Safety Net Clinics Research Articles

Integrating Mental Health in Safety-net Primary Care: A Five-year Observational Study on Visits in a County Health System.

Beginning in 2010, Los Angeles County Departments of Health Services and Mental Health collaborated to increase access to effective mental health care. The Mental Health Integration Program (MHIP) embedded behavioral health specialists in primary care clinics to deliver brief, problem-focused treatments, and psychiatric consultation support for primary care-prescribed psychotropic medications. The aim was to compare primary care visits associated with psychiatric diagnoses before and after MHIP implementation. This retrospective cohort study (2009-2014) examined 62,945 patients from 8 safety-net clinics that implemented MHIP in a staggered manner in Los Angeles. Patients' primary care visits (n=695,354) were either associated or not with a previously identified or "new" (defined as having no diagnosis within the prior year) psychiatric diagnosis. Multilevel regression models used MHIP implementation to predict odds of visits being associated with psychiatric diagnoses, controlling for time, clinic, and patient characteristics. 9.4% of visits were associated with psychiatric diagnoses (6.4% depression, 3.1% anxiety, <1% alcohol, and substance use disorders). Odds of visits being associated with psychiatric diagnoses were 9% higher [95% confidence interval (CI)=1.05-1.13; P<0.0001], and 10% higher for diagnoses that were new (CI=1.04-1.16; P=0.002), after MHIP implementation than before. This appeared to be fueled by increased visits for depression post-MHIP (odds ratio=1.11; CI=1.06-1.15; P<0.0001). MHIP implementation was associated with more psychiatric diagnoses coded in safety-net primary care visits. Scaling up this effort will require greater attention to the notable differences across patient populations and languages, as well as the markedly low coding of alcohol and substance use services in primary care.

The data-collection on adverse effects of anti-HIV drugs (D:A:D) model for predicting cardiovascular events: External validation in a diverse cohort of people living with HIV.

ObjectivesLittle is known about the external validity of the Data‐collection on Adverse Effects of Anti‐HIV Drugs (D:A:D) model for predicting cardiovascular disease (CVD) risk among people living with HIV (PLWH). We aimed to evaluate the performance of the updated D:A:D model for 5‐year CVD risk in a diverse group of PLWH engaged in HIV care.MethodsWe used data from an institutional HIV registry, which includes PLWH engaged in care at a safety‐net HIV clinic. Eligible individuals had a baseline clinical encounter between 1 January 2013 and 31 December 2014, with follow‐up through to 31 December 2019. We estimated 5‐year predicted risks of CVD as a function of the prognostic index and baseline survival of the D:A:D model, which were used to assess model discrimination (C‐index), calibration and net benefit.ResultsOur evaluable population comprised 1029 PLWH, of whom 30% were female, 50% were non‐Hispanic black, and median age was 45 years. The C‐index was 0.70 [95% confidence limits (CL): 0.64–0.75]. The predicted 5‐year CVD risk was 3.0% and the observed 5‐year risk was 8.9% (expected/observed ratio = 0.33, 95% CL: 0.26–0.54). The model had a greater net benefit than treating all or treating none at a risk threshold of 10%.ConclusionsThe D:A:D model was miscalibrated for CVD risk among PLWH engaged in HIV care at an urban safety‐net HIV clinic, which may be related to differences in case‐mix and baseline CVD risk. Nevertheless, the HIV D:A:D model may be useful for decisions about CVD intervention for high‐risk patients.

Factors associated with smoking in low-income persons with and without chronic illness.

INTRODUCTIONTobacco disparities persist among low-income smokers who seek care from safety-net clinics. Many of these patients suffer from chronic illnesses (CILs) that are associated with and exacerbated by smoking. The objective of the current study was to examine the differences between safety-net patients with and without CILs in terms of nicotine dependence and related factors (such as depression, anxiety) and self-efficacy regarding ability to abstain from smoking.METHODSSixty-four low-income smokers who thought about or intended to quit smoking were recruited from the San Francisco Health Network (SFHN) and assessed for CILs, nicotine dependence, depression, anxiety, and smoking abstinence self-efficacy. Four one-way analyses of variance were used to examine the difference between those with and without CIL on the latter four variables.RESULTSThe CIL group had significantly higher anxiety (CIL: 8.0 ± 5.35; non-CIL: 4.44 ± 3.48; p=0.02) and tended to have higher nicotine dependence (CIL: 5.40 ± 2.58; non-CIL: 3.88 ± 2.28; p=0.04). In the CIL group, nicotine dependence was positively correlated with anxiety [r(62)=0.39; p<0.01] and negatively correlated with smoking abstinence self-efficacy [r(62)= -0.38; p<0.01]. Both depression (Spearman’s rho=0.39; p<0.01) and anxiety (Spearman’s rho=0.29; p<0.05) were associated with total number of CIL categories.CONCLUSIONSSafety-net patients who smoke and suffer from CILs may be suffering from higher levels of anxiety and have less confidence in their ability to quit smoking. Incorporating mood management and developing interventions that increase a sense of self-efficacy for refraining from smoking may be necessary to help low-income smokers quit smoking.

