884-P: Mi Puente: A Care Transitions Intervention for At-Risk Hispanics with Multiple Cardiometabolic Conditions

Abstract

Hispanics are disproportionately affected by chronic cardiometabolic conditions (e.g., obesity, diabetes). Unmet behavioral health needs (e.g., mental health problems, stress, lack of health care) contribute to these disparities. Sustainably reducing Hispanic health disparities demands innovative, cost-effective interventions that address both behavioral and physical health. A randomized controlled trial is underway to evaluate Mi Puente - i.e., a Behavioral Health Nurse (BHN) + volunteer Community Mentor (CM) intervention designed to reduce readmissions in N = 560 Hispanics with ≥ 2 cardiometabolic conditions and ≥ 1 behavioral health concern(s) hospitalized at a safety-net hospital near the U.S./Mexico border in San Diego, CA. Qualifying patients at high-risk for readmission are identified via automated electronic medical record reports. The BHN triages patients’ needs, provides education, and conducts tailored coaching and goal-setting. Post-discharge, the BHN conducts telephone follow-up at 1-week, and CMs provide referrals to community resources and transition support via phone for up to 1-month. Prevalent behavioral health concerns were: chronic stress (52.5%), health-related distress (37.3%), and lack of routine medical care (19.8%). Preliminary process data indicated that the BHN met with 82.5% of participants prior to discharge; challenges related to medication adherence (28.7%) and access to outpatient care (41.1%) were common. Approximately 80% received ≥1 CM phone call (M = 1.7± 1.1); the transition home and follow-up appointment(s) were frequently addressed (both 97.9%). Findings reveal high levels of unmet behavioral health needs among hospitalized Hispanics, and the feasibility of a sustainable, low-cost, team model that builds upon personnel commonly found in hospital settings - i.e., nurses and volunteers. Important “lessons learned” will be presented to inform future care transitions programs in high-risk, underserved groups. Disclosure J.I. Bravin: None. M.L. Anderson: None. T. Clark: None. K.L. Savin: None. D. Lara Ledesma: None. J.A. Euyoque: None. A.L. Fortmann: None. A. Philis-Tsimikas: Advisory Panel; Self; AstraZeneca, Lilly Diabetes, Novo Nordisk A/S, Sanofi. Employee; Spouse/Partner; Ionis Pharmaceuticals, Inc. Research Support; Self; Dexcom, Inc., Glooko, Inc., National Institute of Diabetes and Digestive and Kidney Diseases. Stock/Shareholder; Spouse/Partner; Ionis Pharmaceuticals, Inc., Novo Nordisk Inc. L. Gallo: None. Funding National Institutes of Health