Faculty Bibliography

This article discusses how community-based participatory research (CBPR) on hospital care transitions in New Haven, Connecticut led to the development of a new medical respite program to better serve patients who are homeless. Key insights include.

INTRODUCTION: The goal of this project was to use the Consolidated Framework for Implementation Research (CFIR) as the theoretical foundation for developing a web-based clinical decision support system (CDSS) for primary care screening and care coordination by dental hygienists at chairside. METHODS: First, we appraised New York State education and scope of practice requirements for dental hygienists with input from health experts who constituted a Senior Advisory Board for the project, and reviewed current professional guidelines and best practices for tobacco use, hypertension and diabetes screening, and nutrition counseling at chairside. Second, we created algorithms for these four health issues (tobacco, hypertension, diabetes, and nutrition) using evidence-based guidelines endorsed by authoritative professional bodies. Third, an information technology specialist incorporated the algorithms into a tool using an iterative process to refine the CDSS, with input from dental hygienists, dentists, Senior Advisory Board members and research staff. RESULTS: An evidence-based CDSS for use by dental hygienists at chairside for tobacco use, hypertension and diabetes screening, and nutrition counseling was developed with the active participation of the individuals involved in the implementation process. CONCLUSIONS: CDSS technology may potentially be leveraged to enhance primary care screening and coordination by dental hygienists at chairside, leading to improved patient care. Using the CFIR as a pragmatic structure for implementing this intervention across multiple settings, the developed CDSS is available for downloading and adaptation to diverse dental settings and other primary care sensitive conditions.

INTRODUCTION: Twitter use has grown exponentially within the urological community. We aimed to determine the perceptions of the impact of Twitter on users' clinical practice, research, and other professional activities. METHODS: We performed an 11-item online survey of Twitter contributors during two major urological meetings: the European Association of Urology (EAU) and the American Urological Association (AUA) annual meetings. During the EAU 2014 meeting, we distributed the survey via the meeting official Twitter feed. During the AUA 2014 meeting, we applied a new method by directly sending the survey to Twitter contributors. We performed a subset analysis for assessing the perceived impact of Twitter on the clinical practice of physicians. RESULTS: Among 312 total respondents, the greatest perceived benefits of Twitter among users were for networking (97%) and disseminating information (96%), followed by research (75%), advocacy (74%) and career development (62%). In total, 65% of Twitter users have dealt with guidelines on online medical professionalism and 71% of physician users found that Twitter had an impact on their clinical practice, and 33% had made a clinical decision based on an online case discussion. CONCLUSIONS: Our results suggest that Twitter users in the urological community perceive important benefits. These benefits extend to multiple professional domains, particularly networking, disseminating information, remote conference participation, research, and advocacy. This is the first study that has been disseminated to targeted individuals from the urological community directly through tweets, providing a proof of principle for this research method.

Program/Project Purpose: Inter professional education is increasingly recognized as fundamental for health education worldwide. Although effective management is essential for health care improvement, business schools have been underrepresented in global health education. Here we report the Health Innovation Fellowship (HIF), a new training program created for practicing health professionals offered by the Central American Healthcare Initiative (CAHI) and INCAE Business School, Costa Rica. The initial period for this annual program is July 2014 to February 2015. HIF aims to catalyze improvements in the quality, efficiency, and delivery of healthcare for Central Americans in greatest need. Structure/Method/Design: HIF's goal is to provide training in management and leadership for fellows, in order to carry out an innovative health care improvement project in their local region. Participants are selected based on a submitted outline for their proposed project, and why it is innovative and relevant within their current local health care system. The initial cohort of 16 fellows represent eight health-related professions in six Central American countries. HIF is supported by CAHI stakeholders. Desired outcomes for HIF include successful completion of each fellow's project, and providing a positive impact on achieving their goals. All fellows attend four one-week on-site modular training sessions, receive ongoing mentorship, and stay connected through formal and informal networks and webinars to exchange knowledge and support each other. Viability is encouraged by creating a network of increasingly sustainable projects and health professional leaders across Central America, with each successive annual training program. Outcomes & Evaluation: Preliminary data are positive. During each on-site training module, fellows present updated project profiles, which are compared to their earlier project profiles to track progress. A "check-out" process has fellows set concrete goals and timelines to accomplish by the next module, and a "check-in" process reports whether they achieved their previous goals. After the first and second modules, 100% of the fellows considered HIF and its training sessions as "very good" or "excellent" toward meeting their project's goals. More than 50% of the projects have found either financial or political support for their implementation. Upon completion of HIF, fellows complete a quantitative-qualitative exit interview to measure 1) project outcomes and 2) the fellowship's impact on their project design, implementation, quality and effectiveness. Going Forward: Strengths include that both leadership and trainees come from the Global South, and that HIF offers a Global South platform to collaborate with partners in the Global North. Across sites, common themes are defined and unique lessons are learned. The seven-month period is a challenge, which is short for health system improvement efforts. By focusing on innovation and management within a Central American school of business, HIF is a novel capacity-building effort within global health education efforts

