Faculty Bibliography

INTRODUCTION/BACKGROUND:This study aimed to better understand patient and caregiver perspectives on social risk screening across different healthcare settings. METHODS:As part of a mixed-methods multisite study, the authors conducted semistructured interviews with a subset of adult patients and adult caregivers of pediatric patients who had completed the Center for Medicare and Medicaid Innovation Accountable Health Communities social risk screening tool between July 2018 and February 2019. Interviews, conducted in English or Spanish, asked about reactions to screening, screening acceptability, preferences for administration, prior screening experiences that informed perspectives, and expectations for social assistance. Basic thematic analysis and constant comparative methods were used to code and develop themes. RESULTS:Fifty interviews were conducted across 10 study sites in 9 states, including 6 primary care clinics and 4 emergency departments. There was broad consensus among interviewees across all sites that social risk screening was acceptable. The following 4 main themes emerged: (1) participants believed screening for social risks is important; (2) participants expressed insight into the connections between social risks and overall health; (3) participants emphasized the importance of patient-centered implementation of social risk screening; and (4) participants recognized limits to the healthcare sector's capacity to address or resolve social risks. CONCLUSIONS:Despite gaps in the availability of social risk-related interventions in healthcare settings, patient-centered social risk screening, including empathy and attention to privacy, may strengthen relationships between patients and healthcare teams. SUPPLEMENT INFORMATION/UNASSIGNED:This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.

Background: Social risk factors are increasingly understood as important drivers of care utilization, including emergency department (ED) visits. As a result, new social risk screening initiatives are being implemented to direct interventions and inform care. There is limited information on patient acceptability of social risk screening in the ED. The Center for Medicare and Medicaid Innovation (CMMI) proposed a social risk screening tool for their Accountable Health Communities Model that focuses on five actionable domains. In this study, we used the CMMI tool to explore the acceptability of social risk screening to adult patients and caregivers of pediatric patients in EDs.
Method(s): A tablet-based, self-administered survey was administered to a convenience sample of adult ED patients and caregivers of pediatric patients at two adult and two pediatric academic EDs. The survey included the CMMI tool and questions on acceptability of screening. The primary acceptability measure was appropriateness of screening in the ED; a secondary outcome was comfort with including social risk data in electronic health records (EHRs). Cross-sectional data were analyzed using chi-square analyses for bivariate comparison.
Result(s): The survey was completed by 364 participants. 41% of participants screened positive for housing instability, 41% for food insecurity, 19% for transportation insecurity, 13% utilities insecurity, and 1% for interpersonal violence. 23% of respondents endorsed no social risk factors. 73% of patients felt that it was "somewhat" or "very appropriate" to conduct social risk screening in the ED. No statistically significant difference was observed in acceptability of screening between participants who endorsed one or more social risks (74% reported "somewhat" or "very appropriate" to screen) versus none (75%). 70% reported feeling "somewhat" or "completely comfortable" with screening information being included in the EHR.
Conclusion(s): In EDs caring for patients with significant social adversity, there was high patient and caregiver acceptability of social risk screening, and a high level of comfort with screening information being included in EHRs. Further investigation is needed to understand perspectives of patients who did not find social risk screening acceptable

Background: Despite the health care sector's growing interest in systematic collection of social risk data, little is known about patient acceptability of health care-based social risk screening. Acceptability to patients and caregivers has implications for adoption, utility and sustainability. We aimed to explore acceptability of the Center for Medicare and Medicaid Innovation's (CMMI) social risk screening tool, which covers 5 actionable social domains: food, housing, utilities, and transportation security, and personal safety.
Method(s): Cross-sectional analysis of patients or caregivers of pedi-atric patients recruited from 6 primary care clinics (PCCs) and 4 emergency departments (EDs). Participants completed a tablet-based survey that included the CMMI social risk tool and questions related to both acceptability of social screening and predictors of acceptability. The primary acceptability measure was perceived appropriateness of screening in health care settings; a secondary outcome was comfort with including social risk data in electronic health records (EHRs). Multilevel mixed-effects logistic regressions were used to evaluate acceptability measures, clustering by site.
Result(s): 969 patients/caregivers completed the survey; 952 (98%) answered survey questions about acceptability. 72% of participants screened positive for at least 1 of 5 social risks. 80% of respondents reported screening was very or somewhat appropriate; 7% reported screening was very or somewhat inappropriate. 65% of participants reported being completely or somewhat comfortable with social risk data being included in EHRs; 18% reported being completely or somewhat uncomfortable. In the primary multivariable model, participants reporting higher acceptability of social risk screening had higher odds of previous social risk screening in a health care setting (aOR 1.80 [95% CI 1.31-2.47]); not endorsing prior discrimination in a health care setting (aOR 1.45 [95% CI 1.07-1.97]); being from a safety-net setting (aOR 1.85 [95% CI 1.11-3.10]); and being recruited in a PCC (aOR 2.10 [95% CI 1.01-4.32]). Participants who were more comfortable with including social risk data in EHRs had higher odds of previous social risk screening in a health care setting (aOR 1.56 [95% CI 1.17 to 2.09]). There were no associations between specific social risk domains or cumulative number of social risks with either measure of acceptability. No additional respondent-level characteristics were associated with acceptability.
Conclusion(s): Across PCC and ED settings, a majority of respondents found social risk screening acceptable. Acceptability levels did not differ across individual health care settings or level of social risks, though we identified some potentially modifiable factors associated with acceptability. High rates of acceptability support health care-based social screening implementation efforts, although future research should explore how to improve acceptability in specific patient populations and acceptability of EHR integration