Influence of payer coverage and out-of-pocket costs on ordering of NGS panel tests for hereditary cancer in diverse settings.

The landscape of payment for genetic testing has been changing, with an increase in the number of laboratories offering testing, larger panel offerings, and lower prices. To determine the influence of payer coverage and out-of-pocket costs on the ordering of NGS panel tests for hereditary cancer in diverse settings, we conducted semi-structured interviews with providers who conduct genetic counseling and order next-generation sequencing (NGS) panels purposefully recruited from 11 safety-net clinics and academic medical centers (AMCs) in California and North Carolina, states with diverse populations and divergent Medicaid expansion policies. Thematic analysis was done to identify themes related to the impact of reimbursement and out-of-pocket expenses on test ordering. Specific focus was put on differences between settings. Respondents from both safety-net clinics and AMCs reported that they are increasingly ordering panels instead of single-gene tests, and tests were ordered primarily from a few commercial laboratories. Surprisingly, safety-net clinics reported few barriers to testing related to cost, largely due to laboratory assistance with prior authorization requests and patient payment assistance programs that result in little to no patient out-of-pocket expenses. AMCs reported greater challenges navigating insurance issues, particularly prior authorization. Both groups cited non-coverage of genetic counseling as a major barrier to testing. Difficulty of access to cascade testing, particularly for family members that do not live in the United States, was also of concern. Long-term sustainability of laboratory payment assistance programs was a major concern; safety-net clinics were particularly concerned about access to testing without such programs. There were few differences between states. In conclusion, the use of laboratories with payment assistance programs reduces barriers to NGS panel testing among diverse populations. Such programs represent a major change to the financing and affordability of genetic testing. However, access to genetic counseling is a barrier and must be addressed to ensure equity in testing.

Abstract 549: Genomic characterization and monitoring molecular response to treatment in African American (AA) advanced prostate cancer (PC) patients (pts) via next-generation sequencing (NGS): Real-world experience in a safety net hospital Oncology clinic

Abstract Background: AA men have higher PC incidence and mortality than white men. Healthcare access and other socioeconomic factors contribute to these disparities. The high cost of NGS can become an additional factor for disparity. Indeed, minority and uninsured pts were underrepresented in prior NGS studies and NGS-based Precision Oncology clinical trials. Methods: Ben Taub Hospital (BTH) is a safety net hospital serving a racially/ethnically diverse pt population (91% minorities). We retrospectively analyzed NGS data obtained via Tempus|xT tissue assay (DNA sequencing of 648 genes in tumor tissue at 500x depth) and/or Tempus|xF liquid biopsy assay (ctDNA sequencing of 105 genes at 5,000x depth) for germline and/or somatic mutations detected in 117 BTH pts [61 self-identified AA and 56 white (including white Hispanic)] receiving treatment for locally advanced, biochemically recurrent or metastatic PC. We also analyzed de-identified NGS data from a nationwide cohort of 2090 metastatic PC pts (225 AA) previously sequenced with xT and/or xF by Tempus Labs (Chicago, IL). Results: AA BTH PC pts exhibited high frequencies of BRCA2 (14.8%), SPOP (19.7%), AR (16.4%) and TP53 (49.1%) mutations (respective frequencies in white BTH pts were 9%, 7%, 3.6% and 12.5%). TMPRSS2 fusions were less frequent in AA than white pts. Upon treatment with active therapy (hormonal or taxane), the allele frequency of PC-derived ctDNA mutations in the liquid biopsy declined significantly and concordantly to the biochemical (PSA) response. In addition, two out of 61 (3.3%) AA BTH PCs had microsatellite instability [a frequency comparable to that seen in white BTH PC pts (3.6%) and in the nationwide Tempus Labs cohort (3.6% of AA PC pts)], and experienced prompt and durable clinical, biochemical and molecular responses to pembrolizumab, including disappearance of PC-derived mutant ctDNA. On the other hand, four AA PC pts who had progressed on abiraterone or enzalutamide with ctDNA findings of AR mutations previously reported as sensitive in vitro to the newest FDA-approved AR antagonist darolutamide, did not achieve clinical or biochemical response on darolutamide treatment and that was paralleled by lack of molecular (ctDNA fraction) response. Conclusions: The high mutation frequency in key PC drivers in AA pts at our safety net hospital can be attributed to underlying disease biology or the more advanced disease at presentation in AA pts with socioeconomic factors delaying access to healthcare. Wide use of NGS testing is necessary to improve early access of underserved minority populations to novel targeted therapies and to biomarker-based Precision Oncology clinical trials. Liquid biopsy is a minimally invasive tool that allows longitudinal monitoring of response (or lack thereof) to treatment. Citation Format: Tamer Khashab, Salma Kaochar, Alexander D. Le, Samantha Cohen, Attiya B. Noor, Heidi Dowst, Neda Zarrin-Khameh, Michael A. Brooks, Guilherme Godoy, Maria A. Berezina, Anna E. Schwarzbach, Michael E. Scheurer, Martha P. Mims, Nicholas Mitsiades. Genomic characterization and monitoring molecular response to treatment in African American (AA) advanced prostate cancer (PC) patients (pts) via next-generation sequencing (NGS): Real-world experience in a safety net hospital Oncology clinic [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 549.

