
YOU CAN SEE OVER 58,000 PEOPLE
SIGNED UP IN A WEEK TO TRY TO
GET A SLOT ON THAT, TO RECEIVE A
HOUSING VOUCHER.
FEDERAL ASSISTANCE IS NOT AN
ENTITLEMENT PROGRAM.
ONLY A QUARTER OF PEOPLE
ELIGIBLE RECEIVE IT.
LEADING TO CRUSHING BURDENS OF
UNAFFORDABLE HOUSING AND
CONTRIBUTING TO THAT FEELING OF
HELPLESS NESS WHEN FACED WITH
PATIENTS WITH UNMET NEEDS AND I
THINK THE DATA THAT DR. WALLACE
AND DR. DE MARCHIS PRESENTED ON
EXTENT TO WHICH HOUSING NEEDS
RISE TO TOP OF THE LIST MAKES
THIS CASE POWERFULLY.
SO HERE I WANT TO SHIFT TO TALK
ABOUT WHAT THE COVID-19 PANDEMIC
CAN BEGIN TO TEACH US ABOUT THE
RELATIONSHIP BETWEEN HOUSING AND
HEALTH.
IMPORTANTLY, HOW WE CAN BEGIN TO
ADDRESS IT.
BACK IN MARCH OF 2021, AT THE
ONE-YEAR ANNIVERSARY OF THE
COVID PANDEMIC, I READ AN
ARTICLE IN THE "NEW YORK TIMES"
THAT WAS REFLECTING ON THE
PANDEMIC, "WE LEARNED WHAT WAS
POSSIBLE" AND RACHEL COHEN
WRITES THE PANDEMIC OFFERED
GLIMPSES OF WHAT IS POSSIBLE.
BUT WILL ALL THIS BECOME A BLIP
IN HISTORY?
OR WILL IT PROVIDE IMPETUS FOR
LONG-TERM CHANGE?
SHE GOES ON TO WRITE, THROUGH
NATIONWIDE PUBLIC HEALTH ORDERS
TO STAY AT HOME TO CONTAIN THE
VIRUS, THE PANDEMIC FORCED
LAWMAKERS TO STRIKE BETTER
BALANCES BETWEEN THE PROPERTY
RIGHTS OF LANDLORDS AND SAVED OF
THEIR TENANTS.
WITH LOOPHOLES, NEVER BEFORE HAS
CONGRESS THROWN ITS WEIGHT
BEHIND PROTECTING FROM THREAT OF
ADDICTION.
EVICTION.
WE'VE BEEN LOOKING AT HOW
HOUSING RELATES TO HEALTH AND
WHAT WE CAN DO TO SUPPORT
PEOPLE.
IN ONE OF THE STUDIES I'M GOING
TO TALK ABOUT TODAY, WE TRY TO
UNPACK THE EVICTION PROCESS.
TYPICALLY WHEN A HOUSEHOLD GETS
EVICTED IT OCCURS OVER FIVE
STAGES, BEGINNING WITH NOTICE TO
THE TENANT, ULTIMATELY
PROGRESSING THROUGH ENFORCEMENT
OF THE JUDGMENT.
DIFFERENT STATES DURING THE
COVID PANDEMIC BLOCKED STAGES,
SOME BLOCKING LATER PHASES,
OTHERS BLOCKING THE EARLIER
PHASES AS WELL, NOTICE AND
FILING OR STRONGER TYPES OF
MORATORIUMS.
THESE DIFFERENCES MAY HAVE
IMPORTANT RAM RAMIFICATION FOR
HEALTH OUTCOMES, AND USING
LONGITUDINAL DATA SHOWED EXACTLY
THAT LOW INCOME RENTERS LIVING
IN STATES WITH STRONG
MORATORIUMS, THAT BLOCKED EARLY
STAGES OF GIVING NOTICE TO
TENANTS ARE LOWER RATES OF
MENTAL DISTRESS COMPARED TO
STATES THAT DIDN'T HAVE EVICTION
MORATORIUMS.
WE SEE THIS -- THESE LOWER RATES
WERE NOT FOUND IN STATES WITH
WEAK MORATORIUMS THAT BLOCKED
THE LATER PHASES.
THE EFFECT SIZE HERE IS MODEST
BUT THIS IS AT THE POPULATION
LEVEL AND SUGGESTS AS A
POPULATION LEVEL THESE EFFECT
SIZES MAY BE MEANINGFUL.
WE THINK THIS TYPE OF STUDY
UNDERSCORES HOW SOCIAL POLICIES
ARE STRUCTURED HAVE IMPLICATION
IN WELL BEING AND FUTURE EFFORTS
THAT HELP KEEP PEOPLE IN HOUSE
BY LIMITING EVICTIONS.
KNOW -- NOW I WANT TO TALK
ABOUT THE NEIGHBORHOOD CONTEXT,
LOCATION.
I'D LIKE TO FRAME THIS WITH A
PICTURE THAT MANY OF ARE YOU
FAMILIAR WITH SHOWING RED MAP
FROM HOMEOWNERS CORPORATION IN
BALTIMORE, CERTAIN NEIGHBORHOODS
PARTICULARLY WITH FOREIGN BORN
RESIDENTS AND BLACK RESIDENCE
WERE MARKED IN RED INDICATING
THESE NEIGHBORS PRESENTED
HAZARDOUS RISKS FOR LENDERS,
DENYING NEIGHBORHOODS CAPITAL
FOR INVESTMENT AND HELPED
CONTRIBUTE TO WHAT AMOUNTED TO A
STATE SPONSORED SYSTEM OF
SEGREGATION.
THIS IS THE MOST EASILY VISIBLE
EXAMPLE OF NEIGHBORHOOD
SEGREGATION AND POLICIES THAT
PROMOTED BUT IT'S NOT THE ONLY
ONE.
THERE ARE MANY EXAMPLES OF
SYSTEMIC RACISM THAT PERVADE
HOUSING POLICIES AROUND LOCAL
ZONING LAWS THAT HAVE CRITICAL
REVERBERATIONS FOR WHERE AND HOW
PEOPLE LIVE TODAY.
AND SO WORKING WITH COLLEAGUES
I'VE BEEN ATTEMPTING TO MEASURE
IMPACT OF NEIGHBORHOOD CONTEXT
ON HEALTH AND HEALTH CARE,
ESPECIALLY FOR PEOPLE WHO
RECEIVE HOUSING ASSISTANCE AND
WE'VE BEEN TRYING TO ANSWER THE
QUESTION, WHAT WOULD IT LOOK
LIKE IF WE WANTED TO MAXIMIZE
HEALTH IMPACT OF HOUSING
ASSISTANCE?
WE'VE BEEN EXPLORING IN
CHILDHOOD ASTHMA RATES.
RATES ARE HIGH WITH A QUARTER OF
KIDS REPORTING ASTHMA, ONE OF
THE TOP CAUSES OF EMERGENCY
DEPARTMENT VISITS AND WE KNOW IN
BALTIMORE CITY MOUSE ALLERGYEN
IS A DRIVER.
ATTEMPTS AT REMEDIATION HAD
MIXED RESULTS, DIFFICULT TO
ELIMINATE MOUSE AND COCKROACH
INFESTATIONS WHERE IT'S ENDEMIC,
WHEN THAT NEIGHBORING ROWHOUSE
MAY BE VACANT, IT'S HARD TO PLUG
THE HOLES.
TO BEGIN TO UNDERSTAND A
DIFFERENT APPROACH TO
UNDERSTANDING CHILDHOOD ASTHMA
AMONG UNDERRESOURCED NEIGHBORS
WE STARTED THE MOBILITY ASTHMA
PROJECT.
THIS REPRESENTS PARTNERSHIP WITH
THE BALTIMORE REGIONAL HOUSING
PARTNERSHIP, GROWING OUT OF THE
TOM ONLAWSUIT ACLU SUED SAYING
ITS LOCATION OF PUBLIC HOUSING
INCREASED SEGREGATION AND
VIOLATED FAIR HOUSING LAWS, WERE
SUCCESSFUL IN THE LAWSUIT, PART
OF THE REMEDY FOR THAT LAWSUIT
CREATED HOUSING VOUCHERS FOR
HOUSEHOLDS THAT HAD TO BE USED
IN NON-POOR NEIGHBORHOODS,
BALTIMORE REGIONAL HOUSING
PARTNERSHIP HELPS HOUSEHOLDS USE
THESE VOUCHERS TO PROVIDE
SUPPORT, COUNSELING ON CREDIT
SCORES, HELP WITH SECURITY
PAYMENT FOR RENTAL HOUSES,
WORKING WITH LANDLORDS TO FIND
AVAILABLE UNITS, AND THE LIKE,
AND THEY HAVE BEEN INCREDIBLY
SUCCESSFUL OVER THE MANY YEARS.
WE STARTED A RECRUITMENT OF
CHILDREN WITH ASTHMA, WHOSE
FAMILIES WERE ENROLLING IN THE
PROGRAM.
RECRUITED 140 KIDS IN 2016, 126
OF THOSE FAMILIES RECEIVED A
VOUCHER, 121 MOVED, AMONG THOSE
FAMILIES THAT HAVE RECEIVED
VOUCHERS WE'VE SEEN DRAMATIC
CHANGES IN THE NEIGHBORHOODS
THAT THEY LIVE IN.
AWAY THEY MOVED FROM POVERTY
RATE OF 25% TO A AVERAGE POVERTY
RATE OF 6.7%.
AND THE RESULTS ARE
UNPUBLISHED, WITH SIGNIFICANT
REDUCTIONS IN SYMPTOMS WHEN
RUNNING, USING RELIEVER
MEDICINE, OR IN NIGHTTIME
SYMPTOMS.
YOU CAN SEE HERE AVERAGES OUT TO
A MONTH FEWER OF NIGHTTIME
SYMPTOMS, PARALLEL WE'VE
OBSERVED LARGE REDUCTION IN
ASTHMA TRIGGERS INCLUDING MOUSE
AND COCKROACH ALLERGENS AND
CHANGES IN LUNG FUNCTION
INCLUDING FEV1 THAT GOES UP
EARLY ADULTHOOD AND STARTS
DECLINING AND THE RATE OF FEV 1
IS ALSO ASSOCIATED WITH
LONG-TERM OUTCOMES FOR ADULTS,
WE THINK THIS UNDERSTANDING THE
NEIGHBORHOOD CONTEXT CAN DRIVE
OVERALL KIND OF LIFE COURSE
TRAJECTORY FOR PULMONARY HEALTH
AND OVERALL WELL-BEING IS
CRITICAL.
SO AGAIN THESE ARE UNPUBLISHED,
WE'RE STILL DOING SOME OTHER --
ADDITIONAL ANALYSES COMPARING TO
MAKE SURE OUR RESULTS HOLD UP.
THE REGIONAL HOUSING PARTNERSHIP
IN CONJUNCTION ARE HOUSING
AUTHORITY OF BALTIMORE CITY
LAUNCHED THE HEALTHY HOUSING
VOUCHERS, TO TEST WHETHER TRYING
TO RECRUIT CHILDREN WITH
VOUCHERS WHO ARE CURRENTLY
RESIDING IN UNDERRESOURCED
NEIGHBORS MAY WANT HELP MOVING
TO MORE RESOURCED NEIGHBORHOODS,
MAY WANTS TO PARTICIPATE IN
BALTIMORE REGIONAL HOUSING
PROGRAM AND RECEIVE SERVICES.
THIS IS AN EXCITING EXAMPLE
RECRUITING KIDS MOST VULNERABLE
FROM EMERGENCY DEPARTMENT
WORKING POTENTIALLY WITH THE
CITY PUBLIC HEALTH AGENCY, THESE
PARTNERSHIPS ARE BEING DEVELOPED
WORKING WITH THE PEDIATRIC
CLINIC TO TRY TO IDENTIFY THOSE
KIDS WHO MAY BE -- MAY BENEFIT
IN MOVING TO SEE WHETHER THAT
INCREMENTAL COST OF PAYING FOR
MOBILITY SERVICES MAY BENEFIT
AND MAY PROVIDE A NOVEL PATHWAY
FOR THESE PATIENTS.
SO I WANT TO END BY COMING BACK
TO THE IDEA, WE HAVE A GLIMPSE
OF WHAT MIGHT BE POSSIBLE IF WE
START VIEWING HOUSING AS A
CRITICAL FACTOR IN HEALTH AND
HEALTH EQUITY.
THIS IS NOT A NEW INSIGHT.
BUT GOES BACK TO THE ROOTS OF
EPIDEMIOLOGY, ROOTS OF NURSING,
REMINDING US CONNECTION IS
PARAMOUNT.
WE HAVE TO WORK WITH OUR
EMERGENCY DEPARTMENT COLLEAGUES
TOED ADVOCATE FOR CHANGES THAT
MAKE HOUSING IN RESOURCED
NEIGHBORHOODS AFFORDABLE AND
AVAILABLE.
WITH THAT I WANT TO THANK MY
WONDERFUL COLLABORATORS ON
STUDIES AS WELL AS FUNDING FROM
NIH AND OTHER RESOURCES.
THANK YOU.
>> THANK YOU, DR. WALLACE, DE
MARCHIS AND POLLACK.
THESE CONVERSATIONS ARE
CRITICALLY IMPORTANT AND WE
REALLY APPRECIATE AND VALUE YOUR
INSIGHTS AND SHARING ALL OF
THOSE FASCINATING RESULTS FROM
YOUR RESEARCH.
WE DO HAVE TIME FOR A COUPLE OF
QUESTIONS, IF THERE ARE ANY FOR
THIS ROUND OF SPEAKERS.
IF NOT WE CAN WAIT TILL THE
PANEL.
AND TAKE A BREAK.
WE HAVE A BREAK SCHEDULED.
AND WE CAN RECONVENE AT ONE P.M.
WHY DON'T WE DO THAT.
AND WE WILL SEE ALL OF YOU IN
ABOUT 25 MINUTES.
>>WE WILL CONTINUE WITH THREE
OUTSTANDING SPEAKERS WITH SOCIAL
DETERMINANTS OF HEALTH AND
EMERGENCY DEPARTMENT
UTILIZATION.
I'M ACTING DIRECTOR FOR THE
DIVISION OF EXTRAMURAL SCIENCE
PROGRAMS AT THE NINR.
LET ME REMIND YOU WE HOPE TO
HAVE ALL THE QUESTIONS DURING
THE PANEL DISCUSSION AFTER TALKS
ARE CONCLUDED.
HERE IS THE LINE UP. DR. JOSH
VEST, THE FIRST SPEAKER IS A
HEALTH SERVICES RESEARCHER WHO
HAS EFFECTIVENESS IN HEALTH
INFORMATION TECHNOLOGY AND
SYSTEMSMENT DR. VEST'S WORK HAS
EMPLOYED A VARIETY OF RESEARCH
TECHNIQUES FROM LARGE SCALE
DATABASE ANALYSES TO
GEOGRAPHICAL INFORMATION SYSTEM
MAPPING TO SURVEY RESEARCH TO
QUALITATIVE FOCUS GROUP AND
INTERVIEWS.
DR. VEST HAS A PARTICULAR
INTEREST IN THE MEASUREMENT AND
USAGE OF SOCIAL DETERMINANTS
INFORMATION HE IS PROFESSOR
HEALTH POLICY AND MANAGEMENT
INDIANA UNIVERSITY RICHARD FAIR
BANKS SCHOOL OF PUBLIC HEALTH
AND THE RESEARCH INSTITUTES.
HE WILL BE FOLLOWED BY DR.
MELISSA MCCARTHY.
WHO IS A PROFESSOR OF THE
DEPARTMENT OF HEALTH POLICY AND
MANAGEMENT AT THE GEORGE
WASHINGTON UNIVERSITY MILKEN
INSTITUTE SCHOOL OF PUBLIC
HEALTH.
HAS A JOINTS APPOINTMENT IN THE
GEORGE WASHINGTON UNIVERSITY
SCHOOL OF MEDICINE IN DEPARTMENT
OF EMERGENCY MEDICINE.
DR. MCCARTHY, HAS A MASTERS
DEGREE IN EPIDEMIOLOGY AND
ADOCTORAL DEGREE IN HEALTH
SERVICES RESEARCH, PRESENT
RESEARCH FOCUSES ON IDENTIFYING
STRATEGIES AT THE MICROAND MACRO
LEVELS TO ADDRESS SOCIAL
DETERMINANTS OF HEALTH IN THE
MEDICAID POPULATION.
AND FINALLY, THE LAST SPEAKER IN
THIS SESSION DR. ANN ELIZABETH
MONTGOMERY IS ASSOCIATE
PROFESSOR SCHOOL OF PUBLIC
HEALTH UNIVERSITY OF ALABAMA
BIRMINGHAM.
SHE HAS EXTENSIVE EXPERIENCE
USING VETERANS ADMINISTRATION
ADMINISTRATIVE DATA SOURCES TO
ADDRESS HER PRIMARY RESEARCH
INTERESTS, WHICH ARE IDENTIFYING
HOLISTIC RISKS AMONG VETERANS
SEEKING HEALTHCARE AND ASSESSING
INTERVENTIONS INTENDED TO
MITIGATE THIS RISK IN STUDYING
VULNERABLE POPULATIONS AND
RELATED HEALTH DISPARITIES.
HER WORK FOCUSES LARGELY ON
ADDRESSING SOCIAL DETERMINANTS
OF HEALTH INCLUDING HOUSING
INSTABILITY, GENDER, VIOLENCE,
MORALITY, EMPLOYMENT, AND
JUSTICE INVOLVEMENT TO IMPROVE
THE HEALTH OF VETERANS.
SO PLEASE JOIN ME IN WELCOMING
DR.S VEST, MCCARTHY AND
MONTGOMERY WHO WILL EACH SPEAK
FOR 15 MINUTES AFTER WHICH TIME
THERE WILL BE A PANEL DISCUSSION
AND WE HOPE THAT YOU WILL
PARTICIPATE.
PLEASE USE THE CHAT FUNCTION
WHENEVER YOU FEEL LIKE IT TO
BEGIN SUBMITTING YOUR QUESTIONS
DURING THE PRESENTATIONS AND
DURING THE BREAK WE WILL CURATE
THE QUESTIONS FOR THE PANEL
MODERATOR.
DR. VEST.
>> THANK YOU SO MUCH, APPRECIATE
THIS OPPORTUNITY TO TALK TO
Y'ALL.
AND I'M GOING TO BE MEASURING
PATIENT SOCIAL RISK FACTORS,
TALK ABOUT THE CONSIDERATIONS
AND SOME OF THE STUFF WE ARE
SEEING HERE IN INDIANA, THE
PRESENTATIONS HAVE BEEN
PHENOMENAL SO FAR AND I THINK
WILL DOVE TAIL NICELY WITH
EARLIER SPEAKERS.
SO AS MENTIONED, I'M INTERESTED
IN HOW WE MEASURE CONSTRUCTS AND
APPLY THEM TO HEALTHCARE AND
HEALTH POPULATION IMPROVEMENT SO
THERE'S REALLY THREE MAIN WAYS
WE COLLECT SOCIAL RISK FACTORS,
SOCIAL FACTOR INFORMATION.
THEY ALL HAVE STRENGTHS AND
LIMITATIONS.
ONE IS SURVEYS, WE HAVE HEARD
THAT ALREADY, THEY ARE WIDELY
USED, MANY POPULAR SURVEYS ARE
BUILT IN THE EHR SO THEY ARE
ABLE TO CAPTURE STRUCTURED DATA.
PHENOMENAL ADVANTAGE OF A LOT OF
SURVEYS THEY ARE IN MULTIPLE
LANGUAGES AND TRANSLATED ALREADY
SO THERE FOR EVERYBODY TO USE,
EASY OFF THE SHELF SET OF STUFF
THAT IS VERY GOOD.
HOWEVER THEY DO HAVE LIMITATION
USES, THEY ARE NOT PSYCHO
METRICALLY EVALUATED.
AS A RESULTS PULL AND CHOOSE
INSTRUMENTS FROM PSYCHO
METRICALLY EVALUATED TOOLS, A
GOOD COMMON WAY OF BUILDING BUT
DOESN'T MEAN THE TOOLS ARE
PSYCHOMETRICALLY EVALUATED.
IF YOU LOOK AT THE QUESTION
FLAIRS YOU WILL SEE NUANCES IN
QUESTIONS WHICH POSSIBLY DO HAVE
SOME IMPLICATIONS FOR WHAT WE
ARE MEASURING AS A CONSTRUCT OF
SOCIAL FACTOR.
AS MENTIONED EARLIER, THERE'S
WORK FLOW ISSUES AND BURDENS
SURVEYS DO REQUIRE SOMEBODY TO
ANSWER THEM AND ADMINISTRATION.
WE ALSO HAVE THE CHALLENGE OF
RESPONSE BIAS IF WE ARE NOT
DOING UNIVERSAL SCREENING WE RUN
INTO CHALLENGES ON RISK SAL
STRATIFICATION, ADVANCED
ANALYTICS MAKE INFERENCES ABOUT
THE POPULATION AND RESPONSE CAN
COME FROM TWO WAYSES, THE
HEALTHCARE ORGANIZATION DOES NOT
UNIVERSALLY SCREEN PATIENTS OUT
OF EITHER WORK FLOW DEMANDS OR
SOME SORT OF MISGUIDED THOUGHT
ABOUT WHO SHOULD AND SHOULDN'T
BE SCREENED OR ALTERNATIVELY WE
KNOW SOMETIMES PATIENTS DON'T
WANT TO RESPOND TO
QUESTIONNAIRES.
WE ARE USED TO HEALTHCARE AND
USED TO FAIRLY SENSITIVE HEALTH
QUESTIONS BE SOCIAL FACTOR
QUESTIONS ARE JUST AS SENSITIVE
FOR PEOPLE TO RESPOND TO IF THEY
HAD NEGATIVE EXPERIENCES WITH
THE HEALTHCARE SYSTEM IN THE
PAST.
WE CAN TURN TO NLP NATURAL
LANGUAGE PROCESSING AND TEXT
MINING.
THAT HAS ADVANTAGES.
OFTEN SOCIAL DETERMINANTS OR
RISKS ARE DOCUMENTED IN CLINICAL
NOTES.
THE MEDICAL RECORD HAS A LONG
TRADITION OF HAVING A WHERE
THESE POP UP.
WE CAN AUTOMATE THIS INTO BACK
END PROCESSES SO WE CAN BE
MINING CONTINUOUSLY SRI WITH
USEFUL AND HAS POTENTIAL FOR'S
OF USE.
HOWEVER THERE ARE LIMITATIONS
WITHIN NLP, IT IS FAIRLY CUTTING
EDGE IT IS LEARNING TO MEASURE
THESE THINGS IS A CHALLENGE AND
PARTICULARLY WITH SOME OF THE
TEMPORALTY ISSUES GIVEN HOW
FREQUENTLY SOCIAL RISKS AND FANG
TORRS CHANGE OVER TIME.
MEASURING IS A CHALLENGE.
WE HAVE A SELECTION BIAS WITH
NLP.
WHEN WE DO NLP TO EXTRACT SOCIAL
RISK OUT OF NOTES WE ARE NOT
ASKING PATIENTS AND MEASURING
THE PATIENT LEVEL, WE ARE
MEASURING WHAT'S FILTERED
THROUGH THAT PROVIDER PATIENT
INTERACTION.
SO BECAUSE A PATIENT HAS ASOCIAL
RISK DOESN'T MEAN THAT IS ASKED
ABOUT AND EVEN IF ASKED ABOUT IT
DOESN'T MEAN IT IS ANSWERED AND
EVEN IF ANSWERED DOESN'T MEAN
IT'S DOCUMENTED SO IT IS THROUGH
THAT FILTER OF WHAT IS
DOCUMENTED SO THAT WILL
UNDERCOUNT SOME PEOPLE AS WELL.
JUST TRUTHFULLY NOT ALL HEALTH
SYSTEMS ARE ABLE TO RUN NLP AT
SUCH LARGE SCALE.
ROUTINE BASIS.
THE OTHER THING WE CAN TURN TO
IS STRUCTURE DATA.
STRUCTURE DATA IS VERY USEFUL
PARTICULARLY ICDZ CODES, THESE
ICD 10 Z CODES ARE BUILT INTO
EHR SO IT IS EASY TO DOCUMENT
AND WORK THAT WAY.
THAT IS REALLY USEFUL.
HOWEVER, ALL OF THE RESEARCH
INDICATES OUT THERE THEY ARE
DRAMATICALLY UNDERUSED.
IT IS NOT EVEN LIKE A LITTLE
UNDERUSED, IT IS BY MILES ACROSS
THE ENTIRE U.S. HEALTHCARE
SYSTEM THESE THINGS ARE JUST NOT
USED SUFFICIENTLY ENOUGH TO GET
A GOOD HANDLE ON WHAT IS GOING
ON.
WHAT IS OUR SITUATION AND AND
WHERE DOES IT LEAD US TO?
WE THINK ON THIS CALL SOCIAL
RISKS ARE REALLY AN IMPORTANT
QUOTE UNQUOTE CONDITION THAT
SHOULD BE MEASURED.
WE SEE FROM OUR EXISTING
APPROACHES THEY HAVE STRENGTH
BUT IN MANY WAYS WE GET
INCOMPLETE PICTURE OF THE
PATIENT FROM EACH ONE.
THAT IS A CHALLENGE.
WE KNOW THE DATA ARE NOT ALWAYS
COLLECTED AT EVERY ENCOUNTER.
WE ALSO KNOW THAT THE
DEFINITIONS ARE NOT CONSISTENT
ACROSS SYSTEMS AND ACROSS
INSTITUTIONS.
TRUTH TRUTHFULLY, A LOT OF EHR
DATA WE HAVE ACCESS TO ARE ABOUT
DEMOGRAPHICS AND INSURANCE,
PAYMENT INFORMATION SOCIAL
RELATIONSHIPS, ALL ABOUT
LANGUAGE, THAT MIGHT BE REALLY
USEFUL STUFF THAT WE COULD BE
CONSIDERING OUTSIDE OF PURE
STRUCTURE DATA FOR SOCIAL
DETERMINANTS AND RISKS.
I APOLOGIZE, I DO KNOW SOCIAL
DETERMINANTS AND SOCIAL FACTORS
ARE NOT THE SAME THING BUT I
WILL PROBABLY SLIP IN BETWEEN
THEM ROUTINELY SO BRINGING THAT
TOGETHER WHAT ABOUT IF WE
THOUGHT ABOUT COMPUTABLE SOCIAL
RISK FACTOR PHENOTYPES?
AND THINKING ABOUT SOCIAL FACTOR
MEASUREMENT THAT WAY.
JUST SO WE ARE ALL ON THE SAME
PAGE ABOUT DEFINITION, A
PHENOTYPE OF PARTICULAR
PHENOTYPE IS REPRESENTATION OF
PATIENT CONDITIONS OR
CHARACTERISTICS ATTAINED FROM
EHR DATA BY COMBINING A SET OF
DEFINED VARIABLES AND LOGICAL
EXPRESSIONS.
THE BEST EXAMPLE THAT I THINK
PEOPLE CAN RESONATE MOST WITH IS
DIABETES.
SOMEBODY WHO IS -- HAS BEEN
DIAGNOSED WITH DIABETES IS ONLY
ONE FRACTION OF THE ENTIRE
POPULATION WITH DIABETES.
WE KNOW SOME PEOPLE DON'T HAVE
THAT ICD 10 CODE MAY STILL HAVE
AN A 1C OUT OF RANGE OR MAYBE ON
MEDICATIONS THAT ARE INDICATIVE
OF DIABETES.
SO WE CAN USE THOSE OTHER
INFORMATION; MEDICATIONS, LAB
VALUES, PROCEDURES, THAT WOULD
HELP ROUND OUT AND GET THAT
COMPLETE PICTURE OF WHO'S
ACTUALLY SUFFERING FROM A
CONDITION.
AND WE PLAN TO USE THAT FOR
SOCIAL RISK FACTORS.
SO HOW CAN WE BEST MEASURE
SOCIAL RISK FACTORS?
THAT IS WHAT WE ARE BUILDING ON
NOW.
WE HAVE SURVEYS ICD 10 CODES AND
OUR GROUP IS PROPOSING A
COMPUTABLE PHENOTYPE APPROACH.
THAT'S WHAT WE ARE WORKING ON
RIGHT NOW.
HERE IN INDIANA.
WE ARE IN PROCESS FOR DATA -- A
LITTLE BIT OF RESULTS.
WE ARE COLLECTING 1500 SURVEYS
OF ED PATIENTS IN INDIANA.
WE ARE WORKING WITH OUR HEALTH
PARTNERS, A 330 BED SAFETY NET
HOSPITAL WITH 10 FQAC SITES,
ADULTS ONLY FOR THIS STUDY.
ALSO COLLECTING 3,000 STUDIES OF
PRIMARY CARE PATIENTS HERE IN
INDIANA AND AT THE UNIVERSITY OF
FLORIDA.
