Faculty Bibliography

OBJECTIVES:To examine the factors associated with COVID-19 vaccine receipt among healthcare workers and the role of vaccine confidence in decisions to vaccinate, and to better understand concerns related to COVID-19 vaccination. DESIGN:Cross-sectional anonymous survey among front-line, support service and administrative healthcare workers. SETTING:Two large integrated healthcare systems (one private and one public) in New York City during the initial roll-out of the COVID-19 vaccine. PARTICIPANTS:1933 healthcare workers, including nurses, physicians, allied health professionals, environmental services staff, researchers and administrative staff. PRIMARY OUTCOME MEASURES:The primary outcome was COVID-19 vaccine receipt during the initial roll-out of the vaccine among healthcare workers. RESULTS:Among 1933 healthcare workers who had been offered the vaccine, 81% had received the vaccine at the time of the survey. Receipt was lower among black (58%; OR: 0.14, 95% CI 0.1 to 0.2) compared with white (91%) healthcare workers, and higher among non-Hispanic (84%) compared with Hispanic (69%; OR: 2.37, 95% CI 1.8 to 3.1) healthcare workers. Among healthcare workers with concerns about COVID-19 vaccine safety, 65% received the vaccine. Among healthcare workers who agreed with the statement that the vaccine is important to protect family members, 86% were vaccinated. Of those who disagreed, 25% received the vaccine (p<0.001). In a multivariable analysis, concern about being experimented on (OR: 0.44, 95% CI 0.31 to 0.6), concern about COVID-19 vaccine safety (OR: 0.39, 95% CI 0.28 to 0.55), lack of influenza vaccine receipt (OR: 0.28, 95% CI 0.18 to 0.44), disagreeing that COVID-19 vaccination is important to protect others (OR: 0.37, 95% CI 0.27 to 0.52) and black race (OR: 0.38, 95% CI 0.24 to 0.59) were independently associated with COVID-19 vaccine non-receipt. Over 70% of all healthcare workers responded that they had been approached for vaccine advice multiple times by family, community members and patients. CONCLUSIONS:Our data demonstrated high overall receipt among healthcare workers. Even among healthcare workers with concerns about COVID-19 vaccine safety, side effects or being experimented on, over 50% received the vaccine. Attitudes around the importance of COVID-19 vaccination to protect others played a large role in healthcare workers' decisions to vaccinate. We observed striking inequities in COVID-19 vaccine receipt, particularly affecting black and Hispanic workers. Further research is urgently needed to address issues related to vaccine equity and uptake in the context of systemic racism and barriers to care. This is particularly important given the influence healthcare workers have in vaccine decision-making conversations in their communities.

NYC Health + Hospitals (NYC H+H) is the largest safety net health care delivery system in the United States. Prior to the novel coronavirus disease (COVID-19) pandemic, NYC H+H served over one million patients, including the most vulnerable New Yorkers, and billed fewer than 500 telehealth visits monthly. Once the pandemic struck, we established a strategy to allow us to continue to serve existing patients and treat the surge of new patients. Starting in March 2020 we were able to transform the system using virtual care platforms through which we conducted almost 83,000 billable televisits in one month and more than 30,000 behavioral health encounters via telephone and video. Telehealth also enabled us to support patient-family communication, post-discharge follow-up, and palliative care for COVID-19 patients. Expanded Medicaid coverage and insurance reimbursement for telehealth played a pivotal role in this transformation. As we move to a new blend of virtual and in-person care, it is vital that the major regulatory and insurance changes undergirding our COVID-19 telehealth response be sustained to protect access for our most vulnerable patients. [Editor's Note: This Fast Track Ahead Of Print article is the accepted version of the manuscript. The final edited version will appear in an upcoming issue of Health Affairs.].

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

BACKGROUND:The cost of diabetes care accounts for a significant proportion of healthcare expenditures. Cost models based on updated incident complication rates and associated costs are needed to improve financial planning and quality assessment across the U.S. healthcare system. We developed a cost model using published data to estimate the direct medical costs of incident diabetes-related complications in a U.S. population of adults. MATERIALS AND METHODS:A systematic literature review of MEDLINE, EMBASE, and TRIP databases was conducted on studies reporting the incidence and/or cost of diabetes-related complications (cardiovascular disease, neuropathy, nephropathy, ophthalmological disease, and acute metabolic events). A total of 54 studies met eligibility criteria. A baseline model was constructed for a U.S. population with type 1 and 2 diabetes mellitus and used to determine the expected costs of managing such a population over 1-, 3-, and 5-year time horizons. RESULTS:The most costly incident complications in a population of 10,000 adults with diabetes were (1) congestive heart failure (CHF): annual expected cost of $7,320,287, 5-year expected cost of $50,697,865; (2) end-stage renal disease (ESRD): annual expected cost of $4,225,384, 5-year expected cost of $13,211,204; and (3) gangrene: annual expected cost of $2,844,381, 5-year expected cost of $17,200,417. CONCLUSIONS:This cost model estimates the direct healthcare costs of incident diabetes-related complications in a U.S. adult population with diabetes and provides a benchmark for evaluating the cost-effectiveness and potential leakage within a care delivery network.