Optimizing Urine Collection Represents an Important Stewardship Opportunity in Primary Care

Background: Urine cultures are the most common microbiological tests in the outpatient setting and heavily influence treatment of suspected urinary tract infections (UTIs). Antibiotics for UTI are usually prescribed on an empiric basis in primary care before the urine culture results are available. However, culture results may be needed to confirm a UTI diagnosis and to verify that the correct antibiotic was prescribed. Although urine cultures are considered as the gold standard for diagnosis of UTI, cultures can easily become contaminated during collection. We determined the prevalence, predictors, and antibiotic use associated with contaminated urine cultures in 2 adult safety net primary care clinics. Methods: We conducted a retrospective chart review of visits with provider-suspected UTI in which a urine culture was ordered (November 2018–March 2020). Patient demographics, culture results, and prescription orders were captured for each visit. Culture results were defined as no culture growth, contaminated (ie, mixed flora, non-uropathogens, or ≥3 bacteria isolated on culture), low-count positive (growth between 100 and 100,000 CFU/mL), and high-count positive (&gt;100,000 CFU/mL). A multivariable multinomial logistic regression model was used to identify factors associated with contaminated culture results. Results: There were 1,265 visits with urine cultures: 264 (20.9%) had no growth, 694 (54.9%) were contaminated, 159 (12.6%) were low counts, and 148 (11.7%) were high counts. Encounter-level factors are presented in Table 1. Female gender (adjusted odds ratio [aOR], 15.8; 95% confidence interval [CI], 10.21–23.46; P &lt; .001), pregnancy (aOR, 13.98; 95% CI, 7.93–4.67; P &lt; .001), and obesity (aOR, 1.9; 95% CI 1.31–2.77; P &lt; .001) were independently associated with contaminated cultures. Of 264 patients whose urine cultures showed no growth, 36 (14%) were prescribed an antibiotic. Of 694 patients with contaminated cultures, 153 (22%) were prescribed an antibiotic (Figure 1). Conclusions: More than half of urine cultures were contaminated, and 1 in 5 patients were treated with antibiotics. Reduction of contamination should improve patient care by providing a more accurate record of the organism in the urine (if any) and its susceptibilities, which are relevant to managing future episodes of UTI in that patient. Optimizing urine collection represents a diagnostic stewardship opportunity in primary care.Funding: This study was supported by the National Institute of Allergy and Infectious Diseases of the National Institutes of Health (grant no. UM1AI104681). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.Disclosures: None

Improving Access to Care for Adults with Sickle Cell Disease in Los Angeles County

