Faculty Bibliography

Background: Homeless patients visit the ED at rates up to 12 times higher than comparable housed patients, yet there is a paucity of research on how this influences emergency medicine residents, who are the primary physician caregivers in many EDs. Objectives: To characterize the experiences of EM residents in caring for homeless patients and explore how these experiences influence resident personal and professional development. Methods: We conducted in-depth interviews with residents of two northeast urban EM residency programs. A random purposeful sample diverse in training year was selected, with sample size determined by theoretical saturation. Interviews were digitally recorded and professionally transcribed. A core team of three researchers with diverse content-relevant expertise independently coded transcripts and met regularly to reconcile coding differences. The constant comparison method was used to identify new codes and refine existing ones iteratively. The final code structure was applied to all data using Atlas.ti (GmbH). Results: Four core themes pertaining to the resident experience emerged from 23 interviews. First, residents learn how to care for homeless patients through modeling more senior physicians, storytelling, and experience, rather than formal curricular training. Second, residents learn unique aspects of EM by caring for homeless patients. For example, residents learn to integrate social and systems-level factors into medical decision making (i.e., considering homelessness in disposition decisions). Third, residents struggle with role boundaries as emergency physicians when caring for homeless patients. Though the ED regularly fills gaps in the social service system by providing shelter, food, and other non-medical resources, residents vary in how much of this care they embrace as their job. Finally, caring for homeless patients affects residents emotionally. While residents feel pride in EM's mission to serve all patients, they feel frustrated by what they perceive !

Medical respite programs provide care to homeless patients who are too sick to be on the streets or in a traditional shelter, but not sick enough to warrant inpatient hospitalization. They are designed to improve the health of homeless patients while also decreasing costly hospital use. Although there is increasing interest in implementing respite programs, there has been no prior systematic review of their effectiveness. We conducted a comprehensive search for studies of medical respite program outcomes in multiple biomedical and sociological databases, and the grey literature. Thirteen articles met inclusion criteria. The articles were heterogeneous in methods, study quality, inclusion of a comparison group, and outcomes examined. Available evidence showed that medical respite programs reduced future hospital admissions, inpatient days, and hospital readmissions. They also resulted in improved housing outcomes. Results for emergency department use and costs were mixed but promising. Future research utilizing adequate comparison groups is needed.

STUDY OBJECTIVE: Our objective is to determine whether a point-of-care intervention that navigates willing, low-acuity patients from the emergency department (ED) to a Primary Care Clinic will increase future primary care follow-up. METHODS: We conducted a quasi-experimental trial at an urban safety net hospital. Adults presenting to the ED for select low-acuity problems were eligible. Patients were excluded if arriving by emergency medical services, if febrile, or if the triage nurse believed they required ED care. We enrolled 965 patients. Navigators escorted a subset of willing participants to the Primary Care Clinic (in the same hospital complex), where they were assigned a personal physician, were given an overview of clinic services, and received same-day clinic care. The primary outcome was Primary Care Clinic follow-up within 1 year of the index ED visit among patients having no previous primary care provider. RESULTS: In the bivariate intention-to-treat analysis, 50.3% of intervention group patients versus 36.9% of control group patients with no previous primary care provider had at least 1 Primary Care Clinic follow-up visit in the year after the intervention. In the multivariable analysis, the absolute difference in having at least 1 Primary Care Clinic follow-up for the intervention group compared with the control group was 9.3% (95% confidence interval 2.2% to 16.3%). There was no significant difference in the number of future ED visits. CONCLUSION: A point-of-care intervention offering low-acuity ED patients the opportunity to alternatively be treated at the hospital's Primary Care Clinic resulted in increased future primary care follow-up compared with standard ED referral practices.

ABSTRACT: BACKGROUND: A small percentage of high-risk patients accounts for a large proportion of Medicaid spending in the United States, which has become an urgent policy issue. Our objective was to pilot a novel patient-centered intervention for high-risk patients with frequent hospital admissions to determine its potential to improve care and reduce costs. METHODS: Community and hospital-based care management and coordination intervention with pre-post analysis of health care utilization. We enrolled Medicaid fee-for-service patients aged 18-64 who were admitted to an urban public hospital and identified as being at high risk for hospital readmission by a validated predictive algorithm. Enrolled patients were evaluated using qualitative and quantitative interview techniques to identify needs such as transportation to/advocacy during medical appointments, mental health/substance use treatment, and home visits. A community housing partner initiated housing applications in-hospital for homeless patients. Care managers facilitated appropriate discharge plans then worked closely with patients in the community using a harm reduction approach. RESULTS: Nineteen patients were enrolled; all were male, 18/19 were substance users, and 17/19 were homeless. Patients had a total of 64 inpatient admissions in the 12 months before the intervention, versus 40 in the following 12 months, a 37.5% reduction. Most patients (73.3%) had fewer inpatient admissions in the year after the intervention compared to the prior year. Overall ED visits also decreased after study enrollment, while outpatient clinic visits increased. Yearly study hospital Medicaid reimbursements fell an average of $16,383 per patient. CONCLUSIONS: A pilot intervention for high-cost patients shows promising results for health services usage. We are currently expanding our model to serve more patients at additional hospitals to see if the pilot's success can be replicated. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT01292096

OBJECTIVE: To explore medical students' perceptions of their future role as physicians as it relates to personal and professional responsibilities toward the underserved. METHODS: The authors conducted a qualitative content analysis of 53 first-year medical students' reflective essays focusing on the question: "Access to health care is a societal problem. Do physicians have a professional obligation to help by participating in free clinics, or otherwise doing some service-type activity? What are your personal feelings about how you might balance service to other people with personal issues like income, family, and career choice?" RESULTS: The student essays revealed students' awareness of the distinct expertise that enables physicians to offset limited access to health care. Although the majority of respondents supported physicians' responsibility to provide uncompensated care, a minority believed that there was no such responsibility attached to being a physician. Students also recognized the competing demands physicians often encounter that conflict with personal desires for service. CONCLUSION: The use of reflective essays in medical school curricula seems promising, in that they elicited students' beliefs on a complex topic with direct implications for professional identity and career decisions.

Nearly 90 million Americans live below 200% of the federal poverty threshold. The links between lower socioeconomic status and poor health are clear, and all physicians face the resulting challenges in patient care. Current medical school curricula do not adequately prepare students to address this issue despite recommendations from the Association of American Medical Colleges and the Institute of Medicine. In response, students and faculty at the University of Michigan Medical Center established the Poverty in Healthcare curriculum, which encompasses required learning experiences spanning all four years of undergraduate medical education. This article describes the design and implementation of this curriculum. The authors provide thorough descriptions of the individual learning experiences, including community site visits, longitudinal cases, mini-electives, and family centered experiences. The authors also discuss the history, costs, challenges, and evaluation process related to the Poverty in Healthcare curriculum, including issues specifically related to medical students' involvement in developing and implementing the curriculum. This information may be used as a guide for other medical schools in the development of curricula to address this current gap in medical student education.