Table of Contents
The Issue in Brief
The Issue in Brief, July-August 2021, Volume 19, Number 4
Building an Evidence Base for Integration of Social Care Into Health Care: Our Collective Path Ahead
Alicia J. Cohen and colleagues
Background Drs. Cohen and De Marchis write an editorial about three articles in the July-August issue of Annals of Family Medicine, specifically Greenwood-Ericksen et al’s research on Michigan’s Federally Qualified Health Centers; Hoeft et al’s special report about translating lessons learned from behavioral health integration into the social care realm; and Fessler et al’s narrative about how they as medical students stepped away from their medical clerkships to act as community volunteers for people experiencing homelessness during the COVID-19 pandemic.
What This Study Found All three articles serve as a timely call to action, reminding those in health care that work remains to meet the needs of patients, particularly in screening for and intervening on identified social risks. The urgency of this work has only been heightened by the pandemic as patients face new or intensified socio-economic hardships.
Implications
- Collaboration is needed among researchers, policy makers, payers and health care systems to assist in identifying evidence-based practices for social needs integration. This includes improved training and education for all clinical care team members about social risk and social care activities, best practice guidelines, evidence-based interventions, and sustainable funding streams. Social risk data can also more broadly aid advocacy and policy efforts to expand community-based resources, efforts to address health inequities, and population health-level interventions. Furthermore, greater flexibility in using Center for Medicare & Medicaid dollars and the new 2021 Evaluation and Management coding guidelines for social determinants may help with more consistent funding for social care activities.
Robert P. Lennon and colleagues
Background Penn State University researchers conducted a survey in late March 2020, which was completed by almost 6,000 adults enrolled in a central Pennsylvania health care system.
What This Study Found The survey suggests that knowledge about COVID-19 and adherence to behavioral recommendations was generally high among those surveyed. Early concern for COVID-19 outmatched concern for influenza, though researchers believe respondents may have been less focused on their perceived likelihood of contracting COVID-19 and more concerned with its severe impact on their health. Additionally, they found that when the Centers for Disease Control and Prevention began advising social distancing recommendations in the early months of the pandemic, a majority of surveyed adults believed in the effectiveness of social distancing and intended to follow CDC guidelines. Health agency websites like the CDC were most frequently identified as “trusted sources” for COVID-19 information, as opposed to the substantial distrust in COVID-19 information from mass media and politicians.
Implications
- These findings highlight the importance of consistent messaging from trusted sources that reaches diverse groups.
Effectiveness of Physical Exercise in Older Adults With Mild to Moderate Depression
Jesus Lopez-Torres Hidalgo and colleagues
Background Depression is the most frequently diagnosed psychiatric disorder among older adults, with 8% to 16% of older patients presenting with clinically significant depressive symptoms. Researchers in Spain conducted a randomized clinical trial of 347 older adults with mild to moderate depression, comparing the effectiveness of physical exercise and antidepressants as treatment methods. Study participants were assigned to either a group engaged in supervised physical exercise or a group that received antidepressant treatment by their general practitioners.
What This Study Found Depressive symptoms were not significantly different after one month between the two groups. However, after three and six months, the number of people who showed improvement was significantly higher in the antidepressant group. The authors note that the number of participants who withdrew from the study was higher in the physical activity group, while more adverse side-effects were reported in the group treated with antidepressants.
Implications
- Both interventions, specifically antidepressant treatments and physical exercise carried out in group sessions, are capable of reducing depressive symptomatology among persons over the age of 65, diagnosed in primary care with mild-to-moderate depressive disorder. Although the resulting improvement in depressive symptoms is initially similar in both treatment options, antidepressant drug therapy proves superior in the medium term. Despite the fact that the appearance of adverse effects was significantly higher in the group treated with antidepressant drugs, both interventions were found to be satisfactory by the participants and impacted very favorably on their self-perceived health status.
Margaret Greenwood-Ericksen and colleagues
Background Addressing patients’ health-related social needs, like housing and food security, is integral to patient care. Federally Qualified Health Centers (FQHCs) are leaders in screening for and addressing patients’ health-related social needs. However, screening practices vary. This variation is relatively unexplored, particularly with regards to organizational and state policy influences. Study authors conducted in-person, qualitative interviews at Michigan FQHCs to examine how screening approaches vary in the context of statewide social needs screening initiatives and structural factors.