WE HAD BEEN LOOKING AT THE
PREVALENCE OF PATIENTS WITH
SOCIAL FACTORS AND USING THESE
GOLD STANDARD -- CAN'T CALL THEM
GOLD STANDARD, INDEPENDENTLY
ASSESSED SURVEY INSTRUMENTS TO
BE OUR STANDARD FOR REFERENCE
GOING FORWARD.
SO WHAT ARE WE LOOKING AT WHEN
WE SEE OUT INTO OUR COMMUNITY?
WHAT CHALLENGES ARE COMING
ACROSS IN THE ED SIDE A COUPLE
OF HIGHLIGHTS.
THERE IS A SIMPLE QUESTION, IN
12 MONTHS ARE YOU WORRIED YOUR
FOOD WOULD RUN OUT BEFORE YOU
GOT MONEY TO BUY MORE.
FOOD INSECURITY, THE TWO COLUMNS
IN RED IN CONTRAST TO BLUE ARE
INDICATIONS OF BEING AT RISK FOR
FOOT INSECURITY BY THIS
QUESTION.
YOU CAN SEE IN ED WE HAVE GOT
NEARLY HALF OF OUR PATIENTS ARE
ADULT PATIENTS ARE REPORTING
THIS.
THIS IS GOING ON SINCE LAST JULY
SO WE ARE STILL IN THE PANDEMIC
PERIOD ON SOME OF THIS DATA
COLLECTION.
WHEN WE ASK ABOUT A TIME WHEN
THEY WERE NOT ABLE TO PAY THE
MORTGAGE OR RENT ON TIME,
INDICATER ONE INDICATOR HOUSING
INSTABILITY, IT WAS A THIRD OF
THE POPULATION.
WHEN WE GO FORWARD LOOKING AT
JUST GENERAL FINANCE QUESTIONS
LIKE OVERALL FINANCIAL WELL
BEING, WE SEE THAT 16% OF ADULTS
ARE REPORTING CHALLENGES PAYING
FOR FOOD HOUSING MEDICAL CARE,
HEATING, REALLY BASIC STUFF.
WE SEE A LACK OF TRANSPORTATION
AND TRANSPORTATION BARRIER ABOUT
A QUARTER OF ADULT PATIENTS IN
THE ED ARE REPORTING THIS AS
WELL.
AND WE ALSO REPORT QUITE A BIT
OF HISTORY WITH LEGAL ISSUES.
THIS IS NOT CIVIL ISSUES BUT
CRIMINAL ISSUES, 10% OF THE
POPULATION IS REPORTING THIS IN
A VOLUNTARY BASED SURVEY.
SO WHAT ARE WE DOING WITH THESE
THINGS WE ARE COLLECTING
VALIDATED SURVEYS, COLLECTING
THEM IN THE ED SETTING AND IN
PRIMARY CARE.
AND THEY WILL BE OUR INDEPENDENT
CRITERIA.
WE HAVE IN PARALLEL SET UP THE
IDENTIFICATION AND ASSESSMENT OF
POTENTIAL DATA ELEMENTS TO USE
IN OUR PHENOTYPE CONSTRUCTION,
WE HAD AN EXTRA PANEL TOGETHER
OF PEOPLE WITH EXPERTISE IN
SOCIAL DETERMINANTS, IN HEALTH
INFORMATION EXCHANGE, EHR DATA,
TO TALK ABOUT WHAT DATA ELEMENTS
COULD BE INFORMATIVE TO SOCIAL
DETERMINANT MEASUREMENT.
THEY IDENTIFIED 89 STRUCTURAL
DATA ELEMENTS THAT ARE ALREADY
COLLECTED HER, COULD BE USED IN
VARIOUS WAYS, TO ESTABLISH SOME
MEASURES OF SOCIAL RISK.
THAT STUDY IS JUST BEEN
PUBLISHED IN THE AMERICAN
JOURNAL OF MANAGED CARE.
WE HAVE BEEN WORKING ON THE NLP
SIDE, WE HAVE BEEN DOING NLP
DEVELOPMENT FOR HOUSING
FINANCIAL UNEMPLOYMENT AND
INCARCERATION HISTORY AND FOOD
INSECURITY.
WE VALIDATE THESE THROUGH CHART
REVIEW AND PRESENTED THIS AT THE
AMERICAN MEDICAL INFORMATICS
ASSOCIATION ANNUAL SYMPOSIUM.
SO ACROSS THE BOARD WHAT DO WE
GOT?
A LARGE SET OF SURVEYS, WE ARE
COLLECTING BOTH SUFFICIENT
SURVEYS IN THE EHR AND IN
INDEPENDENT SURVEY INSTRUMENT
STAND AS ITS OWN INDEPENDENT
ASSESSMENT OF SOCIAL FACTOR
STANDING.
WE HAVE OUR DATA ELEMENTS FOR
COMPUTABLE PHENOTYPES AND WE
HAVE AN NLP ENGINE AND WE CAN
IMPLY TO EXTRACT OUT OF NOTES.
SO THESE ARE PLANNED ANALYSIS.
T WE ARE DOING THE HEAD TO HEAD
BATTLE ROYALE.
WE ARE TAKING EHR BASED SOCIAL
RISK FACTORS SURVEYS, NLP
DEVELOP PHENOTYPES AND COMPARING
PSYCHOMETRIC PROPERTIESES.
WE WILL COMPARE THEIR PREDICTIVE
ABILITY, ASSESS THE BIAS THAT
MAY BE IN PRESENT IN ANY OF
THESE MEASURES USING MACHINE
LEARNING AND AI TECHNIQUES.
WE ARE ALSO DEVELOPING
PREDICTIVE MODELS FOR SOCIAL
RISK FACTORS IN THE ED
UNDERSTANDING HOW WE CAN
LEVERAGE THIS DATA TO PREDICT
WHO NEEDS RISK FACTOR
INTERVENTIONS, KIND OF A TWO
STAGE SCREENING APPROACH TO MOVE
FORWARD IN THAT WAY.
WE ARE LOOKING BOTH AT PATIENT
PROVIDER ACCEPTABILITY BECAUSE
IT IS A VERY DIFFERENT TYPE OF
SCREENING APPROACH, ALGORITHMIC.
WE ARE LOOKING FOR PERFORMANCE
AND ALSO BE ASSESSING BIAS IN
THAT WAY AS WELL.
I DIDN'T START WITH THIS BUT
THIS IS THE EFFORTS OF A LOT OF
DIFFERENT PEOPLE, I WANT TO
THANK MY CO-AUTHORS HELPING ME
ON THIS PROJECT, OUR WORK HAS
BEEN SUPPORTED BOTH BY OUR CTSI
WHICH IS FUNDED BY NIH HERE ON
CAMPUS AS WELL BY COUPLE OF
GRANTS FROM AHRQ.
SO AS I SAID WE ARE THINKING
ABOUT ALL THESE THINGS IN
PRELIMINARY STEPS AROUND LARGER
STUDIES AROUND SURVEYS THINKING
ABOUT ROLE OF NLP AND TEXT,
STRUCTURED DATA AND POTENTIAL OF
COMPUTABLE PHENOTYPES.
IN LOOKING AT BETTER APPROACHES
TO ME MEASUREMENT OF SOCIAL RISK
FACTOR INFORMATION.
THANK YOU ALL.
>> ALL RIGHT.
THANK YOU SO MUCH.
I'M JUST NOW GOING TO TURN THIS
OVER TO OUR NEXT SPEAKER.
DR. MCCARTHY, CAN YOU SEE THE
SLIDES?
>> I CAN, THANK YOU.
>> GREAT.
>> THANK YOU VERY MUCH.
THANK YOU FOR THE INVITATION TO
BE PART OF THIS ROUND TABLE.
AS DR. VEST NICELY SAID IT IS
INTERESTING AND INFORMATIVE,
REALLY ENJOYING IT.
TODAY I'M GOING TO DESCRIBE A
STUDY THAT WE CONDUCTED THAT WAS
FUNDED BY THE NATIONAL INSTITUTE
OF MINORITY HEALTH AND HEALTH
DISPARITIES.
FIRST I WOULD LIKE TO
ACKNOWLEDGE MY STUDY TEAM
MEMBERS AND ALSO JUST START OUT
BY DESCRIBING THE FRAMEWORK THAT
GUIDES OUR RESEARCH.
I'M HOPING THIS SLIDE IS
FAMILIAR TO EVERYONE AND IT IS
THE WHO MODEL CONCEPTUAL MODEL
OF SOCIAL DETERMINANTS OF
HEALTH.
I THINK WHAT I LIKE MOST ABOUT
IT IS IT KIND OF SEPARATES
STRUCTURAL DETERMINANTS OF
HEALTH FROM INTERMEDIARY
DETERMINANTS OF HEALTH.
THE MOST UPSTREAM DETERMINANTS
OF HEALTH ARE THESE STRUCTURAL
DETERMINANTS, THAT ARE PUBLIC
POLICIES AND VALUES AND
PROGRAMS.
THEY KIND OF DRIVE OUR -- WHERE
WE -- OUR SOCIOECONOMIC POSITION
IN SOCIETY.
THEN OUR OCCUPATION OR
EDUCATION.
THEN DETERMINANTS ARE
INTERMEDIATE DETERMINANTS OF
HEALTH, MATERIAL CIRCUMSTANCES
LIKE HOUSING AND FOOD
INSECURITY, HEALTH BEHAVIORS,
SOCIAL SUPPORTS.
THOSE ARE THE MORE PROXIMAL
INTERMEDIARY DETERMINANTS OF
WHAT DRIVE HEALTH DISPARITIES WE
SEEK IN THE CLINICAL SETTING.
SO I THINK ONE OF THE THINGS I
LOVE MOST ABOUT THE MODEL IS A
LOT OF US ARE TRYING TO ADDRESS
INTERMEDIARY DETERMINANTS OF
HEALTH LIKE HOUSING INSTABILITY
AND FOOD INSECURITY.
WE HAVE TO ALWAYS KEEP IN MIND
THAT WE WANT TO MOVE EVEN
FURTHER UPSTREAM, IT IS JUST AS
IMPORTANT TO ADDRESS THE
UPSTREAM FACTORS THAT DETERMINE
NOSE INTERMEDIARY DETERMINANTS.
FINALLY IN THIS SYSTEM YOU CAN
SEE THE HEALTHCARE SYSTEM WHERE
-- WHICH IS WHAT WE ARE TALKING
ABOUT TODAY HOW DOES THAT
INFLUENCE THE RELATIONSHIP
BETWEEN SOCIAL DETERMINANTS AND
HEALTH AND IT IS REALLY SEEN AS
A MODERATOR, TO ADDRESS MORE SO
THE INTERMEDIARY DETERMINANTS OF
HEALTH.
-- ON HEALTH.
SO WITH THIS FOUNDATION IN MIND,
LET ME DESCRIBE THE STUDY WE
CONDUCTED.
OVER ABOUT 15 MONTH PERIOD
STARTING IN SEPTEMBER OF 2017 WE
CONDUCTED A PROSPECTIVE COHORT
STUDY WHERE WE ENROLLED ALMOST 9
HOW ADULT MEDICAID PATIENTS.
WHEN THEY PRESENTED AT A
HEALTHCARE SETTING EITHER AT
COUPLE OF EMERGENCY DEPARTMENTS,
PRIMARY CARE CLINIC, OBGYN
SETTING.
CLINIC.
ALL THEY HAD TO BE WAS INSURED
BY DEPARTMENT OF DISTRICT OF
COLUMBIA MEDICAID PROGRAM AT THE
TIME.
WHEN THEY CONSENTED THEY WERE
INTERVIEWED BY A RESEARCH
ASSISTANT, ESSENTIALLY DID A
SOCIAL DETERMINANT OF HEALTH
ASSESSMENT AND THEY ALSO AGREED
TO TWO FOLLOW-UP INTERVIEWS 6
AND 12 MONTHS LATER.
THEY ALLOWED US TO OBTAIN A COPY
OF MEDICAID CLAIMS DATA, IT IS
ENCOMPASSINGK HEALTHCARE VISITS,
COSTS PRESCRIPTION DRUGS NURSING
HOME, WHATEVER RELATED
HEALTHCARE INCLUDING EMERGENCY
DEPARTMENTSMENT AND WE GOT THE
CLAIMS DATA FOR FOUR YEAR
PERIOD, TWO YEARS PRIOR AND TWO
YEARS POST WHEN THEY ENROLLED IN
STUDY.
SO ESSENTIALLY WHAT I WILL SHOW
YOU TODAY IS A COMBINATION OF
THE INTERVIEW DATA AND THE
CLAIMS DATA.
YOU CAN SEE FROM THIS SLIDE,
THAT WE ASK PARTICIPANTS ABOUT
NUMBER OF STRUCTURAL AND
INTERMEDIARY DETERMINANTS OF
HEALTH.
DID THEY WORK, HOW MUCH
EDUCATION HAVE THEY OBTAINED.
LOT OF QUESTIONS ABOUT HOUSING,
FOOD INSECURITY, TROUBLE PAYING
DIFFERENT KINDS OF BILLS, HEALTH
BEHAVIORS, VARIOUS PSYCHOSOCIAL
SUPPORTS AND WE ASKED ABOUT
SOCIAL SERVICE USE LIKE THEY
RECEIVE FOOD STAMPS HOUSING
SUBSIDIES, THE CLAIMS DATA GAVE
US A LOT OF INSIGHT INTO
HEALTHCARE UTILIZATION AND
COSTS.
JUST TO DESCRIBE THE SAMPLE
BEFORE YOU, 76% OF MEDICAID
PARTICIPANTS WERE ENROLLED IN A
MEDICAID MANAGED CARE PLAN
VERSUS A FEE FOR SERVICE.
AND 82% HAD BEEN CONTINUOUSLY
ENROLLED IN MEDICAID FOR THE TWO
YEARS PRIOR TO DAY OF STUDY
ENROLLMENT BECAUSE WE HAD ALL
THE CLAIMS AND ELIGIBILITY
FILES.
TWO-THIRDS WERE FEMALE, 90% WERE
BLACK.
51% REPORTED WORKING AT THE TIME
OF ENROLLMENT, AND LESS THAN 20%
HAD NOT YET COMPLETED HIGH
SCHOOL.
41% SMOKED.
AND REPORTED THEY HAD BEEN IN A
RELATIONSHIP WITH SOMEONE WHO
HAD THREATEN THEM OR PHYSICALLY
HURT THEM.
WE HAD A HIGH PREVALENCE OF FOOD
INSECURITY IN THE SAMPLE,
TROUBLE PAYING AT LEAST ONE BILL
WE EWE THE QUESTION FROM VA
ABOUT ARE YOU CONCERNED IN THE
NEXT TWO MONTHS YOU MAY NOT HAVE
HOUSING IN 22% SAID YES.
YOU CAN SEE 48% REPORTED
RECEIVING FOOD STAMPS AND 30%
REPORTED HOUSING ASSISTANCE.
SO WE MEASURED A VARIETY OF
SOCIAL DETERMINANTS OF HEALTH.
ONE OF THE ISSUES PREVIOUS
SPEAKERS ALLUDED TO WAS THAT A
LOT OF SOCIAL DETERMINANTS ARE
CORRELATED WITH EACH OTHER, WITH
THE SUBJECT, A PERSON A PATIENT
REPORTS, HAVING HOUSING
INSTABILITY, ALSO GOING TO TELL
YOU THEY HAVE TROUBLE PAYING
RENT OR THEIR PHONE OR WHATEVER.
SO WE WERE TRYING TO DECIDE
WELL, IF YOU KIND OF LOOK AT ALL
THESE DETERMINANTS SEPARATELY,
YOU MIGHT MASK RELATIONSHIPS
THAT YOU WANT TO KNOW ABOUT,
WANT TO UNDERSTAND BETTER.
THIS SLIDE IS LIKE A HEAT MAP OF
CORRELATION AMONG THE DIFFERENT
SOCIAL DETERMINANTS MEASURED.
SO FOR EXAMPLE, IF SOMEONE
REPORTED TO US, THAT THEY USED
ELICIT DRUGS AND VERY MUCH
LIKELY TO TELL US THEY HAD A
HISTORY OF OF BEING IN JAIL OR
PRISON, THEY SMOKED.
THIS KEEFE THING.
WHAT WE DECIDED TO DO, IS USE
LATENT CLASS ANALYSIS.
WHICH GAVE ABILITY TO WHAT IT
DOES IS LOOK AT THE PATTERN OF
RESPONSES THE PARTICIPANTS HAVE
TO EACH QUESTION.
IT GROUPS PEOPLE THAT HAVE
SIMILAR RESPONSE PATTERNS AMONG
ALL THE QUESTIONS.
THAT YOU WANT TO GIVE THEM THIS
NEXT SLIDES SHOWS YOU THE USE
COME OF THAT.
WAS THE LATENT CLASS ANALYSIS,
IN OUR SAMPLE, IDENTIFIED FOUR
DISTINCT SOCIAL RISK CLASSES.
ALONG THIS X AXIS IS ALL THE
DIFFERENT SOCIAL DETERMINANTS
MEASURED AND ALONG THE Y AXIS IS
THE PREVALENCE OF THESE PROBLEMS
WITHIN EACH OF THE FOUR SOCIAL
RISK CLASSES.
FOR EXAMPLE AT THE TOP OF THE
BOX HERE I CALL THIS THE SOCIAL
RISK CLASS ONE, IS THE LABEL IS
THEY ARE EMPLOYED AND THEY HAVE
THE FEWEST SOCIAL RISKS IN
SAMPLE REPRESENTING 44%
PARTICIPANTS.
WHAT THEY ARE HIGHEST IN IS THEY
ARE NOT MARRIED NOR LIVING WITH
CHILDREN.
BUT THEIR UNEMPLOYMENT RATE IS
RELATIVELY LOW.
ONLY 26%.
YOU CAN SEE OTHER PEAKS THEY
HAVE FEW OTHER SOCIAL RISKS.
THE NEXT GROUP IS ALMOST SAME
LEVEL.
HIGHER LEVEL UNEMPLOYMENT BUT
STILL MORE THAN 50% EMPLOYED IN
THIS GROUP.
THEY ARE REPORTING A LOT OF
FINANCIAL STRAIN TROUBLE PAYING
PHONE, UTILITIES THEIR RENT.
THEY REPRESENT 20% OF OUR SYSTEM
BILL.
THE NEXT GROUP UNEMPLOYED AND --
HAVE HIGHER UNEMPLOYMENT RATE,
UP TO 75, 76% UNEMPLOYED.
THEY ALSO HAVE HIGH SMOKING
RATE, 61%, THEY HAVE LIMITED
ACCESS TO THE INTERNET.
THIS GROUP REPORTED RECEIVING
THE MOST HOUSING ASSISTANCE, AND
FOOD STAMPS.
AND REPPED 27% OF OUR SAMPLE.
THE FINAL THE POOREST SOCIAL
RISK CLASS OR HIGHEST SOCIAL
RISK CLASS IS THIS LAST GROUP,
IT IS 9% OF OUR SAMPLE, THEY ARE
ALSO VERY HIGH RATE OF
UNEMPLOYMENT AND ALSO JUST HIGH
RATES OF A LOT OF OTHER SOCIAL
RISK FACTORS.
JUST TO GIVE YOU WHEN YOU DO
THIS ANALYSIS YOU JUST LOOKING
AT THE -- IT IS NOT AGAINST ANY
OUTCOMES YOU ARE LOOK AT THE
SOCIAL RISK PROFILES BASED ON
THE QUESTIONS.
IF YOU THEN LIKE -- HOW DOES
THIS CORRELATE TO FOR EXAMPLE
HEALTH CONDITIONS.
WE TOOK THE -- WE HAVE THE TWO
YEARS OF CLAIMS DATA PRIOR TO
STUDY ENROLLMENT SO WE TOOK ALL
OF THOSE ICD 10 CODES IN THE
CLAIMS, AND ABLE TO SAY
PREVALENCE OF DIFFERENT PEOPLE
DID THEY HAVE SOME KIND OF
MENTAL HEALTH CONDITION, DO THEY
HAVE A MUSCULOSKELETAL
CONDITION.
THESE ARE TOP THREE CATEGORIES.
YOU CAN SEE BY SOCIAL RISK
CLASS, AS A SOCIAL RISK BECOME
MORE OF THEM, IF YOU MOVE FROM
SOCIAL RISK CLASS ONE WITH
FEWEST TO SOCIAL RISK CLASS
FOUR, YOU SEE INCREASE IN THE
NUMBER OF MEDICAL CONDITIONS AND
ILLNESS SEVERITY THEY HAVE.
SIMILARLY,D IF YOU DO THE SAME
WITH COST, THIS IS TOTAL COST
PER MONTH.
AND WE TOOK -- WE AGGRAVATED
EVERYONE'S -- AGGREGATED COSTS
OVER TWO YEAR PERIOD AND DIVIDED
THEM INTO QUARTILES.
SO THIS IS THE PEOPLE IN THE
LOWEST QUARTILE ONE OR PEOPLE
WITH THE LOWEST COST PER MONTH.
TO THE MEDICAID PROGRAM AND
QUARTILE 4 REPRESENTS HIGHEST.
IF YOU LOOK AT THIS BY SOCIAL
RISK CLASS, FOR EXAMPLE, CLASS
1, SOCIAL RISK CLASS ONE IS MORE
LIKELY TO BE IN THE QUARTILE ONE
WHICH IS THE LOWEST MEDICAID
COST.
PEOPLE SOCIAL RISK CLASS 4 ARE
MORE LIKELY TO BE IN THE HIGHEST
MEDICAID SPENDING CATEGORY.
SO GOING FORWARD WHAT WE DECIDED
TO DO IS RATHER THAN LOOK AT
WHAT IS THE RELATIONSHIP BETWEEN
INDIVIDUAL SOCIAL DETERMINANTS
OF HEALTH ON ED VISITS, WE LOOK
AT HOW DO FOUR SOCIAL RISK CLASS
DO THEY INFLUENCE THE ED SR VISIT
RATE.
WHAT WE THEN DID WAS TOOK
EVERYONE'S CLAIM, EACH PERSON'S
CLAIMS FOR THE TWO YEARS PRIOR
TO STUDY ENROLLMENT AND
IDENTIFIED EVERY EMERGENCY
DEPARTMENT VISIT IF THEY HAVE
ONE.
BOTH ADMITTED TO HOSPITAL AS
WELL AS TREAT AND RELEASE.
WE USE THE MINNESOTA ALGORITHM
TO CATEGORIZE THE E ED VISITS
ACCORDING TO WHERE THEY WERE
PRIMARY CARE TREATABLE VERSUS ED
CARE NEEDED.
SO THESE ARE BOX PLOTS OF THE
DISTRIBUTION OF THE DIFFERENT
KINDS OF ED VISITS BY THEIR
SOCIAL RISK GROUP.
SO FOR EXAMPLE THE PRIMARY CARE
TREATABLE VISITS, 50% OF SOCIAL
RISK CLASS 1, THIS IS 25TH AND
75TH PERCENTILE WITHIN 0 TO 2
VISITS, MAYBE ONE VISIT.
THESE DIAMONDS REPRESENT THE
MEAN NUMBER OF VISITS IN THIS
SOCIAL RISK CLASS.
YOU CAN SEE THAT AS YOU GO UP
THE SOCIAL RISK CLASS AS SOCIAL
RISK CLASS BECOMES MORE SEVERE,
THE MEAN NUMBER OF PRIMARY CARE
TREATABLE VISITS RISE.
AND IT IS EVEN MORE PRONOUNCED
AMONG THE ED CARE NEEDED VISITS.
AND ALSO WE WERE THINKING ABOUT
SOCIAL RISK CLASS AND
RELATIONSHIP TO ED VISITS, IT IS
IMPORTANT TO ALSO REMEMBER, WELL
HOW DOES ILLNESS SEVERITY PLAY
AT THIS BECAUSE OBVIOUSLY PEOPLE
WHO ARE SICKER VISIT THE
EMERGENCY DEPARTMENT MORE.
AND SO THIS JUST SHOWS YOU ALSO
WHEN YOU -- WE USE THE CHRONIC
DISABILITY PAYMENT SYSTEM, THIS
IS A RISK ADJUSTED MEASURE OR
ILLNESS SEVERITY MEASURE, IT WAS
DEVELOPED SPECIFICALLY FOR THE
MEDICAID POPULATION.
WE USE OTHER RISK AS JUSTMENT
MEASURES AND YOU WILL FIND THE
SAME PATTERN.
BUT WHAT THEY DOO IS TAKE ALL
THE DIAGNOSIS -- WHAT THEY DO IS
TAKE ALL DIAGNOSIS DOCUMENTED IN
THE CLAIMS DATA, AND THEN THEY
ASSIGN ILLNESS SEVERITY SCORE
DEPENDING HOW SEVERE THE
CONDITION IS, AND IT IS USUALLY
RELATIONSHIP TO HEALTHCARE
COSTS.
WE CATEGORIZED PATIENTS
ACCORDING TO ILLNESS SEVERITY
USING THE SCORE AND CATEGORIZED
THEM BY THE LOWEST QUARTILE, THE
LEAST SICK TO THE HIGHEST
QUARTILE TO THE MOST SICK.
AND AGAIN, YOU SEE THE PRIMARY
CARE TREATABLE AND ED CARE
VISITS ON AVERAGE RISE THE
SICKER YOU ARE.
FROMS SO WHEN WE HAD THAT
ESTABLISHED, HEN WE MODEL THESE
RELATIONSHIPS.
AND WHAT WE ARE MOST INTERESTED
IN WAS THE RELATIONSHIP OF
SOCIAL RISK CLASS.
WHAT WE SHOW THE RESULTS OF
MODELS FIRST NOT CONTROLLING FOR
ILLNESS, HOW DOES SOCIAL RISK
CLASS ADJUSTED FOR AGE AND
GENDER INFLUENCE THE ED VISIT
RATE?
THE NUMBERS IN RED HERE ARE THE
STATISTICALLY SIGNIFICANT.
AND SO WHAT IT IS SHOWING IS IF
THE PARTICIPANT WAS IN SOCIAL
RISK CLASS 2 COMPARED TO THE
MOST FAVORABLE LOWER SOCIAL RISK
CLASS THE ED VISIT RATE ON
AVERAGE IS 13% HIGHER.
37% HIGHER IF SOCIAL RISK CLASS
3 VERSUS 4 AND 59% HIGHER IF THE
WORST SOCIAL RISK CLASS COMPARED
TO THE BEST ONE.
THAT'S FOR PRIMARY CARE
TREATABLE VISITS.
THE SAME PATTERN EMERGES FOR THE
ED CARE NEEDED.
WHEN YOU CONTROL FOR ILLNESS
SEVERITY, YOU SEE THAT THE
EFFECT, IMPACT IS ATTENUATED BUT
STILL SIGNIFICANT.
SO THESE ARE -- EVEN WHEN YOU
CONTROL FOR HOW SICK A PERSON
IS, THE SOCIAL RISK HOW OFTEN
THEY VISIT THE ED FOR PRIMARY
CARE TREATABLE OR ED CARE NEEDED
VISITS IS GOING TO VARY BY YOUR
SOCIAL RISK CLASS.
WE THEN TESTED WHETHER THERE WAS
INTERACTION AFFECT.
DOES IT MATTER HOW SICK YOU ARE
AND WHAT SOCIAL RISK CLASS YOU
ARE.
ON ED VISIT RATE, WE FOUND
SIGNIFICANT INTERACTION.
SO WHAT THE PATTERN IS, IT IS
REALLY IN THE SICKER PATIENTS
THAT THE SOCIAL RISK CLASS IS
REALLY INFLUENCING THE ED VISIT
RATE.
IN OTHER WORDS WHEN YOUR ILLNESS
SEVERITY, CDPS IS RELATIVERY
LOW, WE ARE NOT SEEING A BIG
DIFFERENCE IN THE ED VISIT RATE
AMONG THE DIFFERENT SOCIAL RISK
CLASS.
ONCE YOU GET TO THE TWO HIGHER
ILLNESS SEVERITY SCORES, THEN
THE SOCIAL RISK CLASS IS MAKING
A BIG DIFFERENCE IN YOUR ED
VISIT RATE FOR PRIMARY CARE
TREATABLE AND ED CARE NEEDED.
THIS PATTERN, THIS INTERACTION
EFFECT IS OBSERVABLE REGARDLESS
OF IF PEOPLE HAVE DIABETES,
CARDIOVASCULAR, WE LOOK AT
VARIETY OF CONDITIONS THAT
PARTICIPANTS HAD.
AND WE STILL FIND THIS EFFECT.
SO IN CONCLUSION I DON'T THINK
IT IS SURPRISING THAT THE MORE
SOCIAL ADVERSITIES A PARTICIPANT
HAS THE MORE ED VISITS THEY HAVE
PRIMARY CARE TREATABLE AND ED
CARE NEEDED.
SOME OF THIS SOCIAL DETERMINANTS
EFFECT IS INDIRECT BECAUSE
SOCIAL DETERMINANTS MAKE A
PERSON I WILL, WE SEE HIGHER
MEDICAL CONDITIONS AMONG PEOPLE
WHO ARE -- HAVE MORE SOCIAL RISK
SO INDIRECT EFFECT THROUGH
MEDICAL CONDITIONS, ILLNESS
SEVERITY.
