Search

Many primary care clinics screen patients for their unmet social needs, such as food insecurity and housing instability, and refer them to community-based organizations (CBOs). However, the ability for patients to have their needs met is difficult to evaluate and address. This study explores patient-reported barriers to accessing referred resources using a conceptual framework that identifies opportunities for intervening to optimize success.Patients who participated in a social needs screening and referral intervention at a Federally Qualified Health Center (FQHC) were called 2 weeks after the clinic encounter. We conducted a directed content analysis across 6 domains of access to examine responses from patients who reported barriers.Of the 462 patients that were reached for follow-up, 366 patients reported 537 total barriers. The most frequent challenges related to resource availability (24.6%, eg, patients waiting for submitted application to process) and approachability (23.8%, eg, patients lacking information needed to contact or access resources). Barriers in the domains of acceptability (21.6%, eg, competing life priorities such as medical issues, major life events, or caretaking responsibilities) and appropriateness (17.9%, eg, resource no longer needed) largely represented patient constraints expressed only after the clinical encounter. It was less common for patients to identify accommodation (eg, physical limitations, language barriers, transportation barriers, administrative complexity) or affordability of community resources as barriers (11.2% and 0.9%, respectively).Findings suggest opportunities for improvement across the access continuum, from initial referrals from primary care staff during the clinical encounter to patients' attempts to accessing services in the community. Future efforts should consider increased collaboration between health and social service organizations, and advocacy for structural changes that mitigate system-level barriers related to resource availability and administrative complexity.

PURPOSE: The most common cause of mortality for many cancer survivors is cardiovascular disease (CVD). This requires a shift in thinking where control of CVD risk factor-related comorbidity is paramount. Our objective was to provide an understanding of adherence to medications for the management of CVD risk factor-related comorbidities among cancer survivors. METHODS: We systematically searched for articles indexed in MEDLINE (via PubMed), Embase, Cochrane (Wiley), PsyclNFO, and Scopus (via Elsevier) for articles published from inception to October 31, 2019, and updated the search on June 7, 2021. English language, original research that assessed medication adherence to common CVD risk factor-related comorbidities among cancer survivors was included. We assessed risk of bias using the Mixed Methods Appraisal Tool. RESULTS: Of the 21 studies included, 57% focused on multiple cancer types. Seventy-one percent used pharmacy-based adherence measures. Two were prospective. Adherence was variable across cancer types and CVD risk factor-related comorbidities. Among the studies that examined changes in comorbid medication adherence, most noted a decline in adherence following cancer diagnosis and throughout cancer treatment. There was a focus on breast cancer populations. CONCLUSIONS: CVD risk factor-related medication adherence is low among cancer survivors and declines over time. Given the risk for CVD-mortality among cancer survivors, testing of interventions aimed at improving adherence to non-cancer medications is critically needed. IMPLICATIONS FOR CANCER SURVIVORS: For many cancer survivors, regularly taking medications to manage CVD risk is important for longevity. Engaging with primary care throughout the cancer care trajectory may be important to support cardiovascular health.

Background: Screening in primary care for unmet individual social needs (e.g., housing instability, food insecurity, unemployment, social isolation) is critical to addressing the deleterious effects on patients’ health outcomes. Evidence is needed regarding approaches to implementing such screening in routine clinical encounters to enhance social care integration. To our knowledge, this is the first study to apply an implementation science framework to identify implementation factors and best practices.Methods: Guided by the Health Equity Implementation Framework (HEIF), we collected qualitative data from providers and patients to evaluate barriers and facilitators to implementing the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE), a standardized social needs screening and response protocol, in a federally qualified health center. Eligible patients (n = 2,192) who received the PRAPARE as a standard of care at three of the center’s clinics (Adult Medicine, Family Medicine, and Pediatrics) were invited to participate in semi-structured interviews. We also obtained front-line clinician perspectives in a semi-structured focus group. We used HEIF domains to inform a directed content analysis.Results: Patients and clinicians (i.e., case managers) reported implementation barriers and facilitators across multiple levels (e.g., clinical encounters, patient and provider factors, inner context, outer context, and societal influence). Implementation barriers included structural and policy level determinants related to resource availability, discrimination, and administrative burden. Facilitators included evidence-based clinical techniques for shared decision making (e.g., motivational interviewing), team-based staffing models, and beliefs related to alignment of the PRAPARE with patient-centered care. We found high levels of patient acceptability and opportunities for adaptation to increase equitable adoption and reach.Conclusion: Our results provide practical insight into the implementation of the PRAPARE or similar social needs screening and response protocols in primary care. Our findings highlight the dynamic relationship between barriers and facilitators to implementation at the individual encounter, organizational, community, and societal levels. Future research should focus on developing discrete implementation strategies to promote social needs screening and response, and associated multisector care coordination to improve health outcomes and equity for vulnerable and marginalized patient populations.

