Unmet Social Need Research Articles

PHP71 - Screening for and Addressing Social Determinants of Health in Managed Care

To evaluate the prevalence of social determinants of health (SDOH) in Medicaid and dual-eligible Medicaid/Medicare populations. AmeriHealth Caritas, a managed care organization operating in 17 states and the District of Columbia, developed operational enhancements to address SDOH (unmet needs in education, health literacy, transportation, material security, and housing) for subsequent integration into its population health management and member engagement strategies. A set of SDOH assessment questions was standardized across 10 managed care plans and integrated into their continuum of services, including new member calls, telephonic and community-based care management assessment tools. Based on these findings, action steps were designed to connect members to community-based resources. Statistical analyses were performed using chi square and F-tests. From all members with collected SDOH data (N=20,339) since August 25, 2017, 38% (n=7,797) were identified as having ≥1 unmet social need (51% of whom had ≥2 unmet social needs) subsequently addressed by staff. As of November 1, 2017, 97% of members (n=19,715) remained eligible, 35% of whom were male. Compared to females, males reported having significantly (p<0.01) higher rates of: less-than high school equivalency (27.8% vs. 23.7%), health literacy challenges (16.5% vs. 12.9%), food insecurity (17.1% vs. 14.1%), homelessness and housing insecurity (2.6% vs. 2.0% and 3.0% vs. 2.6%, respectively). Members reporting housing insecurity and homelessness tended to be older than those who were stable (mean ages: housing insecure, 39 years; homeless, 41 years; stable, 36 years; declined-to-state, 25 years; p<0.001). Older members also reported more health literacy concerns (mean age: stable, 37 years; vulnerable, 49 years; p<0.001). Preliminary analysis indicates a higher rate of unmet social needs among males and older members. Further analysis will evaluate differences among race/ethnicity groups, and add SDOH to multivariable models to identify at-risk subpopulations who may benefit from proactive care management or additional interventions.

(Un)Met needs of community dwelling people with dementia: the importance of providing integrated holistic care

Introduction: Research shows that PwD and their carers often do not receive the type, quality and amount of support needed from health and social care services. This study, part of the Access to Timely Care (Actifcare) JPND-funded project, aimed to identify the (un)met needs of Irish people with dementia (PwD) living at home and to compare these to needs assessments from a family caregiver and an independent Actifcare researcher. Theory/Methods: Forty-three PwD (22 female, mean age 74.05, mean MMSE 20.34) and family caregiver (33 female, mean age 58.12) dyads participated. The Camberwell Assessment of Need for the Elderly (CANE) was completed at baseline, 6-months and 12-months. All raters reported met and unmet need. Caregivers and researchers also reported formal and informal supports received. Additional measures included: Quality of life (Qol-AD, ICECAP-O, Carer-QoL), Neuropsychiatric symptoms (NPI-Q) and carer perseverance. Results: PwD perceived fewer met needs at baseline (M=4.79, SD=3.2) than caregivers (M=8.6, SD=3.78) and researchers (M=8.3, SD=3.6); particularly environmental and physical needs. Researchers identified significantly more unmet need (M=3.28, SD=2.33) than caregivers (M=2.19, SD=2.05) and PwD (M=0.72, SD=1.32). Unmet needs were typically psychological (memory) and social (daytime activities, company) and regularly rated as ‘not the right type of care’. PwD sex had no impact on ratings, but group differences in unmet increased with dementia severity. Greater met needs were significantly related to higher NPI scores and greater functional need. Caregiver ratings of met need indicated longer care perseverance. Lower levels of unmet need were significantly associated with better quality of life. Similar patterns were found at 6- and 12-months with researchers increasingly identifying umet needs. Discussions: PwD reported fewest needs. Although often unaware of their psychological needs, these are generally identified by caregivers with the exception of support for memory difficulties; these were typically reported by researchers. Addressing unmet need positively influenced the dyadic quality of life, yet all groups reported high levels of unmet social need and found available services lacking and inappropriate. High levels of met physical need demonstrates a continued primary policy emphasis on soley supporting these needs. Conclusions: Dementia needs assessments must address the full range of biopsychosocial needs of the PwD and their caregivers such that timely tailored supports can be provided. Case management approaches that integrate the provision of health and social care are recommended. Lessons learned: Meeting physical need alone is not sufficient to maintain quality of life. It is essential to take a holistic view of the individual and their environment in order to adequately assess the support needed. Limitations: Although all PwD were able to report their needs at baseline, fewer were able to do so at 6-months (n=38) and 12-months (n=33). Suggestions for future research: Future research could formally and regularly assess needs from diagnosis onwards. If coupled with analysis of the type, duration and benefits of supports used, greater insight will be gained to enable the development of integrated dementia care that better supports the complex biopsychosocial needs of PwD and their families.