AND WILL IS A SEPARATE DIRECT
EFFECT OF SOCIAL DETERMINANTS OF
ED VISITS. THIS IS LARGELY
SEEING MORE OF EFFECT OF SOCIAL
DETERMINANTS AMONG SICKER
PATIENTS.
AND THEN FINALLY, I WOULD PUT A
PLUG, AS THAT TO ADDRESS THESE
SOCIAL DETERMINANTS WE NEED
MULTI-LEVEL INTERSECT TORR
INTERVENTIONS, THE EXAMPLE GAVE
OF HOUSING AND TRYING TO
INFLUENCE ASTHMA RATES WAS GREAT
SO HEALTHCARE PROVIDER CAN'T DO
IT ALONE, HEALTHCARE SYSTEMS
CAN'T DO IT BUT WE NEED STRONGER
PUBLIC POLICIES TO ADDRESS
INEQUITIES AND THAT CAUSED
HEALTH DISPARITIES THAT WE
SERVE.
THANK YOU.
>> THANK YOU VERY MUCH.
FINALLY FOR OUR LAST SPEAKER IN
THIS SESSION DR. MONTGOMERY.
>> ARE Y'ALL ABLE TO SEE THE
SLIDES?
>> YES, PERFECT.
THANK YOU.
>> GREAT, THANK YOU.
SO MY NAME IS ANN ELIZABETH
MONTGOMERY.
I'M A RESEARCHER WITH THE U.S.
DEPARTMENT OF VETERANS AFFAIRS.
SO I'M GOING TO TALK ABOUT HOW
ONCE WE IDENTIFY SOCIAL
DETERMINANTS OF HEALTH, AND THEN
PROVIDE SERVICES TO PATIENTS, TO
ADDRESS THOSE NEEDS, WHAT IMPACT
DOES THAT HAVE ON OUTCOMES, ON
NUMBER OF OUTCOMES BUT ALSO LOOK
SPECIFICALLY SHARE SOME
EXPLORATORY ANALYSES WE HAVE
DONE LOOKING AT EMERGENCY
DEPARTMENT USE.
JUST A LITTLE BACKGROUND.
THE U.S. DEPARTMENT OF VETERANS
AFFAIRS IS FOCUSED A LOT OF
ENERGY AND RESOURCES ON
PREVENTING AND ENDING
HOMELESSNESS AMONG VETERANS
SINCE 2009.
SINCE THAT TIME THERE'S BEEN
ABOUT A 50% REDUCTION IN THE
NUMBER OF VETERANS EXPERIENCING
HOMELESSNESS.
THE VA HAS DEPLOYED A
MULTI-TIERED STRATEGY TO PREVENT
AND END HOMELESSNESS ROUGHLY
ALONG THE THREE LEVELS OF PUBLIC
HEALTH PREVENTION.
THE PRIMARY LEVEL THERE IS
UNIVERSAL SCREENING FOR HOUSING
INSTABILITY AMONG ALL VETERAN
OUTPATIENTS.
THIS DOESN'T HAPPEN IN THE
EMERGENCY DEPARTMENT OR IN
PATIENT SETTINGS BUT VETERANS
PRESENT FOR OUTPATIENT CARE AT
ANY VA FACILITY IS ASKED
QUESTIONS ABOUT HOUSING
INSTABILITY, SAME QUESTIONS THAT
DR. MCCARTHY MENTIONED IN HER
TALK.
SECONDARY PREVENTION IS PROVIDED
THROUGH NUMBER OF TYPES OF
PROGRAMS SO PROVIDING RAPID
REHOUSING THROUGH SUPPORTIVE
SERVICES FOR VETERAN FAMILIES
FUNDS THAT VA SENDS TO COMMUNITY
BASE ORGANIZATIONS TO HELP
VETERANS TO PREVENT BECOMING
HOMELESS OR PUT THEM BACK INTO
HOUSING P THEY HAVE EXPERIENCED
HOUSING INSTABILITY.
THERE IS A NUMBER OF EMPLOYMENT
ASSISTANCE PROGRAMS, PROGRAMS
FOR VETERANS WHO ARE INVOLVED IN
CRIMINAL JUSTICE PROGRAM,
SYSTEM, AND THEN AT THE TERTIARY
LEVEL THERE IS PERMANENT
SUPPORTIVE HOUSING FOR VETERANS
WHO EXPERIENCED LONG TERM
CHRONIC HOMELESSNESS AND MAY
HAVE OTHER DISABLING CONDITIONS.
THIS IS PROVIDED THROUGH WHAT IS
COMMONLY KNOWN AS SECTION 8
VOUCHER OR HOUSING CHOICE
VOUCHER.
SO VETERANS RECEIVE A DEEP
SUBSIDY TO HELP PAY FOR THEIR
HOUSING.
BUT ALSO RECEIVE WRAP AROUND
SERVICES TO ADDRESS MENTAL
HEALTH ISSUES, MEDICAL ISSUES,
PROVIDED THROUGH THE VA.
THE VA HAS AN OBLIGATION TO
VETERANS TO NOT ONLY SERVE THEIR
MEDICAL NEEDS BUT SOCIAL NEEDS.
SO IT IS A UNIQUE PLACE TO STUDY
SOCIAL DETERMINANTS OF HEALTH
AND IMPACT ON OTHER OUTCOMES.
BECAUSE WE HAVE A NATIONAL
ELECTRONIC HEALTH RECORD SYSTEM
AND ACCESS TO NOT ONLY
INFORMATION ABOUT VETERAN
CHARACTERISTICS AND SOCIAL
DETERMINANTS OF HEALTH, THAT WE
CHECK THROUGH NUMBER OF WAYS AS
DR. VEST DESCRIBED FOR EXAMPLE,
THROUGH CLINICAL REMINDERS WHICH
IS LIKE SURVEY DATA, THROUGH
TEXT, AND NATIONAL -- NATURAL
LANGUAGE PROCESSING AND ALSO
THROUGH ICD CODES.
WE ALSO CAN LOOK AT THEIR OTHER
SERVICE ISSUES.
SO I WANT TO -- AND WITH THOSE
DATA, WE CAN LOOK AT LOTS OF
DIFFERENT OUTCOMES.
WE HAVE LOOKED AT LOTS OF
OUTCOMES INCLUDING DYNAMICS OF
HOUSING INSTABILITY, HEALTH AND
HOMELESS SERVICES USED,
DISPARITIES, MORTALITY AND
SUICIDE.
HEALTH AND HOMELESS SERVICES USE
HAS BEEN THE WORK THAT I HAVE
BEEN INVOLVED IN HAS BEEN AROUND
WHO GETS INTO SERVICE, WHO IS
REFERRED FOR PARTICULAR
SERVICES, AND AGAIN, EMERGENCY
DEPARTMENT SERVICES USE THAT I'M
GOING TO DESCRIBE, IS
EXPLORATORY BUT SHOWS
INTERESTING FINDINGS.
SO WHICH HAD A STUDY WHERE WE
LOOKED AT A COHORT OF VETERANS
WHO WE IDENTIFIED AS
EXPERIENCING HOUSING
INSTABILITY, USING DATA FROM
THEIR ELECTRONIC HEALTH RECORDS.
THEN WHETHER THEY RECEIVED
HOMELESS SERVICES AND WHAT
IMPACT THAT HAS ON THEIR ALL
CAUSE AND SUICIDE MORTALITY.
SO WE KNOW THERE IS A TEMPORAL
ASSOCIATION BETWEEN EXPERIENCE
OF HOMELESSNESS AND SUICIDALITY.
WE FOUND THAT AS THE SORT OF
DATE APPROACHES WHEN A VETERAN
IS IDENTIFIED AS EXPERIENCING
HOMELESSNESS OR REACHES OUT FOR
SERVICES IT COIN SIDES WITH A
PEAK IN -- COINCIDES WITH THE
RATE OF SUICIDE AMONG THAT
POPULATION.
VETTED RAINS WHO REPORT
SUICIDALITY HAVE RATES OF
SUICIDAL IDEATION HIGHER THAN
THOSE HOUSED.
SO WITH THIS STUDY WE WANTED TO
ASSESS USING NATIONAL SAMPLE OF
VETERANS WITH SELF-REPORTED
HOUSING INSTABILITY, WHETHER
PARTICIPATION IN HOMELESS
PROGRAMS THROUGH THE VA REDUCE
THEIR RISK OF MORTALITY.
SO AS I MENTIONED IN DIFFERENT
STUDIES WE USE DIFFERENT
CRITERIA FOR IDAPIING VETERANS
EXPERIENCING SOCIAL DETERMINANTS
OF HEALTH FOR THIS PARTICULAR
STUDY WE ONLY USED THE DATA FROM
THE UNIVERSAL SCREENING HOUSING
INSTABILITY IN THE VA.
SO OUR SAMPLE WAS 169,000
VETERANS WHO BETWEEN 2012 AND
2016 PRESENTED FOR OUTPATIENT
CARE AT A VA ACROSS THE COUNTRY
AND REPORTED THEY WERE CONCERNED
ABOUT THEIR HOUSING IN THE NEXT
TWO MONTHS OR HAD EXPERIENCED
HOUSING INSTABILITY IN THE
PREVIOUS TWO MONTHS.
A LITTLE MORE THAN HALF OF THOSE
LATER ACCESSED VA HOMELESS
PROGRAM.
THE OUTCOMES WE WERE INTERESTED
IN WAS ALL CAUSE MORTALITY AND
THEN SPECIFICALLY SUICIDE
MORTALITY.
REALLY OUR PRIMARY INDEPENDENT
VARIABLE WAS ACCESSING VHA
HOMELESS PROGRAMS, SO WE WANTED
TO LOOK SPECIFICALLY AMONG
VETERANS EXPERIENCING HOUSING
INSTABILITY, IF THEY GOT THAT,
WHAT IMPACT DID IT HAVE ON THEIR
MORTALITY.
WE RAN THREE DIFFERENT COX
REGRESSION MODELS FOR EACH OF
THE TWO OUTCOMES OF YOU WILL ALL
CAUSE AND SUICIDE MORTALITY.
WHICH OBVIOUSLY CONTROLLED FOR
VHA HOMELESS PROGRAM USE AND
ALSO VARIETY OF SOCIO
DEMOGRAPHICS, MILITARY SEXUAL
TRAUMA, DIKE NOSE SEIZE AND --
DIAGNOSES AND EVIDENCE OF
SUICIDAL IDEATION OR ATTEMPT IN
THE MEDICAL REPORT.
REPORT -- RECORD.
SO THIS POPULATION OF VETERANS
WHO SELF-REPORTED HOUSING
INSTABILITY AND DID OR DID NOT
ACCESS A VHA HOMELESS PROGRAM WE
SEE THAT THIS CHART BASICALLY
COME PARIS THE RATE OF SUICIDE
IDEATION, SUICIDE ATTEMPT, ALL
CAUSE DEATH AND SUICIDE DEATH
GATHERED FROM THE ELECTRONIC
HEALTH RECORD DATA.
THE DEATH DATA ARE A DEATH
HAPPENED OR DIDN'T AND METHOD,
EXCUSE ME THE CAUSE OF DEATH,
THERE COULD BE ISSUES AROUND
THERE.
THE SUICIDE IDEATION AND ATTEMPT
IS LIKELY UNDERREPORTED, BECAUSE
A VETERAN HAD THE SEEK CARE AND
HAD THAT AS A DIAGNOSIS IN THEIR
MEDICAL RECORD FOR US TO BE ABLE
TO ACCESS THOSE DATA.
BUT YOU CAN SEE THAT RATES OF --
THE PROPORTION OF VETERANS
EXPERIENCING HOUSING INSTABILITY
WHO DIED DURING THE OBSERVATION
PERIOD WAS HIGHER AMONG THOSE
WHO DID NOT ACCESS VHA HOMELESS
PROGRAM.
WE SEE THE RATES OF SUICIDE
MORBIDITY ARE HIGHER AMONG THOSE
WHO DID ACCESS VHA HOMELESS
PROGRAM,S AND AGAIN I THINK SOME
OF THAT IS BACK TO RELATED TO
BIAS AROUND WE KNOW MORE
INFORMATION ABOUT VETERANS OR
PATIENTS WHO ENGAGE WITH THE
SYSTEM MORE.
IN TERMS OF SUICIDE DEATH WE
DIDN'T SEE AT THIS LEVEL A
DIFFERENCE BETWEEN PROPORTION OF
VETERANS EXPERIENCING HOUSING
INSTABILITY WHO DID AND DID NOT
ACCESS HOMELESS PROGRAMS.
SO WHAT WE DID AGAIN, WE RAN
THREE DIFFERENT MODELS FOR EACH
OF OUTCOMES, SO WE SEE
CONSISTENTLY WHEN THE OUTCOME IS
ALL CAUSE MORTALITY, ACCESSING A
VHA HOMELESS PROGRAM YES OR NO,
THEY ACCESS ANY PROGRAM DURING
OBSERVATION PERIOD, MORTALITY IS
REDUCED.
THE NUMBER OF DIFFERENT PROGRAMS
MEASURE BOTH AS CONTINUOUS AND
ORDINAL MEASURE, FOR THE MOST
PART SIGNIFICANTLY REDUCED THEIR
RISK OF ALL CAUSE MORTALITY.
SUICIDE MORTALITY WE HAVE SOME
DIFFERENT SLIGHTLY DIFFERENT
OUTCOMES, WE DID FIND THIS SORT
OF MEASURE OF SERVICE USE,
WASN'T SIGNIFICANT BUT WE FOUND
THE MORE PROGRAMS, MORE
INTERACTION THAT A VETERAN WITH
SELF-REPORTED HOUSING
INSTABILITY HAD WITH VHA
HOMELESS PROGRAMS, THE MORE
ENGAGEMENT THEIR RISK OF SUICIDE
MORTALITY REDUCED OVER TIME.
SO WE WANTED TO FOLLOW-UP AND
LEARN MORE ABOUT THIS
RELATIONSHIP, WE HAVE A RECENT
WILL I FUNDED STUDY, THIS TITLE
SERVICES TO ADDRESS VETERANS
SOCIAL DETERMINANTS OF HEALTH
REDUCE SUICIDE RISK.
MANY THIS STUDY WE ARE LOOKING
AT THREE DIFFERENT ADVERSE
SOCIAL DETERMINANTS OF HEALTH,
HOUSING INSTABILITY,
UNEMPLOYMENT AND JUSTICE
INVOLVEMENT SO THIS ANALYSIS WE
MODELED WHETHER WHETHER ACCESS
TO SERVICES TAILORED TO ADVERSE
SOCIAL DETERMINANTS OF HEALTH
REDUCES THE ODDS OF HIGH
EMERGENCY DEPARTMENT USE WHICH
IS -- WE CONSIDER FOR THIS
ANALYSIS FOUR OR MORE ED VISITS
THE PAST 12 MONTHS.
THIS IS ON A COHORT OF 937,000
VETERANS WHO HAD ICD CODE, OR
SOME OTHER EVIDENCE IN MEDICAL
RECORD FOR ADVERSE SOCIAL
DETERMINANTS OF HEALTH.
AND WE FIND DIFFERENT RESULTS
FOR THE DIFFERENT SOCIAL
DETERMINANTS OF HEALTH WE LOOKED
AT.
WE SEE VETERANS FOR EXAMPLE WHO
HAVE INDICATOR OF UNEMPLOYMENT,
THOSE WHO AT LEAST HAD SOME
INTERACTION WITH EMPLOYMENT
SERVICES, WERE LESS LIKELY TO BE
HIGH ED USERS.
COMPARED TO THOSE WHO HAD NONE.
THOSE WHO HAD SORT OF MEDIUM
ENGAGEMENT WITH EMPLOYMENT
SERVICES IS PROTECTIVE AGAINST
HIGH ED USER, WE SEE THE
OPPOSITE WITH HOUSING
INSTABILITY SOMETHING WE ARE --
THIS IS THE BEGINNING OF THE
EXPLORATION BECAUSE WE NEED TO
PULL OUT DIFFERENT TYPES OF
HOUSING SERVICES THAT WERE
CONTROLLING FOR THERE.
THERE IS A VERY BIG DIFFERENCE
IN SERVICE LIKE PERMANENT
SUPPORTIVE HOUSING WHERE SOMEONE
IS IN PERMANENT HOUSING WITH
WRAP AROUND SUPPORT SERVICES AND
SOMEONE IN EMERGENCY SHELTER AND
DOESN'T HAVE A HOME.
SO I THINK THAT SOME OF -- WHILE
THE SERVICES DON'T APPEAR
PROTECTIVE FOR HIGH ED USE FOR
HOUSING INSTABILITY COHORT, IT
IS LIKELY THERE ARE DIFFERENCES
BY PROGRAMS.
SO JUST TO SUMMARIZE, AGAIN, VA
IS OBLIGATED TO ADDRESS MEDICAL
ISSUES AND NON-MEDICAL
DETERMINANTS OF HEALTH AMONG
VETERANS.
WE ARE ABLE TO USE VERY RICH
ADMINISTRATIVE DATA THE VA HAS
TO NOT ONLY IDENTIFY PATIENTS
WHO ARE EXPERIENCING WIDE
VARIETY OF SOCIAL DETERMINANTS
OF HEALTH BUT HOW SOCIAL
DETERMINANTS OF HEALTH AND
ACCESS TO SERVICES TO ADDRESS
THEM MAY MITIGATE POOR OUTCOMES.
AGAIN, WE HAVE FOUND IN OUR
PRELIMINARY ANALYSES, THE USE OF
VHA HOMELESS PROGRAMS AMONG
UNSTABLY HOUSED VETERANS IS
PROTECTIVE FOR MORTALITY.
AND PRELIMINARY RESULTS RELATED
TO ED USE IS THAT THERE IS SOME
PROMISING ASSOCIATION THERE AT
LEAST FOR UNEMPLOYMENT AND
JUSTICE INVOLVEMENT AND MORE
WORK NEEDS TO BE DONE TO TEASE
OUT THOSE AFFECTS FOR HOMELESS
PROGRAMS.
COUPLE OF REFERENCES IF YOU ARE
INTERESTED IN LEARNING MORE,
ABOUT THIS, AND HUE FOR YOUR
TIME.
>> THANK YOU SO MUCH.
ONCE AGAIN WE SEE THE ENORMOUS
POWER OF VA EHR SYSTEM AND HUE
FOR FOR THIS INSIGHT.
I WANT TO THANK DR. VEST AND
MCCARTHY AS WELL AS DR.
MONTGOMERY FOR REALLY TERRIFIC
PRESENTATIONS AND THEN I'M GOING
TO TAKE TIME TO INTRODUCE AGAIN
MY COLLEAGUES SARA HUNE WHO WILL
BE THE MODERATOR FOR THE NEXT
SESSION.
SARA.
>> THANK YOU, DOCTOR.
WELCOME TO THIS SESSION ON
HOLISTIC CARE PLANNING.
ACCESS OF EMERGENCY DEPARTMENT
AND COMMUNITY RESOURCES IN
TRANSLATE -- TRANSLATIONAL CARE.
I WOULD LIKE TO INTRODUCE ALL
THE THREE SPEAKERS FOR THIS
SESSION.
AND FIRST SPEAKER WOULD BE DR.
LAUREN TAYLOR.
DR. TAYLOR IS ASSISTANT
PROFESSOR IN THE DEPARTMENT OF
POPULATION HEALTH IN NYU
GROSSMAN SCHOOL OF MEDICINE.
HER RESEARCH EXPLORES THE
ETHICAL CHALLENGES THAT ARISE IN
MANAGING HEALTHCARE
ORGANIZATIONS.
TO DATE SHE HAS TAKEN UP
QUESTIONS ABOUT HOW TO
APPROPRIATELY DIVIDE THE LABOR
ADDRESSING SOCIAL DETERMINE
FANTASTIC, WHETHER HOSPITALS
HAVE RESPONSIBILITIES BEYOND
DELIVERY OF HEALTHCARE, HOW TO
EFFECTIVELY BUILD TRUST IN
CLINICIANS AND INSTITUTIONS AND
WHAT TECHNOLOGY PLATFORM SHOULD
PLAY IN MEDIATING COMMUNITY
CLINICAL RELATIONSHIPS.
OUR SECOND SPEAKER, DR. ALYCIA
BRISTOL.
DR. BRISTOL IS ASSISTANT
PROFESSOR AT THE UNIVERSITY OF
UTAH COLLEGE OF NURSING.
DR. BRISTOL'S RESEARCH BROADLY
SEEKS TO ADDRESS THE CARE NEEDS
OF -- AND FAMILY CAREGIVERS,
PARTICULARLY DURING THE
HOSPITALIZATIONS, AND CARE
TRANSLATION, HER RESEARCH
BACKGROUND INCLUDED EXPLORING
EXPERIENCE AND INVOLVEMENT OF
FAMILY CAREGIVERS DID YOU
RECOLLECT INTRAHOSPITAL
TRANSMISSIONS OR PATIENT
MOVEMENT DURING HOSPITALIZATION
HOSPITALIZATIONS, DR. BRISTOL IS
CURRENTLY EXAMINING THE
INFLUENCE OF INTRAHOSPITAL ON
DISCHARGE PLANNING AND OLDER AS
I ADULT AND CAREGIVER FOR THIS
CHARGE.
FINALLY, OUR THIRD SPEAKER WOULD
BE DR. MARGARET MARGARET KALOW,
PATRICIA J MALI M.D. ENDOWED
SCHOLAR IN PEDIATRIC EMERGENCY
MEDICINE RESEARCH.
ATTENDING PHYSICIAN IN BOTH,
EMERGENCY MEDICINE AND PEDIATRIC
EMERGENCY MEDICINE AT MASS
GENERAL HOSPITAL.
HER WORK FOCUSES ON DEVELOPING
INTERVENTIONS TO REDUCE
DISPARITIES IN EMERGENCY CARE,
AND DESIGNING STRATEGIES TO USE
EMERGENCY DEPARTMENT VISIT TO
ADDRESS ADVERSE SOCIAL
DETERMINANTS OF HEALTH.
PLEASE HOLD YOUR QUESTIONS FOR
THE PANEL DISCUSSION AND
SUBMITTING YOUR QUESTIONS AT ANY
TIME DURING THE PRESENTATIONS.
DURING THE BREAK WE WILL CURATE
THE QUESTIONS FOR THE MODERATOR.
THANK YOU.
I WILL TURN IT TO DR. TAYLOR.
>> WONDERFUL.
THANK YOU VERY MUCH I APPRECIATE
IT.
LET ME BE SURE Y'ALL CAN HEAR
ME, CORRECT?
>> YES.
>> WONDERFUL.
YOU CAN SEE MY SLIDES.
I SEE MICHAEL SETTING THE TABLE
FOR CONCRETE DATA ON
INTERVENTIONS AND WAYS FORWARD.
MY GOAL IS TO SET THE TABLE FOR
WHERE THE STATE OF PLAY IS
AROUND CREATING HEALTHCARE
COMMUNITY OR CLINICAL COMMUNITY
RELATIONSHIPS.
AND PARTICULARLY FOCUSED ON
TRYING TO CREATE REFERRAL
PATHWAYS FROM EMERGENCY
DEPARTMENTS TO SOCIAL SERVICE
ORGANIZATIONS OR COMMUNITY BASED
ORGANIZES.
I USE THOSE TWO TERMS VIRTUALLY
INTERCHANGEABLY.
WHAT I WOULD LIKE TO TRY TO
LEAVE YOU WITH AT THE END OF TEN
MIGHT BEES WHICH IS GOING TO GO
INCREDIBLY QUICKLY, IS THAT
NON-MEDICAL CRISES OFTEN LAND
PATIENTS IN EMERGENCY DEPARTMENT
AND I THINK FOR THOSE WHO WORK
IN THE EMERGENCY NURSING THIS IS
ALMOST SELF-EVIDENT, LET'S START
THERE.
WHEN THIS HAPPENS FRONT LINE
CLINICIANS AND NUR NURSES AND
MANAGERS WILL BE SERVED
PARTICULAR EXPERTISE SOCIAL
DETERMINANTS OF HEALTH, THAT LIE
OUTSIDE THE STANDARDS HEALTHCARE
DELIVERY SYSTEM.
THE GOAL FOR ME TODAY IS TO
ADDRESS THE QUESTION THOUGH I
WON'T FULLY ADDRESS IT, WHY HAVE
SUCH REFERRAL PATHWAYS BEEN
DIFFICULT TO ESTABLISH WHY CAN'T
IT BE A NURSE MANAGER CAN FIND
THE EMERGENCY DEPARTMENT REALIZE
WHAT THEY SEEK IS HOUSING OR
THEIR HEALTHCARE CONDITION IS
BEING SUBSTANTIALLY EXACERBATED
BY HOUSING INSTABILITY.
AND REALLY BE ABLE TO KIND OF IN
A WARM HAND OFF WITH PEOPLE WITH
HOUSING EXPERTISE. THE WAY THAT
I THINK ABOUT THIS WHOLE FIELD
OF PLAY, HOW HEALTHCARE AND
COMMUNITY BASED ORGANIZATIONS
WORK TOGETHER OR HEALTHCARE
PURSUES DELIVERY OF HOLISTIC
CARE, TITLE OUR SESSION, THERE
IS FOUR CHALLENGES OR FOUR
STRATEGIC ISSUES THAT A
HEALTHCARE MANAGER HAS TO
CONFRONTS. EN ONE WE HEARD ABOUT
TODAY IS HOW DO I SCREEN AND
IDENTIFY HIGH RISK PATIENTS OR
HOW SCREEN IDENTIFY MAYBE EVEN
NOT HIGH RISK BUT PATIENTS WITH
PARTICULAR SOCIAL NEEDS.
THE SECOND IS NOW I HAVE
IDENTIFIED PEOPLE WHO HAVE NEEDS
THAT LIE OUTSIDE MY EXPERTISE.
NOW HOW DO I THINK ABOUT MEETING
THOSE NEEDS.
THAT IS SOMETIMES CALLED A MAKE
BY DECISION, A DECISION DO I TRY
TO CULTIVATE NEW CAPACITIES
WITHIN THE HEALTHCARE SYSTEM OR
WITHIN MY CLINIC?
OR IS IT GOING TO BE A BY
STRATEGY WHICH MEANS I'M GOING
TO REFER THEM ELSEWHERE IN THE
BUY INFERS YOU WILL PAY SOME
PARTNER ORGANIZATION FOR THEIR
TIME STAFFING SERVICES. LET'S
GO WITH BY PREFERRED STRATEGY
POLICY MAKERS THEN HEALTHCARE
MANAGER IS HOW TO VET POTENTIAL
PARTNER ORGANIZATIONS, I DID A
LOT OF MY RESEARCH IN BOSTON,
AND I ONCE COUNTED SOMETHING
LIKE 50 PLUS FOOD PANTRIES IN A
TWO SQUARE MILE RADIUS.
IF YOU WERE BOSTON MEDICAL
CENTER YOU LOOK AT YOUR BACKYARD
AND YOU THOUGHT GREAT I NEED A
FOOD PANTRY PARTNER, NUTRITION
SOLUTION PARTNER, HOW DO YOU
BEGIN TO SORT THROUGH.
HOW DO YOU BEGIN TO ASSESS
QUALITY.
FINALLY SAY YOU IDENTIFY A
PARTNER AND SAY GREAT, WE ARE IN
AN OPERATIONAL RELATIONSHIP,
MONEY CHANGING HANDS IN RETURN
FOR SERVICES HOW DO WE GO ABOUT
DAY TO DAY SHARING INFORMATION
ABOUT PATIENTS.
TALKING TO ONE ANOTHER TO MAKE
SURE THAT THE HEALTHCARE
DELIVERY THAT I'M DOING AND THE
SOCIAL SERVICE DELIVERY THEY ARE
DOING IS WORKING IN CONCERT.
I WOULD SAY I THINK THE TOP TWO
HAVE BEEN ADDRESSED MORE FULLY
BY SOME OF MY PREDECESSORS HERE,
AND MY FOCUS TENDS TO BE ON
THESE BOTTOM TWO, THE VETTING OR
IDENTIFICATION OF PARTNERS,
CBOs AND THE OPERATIONAL
CHALLENGES OF WORKING WITH THEM.
SO I WOULD JUST SAY IT'S
IMPORTANT NOT TO BE AHISTORICAL
WHEN TALK ABOUT WOULDN'T IT BE
NICE TO HAVE STRONGER
COMMUNALLITY LINKAGES.
I THINK TO TAKE A LOOK AT
HISTORY TO REALIZE JUST HOW
DIFFERENTLY HEALTHCARE SERVICES
AND SOCIAL SERVICES HAVE BEEN
TREATED IN THIS COUNTRY FOR AT
LEAST 150 YEARS.
