Safety Net Clinics Research Articles

Barriers to dental utilization among Medicaid-enrolled young children from primary care practices in Northeast Ohio.

To evaluate the individual and community factors that contribute to dental utilization among young children on Medicaid utilizing the Anderson Model and the Socio-Ecological Framework. This observational cross-sectional study was conducted using baseline data (socio-demographics, clinical dental need) from a cluster-randomized hybrid effectiveness-implementation trial among 1021 child-parent dyads recruited from primary care practices across northeast Ohio. The baseline data were then linked to dental Medicaid claims data (categorized as any dental visit, volume, and type in the past 12 months) and ICD-10 codes from the child's EHR data (individual-level) together with Dental Health Provider Shortage Area (HPSA) status and Area Deprivation Index (ADI) which were obtained at the neighbourhood-level using home address of each dyad (community-level). Multivariable analyses using generalized estimating equations (GEE) accounted for clustering by practice, and models included individual-level alone, and individual + community-level factors to evaluate their effects on dental utilization. Medicaid claims data indicated that among the 1021 children (mean age: 4.3 ± 1.1 years; 54.4% males; 43.8% Black, Non-Hispanic), a majority of children were seeing the dentist at least once a year by the age of 4 (56.1%). The mean ADI of their neighbourhoods was 109.22 (20.2) and 27.5% lived in a HPSA area. The GEE analyses revealed that individual factors such as older children, parents being married, and continuous Medicaid enrollment were associated with significantly higher dental utilization. Among community factors, being in a HPSA had an OR = 1.53 (CI: 1.03, 2.27) associated with higher dental utilization. Being in a HPSA was associated with higher dental utilization possibly due to dentists or safety net dental clinics in these areas accepting Medicaid-eligible children.

Brief Report: The Role of Substance Use in Structural Heart Disease Among Women Living With HIV.

People living with HIV have increased risk of cardiovascular disease, but few studies focus on women with HIV (WWH) and few account for the use of multiple substances. We recruited WWH from San Francisco shelters, free meal programs, street encampments, and a safety net HIV clinic. Between 2016 and 2019, participants completed 6 monthly interviews, specimen collection, and a transthoracic echocardiogram. We assessed associations between 3 echocardiographic indices of cardiac hypertrophy (concentric hypertrophy, concentric remodeling, and eccentric hypertrophy) and study factors, including cardiovascular risk factors, substance use, and HIV-specific factors (CD4 + count, viral load, HIV medication). Among 62 participants, the average age was 53 years and 70% were ethnic minority women. Just over 70% had elevated blood pressure. Toxicology-confirmed substance use included tobacco (63%), cannabis (52%), cocaine (51%), methamphetamine (29%), and alcohol (26%). Concentric hypertrophy was detected in 26% of participants. It was positively associated with cocaine use [adjusted relative risk (aRR) = 32.5, P < 0.01] and negatively associated with cannabis use (aRR = 0.07, P < 0.01). Concentric remodeling was detected in 40% of participants. It was positively associated with cocaine use (aRR = 11.2, P < 0.01) and negatively associated with cannabis use (aRR = 0.17, P = 0.02). Eccentric hypertrophy was not significantly associated with factors studied here. Routine evaluation of stimulant use as a contributing factor to cardiovascular risk may improve risk assessment in WWH. Whether cannabis use mitigates the impact of cocaine use on structural heart disease among WWH merits further investigation.

Reducing Inequity in the Use of Automated Insulin Delivery Systems by Adults With Type 1 Diabetes: Key Learnings From a Safety Net Diabetes Clinic Program