In the United Kingdom (UK), link worker social prescribing has emerged as an option to improve long-term condition management and address primary care patients' non-medical needs by linking patients with community-based activities and support. Social prescribing is a complex, heterogenous intervention, and there is currently no taxonomy of components to guide its implementation and evaluation. This study aimed to identify and categorise the components of link worker social prescribing schemes in the United Kingdom. A scoping review of peer-reviewed literature was conducted. Six databases were used to identify papers that met inclusion criteria. Eligible articles were original research studies in the United Kingdom describing interventions that included (1) initial referral of adults with chronic physical health conditions and/or unmet social needs from primary care to a link worker or equivalent role, (2) consultation with a link worker or equivalent role and (3) referral to a community-based or government service. Of the 1078 articles identified, 32 met study eligibility criteria, representing 22 social prescribing schemes. We drew from the template for intervention description and replication (TIDieR) to identify, organise and report intervention components. We found wide variations in geography, target populations and intervention components such as activities and procedures conducted by primary care staff and link workers, organisational and staffing configurations and use of tools and financing approaches to facilitate adoption. Intervention components are summarised into a taxonomy to guide future research, policy and practice efforts in addition to supporting standardised intervention reporting.

Objective We developed a peer-led group program for Veterans called Taking Charge of My Life and Health (TCMLH) that emphasizes patient education, goal setting, shared decision making, and whole person care. Our aim was to conduct an evaluation of a facilitator training course to deliver TCMLH in VA sites. Methods Repeated measures ANOVA models were used to examine change over three timepoints (pre-test, post-test, and two-month follow-up) in outcomes of attitudes, knowledge, skills, and self-efficacy related to patient empowerment, skills acquisition, self-care strategies, and curriculum facilitation. Qualitative data analysis of participant feedback was used to identify potential training adaptations and barriers to TCMLH delivery. Results Our sample comprised 70 trainees who completed all three assessments. Participants reported high levels of training satisfaction, quality, and utility, and sustained improvements in knowledge of Whole Health, self-efficacy for group facilitation, and self-efficacy for using Whole Health concepts and tools. Implementation barriers included challenges related to group management and site logistics. Conclusion The facilitator training course improved knowledge and self-efficacy associated with successful peer-led program delivery and identified opportunities to improve the training course and TCMLH dissemination. Practice Implications: Findings provide insights on the design and implementation of training models to support peer-led programs.

Evidence-based approaches promoting patient engagement and chronic illness self-management include peer support, shared decision-making, and education. Designed based on these components, Taking Charge of My Life and Health (TCMLH) is a group-based, ‘Whole Person’ care program promoting mental and physical self-care and patient empowerment. Despite evidence of effectiveness, little is known about implementation for TCMLH and similar programs. In this first-of-its-kind, multi-methods evaluation conducted between 2015–2020, we report on implementation strategies and intervention adaptations with a contextual analysis to describe TCMLH translational efforts in Veterans Health Administration (VHA) facilities across the United States. Quantitative and qualitative data were collected via listening sessions with TCMLH facilitators, open-ended survey responses from facilitators, and quarterly reports from clinical implementation sites. We used the Consolidated Framework for Implementation Research (CFIR) to analyze, interpret, and organize qualitative findings, and descriptive statistics to analyze quantitative data. Most TCMLH programs (58%) were adapted from the original format, including changes to the modality, duration, or frequency of sessions. Findings suggest these adaptations occurred in response to barriers including space, staffing constraints, and participant recruitment. Overall, findings highlight practical insights for improving the implementation of TCMLH, including recommendations for additional adaptations and tailored implementation strategies to promote its reach.

