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Open Access Publications from the University of California

Scholarly Works (10 results)

  • Article
  • Peer Reviewed
UC San Francisco Previously Published Works (2018)
    Cover page: Homelessness and Emergency Medicine: Where Do We Go From Here?
    • Article
    • Peer Reviewed
    UC San Francisco Previously Published Works (2021)

    Background

    The COVID-19 pandemic created a major public health crisis that disrupted economic systems, social networks and individual behaviors, which led to changes in patterns of health care use. Factors associated with emergency department (ED) visits during the pandemic among especially high-risk individuals are unknown. We used a "Big Events" approach, which considers major disruptions that create social instability, to investigate ED use in people experiencing homelessness or housing instability, many of whom use drugs.

    Methods

    Between July and December 2020, we conducted a community-based San Francisco study to compare homeless and unstably housed (HUH) women who did and did not use an ED during the first 10 months of the pandemic.

    Results

    Among 128 study participants, 34% had ≥1 ED visit during the pandemic. In adjusted analysis, factors significantly associated with ED use included experiencing homelessness, cocaine use and increased difficulties receiving drug use treatment during the pandemic.

    Conclusion

    These findings build on the "Big Events" approach to considering risk pathways among people who use drugs. They suggest the importance of ensuring access to housing and low-barrier non-COVID health services, including drug treatment, alongside crisis management activities, to reduce the health impacts of public health crises.
      Cover page: Using a “Big Events” framework to understand emergency department use among women experiencing homelessness or housing instability in San Francisco during the COVID-19 pandemic
      • Article
      • Peer Reviewed
      UC San Francisco Previously Published Works (2011)
      Abstract Background A small percentage of high-risk patients accounts for a large proportion of Medicaid spending in the United States, which has become an urgent policy issue. Our objective was to pilot a novel patient-centered intervention for high-risk patients with frequent hospital admissions to determine its potential to improve care and reduce costs. Methods Community and hospital-based care management and coordination intervention with pre-post analysis of health care utilization. We enrolled Medicaid fee-for-service patients aged 18-64 who were admitted to an urban public hospital and identified as being at high risk for hospital readmission by a validated predictive algorithm. Enrolled patients were evaluated using qualitative and quantitative interview techniques to identify needs such as transportation to/advocacy during medical appointments, mental health/substance use treatment, and home visits. A community housing partner initiated housing applications in-hospital for homeless patients. Care managers facilitated appropriate discharge plans then worked closely with patients in the community using a harm reduction approach. Results Nineteen patients were enrolled; all were male, 18/19 were substance users, and 17/19 were homeless. Patients had a total of 64 inpatient admissions in the 12 months before the intervention, versus 40 in the following 12 months, a 37.5% reduction. Most patients (73.3%) had fewer inpatient admissions in the year after the intervention compared to the prior year. Overall ED visits also decreased after study enrollment, while outpatient clinic visits increased. Yearly study hospital Medicaid reimbursements fell an average of $16,383 per patient. Conclusions A pilot intervention for high-cost patients shows promising results for health services usage. We are currently expanding our model to serve more patients at additional hospitals to see if the pilot's success can be replicated. Trial registration Clinicaltrials.gov Identifier: NCT01292096
        Cover page: An intervention to improve care and reduce costs for high-risk patients with frequent hospital admissions: a pilot study
        • Article
        • Peer Reviewed
        UC San Francisco Previously Published Works (2022)

        Importance

        There has been recent media attention on the risk of excess mortality among homeless individuals during the COVID-19 pandemic, yet data on these deaths are limited.

        Objectives

        To quantify and describe deaths among people experiencing homelessness in San Francisco during the COVID-19 pandemic and to compare the characteristics of these deaths with those in prior years.

        Design, setting, and participants

        A cross-sectional study tracking mortality among people experiencing homelessness from 2016 to 2021 in San Francisco, California. All deceased individuals who were homeless in San Francisco at the time of death and whose deaths were processed by the San Francisco Office of the Chief Medical Examiner were included. Data analysis was performed from August to October 2021.