BackgroundRecent advancements in diabetes technology have significantly improved Type 1 diabetes (T1D) management, but disparities persist, particularly in the adoption of automated insulin delivery (AID) systems within minoritized communities. We aimed to improve patient access to AID system training and overcome clinical inertia to referral. MethodsWe report on a transformative program implemented at Boston Medical Center, the largest safety-net hospital in New England, aimed at reducing disparities in AID system utilization. We employed a multidisciplinary team and quality improvement principles to identify barriers and develop solutions. Strategies included increasing access to diabetes educators, creating a referral system, and developing telemedicine education classes. We also made efforts to raise clinician awareness and confidence in recommending AID therapy. ResultsAt baseline, 13.5% of our clinic T1D population was using an insulin pump. The population referred included 97 people with T1D (49% female, mean A1c 8.7%, 68% public insurance beneficiaries, 25% Hispanic and 25% non-Hispanic Black). Results from the first year showed a 166% increase in AID system use rates, with 64% of referred patients starting on AID. Notably, 78% of patients with A1c >8.5% adopted AID systems, addressing a gap in representation observed in clinical efficacy trials. The initiative successfully narrowed disparities in AID use among minoritized populations. ConclusionsThe program's success among minoritized patients underscores the significance of tailored, collaborative, team-based care and targeted educational initiatives. Our experience provides a foundation for future efforts to ensure equitable access to diabetes technologies, emphasizing the potential of local quality improvement interventions.

Barriers to cervical cancer prevention in a safety net clinic: gaps in HPV vaccine provider recommendation and series completion among Ob/Gyn patients.

The primary objective of this study was to evaluate patients' knowledge regarding HPV vaccination and vaccine uptake in a diverse patient population. The secondary objective was to evaluate factors influencing the decision to vaccinate, potential barriers to vaccination, and to assess whether HPV vaccines were offered to or discussed with eligible patients in a safety net Obstetrics and Gynecology (Ob/Gyn) clinic. A 28-item survey was developed using Likert scale survey questions to assess patient agreement with statements regarding HPV and the vaccine. The surveys were administered to patients in the Ob/Gyn outpatient clinics from May 2021 through September 2022. Additionally, pharmacy data were reviewed and chart review was performed as a quality improvement initiative to assess the impact of expanded HPV vaccine eligibility to patients with private insurance on vaccine uptake. Descriptive statistics were performed. 304 patients completed surveys from May 2021 through September 2022. The median age of respondents was 32 (range 18-80). 16 (5%) were Non-Hispanic White, 124 (41%) were Hispanic White, 58 (19%) were Non-Hispanic Black, 6 (2%) were Hispanic Black, 29 (9.5%) were Haitian, 44 (14%) were Hispanic Other, 7 (2%) were Non-Hispanic Other, 20 (6.6%) did not respond. 45 (14%) patients were uninsured. Many patients (62%) reported that a physician had never discussed HPV vaccination with them. Seventy nine percent of patients reported they had never received the HPV vaccine, and 69% of patients reported that lack of a medical provider recommendation was a major barrier. Among patients to whom HPV vaccination had been recommended, 57% reported that the vaccine was not available the same day in clinic. Our study demonstrated that many patients never had a provider discuss HPV vaccination with them and never received the HPV vaccine. Additionally, amongst those who did initiate HPV vaccination, completion of the series remains a key barrier. Ensuring that providers discuss HPV vaccination and that patients receive HPV vaccines, along with expanding access to and convenience of HPV vaccination are critical aspects of preventing cervical cancer.

Evaluation of a human papillomavirus vaccination training implementation in clinical and community settings across different clinical roles.

Improving human papillomavirus (HPV) vaccination is a national priority but uptake declined following the coronavirus pandemic. A strong predictor of HPV vaccination in the USA is a strong provider recommendation. Therefore, we developed a brief, asynchronous training on HPV vaccine recommendations in clinical and community settings as part of a multisite quality improvement initiative. This paper aims to describe the implementation and initial outcomes of the training provided. A 20-minute training on HPV vaccine bundled recommendations, motivational interviewing, and brief responses to patient concerns (Communicating about HPV vaccination to Adults and Teens; HPV CHAT) was implemented at seven safety-net clinics, two practice-based research network clinics, and nine county immunization clinics. We integrated training with clinical care teams; thus, we assessed immediate training outcomes across their different clinical roles compared to pre-training. In April-May 2022, HPV CHAT training was launched. One hundred eighty-seven people participated in the training and completed the pre-/postevaluation surveys. Knowledge about the HPV vaccine guidelines improved with notable changes in correctly reporting vaccine eligibility (P < .05). A significant change in participants' confidence when addressing safety concerns and answering questions about the HPV vaccine (clinicians, 26.8% and 17.1%; nurses, 29.0% and 23.2%, and clinical staff, 18.2% and 37.7%) was observed. At post-test, more than 85% of clinicians and nurses reported their plan to routinely recommend the HPV vaccine. This quality improvement initiative demonstrated implementation feasibility of a brief HPV vaccine training that improved provider and clinical staff knowledge, confidence, and intention to routinely recommend HPV vaccination.