Introduction: In 2005 the life expectancy for adults with sickle cell disease (SCD) in Los Angeles (LA) county was 35-38 years (Powars 2005), lower than the national average. Lack of access to care was a significant factor in these early deaths. By comparison, the lifespan of patients in the UK National Health Service is much longer (Gardner 2016). In 2009 the only comprehensive adult sickle cell program in LA outside the Kaiser system closed. The California Department of Public Health found that 51% of the adults in CA with SCD live in LA county (Paulukonis 2014). Thus the majority of the 1500 adults living in the largest county in the US have had no access to comprehensive care for over 7 years. The problem is especially acute in southern LA county where many of the adults reside. The dearth of programs for adults drives them to seek recurrent care in emergency departments. Recognizing this as a county-wide public health issue, the LA Department of Health partnered with the Pacific Sickle Cell Regional Collaborative (PSCRC) in 2015 to establish an advanced practice medical home at the Martin Luther King Jr. Outpatient Center to fill this important gap in services.Methods: The PSCRC was formed when we received a grant from the Health Resources and Services Administration (HRSA) in 2014. One of the aims of this grant was to improve access to care for adults. The Sickle Cell Clinic at MLK OPC is the result of a collaboration with the Sickle Cell Disease Foundation of California, PSCRC and the LA County Department of Health Services (LACDHS). Representatives from PSCRC initially approached the CMO of LACDHS to identify the need. Based on demographic data organized by zip code, a concentration of a projected 1000 adults was noted to live in South Los Angeles in the catchment area for MLK OPC. In discussion with the chief medical officer at MLK OPC, the team decided to pursue a whole-person approach to SCD care that would include integrated primary care, specialty services, mental health treatment, and complementary medicine in the same site.Results: After intense and focused planning, including a PR campaign, the clinic opened August 2016. The staff includes a hematologist with expertise in SCD, a primary care provider, a nurse educator and two community health workers trained by the Foundation. In the first 10 months we have cared for 23 patients. All but two of these patients are from the south LA county area. The age range of the patients is 20-62 years of age. The majority of the patients are genotype SS. All patients were on Medicaid or Medicare insurance.This first cohort of patients is notable for health complications due to lack of coordinated, preventive services. This was measured by a number of indicators: outpatient visits in the 12 months prior to coming to MLK, immunizations, iron overload, and use of Hydroxyurea (HU) (Table 1). One quarter of the patients had no care other than ED or inpatient care for the 12 months preceeding their first visit to our clinic. 100% of the patients had were missing one or more adult immunizations (hepatitis B, tetanus, pneumococcal disease, meningitis, seasonal flu, HPV).Three patients are severely iron overloaded due to multiple transfusions as inpatients with no hematology follow up to address chelation issues. One of those patients required a liver transplant. 39% of the patients (9 patients) seen were eligible for HU but were not on the drug. 17% (4 patients) were on the drug but were noncompliant or poorly managed with episodes of neutropenia. Of those 13 total patients, 11 are now on HU with good compliance and excellent monitoring of drug.Conclusion: The creation of an advance practice medical home for adults with SCD in Los Angeles demonstrates a successful regional approach that engages medicine, public health, and community based organization leaders to build SCD clinical services in less than a year. This safety net clinic now provides team based primary and specialty care to adults whose only option previously was an emergency room. Our early statistics demonstrate that many patients were not getting appropriate care for their disease due to lack of primary and hematology access. As our patient numbers grow, we expect to see continued improvement for patients which will be measured through a new CDC surveillance project which will track utilization and health outcomes. This model holds promise for replication in other locales to effectively address national inequities in sickle cell care. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Evaluating the Effects of Opioid Prescribing Policies on Patient Outcomes in a Safety-net Primary Care Clinic