        Exposure

        Homelessness, based on homeless living status in an administrative database.

        Main outcomes and measures

        Descriptive statistics were used to understand annual trends in demographic characteristics, cause and manner of death (based on autopsy), substances present in toxicology reports, geographic distribution of deaths, and use of health and social services prior to death. Total estimated numbers of people experiencing homelessness in San Francisco were assessed through semiannual point-in-time counts. The 2021 point-in-time count was postponed owing to the COVID-19 pandemic.

        Results

        In San Francisco, there were 331 deaths among people experiencing homelessness in the first year of the COVID-19 pandemic (from March 17, 2020, to March 16, 2021). This number was more than double any number in previous years (eg, 128 deaths in 2016, 128 deaths in 2017, 135 deaths in 2018, and 147 deaths in 2019). Most individuals who died were male (268 of 331 [81%]). Acute drug toxicity was the most common cause of death in each year, followed by traumatic injury. COVID-19 was not listed as the primary cause of any deaths. The proportion of deaths involving fentanyl increased each year (present in 52% of toxicology reports in 2019 and 68% during the pandemic). Fewer decedents had contacts with health services in the year prior to their death during the pandemic than in prior years (13% used substance use disorder services compared with 20% in 2019).

        Conclusions and relevance

        In this cross-sectional study, the number of deaths among people experiencing homelessness in San Francisco increased markedly during the first year of the COVID-19 pandemic. These findings may guide future interventions to reduce mortality among individuals experiencing homelessness.
          • Article
          • Peer Reviewed
          UC San Francisco Previously Published Works (2014)

          Purpose

          To examine correlates of emergency department (ED) use and hospitalizations in a community-based cohort of homeless and unstably housed women, with a focus on the role of physical health and pain.

          Methods

          We conducted a cross-sectional analysis of baseline survey results from a study of homeless and unstably housed women in San Francisco. Primary outcomes were any self-reported ED visit and inpatient hospitalization over the prior 6 months. Primary independent variables of interest were self-reported physical health status, as measured by the Short Form-12 (SF-12), and bodily pain. Other potential covariates were organized using the Gelberg-Andersen Behavioral Model for Vulnerable Populations. Standard bivariate and multivariable logistic regression techniques were used.

          Results

          Three hundred homeless and unstably housed women were included in the study, of whom 37.7% reported having an ED visit and 23.0% reported being hospitalized in the prior 6 months. Mean SF-12 physical health scores indicated poorer than average health compared with the U.S. norm. Most women (79.3%) reported at least some limitation in their daily activities owing to pain. In adjusted analyses, moderate and high levels of bodily pain were significantly correlated with ED visits (odds ratio [OR], 2.92 and OR, 2.57) and hospitalizations (OR, 6.13 and OR, 2.49). As SF-12 physical health scores decreased, indicating worse health, the odds of ED use increased. Predisposing, enabling, and additional need factors did not mediate these associations.

          Conclusions

          Physical health and bodily pain are important correlates of ED visits and hospitalizations among homeless and unstably housed women. Interventions to reduce ED use among women who are homeless should address the high levels of pain in this population.
            Cover page: Correlates of Hospital Use in Homeless and Unstably Housed Women: The Role of Physical Health and Pain
            • Article
            • Peer Reviewed
            Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, Volume 22, Issue 4 (2021)

            Introduction: Emergency department (ED) patients have higher than average levels of food insecurity. We examined the association between multiple measures of food insecurity and frequent ED use in a random sample of ED patients.

            Methods: We completed survey questionnaires with randomly sampled adult patients from an urban public hospital ED (n = 2,312). We assessed food insecurity using four questions from the United States Department of Agriculture Household Food Security Survey. The primary independent variable was any food insecurity, defined as an affirmative response to any of the four items. Frequent ED use was defined as self-report of ≥4 ED visits in the past year. We examined the relationship between patient food insecurity and frequent ED use using bivariate and multivariable analyses and examined possible mediation by anxiety/depression and overall health status.