“Don't fuss at our staff”: A moral economy of volunteerism in South Carolina safety net clinics

In South Carolina, a state that has foregone Medicaid expansion, working poor residents often rely on safety net clinics for medical care. This care often occurs far from major hospitals, in different, inferior, spaces where limited services are provided in lesser circumstances. The temporary and conditional aid provided in these clinics is meant as a last resort, but often serves as the only source of care for many working poor patients, who must manage the effects of sustained precarity and protracted immiseration with conditional aid provided by volunteers. Here I explore the function that volunteering plays in regulating patients' utilization, and ability to contest, the quality of safety net care. Using ethnographic examples and interview data I show how the needs of patients—referred to in the clinics as “clients”—are managed and contained by a moral economy of volunteer care. These reciprocal obligations of debt and duty preclude working poor patients from making demands of, or lodging complaints against, the free clinics' staff, due to their capacity as volunteers, and leaves the state's safety net effectively unassailable to accusations of inefficacy or neglect. Consequently, patients must defer care, ignore episodes of maltreatment, and ration and share prescription medications, lest they be considered recusant or deemed not sufficiently appreciative of the volunteer staff dedicating their time to them. As a result of this moral economy, the plight of the state's uninsured working poor residents goes under-recognized as the safety net absorbs their cases, hiding the attritional nature of the ostensibly free care they receive and ration.

Patient experiences with prenatal cell-free DNA screening in a safety net setting.

Thirty-five states, including Florida, now cover cell-free DNA (cfDNA) screening of fetuses for all pregnant patients enrolled in state public insurance programs. We interviewed Black and Hispanic obstetric patients at a safety net clinic in Florida shortly after the state rolled out cfDNA as a first-tier screening method for publicly insured patients. Black and Hispanic patients receiving prenatal care from a prenatal or maternal fetal medicine clinic at a federally qualified health center in Jacksonville, FL were invited to participate in a qualitative interview in English or Spanish to explore experiences and perceptions of prenatal cfDNA screening. Participants were recruited following their first prenatal visit when cfDNA is typically introduced. Interview transcripts were qualitatively analyzed for iterative themes based on principles of grounded theory. One hundred Black and Hispanic patients (n=51 non-Hispanic Black, n=43 Hispanic, n=3 Hispanic Black, n=3 Not Reported/Other) completed an interview. Participants described minimal opportunity for pre-screening counseling and limited health literacy about cfDNA or its uses. Some believed that cfDNA could positively impact pregnancy health. Many were unsure if they had received cfDNA even though they were aware of the information provided by it. Most participants expressed an interest in cfDNA as a means for early detection of fetal sex and as an additional indication of general fetal health. Patient experiences indicate limited informed consent and decision-making for cfDNA, discordant with professional guidelines on pre-screen counseling. Our findings suggest that there should be additional investment in implementing cfDNA in safety net settings to ensure that patients and providers receive the support necessary for effective patient counseling and follow-on care for the ethical implementation of cfDNA.

Identifying virtual care modality in electronic health record data.

Virtual care increased dramatically during the COVID-19 pandemic. The specific modality of virtual care (video, audio, eVisits, eConsults, and remote patient monitoring) has important implications for the accessibility and quality of care, but rates of use are relatively unknown. Methods for identifying virtual care modalities, especially in electronic health records (EHR) are inconsistent. This study (a) developed a method to identify virtual care modalities using EHR data and (b) described the distribution of these modalities over a 3-year study period. EHR data from 316 primary care safety net clinics throughout the study period (4/1/2020-3/31/2023) were included. Visit type (in-person vs virtual) by adults >18 years old were classified. Expert consultation informed the development of two algorithms to classify virtual care visit modalities; these algorithms prioritized different EHR data elements. We conducted descriptive analyses comparing algorithms and the frequency of virtual care modalities. Agreement between the algorithms was 96.5% for all visits and 89.3% for virtual care visits. The majority of disagreement between the algorithms was among encounters scheduled as audio-only but billed as a video visit. Restricting to visits where the algorithms agreed on visit modality, there were 2-fold more audio-only than video visits. Visit modality classification varies depending upon which data in the EHR are prioritized. Regardless of which algorithm is utilized, safety net clinics rely on audio-only and video visits to provide care in virtual visits. Elimination of reimbursement for audio visits may exacerbate existing inequities in care for low-income patients.