THIS HISTORY SOMETHING THAT MY
COLLEAGUE BETSY BRADLEY AND I
SPENT TIME ON IN THE AMERICAN
HEALTHCARE PARADOX, THE WHOLE OF
CHAPTER TWO WAS ABOUT TRYING TO
CHART THESE INCREDIBLY DISTINCT
PATHS EVEN AS WE RECOGNIZE
SOCIAL DETERMINANTS OF HEALTH
ARE INTEGRAL TO HEALTH, WE WANT
TO AND ASPIRE TO DELIVER
HOLISTIC CARE, THE OPERATIONAL
DEVELOPMENT OF THESE TWO SECTORS
HAS BEEN QUITE DISTINCT.
WHILE I WON'T GO INTO HISTORY
MUCH THE RESULTS ARE DISTINCT
ORGANIZATIONAL LANDS SCAPES WITH
OFTEN HUGE ORGANIZATIONS IN THE
HEALTHCARE SIDE COMPARED TO THE
SIZE OF SOCIAL SERVICE
ORGANIZATIONS.
THAT HUGENESS COMES THROUGH IN
NUMBER OF EMPLOYEES ANNUAL
REVENUE, PHYSICAL PLANT, JUST
TENDS TO REALLY BE STORY OF
DAVID AND GOLIATH.
AS I SAY IN JUST A MOMENT THE
CBOs FEEL THAT SHARPLY.
YOU HAVE PRIVATE INSURANCE,
REALLY PROPELLING HEALTHCARE
DEVELOPMENT, AND HEALTHCARE
DELIVERY.
SOCIAL SERVICE DELIVERY HAS BEEN
LARGELY MANDATE OF THE STATE,
GOVERNMENT FINANCING, ALTHOUGH
INCREASINGLY OVER THE 20TH
CENTURY, 21ST CENTURY, IT IS
AUGMENTED BY THE QUOTE UNQUOTE
THIRD SECTOR INDEPENDENT
NON-PROFITS ON CHARITABLE
CONTRIBUTIONS.
VERY DIFFERENT STAFFING MODELS,
DISTINCT REGULATORY AND PRIVACY
REGULATIONS WHICH REALLY COMES
IN TO FULL VIEW WHEN YOU
CONFRONT HIPAA CHALLENGES WITH
SHARING INFORMATION BETWEEN
HEALTHCARE AND SOCIAL SERVICES
AND THEN THIS IS THE ONE THAT I
WANTED TO TAKE 30 SECONDS ON.
DISTINCT CONCEPTIONS WHAT GOOD
QUALITY OR MANAGEMENT LOOKS
LIKE.
A LOT OF THIS IS COMING NOT ONLY
OUT OF STUDIES OF HISTORY BUT
NOW PROBABLY UPWARDS OF 150
CONVERSATIONS WITH HEALTHCARE
AND SOCIAL SERVICES FOLKS ABOUT
RELATIONSHIP TO ONE ANOTHER.
WHEN I TALK TO HEALTHCARE FOLKS
AND SAY WHAT DOES GOOD QUALITY
CARE LIKE, OFTEN WHAT PEEP POINT
TO IS TO SAY GOOD QUALITY CARE
IS DELIVERING THE SAME SERVICE
TO THE SAME CASE PRESENTATION
EACH TIME.
SO WHATEVER THE PERSON SHOWS UP
WITH I MAKE AN IDENTIFICATION OF
WHAT I THINK THE DIFFERENTIAL IS
OR WHAT THEY NEED AND REGARDLESS
OF RACE GENDER AGE, I'M FLYING
TO -- CONFINED TO THOSE
CHALLENGES UNLESS MEDICALLY
RELEVANT AND I HIT THE MARK WITH
LIKE A PRETTY PROTOCOLIZED
APPROACH TO PROBLEM SOLVING.
SO THERE'S SOMETHING ABOUT
SAMENESS ROUTINENESS, PROTOCOLS,
THAT REALLY STANDS OUT AS A
HALLMARK OF GOOD CARE.
MY MOM JUST WENT INTO THE
HOSPITAL A COUPLE OF WEEKS AGO
AND SHE GOT PUT ON A SEPSIS
PROTOCOL THAT WE ARE SURE SAVE
HER LIFE, THAT IS GOOD IN
HEALTHCARE.
WHEN I TALK ABOUT WHAT GOOD LOOK
LIKE IN A CBO OR SOCIAL SERVICE
WORLD THE WORDS THAT PROTOTO TOP
ARE INCREDIBLY DIFFERENT.
WHEN I SAY WHAT IS THAT LOOK
LIKE THEY SAY IT LOOKS LIKE
TAILORING SERVICES TO THE
INDIVIDUAL IN FRONT OF ME.
NO TWO PEOPLE RECEIVE THE SAME
THING BUT INSTEAD WE HAVE
CURATED OR ADAPTED WHAT WE ARE
ABLE TO PROVIDE FOR THAT PERSON
OR FAMILY CIRCUMSTANCES.
I P NOT SAYING THE TRUTH DOESN'T
LIE IN BETWEEN OR BOTH
HEALTHCARE AND SERVICES NEED
BOTH APPROACHES BUT THERE ARE,
DIFFERENT EMPHASES ON
STANDARDIZATION VERSUS
CUSTOMIZATION AND THAT WILL MAKE
IT DIFFICULT FOR TWO SECTORS TO
COME UP WITH UNIFIED PLAN OF
ACTION, A CONCEPTION OF WHAT
CERTAIN SERVICES ARE WORTH, AND
WHAT SHOULD BE PAID FOR THEM.
HEALTHCARE SERVICE
RELATIONSHIPS, WITH PUBLISHED
QUARTERLY BACK IN DECEMBER OF
2020.
THE HIGH TAKE AWAY POINTS HERE,
QUALITATIVE STUDY OF COMMUNITY
BASED ORGANIZATIONS IN
MASSACHUSETTS.
IT WAS INCLUSIVE OF HOUSING
TRANSPORTATION NUTRITION, LOTS
OF COMMUNITY CENTERS, SOME JOB
TRAINING AND EDUCATION.
QUITE A DIVERSE SET.
CERTAINLY FUTURE WORK IN THIS
AREA SHOULD START QUICKLY
DRILLING DOWN BECAUSE THOSE ARE
NOT ALL THE SAME, WE NEED MORE
SPECIFIC UNDERSTANDING WHAT IS
PARTICULAR TO HOUSING DIFFERENT
FROM NUTRITION.
FOR THIS STUDY DATA COLLECTING
2018, PAINT WITH BROAD BRUSH AND
I WOULD SAY ONE THING WE HEARD
AGAIN AND AGAIN IS THEY ARE
FINANCIALLY PRECARIOUS.
YOU CAN SEE THAT IN QUOTE.
THAT STRATEGIC INTEREST
PARTNERING WITH HEALTHCARE.
WHAT THAT SOUNDED LIKE IN CBOs
WERE THINGS LIKE A CBO LEADER
MORE DELIBERATE EFFORT TO MARKET
AND TRY TO DEVELOP RELATIONSHIPS
FOR REFERRALS SPECIFICALLY FOR
THE HEALTHCARE PROVIDERS.
I THINK ANYTHING WE CAN TRY TO
DO TO GET SERVICE PROVIDERS
PARTICULARLY HOSPITALS WHO HAVE
PRETTY SIGNIFICANT RESOURCES AT
HAND TO CONNECT WITH COMMUNITY
ORGANIZATIONS, IS A GOOD THING.
SO LOOK AT THIS SLIDE, YOU SET
UP HOLISTIC CARES PARTNERSHIP
BETWEEN HEALTHCARE AND SOCIAL
SERVICES AND HERE YOU ARE
TELLING US SERVICES ARE GAME AND
WANT TO PARTNER.
SO WHAT IS THE CHALLENGE HERE.
THE CHALLENGE IS REALLY IN THE
SPECIFICS AND DETAILS OF HOW
THESE CONNECTIONS CAN BE FORGED.
AGAIN AND AGAIN THOUGH CBO SAID
TO ME YEAH, CONCEPTUALLY I VERY
MUCH WANT TO A RELATIONSHIP WITH
HEALTHCARE.
THEY ALSO REPORTED BUT WE HAVE
TROUBLE FINDING OUR WAY AND
GETTING IN THE SAME ROOM AND
AGREEING ON WHAT WE SHOULD BE
DOING.
THIS IS EMBLEMATIC QUOTE, WHAT
WE LEARNED FROM MEETING A COUPLE
OF MONTHS AGO, WE SPEAK ENTIRELY
DIFFERENT LANGUAGE.
SITTING HOSPITAL PEOPLE HAVING
LUNCH AND WE WERE TALKING FOR
TEN MINUTES, ACTUALLY WE HAVE NO
IDEA WHAT YOU SAID.
THIS COMES UP AGAIN AND AGAIN.
ONE FAVORITE STORY ABOUT HOW
HEALTHCARE AND SOCIAL SERVICES
CAN BE TWO PLANES IN THE NIGHT
-- OR SHIPS IN THE NIGHT IS CBO
SAYING TO ME THIS WAS SOMEONE
WHO RAN HOUSING ORGANIZATION AND
HAD A DIRECT LINE TO THE TENANT
ORGANIZATION.
SO SOMEONE IN THE HOSPITAL AND
RURAL COMMUNITY CALL AND SAID
CAN YOU ROUND UP TENANTS AND
MAKE IT TO THIS MEETING NEXT
WEEK.
SO THE HOUSING PROVIDERS SAID
SURE, THAT SOUNDS LIKE A GOOD
OPPORTUNITY.
SO GOT A FEW TOGETHER, THEY ALL
WENT TO THE HOSPITAL, THESE TEND
TO HAPPEN ON HEALTHCARE
TERRITORY.
BUT THEY WENT TO HOSPITAL AND
HAD THE MEETING.
AND THE HOUSING LEADER SAID TO
ME IT WAS JUST SO DEEPLY
UNCOMFORTABLE BECAUSE WE GOT
THERE AND THERE THEY HAD BROUGHT
FIVE OR SIX PEOPLE FROM THE
HEALTHCARE ORGANIZATION ALL WHOM
ARE DRESSED TO THE NINES.
IN VERY, VERY FANCY CLOTHES.
ALL THE HEALTHCARE PEOPLE SAT ON
ONE SIDE OF THE TABLE AND WE
WOUND UP ON THE OTHER SIDE OF
THE TABLE.
THEY DIDN'T HAVE AN AGENDA.
THE HEALTHCARE PEOPLE SAT THERE
AND SAID WE WANT YOU TO TELL US
WHAT IT IS LIKE LIVERING IN SUCH
AND SUCH PUBLIC HOUSING
DEVELOPMENT.
I THINK IT IS AN INTERESTING
STORY BECAUSE I COULD FEEL
CLEARLY THIS HOUSING PERSON FELT
A LITTLE LIKE INSULTED, MAYBE
MOVING TOWARDS OFFENDED BY THE
MEETING YET I COULD ALSO
INTERNALIZE OH, THESE FOLKS GOT
DRESSED TO THE NINES FOR THE
MEETING.
IN SOME WAY THAT IS A SIGN OF
RESPECT.
THAT'S HEALTHCARE TRYING TO SHOW
UP AND SAY WE TAKE YOU VERY
SERIOUSLY.
WE WANT TO LISTEN CLOSE TO WHAT
YOU HAVE TO SAY.
THE NO AGENDA, MAN IT MUST HAVE
TAKEN RESTRAINT OR DO YOU HAVE
TAKEN RESTRAINT FOR THESE
HEALTHCARE FOLKS TO GO IN AND
SAY THE FLOOR IS YOURS, TELL US
ABOUT YOUR LIVED EXPERIENCE.
AND NOT DRILL DOWN TO HERE IS
AGENDA A THROUGH E AND WE ARE
OPERATIONAL RIGHT NOW.
SO AGAIN NICE STORY NOT BECAUSE
IT PAINTS HEALTHCARE AS 100% OF
THE LENS BUT SHOWS HOW THE SAME
ACTION CAN MEAN VERY DIFFERENT
THINGS TO HEALTHCARE AND SOCIAL
SERVICES.
I WANT TO END BY SAYING I THINK
CHANGES IS A FOOT AND CHANGE IS
AFOOT FOR HEALTHCARE COMMUNITY
ORGANIZATIONS AND RELATIONSHIPS
BECAUSE OF ARRIVAL OF NEW
TECHNOLOGY PLATFORMS AN BUSINESS
MODELS.
SO I WANT TO CLOSE BY SUGGESTING
THAT THE ARRIVAL OF THESE
TECHNOLOGY PLATFORMS AND YOU
MIGHT KNOW SOME OF THE NAMES
LIKE UNITE US, THEY STAND TO
RESHAPE THE HEALTHCARE CBO
RELATIONSHIPS BY THREE, ONE
FACILITATING ELECTRONIC
REFERRAL, TWO, ALLOWING A MODE
FOR CONSISTENT PAYMENT, TO
CBOs FROM HEALTHCARE.
THREE, BRINGING IN A NEW -- I HE
HESITATE TO SAY AGE BUT NEW
GUISTE AROUND QUALITY
MEASUREMENT IN THE SOCIAL
SERVICES DELIVERY SECTOR.
THESE ARE THE BIG NAMES IN THE
INNOVATION PLATFORM SPACE,
SHOULD BE ON HERE, THERE IS A
LOTTED LINE BETWEEN UNITE US AND
NOW POW BECAUSE IT ACQUIRED NOW
POW NOT LONG AGO.
AS I SEE IT, THERE IS ONGOING
FOOT RACE BETWEEN PLATFORM
COMPANIES WHO ARE TRYING TO GET
IN WITH HEALTHCARE CLIENTS
HEALTHCARE IS PAYER FOR YOUR
SERVICES STATE BY STATE THESE
COMPANIES ARE DUKING IT OUT.
MARKET BY MARKET.
TO TRY AND GET THOSE HEALTHCARE
ORGANIZATIONS SIGNED UP BECAUSE
ONCE THEY ARE SIGNED UP YOU CAN
ONLY BE A PLAYER WITH ONE OF
THESE.
YOU SIGN ON GENERALLY TO ONE
NETWORK OR THE OTHER.
SO I'M WORKING ON A PIECE NOW
AND I WILL CLOSE WITH THIS
SLIDE.
TRYING TO SUGGEST THESE STOH
PLATFORMS OR TECHNOLOGY
COMPANIES REALLY STAND TO BE
MARKET MAKERS.
THAT IS A LITTLE BIT OF
CONTROVERSIAL IDEA, BUT I THINK
THEY DO STAND TO BE MARKET
MAKERS IN TERMS OF CONNECTING
HEALTHCARE SOCIAL SERVICE
ORGANIZATIONS AND POSITIONING
HEALTHCARE AS POTENTIAL BUYER OF
SOCIAL SERVICE.
THIS IS FACILITATED BY STATE
POLICIES EMPHASIZING HEALTHCARE
TO HAVE PAID CONTRACTS WITH
COMMUNITY BASED ORGANIZATIONS.
THIS IS CERTAINLY THE CASE,
CURRENTLY BASED AND CERTAINLY
THE CASE IN MAZAMA WHERE WHERE I
WAS FOR Ph.D..
THE TWO THINGS THAT I THINK ARE
HAPPENING QUICKLY AS A RESULT OF
THESE PLATFORMS IS THEY ARE
FACILITATING BIDIRECTIONAL
REFERRALS, BY LIMITING
ADMINISTRATIVE HASSLE, NO LONGER
IF YOU ARE REALLY IN MESH ON
THESE TECHNOLOGY PLATFORMS DO
YOU HAVE TO GO TO PEN AND PAPER,
PICK UP THE PHONE THE MAKE A
PARTICULAR CALL, GET THE
PARTICULAR PERSON YOU NIGHT KNOW
AT SHELTER INSTEAD IT CAN BE
FAIRLY AUTOMATED AND KIND OF ONE
CLICK.
THEN THEY ALSO LOWER SEARCH
COSTS.
BY WHICH I MEAN THE TIME NEEDS
TO SPEND -- USED TO TAKE TO SAY
PATIENT WHAT IS YOUR HOME ZIP
CODE, SHOULD I FIND SOMETHING
CLOSE TO ZIP CODE, CLOSE TO BUS
ROUTE, HOW SHOULD I START THESE.
ALL THAT LITERAL SEARCHING FOR
WHICH CBO MIGHT BE MOST
APPROPRIATE FOR PATIENT CAN BE
DONE QUITE QUICKLY.
THAT REDUCTION IN SEARCH COSTS
ARE MEANINGFUL.
SO I THINK IN SOME WAYS IF YOU
ARE ENTHUSIAST FOR HOLISTIC CARE
AND HEALTHCARE SOCIAL SERVICE
RELATIONSHIPS THESE TECHNOLOGY
PLATFORMS ARE IN MANY RESPECTS
GOOD NEWS.
ONE THING I WOULD SAY WE SHOULD
ALL KEEP OUR EYES OPEN TO, IS
THE RISK OF HAVING A HUGE AMOUNT
OF DATA COLLECTED IN WHAT IS
LIKELY TO ONE DAY BE
MONOPOLISTIC PROVIDER.
I SAY PRIVATE BECAUSE THIS LAST
POINTS IS JUST THAT IS
INTERESTING FROM POLITICAL
ECONOMY PERSPECTIVE TO THINK
ABOUT WHAT IT MEANS TO HAVE
LARGELY VENTURE CAPITAL BACKED
PRIVATE COMPANIES MEDIATING
LARGELY NON-PROFIT
RELATIONSHIPS.
SO IF YOU THINK ABOUT PULL
TECHNOLOGY COMPANIES OUT FOR A
MOMENT, WE HAVE MOSTLY
NON-PROFIT HEALTHCARE DELIVERY
SYSTEMS.
NOT EXCLUSIVELY BUT MOSTLY.
AND MOSTLY NOT PROFIT SOCIAL
SERVICE PROVIDERS.
THEN IF YOU THINK THESE
RELATIONSHIPS ARE GOING TO BE
MEDIATED BY AND MADE MORE COMMON
AS A RESULT OF UNITE US OR OTHER
LOOK ALIKES YOU SUDDENLY HAVE A
LITTLE BIT OF A DIFFERENT
LANDSCAPE TO THINK ABOUT WHAT IS
IN THE PUBLIC INTEREST AND IS
THERE A RISK THAT AS HE IS
PLATFORMS GROW LARGER AND LARGER
AND LARGER.
AS I SAID IT IS A FOOT RACE, I
DON'T THINK MANY WILL WIN, I
THINK WE WILL HAVE BASICALLY ONE
WINNER PER MARKET.
THEN ARE THERE THINGS WE SHOULD
JUST BE THINKING DIFFERENTLY
ABOUT.
IN TERMS OF THE REGULATION OF
THESE PLATFORMS TO MAKE SURE
THAT THEY CONTINUE TO SERVE
PUBLIC INTEREST AND MOST
IMPORTANTLY PATIENT INTEREST.
I HOPE I WET THE PALATE A BIT.
I WILL PAUSE THERE AND TAKE ANY
QUESTIONS ON ANYTHING COMMUNITY
CLINICAL RELATIONSHIPS, TRUST
WHICH I DIDN'T TALK ABOUT A TON
HERE OR THESE TECHNOLOGY
PLATFORMS ON BACKSIDE.
THANKS VERY MUCH.
>> THANK YOU, DR. TAYLOR.
I AGREE, A LOT OF THINGS YOU
SHARED WITH US.
NEXT SPEAKER WILL BE DR.
BRISTOL.
>> HELLO, WELCOME.
CAN YOU SEE MY SLIDES?
THEY ARE IN PRESENTER VIEW.
PERFECT.
OKAY.
IT IS AN HONOR TO BE HERE TODAY
PRESENTING AND I WANT TO THANK
ALL PREVIOUS SPEAKERS FOR THEIR
PRESENTATIONS, I TRULY ENJOYED
EACH AND EVERY ONE.
TODAY I WILL BE TALKING ABOUT
HIGHLIGHTING CARE TRANSITION IN
EMERGENCY DEPARTMENT AND REALLY
THINKING ABOUT HOW IMPORTANT
ASSESSMENT OF SOCIAL LEADS ARE
DURING TRANSITION AND ROLE OF
CAREGIVERS.
I HAVE NO NO DISCLOSURE AND I
WANTED TO ACKNOWLEDGE FUNDING
WAS SUPPORTED THROUGH A PILOT
GRANT FROM THE M ETHEL JONES
NURSING RESEARCH CENTER AT THE
UNIVERSITY OF UTAH.
WHEN WE THINK ABOUT CARE
TRANSITIONS IN THE EMERGENCY
DEPARTMENT, WE OFTEN MIGHT HEAR
THE THOUGHT ABOUT REVOLVING
DOOR.
PATIENTS ARE FREQUENTLY ENTERING
LEAVING AND REENTERING THE
EMERGENCY DEPARTMENT.
IT IS IMPORTANT WHEN WE THINK
ABOUT THESE TRANSITIONS AND
PATIENTS WE ALSO THINK ABOUT WHO
IS ACCOMPANYING PATIENTS.
FREQUENTLY WHEN WE THINK ABOUT
OLDER ADULT PATIENTS, WE KNOW
THAT THEY RELY ON CAREGIVERS OR
FAMILY AND FRIENDS WHO STEP INTO
CARE GIVING ROLE TO HELP SUPPORT
THEM AS THEY NAVIGATE THE
HEALTHCARE SYSTEM AND AS THEY
ARE DEALING WITH CHANGES IN
THEIR HEALTH STATUS.
AND FREQUENTLY DURING THE THE
ENTRY INTO THE EMERGENCY
DEPARTMENT CAREGIVERS MAY BE
OVERLOOKED.
THERE IS A LOT OF EMPHASIS
PLACED ON PATIENTS AND
ADDRESSING PATIENT NEEDS WHICH
IS OF COURSE IMPORTANT BUT
CAREGIVERS REPRESENT KEY SOURCES
OF INFORMATION FOR HEALTHCARE
PROFESSIONALS, ESPECIALLY WHEN
WORKING WITH OLDER ADULTS WHO
HAVE COGNITIVE IMPAIRMENT OR
OTHER CHALLENGES.
SO IT IS IMPORTANT TO THINK
ABOUT HOW WE ALSO CAN ASSESS AND
INCLUDE CAREGIVER SOCIAL NEEDS
WHEN WE ARE LOOKING AT CARE
TRANSITION.
THERE ARE DIFFERENT CARE
TRANSITIONS THAT OCCUR MANY THE
EMERGENCY DEPARTMENT.
OF COURSE THERE ARE COMMUNITY TO
ED TRANSITIONS, SUCH AS COMING
FROM A HOME STUDY LONG TERM CARE
OR OTHER FACILITY INTO THE
EMERGENCY DEPARTMENT.
WE HAVE OUR ED BACK TO COMMUNITY
TRANSITIONS THAT ARE ALSO
REFERRED TO AS ED DISCHARGE.
THEN WE HAVE OUR ED TO INPATIENT
TRANSITION.
THESE ARE REFERRED TO AS
INTERHOSPITAL TRANSITIONS WHICH
REPRESENT THE MOVEMENT OF A
INDIVIDUAL FROM EMERGENCY
DEPARTMENT TO A CRITICAL CARE
UNIT OR MEDICAL SURGICAL UNIT.
AS WELL AS MOVEMENTS THAT MIGHT
OCCUR WITHIN THE SAME UNIT.
SO AN INDIVIDUAL MIGHT BE MOVED
WITHIN THE EMERGENCY DEPARTMENT
FROM ROOM -- ONE ROOM TO
ANOTHER.
IT IS IMPORTANT WE CONSIDER
THESE DIFFERENT TRANSITIONS
BECAUSE THEY ARE THEY CAN BE
INFLUENCED BY THE ENVIRONMENT OF
THE HEALTHCARE SYSTEM.
IN CARE TRANSITIONS, THERE IS A
LOT OF EMPHASIS PLACED ON
PROMOTING WELL COORDINATED
MOVEMENTS, INVOLVING PATIENT
CAREGIVER VOICES, HOWEVER, DUE
TO ENVIRONMENTAL ISSUES, SUCH AS
OVERCROWDING, STAFF SHORTAGES,
ALL THOSE CAN CHALLENGE THE
ABILITY OF HEALTHCARE
PROFESSIONALS TO MAINTAIN A HIGH
LEVEL OF CARE COORDINATION.
ONE WAY TO ENSURE PATIENTS NEEDS
ARE INCLUDED IN OUR -- AND ARE
CONSIDERED WHEN PLANNING TO MOVE
PATIENTS OR TRANSFER THEM
BETWEEN DIFFERENT CARE SETTINGS
IS TO INCLUDE SOCIAL NEEDS
ASSESSMENT AS HAS BEEN
HIGHLIGHTED IN MANY
PRESENTATIONS HERE TODAY.
AND WHEN WE ARE LOOKING AT
CAREGIVERS SOCIAL NEEDS
ASSESSMENT HELP PROMOTE AND
RECOGNIZE PRIORITIES THAT
CAREGIVERS MIGHT BE WORRIED
ABOUT, MIGHT BE CONCERNED ABOUT
AS THEY ARE ASSUMING NEW CARE
DUTIES OR AS THEY MIGHT BE
THINKING ABOUT CARE THAT THEY
MUST DELIVER POST DISCHARGE, AND
SO WHEN WE LOOK AT CAREGIVERS
ARE WE ADDRESSING SOCIAL NEEDS
EARLY DURING THESE TRANSITIONS
RATHER THAN WAITING FOR DISOF
DISCHARGE WHEN THINGS ARE
RUSHED, CHAOTIC AND WE MIGHT BE
MISSING KEY SOCIAL NEEDS THAT
WOULD IMPACT POST DISCHARGE CARE
AND THAT MIGHT INFLUENCE RETURN
VISIT BACK TO THE EMERGENCY
DEPARTMENT.
TO BETTER UNDERSTAND HOW SOCIAL
NEEDS CURRENTLY ADDRESS DURING
CARE TRANSITIONS IN THE
EMERGENCY DEPARTMENT, AS MEMBER
OF THE CARE TRANSITIONS GROUP,
THE GERIATRIC EMERGENCY CARE
APPLIED RESEARCH NETWORK, WE
CONDUCTED A SCOPING REVIEW TO
SEE WHAT INTERVENTIONS WERE IN
USE AND HOW THEY WERE ADDRESSING
SOCIAL NEEDS.
WE FOUND OUT OF 248 ARTICLES, 17
MET INCLUSION CRITERIA, THAT WAS
LOOKING AT THE DISCHARGE OF
PATIENTS FROM THE EMERGENCY ROOM
TO COMMUNITIES SETTINGS SUCH AS
HOME, LONG TERM CARE, ASSISTED
LIVING.
THEN OUR OUTCOME OF INTEREST
LOOKING AT HEALTHCARE
UTILIZATION OR RETURN VISITS TO
THE EMERGENCY DEPARTMENT AS WELL
AS FOLLOW-UP APPOINTMENTS AND
OTHER PATIENT REPORTED OUTCOMES.
WE DID FIND MAJORITY OF THESE
CARE TRANSITION INTERVENTIONS
ADDRESS AT LEAST ONE SOCIAL NEED
AND WE SAW A VARIETY OF FACTORS
LOOKING AT ACCESS TO FOOD ACCESS
TO HEALTHCARE SERVICES, AND
ACCESS TO MEDICATIONS.
OR SOME COMBINATION OF THOSE
FACTORS.
VERY FEW CONSIDERED
TRANSPORTATION OR INTERVENTION
TARGETING HOUSING OR FINANCIAL
CONCERNS.
NO CARE TRANSITION INTERVENTION
CONSISTENTLY REDUCE SUBSEQUENT
HEALTHCARE UTILIZATION OR OTHER
PATIENT CENTERED OUTCOMES SUCH
AS QUALITY OF LIFE OR FUNCTIONAL
STATUS.
THE OTHER KEY ASPECT TO THAT WAS
MISSING FROM INTERVENTIONS WAS
THERE WAS A LACK OF CONSISTENT
CONSIDERATION OF CAREGIVER
SOCIAL NEEDS AS WE KNOW WITH
OLDER ADULTS RELY ON CAREGIVERS
OFTEN FOR TRANSPORTATION FOR
HELP WITH FOOD PREPARATION, WITH
HELP WITH GOING TO DIFFERENCE
HEALTHCARE APPOINTMENTS AND SO H
IS A CRITICAL GAP THAT CAN
REALLY BE INFLUENCING THE
POTENTIAL REASONS FOR WHY
PATIENTS ARE RETURNING TO THE
EMERGENCY DEPARTMENT OR SEEKING
OUT FURTHER AID AS WE ARE
OVERLOOKING HOW CAREGIVERS WHAT
THEIR NEEDS ARE, AND HOW WE --
HOW THEY ARE CRITICAL TO
SUPPORTING THE PATIENT OUTCOMES.
WHILE WE HAVE LOOKED IN THE
LITERATURE THE TRANSITION FROM
THE EMERGENCY DEPARTMENT TO
COMMUNITY OR COMMUNITY TO THE
EMERGENCY DEPARTMENT, WHICH IS
HIGHLIGHTED CHALLENGES RELATED
TO COMMUNICATION, AND
COMMUNICATING THE HEALTH STATUS
OF PATIENTS, VERY LITTLE IS
KNOWN ABOUT THE TRANSITIONS THAT
OCCUR WITHIN THE HOSPITAL AND
HOW THAT INFLUENCES CAREGIVER
ABILITY TO SUPPORT INDIVIDUALS
IN THE COMMUNITY OR POST
DISCHARGE AND HOW THAT MIGHT
RELATE THEN TO THE READMISSION
TO HOSPITAL OR RETURN VISIT TO
THE EMERGENCY DEPARTMENT.