            Results: One-third (30.9%) of study participants reported frequent ED use, and half (50.8%) reported any food insecurity. Prevalence of food insecurity was higher among frequent vs. non-frequent ED users, 62.8% vs 45.4% (P <0.001). After controlling for potential confounders, food insecurity remained significantly associated with frequent ED use (adjusted odds ratio 1.48, 95% confidence interval, 1.20-1.83). This observed association was partially attenuated when anxiety/depression and overall health status were added to models.

            Conclusion: The high observed prevalence of food insecurity suggests that efforts to improve care of ED patients should assess and address this need. Further research is needed to assess whether addressing food insecurity may play an important role in efforts to reduce frequent ED use for some patients.

              Cover page: Cross-sectional Analysis of Food Insecurity and Frequent Emergency Department UseCreative Commons 'BY' version 4.0 license
              • Article
              • Peer Reviewed
              Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, Volume 24, Issue 2 (2023)

              Introduction: Emergency departments (ED) function as a health and social safety net, regularly taking care of patients with high social risk and need. Few studies have examined ED-based interventions for social risk and need. 

              Methods: Focusing on ED-based interventions, we identified initial research gaps and priorities in the ED using a literature review, topic expert feedback, and consensus-building. Research gaps and priorities were further refined based on moderated, scripted discussions and survey feedback during the 2021 SAEM Consensus Conference. Using these methods, we derived six priorities based on three identified gaps in ED-based social risks and needs interventions: 1) assessment of ED-based interventions; 2) intervention implementation in the ED environment; and 3) intercommunication between patients, EDs, and medical and social systems. 

              Results: Using these methods, we derived six priorities based on three identified gaps in ED-based social risks and needs interventions: 1) assessment of ED-based interventions, 2) intervention implementation in the ED environment, and 3) intercommunication between patients, EDs, and medical and social systems. Assessing intervention effectiveness through patient-centered outcome and risk reduction measures should be high priorities in the future. Also noted was the need to study methods of integrating interventions into the ED environment and to increase collaboration between EDs and their larger health systems, community partners, social services, and local government.

              Conclusion: The identified research gaps and priorities offer guidance for future work to establish effective interventions and build relationships with community health and social systems to address social risks and needs, thereby improving the health of our patients.

              • 1 supplemental ZIP
              Cover page: Proceedings from the 2021 SAEM Consensus Conference: Research Priorities for Interventions to Address Social Risks and Needs Identified in Emergency Department PatientsCreative Commons 'BY' version 4.0 license
              • Article
              • Peer Reviewed
              Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, Volume 24, Issue 2 (2023)

              Introduction: Despite literature on a variety of social risks and needs screening interventions in emergency department (ED) settings, there is no universally accepted or evidence-based process for conducting such interventions. Many factors hamper or promote implementation of social risks and needs screening in the ED, but the relative impact of these factors and how best to mitigate/leverage them is unknown. 

              Methods: Drawing on an extensive literature review, expert assessment, and feedback from participants in the 2021 Society for Academic Emergency Medicine Consensus Conference through moderated discussions and follow-up surveys, we identified research gaps and rated research priorities for implementing screening for social risks and needs in the ED. We identified three main knowledge gaps: 1) screening implementation mechanics; 2) outreach and engagement with communities; and 3) addressing barriers and leveraging facilitators to screening. Within these gaps, we identified 12 high-priority research questions as well as research methods for future studies. 

              Results: Consensus Conference participants broadly agreed that social risks and needs screening is generally acceptable to patients and clinicians and feasible in an ED setting. Our literature review and conference discussion identified several research gaps in the specific mechanics of screening implementation, including screening and referral team composition, workflow, and use of technology. Discussions also highlighted a need for more collaboration with stakeholders in screening design and implementation.  Additionally, discussions identified the need for studies using adaptive designs or hybrid effectiveness-implementation models to test multiple strategies for implementation and sustainability. 