Association Between Substance Abuse and Mental Illness Symptoms Screener (SAMISS) Scores and HIV Care Continuum Outcomes in People Newly Diagnosed with HIV in the US South.

Mental illness (MI) and substance use (SU) are highly prevalent among people with HIV (PWH) and impact care outcomes. The Substance Abuse and Mental Illness Symptoms Screener (SAMISS) is a validated screener for MI and SU, but it is unknown how screening results at entry to care correlate with subsequent HIV outcomes. This is a retrospective chart review of individuals newly diagnosed with HIV between 2016 and 2019 in a Southern US, safety-net clinic. Baseline demographics, HIV risk factors, socioeconomic variables, and SAMISS screening scores were collected. Outcomes included retention in care, achieving virologic suppression (VS), and continuous VS. Data analyses included stepwise Cox and logistic multivariate regression modeling. Among the 544 newly diagnosed PWH, mean age was 35, 76% were male, 46% non-Hispanic Black, 40% Hispanic/other. Overall, 35% screened positive for SU and 41% for MI. A positive SU (odds ratio (OR) 0.66, p = 0.04) or MI (OR 0.65, p = 0.03) SAMISS screening was associated with lower retention in care in univariate analysis, but was not statistically significant after adjusting for other variables. Positive SAMISS screening for SU and MI were both associated with reduced continuous VS in univariate and multivariate analyses (SU: adjusted OR (aOR) 0.67, p = 0.05; MI: aOR 0.66, p = 0.03). SAMISS is a useful tool for prospectively identifying individuals at risk for low retention in care and for not achieving sustained VS. Future interventions guided by SAMISS may improve HIV care continuum outcomes.

Determining a urinary-specific antibiogram and risk factors of trimethoprim/sulfamethoxazole, ciprofloxacin and multidrug resistance among Enterobacterales in primary care.

Risk factors for ciprofloxacin or MDR in primary care urine specimens are not well defined. We created a primary care-specific antibiogram for Escherichia coli isolates from cases with complicated and uncomplicated urinary tract infection (UTI) and evaluated risk factors for ciprofloxacin, trimethoprim/sulfamethoxazole and MDR among Enterobacterales. We conducted a cross-sectional study to determine resistance and risk factors by collecting urine cultures from all patients (≥18 years) presenting with provider-suspected UTI at two primary care, safety-net clinics in Houston, TX, USA between November 2018 and March 2020. Among 1262 cultures, 308 cultures grew 339 uropathogens. Patients with Enterobacterales (n = 199) were mostly female (93.5%) with a mean age of 48.5 years. E. coli was the predominant uropathogen isolated (n = 187/339; 55%) and had elevated trimethoprim/sulfamethoxazole (43.6%) and ciprofloxacin (29.5%) resistance, low nitrofurantoin (1.8%) resistance, and no fosfomycin resistance. Among E. coli, 10.6% were ESBL positive and 24.9% had MDR. Birth outside the U.S.A., prior (2 year) trimethoprim/sulfamethoxazole resistance, and diabetes mellitus were associated with trimethoprim/sulfamethoxazole resistance. Prior (60 day) fluoroquinolone use, prior ciprofloxacin resistance and both diabetes mellitus and hypertension were strongly associated with ciprofloxacin resistance. Prior fluoroquinolone use and a history of resistance to any studied antibiotic were associated with MDR, while pregnancy was protective. We found elevated resistance to UTI-relevant antimicrobials and novel factors associated with resistance; these data can be incorporated into clinical decision tools to improve organism and drug concordance.

Lower PrEP Retention among Young and Black Clients Accessing PrEP at a Cluster of Safety Net Clinics for Gay and Bisexual Men.