Purpose of ReviewThere is a growing evidence base describing population health approaches to improve blood pressure control. We reviewed emerging trends in hypertension population health management and present implementation considerations from an intervention called Team-supported, Electronic health record-leveraged, Active Management (TEAM). By doing so, we highlight the role of population health managers, practitioners who use population level data and to proactively engage at-risk patients, in improving blood pressure control.Recent FindingsWithin a population health paradigm, we discuss telehealth-delivered approaches to equitably improve hypertension care delivery. Additionally, we explore implementation considerations and complementary features of team-based, telehealth-delivered, population health management. By leveraging the unique role and expertise of a population health manager as core member of team-based telehealth, health systems can implement a cost-effective and scalable intervention that addresses multi-level barriers to hypertension care delivery.SummaryWe describe the literature of telehealth-based population health management for patients with hypertension. Using the TEAM intervention as a case study, we then present implementation considerations and intervention adaptations to integrate a population health manager within the health care team and effectively manage hypertension for a defined patient population. We emphasize practical considerations to inform implementation, scaling, and sustainability. We highlight future research directions to advance the field and support translational efforts in diverse clinical and community contexts.

IntroductionAddressing the social determinants of health (SDOH) is critical to reducing health inequalities. In the United States (US), national guidance recommends healthcare providers screen for and respond to social needs, such as food insecurity and housing instability. However, health providers often lack the staff and resources to ensure patients can access social services or community resources. Volunteers can build capacity to integrate health and social care as community resource navigators. Description of context and objectiveOur interdisciplinary team of students, clinicians, and researchers co-developed a curriculum to train student volunteers as community resource navigators to work with patients at a community health center in North Carolina via telephone. The learning objectives for our curriculum included (1) knowledge of SDOH and association with health outcomes, (2) familiarity with local resources and ability to provide navigation support to help patients connect to resources, and (3) patient communication skills over the phone, including active and empathetic listening, motivational interviewing, and cultural humility. Targeted populationOur training targets university students interested in or currently pursuing health professions. Highlights (innovation, impact and outcomes)Our training was first offered to a cohort of 9 undergraduate and nursing students in 2019, and then revised and offered to 12 undergraduate and graduate students over 6 weeks in 2020. Across the cohorts, 10 students were trained to serve patients in English and 9 were trained to serve patients in Spanish. The multi-modal curricula, delivered by experienced student navigators, consisted of five components: didactic instruction on SDOH and program logistics, mock patient calls and documentation, shadowing of experienced navigators, supervised calls with real patients, and homework assignments. In 2020, we adapted our training materials for virtual delivery due to the COVID-19 pandemic. In the training evaluation, trainees described the knowledge and skills gained from the training, the long-term benefits towards their educational and professional career goals, and interactive delivery of the training. Learners also described areas for improvement, including more time learning about community resources and practicing challenging patient conversations. In the last two years, student volunteers have served over 500 clinic patients, majority of whom were low-income, uninsured, and racial and ethnic minorities. Comments on transferabilityOur training has the potential to be replicated by other university student volunteers, clinical leaders, or clinician-educators. All training materials are publicly available for use on our program website. Information related to available community resources, clinic workflows, and data entry will need to be adapted for local context. Conclusions (comprising key findings, discussion and lessons learned)Our peer-to-peer, multi-modal training provides student volunteers with the knowledge and skills to become community resource navigators and future champions for integrated health and social care. We found that in-depth discussions of local community resources, interactive delivery with small-group learning, and sufficient opportunities to practice skills in diverse scenarios are essential to successful training. Student volunteers, eager for meaningful clinical experiences, are an untapped and low-cost resource that can be leveraged in healthcare settings to address patients’ unmet social needs.

BACKGROUND Healthcare providers are increasingly screening patients for unmet social needs (e.g., food, housing, transportation, social isolation) and referring patients to relevant community-based resources and social services. Patients’ connection to referred services is often low, however, suggesting the need for additional support to facilitate engagement with resources. Short message service (SMS) text messaging presents an opportunity to address barriers related to contacting resources in an accessible, scalable, and low-cost manner. OBJECTIVE In this multi-methods pilot study, we aim to develop an automated SMS-based intervention to promote patient connection to referred social needs resources within two weeks of the initial referral, as well as evaluate its feasibility and patient acceptability. This protocol describes the intervention, conceptual underpinnings, study design, and evaluation plan to provide a detailed illustration of how SMS technology can complement current social needs screening and referral practice patterns without disrupting care. METHODS This SMS-based intervention augments an existing social needs screening, referral, and navigation program at a federally qualified health center (FQHC). Patients who received at least one referral for any identified unmet social need are sent two rounds of SMS messages over two weeks. The first round consists of 5-10 messages that deliver descriptions of and contact information for the referred resources. The second round consists of 2 messages that offer a brief reminder to contact the resources. Participants will evaluate the intervention via survey and semi-structured interview, informed by an adapted technology acceptance model. Rapid qualitative and thematic analysis will be used to extract themes from the responses. Primary outcomes are implementation feasibility and patient acceptability. Secondary outcomes relate to intervention effectiveness: reported attempt to connect and successful connection to referred resources two weeks after the initial referral encounter. RESULTS The study received regulatory approval in May 2021, and we anticipate enrolling 15-20 participants for this initial pilot. CONCLUSIONS This protocol presents detailed implementation methods about a novel automated SMS intervention for social care integration within primary care. By sharing the study protocol early, we intend to facilitate the development and adoption of similar tools across different clinical settings, as more healthcare providers seek to address the unmet social needs of patients. Study findings will provide practical insights into the design and implementation of SMS-based interventions to improve social and medical care coordination.