TO BEGIN TO DEVELOP THIS
UNDERSTANDING WE ARE CURRENTLY
CONDUCTING A PILOT STUDY THAT IS
LOOKING AT PATIENT AND CAREGIVER
REPORTED DISCHARGE READINESS
SCORES WITH PATIENT FACTORS AND
THE NUMBER OF TRANSITION OF
PATIENT EXPERIENCE DURING
HOSPITALIZATION.
WE HAVE ALSO CONDUCTED
INTERVIEWS WITH CAREGIVERS.
WE HAVE FOUND THROUGH LOOKING AT
THESE IN PATIENT TRANSFERS AN
CAREGIVER DISCHARGE READINESS,
THAT WHEN WE SEE FEWER
TRANSITIONS, WE DO SEE HIGHER
REPORTED CAREGIVER READINESS,
THIS IS OUR PRELIMINARY RESULTS
THAT HAVE NOT BEEN PUBLISHED.
BUT WE DO SEE THIS ASSOCIATION
AND WHEN WE HAVE RUN OUR
LOGISTIC REGRESSION WE SEE THAT
THIS IS SIGNIFICANT FOR
CAREGIVERS BUT IT IS NOT
SIGNIFICANT FOR PATIENTS.
SO WILL IS A LIKELIHOOD WHEN
PATIENTS ARE EXPERIENCING
NUMEROUS TRANSITIONS WITHIN THE
HOSPITAL SETTING, THAT THE
CAREGIVERS MAY FEEL LESS
PREPARED FOR POST DISCHARGE
CARE.
ADDITIONALLY WE HAVE FOUND THERE
IS A RELATIONSHIP, THE
RELATIONSHIP BETWEEN CAREGIVER
AND PATIENT IS INFLUENCING
CAREGIVER DISCHARGE READINESS
SCORES.
WE FOUND THAT WHEN THE CAREGIVER
HAS A SPOUSAL OR PARTNER
RELATIONSHIP WITH THE PATIENT
THEY ARE 121% MORE LIKELY TO
FEEL READY FOR DISCHARGE VERSUS
CAREGIVERS WHO DON'T -- WHO HAVE
A NON-SPOUSE RELATIONSHIP.
THIS IS ECHOED IN OUR
QUALITATIVE FINDINGS.
WHEN WE INTERVIEWED CAREGIVERS
WE FOUND THAT WHILE CAREGIVERS
ACKNOWLEDGED THAT THEY WERE IN
-- THEY RECEIVE DISCHARGE
EDUCATION, DISCHARGE INSTRUCTION
THEY REPORTED THAT IT WAS A VERY
PASSIVE EVENT, THEY WERE HANDED
INFORMATION THAT WAS PRINTED OUT
THAT WAS NOT ALWAYS TAILORED TO
THEIR SPECIFIC POST DISCHARGE
CARE.
BUT THEY DID REPORT THEY
RECEIVED IT AND THEY WERE --
THEY APPRECIATED THOSE HAND
OUTS.
HOWEVER, WE SEE INSTANCES WHERE
CAREGIVERS RECOGNIZE THEY STILL
WERE NOT TRULY PREPARED FOR THE
BURDEN OF CARE THEY MIGHT FACE
AFTER LEAVING THE HOSPITAL
SETTING.
THIS CAREGIVER SHARED HOW SHE
RECEIVED TECHNICAL INFORMATION
ABOUT USING THE OXYGEN TANK BUT
THERE WAS STILL A LOT OF WORRY
SHE EXPERIENCED BECAUSE THE
PATIENT SHE FELT WAS STILL VERY
ILL.
WE SEE THIS ECHOED IN PREVIOUS
WORK WHEN LOOKING AT CAREGIVERS
AND THEIR REPORTED BURDEN.
WE KNOW WHEN CAREGIVERS FEEL
UNPREPARED FOR POST DISCHARGE
CARE, THEY ARE MORE LIKELY TO
SEEK OUT RETURN VISIT TO
EMERGENCY DEPARTMENT.
OR TO SEEK PLACEMENT OF THE
INDIVIDUAL IN SOME KIND OF LONG
TERM CARE SERVICE.
ASSISTED LIVING FACILITY, OR
SOMETHING SIMILAR.
ADDITIONALLY THIS CAREGIVER
SHARED HOW THEY RECEIVED
INFORMATION ABOUT MEDICATION AND
RECEIVED INFORMATION ABOUT WHO
TO CONTACT IF SOMETHING WERE TO
HAPPEN BUT MENTAL HEALTH OF THE
PATIENT WAS LARGELY OVERLOOKED.
AND THE CAREGIVER WAS EXTREMELY
WORRIED ABOUT HOW TO ADDRESS
MENTAL HEALTH NEEDS OF THE
INDIVIDUAL, HOW TO SUPPORT THIS
INDIVIDUAL.
FINALLY WE HAVE THIS FROM A
NON-CAREGIVER WHO SHARED THEIR
EXPERIENCES WITH DISCHARGE AND
HIGHLIGHTED HOW NON-TRADITIONAL
RELATIONSHIPS BETWEEN CAREGIVER
AND PATIENTS PLACES ADDITIONAL
BURDENS AND BARRIERS TO BEING
INCLUDED DURING CARE TRANSITIONS
AND DISCHARGE PLANNING.
THIS CAREGIVER WAS NOT NOTIFIED
UNTIL THE DAY AFTER DISCHARGE
THE PERSON HAD BEEN DISCHARGED.
THIS WAS A EXTREMELY DIFFICULT
AS THE PATIENT WAS HOMELESS AND
CAREGIVER HAD MADE PLANS FOR THE
INDIVIDUAL TO COME AND LIVE WITH
HER.
WE SEE THIS ECHOED IN PREVIOUS
WORK LOOKING AT INTERHOSPITAL
TRANSITIONS.
WHEN CAREGIVERS FEEL LEFT OUT OF
TRANSITIONS, THEY TEND TO HAVE
NEGATIVE VIEWS OF THE HEALTHCARE
SYSTEM, THEY LOSE TRUST AND THEN
THERE IS WORRY ABOUT ADHERENCE
TO FOLLOWING INSTRUCTIONS OR
LOOKING AT THE ACTS OF
HEALTHCARE PROFESSIONALS IN A
POSITIVE MANNER.
SO OUR FUTURE DIRECTIONS THEN
WOULD INCLUDE THINKING ABOUT
DEVELOPING THE SPECIFIC
INTERVENTIONS AND TOOLS THAT
WOULD PROMOTE INVOLVEMENT OF
CAREGIVERS DURING THESE
TRANSITIONS IN PARTICULAR HOW WE
CAN INCLUDE ASSESSMENT OF
CAREGIVER SOCIAL NEEDS DURING
THESE CARE TRANSITIONS.
IT IS OFTEN DIFFICULT FOR
INDIVIDUALS TO BE RECOGNIZED AS
CAREGIVERS, WHILE THE PATIENT IS
IN THE HOSPITAL AND TO BE
ACTIVELY INVOLVED WHEN DECISIONS
ARE MADE, WHEN TEAMS, HEALTHCARE
TEAMS GET TOGETHER AND
COMMUNICATE ABOUT PATIENT
STATUS, CAREGIVERS ARE OFTEN
LEFT OUT OF THE CONVERSATIONS.
SO IN IN SUMMARY IT WOULD BE
VERY IMPORTANT FOR US TO THINK
ABOUT ALSO INVOLVING CAREGIVERS
IN OUR SOCIAL NEEDS ASSESSMENT.
I WANT TO ACKNOWLEDGE THESE
INDIVIDUALS FOR THEIR SUPPORT
AND INVOLVEMENT IN THE RESEARCH.
THANK YOU.
>> THANK YOU, DR. BRISTOL.
OUR NEXT SPEAKER WILL BE DR.
KALOW.
>> CAN YOU SEE MY SLIDES?
>> YES.
>> THANK YOU.
WE HAVE SPOKEN A LOT ABOUT
STRATEGIES FOR DOING SOCIAL
DETERMINANTS OF HEALTH SCREENING
IN THE EMERGENCY DEPARTMENT, AND
I THINK IT IS WORTH GOING BACK
TO EARLY DATA FROM 2015 JUST TO
EMPHASIZE THIS IS SOMETHING ED
PROVIDERS WANT TO DO AND FEEL
LIKE IS INCLUDED WITHIN THEIR
RESPONSIBILITIES.
BUT PEEL LIKE THEY CAN'T DO
WELL.
BECAUSE THEY DON'T HAVE ENOUGH
TIME, NOT ENOUGH KNOWLEDGE,
DON'T HAVE ABILITY TO ACT, DON'T
HAVE THOSE CONNECTIONS DR.
TAYLOR WAS EMPHASIZING WITH THE
COMMUNITY BASED ORGANIZATIONS.
OR STRATEGIES CONNECTING PEOPLE
TO THOSE RESOURCES. QUALITATIVE
RESEARCH FROM MY COLLEAGUES
EMPHASIZES THIS, WITH QUOTE I
THINK HOUSING SCREENING IS A
GREAT IDEA BECAUSE PEOPLE HAVE
TOO MUCH PRIDE ON THEIR OWN, IT
IS GOOD INFORMATION BECAUSE YOU
DON'T KNOW WHO IS HOMELESS OF
NOT, LOOK AT ME, I DON'T LOOK
LIKE HOMELESS, NEVER CAN TELL,
IF YOU DON'T ASK ME YOU DON'T
KNOW.
SIMILAR TO WHAT WE HAVE HEARD
THROUGHOUT THE DAY, IT IS
IMPORTANT TO DO THIS CAREFULLY,
PEOPLE ARE FEARFUL YOU WILL
REPORT TO DHS OR THERE WILL BE
JUDGMENT OR YOU NEED A HANDOUT.
WE ASK QUESTIONS IN THE
EMERGENCY DEPARTMENT SENSITIVE
AND ASKED CAREFULLY ALL THE
TIME.
THIS IS RESEARCH FROM MY TEAM
LOOKING AT SCREENING ACROSS NEW
ENGLAND EMERGENCY DEPARTMENT AND
YOU CAN SEE THAT WE ASK ABOUT
INTIMATE PARTNER VIOLENCE
SUBSTANCE USE AN MENTAL HEALTH
BETWEENMENT AND 95% OF THE TIME
AT TRIAGE.
WHEN IT COMES TO ASKING SOCIAL
DETERMINANTS OF HEALTH LIKE
HOUSING INSTABILITY, FOOD
INSECURITY, TRANSPORTATION
UTILITIES WE DO MUCH WORSE
ASKING ABOUT IT ONLY 33% FOR
HOUSING INSTABILITY TO 6%
UTILITIES. THESE ARE KINDS OF
QUESTIONS WE COULD ASK.
IT IS A REAL MISSED OPPORTUNITY
BECAUSE AS YOU HEARD OVER AND
OVER THE HIGHEST RISK PATIENTS
ARE IN THE EMERGENCY DEPARTMENT
AND YET EXISTING POLICY
INITIATIVES FOCUS PRIMARILY ON
PCP SCREENING.
SO HERE IN MASSACHUSETTS WHERE I
AM FROM OUR ACCOUNTABLE CARE
ORGANIZATION EMPHASIZED OVER AND
OVER SCREENING FOR SOCIAL
DETERMINANTS OF HEALTH IN THE
PRIMARY CARE OFFICE.
THAT MEANS YOU ARE ONLY
SCREENING PEOPLE WHO HAVE
WHEREWITHAL TO GET THERE, SO
THOSE ARE PEOPLE WHO ALREADY
HAVE ACCESS TO TRANSPORTATION
AND SOME LEVEL OF ACCESS TO CARE
AND WE RISK POTENTIALLY
EXACERBATING THIS DISPARITIES IF
THOSE ARE THE ONLY PEOPLE WE ARE
CONNECTING TO RESOURCES. SO I
WANT TO TALK ABOUT NEW STRATEGY
AROUND THREE ISSUES OF
IDENTIFICATION, CONNECTIONS AND
LINKAGE AND OUTCOME MEASUREMENT.
IN PARTICULAR, IF WE THINK ABOUT
IDENTIFICATION WE ARE GOING TO
TALK ABOUT CONTENT, THEN TALK
ABOUT FEASIBILITY.
WE TALKED ABOUT DISTINCTIONS
BETWEEN SOCIAL RISK AND SOCIAL
NEED ABOUT WHETHER WE THINK
ABOUT USING QUESTIONNAIRES OR
THINK ABOUT USING INFORMATION
WHERE PATIENT DESCRIBES FOR US
DIRECTLY WHEN THOSE THEY WANT OR
NEED FROM THE HEALTHCARE SYSTEM.
THIS IS DATA FROM ED WHERE WE
TRIED TO COMPARE ANSWERS IN THE
SAME POPULATION OF PATIENTS IN
OUR ED.
WE FOUND THAT ABOUT A THIRD OF
PATIENTS HAD SOCIAL RISK, A
THIRD HAD NEED AND INCOMPLETE
OVERLAP.
SIMILAR TO DATA THAT WAS
PRESENTED EARLIER, WE FOUND
SPANISH SPEAKERS AND
NON-HISPANIC BLACK PATIENTS WERE
MORE LIKELY TO REPORT SOCIAL
NEED.
WE THEN DID A SIMILAR ANALYSIS
LOOKING AT OUR ACO.
SO ALL THE MEDICAID PATIENTS WHO
WERE TAKEN CARE OF IN THE
HEALTHCARE SYSTEM SCREENED IN
PRIMARY KARAK AT THISES.
NOW WE HAVE 27,000 PEOPLE WHO
COMPLETED 30,000 SCREENS.
45% WERE POSITIVE FOR ONE SOCIAL
RISK.
19% WERE POSITIVE FOR SOCIAL
NEED AND 35% WERE POSITIVE FOR
BOTH.
6% WERE NEGATIVE FOR SOCIAL RISK
BUT POSITIVE FOR SOCIAL NEED.
SO THEY SCREENED NEGATIVE ON
YOUR TEST SCREENER, BUT STILL
WOULD HAVE REQUESTED ASSISTANCE.
WHO WERE THOSE PEOPLE?
PATIENTS NON-WHITE, THOSE WHO
COME FROM PRACTICES WITH A
HIGHER PROPORTION OF LIMITED
ENGLISH PROFICIENCY OR MEDICAID
PATIENTS THOSE ARE ONES MOST
LIKELY TO REPORT SOCIAL NEED
WITH OR WITHOUT SOCIAL RISK.
AMONG THE PEOPLE WHO REPORT
SOCIAL RISK THE PATIENTS BLACK
WHO PREFER NON-ENGLISH LANGUAGE
OR WHO WERE IN PRACTICE TO CARE
OF PEOPLE WITH LIMITED
PROFICIENCY OR MEDICAID NEEDS,
HAD HIGHER ODDS OF REPORTING
SOCIAL NEED IN DIFFERENT DOMAIN
THAN SOCIAL RISK.
WHAT THIS SUGGESTS TO ME IN OUR
SETTING IS RISK SCREENING ALONE
IS INSUFFICIENT AND INEQUITABLE.
SO IT IS SUPER IMPORTANT THAT
WHATEVER TOOL WE PICK NOT ONLY
SCREENS FOR SOCIAL RISK BUT ALSO
SCREENS FOR SOCIAL NEED.
THAT IS SUPER CHALLENGING TO
IMPLEMENT IN THE EMERGENCY
DEPARTMENT BECAUSE MOST EXISTING
TOOLS ARE REALLY LONG.
I HAVE INCLUDED ON THIS SLIDE
THE TOOL THAT IS USED IN OUR
INSTITUTION.
AND YOU CAN SEE THE TOP IS
FOCUSED O ON SOCIAL RISK AND AT
THE BOTTOM WE GET TO SEMBLANCE
OF ASKING WHAT IT IS THAT THEY
WANT.
THE PRIMARY FOCUS IS REALLY ON
REST.
IT IS ALSO OF COURSE SUPER
IMPORTANT TO MAKE SURE THE TOOLS
ARE AVAILABLE.
IN MULTIPLE LANGUAGES.
WE ATTEMPTED TO BUILD A TOOL
THAT WOULD BE USEFUL IN THE
EMERGENCY DEPARTMENT AND QUICK
EASY TO UNDERSTAND.
WE STARTED WITH INITIAL TOOL
DOMAINS TO MATCH ACCOUNTABLE
HEALTH COMMUNITIES THE FOOD
HOUSING TRANSPORTATION UTILITIES
AND SAFETY AND IMPORTANTLY WE
PICKED QUESTIONS IN THE PUBLIC
DOMAIN BECAUSE WE WANTED TO BE
SOMETHING WE BOTH USE FOR FREE
AND CONDUCTED COGNITIVE
INTERVIEWS IN ENGLISH AND
SPANISH.
WE FOUND THAT PEOPLE STRUGGLED
TO UNDERSTAND A LOT OF THESE
QUESTIONS.
THEY WERE INTERPRETING THEM
DIFFERENTLY, ACROSS DIFFERENT
INDIVIDUALS AND ALSO DIFFERENTLY
THAN WE THOUGHT THEY WERE GOING
TO BE.
THOSE THINK ALOUD APPROACHES ARE
REALLY IMPORTANT TO MAKING SURE
PEOPLE ARE UNDERSTANDING THE
QUESTIONS THE WAY YOU WANT THEM
TO BE INTERPRETED.
ULTIMATELY WE END UNDERSTOOD
REMOVING DOMAIN OF SAFETY FROM
OUR SCREENER BECAUSE THERE WAS
REALLY ENORMOUS INCONSISTENCY
HOW IT WAS INTERPRETED ACROSS
PATIENT POPULATION, RANGING FROM
PEOPLE THINKING ABOUT IT IN
TERMS OF DOMESTIC VIOLENCE TO
NEIGHBORHOOD SAFETY AND DIDN'T
MATCH TO A BODY OF RESOURCES IN
THE COMMUNITY.
WHAT THIS BROUGHT UP IS TENSION
BETWEEN COMPLETENESS, SPEEDS
COMPREHENSIVENESS WITHIN THE
TOOL.
AND THE FACT THE TOOL THAT IS
APPROPRIATE FOR SCREENING IN THE
EMERGENCY DEPARTMENT MAY NOT BE
THE SAME AS THE TOOL APPROPRIATE
IN THE PRIMARY CARE SETTING OR
OBGYN CLINIC OR SOMEWHERE YOU
HAVE A LONGER LONGITUDINAL
RELATIONSHIP.
WITH THE PATIENT, AND THEN A
BRIEFER SCREENER FOCUSED ON MORE
IMMEDIATE RECOGNIZE MAYBE
SOMETHING MORE APPROPRIATE FOR
USE IN THE EMERGENCY DEPARTMENT:
ONCE YOU HAVE IDENTIFIED SOCIAL
RISK AND NEEDS HOW DO WE THINK
ABOUT CREATING A TRUE CONNECTION
BETWEEN THE PATIENT AND THE
RESOURCES.
SO WE SIMILAR TO WORK DR. TAYLOR
DID EARLIER QUALITATIVE
INTERVIEWS WITH ED PATIENTS AND
ALSO WITH COMMUNITY ORGANIZATION
LEADERS ENGLISH AND SPANISH
FOCUS ON COMMUNITY ORGANIZATIONS
THAT WE ANTICIPATED WOULD BE
RECEIVING THE REFERRALS OF
PATIENTS FROM EMERGENCY
DEPARTMENT.
SO FOOD PANTRIES HOMELESS
SHELTERS IN OUR NEIGHBORHOOD.
TRYING TO UNDERSTAND WHAT IT IS
THEY WANTED FROM THIS
BIDIRECTIONAL RELATIONSHIP IN
THE EMERGENCY DEPARTMENT AS WE
WERE CREATING A REFERRAL
PATHWAY.
THERE ARE THREE CATEGORIES OF
THESE THAT I WANT TO TALK TO YOU
ABOUT TODAY.
THE FIRST NO SURPRISE TO THIS
AUDIENCE IS IMPORTANCE OF ED
UTILIZATION AND SCREENING WITH
EMERGENCY DEPARTMENT,
CONSISTENTLY OUR PATIENTS
DESCRIBE CHALLENGES ACCESSING
PCP AND INCONSISTENT SCREENING
AT THEIR PCP.
THIS IS JUST ONE QUOTE, HOURS
CLOSE AT 3 I GET OUT OF WORK AT
3 THEY GET OUT OF SCHOOL AT 3,
DURING WEEK SICK BABIES ON THE
WEEKEND SO IN ORDER TO GO WITH
THESE KIDS FOR ANYTHING I HAD TO
TAKE DAY OFF WORK, TAKE TIME OFF
OF SCHOOL WHICH IS NOT RIGHT.
SO THESE PATIENTS ARE IN THE ED,
THE ONES WITH HIGHEST NEEDS.
A LOT OF CHALLENGES AROUND
SCREENING AND COMMUNITY
RESOURCES.
THE FIRST WE NEED TO MAKE SURE
SYSTEMS ADDRESS HEAD ON IS FEAR
AN MISTRUST.
WE TALKED ABOUT THIS AT VARIOUS
POINTS HOW DATA IS RECORDED,
WHERE IT'S STORED AND WE NEED TO
BE REALLY EXPLICIT HOW WE
ADDRESS THIS BUILDING OUTS THE
SYSTEMS.
WE HEARD THIS A LOT PARTICULARLY
IN OUR SPANISH LANGUAGE
INTERVIEW BUS ALSO ENGLISH
LANGUAGE INTERVIEWS FEAR OF
RECEIVING ANY HELP FROM ANYBODY
IF YOU ARE UNDOCUMENTED.
NOT JUST FEAR WHAT IT IS AND HOW
MUCH INFORMATION DO I HAVE TO
PROVIDE, IMMIGRATION AND
DEPORTATION FEAR, MOVING PEOPLE
DONGMENTED WILL SAY NO, THANK
YOU BECAUSE THE FEAR THE PUBLIC
CHARGE CLAUSE APPLY.
THEN THE QUESTIONS AROUND
COLLECTION MAINTENANCE AND
TRANSMISSION OF ACCURATE
INFORMATION.
THIS IS KEY.
HOW DO YOU MAKE SURE IN A WORLD
OF CHANGING RESOURCE, IF YOU
HAVE SMALL CBOs, THE HOURS ARE
CHANGING OVER TIME, FOOD
PANTRIES MOVING HOW DO YOU MAKE
SURE GOOD INFORMATION HANDING
OUT REMAINS ACCURATE, OR IF YOU
ARE CONTRACTING TO RESOURCE
PROVIDER, LIKE -- HOW DO YOU
MAKE SURE THEIR INFORMATION IS
ACCURATE.
WE HAVE DONE SOME CHECKS ON THAT
DATA IT IS NOT PERFECT EITHER
AND YOU REALLY DON'T WANT TO BE
IN THE POSITION OF STANDING OUT
INACCURATE INFORMATION TO FOLKS
AND FINALLY MAKING SURE THE
INFORMATION YOU ARE HANDING OUT
TO PEOPLE ADDRESSES TIME AND
RESOURCE CONSTRAINTS.
THIS WAS A QUOTE THAT WE THOUGHT
WAS REALLY ILLUMINATING.
A PATIENT DESCRIBING RECEIVING
INFORMATION IN THE HOSPITAL THE
STUFF IS THERE BUT UNLESS
WRITING IT DOWN OR TAKE A
PICTURE WITH YOUR PHONE, MIGHT
SEE IT AND GO WOW, I WOULD LIKE
TO DO THAT BUT REMEMBER TO TAKE
A PICTURE, REMEMBER TO GRAB THE
INFORMATION COULD BE HARD SO HOW
DO WE MAKE SURE THE INFORMATION
LEADS WITH PATIENT.
WE HAVE A LOT OF SUGGESTIONS FOR
IMPROVEMENT AND PROGRAM
DEVELOPMENT.
MIXED PREFERENCES WHETHER PEOPLE
WANTED IT TO BE VERBAL OR
ELECTRONICALLY DELIVERED, AND
WHEN WE STUDY THAT IN RANDOMIZED
CONTROL TRIAL IT IS MIXED, NOT A
CLEAR WINNER BETWEEN VERBAL OR
ELECTRONIC DELIVERY OF
RESOURCES.
BUT EVERYBODY WANTS CENTRALIZED
RESOURCE INFORMATION
COORDINATION.
IS WILL SOME WAY FOR THE
HOSPITAL OR ORGANIZATION IN THE
HOSPITAL WORKING WITH TO HOLD
THE KNOWLEDGE OF ORGANIZATION TO
BE ABLE THE SHARE THAT.
UPDATE ON WHAT PLACES, BEDS AND
HOURS ARE, AND HOW THEIR HOURS
CHANGE.
THERE WAS INTEREST IN THE IDEA
OF ON DEMAND INFORMATION
NAVIGATION.
IS THERE A WAY TO TEXT AND BE
LIKE WHERE CAN I GO NOW TO GET
FOOD.
WHAT IF THERE WAS AUTOMATIC
RESPONSE, WHERE DO I GET FOOD
02116 OR WHATEVER, THAT'S COOL.
IS THERE SOMETHING COMPUTER
SYSTEM THAT COULD GENERATE
RESPONSES TO QUESTIONS AND
PATIENTS COULD BE EDUCATED HOW
THAT WORKS BEFORE THEY LEAVE ED
AND HAVE THAT INFORMATION ON
HAND.
SO WE DECIDED TO BUILD IT.
WE BUILT A SYSTEM THAT WOULD
TEXT PATIENTS QUESTIONS ABOUT
SOCIAL RISK AND NEEDS AND IF
THEY SCREEN POSITIVE THEY WOULD
GET TEXTED BACK GEOGRAPHICALLY
PROXIMATE RESOURCE AND WE PLAN
TO DO A RANDOMIZE CONTROL TRIAL
OF THAT SYSTEM VERSUS OUR
STANDARD VERBAL SCREENING AND
HAND OUT.
THE IDEA IS STUDY HOW MANY
PEOPLE ABLE TO LIG TO RESOURCES
AN MIXED METHOD EVALUATION TO
INTERVIEW EVERYONE WHO FAILED TO
LEAD TO RESOURCE AND TRYING TO
UNDERSTAND WHAT THE BARRIERS
WERE.
WE GOT REALLY IMPORTANT AND
INTERESTING EARLY DATA AROUND
IMPORTANCE OF THIS KIND OF
ASSISTANCE, PEOPLE CHALLENGED BY
THE PAPER VERSION AND SEEMED TO
LIKE THE TEXT MESSAGE BETTER.
THERE WERE CONSISTENT BARRIERS
BEYOND RESOURCE IDENTIFICATION.
THERE WAS SMALL SUBSET OF PEOPLE
KNOWING THE FOOD PANTRY WAS
ENOUGH AND MORE PEOPLE WHO
NEEDED MORE HAND HOLDING AND
HELP TO GET THERE.
AND WOULD HAVE REALLY BENEFITED
FROM MORE IN PERSON ASSISTANCE.
THEN COVID HAPPENED.
ALL THE FOOD PANTRIES AND
HOMELESS SHELTERS SHALT DOWN AND
EVERY SINGLE RESOURCE CHANGED
THEIR LOCATION, THEIR
ELIGIBILITY CRITERIA AND HOW YOU
ACCESS THEM.
AND IT WAS TOO HARD TO UPDATE
THE TEXT MESSAGE SYSTEM FAST
ENOUGH TO MAKE IT RESPONSIVE TO
THE CHANGES IN DATA IN REAL
TIME.
SO WE WENT BACK TO PAPER HAND
OUTS BECAUSE THAT WAS THE ONLY
THING YOU COULD MOVE FAST ENOUGH
ON TO MAKE SURE WE WERE
PROVIDING ACCURATE INFORMATION.
SO WE ARE TRYING AGAIN.
WE RECEIVED A POSITIVE SCORE ON
A GRANT TO DO SIMILAR TEXT
MESSAGING INTERVENTION IN TIME
HOPEFULLY LESS CHAOTIC AND
INTERESTING TO SEE IF IT WORKS.
WITH A LOT THAT WE HAVE LEARNED
FROM THIS PILOT.
AND IT WILL HAVE AND IN PERSON
NAVIGATIONAL ASSISTANCE ARM AS
WELL AS TEXT MESSAGING ARM.
I THINK WE LEARNED FROM THIS
PILOT THAT INFORMATION ALONE IS
INSUFFICIENT.
ONCE YOU HAVE SUCCESSFULLY
CONNECTED PEOPLE TO RESOURCES,
THE NEXT QUESTION IS, HOW DO WE
MEASURE WHETHER OR NOT WE HAVE
MADE A DIFFERENCE FOR FOLKS.