Young men of color who have sex with men are vulnerable to HIV and experience poor PrEP uptake and retention. We conducted a secondary data analysis and calculated adjusted Prevalence Odds Ratios (aPORs) for PrEP retention along with 95% CIs at 90, 180, and 360 days at an organization running safety net clinics in Texas for gay and bisexual men. We found statistically significant association with age, race, in-clinic versus telehealth appointments, and having healthcare insurance. White clients had an aPOR of 1.29 [1.00, 1.67] as compared to Black clients at 90 days. Age group of 18-24 had a lower aPOR than all other age groups except 55 or older at all three time periods. Clients who met providers in person had an aPOR of 2.6 [2.14, 3.19] at 90, 2.6 [2.2, 3.30] at 180 days and 2.84 [2.27, 3.54] at 360 days. Our findings highlight the need for population-specific targeted interventions.

Building Authentic Connection in the Patient-Physician Relationship.

Delivering optimal patient care is impacted by a physician's ability to build trusting relationships with patients. Identifying techniques for rapport building is important for promoting patient-physician collaboration and improved patient outcomes. This study sought to characterize the approaches highly skilled primary care physicians (PCPs) use to effectively connect with diverse patients. Using an inductive thematic analysis approach, we analyzed semi-structured interview transcripts with 10 PCPs identified by leadership and/or colleagues for having exceptional patient communication skills. PCPs practiced in 3 diverse clinic settings: (1) academic medical center, (2) Veterans Affairs clinic, and (3) safety-net community clinic. The thematic analysis yielded 5 themes that enable physicians to establish connections with patients: Respect for the Patient, Engaged Curiosity, Focused Listening, Mutual Participation, and Self-Awareness. Underlying all of these themes was a quality of authenticity, or a state of symmetry between one's internal experience and external words and actions. Adopting these communication techniques while allowing for adaptability in order to remain authentic in one's interactions with patients may facilitate improved connection and trust with patients. Encouraging physician authenticity in the patient-physician relationship supports a shift toward relationship-centered care. Additional medical education training is needed to facilitate authentic connection between physicians and patients.

Situations predisposing primary care patients to use antibiotics without a prescription in the United States.

Patients' situations can impact their intentions to use antibiotics without medical guidance (non-prescription use) in the future. This survey determines the prevalence of intended (future) use of non-prescription antibiotics for 13 predefined situations and identifies the sociodemographic characteristics associated with intended use for these types of situations. Patient surveys (N = 564) were conducted from January 2020 to June 2021 in the waiting rooms of 6 safety-net primary care clinics and 2 emergency departments in a private healthcare system. We used principal component analysis to identify 3 situational summary factors: barriers to a doctor visit, accessibility of non-prescription antibiotics, and previous symptom relief with antibiotics. Multivariate linear regression identified the sociodemographic predictors associated with each summary factor. The most common situations triggering patients to use non-prescription antibiotics were a perceived high cost of doctor visits (29.8%), having leftover prescription antibiotics (50.4%), and experiencing symptom relief with prior use of antibiotics (47.5%). Multivariate regression results revealed that younger patients (P < 0.04) and patients attending the safety-net health system (P < 0.001) had more intended use of non-prescription antibiotics for all 3 summary factors. Future stewardship interventions should consider the types of situations that drive patients' decisions to use antibiotics without a prescription. Interventions aimed at reducing barriers to health care (eg, high costs and long waits associated with doctor appointments) and educating individuals on medically appropriate, nonantibiotic treatment options may reduce antibiotic use and antimicrobial resistance.