Background During the COVID- 19 pandemic, the use of telemedicine (virtual synchronous visits via phone or video format) to deliver health care increased significantly. Objective Explore endocrine provider experience and perspective on the use of telemedicine visits, compared to face-to-face encounters, to manage patients with type 2 diabetes (T2DM). Methods A survey was designed based on published literature and further refined based on stakeholder feedback through individual interviewing and pilot testing with Endocrinology providers. Survey domains included self-reported demographics, clinical time spent conducting telemedicine visit, perceived benefits and utility and barriers to incorporating telemedicine into practice. The anonymous uncompensated survey was completed via REDCap by Endocrinology providers at a leading academic medical center in the USA. Results were analyzed using descriptive statistics. Significance was tested using two tailed Mann-Whitney U Tests (α= 0.5). Results Forty-five surveys were electronically distributed. The response rate was 58% (N=26) with 85% being physicians and 15% nurse practitioners. Majority (85%) of the respondents identified as female and 42% had been practicing for >10 years. Since March 2020, 69% of providers reported spending more than 25% of their clinical time on telemedicine visits. Respondents under the age of 40 and those with less than 10 years of experience spent significantly less time on video visits compared to providers over the age of 40 (p= 0. 036 and providers with more than 10 years of experience (p = 0. 049). When comparing face-to-face visits to telephone visits for established patients, 58% of providers felt telephone based virtual visits were not as effective, whereas 4% felt video based virtual visits were not as effective. When comparing face-to-face visits for new patients to telephone visits, 92% of providers felt telephone based virtual visits were not as effective, whereas 39% felt video based virtual visits were not as effective. Most (92%) of respondents felt telemedicine increased patient access to care though there was a difference in the perceived quality of care delivered based on visit modality, with video visits preferred over telephone. Although the loss of physical exam opportunities was concerning to most respondents (92%), the level of concern was lower with video visits. The most frequently reported barriers to incorporating telemedicine were changes to clinic workflow (73%), low reimbursement (62%), and patient complexity (50%). All respondents plan to continue to offer telemedicine visits once the pandemic is over. Conclusion Telemedicine is an increasingly used tool for the management of T2DM. The type of visit and level of familiarity with the patient were cited as important factors for matching patient to mode of delivery. Understanding provider perspectives on facilitators, barriers, and benefits of telemedicine is useful for developing best practices and hybrid models of delivery of T2DM care. Presentation: No date and time listed

Background Health systems are increasingly using standardized social needs screening and response protocols including the Protocol for Responding to and Assessing Patients’ Risks, Assets, and Experiences (PRAPARE) to improve population health and equity; despite established relationships between the social determinants of health and health outcomes, little is known about the associations between standardized social needs assessment information and patients’ clinical condition. Methods In this cross-sectional study, we examined the relationship between social needs screening assessment data and measures of cardiometabolic clinical health from electronic health records data using two modelling approaches: a backward stepwise logistic regression and a least absolute selection and shrinkage operation (LASSO) logistic regression. Primary outcomes were dichotomized cardiometabolic measures related to obesity, hypertension, and atherosclerotic cardiovascular disease (ASCVD) 10-year risk. Nested models were built to evaluate the utility of social needs assessment data from PRAPARE for risk prediction, stratification, and population health management. Results Social needs related to lack of housing, unemployment, stress, access to medicine or health care, and inability to afford phone service were consistently associated with cardiometabolic risk across models. Model fit, as measured by the c-statistic, was poor for predicting obesity (logistic = 0.586; LASSO = 0.587), moderate for stage 1 hypertension (logistic = 0.703; LASSO = 0.688), and high for borderline ASCVD risk (logistic = 0.954; LASSO = 0.950). Conclusions Associations between social needs assessment data and clinical outcomes vary by cardiometabolic condition. Social needs assessment data may be useful for prospectively identifying patients at heightened cardiometabolic risk; however, there are limits to the utility of social needs data for improving predictive performance.