Background: As research supporting potential benefits of social risk screening in health settings continues to emerge, there is little data on the patient perspective on social screening. The aim of this study is to describe the perspectives and preferences of patients and caregivers on being screened for social risks in diverse health care settings.
Method(s): As part of a larger mixed Methods multi-site study, we conducted semi-structured interviews lasting approximately 30 minutes with patients or caregivers who had completed the Center for Medicare and Medicaid Innovation (CMMI) social risk screening tool. After completion of the screening questions, 5 randomly selected respondents from each of 10 study sites were invited to participate in an interview. Interviews were conducted in English or Spanish. The interview guide asked about reactions to social risk screening and screening acceptability, preferences on screening administration, prior experiences that informed perspectives, and expectations for social assistance. Interviews were recorded, transcribed and translated. Two coders used basic thematic analysis and constant comparative Methods to identify codes, group codes into unified themes and map themes into domains of screening acceptability.
Result(s): Fifty adult patients or caregivers participated in semi-structured interviews across all study sites, which included 6 primary care clinics and 4 emergency departments. Respondents were 78% female, 36% Black, 32% Hispanic, 20% caregivers, and 71% reported having one or more social risk factor. There was broad consensus among interviewees across all clinical sites that social risk screening was acceptable. Several themes emerged: (1) respondents felt screening was the " right thing to do; " (2) respondents identified framing and compassionate approach as the most important aspects of administration; (3) respondents had insight into the connections between social risks and physical and mental health. Despite overall agreement that social risk screening is appropriate, respondents did not expect their health care team to address or resolve all of the identified issues. Interviewees felt referrals out to social services and resource sheets were adequate, and that there was benefit to the act of screening itself. Patients emphasized that screening should be done with empathy while protecting patient confidentiality.
Conclusion(s): Respondents agree that social risk screening is important, acceptable, and relevant to health. Respondents believed social risk screening would be most acceptable when implemented by a clinic staff member trained to ensure privacy and compassion. Despite published concerns about futility of social risk screening when social resources are inadequate, respondents expressed that they did not expect the health care system, and physicians in particular, to solve unmet social problems. Done appropriately, screening for social risk can build trust and strengthen relationships between patients and health care providers

To boost performance on a range of metrics, the 55-bed ED at NYU Lutheran Medical Center in Brooklyn, NY, transitioned to a pod system in August 2016. The approach, which is designed to foster team-based care, involves assigning physicians and nurses to designated geographic areas throughout the day, minimizing the movement of physicians as well as the need for phone communication. When coupled with other changes, including the introduction of point-of- care testing, the pod initiative has enabled the ED to reduce lengths of stay for all treat-and-release patients to less than three hours for the first time in the history of the department, according to administrators. There were multiple challenges involved with the transition to a pod system, including the need to match physician schedules with patient volume, but clinicians note the approach has produced improved physician-nurse communications. Administrators credit the creation of a process improvement team with giving frontline staff a voice in planned improvements while also facilitating the change process.

Early palliative care consultation ha the potential to provide comfort to patients and families, and decrease costs and length of stay.

STUDY OBJECTIVE: Observation unit admissions have been increasing, a trend that will likely continue because of recent changes in reimbursement policies. The purpose of this study is to determine the effect of the availability of observation units on hospitalizations and discharges to home for emergency department (ED) patients. METHODS: We studied ED visits with a final diagnosis of chest pain in the National Hospital Ambulatory Medical Care Survey from 2007 to 2010. ED visits that resulted in an observation unit admission were propensity-score matched to visits at hospitals without an observation unit. We used logistic regression to develop a prediction model for hospitalization versus discharge home for matched patients treated at nonobservation hospitals. The model was applied to matched observation unit patients to determine the likely alternative disposition had the observation unit not been available. RESULTS: There were 1,325 eligible visits that represented 5,079,154 visits in the United States. Two hundred twenty-seven visits resulted in an observation unit admission. The predictive model for hospitalization had a c statistic of 0.91; variables significantly associated with subsequent hospitalization included age, history of coronary atherosclerosis, systolic blood pressure less than 115 beats/min, and administration of antianginal medications. When the model was applied to matched observation unit patients, 49.9% of them were categorized as discharge home likely. CONCLUSION: In this study, we estimated that half of ED visits for chest pain that resulted in an observation unit admission were made by patients who may have been discharged home had the observation unit not been available. Increased availability of observation units may result in both decreased hospitalizations and decreased discharges to home.