Effectiveness-implementation hybrid trial of Spanish language, digital cognitive-behavioral therapy (dCBT) intervention for depression and anxiety – protocol for the SUPERA (SUpport from PEeRs to expand Access) study

BackgroundLimited English Proficiency (LEP) Latinxs experience a longer duration of untreated depression and anxiety. LEP Latinxs have difficulty accessing mental healthcare due to insufficient Spanish-speaking behavioral/mental health clinicians to meet demand. These under-resourced healthcare systems are less likely to be the site for the implementation of innovations. Digital interventions can provide an effective option for overcoming these barriers; yet, when digital evidence-based treatments are available, uptake and engagement is often low. This manuscript presents the protocol for the SUPERA (SUpport from PEeRs to expand Access) study which will evaluate the implementation of an evidence-based, Spanish language, digital cognitive-behavioral therapy (dCBT) intervention (i.e., SilverCloud) in safety-net primary care clinics for LEP Latinx patients with depression or anxiety. MethodsWe will conduct an effectiveness-implementation hybrid trial (Type 2) design comparing engagement and clinical outcomes in two modalities of dCBT delivery (peer-supported vs. unsupported). We will also compare provider-level outreach (using a clinic patient registry) versus inreach (traditional provider referral) to compare rates of initiation, completion, and cost. Participants will be 426 LEP Latinx adults ≥18 years of age, PHQ-9 ≥ 10 or GAD-7 ≥ 8, with access to the internet via smartphone, and not currently receiving individual psychotherapy. We will collect baseline, post-intervention (8 weeks), and follow up (3 months) data. ConclusionThe long-term goal of this research is to aid in the implementation of digital mental health interventions that can be sustainably implemented in low-resourced settings, while reducing the reliance on professionals, overcoming workforce deficits, and increasing relevance for diverse populations.

COMPARING IN-PERSON ONLY, TELEMEDICINE ONLY, AND HYBRID HEALTH CARE VISITS AMONG OLDER ADULTS IN SAFETY-NET CLINICS

Abstract Introduction Older adults face challenges in seeking healthcare. This study examined factors associated with in-person only versus telemedicine only versus hybrid healthcare visits among adults 65+ in safety-net clinics. Methods Data was obtained from a large Texas-based Federally Qualified Health Center (FQHC) network. The dataset included 12,279 appointments for 3,914 unique older adults between March and November 2020. The outcome of interest was a 3-level indicator of telemedicine visits: in-person visits only, telemedicine visits only, and hybrid (In person + Telemedicine) visits during the study period. We used a multinomial logit model adjusting for patient-level characteristics to assess the strength of the relationships. Results Compared to their white counterparts, Black and Hispanic older adults were significantly likely to have telemedicine only visits vs in-person only visits (Black RR: 0.59, 95% CI 0.41-0.86; Hispanic RR: 0.46, 95% CI 0.36-0.60). However, there were no significant racial and ethnic differences in hybrid utilization (Black RR: 0.91, 95% CI 0.67-1.23; Hispanic RR: 0.86, 95% CI 0.70-1.07). Discussion Our findings suggest that hybrid opportunities may bridge racial and ethnic disparities in access to care. Clinics should consider building capacity for both in-person and telemedicine opportunities as complementary strategies.

EVALUATE THE IMPACT OF INTERDISCIPLINARY EDUCATION AND TELEHEALTH PRIMARY CARE: QUALITY AND EFFICIENCY

Abstract In a provider shortage area, an Interprofessional Education and Telehealth Primary Care (IPETC) for geriatrics workforce was developed in 2020. To analyze the impact of IPETC on quality and efficiency of care, we measured quality outcomes defined by the CMS defined quality measures - dementia caregiver education/referral and advance care plan, and efficiency outcomes by estimating healthcare cost savings from reducing hospitalization. Two-hundred forty-four community-dwelling adults aged 60 to 97 with mild to moderate dementia were selected in an urban safety-net primary care clinic. Propensity - demographics and comorbidity was matched. Main outcomes were (A) number of hospitalization and 90-day rehospitalization rate, hospitalization-related healthcare cost estimates from the State Inpatient Dataset using the ICD-10 codes of principal diagnosis and hospital length of stay between January-December 2021. One-hundred twenty-two patients were cared by primary care providers who received the IPETC;122 patients were by those who did not have the IPETC; (2) CMS quality measures were compared between 2019 (baseline) and 2021 of patients cared by providers with IPETC. Number of hospitalization with IPETC was fewer than those without IPETC (0.72 vs. 1.38, p &amp;lt; .01). Number of 90-day rehospitalization with IPETC was fewer than those without IPETC (0.14 vs. 0.30, p &amp;lt; .01). An average cost-saving of $20,289 per patient was observed among those with IPETC than those without IPETC (p &amp;lt; .001). CMS quality measures improved from 15.6% to 51.0% in dementia caregiver education/referral; 10.2% to 24.7% in documented advance care plans.