We pilot tested a carepartner-assisted intervention to improve oral hygiene in persons with cognitive impairment (participants) and help carepartners become leaders who can adapt approaches that foster participants' ability to develop new skills for oral hygiene care. Following the intervention, we conducted interviews with participants and carepartners to understand their challenges in working together to learn new oral hygiene skills. Participants reported challenges such as frustration using the electric toothbrush correctly, lack of desire to change, uncertainty about correctness of technique, and difficulty sustaining two minutes of toothbrushing. Carepartners reported challenges such as learning a new way of toothbrushing, learning new communication techniques, switching from instructing to working together, learning to balance leading with being too bossy, and being mindful of word choices. Findings suggested that despite challenges, participants were able to learn adaptive strategies to support new oral hygiene behaviors with support of the carepartner as the adaptive leader.

Objective An emerging literature suggests patients with chronic illnesses can benefit from integrated, person-centric approaches to health care, including group-based programs. However, much of the research in this area is disease specific. The objective of this study was to collect preliminary evidence on the efficacy of Taking Charge of My Life and Health (TCMLH), a Whole Health group-based program that emphasizes self-care and empowerment on the overall health and well-being of veterans, a population burdened with high rates of multiple chronic conditions. Method Self-reported outcomes, including standardized survey measures, were collected at pretest, posttest, and 2-month follow-up from 77 participants across 15 groups at four VA sites. Random intercept mixed-model regressions were used to analyze data. Results Results from this initial study showed high satisfaction with the program and facilitators, and high attendance. There were significant pre–post gains in self-care attitudes and behaviors, patient motivation, meaning and purpose, mental health, perceived stress, goal progress, and goal-specific hope. Outcomes were maintained at 2-month follow-up for patient motivation, perceived stress, goal-specific hope, and goal progress. Significant gains were observed in health care empowerment and physical health from pretest to follow-up. Conclusions Preliminary findings support the efficacy of TCMLH, a Whole Health group-based program that emphasizes patient empowerment, self-care practices, and peer support. Future research priorities include a rigorous evaluation with a larger sample size and control group to assess effectiveness.

Background: Our objective was to examine the variation in telemedicine adoption by specialty line and patient demographic characteristics after the initial peak period of the coronavirus disease 2019 pandemic when in-person visits had resumed and visit volume returned to prepandemic levels. Materials and Methods: Aggregated encounter data were extracted for six service lines (dermatology, psychiatry, endocrinology, cardiology, orthopedics, and nonurgent primary care) in an integrated health system across three time periods: July 1 to September 30, 2019 (n = 239,803), July 1 to September 30, 2020 (n = 245,648), and December 29, 2019 to October 3, 2020 (n = 624,886). Risk ratios were calculated to assess the relative use of telemedicine compared with in-person encounters and telemedicine modality (i.e., synchronous audio/video vs. audio-only telephone) by patient race, age, sex, and insurance type. Results: By June 2020, total visit volume returned to prepandemic levels. Differences in patient demographics between July 1 to September 30, 2020 and the previous year's baseline were negligible. Telemedicine adoption varied by medical specialty, from 3.2% (dermatology) to 98.3% (psychiatry) of visits. African American and male patients were less likely to use telemedicine (telephone or video) compared with white and female patients. Among telemedicine encounters, African American, publicly insured, and older patients were less likely to use video compared with white, commercially insured, and younger patients. Discussion: Variation in telemedicine adoption and modality underscores the importance of balancing patient- and clinic-level implementation factors to promote sustainable, equitable telemedicine integration. Conclusion: Understanding current trends in the “new normal” of telemedicine provides valuable insights into future implementation and financing.