What This Study Found Researchers identified four themes: 1) Statewide initiatives and local leadership drove variation in screening practices. 2) Community health workers played an integral role in identifying patients’ needs and their roles often shifted from “screener” to “implementer.” 3) Social needs screening data was variably integrated into electronic health records and infrequently used for population health management and 4) Sites experienced barriers to social needs screening that limited their perceived impact and sustainability.
Implications
- FQHCs placed value on the role of community health workers, on sustainable initiatives, and on funding to support continued social needs screening in primary care settings. Determining the optimal approaches to screening is important to advancing community health
Ngaire Kerse and colleagues
Background Given the aging world population, there is international interest in helping older people live longer and healthier lives. Avoiding unplanned hospital admissions is an important aspect of care for older people. Palapar et al studied the ways primary care practice characteristics influence outcomes such as unplanned hospitalizations, function and well-being. They investigated the variability in older people’s outcomes by primary care physicians and practice characteristics in New Zealand and the Netherlands.
What This Study Found None of the physician or practice characteristics were significantly associated with rates of unplanned admissions in the New Zealand sample. In contrast, in the Netherlands sample, researchers found higher rates of admissions in large practices and practices staffed with a practice nurse who typically works in the primary care setting with general practitioners.
Implications
- It is unclear if these associations are causal or if the increase in hospitalizations represent higher or lower quality care. Considering these findings, the authors conclude that the central focus of international health policies on reducing hospital overuse should approach primary health care structural reform carefully.
Lixin Guo and colleagues
Background Approximately 642 million people are expected to be diagnosed with diabetes by 2040, with Asians representing more than 55% of cases. Researchers conducted the first large-scale study since the implementation of medical insurance in China to evaluate the complexity and cost of drug therapy for Asian people with diabetes. They used available treatment records from Beijing’s medical insurance bureau from 2016 to 2018 and looked at five outcomes, including: 1) quantity of outpatient medications, 2) number of co-morbidities diagnosed, 3) estimated annual cost of the outpatient drug regimen, 4) drug therapy strategies for diabetic patients and 5) the most commonly prescribed drug class in the patient cohort.
What This Study Found Over three years, there was a gradual decrease of almost 9% decrease in the average quantity of diabetes medications. The mean usage of both anti-glycemic and non-antiglycemic drugs decreased by 3.6% and 12.8%, respectively. Researchers found an 18.39% decrease in estimated annual medication costs. The decrease in medical costs could be due to rational use of medications, leading to a decrease in the usage of medications over the three years. This is especially true for what the authors call the needless use of most types of insulin. This could have indirectly led to decreased costs.
Implications
- Therapeutic drugs should be selected with caution according to the diet and lifestyle of each individual.
Lower Likelihood of Burnout Among Family Physicians From Underrepresented Racial-Ethnic Groups
Montgomery Douglas and colleagues
Background More than 40% of physicians in the United States reported at least one symptom of burnout, which is particularly high among family physicians. This study examined a nationally-representative sample of family physicians to determine whether physician race-ethnicity was associated with burnout among a nationally-representative sample of family physicians. Of the 3,096 physicians studied, 450 (15%) were from racial-ethnic groups underrepresented in medicine (UIM), which include Blacks/African Americans, Hispanics/Latinos, American Indians and Pacific Islanders who together comprise 30-35% of the general population yet account for only 12.4% of family physicians.
What This Study Found Study findings support the researchers’ hypothesis that UIMs were significantly less likely than their non-UIM counterparts to report emotional exhaustion and depersonalization. This may be attributed to practicing in more racially-diverse counties and being less likely to practice obstetrics, both of which partially mediated the protective effect of UIM status on depersonalization. The mediating effect of working in more racially and ethnically diverse counties is consistent with evidence of the beneficial effect of cultural diversity on health outcomes for minorities and better overall self-rated health among adults.
Implications
- Understanding the attributes of UIMs that may prevent burnout could also provide insights for developing a more resilient physician workforce.