BackgroundAfter decades of liberal opioid prescribing, multiple efforts have been made to reduce reliance upon opioids in clinical care. Little is known about the effects of opioid prescribing policies on outcomes beyond opioid prescribing.ObjectiveTo evaluate the combined effects of multiple opioid prescribing policies implemented in a safety-net primary care clinic in San Francisco, CA, in 2013–2014.DesignRetrospective cohort study and conditional difference-in-differences analysis of nonrandomized clinic-level policies.Patients273 patients prescribed opioids for chronic non-cancer pain in 2013 at either the treated (n=151) or control clinic (n=122) recruited and interviewed in 2017–2018.InterventionsPolicies establishing standard protocols for dispensing opioid refills and conducting urine toxicology testing, and a new committee facilitating opioid treatment decisions for complex patient cases.Main MeasuresOpioid prescription (active prescription, mean dose in morphine milligram equivalents [MME]) from electronic medical charts, and heroin and opioid analgesics not prescribed to the patient (any use, use frequency) from a retrospective interview.Key ResultsThe interventions were associated with a reduction in mean prescribed opioid dose in the first three post-policy years (year 1 conditional difference-in-differences estimate: −52.0 MME [95% confidence interval: −109.9, −10.6]; year 2: −106.2 MME [−195.0, −34.6]; year 3: −98.6 MME [−198.7, −23.9]; year 4: −72.6 MME [−160.4, 3.6]). Estimates suggest a possible positive association between the interventions and non-prescribed opioid analgesic use (year 3: 5.2 absolute percentage points [−0.1, 11.2]) and use frequency (year 3: 0.21 ordinal frequency scale points [0.00, 0.47]) in the third post-policy year.ConclusionsClinic-level opioid prescribing policies were associated with reduced dose, although the control clinic achieved similar reductions by the fourth post-policy year, and the policies may have been associated with increased non-prescribed opioid analgesic use. Clinicians should balance the urgency to reduce opioid prescribing with potential harms from rapid change.

Implementation of a pilot teleretinal screening protocol for hydroxychloroquine retinopathy in a Los Angeles County safety net clinic

Introduction This study aimed to determine whether teleretinal screening for hydroxychloroquine retinopathy (HCQR) improves clinical efficiency and adherence to recommended screening guidelines compared to face-to-face screening among patients in a large safety net medical system. Methods In this retrospective cohort study of a consecutive sample of 590 adult patients with active HCQ prescriptions seen in the outpatient ophthalmology clinic at Los Angeles County + University of Southern California Medical Center from 1 September 2018 to 25 November 2019, 203 patients underwent technician-only tele-HCQR screening (THRS), and 387 patients underwent screening with traditional face-to-face visits (F2FV) with an eye-care provider. Data on clinic efficiency measures (appointment wait time and encounter duration) and adherence to recommended screening guidelines were collected and compared between the two cohorts. Results Compared to F2FV, the THRS cohort experienced significantly shorter median (interquartile range) time to appointment (2.5 (1.5–4.6) vs. 5.1 (2.9–8.4) months; p < 0.0001), shorter median encounter duration (1 (0.8–1.4) vs. 3.7 (2.5–5.2) hours; p < 0.0001) and higher proportion of complete baseline screening (102/104 (98.1%) vs. 68/141 (48.2%); p < 0.001) and complete chronic screening (98/99 (99%) vs. 144/246 (58.5%); p < 0.001). Discussion A pilot THRS protocol was successfully implemented at a major safety net eye clinic in Los Angeles County, resulting in a 50.9% reduction in wait times for screening, 72.9% reduction in encounter duration and 49.9% and 40.5% increases in proportions of complete baseline and chronic screening, respectively. Tele-HCQ retinal screening protocols may improve timeliness to care and screening adherence for HCQR in the safety net setting.

511-P: Treatment Burden, Glycemic Control, and Social Determinants of Health in Patients with Type 2 Diabetes

Burden of treatment (BoT) is the work of self-management of chronic conditions and its impact on function and well-being. BoT may negatively affect behavioral outcomes. With 90% of patients with type 2 diabetes (T2DM) having at least 1 comorbid condition, BoT may be important to consider, especially among populations experiencing disparities. However, links between BoT and clinical outcomes are unclear. Using a cross-sectional survey and electronic health record data, we sought to determine associations between BoT (using a validated measure) and glycemic control (A1c) among low-income patients with T2DM in 6 safety net primary care clinics, and whether BoT and A1c were related to medication adherence and social determinants of health (SDOH). We used descriptive statistics and correlations, then ANOVA to compare 4 groups by high vs. low A1c (cut at 7%) and BoT (cut at median). Of 192 respondents, average age was 55 with 63% female and 64% non-white; 23% had low health literacy, 26% worried about housing, 35% reported medical-related financial difficulties, and 17% did not always have enough food. Average A1c was 7.6%. While there was no association between A1c and BoT (rho=0.01, p=0.86), both were independently associated with health literacy, perceived self-management self-efficacy, and diabetes-related distress (rho range 0.15-0.65, p=&amp;lt;0.001-0.04). A1c was not associated with medication adherence, but BoT was (rho=0.24, p=0.001). Housing worry, financial difficulties, and food insecurity were higher, and adherence lower, in the High A1c - High BoT group than in the Low A1c - Low BoT group (p=0.006-0.01). For the High A1c - Low BoT and Low A1c - High BoT groups, BoT was more important than A1c for these associations. The relationships between BoT and A1c are complex, but SDOH and adherence may be important mediators. These may be appropriate intervention targets for glycemic control, particularly among low-income and minority patients. Determining causality requires further study. Disclosure E. A. Rogers: None. S. T. Manser: None. S. Arriaza: None. M. Linzer: Other Relationship; Self; American College of Physicians, CRICO Malpractice and Harvard University, Research Support; Self; Agency for Healthcare Research and Quality, American Board of Internal Medicine, American Medical Association, Institute for Healthcare Improvement, National Heart, Lung, and Blood Institute, National Institute for Nursing Research. Funding National Institutes of Health (K23DK118207)