Introduction: While unmet social needs are major drivers of health outcomes, most health systems are not fully integrated with the social care sector to address them. In this case study, we describe the development and implementation of a model utilizing student volunteer community resource navigators to help patients connect with community-based organizations (CBOs). We then detail initial implementation outcomes and practical considerations for future work. Methods: We used the Ten Essential Public Health Services Framework to guide program planning of a student “Help Desk” model for a community health center. Planning included a literature review, observation of exemplar programs, development of a CBO directory, and evaluation of the center’s patient population, clinical workflows, and data infrastructure. We piloted the model for two months. After pilot completion, we reviewed patient data to understand the feasibility of the student “Help Desk” model. We utilized planning and pilot execution materials, as well as pilot data, to develop and discuss practical considerations. Results: Design and implementation complemented ongoing social needs screening and referral to CBOs by center case managers. Patients were asked if they would accept telephone follow-up by volunteers two and four weeks after the clinic visit. Of 61 patients screened, 29 patients were referred for follow-up. Ninety percent were reached at least once during the follow-up period, and 48% of patients referred reported connecting to at least one CBO. Only 27% of patients required escalation back to case managers, and no emergency escalation was needed for any patients. Students, faculty advisors, and community health center frontline staff and leadership supported the scale up and continuation of the “Help Desk” model at the community health center. Discussion: Successful implementation required multi-sectoral collaboration, welldefined scope of practice, and data interoperability. Student volunteers are untapped resources to support integrated health and social care.

PURPOSE. Social determinants of health, including food insecurity, housing instability, social isolation, and unemployment are important drivers of health outcomes and utilization. To inform implementation of social needs screening and response protocols, there is a need to identify the associated costs in routine primary care encounters. METHODS. We interviewed key stakeholders in four diverse community health centers that had adopted a widely used social needs screening and response protocol. We evaluated costs using an activity-based costing tool across both the initial implementation phase and ongoing maintenance phase. RESULTS. Clinic costs were associated with workforce development, planning, and electronic health record integration. These initial implementation costs varied by site ($6,644–$ 49,087). On a per-patient basis, ongoing maintenance costs ranged from $9.76 to $47.98. CONCLUSION. Our findings can aid in designing reimbursement mechanisms tied to social needs screening and response to accelerate translational efforts and promote health equity.

Background: Breast implant illness (BII) is a systemic autoimmune complication associated with breast implants. Breast implants are used for cosmetic augmentation, reconstructive surgery post-breast cancer treatment, or for prophylactic mastectomy. Thus, these implants are important for quality of life of the subjects. Through this work, we sought to characterize breast implant associated autoimmune disorders and discuss possible causes for its etiology. Methods: The PubMed and OVID databases were interrogated from 1990-2020 using a query strategy including search term combinations of “implants”, “breast implant illness”, “autoimmune”, “systemic illness”. Results: BII includes a spectrum of autoimmune symptoms such as fatigue, myalgias/arthralgias, dry eyes/mouth, and rash. Review of epidemiological studies in the past thirty years exhibited evidence affirming an association between breast implants and autoimmune diseases. The most commonly recognized were Sjogren’s, rheumatoid arthritis, systemic sclerosis, and Raynaud’s syndrome. Explantation resulted in alleviation of symptoms in over 50% patients, strengthening the hypothesis associating breast implants to these problems. Studies have shown silicone is a biologically inert material and unlikely to be the cause of these symptoms. This is supported by the fact that increased risk of autoimmune disease was also reported in patients with other implantable biomaterials such as orthopedic implants. Recent studies conducted by our group and other researchers shed light on a possible role of bacterial biofilm and subsequent host-pathogen interactions as a confounding factor to this problem. Conclusion: BII could be dependent on biofilm infection and the microenvironment around the implants. Should explantation of the implant continue to be the gold standard for treatment, or should more research be done to treat the underlying cause? The true pathophysiology behind these complaints must be further investigated so that accurate treatment regimens other than explantation can be developed. Translational significance of these studies is not limited to breast implants but extends to other implants as well.

This study offers a description of factors that predict the adoption of mobile health technologies (mHealth) and their application for health self-management in emerging adults. Primary data collection occurred at three diverse postsecondary educational institutions (N= 1,329). The analysis used a logistic regression to identify predictors of mHealth adoption. Descriptive analyses are presented on health self-management applications and perceived ease of use and effectiveness. Use of mHealth was high in respondents (58.5%). Factors associated with increased likelihood of mHealth adoption included being female, overweight or obese, having a chronic condition, eating the recommended amount of daily fruit, and engaging in regular moderate exercise. Low household income was associated with being less likely to use mHealth. The most common self-management application for mHealth was for tracking physical activity. Findings related to ease of use and effectiveness ratings by applications may provide insight into designing more effective mHealth tools in this population.