Primary Care's Historic Role in Vaccination and Potential Role in COVID-19 Immunization Programs
John M. Westfall and colleagues
Background Researchers examined the role of primary care physicians and other clinicians in delivering vaccinations in the United States. They used two main datasets to create an in-depth analysis of services delivered to Medicare patients, followed by analysis of the Agency for Healthcare Research and Quality’s 2017 Medical Expenditure Panel Survey (MEPS) to determine where patients are getting vaccinated and by whom.
What This Study Found In the 2017 Medicare Part B Fee-For-Service, primary care physicians provided the largest share of services for vaccinations (46%), followed by mass immunizers (45%), then nurse practitioners/physician assistants (5%). The MEPS showed that primary care physicians provided a majority of clinical visits for vaccination (54%).
Implications
- Primary care physicians have played a crucial role in vaccination delivery to the
U.S. population, including the elderly. They are well positioned to help with administering
COVID-19 vaccinations. They are also equipped to provide clinical guidance to help
patients interpret results from COVID-19 testing and immunity determinations and can
answer vaccine questions.
Applying Lessons From Behavioral Health Integration to Social Care Integration in Primary Care
Theresa J. Hoeft and colleagues
Background Although interest is accelerating around addressing patients’ social and economic needs, effective and sustainable strategies for integrating social care practices into health care delivery have not yet been identified.
What This Study Found This paper synthesized learnings from primary care and behavioral health care integration and translated them into organizing principles with the goal of advancing social care integration practices to improve the health of patients and communities.
Implications
- Lessons learned from over two decades of research on behavioral health integration could be applied to efforts to integrate social care into primary care.
Michelle's Story: The Complexity of Patient Care in a Family Medicine Residency Clinic
Kathryn Justesen and colleagues
Background The authors use a patient story to put into context their experiences as family physicians who care for patients with complex health care needs that go beyond just physical symptoms or a single morbidity.
What This Study Found Family physicians care for patients with increased medical complexity, which may include both medical and mental health diagnoses, and are often combined with substance abuse disorders and low socioeconomic status. The authors’ experiences highlight the importance of addressing social determinants of health, which they say permeate the context of health and health care. Factors such as financial challenges, limited transportation, food insecurity and low health literacy have a profound influence on health.
Implications
- Family physicians are in a unique position to treat patients appropriately and efficiently by embracing the complexities of the patients they encounter. By doing so, family physicians can help improve health outcomes and manage health care costs in patient populations that increasingly present with complex health needs.
Virtual Care: Choosing the Right Tool, at the Right Time
Kumara Raja Sundar
Background Kumara Raja Sundar, MD, a family physician at Kaiser Permanente of Washington, uses two media synchronicity theory principles – conveyance and convergence – as a framework for choosing the right medium of care for his patients. Sundar discusses how operating within this framework changed his own practice and decision making during the COVID-19 pandemic, particularly with the use of telemedicine versus in-person clinic visits.
What This Study Found Sundar explains that the theory of conveyance focuses on transmitting and processing diverse information to understand a situation. It requires time to analyze data, create patterns and make conclusions. Convergence focuses on discussing pre-processed information to achieve a mutual understanding of it. It often requires a rapid exchange of information to allow immediate feedback to test and verify each person’s knowledge.
Implications
- Patients benefit from telehealth’s convenience when they have access to the right technology but that they must also have access to all care options. Doctors must guide patients towards the right care medium that suits them best, in the correct order, and use all those tools efficiently and effectively. It is the only way we will be able to achieve our mission of healing, according to Sundar.
Sandwiches, 6 Feet Apart: Reflections on Community (and Medical School) During COVID-19
Margaret Fessler and colleagues
Background In this essay, four University of Michigan Medical School students write about being removed from their clinical clerkships and returning to the community to support their neighbors experiencing homelessness during the COVID-19 pandemic.
What This Study Found The students talk about their experiences making brown bag lunches for people experiencing homelessness and their work as community volunteers for temporary shelters.
Implications
- Fessler et al write that though formal education was stalled, they reconnected with the initial desire that led them to pursue medical education in the first place and developed key skills in communication, relating to others, and compassion that they believe will enable them to become better physicians in the future.