HbA1c Change in Patients With and Without Gaps in Pharmacist Visits at a Safety-Net Resident Physician Primary Care Clinic

HbA1c Change in Patients With and Without Gaps in Pharmacist Visits at a Safety-Net Resident Physician Primary Care Clinic

Longitudinal Observation of Outcomes and Patient Access to Integrated Care Following Point-of-Care Glycemic Screening in Community Health Center Dental Safety Net Clinics.

Introduction: Rates of diabetes/prediabetes continue to increase, with disparity populations disproportionately affected. Previous field trials promoted point-of-care (POC) glycemic screening in dental settings as an additional primary care setting to identify potentially at-risk individuals requiring integrated care intervention. The present study observed outcomes of POC hemoglobin A1c (HbA1c) screening at community health center (CHC) dental clinics (DC) and compliance with longitudinal integrated care management among at-risk patients attending dental appointments.Materials and Methods: POC HbA1c screening utilizing Food and Drug Administration (FDA)-approved instrumentation in DC settings and periodontal evaluation of at-risk dental patients with no prior diagnosis of diabetes/prediabetes and no glycemic testing in the preceding 6 months were undertaken. Screening of patients attending dental appointments from October 24, 2017, through September 24, 2018, was implemented at four Wisconsin CHC-DCs serving populations with a high representation of disparity. Subjects meeting at-risk profiles underwent POC HbA1c screening. Individuals with measures in the diabetic/prediabetic ranges were advised to seek further medical evaluation and were re-contacted after 3 months to document compliance. Longitudinal capture of glycemic measures in electronic health records for up to 2 years was undertaken for a subset (n = 44) of subjects with available clinical, medical, and dental data. Longitudinal glycemic status and frequency of medical and dental access for follow-up care were monitored.Results: Risk assessment identified 224/915 (24.5%) patients who met inclusion criteria following two levels of risk screening, with 127/224 (57%) qualifying for POC HbA1c screening. Among those tested, 62/127 (49%) exhibited hyperglycemic measures: 55 in the prediabetic range and seven in the diabetic range. Moderate-to-severe periodontitis was more prevalent in patients with prediabetes/diabetes than in individuals with measures in the normal range. Participant follow-up compliance at 3 months was 90%. Longitudinal follow-up documented high rates of consistent access (100 and 89%, respectively), to the integrated medical/DC environment over 24 months for individuals with hyperglycemic screening measures.Conclusion: POC glycemic screening revealed elevated HbA1c measures in nearly half of at-risk CHC-DC patients. Strong compliance with integrated medical/dental management over a 24-month interval was observed, documenting good patient receptivity to POC screening in the dental setting and compliance with integrated care follow-up by at-risk patients.

Availability of Sexually Transmitted Disease and HIV Clinical Services: Ending the HIV Epidemic Versus Non-Ending the HIV Epidemic Jurisdictions, 2018.

We assessed sexually transmitted disease/human immunodeficiency virus (HIV) service availability at the primary sexually transmitted disease safety net clinic by phase I Ending the HIV Epidemic jurisdiction status. HIV testing was >90%. In Ending the HIV Epidemic jurisdictions, 22% of primary safety net clinics initiated and/or provided preexposure prophylaxis (PrEP), 46.6% provided PrEP education or referral only, and 29.9% did not provide any PrEP services.