Background Epilepsy affects nearly 50 million people worldwide. Self-management is critical for individuals with epilepsy in order to maintain optimal physical, cognitive, and emotional health. Implementing and adopting a self-management program requires considering many factors at the person, program, and systems levels. We conducted a systematic review of qualitative and mixed-methods studies to identify facilitators and barriers that impact implementation and adoption of self-management programs for adults with epilepsy. Methods We used established systematic review methodologies for qualitative and mixed-methods studies. We included studies addressing facilitators (i.e., factors that aided) or barriers (i.e., factors that impeded) to implementation and adoption of self-management interventions for adults with epilepsy. We conducted a narrative thematic synthesis to identify facilitators and barriers. Results The literature search identified 2700 citations; 13 studies met eligibility criteria. Our synthesis identified five themes that categorize facilitators and barriers to successful implementation epilepsy self-management: (1) relevance, intervention content that facilitates acquisition of self-management skills; (2) personalization, intervention components that account for the individual’s social, physical, and environmental characteristics; (3) intervention components, components and dosing of the intervention; (4) technology considerations, considerations that account for individual’s use, familiarity with, and ownership of technology; and (5) clinician interventionist, role and preparation of the individual who leads intervention. We identified facilitators in 11 of the 13 studies and barriers in 11 of the 13 studies and classified these by social-ecological level (i.e., patient/caregiver, program, site/system). Conclusion Identification of facilitators and barriers at multiple levels provides insight into disease-specific factors that influence implementation and adoption of self-management programs for individuals with epilepsy. Our findings indicate that involving individuals with epilepsy and their caregivers in intervention development, and then tailoring intervention content during the intervention, can help ensure the content is relevant to intervention participants. Our findings also indicate the role of the clinician (i.e., the individual who provides self-management education) is important to intervention implementation, and key issues with clinicians were identified as barriers and opportunities for improvement. Overall, our findings have practical value for those seeking to implement and adopt self-management interventions for epilepsy and other chronic illnesses. Systematic review registration PROSPERO registration number is CRD42018098604.

BACKGROUND: Successful diabetes care requires patient engagement and health self-management. Diabetes shared medical appointments (SMAs) are an evidence-based approach that enables peer support, diabetes group education, and medication management to improve outcomes. The purpose of this study is to learn how diabetes SMAs are being delivered in North Carolina, including the characteristics of diabetes SMAs across the state. METHOD: Twelve health systems in the state of North Carolina were contacted to explore clinical workflow and intervention characteristics with a member of the SMA care delivery team. Surveys were used to assess intervention characteristics and delivery. RESULTS: Diabetes SMAs were offered in 10 clinics in 5 of the 12 health systems contacted with considerable heterogeneity across sites. The majority of SMAs were open cohorts (80%), offered monthly (60%) for 1.5 hours (60%). SMAs included a mean of 7.5 ± 3.4 patients with a maximum of 11.2 ± 2.7 patients. Survey data revealed barriers (cost-sharing and provider buy-in) to, and facilitators (leadership support and clinical champions) of, clinical adoption and sustained implementation. LIMITATIONS: External validity is limited due to the small sample size and geographic clustering. CONCLUSION: There is significant heterogeneity in the delivery and characteristics of diabetes SMAs in North Carolina with only modest uptake across the health systems. Further research to determine best practices and effectiveness in diverse, real-world clinical settings is required to inform implementation and dissemination efforts.

Introduction: In an effort to improve health outcomes and promote health equity, healthcare systems have increasingly begun to screen patients for unmet social needs and refer them to relevant social services and community-based organizations. This study aimed to identify factors associated with the successful connection (ie, services started) to social needs resources, as well as factors associated with an attempt to connect as a secondary, intermediate outcome. Methods: This retrospective cohort study included patients who had been screened, referred, and subsequently reached for follow-up navigation from March 2019 to December 2020, as part of a social needs intervention at a federally qualified health center (FQHC). Measures included demographic and social needs covariates collected during screening, as well as resource-related covariates that characterized the referred resources, including service domain (area of need addressed), service site (integration relative to the FQHC), and access modality (means of accessing services). Results: Of the 501 patients in the analytic sample, 32.7% had started services with 1 or more of their referred resources within 4 weeks of the initial referral, and 63.3% had at least attempted to contact 1 referred resource, whether or not they were able to start services. Receiving a referral to resources that patients could access via phone call or drop-in visit, as opposed to resources that required additional appointments or applications prior to accessing services, was associated with increased odds (aOR 1.95, 95% CI 1.05, 3.61) of connection success, after adjusting for age, sex, race, ethnicity, education, number of social needs, and resource-related characteristics. This study did not find statistically significant associations between connection attempt and any variable included in adjusted analyses. Conclusion: These findings suggest that referral pathways may influence the success of patients’ connection to social needs resources, highlighting opportunities for more accessible solutions to addressing patients’ unmet social needs.

