Faculty Bibliography

The objective of this study was to compare unannounced standardized patient (USP) and patient reports of care. Patient satisfaction surveys and USP checklist results collected at an urban, public hospital were compared to identify items included in both surveys. Qualitative commentary was reviewed to better understand USP and patient satisfaction survey data. Analyses included χ² and Mann-Whitney U test. Patients provided significantly higher ratings on 10 of the 11 items when compared to USPs. USPs may provide a more objective perspective on a clinical encounter than a real patient, reinforcing the notion that real patients skew overly positive or negative.

BACKGROUND: Social determinants of health (SDoH) play a significant role in health outcomes, but little is known about care teams' attitudes about addressing SDoH. Our safety-net clinic has begun to implement SDoH screening and referral systems, but efforts to increase clinical responses to SDoH necessitates an understanding of how providers and clinical teams see their roles in responding to particular SDoH concerns.
METHOD(S): An annual survey was administered (anonymously) to clinical care teams in an urban safety-net clinic from 2017-2019, asking about ten SDoH conditions (mental health, health insurance, food, housing, transportation, finances, employment, child care, education and legal Aid). For each, respondents rated with a 4-point Likert-scale whether they agreed that health systems should address it (not at all, a little, somewhat, a great deal). They also indicated their agreement (using strongly disagree, somewhat disagree, somewhat agree, strongly agree) with two statements 1) resources are available for SDoH and 2) I can make appropriate referrals.
RESULT(S): 232 surveys were collected (103 residents, 125 faculty and staff (F/S), 5 unknown) over three years. Of note, mental health (84%) and health insurance (79%) were seen as very important for health systems to address, with other SDoH items seen as very important by fewer respondents. They reported little confidence that the health system had adequate resources (51%) and were unsure how to connect patients with services (39%). When these results were broken out by year, we found the following: In 2017 (n=77), approximately 35% of respondents thought the issues of employment, childcare, legal aid, and adult education should be addressed "a little," but in 2018 (n=81) and 2019 (n=74) respondents found the health system should be more responsible, with over 35% of respondents stating that these four issues should be addressed "somewhat" by health systems. In addition, half of respondents in 2019 felt that financial problems should be addressed "a great deal," up from 31% in 2017. Across all years, food, housing, mental health, and health insurance were seen as SDoH that should be addressed "a great deal". It is of note that respondents across all years reported limited understanding of referral methods and options available to their patients.
CONCLUSION(S): Many of the SDoH conditions were seen by respondents as outside the purview of health systems. However, over the three years, more members increased the number of SDoH conditions that should be addressed a "great deal." Responses also indicated that many of the team members do not feel prepared to deal with "unmet social needs". Additional examination of clinic SDoH coding, referral rates, resources, and team member perspectives will deepen our understanding of how we can cultivate a culture that enables team members to respond to SDoH in a way that is sensitive to their needs and patient needs