THERE WAS A REALLY EXCELLENT
SYSTEMATIC REVIEW TAXONOMY THAT
CAME OUT THAT STARTS TO THINK
WHETHER THE RIGHT OUTCOMES FOR
MEASURING THIS WORK, SO WE HAVE
OFTEN MEASURED DID THEY CONTACT
THE SERVICE OR ORGANIZATION, DID
THEY CALL 211, CALL THE FOOD
PANTRY, SOME MEASURED WHETHER
THEY ENROLLED OR RECEIVED A NEW
SERVICE, WHETHER SOCIAL NEEDS
WERE ADDRESSED WHETHER THE
PARTICIPANT RATING OF EXPERIENCE
WERE THEY SATISFIED.
THERE IS ROOM FOR MORE WORK TO
BE DONE HERE ON OTHER
PARTICIPANT REPORTED OUTCOMES.
AND ALSO ON UTILIZATION AND COST
OUTCOMES.
FOLLOWING THIS KIND OF SERVICE
INTERVENTION.
ULTIMATELY WHAT I WOULD LIKE TO
SEE IS HOW TO EWE EMERGENCY
DEPARTMENT AS SAFETY NET.
WE THINK ABOUT WHETHER THE UNMET
ACCESS NEEDS, WHAT ARE THE UNMET
INFORMATIONAL NEEDS, UNMET
SOCIAL NEEDS AND THINK ABOUT ED
INTERVENTIONS THAT CAN ADDRESS
ALL OF THEM AND MEASURE THOSE
OUTCOMES.
RIGOROUSLY.
AS WE THINK ABOUT THOSE FEATURE
DIRECTIONS AROUND IDENTIFICATION
INTERVENTIONS AND OUTCOME, FOR
IDENTIFICATION IT NEEDS TO BE
ELECTRONIC SCALABLE AND BASED ON
PATIENT NEED, WE WANT TO
IDENTIFY PATIENTS WHO NEED
INPATIENT, WE WANT TO BE CAREFUL
ABOUT STIGMA AND ADVERSE
CONSEQUENCES, AS WE THINK ABOUT
INTERVENTIONS, WE WANTS THE MAKE
SURE WE HAVE UPDATED CENTRALIZED
INFORMATION SYSTEMS AND TRUE
CONNECTIONS TO RESOURCES NOT
JUST HAHN OUTS.
OUR OUTCOMES NEED TO BE USE AND
CHANGE BASED TO MAKE A REAL
DIFFERENCE DO WE GET ELECTRICITY
TURNED ON NOT JUST CALL THE
HOTLINE.
AND MAKING SURE WE ARE MEASURING
TRUE PATIENT CENTERED REPORTED
OUTCOMES.
THIS IS MY CONTACT INFORMATION
LOOK FORWARD TO TAKING YOUR
QUESTIONS DURING THE PANEL.
>> THANK YOU, THANK YOU ALL.
DR. TAYLOR AND DR. BRISTOL AND
DR. KALOW.
WE ARE GOING TO HAVE A BREAK
I WILL SEE YOU AT 3.
>> HELLO EVERYONE, WELCOME
BACK TO THIS AFTERNOON'S PANEL
DISCUSSION.
I'M SENIOR ASSOCIATE FOR
EMERGENCY NURSING RESEARCH AT
EMA AND ONE OF THE MEMBERS OF
THE PLANNING COMMITTEE FOR THE
EVENT.
DR. BILLY ROW IS A IS CO-CHIEF
RESEARCH FELLOW DEPARTMENT OF
PSYCHIATRY BEHAVIORAL SCIENCES
AT MEMORIAL SLOAN-KETTERING
CANCER CENTER.
AS A PREVIOUS ROBERT WOOD
JOHNSON FOUNDATION FUTURE OF
NURSING SCHOLAR AT UNIVERSITY OF
PENNSYLVANIA, HIS STREAMS OF
RESEARCH IS ON CANCER PAIN
DISPARITIES LGBTQ INCLUSIVE
PALLIATIVE CARE AND
PSYCHOASSISTED THERAPY IN
CONTEXT OF CANCER RELATED
STRESS.
DR. ROSA WAS LEAD RESEARCHER FOR
THE 2021 NURSES FOR HEALTH
EQUITY GUIDELINES FOR SOCIAL
DETERMINANTS OF HEALTH POLICY
REPORT ENDORSED BY WORLD HEALTH
ORGANIZATION AMONG OTHERS.
JOIN ME IN WELCOMING DR. ROSA.
>> THANK YOU SO MUCH, CAN YOU
HEAR ME OKAY?
>> YES.
>> WONDERFUL.
THANK YOU.
I'M REALLY HONORED TO BE HERE
TODAY TO MODERATE THIS
DISCUSSION.
I WANT TO START BY THANKING AND
ACKNOWLEDGING YVONNE BRYAN
ROBBIE DA AND TANYA STRAUGHT,
THE REST OF THE PLANNING
COMMITTEE TEAM WHO I DID NOT
MENTION BY NAME, JUST SUCH AN
INCREDIBLE AMOUNT OF WORK AND
PASSION THAT WENT ON BEHIND THE
SCIENCE OF THIS PROGRAM SO MY
HAT IS OFF TO YOU.
THANK YOU SO MUCH.
I'M SPYING TO YOU FROM THE
ANCESTRAL LANDS OF THE -- PEOPLE
MORE BROADLY KNOWN TODAY AS NEW
YORK CITY.
AND SO I WANT TO ACKNOWLEDGE AND
HONOR DIVERSE AND VIBRANT
INDIGENOUS PEOPLE'S AND
TRADITIONS THAT INHABIT THIS
LAND TODAY.
I ALSO THINK IT IS REALLY
IMPORTANT TO DISCLOSE MY OWN
SOCIAL LOCATION AS I COME TO YOU
TO MODERATE THIS DISCUSSION ON
THE SOCIAL DETERMINANTS OF
HEALTH AND HEALTH EQUITY.
SO I COME TO YOU AT THE
INTERSECTION OF MULTIPLE
IDENTITIES, OF HISTORICAL
PRIVILEGE, BEING WHITE, BEING A
CIS GENDERED MAN HIGHLY EDUCATED
HOUSING AND FOOD SECURE AND
SOMEBODY WHO IS PHYSICALLY WELL
ABLED.
AND ALSO SOME IDENTITIES OF
HISTORICAL EXCLUSION IDENTIFYING
AS A GAY PERSON, AS A FIRST
GENERATION COLLEGE STUDENT AND
AS THE DESCENDENT OF IMMIGRANT
ANCESTORS.
SO AGAIN AND AGAIN TODAY I HAVE
BEEN REMINDED OF DR. PAUL FARMER
MANY OF YOU PROBABLY KNOW WE
LOST A TREMENDOUS GIANT IN THE
GLOBAL HEALTH FIELD LAST WEEK,
DR. PAUL FARMER WHO FOUNDED
PARTNERS IN HELP AND HE WAS A
TREMENDOUS SOCIAL JUSTICE
ADVOCATE.
AND HE ASKED THIS QUESTION, IF
ACCESS TO HEALTHCARE IS
CONSIDERED A HUMAN RIGHT, WHO IS
CONSIDERED HUMAN ENOUGH TO HAVE
THAT RIGHT.
IF ACCESS TO HEALTHCARE IS
CONSIDERED A HUMAN RIGHT, WHO IS
CONSIDERED HUMAN ENOUGH TO HAVE
THAT RIGHT.
SO I HAVE BEEN SO MOVED TODAY BY
INNOVATIVE METHODS AND APPROACH
THAT HAVE BEEN EMPLOYEDD BY
THESE RESEARCHERS TO ADVANCE
EQUITY AND INCLUSION AND REALLY
TACKLE THE SOCIAL DETERMINANTS
OF HEALTH WITH SUCH RIGOR AND
FOR ME AS NURSE BY BACKGROUND
THIS SCIENCE REALLY SPOKE TO THE
WAYS THAT NURSES AND OTHER
HEALTH WORKERS CAN FULFILL THEIR
ETHICAL OBLIGATION TO ATTEND TO
THE HUMAN CONDITION AT
INDIVIDUAL, POPULATION, PUBLIC
HEALTH LEVELS IN A MORE HOLISTIC
AND SOCIALLY CONSCIOUS WAY.
SO I'M GRATEFUL.
I THOUGHT IT WOULD BE HELPFUL TO
START WITH A BRIEF OVERVIEW
WHERE WE HAVE BEEN DURING THIS
ROUND TABLE.
AS RESEARCHERS HAVE MAPPED OUT
THIS INCREDIBLE CARTOGRAPHY OF
SOCIAL DETERMINANTS IN CONTEXT
OF ED CARE.
SO YESTERDAY OF COURSE DR. RENEE
SHAW STARTED US OFF TALKING
ABOUT THE STRUCTURAL SICKNESS OF
INEQUITY IN OUR ED CARE SYSTEM.
REALLY POKING HOLES IN THE
NOTION ARISING TIDE LIFTS ALL
BOATS WHICH IS GREAT NEWS IF YOU
HAPPEN TO HAVE A BOAT.
DR. CAROL DEFRANCIS TODAY GAVE
AN OVERVIEW OF ED VISITS IN THE
U.S. STRATIFYING VISITS BY
NUMBER OF VARIABLES AGE, RACE
ETHNICITY GEOGRAPHY INSURANCE
TYPE AND SO ON.
WE HEARD FROM DR.S WALLACE,
DEMARCUS AND BILL LACK ABOUT
ADDRESSING SPECIFIC SOCIAL NEEDS
TO PROVIDE CONTEXTUALIZED PERSON
FOCUSED CARE IN ED.
DR. VEST MCCARTHY AND MONTGOMERY
TALKED SOCIAL DETERMINANTS OF
HEALTH AND ED UTILIZATION WITH
DISCUSSION OF SOCIAL RISK IN THE
ED.
AND THEN WE HEARD FROM DR.S
TAYLOR BRISTOL AND SAMUELS KALOW
ON THE INTERPLAY OF ED AND
COMMUNITY RESOURCES IN
TRANSITIONAL CARE.
OF COURSE DR. SHANNON ZINK SET
THIS INTO MOTION WITH THE ISSUES
AND SCIENCE TODAY DIRECTLY
ADVANCES THE STRATEGIC PLAN OF
NINR AND LARGER NIH COMMUNITY.
SO I'M GOING TO GO BACK AND
FORTH BETWEEN SOME GENERAL
QUESTIONS FOR OUR PANEL AND SOME
VERY SPECIFIC QUESTIONS FOR
INDIVIDUAL PRESENTERS.
THE FIRST QUESTION IS A LITTLE
MORE GENERAL.
I DO INVITE ANY PRESENTERS FROM
TODAY TO JUMP IN.
IT IS IN REFERENCE TO SOMETHING
DR. SHAW SAID YESTERDAY.
SHE NOTED THAT EVEN THE BEST
INTENTIONS TO HEAL SICK HEALTH
SYSTEM CAN WIDEN GAPS BETWEEN
ADVANTAGE AND DISADVANTAGED IN
OUR SOCIETY.
I WOULD LIKE TO HEAR FROM OUR
PRESENTERS SOME OF THE TANGIBLE
STEPS WE CAN TAKE AS RESEARCHERS
PARTICULARLY THOSE OF US
PARTNERING WITH COMMUNITY AND
CLINICIAN STAKEHOLDERS.
TO ENSURE THAT WE DON'T
CONTRIBUTE TO WIDENING THIS GAP.
I SEE ANDREA WALLACE, GO AHEAD.
DISBELIEFSN'T SURE IF I SHOULD
RAISE MY HAND.
I THINK FROM -- AS YOU HEARD
FROM OUR PRESENTATION I THINK IT
IS REALLY BEING SENSITIVE AND
AWARE OF HOW WE ARE APPROACHING
PATIENTS AND THAT WE JUST AREN'T
REINFORCING STEREOTYPES, THAT WE
ARE REINFORCING INEQUITIES.
I MEAN, THE PATIENTS WE TALK TO
ABOUT THIS, THEY ARE OPEN TO IT
BUT IT IS -- IT IS -- MET WITH
SUSPICIONS AND CONCERNS OF
PRIVACY, AND OF COURSE THAT'S
GOING TO JUST BE MAGNIFIED
DIFFERENT THAT HAVE HAD NEGATIVE
EXPERIENCES IN OUR HEALTHCARE
SYSTEM AND DISTRUST.
I THINK THAT THAT IS -- WITH
THAT AWARENESS AND ACCOUNTING
FOR DISTRUST, I'M REALLY
INSPIRED BY THE WORK OF THIS --
OF EVERYONE I HEARD FROM TODAY
THAT REALLY EMPHASIZES THAT AND
UNDERSTAND THAT MORE DEEPLY AND
THE WORK THAT WE ARE DOING WITH
PATIENTS.
>> GREAT.
THANK YOU.
DR. DEMARCUS YOU MUST HAVE A
CRYSTAL BALL BECAUSE IT WAS -- I
WAS ABOUT TO ASK FOR YOUR
INSIGHTS ON THAT AS WELL.
>> THANK YOU FOR THE GREAT
QUESTION AND I AGREE WITH DR.
WALLACE, 100%.
I THINK ALSO HOW WE ANALYZE AND
COLLECT THE DATA WE ARE GAIN OF
RESEARCH -- THE DATA ON, WHAT WE
WERE DOING I THINK IS REALLY
IMPORTANT.
WE HAVE BEEN WORKING WITH SOME
PRIMARY CARE SETTINGS WHO HAVE
BEEN TELLING US WE SCREEN
EVERYONE THE SAME, RESOURCES THE
SAME BUT WE ARE LOOKING AT OTHER
DATA AND FINDING THERE ARE
ACTUALLY DIFFERENCES IN WHO IS
GETTING SCREENED RELATED TO
LANGUAGE RACE ETHNICITY AND SOME
PART RELATED TO PATIENTS WITH
INTEREST AND ENGAGEMENT WHICH
COULD BE RELATED TO WHAT DR.
WALLACE NOTED TOO, HISTORICAL
TRAUMA EXPERIENCES CURRENT
EXPERIENCES WITH THE HEALTHCARE
SYSTEMS.
BUT I THINK IT IS REALLY
IMPORTANT THAT WE ARE TRACKING
THAT DATA ACTUALLY LOOKING AT
THE IMPACT ON EQUITY.
WITH THE WORK THAT WE ARE DOING
SO WE CAN MAKE SURE WHICH ARE
NOT WIDENING DISPARITIES AND
IDEALLY CLOSING THE GAPS WE ARE
SEEKING TO DO WITH THIS WORK.
>> THANK YOU.
THAT LENDS ITSELF TO SPECIFIC
QUESTION I HAD FOR BOTH YOU AND
DR. WALLACE.
YOU BOTH GAVE REFERENCE IN THE
CHAT TO ASKING QUESTIONS ABOUT
PRIOR EXPERIENCES OF
DISCRIMINATION AND HEALTHCARE
SETTINGS.
DO YOU HAVE RECOMMENDATIONS TO
SUPPORT RESEARCHERS AND HAVING
THESE CONVERSATIONS WITH
RESEARCH PARTICIPANTS?
I'M PARTICULARLY CURIOUS BECAUSE
EXPERIENCE IS OF PRIOR
DISCRIMINATION ARE COUPLED WITH
TRAUMA OF REJECTION OR RACISM OR
DISENFRANCHISEMENT.
HOW DO WE ELICIT THAT
INFORMATION AND EMPATHETIC AND
SUPPORTIVE WAY THAT AVOIDS HARM
AND MAY ACTUALLY BE ENCOURAGING
AND HEALING FOR PARTICIPANTS?
>> I CAN JUMP IN, NOT SURE IF I
HAVE SPECIFIC RECOMMENDATIONS,
WE ARE TAKING -- WE ARE
CONSIDERING THAT IN OUR
LONGITUDINAL STUDY WHERE WE HAVE
PATIENTS ENGAGED WITH US.
SO I FEEL LIKE WE CAN ASK THOSE
QUESTIONS AND APPROACH THAT.
BUT IT IS AN AREA, INTERESTINGLY
ENOUGH IN OUR CURRENT STUDY WE
ARE SEEING A GREAT DEAL MORE
ENGAGEMENT OF PATIENTS WHO ARE
SPANISH SPEAKERS.
SO WE WANT TO DELVE INTO THAT
MORE IN TERMS OF DIFFERENCES IN
THE SCREENING, THE ANSWERS EARLY
ON IN THE STUDY BUT ONCE THEY
GET IN AND CONNECTED WITH US, WE
ARE ACTUALLY SEEING MORE
CONNECTION WITH THE COMMUNITY
BASED SERVICES.
I DON'T KNOW IF THAT IS
ANSWERING YOUR QUESTION.
BUT I THINK IT IS -- I WORK WITH
AMAZING QUALITATIVE
INVESTIGATORS WITH RE-ENGAGEMENT
FOLKS AND TRYING TO MAKE SURE
THAT OUR WORK IS GROUNDED IN
GOOD BEST PRACTICES.
WITH THAT.
I DON'T KNOW IF THAT ANSWERS
ANYTHING.
>> GREAT.
>> MAYBE MOLLY HAS SOMETHING
MORE.
>> TO ADD TO THAT I THINK THAT
THERE IS A LOT WE CAN LEARN FROM
TRAUMA INFORMED CARE APPROACHES
EMPATHETIC INQUIRY AND WE HAVE
SEEN IN RECENT VARIES WITH
PERMISSIONS THEY FIND THOSE
TRAININGS HELPFUL.
AND STAFF AS WELL CALLED WARRANT
COULD CULTURALLY APPROPRIATE
TRAINING SO EQUIPPING THE STAFF
WHO WILL BE DOING THIS WORK WITH
THE TOOLS THEY NEED TO TALK WITH
PATIENTS FEEL COMFORTABLE
TALKING WITH PATIENTS AND MAKING
SURE RESOURCES ARE AVAILABLE
DIFFERENTLY WHICH IS -- BECAUSE
WE -- IT SEEMS LIKE ONE THING
THAT IS CREATING BARRIERS IS
WHEN RESOURCES AND INTERPRETERS
AREN'T ALWAYS AVAILABLE SO
PATIENTS AREN'T GETTING
SCREENING AND ACTIVITY IT IS
SAME WAY THEY ENGLISH OR SPANISH
SPEAKING COUNTER PARTS MAY BE SO
THERE IS A LOT WE CAN PULL FROM
WORK DONE IN OTHER AREAS AND
THEN INTERPERSONAL VIOLENCE
REALM THAT HAS APPLICANT HERE AS
WELL.
>> WONTFUL.
THANK YOU SO MUCH P. ANOTHER
GENERAL QUESTION.
TO THE GROUP OF PRESENTERS
TODAY.
THIS IS FROM DR. YES, SIR IS A
HENESY, SORRY IF I MISPRONOUNCED
YOUR LAST NAME BUT BASED ON THE
DATA SHARED THROUGHOUT THE TALKS
AND LITERATURE WE KNOW
DISPARITIES IN ED POPULATIONS
ARE EVIDENT SO RECOGNIZING THERE
ARE UNDERLYING STRUCTURAL
INEQUITIES AND TOTAL REFORM IS
RECOMMENDED, AS DR. SHAW
RECOMMENDED, WHERE DOES ONE
START?
ARE MORE DESCRIPTIVE STUDIES
NEEDED AND/OR HOW DO WE MOVE
TOWARDS INTERVENTION.
WHAT CAN WE DO GIVEN HOW COMPLEX
EMBEDDED THE ISSUES ARE IN OUR
COMMUNITY AND IN OUR COUNTRY?
ANY OF THE SPEAKERS CAN JUMP IN.
DR. SAMUEL SAMUELS KALOW.
>> GREAT QUESTION.
I THINK YOU TOUCH ON A REALLY
IMPORTANT POINT WHICH IS THAT
WHILE DESCRIPTIVE WORK REMAINS
REALLY IMPORTANT YOU HAVE HEARD
A LOT OF US TALK ABOUT THIS
FEELING THAT WE NEED TO DO MORE.
THAT WE HAVE -- WE ARE AS NEAR
AS EPIDEMIOLOGY AROUND
DISPARITIES AND I THINK THE
QUESTION OF WHAT WE CAN DO IS
STARTING TO BE DEFINED.
YOU HAVE HEARD WORK FROM PEOPLE
TALKING ABOUT DIFFERENT
STRATEGIES, FOR STARTING TO
IDENTIFY EMERGENCY DEPARTMENT
SOCIAL NEEDS IN REALLY
SYSTEMATIC WAYS.
ENORMOUS VOLUMES OF FOLKS SCREEN
IN UTAH, FOLKS HAVE DONE AMAZING
MULTI-CENTER WORK, WE DEVELOPED
A SHORT FORM READER THAT IS EASY
IF YOU DON'T HAVE A TOP OF
RESOURCES TO PUT INTO IT SO
THERE'S WAYS TO THINK HOW THIS
CAN BE DONE DEPENDING ON
RESOURCES OF YOUR SETTING.
TO START TO THINK ABOUT WHAT
OPPORTUNITIES YOU HAVE IN YOUR
STUDY TO THINK ABOUT WHAT ARE
THE NEEDS YOUR PATIENT
POPULATION IS PRESENTING WITH,
AND WHAT ARE THE COMMUNITY
RESOURCES THAT YOU CAN START TO
MANAGE WITH THOSE NEEDS.
IT IS EASY TO START TO GET
OVERWHELMED BY THINKING ABOUT
THE NEEDS ARE OVERWHELMING AND
THERE ARE HUNDREDS OF THEM.
SO I WOULD ENCOURAGE YOU TO
THINK ABOUT MAYBE STARTING WITH
A RELATIVELY SMALLER SET OF
TRACTABLE ONES AND STARTING TO
BUILD FRAMEWORK FOR OH WE NOW
HAVE DONE A GOOD JOB WITH THIS
ONE NOW WE CAN MIX INTO ANOTHER
AND START TO GROW UPWARD FROM
THERE.
THIS IS A MOMENT WHERE STARTING
TO GIVE OUT ED BASED
INTERVENTIONS IS REALLY POSSIBLE
AND FEASIBLE.
>> WHILE I HAVE YOU HEAR THERE
WAS A SPECIFIC QUESTION FOR YOU
AND YOUR WORK.
NOT SURE WHO THIS CAME FROM BUT
THE QUESTION WAS HOW DO YOU
THOUGHT ABOUT SOME APP PATIENTS
WITH PHONES CAN DOWNLOAD THAT
CAN PROVIDE EDUCATION,
RESOURCES, ET CETERA TO PATIENTS
AT ANY TIME, THIS COULD BE
UPDATED RESOURCES COULD BE
ADDED, ET CETERA.
AND YOU CAN ALSO RECEIVE
FEEDBACK THROUGH BRIEF SURVEYS
TO EVALUATE AFFECT OF YOUR
INTERVENTIONS.
>> SO THAT IS A GREAT POINT.
MY COLLEAGUE ERIC AT BOSTON
CHILDREN'S HAS DEVELOPED AN APP
THAT SITS ON TOP OF THE TWO IN
ONE PLATFORM IN BOSTON.
ALLOWS PATIENTS OR PROVIDERS TO
BE ABLE TO ACCESS THAT
INFORMATION IN REAL TIME.
I THINK THERE ARE LOT OF
PATIENTS FOR WHOM THE APP WOULD
BE REALLY BENEFICIAL.
I THINK THERE ARE A LOT OF
CHALLENGES TO ASSUMING THAT
EVERYONE NEED THESE RESOURCES
HAS ACCESS TO A SMART PHONE AND
IN THE EARLY PILOT WORK MOST
PATIENTS HAD ACCESS TO A TEXT
MESSAGE CAPABLE PHONE BUT NOT
EVERYBODY HAD ACCESS TO A SMART
PHONE.
SO THAT WAS PART OF WHY WE FELT
LIKE IT WAS RELATIVELY IMPORTANT
TO STICK TO THE LOWER TEXT
MESSAGING VERSION OF THIS.
YOU CAN DO IT ON FLIP PHONE OR
BURNER PHONE.
SO THAT WAS HOW WE ENDED UP WITH
THAT STRATEGY RATHER THAN APP.
BUT MAYBE MULTIMULTILY THE
ANSWER IS MULTI-MODAL.
SOME OTHERS DO BETTER ON PAPER
AND SOME DO BETTER WITH TEST
MESSAGING AND SOME BETTER WITH
APP AND THE SOPHISTICATION OF
THIS WILL GROW AS WE START TO
UNDERSTAND THE BEST STRATEGIES
FOR MATCHING PEOPLE TO THE
INFORMATION AND COMMUNICATION
RESOURCES INVESTED FOR THAT AND
ALSO TO NAVIGATIONAL RESOURCES
THEY NEED.
SPEAKER5: EXCELLENT, THANK YOU
SO MUCH.
SO ANOTHER GENERAL QUESTION,
THIS GOES BACK TO DR. MCCARTHY
WHO IS REALLY ACKNOWLEDGING THE
SOCIAL DETERMINANTS MODEL THAT
INCLUDED STRUCTURAL RACISM AND
STRUCTURAL DETERMINANTS FURTHER
UPSTREAM FROM INDIVIDUAL
DETERMINANTS THAT MANY OF US
TEND TO FOCUS ON.
SO MORE BROADLY, OUTSIDE OF THE
ED CONTEXT THERE'S A SIGNIFICANT
AMOUNT OF SCHOLARLY DISCOURSE
ABOUT THE USE OF RACE AS A
VARIABLE IN RESEARCH.
RECOGNIZING THAT RACE IS A
SOCIAL CONSTRUCT BORN OUT OF
RACISM, SUGGESTIONS ON HOW DO WE
ADVANCE THE SCIENCE IN A WAY
THAT INTENTIONALLY AND
SUSTAINABLY DISENTANGLES RACE AS
A VARIABLE FROM STRUCTURAL
RACISM AS PREDICTOR AND
PERPETRATOR OF HEALTH INEQUITY.
ANY THOUGHTS FROM OUR PANEL?
ANY THOUGHTS DR. MCCARNEY?
BY ANY CHANCE?
>> YOU ASK TOUGH QUESTIONS.
BECAUSE IT IS INTERESTING, I
HAVE BEEN THINKING A LOT MORE
ABOUT LIKE EMPLOYMENT FOR
EXAMPLE, IF WE COULD HELP OUR
PATIENTS GET BETTER JOBS.
HOW THAT COULD EASE THE HOUSING
PROBLEMS AND THE FOOD
INSECURITY.
SO FOCUSING LESS ON RACISM AND
JUST MORE POSITIVE -- YOU KNOW.
I DON'T REALLY KNOW AND I
HAVEN'T MEASURED THAT IN THE
STUDIES THAT WE HAVE DONE, HOW
MUCH THAT IS AFFECTING THINGS.
I WILL SAY TOTALLY NOT RELATED
TO RACISM BUT AS I WAS LISTENING
TO A LOT OF THE PRESENTATIONS
TODAY, WE ARE SCREENING AND THEN
TRYING TO TO INTERVENE, WHEN WE
DID THAT, IT IS ALMOST LIKE A
LOT OF THESE SOCIAL DETERMINANTS
ARE CHRONIC CONDITION.
AND WHEN PEOPLE SAY THEY HAVE
FOOD INSECURITY OR THEY HAVE
HOUSING INSTABILITY THEY DON'T
FOLLOW-UP ON THE RECOMMENDATIONS
YOU GIVE THEM BECAUSE THEY HAVE
BEEN DEALING WITH THESE PROBLEMS
FOR YEARS.
LIKE LAUREN TAYLOR SAID SOCIAL
SERVICES ARE SO UNDERFUNDED
COMPARED TO THE MEDICAL CARE,
THAT WE DON'T HAVE THE RESOURCES
TO HELP ALL PEOPLE IN NEED.
YOU CAN'T GET LIKE DR. POLLACK
SAID, THAT SUBSIDIZES HOUSING
FOR PEOPLE TO GET A VOUCHER, IT
IS JUST SO BACKED UP.
SO WILL IS ALL THESE PROBLEMS.
ON TOP OF RACISM AND OTHER
STUFF.
SO I DON'T KNOW WHERE TO BEGIN.
WE HAVE LOTS OF ISSUES.
SO WHEN I SEE THINGS LIKE PEOPLE
TRYING TO PARTNER WITH HOUSING
AND OTHER PLACES I THINK WE
REALLY HAVE TO PUT THOSE IN
PLACE BECAUSE SCREENING TELLS US
WE HAVE A LOT OF NEED BUT WE
CAN'T -- HOW MUCH WE CAN REALLY
SOLVE THAT NEED.
I DON'T KNOW.
SORRY, THAT DIDN'T ANSWER YOUR
QUESTION.
>> I THINK IT IS A HARD QUESTION
BECAUSE I'M FOOLISH TO THINK
ANYBODY IS ABLE TO ANSWER IT
FULLY TODAY.
BUT CERTAINLY THE DISCOURSE IS
WELCOME.
ANY OTHER COMMENTS ON THAT
QUESTION?
RACE AN RACISM, RACE AS FEW DOES
VARIABLE?