Multi-level QI interventions in a safety-net academic oncology clinic.

e18665 Background: Clinic cycle time is a performance metric and prolonged wait times may impact patient satisfaction and/or treatment outcomes. In primary care clinics, studies show prolonged cycle times detract from patient satisfaction. Fewer studies examine specialty clinics such as oncology which require multi-faceted care. Our Harris Health System (HHS) serves a diverse county with high patient volume with physician learners and limited providers due to limited resources. Our patient satisfaction assessments previously identified prolonged wait times as an area for improvement. Our team studied and process mapped operations with the goal of improving clinic efficiency. Our primary objective is to streamline the process for our outpatient oncology appointments measured through patient cycle times. We aimed to decrease the cycle time by 25% and improve patient satisfaction. Methods: From January 2018 through December 2019, the cycle time processes for Smith Thursday Oncology Clinics in the HHS were mapped and analyzed, and sequential PDSA (Plan-Do-Study-Act) cycles were completed to reduce non-value-added time. Six-month cycle times before and after implementation of three process changes implemented were compared with t-test analysis. Next, NRC (National Research Corporation) Health patient satisfaction data for the corresponding time frames was compared with both t-test and chi-square analyses. Results: Patient cycle time from July 2018 – December 2018 was compared to July 2019 – December 2019 with a t-test analysis. Our results showed a significant (p = 0.036) reduction in cycle time. The average percent decrease in cycle time was 19%. NRC patient satisfaction data inquiries, including overall satisfaction, informed regarding appointment delays, and waiting for more than 15 minutes were reviewed for this same time frame. We found trends in all three categories showing improvements in scores with p-values of 0.483, 0.821 and 0.282 respectively. Conclusions: Through multi-level interventions we were able to significantly reduce clinic cycle times. Trends towards improvement were seen as the population assessed was in the hundreds and not thousands needed for significance. Our academic teaching model is meaningful to study as it serves a high patient volume and educates future oncologists, especially pertinent when a shortage of oncologists in anticipated in the future. Additionally, our patients receive high quality care with nursing, education and infusion services. An area for improvement is communication with patients during their cycle times and other early QI work in our clinics show patients are interested in further education. Our underserved patient population is multi-ethnic, has unassessed health literacy, and frequent language barriers. Better efficiency in the clinics and utilization of cycle time can have multiple patient benefits that warrant further work in QI.

Acceptability of Text Messaging and Disparities in Mobile Health Access in Women's Health Care: A Survey Study.

Objective: Few studies in women's health care have utilized text messaging as a data collection tool. Our aims were to (1) determine the willingness of Obstetrics and Gynecology (Ob/Gyn) patients to participate in text message surveys, (2) determine the patient-preferred mode of survey distribution, (3) compare preferences between a low-resource and university population, and (4) review the practical aspects of implementing text message surveys. Methods: Paper surveys were distributed to Ob/Gyn clinic patients at two academic centers. English and Spanish speakers were included. Questions assessed sociodemographic data, survey preferences, and text messaging preferences. Appropriate tests were used to look for associations between demographics and survey preferences. Results: One hundred eighty-two participants completed the survey. Respondents were seen at either a university (42%) or a safety net (58%) clinic. Most owned a mobile phone (94%), used text messaging everyday (88%), and had an unlimited data plan (83%). Of the respondents willing to participate in a survey, text messaging was the preferred survey method (70%), followed by phone (14%) and mobile applications (8%). Fifty-six percent of respondents were willing to participate in a daily text message survey. There were no associations between socioeconomic status and survey preferences or willingness to participate in text message surveys. Survey preference was associated with age (p < 0.01). Respondents of all age groups preferred text message surveys; however, those aged 31-60 years were most likely to prefer text messaging (odds ratio: 8.3, confidence interval: 2.6-29.8). Conclusions: Most Ob/Gyn patients are willing and able to participate in text message surveys, and text messaging is the most preferred survey method across sociodemographic categories.

A Multidisciplinary Diabetes Clinic Improves Clinical and Behavioral Outcomes in a Primary Care Setting.

The percentage of adults achieving hemoglobin A1c goals less than 7% remains a challenge. The study objective was to evaluate effects of a multidisciplinary approach on behavioral outcomes and mean change in A1c in immediate start (intervention) versus 6-month delay (control) groups at 6 months. The study assessed 111 patients recruited from a safety-net primary care clinic with a pharmacist-led multidisciplinary team and found that the intervention improved mean A1c outcomes for patients with type 2 diabetes. A1c values were measured every 3 months, and a self-efficacy scale to measure behaviors was evaluated at baseline and 6 months. After 6 months from baseline, the intervention group showed an A1c decrease of 2.4 compared with the control group's 1.1 decrease. Mean increase in self-efficacy score in the intervention group at baseline versus after 6 months showed a statistically significant change (P = .01) compared with the control group (P = .26). Results revealed a post hoc association between A1c and PHQ-9 such that patients with higher baseline PHQ-9 scores experienced greater mean decrease in A1c. In the immediate start arm, mean A1c values decreased from 10.6 at baseline to 7.7 at month 12. For the delayed intervention group, mean A1c values decreased from 10.2 at baseline to 9.0 after 6 months.

