Health care organizations in the United States have transformed at an unprecedented rate since March 2020 due to COVID-19, most notably with a shift to telemedicine. Despite rapidly adapting health care delivery in light of new safety considerations and a shifting insurance landscape, primary care offices across the country are facing drastic decreases in revenue and potential bankruptcy. To survive, primary care's adaptations will need to go beyond virtual versions of traditional office visits. Primary care is faced with a chance to redefine what it means to care for and support patients wherever they are. This opportunity to shape the "new normal" is a critical step for primary care to meet its full potential to lead a paradigm shift to patient-centered health care reform in America during this time when we need it most.
Objective: To systematically review how safety-net hospitals' status is identified and defined, discuss current definitions' limitations, and provide recommendations for a new classification and evaluation framework. Data Sources: Safety-net hospital-related studies in the MEDLINE database published before May 16, 2019. Study Design: Systematic review of the literature that adheres to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data Collection/Extraction Methods: We followed standard selection protocol, whereby studies went through an abstract review followed by a full-text screening for eligibility. For each included study, we extracted information about the identification method itself, including the operational definition, the dimension(s) of disadvantage reflected, study objective, and how safety-net status was evaluated. Principal Findings: Our review identified 132 studies investigating safety-net hospitals. Analysis of identification methodologies revealed substantial heterogeneity in the ways disadvantage is defined, measured, and summarized at the hospital level, despite a 4.5-fold increase in studies investigating safety-net hospitals for the past decade. Definitions often exclusively used low-income proxies captured within existing health system data, rarely incorporated external social risk factor measures, and were commonly separated into distinct safety-net status categories when analyzed. Conclusions: Consistency in research and improvement in policy both require a standard definition for identifying safety-net hospitals. Yet no standardized definition of safety-net hospitals is endorsed and existing definitions have key limitations. Moving forward, approaches rooted in health equity theory can provide a more holistic framework for evaluating disadvantage at the hospital level. Furthermore, advancements in precision public health technologies make it easier to incorporate detailed neighborhood-level social determinants of health metrics into multidimensional definitions. Other countries, including the United Kingdom and New Zealand, have used similar methods of identifying social need to determine more accurate assessments of hospital performance and the development of policies and targeted programs for improving outcomes.
Neighborhood disadvantage reflects historic and ongoing systemic injustices.Without addressing these upstream social determinants of health, hospitals may face different risk profiles for important quality metrics. Our objective was to assess differences in hospital characteristics where the proportion of patients residing in severely disadvantaged neighborhoods was high versus low. Using Medicare feefor-service claims between January 1, 2014 and November 30, 2014 (5,807,499 hospital stays), we calculated area disadvantage share (ADS), the proportion of each hospital's discharges to severely disadvantaged neighborhoods, for 4528 hospitals.We examined hospital characteristics by a distribution of ADS and by risk-adjusted 30-day readmission. Hospitals in the highest decile cared for a higher proportion of Black patients, were more often located in rural areas, and had a higher patient risk of 30-day readmission compared with all other deciles. Hospitals face unequal burdens of neighborhood disadvantage, a factor distinct from other social determinants such as rurality.
Medicare’s Hospital Readmissions Reduction Program (HRRP) places disproportionate penalties on hospitals serving populations with complex medical and social needs. Without measures to identify the social need intensity of populations cared for by these hospitals, the HRRP cannot account for these risk factors, leading to burdensome penalties that may inadvertently hinder the ability of such hospitals to care for vulnerable populations. The objective of this study is to characterize the social need intensity of US hospital acute care populations. Using the Area Deprivation Index (ADI), a validated measure that ranks neighborhood socioeconomic disadvantage based on income, employment, housing, and education factors, we determined an “Area Deprivation Share” (ADS) for hospitals with 25 or more discharges using 100% of national Medicare claims data from 2013-2014. Hospital ADS is the proportion of qualifying discharges residing in the most disadvantaged neighborhoods (ADI ≥ 80th percentile) out of all qualifying discharges during the study period. Of 4,603 hospitals, median ADS was 17% (Interquartile Range: 6% - 34%). Hospitals in the highest quintile of ADS (39% to 100%), were more frequently located in small towns or isolated rural areas (52.6%, comparted to 24.2% in lower quintiles) and served a higher percentage of Black patients (19.0%, comparted to 9.7% in lower quintiles). ADS is a potential tool to inform future Medicare policy decisions. Additional research will inform how hospitals target care processes to meet the needs of older adults with complex social needs. Further study can also explore overlapping disadvantage domains of socioeconomic status, race, and rurality.
Context: Changes to the transportation system that promote active transportation -walking, cycling, public transit -can promote important population health gains. However, these potential benefits may not impact everyone equally. We do not know how much they may address, or conversely exacerbate, existing racial and socioeconomic health disparities.Objective: This study aims to review existing research that investigates the distribution of health impacts of active transportation interventions across indicators of race, ethnicity, or socioeconomic status (SES).Study Design and Analysis: We conducted a scoping review of peer-reviewed literature to identify studies evaluating the health outcomes of active transportation interventions and comparing differences between groups based on race, ethnicity, or SES. We searched PubMed, Scopus, Web of Science, and Transport Research International Documentation between January 1, 2000 and October 21, 2020. We reviewed records for study characteristics and if/how equity was included in the conceptual model, design, analysis, or discussion.Results: Our search resulted in 7226 records that we screened for keyword relevance by title. We identified 3246 abstracts to review further but ultimately found only 10 studies meeting all our inclusion criteria. These 10 studies evaluated behavior change programs, pedestrian and cycling infrastructure improvements, and increased transit infrastructure or access. Eight of these studies found that the intervention had a positive impact on health outcomes overall. When compared across indicators of participant race, ethnicity, or SES, nine found either no significant difference or a favorable impact of the intervention on the health outcome for disadvantaged groups studied.
With new infection control guidelines in March 2020, the navigators began working remotely, connecting with clinicians and patients by telephone. We conducted interviews with clinicians and staff to identify barriers and opportunities for screening and referring patients to the CRNP. These interviews yielded key themes-communication, opportunities to improve original workflow, and new barriers with off-site navigators. We identified clear communication, easy access to navigator contact information for referrals, and increased frequency of reminders to screen for social needs as specific targets for quality improvement.We have now developed multiple opportunities for patients to screen into and be connected to the CRNP. This multifaceted screening/referral process involves sharing updated contact information for the navigators with all staff through an electronic health record "smartphrase." Navigators join our daily clinic huddle every Monday to provide updates and reminders to clinic staff about how to connect with navigators off-site.We established a "universal screening" protocol, providing all patients at office visits with a brief handout about how to contact navigators directly.Survey results evaluating these updated workflows suggest that most clinicians are contacting the navigators for patients, with their consent. In other cases, clinicians discuss how to contact the navigators with patients, enabling patients to make the connection directly. Based on feedback from this survey we are continuing to improve 2-way communication between clinicians and navigators. LEARNINGDespite an increase in telehealth and a shift to new workflows that limited physical interactions in our clinic, we were able to use virtual workflows to continue connecting patients with resources to address their unmet social needs. We achieved this by integrating off-site community partners into telephone huddles, shared health record reminders, and telephone/e-mail connections. Other clinics can connect patients with similar social prescribing programs by providing team members and patients with multiple pathways for screening and referrals and involving community partners in regular telephone "huddles." These strategies can help reinforce meaningful community-clinic partnerships that support patients to surmount structural and systemic barriers to health.Read more or post commentaries on this article.Supplemental materials, including references, prior presentations, funding support, and acknowledgments
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