BACKGROUND: On October 2012, Hurricane Sandy struck New York City, resulting in unprecedented damages, including the temporary closure of Bellevue Hospital Center and its primary care office-based buprenorphine program. OBJECTIVES: At 6 months, we assessed factors associated with higher rates of substance use in buprenorphine program participants that completed a baseline survey one month post-Sandy (i.e. shorter length of time in treatment, exposure to storm losses, a pre-storm history of positive opiate urine drug screens, and post-disaster psychiatric symptoms). METHODOLOGY: Risk factors of interest extracted from the electronic medical records included pre-disaster diagnosis of Axis I and/or II disorders and length of treatment up to the disaster. Factors collected from the baseline survey conducted approximately one month post-Sandy included self-reported buprenorphine supply disruption, health insurance status, disaster exposure, and post-Sandy screenings for PTSD and depression. Outcome variables reviewed 6 months post-Sandy included missed appointments, urine drug results for opioids, cocaine, and benzodiazepines. RESULTS: 129 (98%) patients remained in treatment at 6 months, and had no sustained increases in opioid-, cocaine-, and benzodiazepine-positive urine drug tests in any sub-groups with elevated substance use in the baseline survey. Contrary to our initial hypothesis, diagnosis of Axis I and/or II disorders pre-Sandy were associated with significantly less opioid-positive urine drug findings in the 6 months following Sandy compared to the rest of the clinic population. CONCLUSION: These findings demonstrate the adaptability of a safety net buprenorphine program to ensure positive treatment outcomes despite disaster-related factors.

Depression is common in nursing facility residents. Depression data obtained using the Minimum Data Set (MDS) 3.0 offer opportunities for improving diagnostic accuracy and care quality. How best to integrate MDS 3.0 and other data into quality improvement (QI) activity is untested. The objective was to increase nursing home (NH) capability in using QI processes and to improve depression assessment and management through focused mentorship and team building. This was a 6-month intervention with five components: facilitated collection of MDS 3.0 nine-item Patient Health Questionnaire (PHQ-9) and medication data for diagnostic interpretation; education and modeling on QI approaches, team building, and nonpharmacological depression care; mentored team meetings; educational webinars; and technical assistance. PHQ-9 and medication data were collected at baseline and 6 and 9 months. Progress was measured using team participation measures, attitude and care process self-appraisal, mentor assessments, and resident depression outcomes. Five NHs established interprofessional teams that included nursing (44.1%), social work (20.6%), physicians (8.8%), and other disciplines (26.5%). Members participated in 61% of eight offered educational meetings (three onsite mentored team meetings and five webinars). Competency self-ratings improved on four depression care measures (P = .05 to <.001). Mentors observed improvement in team process and enthusiasm during team meetings. For 336 residents with PHQ-9 and medication data, depression scores did not change while medication use declined, from 37.2% of residents at baseline to 31.0% at 9 months (P < .001). This structured mentoring program improved care processes, achieved medication reductions, and was well received. Application to other NH-prevalent syndromes is possible.