HOW DO CARE HOME STAFF EXPERIENCE, UNDERSTAND AND MANAGE AGITATION IN RESIDENTS WITH DEMENTIA? A QUALITATIVE STUDY

Agitation in dementia is common, persistent, distressing and related to care home admission and increased costs. There is limited evidence for sustained effects of any intervention targeting agitation in care home residents and little is known about how front-line care home staff understand and manage agitated residents. To inform the development of sustainable and practical psychosocial interventions for agitation we conducted the first qualitative study of care home staff experiences of caring for agitated residents. We conducted 25 in-depth interviews with staff from six care homes. We used purposive sampling to include staff of either sex, differing ages, ethnicities, nationalities and with different roles. We transcribed interviews and entered them into NVivo 11 software and conducted thematic analysis. Care staff experienced agitation as diverse, unpredictable and of varying severity. They reported feeling frightened, powerless and overwhelmed when residents were agitated, especially when attempted solutions did not work, or if they felt unsupported by colleagues and managers or unable to meet the competing demands of their role. Staff understood agitation as expression of unmet social, emotional, physical or environmental need, which the person with dementia can no longer resolve. Despite experiencing a range of barriers to managing agitation at individual, interpersonal, organizational and socio-political levels, staff responses to agitation were flexible and adaptive, applying a process of ‘trial and error’ based upon prior experience. Strategies ranged from ‘hands on’ de-escalation techniques, to team based approaches, however it was acknowledged that sometimes ‘nothing worked’. Medication was described as a last resort, with side-effects and limited effectiveness. Using skilled communication, getting to know residents and maximising pleasant interaction was seen as integral to preventing agitation from happening. Future RCTs of psychosocial interventions to reduce agitation in care homes should support staff to respond to resident unmet needs and incorporate how staff can minimise the impact of agitation upon themselves. To ensure sustainability, interventions should build upon approaches and strategies already being used by care home staff whilst addressing barriers to staff putting potentially beneficial strategies into practice.

WA40 The good neighbour partnership: why do we need it? who is going to do it? how on earth are we going to evaluate it?

: This one-hour symposium considers Milford Care Centre's Compassionate Communities Good Neighbour Partnership and it's evaluation by an international team, led by Maynooth University and funded by the All Ireland Institute of Hospice and Palliative Care, The Irish Cancer Society, The Irish Hospice Foundation and Milford Care Centre. The symposium will be divided into three sections: 1. The Good Neighbour Partnership: Why do we need it? In this section we will describe the findings from a recent scoping study to determine the social and practical needs of community dwelling adults (and their families) living with advanced life limiting illness at home. We will consider the rationale for specialist palliative care services, working with community groups, to lead the development of a volunteer-based social model of care to address unmet need. 2. The Good Neighbour Partnership: How do we recruit and train volunteers? We will share our process and experience of recruiting and training 15 Compassionate Communities Volunteers to assess unmet social and practical need, and to mobile the person's circle of community to meet those needs. An understanding of the motivating factors of volunteers will be shared. 3. The Good Neighbour Partnership: How on earth are we going to evaluate it? Here we describe the INSPIRE study - Investigating Social and Practical Supports at the End of life. An exploratory delayed intervention randomised controlled trial (framed by the MRC Framework for Complex Interventions) to assess the feasibility, acceptability and potential effectiveness of the Good Neighbour Partnership.