>> I WILL SAY IN MY HOSPITAL OUR
IRB IS ON A JOURNEY TO BECOMING
AN ANTI-RACIST IRB AND THAT'S
ONE OF THE THINGS THAT WE ARE
NOW ASKING INVESTIGATORS TO
COMMENT ON IN THEIR IRB
APPLICATION.
WHEN THEY DO ASK TO USE RACE OR
ETHNICITY.
THESE VARIABLES, HOW EXACTLY ARE
YOU PLANNING TO USE THAT AND
HAVE YOU THOUGHT ABOUT ANY WAYS
IN WHICH FINDINGS OF YOUR
RESEARCH MIGHT HURT PARTICULAR
GROUPS?
SO MAKING SURE JUST THAT
RESEARCH TEAM NOT TO SAY YOU ARE
NOT ABLE TO USE THAT VARIABLE
BUT MAKING SURE IT IS IN THE
BACK OF THEIR MIND, SOMETIMES
OUR RESEARCH HAS UNINTENDED
CONSEQUENCES AND WE SHOULD BE
THINKING ABOUT THAT AS WE ARE
PLAN AND MOVING FORWARD.
THAT SORT OF THING MOVING
FORWARD THINKING ABOUT IT HAVING
CONVERSATIONS ON THEIR TEAMS,
CONSIDERING WHAT EXACTLY THEY
ARE GOING DO TO DO WITH THE
INFORMATION ASIDE FROM TABLE
ONE.
AND HOW IT CAN BE USEFUL AND
EMPOWERING FOR GROUPS THAT HAVE
BEEN MARGINALIZED IN THE PAST.
>> THAT IS REALLY GREAT.
SOUNDS LIKE IT IS REALLY
ENCOURAGING TEAM REFLECTION AND
SCIENTIFIC REFLECTION AND DESIGN
AND IMPLEMENTATION OF STUDIES.
THANK YOU FOR SHARING THAT.
QUESTION YOULY FOR DR.
DEFRANCIS.
CONSIDERING THE CURRENT STATE OF
MATERNAL INFANT MORBIDITY AND
MORTALITY, HEALTHCARE
DISPARITIES IN THIS POPULATION
SOCIAL DETERMINANTS OF HEALTH
AND INCREASE IN OB DESSERTS AND
MATERNITY UNIT CLOSURE, DOES
HMSIS CAPTURE DATA ON PREGNANCY
AND POSTPARTUM POST PREGNANCY
SCREENING AND OB EMERGENCY
SPECIFICALLY?
IF SO, WHAT IMPACT DID THEY HAVE
ON ED USAGE OF THIS POPULATION?
COMPLICATIONS IN PREGNANCY,
PROBLEMS WITH PREGNANCY, THIS IS
ALL CODED TO ICD 10 CM.
I SAW THE QUESTION IN THE CHAT
SO I SCURRIED BACK AND WE HAVE
SOME TABLES UP ON OUR WEBSITE
AND ACTUALLY I WENT TO LOOK AND
AGAIN, THIS IS JUST A CURSORY
LOOK AND FROM WHAT I COULD SEE,
IN OUR DATA THERE HASN'T BEEN
MUCH CHANGE.
IT IS STABLE.
THAT IS NOT TO SAY THERE HASN'T
BEEN CHANGE BUT AT LEAST IN THE
HAMSA DATA THERE IS NOT UPTICK
OR DECREASE, IT IS ROUGHLY ABOUT
THE SAME.
BUT I WANT TO POINT OUT A COUPLE
OF THINGS, I TALK ABOUT HOSPITAL
CARE SURVEY, WE PUT OUT A REPORT
A FEW MONTHS AGO LOOKING AT
WOMEN WHO DELIVERED IN THE
HOSPITAL AND THEN FOLLOWED TO
SEE IF THEY HAD A POSTPARTUM
EMERGENCY DEPARTMENT VISIT.
HOSPITAL CARE DATA IS NOT GNASH
NATIONALLY REPRESENTATIVE BUT
THIS PARTICULAR STUDY WAS BASED
ON 158 HOSPITALS AND AGAIN POINT
BEING THERE WAS 100,000
DELIVERIES IN THE DATA SET AND
ABOUT 6% OF THE WOMEN DID HAVE
POSTPARTUM ED VISIT.
I CAN DROP STUDY MANY THE CHAT.
SO AGAIN VERY IMPORTANT TOPIC.
WE ARE WELL AWARE OF, AND ALSO
ONE LAST THING I WANT TO SAY
AGAIN NOT DIRECTLY RELATED TO
HMSIS BUT WE COLLECT DATA AT
NCHS FROM FEDERALLY QUALIFIED
HEALTH CENTERS AND WE ARE
ACTUALLY MOVING THE COLLECTING
ON SITE ABSTRACTION AND REMOVING
NOW THE COLLECTION OF ELECTRONIC
HEALTH RECORD DATA AND IN THE
PROCESS OF RECRUITING A
NATIONALLY REPRESENTATIVE SAMPLE
AND ACTUALLY HAVE SOME PCOR
FUNDING TO LOOK AT MATERNAL
HEALTH MATERNAL MORBIDITY, WE
WILL BE LINKING TO THE NATIONAL
DEAF INDEX AND HUD DATA SO THAT
IS TO COME.
STAY TUNED BECAUSE WE ARE
IMPORTANT TOPIC ON MATERNAL
HEALTH MATERNAL MORBIDITY.
WE ARE TRYING TO DO SOME AGAIN
THINGS AT THE NATIONAL LEVEL TO
ADDRESS THAT ISSUE.
THANK YOU.
>> THANK YOU SO MUCH DR.
DEFRANCIS.
I WILL DRAW THE ATTENTION OF
ATTENDEES TO THE CHAT WHERE
THERE IS A VERY ACTIVE
CONVERSATION GOING ON AND
FOLLOWING UP ON SPECIFIC
QUESTIONS THAT HAVE BEEN ASKED.
FEEL FREE TO PARTICIPATE IN THAT
BECAUSE I CAN (INAUDIBLE) TO
LISTEN TO ME NECESSARILY.
SO SOME MORE SPECIFIC QUESTIONS
TO DR. TAYLOR.
SO FROM YOUR WORK WHAT
SUGGESTIONS DO YOU HAVE FOR
HEALTHCARE FOLKS WHO WOULD
REALLY LIKE TO PARTNER WITH
COMMUNITY ORGANIZATIONS TO HELP
NURTURE THOSE RELATIONSHIPS ON
TERMS THAT ARE COMFORTABLE FOR
THE PARTNERS VERSUS COMFORTABLE
FOR THE HEALTHCARE FOLKS.
>> THANKS SO MUCH, BILLY.
I DO HAVE A LITTLE ONE IN THE
BACK SO IF YOU HEAR A SLEEKY
WILL DO MY BEST.
I GOT THREE CONCRETE THINGS,
PEOPLE HAVE ASKED ME THIS
BEFORE.
ONE IS RESEARCH HAS SHOWN AGAIN
AND AGAIN THAT IF YOU CAN FOSTER
RELATIONSHIP BETWEEN HEALTHCARE
AND SOCIAL SERVICES, WITH PEOPLE
WHO ARE LIKE TRAINED AS THE
POINT PERSON ON BOTH SIDES, IT
GOES REALLY LONG WAY, THINK
ABOUT HAVING A SOCIAL WORKER IN
SOCIAL SERVICE ORGANIZATION RUN
POINT ON THE PARTNERSHIP
MANAGEMENT AND PUT SOMEONE WHO
IS ALSO A SOCIAL WORKER IN THE
HEALTHCARE SETTING ON THE OTHER
SIDE.
IT IS A REALLY NICE WAY TO TRY
AND BROKER AND CROSS THE CHASM
OF WHAT IS OTHERWISE A HUGE
CULTURAL DIFFERENCE BETWEEN THE
ORGANIZATIONS, IF YOU JUST HAVE
PEOPLE WHO SPEAK THE SAME
LANGUAGE IN ALMOST LIKE A
TRANSLATION ROLE.
THAT IS ONE.
A SECOND IS BACK TO STORY ABOUT
THE HOSPITAL MEETING THAT WENT
AWRY, JUST MAKES A HUGE
DIFFERENCE EARLY IN THE
ORGANIZATION IF HEALTHCARE FOLKS
ARE WILLING TO LEAVE THEIR OWN
PREMISES.
IF YOU ARE WILLING TO GO AND
HAVE MEETINGS, AT A SOCIAL
SERVICE ORGANIZATION OR EVEN AT
NEUTRAL POINT THERE IS REALLY
SOMETHING INTIMIDATING FOR
PEOPLE WALKING INTO A HEALTHCARE
SYSTEM OR INTO A HEALTHCARE
DELIVERY SITE AND FEELING LIKE
THIS IS A TOTAL INSTITUTION THAT
I AM NOT FAMILIAR WITH, THAN
JUST BEING WILLING TO TRAVEL
SPEND THE EXTRA 15, 20 MINUTES
HOWEVER IT TAKES TO BE THE ONE
WHO GOES AND NEEDS SOMEWHERE
ELSEWHERE IS BIG.
THREE, WHEN IT COMES TO
CONTRACTING IT COULD GOD A HUGE
WAY IF HEALTHCARE WAS WILLING TO
SAY DO YOU WANT TO PUT FORWARD
THE BOILERPLATE CONTRACT BECAUSE
HEALTHCARE BOILERPLATE CONTRACTS
ARE OVER THE TOP INTIMIDATING
AND SKEW DISCUSSION IN TERMS OF
WHAT HEALTHCARE WANTS TO MEASURE
AND THEIR POLICY RECOMMENDATIONS
ANDIA DA.
IF EVEN AT SOME POINT IN THE
CONTRACT NEGOTIATIONS YOU GIT
THERE, GIVING THE SOCIAL
SERVICES ADMINISTRATION AN
OPPORTUNITY TO PUT FORWARD THEIR
VERSION WHERE THEY WANT TO START
HELPS.
>> I THOUGHT I WAS A HERO BY
MODERATING THAT WITH A 60-POUND
LAB AT MY FEET BUT YOU WIN.
ALSO THERE WAS REQUEST IF YOU
KNOW HEALTH AND HUMAN SERVICES,
IF YOU CAN PUT THAT IN THE CHAT,
IF SOMEBODY MIGHT BE ABLE THE
ACCESS IS THAT.
>> ABSOLUTELY.
>> THANK YOU.
SO THERE IS GREAT QUESTION IN
THE CHAT, FROM KAREN JENNINGS
MATHIS HOW RESEARCHERS ARE
CONSIDERING AND/OR EVALUATING
IMPACT OF MENTAL HEALTH PROBLEMS
OR CHALLENGES IN THEIR RESEARCH.
ANY OF THE PANELISTS FEELING
STRONGLY ABOUT ANSWERING THAT
QUESTION?
HOW ARE RESEARCHERS CONSIDERING
AND EVALUATING HEALTH PROBLEMS
OR CHALLENGES IN THEIR RESEARCH?
>> I FEEL LIKE I HAVE BEEN
SPEAKING A LOT SO ANYONE
INTERRUPT ME AT ANY POINT.
BUT I CAN IN BRIEF SAY WE ARE
NOT STUDYING IT ENOUGH
ESPECIALLY EMERGENCY DEPARTMENT
SETTINGS AND OTHERS WE KNOW
MENTAL HEALTH IS INFLUENCING
PATIENTS ABILITY TO ACCESS
SERVICES.
I GAVE A TALK YESTERDAY TO ONE
OF THE NATIONAL COUNCILS ON
MENTAL HEALTH AND WELLNESS AND
THIS IS A FIELD INTEGRATION OF
SOCIAL CARE THEY ARE ACTIVELY
TRYING TO GET MORE INVOLVED
WITH.
SO WE SHOULD BE TAKING INTO
ACCOUNT AND THERE ARE STUDIES
OUT THERE TRYING TO LOOK AT
INFLUENCE CORRELATIONS BETWEEN
MENTAL HEALTH AND HAVING SOCIAL
RISK NEEDS AND THE FIELD OF
BEHAVIORAL HEALTH AND PSYCHIATRY
IS DOING A LOT OF SOCIAL CARE
THOUGH NOT SYSTEMATIC WAY OF
INTEGRATE SYSTEMATIC SCREENING
AND ASSISTANCE PROGRAMS.
BUT SOMEPLACE THEY ARE WORKING
TO GET MORE INVOLVED WITH AS
WELL.
>> ONE OTHER THOUGHT TOO IS THAT
I THINK MENTAL HEALTH,
ESPECIALLY A SCREENING IS MORE
SENSITIVE MEASURE FOR SOCIAL
DETERMINANTS.
IF SOMEBODY FACES HOUSING
INSTABILITY AND LOSES THEIR JOB
AND YOU HAVE A LONGITUDINAL
STUDY YOU WILL SEE THE OUTCOME,
THE HEALTH OUTCOME OF THAT MORE
QUICKLY IN THE MENTAL HEALTH
THAN YOU WILL LIKE WHEN DOES A
PERSON DEVELOP DIABETES OR
HYPERTENSION.
SO I THINK ACTUALLY MENTAL
HEALTH SCREENERS ARE GREAT FOR
CHANGES IN ADVERSE CHANGES IN
YOUR SOCIAL ECONOMIC
CIRCUMSTANCES.
>> ANYONE ELSE ON THAT NOTE?
>> I WILL ADD SOMEONE ELSE WHO
HAS SPOKEN TOO MUCH TODAY.
TO MOLLY'S POINT AND MELISSA,
THE LONGITUDINAL OUTCOMES IN
TERMS OF DISTRESS AND ANXIETY,
ABSOLUTELY THOSE ARE FANTASTIC
MEASURES TO TRACK.
BUT TO MOLLY'S POINT I THINK IS
THAT -- WHAT WE HAVE SEEN IN OUR
OWN ED IS THAT YES, BEHAVIOR,
MENTAL HEALTH CRISES ADDICTION,
THOSE ARE THE MOST UNDERSCREENED
PATIENTS IN OUR POPULATION.
IT IS THE FIRST DIAGNOSIS THAT
SENDS OUR STAFF INTO THE CORNER
AND SAYING THE PATIENT REFUSES
TO SCREEN.
SO WE HAVE WORK TO DO.
THAT IS WHAT WE KNOW AT LEAST
NUMBER OF PEOPLE AND HOW MUCH
WORK WE HAVE TO DO BUT THAT IS
ALL WE KNOW.
>> THERE HAD BEEN A QUESTION
ACTUALLY FOR DR. POLLACK NOT
SURE WAS HERE AT THE MOMENT BUT
LOOKING AT HOUSING INSECURITY
ALONGSIDE MENTAL HEALTH
CONDITIONS AND REALLY NOTICING
THAT PEOPLE DESTABILIZE WHEN
HOUSING SITUATION BECOMES MORE
TENUOUS AND BEING CURIOUS
WHETHER THERE HAVE BEEN
INTERVENTION STUDIES EXAMINING
THAT RELATIONSHIP CURIOUS IF
ANYBODY ELSE MIGHT BE ABLE TO
ANSWER THAT QUESTION.
EVEN PEOPLE WHO SAY THEY HAVE
SPOKEN A LOT FEEL FREE THE CHIME
IN.
>> I THINK THERE IS A GOOD BOOK.
IS IT JEFF -- HAS WRITTEN
EVICTION, HE'S DONE A LOT OF
WORK AROUND HOUSING INSTABILITY
EVICTION AND MENTAL HEALTH AND
SO HIS WORK IS FANTASTIC IF
ANYBODY IS NOT FAMILIAR WITH IT.
STRONG EVIDENCE OF THAT.
SOMETIMES IT IS FUNNY BECAUSE
LIKE WHEN WE ARE TALKING OPIOID
ADDICTION FOR EXAMPLE, EDs
HAVE BEEN RELUCTANT TO GET
INVOLVED IN THAT.
THAT IS -- GOES BACK TO RENEE'S
POINT YESTERDAY ABOUT SOME TIMES
STRUCTURAL INEQUITIES WHERE HERE
WE HAVE PEOPLE COMING IN IN DIRE
NEED OF TREATMENT AND WE HAVE
IGNORED THAT UNTIL RECENTLY
UNTIL THE YALE STUDY WAS DONE
AND SHOWED THAT, YOU KNOW, WE
START THE PROCESS IN THE ED WE
ARE MORE SUCCESSFUL AT MOVING
PEOPLE INTO LONGER TREATMENT.
WE WERE AFRAID TO TACKLE THAT
FOR A LONG TIME.
>> THEY THINK IT IS CONFUSING TO
PROVIDERS BECAUSE OPIOID MISUSE
DISORDER HAS REALLY BECOME
CONFLATED WITH NEED FORE PAIN
TREATMENT.
STUDIES HAVE SHOWN -- ONE BY DR.
ANDREA OUT OF DANA-FARBER THAT
LOOKED AT DATA BETWEEN 2007 AND
2017 OF CANCER INCIDENCE AND
SHOWED THIS MARKED INCREASE OF
ED HOSPITALIZATIONS RELATED TO
PAIN ADMISSION AND SUBSEQUENT
HOSPITALIZATION DUE TO PAIN
ALONGSIDE STATISTICALLY
SIGNIFICANT DECREASE IN OPIOID
PRESCRIBING.
SO THE LACK OF CLINICAL GUIDANCE
FOR A LOT OF CLINICS HOW TO
MANAGE OPIOID MISUSE DISORDER AS
A DISTINCT MEDICAL CONDITION
VERSUS ADEQUATELY ETHICALLY
TREATING PAIN AND DISTRESS.
LAUREN DID YOU WANT TO ADD
SOMETHING?
>> I WAS GOING TO VALIDATE THE
POINT THERE ARE NUMBER OF
HOUSING STUDIES THAT SHOW
IMPROVEMENT IN MENTAL HEALTH AND
I THINK IT UNDERSCORES HOW
IMPORTANT IT IS TO MEASURE
MENTAL HEALTH OUTCOMES IN
VARIETY OF INTERVENTION CONTEXT
BECAUSE REALITIES OF RESEARCH
MEAN WE ARE OFTEN NOT FOLLOWING
PEOPLE LONGITUDINALLY UNTIL THE
FIVE YEAR MARK OR SEVEN YEAR
MARK OR TEN YEAR MARK AN MENTAL
HEALTH CHANGES ARE THINGS THAT
OCCUR FIRST.
SO WHEN YOU ONLY HAVE FUNDING
FOR THREE YEAR STUDY OR FUN YEAR
STUDY YOU CATCH A CHANGE IN
MENTAL HEALTH OUTCOMES BEFORE
YOU WOULD HAVE POTENTIALLY
CAUGHT A CHANGE IN PHYSICAL
HEALTH OUTCOMES SO THAT HOUSING
REVIEW I DROPPED IN THE CHAT I
DID A FEW YEARS AGO BUT IN TERMS
OF CONNECTING HOUSING
IMPROVEMENT OF VARIOUS GUYSES,
TO HELP IMPROVEMENT, THE
STRONGEST CONNECTION IS BETWEEN
HOUSING IMPROVEMENT AND VARIOUS
KINDS OF MENTAL HEALTH.
>> THANKS LAUREN.
>> LAUREN'S POINT ALSO MAKES ME
THINK ABOUT SOMETHING ALSO
TRYING TO EXPLORE IN TERMS OF
LASH NATURAL FOR SCREENING AND
WE HAVE DONE A STUDY AND SOME
OTHER GROUPS HAVE FOUND PATIENTS
REPORT BENEFIT FROM JUST BEING
ASKED ABOUT SOCIAL RISK.
SO THAT BEING HELPING WITH
STRENGTHENING RELATIONSHIPS AND
RAPPORT, WE HAVEN'T SPECIFICALLY
LOOKED AT IT, I DON'T BELIEVE
OTHERS IN TERMS OF RELATIONSHIP
BETWEEN THAT AND THEN MENTAL
HEALTH DRAWING THAT LINK
EXPLICITLY BUT IT IS ANOTHER
INTERESTING AREA TO EXPLORE THAT
BEYOND THE ASSISTANCE OR LIKE
ADJUSTMENT TO MEDICAL CARE WE
PROVIDE, ARE THERE POTENTIAL
BENEFITS IN ADDITION TO
POTENTIAL INTENDED CONSEQUENCES
AND HARMS WE MIGHT BE DOING WITH
SCREENING THAT WOULD BE
INTERESTING TO FURTHER EXPLORE.
>> SO SHIFTING GEARS A LITTLE
BIT I HAVE A QUESTION FOR DR.
BRISTOL.
DR. BRISTOL CAN YOU SPEAK TO
IMPACT OF THE COVID PANDEMIC AND
VISITOR RESTRICTION POLICIES
HAVE HAD ON UNMET CAREGIVER
SOCIAL NEEDS AND DO YOU HAVE ANY
SUGGESTIONS ABOUT HOW WE MIGHT
ADDRESS THOSE NEEDS AS
RESTRICTIONS CONTINUE AND
SYSTEMS PREPARE FOR FUTURE COVID
SURGES.
>> GREAT QUESTION.
THANK YOU.
THIS -- WHEN WE WERE CONDUCTING
OUR INTERVIEWS WE ACTUALLY HAD
CAREGIVERS WHO WERE AT DIFFERENT
POINTS OF THE COVID PERIOD SO
THERE WAS SOME PERIODS WHERE
THEY HAD VERY LITTLE ACCESS TO
VISITATION.
SOME PERIODS WHERE VISITATION
POLICY WAS RELAXED BUT THERE IS
DEFINITELY A SIGNIFICANT OVERALL
IMPACT COVID HAD FOR CAREGIVERS,
ONE CAREGIVER JUST STORY JUST
STANDS OUT TO ME, SHARED HOW HER
HUSBAND WAS SCHEDULED FOR
SURGERY AND THOUGHT IT WAS AN
OUTPATIENT PROCEDURE, HE DROVE
HIMSELF, AND TOLD HIS WIFE I
WILL BE BACK LATER THIS
AFTERNOON, SHE WAS NOT ALLOWED
TO GO WITH HIM TO THE
PRE-SURGICAL VISIT SO SHE JUST
THOUGHT HE WAS TELLING THE
TRUTH.
HE SHOWED UP, IT WAS AN
INPATIENT HOSPITAL STAY, LONG
STORY SHORT HE WAS IN THE
HOSPITAL FOR FIVE DAYS, AND JUST
THE PANIC AND THE DIFFICULTY
THAT CAUSED FOR THEM OVER THAT
COMMUNICATION ISSUE, WAS VERY
SIGNIFICANT FOR THAT POST
DISCHARGE COPING AND THE
DIFFICULTY THEY HAD IN ADJUSTING
TO THIS UNEXPECTED TYPE SURGICAL
EVENT.
SO DEFINITELY FOR CAREGIVERS FOR
OLDER ADULTS THE PRESENCE OF THE
CAREGIVER AT BEDSIDE IS
CRITICAL, CAREGIVERS RECOGNIZE
IF THEY ARE NOT AT THE BEDSIDE
THE HEALTHCARE SYSTEM TENDS NOT
TO REACH OUT AND INCLUDE THEM
AND GIVE THEM UPDATES.
SO THERE IS A CHALLENGE IN
KNOWING WHAT IS GOING ON AND
THEN THE SCARY RESPONSIBILITY OF
I HAVE TO ASSUME ALL THESE NEW
THINGS BUT I DON'T KNOW WHAT I
NEED TO DO, I WASN'T THERE.
IT IS JUST CAN BE VERY
OVERWHELMING.
TO THE QUESTION EARLIER ABOUT
MENTAL HEALTH I WAS GOING TO ADD
THAT OFTEN WE FORGET THE MENTAL
HEALTH OF FAMILY MEMBERS OR
MENTAL HEALTH OF THE CAREGIVER
CAN DRAMATICALLY IMPACT THE
INDIVIDUAL PATIENT AND
DRAMATICALLY IMPACT THE WHOLE
WELL BEING OF THE RELATIONSHIP
OF THE FAMILY UNIT.
SO DEFINITELY WE UNDERSTAND WHY
THERE WAS VISITOR RESTRICTION
DURING COVID SO THE NEGATIVE
CONSEQUENCES OF THAT FOR OLDER
ADULTS IS VERY SIGNIFICANT.
>> THANK YOU SO MUCH.
I ALSO WANT TO HE CAN KNOW WHAT
TANYA STROUT HAS WRITTEN MANY
CHAT NOT HAVING FAMILIES AND
CAREGIVERS IN THE ED DURING THE
PANDEMIC WAS ONE OF THE WORST
THING, AS A PALLIATIVE
SPECIALIST MYSELF I'M PATHOSES
WITH THAT FOR PEOPLE NOT ABLE TO
BE WITH THEIR LOVED ONES AT THE
END OF LIFE AND OF COURSE THAT
IS GOING TO INFORM A WHOLE WAVE
OF COMPLICATED GRIEF AND MASS
BEREAVEMENT IN THAT SENSE.
I'M ALSO CURIOUS DR. BRISTOL
ABOUT CAREGIVERS FROM
HISTORICICALLY EXCLUDED GROUPS,
SOME OF MY WORK IS ABOUT LGBTQ
IDENTIFIED PATIENTS AND THEIR
CHOSEN FAMILIES.
SO WE HAVE JUST WORKED ON A
PROJECT AROUND REALLY HELPING TO
ENSURE THE CHOSEN FAMILIES OF
LGBTQ IDENTIFIED PATIENTS WHO
VERY OFTEN FORM SOCIAL SUPPORT
STRUCTURE FOR THESE PATIENTS AND
THE ILLNESS CONTEXT.
ARE SEEN AND VIEWED BY HEALTH
SYSTEMS AS CAREGIVERS OR
INCLUDED IN DECISION MAKING AND
CARE PLANNING PROCESSES OR
INTEGRATED TO SOCIAL
PRESCRIBING, ET CETERA.
CURIOUS IF YOU HAVE SEEN ANY OF
THAT IN YOUR WORK OR HAVE
ANYTHING TO ADD ABOUT HOW WE CAN
ACCOUNT FOR THAT.
>> YES, I HAVE UNFORTUNATELY
SEEN THAT.
AS I HIGHLIGHTED WHEN WE SEE THE
NON-TRADITIONAL RELATIONSHIPS
WHERE IT IS A FRIEND OR SOMEONE
MAYBE NOT RECOGNIZES AS SPOUSE
PARTNER.
THERE'S ADDITIONAL BARRIERS TO
BE INCLUDED OR TO BE RECOGNIZED
AS THE PERSON OF CONTACT.
OFTEN IF CAREGIVERS OFTEN
HEALTHCARE STAFF MAY AGAIN DUE
TO CHAOTIC ENVIRONMENT PROVIDING
CARE IT IS EASY TO OVERLOOK
FAMILIES NOT PRESENT AND DO I
NEED TO REACH OUT TO SOMEONE TO
INCLUDE THEM IN COMMUNICATION
ABOUT CARE PLANNING, DECISIONS
THAT NEED TO BE MADE, ET CETERA.
SO IF THE CAREGIVER IS NOT
SOMEONE WHO IS LISTED AS SPOUSE
THEN THEY FACE ADDITIONAL
BARRIERS ABOUT HIPAA CONCERNS,
CAN WE SHARE INFORMATION WITH
THIS PERSON, NOT MARRIED, WHAT
KIND OF STAFF MAY WORRY ABOUT
THAT.
SO DEFINITELY THERE ARE THOSE
BARRIERS AND SO WE REALLY IN THE
EHRs THERE ARE PLACES TO LIST
POINT OF CONTACT, THE PERSON TO
CONTACT BUT THERE IS NOT ALWAYS
A CLEAR PLACE TO LIST THIS
PERSON HAS THIS CAREGIVER PLEASE
ENSURE THAT YOU COMMUNICATE WITH
THIS INDIVIDUAL.
GOING FORWARD THAT IS A --
SOMETHING THAT IS IMPORTANT TO
THINK ABOUT HOW DO WE BUILD THAT
IN, HOW DO WE WHEN PATIENTS ARE
TRANSITIONING BETWEEN UNITS DO
WE MAKE SURE THAT INFORMATION
GOES ALONG WITH THE PATIENT.
SO THEY DON'T HAVE TO ARRIVE AT
THE NEW LOCATION AND TELL
EVERYONE AGAIN I HAVE THIS
PERSON PLACE CONTACT THEM,
PLEASE MAKE SURE YOU INCLUDE
THEM.
SO REALLY THINKING HOW THAT IS
MORE SMOOTHLY INCORPORATED AND
SCHEMEATICALLY DONE FOR EVERY
PATIENT WITH A SIGNIFICANT
PARTNER OR CAREGIVER IS A REALLY
IMPORTANT THING TO THINK ABOUT.
>> THANK YOU SO MUCH, DR.
BRISTOL.
SO WE HAVE A FEW MINUTES LEFT, I
WILL ASK MY QUESTION, IF THAT IS
OKAY.
SO MY QUESTION IS ABOUT ACTUALLY
THE SOCIAL DETERMINANTS OF
HEALTHCARE WORKERS.
SO WE HAVE TALKED ABOUT PATIENTS
AND POPULATIONS, AND DIFFERENT
GROUPINGS WITHIN THE U.S.
POPULATION LARGELY.