Telemedicine can facilitate population health management by extending the reach of providers to efficiently care for high-risk, high-utilization populations. However, for telemedicine to be maximally useful, data collected using telemedicine technologies must be reliable and readily available to healthcare providers. To address current gaps in integration of patient-generated health data into the electronic health record (EHR), we examined 2 patient-facing platforms, Epic MyChart and Apple HealthKit, both of which facilitated the uploading of blood glucose data into the EHR as part of a diabetes telemedicine intervention. All patients were offered use of the MyChart platform; we subsequently invited a purposive sample of patients who used the MyChart platform effectively (n = 5) to also use the Apple HealthKit platform. Patients reported both platforms helped with diabetes self-management, and providers appreciated the convenience of the processes for obtaining patient data. Providers stated that the EHR data presentation format for Apple HealthKit was challenging to interpret; however, they also valued the greater perceived accuracy the Apple HealthKit data. Our findings indicate that patient-facing platforms can feasibly facilitate transmission of patient-generated health data into the EHR and support telemedicine-based care.

This study describes the feasibility of implementing personalized health planning (PHP) within shared medical appointments (SMAs) for patients with type 2 diabetes mellitus. The PHP-SMA approach was designed to synergize the benefits of SMAs with those of PHP, enabling greater patient engagement focused on meeting individualized therapeutic goals in a group setting.Patients were assigned randomly to a PHP-SMA or a standard eight-session SMA series. Standard SMAs included an interactive educational curriculum delivered in group medical encounters. The PHP-SMA included the addition of a patient self-assessment, health risk assessment, shared patient-provider goal setting, creation of a personal health plan, and follow-up on clinical progress. Clinical and patient-reported outcomes and qualitative data from focus groups with patients, providers, and administrative staff were used for evaluation. Qualitative data explored facilitators and barriers to implementation of the PHP-SMA. The Consolidated Framework for Implementation Research was used to provide insight into implementation factors.PHP was successfully integrated into SMAs in a primary care setting. Patients in the PHP-SMA (n = 12) were more likely to attend ≥5 sessions than patients assigned to the standard SMA (n = 7; 58% PHP, 28.5% control). Qualitative data evaluation described the advantages and barriers to PHP, the team-based approach to care, and patient participation. The PHP-SMA group experienced reductions in hemoglobin A1c, low-density lipoprotein, blood pressure, and body mass index, as well as successful attainment of health goals.The PHP-SMA is a proactive and participatory approach to chronic care delivery that synergizes the benefits of PHP within SMAs. This study describes the components of this intervention; collects evidence on feasibility, acceptability, and clinical outcomes; and identifies implementation barriers and facilitators. The PHP-SMA warrants further evaluation as an approach to improve health outcomes in patients with common chronic conditions.

Background Although self-management is recommended for persons with epilepsy, its optimal strategies and effects are uncertain. Purpose To evaluate the components and efficacy of self-management interventions in the treatment of epilepsy in community-dwelling persons. Data sources English-language searches of MEDLINE, Cochrane Central Register of Controlled Trials, PsycINFO, and CINAHL in April 2018; the MEDLINE search was updated in March 2019. Study selection Randomized and nonrandomized comparative studies of self-management interventions for adults with epilepsy. Data extraction An investigator assessed study characteristics; intervention details, including 6 components of self-management; and outcomes, which were verified by a second reviewer. Risk of bias (ROB) was assessed independently by 2 investigators. Data synthesis 13 randomized and 2 nonrandomized studies (2514 patients) evaluated self-management interventions. Interventions were delivered primarily in group settings, used a median of 4 components, and followed 2 general strategies: 1 based on education and the other on psychosocial therapy. Education-based approaches improved self-management behaviors (standardized mean difference, 0.52 [95% CI, 0.0 to 1.04]), and psychosocial therapy-based approaches improved quality of life (mean difference, 6.64 [CI, 2.51 to 10.77]). Overall, self-management interventions did not reduce seizure rates, but 1 educational intervention decreased a composite of seizures, emergency department visits, and hospitalizations. Limitation High ROB in most studies, incomplete intervention descriptions, and studies limited to English-language publications. Conclusion There is limited evidence that self-management strategies modestly improve some patient outcomes that are important to persons with epilepsy. Overall, self-management research in epilepsy is limited by the range of interventions tested, the small number of studies using self-monitoring technology, and uncertainty about components and strategies associated with benefit. Primary funding source U.S. Department of Veterans Affairs. (PROSPERO: CRD42018098604).