Statement of Problem Or Question (One Sentence): How do we provide effective, dignified primary care for medically complex patients with homelessness in a safety-net health system? Objectives of Program/Intervention (No More Than Three Objectives): To effectively engage homeless patients with complex barriers to primary care To provide dignified, trauma-informed care focused on patient-oriented care goals while addressing addiction, mental health, and chronic disease To implement an interdisciplinary care team model in a safety-net health care system combining primary care, social work, care coordination, and nursing Description of Program/Intervention, Including Organizational Context (E.G. Inpatient Vs. Outpatient, Practice or Community Characteristics): Unstably housed people with complex chronic disease often receive fragmented care from various emergency departments and inpatient settings, accruing high rates of acute care utilization without improvements in health. Recently, intensive outpatient models have emerged to better manage high need patients. Here we describe our efforts to create a complex care clinic for medically, socially, and behaviorally complex patients with unstable housing at the largest safety-net health system in the United States. Launched in August 2018, the clinic aims to engage patients in a trusting healthcare environment and break the cycle of disease, addiction, and housing instability. Our team includes four buprenorphine-waivered internal medicine physicians, a social worker, care coordinator, and home care nurse provided by our system's Medicaid Health Home. Patients are referred from the ED, inpatient service, other clinics, street outreach organizations, shelters, and jails. They receive extensive care coordination; on-site addiction, medical, and social services; home nursing visits; and collaboration with shelters and community based organizations. Measures of Success (Discuss Qualitative And/Or Quantitative Metrics Which Will Be Used To Evaluate Program/Intervention): A quantitative analysis will be used to determine program impact on clinical outcomes and utilization, patient experience, and provider satisfaction. Both quantitative and qualitative measures will be used to evaluate clinic capacity, services provided, patient engagement, and progress towards patient-oriented care goals. Findings To Date (It Is Not Sufficient To State Findings Will Be Discussed): From August through December 2018, 156 referrals were given appointments and 83 patients completed at least one appointment. Of those, at least 44 patients (53%) returned for a second visit. On average patients completed 2.1 visits. We had a 16% cancellation rate and 38% no show rate. Patients are mostly male, middle-aged and street or shelter dwelling with common diagnosis of substance use disorder, lower extremity wounds, and hypertension. Our most engaged patients (> 3 visits, n=15) have seen an average reduction in ED visits by 68% and inpatient admissions by 58% within our system compared to pre-clinic intervention. Key Lessons For Dissemination (What Can Others Take Away For Implementation To Their Practice Or Community?): Relationships have been a core element of patient care, building an interdisciplinary team, and developing referral and collaborative resources internally and in the community. Our focus on a patient-directed care plan, warm hand-offs, continuity of care, and community outreach has also allowed this model to succeed

Statement of Problem Or Question (One Sentence): Does actionable feedback on patient safety indicators and responses to disclosed social determinants of health (SDOH) impact clinical behavior? Objectives of Program/Intervention (No More Than Three Objectives): (1) Develop/disseminate quarterly audit-feedback reports on SDoH practice behavior, focusing on elicitation of patient information. (2) Enhance our understanding of factors related to disparities in safety/quality of care. (3) Increase rates of SDoH documentation and referral. Description of Program/Intervention, Including Organizational Context (E.G. Inpatient Vs. Outpatient, Practice or Community Characteristics): We sent Unannounced Standardized Patients (USPs) with SDoH-related needs to care teams in two urban, safety-net clinics. Data collected on practice behaviors were used for cycles of audit and feedback on the quality of electronic health record (EHR) documentation, team level information sharing, and appropriate service referral. Reports contained an evolving educational component (e.g. how to recognize, refer, and document SDoH). We disseminated reports to teams (doctors, nurses, physician's assistants, medical assistants, and staff) at routine meetings and via email. Measures of Success (Discuss Qualitative And/Or Quantitative Metrics Which Will Be Used To Evaluate Program/Intervention): Three audit feedback reports have been distributed to date. Survey data was collected at two time points, 2017 (n=77) and 2018 (n=81), to assess provider attitude changes and integration of feedback into clinical practice. Measures included change in team knowledge and attitudes towards SDoH, and response to/documentation of presented SDoH (measured via post-visit checklist and EMR). Findings To Date (It Is Not Sufficient To State Findings Will Be Discussed): Preliminary data shows no change or improvement in documentation of SDoH and limited variation between firm-level responses. (1) Only 7% of providers reported feeling strongly confident in knowing how to make referrals for social needs in 2018; no improvement since 2017. (2) Despite regular report distribution, 58% of providers reported having received no formalized feedback on responding to SDoH. 24% reported maybe or not sure. (3) 86% of 2018 survey participants self-reported having referred a patient to appropriate services when a social need was identified. Our referral data says otherwise, referrals occur for less than 30% of visits with SDoH-related needs. Key Lessons For Dissemination (What Can Others Take Away For Implementation To Their Practice Or Community?): Results suggest disconnect between team data and individual reporting: most report they refer but data suggests few do. Deeper integration of reports into team processes, attachment of feedback to curricula, and increased frequency of regular feedback may be needed for accountability. These preliminary Results help refine audit feedback methodology but research is needed to understand motivation and systems barriers to referral and documentation. Future research will look at provider attitudes toward referral processes