EVALUATE THE IMPACT OF INTERDISCIPLINARY EDUCATION AND TELEHEALTH PRIMARY CARE: QUALITY AND EFFICIENCY

Abstract In a provider shortage area, an Interprofessional Education and Telehealth Primary Care (IPETC) for geriatrics workforce was developed in 2020. To analyze the impact of IPETC on quality and efficiency of care, we measured quality outcomes defined by the CMS defined quality measures - dementia caregiver education/referral and advance care plan, and efficiency outcomes by estimating healthcare cost savings from reducing hospitalization. Fifty eight community-dwelling adults aged 67 to 94 with mild to moderate dementia were selected in an urban safety-net primary care clinic. Propensity - demographics and level of physical impairment was matched. Main outcomes were (A) hospitalization-related healthcare cost estimates from the State Inpatient Dataset using the ICD-10 codes of principal diagnosis and hospital length of stay between January-December 2021. Twenty nine patients were cared by primary care providers who received the IPETC;29 patients were by those who did not have the IPETC; (2) CMS quality measures were compared between 2019 (baseline) and 2021. An average cost-saving of $22,135 per patient was observed among those treated by the healthcare providers who received the IPE/telehealth curriculum training than those treated by the providers without the training. CMS quality measures improved from 15.6% to 51.0% in dementia caregiver education/referral; 10.8% to 42.8% in documented advance care plans. Innovative interdisciplinary education and telehealth primary care has shown improvement of quality and efficiency of dementia care in a provider shortage area.

The impact of primary care access on autism spectrum disorder awareness in an underserved population.

American Academy of Pediatrics (AAP) recommendations for Autism Spectrum Disorder (ASD) screening do not specifically address safety-net clinics, which provide multidisciplinary healthcare services to underserved patients. This project explored the potential for ASD screening in safety-net clinics by assessing parental perceived knowledge of ASD at JayDoc Free Clinic, a student-run safety-net clinic in Wyandotte County, Kansas. May through December 2022, patients who reported to be the parent of a minor received a demographic survey and a Likert-style questionnaire assessing perceived knowledge of ASD, including understanding the importance of ASD screening and ASD signs and symptoms. Responses were categorized into positive, negative, and unsure. Demographic variables included the minor's primary care provider (PCP) status. Results were analyzed using bivariate analysis, with chi-square tests for significance (p-value ≤ 0.05). Of the 52 participants who completed at least one Likert response, 55.8% reported their child had a PCP. Responses were somewhat balanced with 44.2% positive for understanding the importance of ASD screening and 53.8% positive for understanding ASD signs and symptoms. For understanding the signs and symptoms of ASD, an unsure response (32.7% of responses) was statistically associated with a lack of PCP (p = 0.017). The balance of positive with negative and unsure responses could reflect lack of ASD knowledge and may relate to healthcare inaccessibility. This is consistent with the significant association between lack of PCP and unsure responses for understanding ASD signs and symptoms. ASD screening and education in safety-net clinics like JayDoc could be valuable, particularly for children without a PCP.

Abstract IA020: Adaptation of provider and staff targeted evidence-based interventions in safety-net settings to achieve equitable HPV vaccination