              Conclusion: Through a robust consensus process we developed an actionable research agenda for implementing social risks and needs screening in EDs. Future work in this area should use implementation science frameworks and research best practices to further develop and refine ED screening for social risks and needs and to address barriers as well as leverage facilitators to such screening.

                Cover page: 2021 SAEM Consensus Conference Proceedings: Research Priorities for Implementing Emergency Department Screening for Social Risks and NeedsCreative Commons 'BY' version 4.0 license
                • Article
                • Peer Reviewed
                UC San Francisco Previously Published Works (2019)

                Introduction

                Despite recent growth in healthcare delivery-based social risk screening, little is known about patient perspectives on these activities. This study evaluates patient and caregiver acceptability of social risk screening.

                Methods

                This was a cross-sectional survey of 969 adult patients and adult caregivers of pediatric patients recruited from 6 primary care clinics and 4 emergency departments across 9 states. Survey items included the Center for Medicare and Medicaid Innovation Accountable Health Communities' social risk screening tool and questions about appropriateness of screening and comfort with including social risk data in electronic health records. Logistic regressions evaluated covariate associations with acceptability measures. Data collection occurred from July 2018 to February 2019; data analyses were conducted in February‒March 2019.

                Results

                Screening was reported as appropriate by 79% of participants; 65% reported comfort including social risks in electronic health records. In adjusted models, higher perceived screening appropriateness was associated with previous exposure to healthcare-based social risk screening (AOR=1.82, 95% CI=1.16, 2.88), trust in clinicians (AOR=1.55, 95% CI=1.00, 2.40), and recruitment from a primary care setting (AOR=1.70, 95% CI=1.23, 2.38). Lower appropriateness was associated with previous experience of healthcare discrimination (AOR=0.66, 95% CI=0.45, 0.95). Higher comfort with electronic health record documentation was associated with previously receiving assistance with social risks in a healthcare setting (AOR=1.47, 95% CI=1.04, 2.07).

                Conclusions

                A strong majority of adult patients and caregivers of pediatric patients reported that social risk screening was appropriate. Most also felt comfortable including social risk data in electronic health records. Although multiple factors influenced acceptability, the effects were moderate to small. These findings suggest that lack of patient acceptability is unlikely to be a major implementation barrier.

                Supplement information

                This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.
                  Cover page: Part I: A Quantitative Study of Social Risk Screening Acceptability in Patients and Caregivers
                  • Article
                  • Peer Reviewed
                  UC San Francisco Previously Published Works (2019)

                  Introduction

                  This study aimed to better understand patient and caregiver perspectives on social risk screening across different healthcare settings.

                  Methods

                  As part of a mixed-methods multisite study, the authors conducted semistructured interviews with a subset of adult patients and adult caregivers of pediatric patients who had completed the Center for Medicare and Medicaid Innovation Accountable Health Communities social risk screening tool between July 2018 and February 2019. Interviews, conducted in English or Spanish, asked about reactions to screening, screening acceptability, preferences for administration, prior screening experiences that informed perspectives, and expectations for social assistance. Basic thematic analysis and constant comparative methods were used to code and develop themes.

                  Results

                  Fifty interviews were conducted across 10 study sites in 9 states, including 6 primary care clinics and 4 emergency departments. There was broad consensus among interviewees across all sites that social risk screening was acceptable. The following 4 main themes emerged: (1) participants believed screening for social risks is important; (2) participants expressed insight into the connections between social risks and overall health; (3) participants emphasized the importance of patient-centered implementation of social risk screening; and (4) participants recognized limits to the healthcare sector's capacity to address or resolve social risks.

                  Conclusions

                  Despite gaps in the availability of social risk-related interventions in healthcare settings, patient-centered social risk screening, including empathy and attention to privacy, may strengthen relationships between patients and healthcare teams.

                  Supplement information

                  This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.
                    Cover page: Part II: A Qualitative Study of Social Risk Screening Acceptability in Patients and Caregivers
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