BUT GIVEN THE COVID PANDEMIC AND
ALL REPORTS OF BURN OUT MORAL
SUFFERING AND TURN OVER, IN SOME
OF THE MORE GLOBAL REPORTS ON
THE SOCIAL DETERMINANTS OF
HEALTH DOCTORS FOR HEALTH EQUITY
REPORT, LED BY WHO NURSES FOR
HEALTH EQUITY REPORT, THERE HAVE
BEEN A LOT OF RECOMMENDATIONS
ABOUT HEALTH SYSTEMS AND THE
ROLES OF HEALTHCARE
ORGANIZATIONS AS EMPLOYERS AND
MANAGERS AND COMMISSIONERS WHO
ARE REALLY ACCOUNTABLE FOR
ENSURING THE WELFARE AND THE
WELL BEING AND DIVERSITY AND
INCLUSION OF HEALTHCARE WORKERS.
SO I'M CURIOUS UP FROM YOU AS
RESEARCHERS WHAT STEPS DO YOU
FOR SEE NEEDING TO TAKE FOR ED
HEALTH BEHAVIORS TO ENSURE THEIR
SOCIAL DETERMINANTS OF HEALTH
ARE ADDRESSED SO THAT WE CAN
REALLY SUSTAIN AND SUPPORT THEM?
GO AHEAD ANDREA JAY.
>> OUR HEALTH SYSTEM IS
INVESTIGATING A NUMBER OF
PROGRAMS TO TRY TO FIGURE OUT
HOW TO ADDRESS THIS.
ONE HAS BEEN A RELATIONAL
LEADERSHIP MODEL, I AM TRYING TO
FOSTER THIS IDEA OF
CONNECTEDNESS AND WITHOUT GOING
INTO DETAILS WHAT INVOLVED IN
THAT.
I DO KNOW THAT WE HAVE BEEN
TRYING TO FIGURE OUT WHAT IT IS
AGAIN I FEEL LIKE EVERY ANSWER I
GIVE I RAISE MORE QUESTIONS.
BUT I DO KNOW THAT IT HAS BEEN
AN ACTIVE PURSUIT BY HEALTHCARE
SYSTEMS OUT THERE BOTH OUR OWN
AS WELL AS OUR OTHERS, OTHER
SYSTEMS IN THE AREA.
THAT IS ONE MODEL, LEADERSHIP
MODEL.
>> EXCITING.
THANK YOU.
ANY OTHER THOUGHTS ON THAT
QUESTION?
ALL RIGHT.
ANY FINAL THOUGHTS OVERALL
BEFORE WE CLOSE?
SO AS WE PREPARE FOR THIS FINAL
KEYNOTE FROM DR. PHYLLIS SHARPS
I WANT TO CALL THE MEMORY OF DR.
PAUL FARMER AGAIN AND
FUNDAMENTAL TRUTH OF HEALTH AS A
HUMAN RIGHT AND LEAVE YOU WITH
THIS QUOTE.
HE SAID THAT HUMAN RIGHTS
VIOLATIONS ARE NOT ACCIDENTS.
THEY ARE NOT RANDOM IN
DISTRIBUTION OR EFFECT.
RIGHTS VIOLATIONS ARE RATHER
SYMPTOMS OF DEEPER PATHOLOGIES
OF POWER AND ARE LINKED
INTIMATELY TO THE SOCIAL
CONDITIONS THAT SO OFTEN
DETERMINE WHO WILL SUFFER ABUSE
AND WHO WILL BE SHIELDED FROM
HARM.
I'M VERY, VERY GRATEFUL TO HAVE
MODERATED THIS DISCUSSION AND
I'M SO GRATEFUL TO THE
RESEARCHERS FOR ALL THE WORK
THAT YOU DO.
THANK YOU SO MUCH.
>> YOU ARE MUTED.
>> OF COURSE I AM, WE ARE STILL
-- THANK YOU SO MUCH, DR. ROSA
FOR THE FINAL COMMENTARY AS WELL
AS ENGAGING THOUGHTFUL
DISCUSSION WITH PARTICIPANTS, WE
THANK YOU PANELISTS AND I WILL
TURN IT OVER TO YVONNE BRYAN.
>> THANK YOU SO MUCH.
SO I'M YVONNE BRYAN, SENIOR
ADVISOR IN THE NINR OFFICE OF
DIRECTOR.
IT IS MY GREAT HONOR TO PRESENT
TO YOU THE END NOTE SPEAKER DR.
PHYLLIS SHARPS.
DR. SHARPS IS PROFESSOR EMERITUS
AND FORMER LCM LAWLER ENDOWED
CHAIR OF ASSOCIATE DEAN FOR
COMMUNITY PROGRAMS AND
INITIATIVES AT THE JOHNS HOPKINS
SCHOOL OF NURSING.
DR. SHARPS WAS INAUGURAL
DIRECTOR FOR THE JOHNS HOPKINS
SCHOOL OF NURSING CENTER FOR
COMMUNITY INNOVATION AND
SCHOLARSHIP.
THE EAST BALTIMORE COMMUNITY
NURSE CENTERS THREE COMMUNITY
NURSE LED INITIATIVES OF THE
SCHOOL OF NURSING.
SHE ALSO ESTABLISHED THE HEALTH
AND WELLNESS PROGRAM AT THE
HENDERSON HOPKINS PARTNERSHIP
SCHOOL.
HER PRACTICE AND RESEARCH
EXAMINE CONSEQUENCES OF INTIMATE
PARTNER VIOLENCE AMONG PREGNANT
AND PARENTING WOMEN.
SPECIFICALLY THE EFFECTS OF
INTIMATE PARTNER VIOLENCE ON THE
PHYSICAL AND MENTAL HEALTH OF
PREGNANT WOMEN INFANTS AND VERY
YOUNG CHILDREN.
SHE HAS PUBLISHED NUMEROUS
ARTICLES AND BOOK CHAPTERS ON
IMPROVING REPRODUCTIVE HEALTH
AND REDUCING VIOLENCE AMONG
AFRICAN AMERICAN WOMEN.
PLEASE JOIN ME IN WELCOMING DR.
SHARPS.
>> GOOD AFTERNOON.
AND I -- I AM VERY PLEASED TO
HAVE THE OPPORTUNITY TO -- SEE
IF I CAN GET THIS TO WORK.
VERY PLEASED TO HAVE THIS
OPPORTUNITIES TO PRESENT THE
KEYNOTE -- THE ENDING
REFLECTIONS.
I WOULD FIRST LIKE TO
ACKNOWLEDGE I AM PRESENTING FROM
MY HOME IN MARYLAND.
THE (INAUDIBLE) TRIBE WHICH COME
PRIDES (INDISCERNIBLE) I WOULD
ALSO SAY THAT I HAVE NO
DISCLOSURES BUT I WOULD -- WHILE
THIS IS NOT A PRESENTATION ON
RESEARCH, MENTION FROM WORK I
HAVE DONE WHICH WAS FUNDED BY
NINR AND NICHD.
LIKE TO TAKE THIS OPPORTUNITY TO
THANK THE NATIONAL INSTITUTES OF
NURSING RESEARCH, EMERGENCY
NURSING ASSOCIATION, AND ALL THE
MEMBERS OF THE PLANNING
COMMITTEE THAT GAVE ME THIS
OPPORTUNITY TO PRESENT
REFLECTIONS.
I WILL PUT THIS DISCLAIMER,
THESE ARE MY REFLECTIONS AND
INTERPRETATION WHAT I HAVE HEARD
OVER THE PAST (INAUDIBLE) WE
HAVE SEEN AND HEARD AMAZING
SCIENCE THAT EXAMINED MANY
ASPECTS OF EMERGENCY CARE.
IN THE CONTEXT OF SOCIAL
DETERMINANTS OF HEALTH AND HOW
TO INTEGRATE THAT SCREENING.
WE HAVE HEARD THE (INAUDIBLE)
HAVING EXAMINE SYSTEMS PROVIDER
AND PATIENT PERSPECTIVES, AND
OPPORTUNITIES FOR IMPLEMENTING
SOCIAL DETERMINANTS OF HEALTH
SCREENING AND INTERVENTION IN
EMERGENCY DEPARTMENT SETTINGS.
I THINK THE PRESENTATIONS WE
HAVE HEARD BOTH (INAUDIBLE) MAY
INFORM OUR RESEARCH.
THE KEYNOTE SET THE CONTEXT OF
ALL OTHER PRESENTATIONS WE
HEARD.
OFTEN PEOPLE THINK OF ED IN HER
PRESENTATION SHE -- I THINK
STATED THAT OFTEN PEOPLE THINK
OF EMERGENCY DEPARTMENTS AS A
SAFETY NET MOST VULNERABLE.
SHE DID PRESENT DATA THAT HELPED
ON STRUCTURAL INEQUALITIES IN
THE DELIVERY OF ED CARE THAT
CONTRIBUTES TO HEALTH AND
PERSISTENT DISPARITIES AND THAT
SOME OFTEN ENSURED POPULATIONS
ACCESS TO QUALITY CARE BELIEVE
WE ARE NOT IMPACTED BY CARE BY
ED CARE OR THE LACK OF QUALITY
ED CARE AND CERTAINLY HER
GRAPHIC ON BOATS RISING I THINK
BROUGHT HOME THE POINT THAT HIGH
QUALITY ED CARE IMPROVES CARE
FOR (INAUDIBLE) AND VULNERABLE
POPULATIONS.
IT WAS-CONTEXT I WANT US TO
THINK ABOUT THAT WE NEED TO
DEVELOP (INAUDIBLE) ED CARE.
WHAT THEN FOLLOWED WAS A NUMBER
OF PRESENTATIONS ON MODELS FOR
ED CARE AND SOME WE HEARD DATA
THAT WAS PRESENTED ON THE
DEMOGRAPHICS AND PROFILES OF THE
ED INCLUDING POPULATION -- WE
LEARN THAT MANY PATIENTS PRESENT
TO ED WITH AT LEAST ONE UNMET
SOCIAL AND CHALLENGE IS HOW THAT
EDs ARE FACING PRESSURE TO
ADDRESS SOCIAL NEEDS AND TO DO
THIS RAPIDLY AND TO SCALE UP
DEVELOPING INTERVENTIONS THAT
WILL AND SCREENING THAT WILL
IDENTIFY SOCIAL NEEDS.
THE CHALLENGE IS HOW TO
IMPLEMENT SCREEN INTERVENTIONS
IN TRADITIONAL CONTEXT OF ED
CARE AS WE KNOW TODAY.
WE HAVE HEARD SOME THINGS
SUGGEST THERE ARE OPPORTUNITIES
AS WE CONTINUE TO RESEARCH AND
DEVELOP EXPERT IN ED.
ONE OPPORTUNITY IS I BELIEVE IS
THAT ED CARE FOR TOO LONG WE
PROBABLY THOUGHT OF THE ED
SYSTEM AS SEPARATE PART OF CARE
AND MORE TOWARDS COMPLEX
COMPREHENSIVE INTEGRATION OF ED
IN CARE FOR VULNERABLE
POPULATIONS.
WE NEED TO CERTAINLY PURSUE
RESEARCHERS FOR BEST PRACTICES
WITH DOCUMENTED EFFECTIVE
OUTCOMES AND CARE THAT HEALTH
INEQUITIES AND DISPARITIES.
OF COURSE THE CHALLENGE IS HOW
WE ADDRESS THAT GIVEN THE TIME
AND (INAUDIBLE) CARE.
SYSTEMS WE NEED CERTAINLY
INCREASE SYSTEM AND EFFECTIVE
SYSTEMS TO STORE AND (INAUDIBLE)
PATIENT SCREENING OUTCOMES AN
PROTOCOLS OR PROCEDURES FOREL
TIME INTERVENTIONS WE HEARD FROM
SEVERAL PATIENTS CERTAINLY NOT
ALL FOLLOW-UP PATIENT
(INAUDIBLE) TO ADDRESS THEIR
NEEDS WHEN IN REAL TIME THEY CAN
USE (INAUDIBLE) YOU HAVE HEARD
THAT HOW WE ARE ABLE TO
INTEGRATE DIGITAL RESOURCES TO
SUPPORT INNOVATION AND DIRECT
CARE.
OPPORTUNITY WAS WITH SOME OF THE
STUDIES THAT SHOW THAT PATIENTS
DO SOMEWHAT SCREENING AND SOME
ARE ACCEPTING AND WANT STUDIES
PARTICULARLY THE WALLACE STUDY
HAS SHOWN IT IS FEASIBLE AND WE
HEARD THE DIFFERENT ON NEEDS
VERSUS RISK AND THAT FOCUS MUCH
OF THE SCREENING IS BASED ON
RISK THOSE THAT HAVE NEEDS THAT
PERHAPS WE CAN DESIGN
INTERVENTIONS.
AND THEN SOME PATIENTS FOLLOW-UP
WORK GROUPS DO NOT.
AND CERTAINLY THERE ARE
VARIABLES FOR PATIENTS WHO DO
NOT ACCEPT HELP.
SOME OF THE CHALLENGES IN TRYING
TO IMPLEMENT SCREENING IN ED
SETTINGS ARE TIME CONSTRAINTS,
STAFF TRAINING, AND THIS IS ALSO
-- MOST SCREENERS HAVE BEEN
DEVELOPED FOR PRIMARY CARE
SETTINGS VERSUS ED SETTINGS, SO
THERE IS A QUESTION
ACCEPTABILITY OF THE
PSYCHOMETRIC CHARACTERISTICS OF
THIS, ARE WE SCREENING FOR
SOCIAL NEEDS OR SOCIAL RISK?
AND THEN HOW DO WE DO THAT AND
HOW DO WE STORE IT.
AND TECHNOLOGY TO IDENTIFY
RESOURCES TO FURTHER PARTNERSHIP
WITH CBOs AND THEN OF COURSE
FROM THE PATIENT PERSPECTIVES
THERE ARE CHALLENGES AROUND
GIVEN MANY WHO USE EMERGENCY
DEPARTMENTS HAVE HAD UNPLEASANT
ADVERSE NEGATIVE INTERACTIONS,
TO -- THEY CERTAINLY WISH TO BE
TREATED WITH DIGNITY, THERE ARE
PRIVACY AND WHAT HAPPENS TO THE
INFORMATION AND DO WE PURSUE
SCREENING FOR SOCIAL NEEDS OR
FOCUS SCREENING?
AND THEN (INAUDIBLE) ABILITY OF
THE -- ON OUR -- MIGHT HAVE
ENGLISH OR SPANISH BUT WE HAVE A
VERY DIVERSE (INAUDIBLE) IN OUR
COUNTRY AND CERTAINLY
INCREASING, SO THERE ARE MANY
LANGUAGES THAT WE NEED TO THINK
ABOUT.
IN MY OWN NIH FUNDED RESIRNLG
LOOK AT BEST WAYS TO SCREEN FOR
INTERNET PARTNER VIOLENCE.
COMPARE TECHNOLOGY DIGITAL
TABLET APPROACH TO SCREENING AND
INTERVENTION, PAPER AND PENCIL
AND WE FOUND THAT THERE WAS NO
(INAUDIBLE) WE DIDN'T
(INAUDIBLE) WE ALSO LEARNED IS
REGARDLESS OF THE METHOD USED,
TRAINING STAFF AND HOW TO ASK
QUESTIONS WHEN TO ASK QUESTIONS
HOW TO FRAME THEM ARE IMPORTANT.
I THINK THIS IS AN IMPORTANT
FINDING PERHAPS FOR HEALTH
DEPARTMENTS AND HOME VISIT
PROGRAMS WHO ARE OFTEN
STRUGGLING WITH HOW TO CONTINUE
TO SUPPORT THIS MECHANISM OF
CARE, THAT IF FOLKS -- IF STAFF
ARE TRAINED IN SUPPORT HOW TO
ASK QUESTIONS AND HOW TO
INTERVENE ABUSED WOMEN WILL
ACCEPT IT.
ANOTHER STUNT AROUND
INTERVENTIONS.
MANY DO DESIRE, WE HEARD FROM
DR. MONTGOMERY WITH VA
POPULATION PROMISING RESULTS TA
TAYLOR MIGHT MAKE A DIFFERENT
(INAUDIBLE) INTERVENTION REDUCE
ED USES.
WE ALSO REAL TIME RESOURCES
VERSUS -- PERHAPS FORMAL HAND
OFFS MAKE IN TERMS OF FOLLOW UP
HEALTH (INAUDIBLE) WE ALSO HEARD
THAT TRADITION CARE --
TRANSITION CARE CERTAINLY --
PATIENTS LEAVE THE EMERGENCY
DEPARTMENT IMMEDIATE TO INVOLVE
CAREGIVERS AND FAMILY MEMBERS
AND THAT IS IMPORTANT TO THE
SUCCESS OF.
SOME OF THE CHALLENGES AND
IMPLEMENT -- IN IMPLEMENTING ED
SETTINGS IS WE SUPPORT
CONTINUITY OF CARE.
WE RECOGNIZE SUCCESS AND DEVELOP
RESOURCES FOR CAREGIVERS TO
SUPPORT THE IDENTIFIED PATIENTS.
AND DEVELOPING PARTNERSHIPS WITH
CBOs ACCESS PRIVACY
INFORMATION SHARING IN MUCH OF
THE WORK COMMUNITY CENTERS
INVOLVE PARTNERING WITH,
SOMETIMES CARE PROVIDERS AND
(INAUDIBLE) PEOPLE WE NEED TO
LEARN DIFFERENT APPROACHES TO
WORKING WITH MEMBERS IN
COMMUNITY AND ALSO UNDERSTANDING
THAT OFTEN THE MEMBERS IN THE
STATE (INAUDIBLE) HAVE
SOLUTIONS.
STAFF TRAINING IS IMPORTANT,
RESOURCES, AND THEN WE HAVE
SEVERAL PAPERS ON HOW DO WE
EVALUATE EFFECTIVENESS OF
OUTCOMES.
WHAT DIFFERENCE DID IT MAKE,
WHAT WERE THE BARRIERS AND
FACILITATORS AND WHAT ARE THE
ACTUAL OUTCOMES WE SHOULD BE
LOOKING AT.
SO (INAUDIBLE) TALKED ABOUT ED
INTERVENTIONS AND COMMUNITY
CONNECTIONS.
TRANSITIONS THAT EXTEND ED
INTERVENTION TO COMMUNITY BASED
CARE.
SO THERE IS AN OPPORTUNITY THERE
FOR NEW MODELS OF CARE WE
CERTAIN WILL I HEARD DR. POLLACK
ABOUT THE IMPORTANCE OF
ADDRESSING HOUSING.
AND CHALLENGES THERE AND MODERN
DAY NURSING.
FLORENCE NIGHTINGGALE NOTED MORE
THAN A HUNDRED YEARS AGO
IMPORTANCE OF ADEQUATE HOUSING
IS CRITICAL TO GOOD HOUSING.
THE PILOT PROGRAM WE CALLED
HEALTH IN HOUSING, TO WHERE
PEOPLE LIVED AND WE IMPLEMENTED
HEALTH AND WELLNESS NURSE LED
CLINICS THIS IN SENIOR DEPENDENT
-- INDEPENDENT LIVING SHELTERS
THAT WOMEN AND TRANSITIONAL
HOUSING AND ONE OF THE IMPORTANT
OUTCOMES THAT DOCUMENT IN ALL
THOSE APPROACHES.
THESE WERE NURSE FACULTY
PRACTICE MODELS COMBINATION OF
FACULTY COMMUNITY FACULTY
(INAUDIBLE) UNDERGRADUATE AND
GRADUATE STUDENTS.
WE WERE ABLE TO MAKE CHANGES IN
HIGH USE OF EMERGENCY DEPARTMENT
FOR THOSE PATIENTS.
THOSE -- ANOTHER DR. ADLER AS
EARLY AS 2008 ONE OF THE FIRST
RESEARCH SETTING LOOK AT SOCIAL
EMERGENCY MEDICINE AND THERE WAS
RECOGNITION THAT IS THE SOCIAL
ENVIRONMENT WHICH WE HAD BEEN
TALKING EXTENSIVELY IMPACT
PARTICULARLY OF THOSE WHO WERE
USING ED CARE.
THAT WOULD BE ABLE TO DEVELOP
RESEARCH STRATEGIES AND METHODS
TO EXAMINE THOSE CHANGES AND
WHAT HAPPENS WHEN WE ADDRESS
NEEDS.
ONE OF HIS PROGRAMS HEALTH
ADVOCACY PROGRAM OR HELP DESKS
WERE SET UP IN EMERGENCY
DEPARTMENTS TO HELP PATIENTS
NAVIGATE SHOWED VERY FAVORABLE
OUTCOMES.
(INAUDIBLE) THERE IS A HEALTH
ADVOCATE PROGRAM WITHIN
ADDRESSES THINGS SUCH AS HOUSING
UTILITIES, TRANSPORTATION, AND
DOES MAKE A DIFFERENCE IN
PEDIATRIC HEALTHCARE.
(INAUDIBLE) WHICH PROVIDES SHORT
-- ANYONE THAT IS SEEN IN AN
EMERGENCY THERE IS (INAUDIBLE)
OPERATED BY INTERNAL MEDICINE
AND DOES PROVIDE THAT SUPPORT TO
GET FOLKS INTO MEDICAL HOMES,
AND IT IS INTERDISLYNARY
PHYSICIANS -- INTERDISCIPLINARY
AND WORK ON IDENTIFIED NEEDS AND
PROVIDE RESOURCES FOR
INDEPENDENT (INAUDIBLE).
ANOTHER EXAMPLE OF (INAUDIBLE)
PEOPLE BY COLLEAGUES DR. JOHN
(INAUDIBLE) UNIVERSITY INJURIES
DUE TO SHOOTING STABBINGS,
ASSAULTS AND SO FORTH.
AND IN HIS PROGRAM CARE IS
IMPLEMENTED TO ADDRESS PHYSICAL
AND EMOTIONAL WOUNDS AND PROGRAM
HAS BEEN IMPACT AND ALSO THE
STAFF (INAUDIBLE) WORK IN CITY
WIDE TO ADDRESS LONG-TERM
STRATEGIES TO VIOLENCE IN URBAN
SETTINGS.
SO I THINK IN ALL OF WHAT WE
HAVE HEARD, THERE ARE SOME
VALUABLE INSIGHTS FOR MOVING
RESEARCH FORWARD MODELS OF CARE
THAT INTEGRATE CONTINUITY OF
CARE ACROSS ED COMMUNITY
SETTINGS.
DATA AND SURVEILLANCE SYSTEMS
THAT CAPTURE INFORMATION NEEDED
TO EVALUATE CARE, OUTCOMES AND
WHAT WE NEED TO UNDERSTAND IF
IMPROVING OUTCOMES AND QUALITY
OF CARE.
SOCIAL NEEDS ASSESSMENT
SPECIFICALLY APPROPRIATE
EMERGENCY DEPARTMENT AND
POPULATIONS.
REAL TIME INTERVENTIONS THAT
(INAUDIBLE) INTEGRATION OF
TECHNOLOGY FOR ASSESSMENT
INTERVENTION AND FOR DOCUMENTING
OUTCOMES AND EFFECTIVENESS,
ACROSS SETTINGS.
PERHAPS MORE FAMILY FOCUS AND
INCORPORATING PATIENTS AND
CAREGIVERS. I WOULD LIKE TO
CONCLUDE MY REFLECTIONS BY
NOTING THE RESEARCH BASED
ASSESSMENT PREVENTION STRATEGIES
TO ADDRESS EQUALITY --
INEQUALITY AND HEALTH
DISPARITIES AND SOCIAL
DETERMINANTS OF HEALTH SHOULD
ADOPT INTEMPERATE AND DEVELOP
RESEARCH METHODOLOGY THAT
ADDRESS JUSTICE PRINCIPLES.
TO DO THE WORK TO ADDRESS HEALTH
INEQUALITIES AND PERSISTENT
HEALTH DISPARITIES, PRINCIPLE --
THE SOCIAL JUSTICE PRINCIPLES,
SUCH AS ANTS RACISM,
ANTI-VIOLENCEN, ANTI-(INAUDIBLE)
ANTI-OPPRESSION AN ANTI-POVERTY,
AS RESEARCHERS WE NEEDS TO BE
METHODOLOGIES THAT INCORPORATE
AND ADDRESS THESE ISSUES THAT
MANY PATIENTS (INAUDIBLE).
THANK YOU.
>> HAVING TROUBLE WITH MY
CAMERA.
NOT SURE WHAT IS GOING ON HERE.
IN ANY EVENT, I THINK MY VIDEO
WAS STOPPED BY SAM, SAM, CAN YOU
THANK YOU SO VERY MUCH, DR.
SHARPS FOR THAT THOUGHTFUL
SYNTHESIS REFLEXION.
REALLY HIGHLIGHTED THE CHALLENGE
AND OPPORTUNITIES.
WE ARE SO GRATEFUL TO YOU.
I WANT TO ECHO WHAT YOU SAID
ABOUT AN AMAZING DAY OF
INSIGHTFUL THOUGHT PROVOKING
STIMULATING SCIENCE.
SO BEFORE I TURN THIS OVER TO
DR. STROUT AND ZINK, I WANT TO
MAKE A LAST CLOSING COMMENTS.
WE ARE REALLY VERY EXCITED ABOUT
INCREASED INTEREST AND
PARTICIPATION IN THIS YEAR'S
VIRTUAL ROUND TABLE.
AS WE GET READY TO RELEASE OUR
NEXT STRATEGIC PLAN WE WILL BE
TAKING A LOOK HOW BEST TO USE
FUTURE EVENTS, SUCH AS TODAY'S
EVENTS.
TO REACH AS BROAD AN AUDIENCE AS
POSSIBLE.
TO PROMOTE NURSING SCIENCE.
IN THAT REGARD, PLEASE STAY
TUNED TO OUR WEBSITE AS WE
ANNOUNCE OUR UPCOMING PLANS.
SO I THANK YOU SO VERY MUCH.
AND NOW I WILL TURN IT OVER TO
DR. STROUT.
>> THANK YOU, DR. BRYAN AND DR.
SHARPS.
ON BEHALF OF THE EMERGENCY
NURSES ASSOCIATION AND THE ENA
EMERGENCY NURSING RESEARCH
ADVISORY COUNCIL, THANK YOU SO
MUCH TO SPEAKERS PANELIST
ATTENDEES, EVERYONE WHO WORKED
SO HARD AND PREPARING FOR THE
ROUND TABLE, THIS YEAR.
WE HAD VALUABLE LEARNINGS OVER
THE COURSE OF TIME TOGETHER THE
LAST FEW DAYS AND THIS WORK IS
CHALLENGING.
THE ISSUES WE FACE ARE COMPLEX
AND THERE ARE MANY I FEEL
HOPEFUL OUR COLLECTIVE EFFORTS
WILL ALLOW US TO INTEGRATE NEW
WAYS TO ADDRESS SOCIAL
DETERMINANTS INEQUITIES FOR THE
PATIENTS THAT WE SERVE AND
EMERGENCY SETTINGS AS WE WORK
FOR MORE EQUITABLE SYSTEMS AND
FIND WAYS TO NURTURE FLOURISHING
OF ALL PEOPLE.
DR. ZINC, TURN IT TO YOU TO
OFFER CLOSING THOUGHTS FOR THE
GROUP.
>> THANK YOU.
I AGREE, ECHO EVERYONE'S
COMMENTS, IT WAS A WONDERFUL
DAY, ENJOYED LAST EVENING AS
WELL.
SO THANK YOU SO MUCH FOR JOINING
NINR AND EMERGENCY NURSES
ASSOCIATION FOR THIS YEAR'S
ROUND TABLE.
FROM CONTEXT TO CARE
UNDERSTANDING THE CONVERGENCE OF
SOCIAL FACTORS AND EMERGENCY
DEPARTMENT CARE.
THANK YOU SO MUCH TO DR. SHARPS
FOR YOUR THOUGHTFUL REFLECTIONS.
I WANT TO EXTEND MY THANKS TO
THE EMERGENCY NURSES ASSOCIATION
FOR PARTNERING WITH US AT NINR
TO PRESENT THIS YEAR'S ROUND
TABLE.
I ALSO WISH TO THANK OUR KEYNOTE
SPEAKER, DR. RENEE SHAW, AND ALL
OF OUR DISTINGUISHED SPEAKERS
TODAY WHO PROVIDED REALLY
VALUABLE INSIGHT IN RESPONSE TO
PROGRAMS THEME.
I EXTEND A HUGE THANK YOU TO DR.
YVONNE BRYAN FOR ADMINISTERING
THE ROUND TABLE.
IT IS A PLEASURE TO HAVE YOU AT
NINR.
FINALLY, THANK YOU TO ALL OF OUR
ATTENDEES, CERTAINLY YOUR
COMMITMENT TO SOLVING THE
SYSTEMIC ISSUES, THAT LEAD TO
HEALTH INEQUITIES IS INVALUABLE.
WE LOOK FORWARD TO FUTURE
PARTNERSHIPS.
AGAIN, THANK YOU ALL SO MUCH.
AND GOOD NIGHT.