Leadership, stakeholder culture, and social innovation: The role of care and compassion

The resolution of some of the most pressing social problems in the world (poverty, pollution, pandemics) calls for leadership support, engagement and innovation from different sectors, including business. In this paper we examine if and how business leaders engage in social innovation. Social innovation refers to a novel solution that will be developed for the purpose of addressing an unmet social need or problem (e.g. problem of justice, fairness, environmental preservation, better education, or improved health) – with the benefits primarily accruing to stakeholders in need or whole underprivileged societies. We show that different leadership perspectives (shareholder versus stakeholder) and leadership approaches (personalized versus socialized) affect the quality of social innovation (first-order versus second-order solutions) pursued by business leaders. While a first-order solution deals with the symptoms of a problem, a second-order solution is designed to tackle the roots of a problem. We argue that leaders with a stakeholder perspective and socialized approach are more likely to foster sustainable second-order social innovations geared toward treating the roots of societal problems due to their care and compassion for stakeholders. We also demonstrate that the stakeholder culture of an organization has a mediating role in the innovation process and either hinders or fosters leaders to engage in second-order social innovation. Moreover, we discuss the possibilities of leaders to foster a climate of social innovation within the organization.

Chronic Posttraumatic Stress Disorder After Facial Injury: A 1-year Prospective Cohort Study

This study examined the prevalence, severity, and predictors of persistent traumatic stress symptoms in socioeconomically disadvantaged adults after orofacial injury. A 1-year prospective study of 336 socioeconomically disadvantaged adults treated for orofacial injury at a Level I trauma center was conducted. Univariate analyses were performed on early measures of injury characteristics, prior trauma exposure, coping resources, and psychosocial functioning to select potential predictors of 1-year posttraumatic stress disorder (PTSD) scores; independence of variable contribution was then evaluated in multiple regression analyses. A substantial number of patients (23%) continued to experience significant PTSD symptomatology at 12 months. Predictors of PTSD symptoms at 12 months included current and lifetime mental health and social service needs, lifetime social service use, prior trauma exposure, sum of stressful life events in the year preceding injury, patient report of pain severity and inadequate social support at 10 days postdischarge, and PTSD scores at 1 month. One-month PTSD symptoms, unmet social service need, and need for more instrumental and emotional support were independent predictors of 12-month PTSD outcomes. Limitations include loss to follow up, use of self-report measures, and the possibility of additional traumatization in the follow-up year influencing symptom levels. Many socioeconomically disadvantaged adults manifest negative psychological outcomes even 1 year after an orofacial injury. Poor social support and unmet social service needs immediately after the injury, as well as high PTSD symptoms at 1 month postinjury, are strongly associated with the risk of developing chronic PTSD. The surgical management of orofacial injuries in disadvantaged individuals should integrate case management that addresses psychosocial sequelae and patient service needs.

Evaluating rehabilitation using cost-consequences analysis: an example in Parkinson's disease

Objective: To use cost-consequences analysis to evaluate rehabilitation, and to discuss some practical limitations. Design: Case study of a cost-consequences analysis. Setting: Day hospital. Subjects: People with Parkinson's disease without major cognitive loss, and their carers. Intervention: A programme of multidisciplinary rehabilitation, delivered for one day per week over six weeks, and including 2 h of individual therapy (physical, occupational, speech and language, specialist nurse) and group activities on each occasion. Main measures: Costs: direct and overhead costs of treatment; participant travel. Consequences: patient outcomes (mobility, speech and language, disability, psychological well-being, health-related quality of life); carer outcomes (psychological well-being, health-related quality of life, strain); social service utilization; satisfaction. Results: In this example the main costs were facility's overheads and hospital-provided transport. The consequences of the intervention were improved immediate outcomes for patients that diminished over four months, discovery of unmet social services need, high satisfaction. No benefits for carers were observed. Conclusion: A cost-consequences analysis provides a clear descriptive summary for decision-makers that is easier to interpret than cost-effectiveness, cost-utility and cost-benefit analysis. It is a useful technique in rehabilitation research where multiple outcomes and several perspectives (health service, patient, carer) are relevant. However limitations remain: it is difficult to capture all consequences because of data deficiencies and long-term effects; evaluations of individual interventions are partial and do not guarantee economic rationality; local studies may not be generalizable; fixed protocols impede the evaluation of alternative service configurations.