Effectiveness and Cost-effectiveness of Mailed FIT in a Safety Net Clinic Population.

Mailed fecal immunochemical testing (FIT) can increase colorectal cancer (CRC) screening rates, including for vulnerable patients, but its cost-effectiveness is unclear. We sought to examine the effectiveness and cost-effectiveness of the initial cycle of our mailed FIT program from November 2017 to July 2019 in a federally qualified health center (FQHC) system in Central Texas. Single group intervention and economic analysis PARTICIPANTS: Eligible patients were those ages 50-75 who had been seen recently in a system practice and were not up to date with screening. The program mailing packet included an introductory letter in plain language, the FIT itself, easy to read instructions, and a postage-paid lab mailer, supplemented with written and text messaging reminders. We measured effectiveness based on completion of mailed FIT and cost-effectiveness in terms of cost per person screened. Costs were measured using detailed micro-costing techniques from the perspective of a third-party payer and expressed in 2019 US dollars. Direct costs were based on material supply costs and detailed observations of labor required, valued at the wage rate. Of the 22,838 eligible patients who received program materials, mean age was 59.0, 51.5% were female, and 43.9% were Latino. FIT were successfully completed by 19.2% (4395/22,838) patients at an average direct cost of $5275.70 per 500-patient mailing. Assuming completed tests from the mailed intervention represent incremental screening, the direct cost per patient screened, compared with no intervention, was $54.83. Incorporating start-up and indirect costs increases total costs to $7014.45 and cost per patient screened to $72.90. Alternately, assuming 2.5% and 5% screening without the intervention increased the direct (total) cost per patient screened to $60.03 ($80.80) and $67.05 ($91.47), respectively. Mailed FIT is an effective and cost-effective population health strategy for CRC screening in vulnerable patients.

Challenges of Using Videos in Exam Rooms of Safety-Net Clinics to Encourage Patient Self-Disclosure of Intimate Partner Violence and to Increase Provider Screening.

Identifying intimate partner violence (IPV) in clinics allows for early intervention. We tested a comprehensive approach in five safety-net clinics to encourage female victims to self-identify and providers to screen. The main components were (a) short, multilingual videos for female patients; (b) provider training; and (c) management tools. Although videos were viewed 2,150 times, only 9% of eligible patients watched them. IPV disclosure increased slightly (6%). Lack of internal champions, high turnover, increased patient load, and technological challenges hindered outcomes. Safety-net clinics need feasible methods to encourage IPV screening. Management champions and IT support are essential for video-based activities.

Promoting Physical Activity Through Policy at a Single Safety-Net Clinic: A Pilot Study.

Physical inactivity is a major issue for African Americans that contributes to increased risk for chronic conditions including obesity, heart disease, diabetes, and cognitive decline. The purpose of this single-clinic pilot study aimed to determine if a physical activity policy would increase primary-care provider discussions of physical activity during clinic visits using the Exercise is Medicine initiative as a guide. The study design involved data collection at three time points. Participants were recruited from a single clinic providing high quality healthcare without regard to ability to pay. Participants included 109 African American patients between the ages of 24 and 81 (39 pre-intervention, 40 at 6 weeks post-intervention, and 30 at 12-months post-intervention). The primary outcome measure was participants' answers related to whether a physical activity discussion occurred with their primary-care provider. At baseline, 13% of participants reported a physical activity discussion with their provider, this increased to 33% at 6 weeks post-intervention. However, at 12-months post-intervention, the percentage of participants who reported a physical activity discussion decreased to 23%. Exercise is an underused evidence-based strategy that should be prescribed as a medicine to prevent and manage many chronic health conditions. This pilot study demonstrated the feasibility of improving provider-patient communications related to the importance of daily physical activity behaviors. Further research is needed to determine how to employ and sustain a clinic level policy that will encourage physical activity discussions at every visit.

Use of a portable infrared 3D scanning device measuring limb volume in a safety net hospital breast clinic.

Use of a portable infrared 3D scanning device measuring limb volume in a safety net hospital breast clinic.