Abstract Implementation science, conducted through a health equity lens and participatory stakeholder-engaged approach, can inform how to best to adapt and sustain interventions within safety-net settings (e.g., federally qualified health centers, hospital-affiliated clinics, county health systems reaching medically underserved communities) to achieve long-term cancer health equity. The current challenge in implementation science and cancer health equity is not a lack of knowledge about what works for cancer prevention and control improvement, but how to integrate, adapt and sustain effective evidence-based strategies (EBS) and tools into local community and clinic contexts where they are needed most. As an example, HPV vaccination rates remain below target levels among adolescents in the United States, which is particularly concerning in medically underserved with persistent disparities in HPV-associated cancer burden. There are numerous evidence-based strategies designed to improve HPV vaccination, but few are routinely used, much less sustained in safety-net settings. Significant disruptions due to the COVID-19 pandemic further support the need to understand implementation context and processes for implementation needs of EBS for HPV vaccination in safety-net clinics. This educational session presentation focuses on how to advance adaptation and fit of EBS for HPV vaccination improvement in diverse contexts and settings for medically underserved populations with the broader goal of addressing cancer health equity through implementation science. We share our work in understanding the perspectives of stakeholders serving diverse communities in an NCI-funded HPV vaccine implementation study. We demonstrate the need for EBS and implementation processes to be tailored to the local context, community needs, and engaged with key clinic leadership and implementors throughout. From the multi-site FQHC demonstration phase of our study, we assess ongoing adaptation of EBS (provider trainings, clinic staff education, workflow assessment, and audit and feedback) and implementation processes at multiple levels (broader system, individual clinic sites, providers and staff). We also systematically integrate relevant structural and social determinants into interventions to meet the needs of diverse communities. Adaptation to clinical contexts as well as current HPV vaccination content (e.g. age 9, addressing vaccine hesitancy, community-specific concerns) are necessary to maximize fit and sustainability. Findings from these examples can inform adaptation requirements of implementing evidence-based strategies to address cancer health equity for other cancer sites and cancer prevention targets. Further, this educational session informs a broader understanding of resources and processes needed to sustain EBS for HPV vaccination over time and research needs within the intersection of implementation science and cancer health equity. Citation Format: Jennifer Tsui, Samantha Garcia, Michelle B. Shin, Kylie Sloan, Emily Dang, Lourdes Baezconde-Garbanati, Lawrence Palinkas, Benjamin F. Crabtree. Adaptation of provider and staff targeted evidence-based interventions in safety-net settings to achieve equitable HPV vaccination [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr IA020.

Clinical Factors Associated with Cognitive Impairment and Dementia Among Patients Experiencing Homelessness

AbstractBackgroundThe population of people experiencing homelessness (PEH) is aging; Half of PEH are now 50 years old or older. Cognitive impairment among PEH is thought to occur earlier, at higher prevalence, and progress faster than in the general population. Homelessness and associated marginalized conditions pose substantial barriers to care of people with cognitive impairment or dementia.MethodWe examined the prevalence of cognitive impairment, dementia, and clinical factors associated with these diagnoses among PEH seen between 7/1/2019‐5/31/2022 in a San Francisco safety net clinic. Medical record data for those who accessed services targeting homeless adults was retained for analysis. We analyzed the data using chi‐squared, T‐tests, and adjusted regression on select variables.ResultAmong 8,387 adults who experienced homelessness, 326 (3.9%) had a diagnosis indicating cognitive impairment or dementia. Of these, the majority (303, 92.9%) had non‐specific diagnoses, such as “cognitive impairment” (207, 2.5%), problems with “cognitive function” (19, 0.2%), or “memory issues” (77, 0.9%). 114 had specific diagnoses such as dementia (74, 0.9%), Alzheimer’s (6, 0.1%), or neurocognitive disorder (34, 0.4%). Some diagnoses overlapped (e.g. “cognitive impairment” and “dementia” were coded for one patient.) More of those with dementia or cognitive impairment had HIV, diabetes, hypertension, depression and/or anxiety, alcohol‐use disorder, and prior TBI. Those with dementia/cognitive impairment were more likely to be male and older (Table 1). More of those with dementia/cognitive impairment were white, Black, or Asian/Pacific Islander, and fewer were Latinx. Since their last clinical encounter, more of those with dementia/cognitive impairment died. In adjusted regression, the difference in hypertension, depression/anxiety, alcohol use disorder, TBI, gender, and mortality remained significant (p&lt;0.05).ConclusionPrevalence of dementia and cognitive impairment in this patient cohort is lower than has been previously estimated in PEH (4% vs up to 25%). Non‐specific diagnoses were more commonly recorded, suggesting under‐identification and under‐diagnosis in non‐research conditions. Those with dementia or cognitive impairment diagnoses had more chronic disease and psychiatric illness, and higher mortality than those without any diagnosis. Better identification of those with cognitive impairment and dementia among PEH can help define areas of focus in the care of these marginalized individuals.