Skip to main content
eScholarship
Open Access Publications from the University of California

Scholarly Works (31 results)

  • Article
  • Peer Reviewed
UCLA Previously Published Works (2022)
Behavioral health integration (BHI) within primary care settings is shown to improve outcomes. However, achieving BHI requires identifying best practices and a reliable tool that can be used to measure existing levels and progress toward BHI. The objective of this study was to develop and apply a conceptual framework to measure BHI, test the approach, and examine challenges to achieving BHI. Surveys and interviews were conducted with key informants within 17 designated public hospitals in California at the midpoint of participating in a 5-year project to establish BHI. A framework and coding methodology were developed to assess BHI best practices at each hospital. BHI status was assessed in the domains of infrastructure and process. Each domain included 5 themes such as electronic health record integration and functionality (infrastructure) and interprovider communication (process). Themes were assessed using a 6-point scale for various activities under a theme and associated weights. Theme-specific values were standardized from 0% to 100% to compare BHI scores between hospitals. Overall progress toward BHI ranged from scores of 52% to 83% (mean 63%) and indicated greater contribution of infrastructure versus process implementation. Within the infrastructure domain, scores were higher for having institutional and provider support, but lagged in establishing provider proximity. Within the process domain, scores were highest for implementation of behavioral health screening, but were frequently lower for other themes such as use of care coordination and referral processes. Further research is needed to test the robustness of this approach in other settings.
    Cover page: Measuring Behavioral Health Integration in Primary Care
    • Thesis
    • Peer Reviewed
    UCLA Electronic Theses and Dissertations (2023)

    Unhealthy alcohol use, alcohol use that increases the risk of negative health and life consequences, is one of the leading preventable causes of morbidity and mortality in the United States, but treatment is often underutilized or delayed. In three studies, this dissertation applies the Multi-Level Health Outcomes Framework to explore patient, provider, and system-level factors related to receipt of treatment for unhealthy alcohol use.

    The first study examined data from a population-based survey and applied weighted logistic regression to assess the relationship between patient characteristics and receipt of help among individuals regularly engaging in unhealthy alcohol use. Individuals from certain racial/ethnic minority groups were less likely to receive help, while findings suggested higher likelihood of receipt of help among those with Medicaid insurance, higher education, and higher severity alcohol use. Knowledge of the factors associated with receipt of help for alcohol use can inform targeted interventions to increase treatment receipt.

    The second study utilized survey and Medicaid claims data from an evaluation of the Public Hospital Redesign and Incentives in Medi-Cal (PRIME) program to assess the relationship between behavioral health integration (BHI) and alcohol-related outcomes among primary care patients with alcohol-related diagnoses in 17 designated public hospitals in California. Using multilevel logistic regression, no significant associations were observed between overall BHI and main outcomes, but associations emerged between subcomponents of BHI and receipt of alcohol-related care. Findings warrant further research into relationships between specific components of BHI and receipt of care for alcohol use.

    The third study applied template and content analysis to assess data from narrative reports completed by hospital leadership over a five-year period obtained from an evaluation of the PRIME program to assess implementation of screening, brief intervention, and referral to treatment (SBIRT) for alcohol and substance use among primary care patients receiving care from 22 public hospitals in California. Findings highlighted wide variation in SBIRT processes and aspects of planning, education, and restructuring particularly influential in driving progress in implementing SBIRT.

    Collectively, this dissertation highlights factors influencing receipt and provision of care to inform efforts to promote earlier identification and treatment of unhealthy alcohol use.

      • Article
      • Peer Reviewed
      UC San Francisco Previously Published Works (2016)
      To explore the content of patient-provider e-mails in a safety-net primary care clinic, we conducted a content analysis using inductive and deductive coding of e-mail exchanges (n = 31) collected from January through November 2013. Participants were English-speaking adult patients with a chronic condition (or their caregivers) cared for at a single publicly funded general internal medicine clinic and their primary care providers (attending general internist physicians, clinical fellows, internal medicine residents, and nurse practitioners). All e-mails were nonurgent. Patients included a medical update in 19% of all e-mails. Patients requested action in 77% of e-mails, and the most common requests overall were for action regarding medications or treatment (29%). Requests for information were less common (45% of e-mails). Patient requests (n = 56) were resolved in 84% of e-mail exchanges, resulting in 63 actions. These results show that patients in safety-net clinics are capable of safely and effectively using electronic messaging for between-visit communication with providers. Safety-net systems should implement electronic communications tools as soon as possible to increase health care access and enhance patients' involvement in their care.
        Cover page: A Mixed-Methods Study of Patient–Provider E-Mail Content in a Safety-Net Setting
        • Article
        • Peer Reviewed
        UC San Francisco Previously Published Works (2016)

        Background

        The high prevalence of limited health literacy among patients threatens the success of secure electronic messaging between patients from diverse populations and their providers.

        Objective

        The purpose of this study is to generate hypotheses about the readability of patient and provider electronic messages.

        Methods

        We collected 31 patient-provider e-mail exchanges (n = 119 total messages) from a safety-net primary care clinic. We compared the messages' mean word count and Flesch-Kincaid Grade Levels (FKGLs), calculated the frequency of provider messages below an FKGL = 8, and assessed readability concordance between patients' and providers' messages.

        Results

        Patients used more words in their initial e-mails compared to providers, but the FKGLs were similar, and 68% of provider messages were written below an FKGL = 8. Of 31 exchanges, 9 (29%) contained at least one patient message with an FKGL > 3 grade levels lower than the corresponding provider message(s).

        Conclusion

        Our study demonstrates that most providers are able to respond to patient electronic messages with a matching reading level.
          Cover page: Readability assessment of patient-provider electronic messages in a primary care setting
          • Article
          • Peer Reviewed
          UC San Francisco Previously Published Works (2016)

          Introduction

          Tobacco-attributable deaths contribute significantly to the increased mortality observed among homeless adults aged 50 years or more. Little is known about the epidemiology of tobacco use among older homeless individuals. This longitudinal cohort study examines smoking behaviors and factors associated with smoking cessation among homeless individuals aged 50 years or more.

          Methods

          We recruited a prospective cohort of 350 homeless individuals sampled from the community in Oakland, California. At 6 months follow-up, participants reported their cigarette quit attempts and 30-day abstinence. We used multivariable logistic regression to examine factors associated with making a quit attempt at follow-up, hypothesizing that heavier smokers would be less likely to make a quit attempt.

          Results

          Of the 272 ever-smokers, 229 (84.2%) were current smokers (quit ratio 15.8). Among current smokers at enrollment who had a follow-up interview at 6 months, 43.6% (n = 71) reported making a quit attempt during the follow-up. Of those who reported making a quit attempt, 14.3% (n = 10) reported 30-day abstinence at follow-up. Among those who had reported making a quit attempt at follow-up, 22.5% had used nicotine replacement therapy (NRT). Staying in shelters (adjusted odds ratio [AOR] = 2.5, 95% confidence interval [CI] = 1.0-5.8) was associated with higher odds of making a quit attempt at follow-up. Higher cigarette consumption was associated with lower odds of making a quit attempt (AOR = 0.9, 95% CI = 0.8-0.9).

          Conclusions

          In this study of tobacco use in older homeless adults, rates of quit attempts were similar to that observed in the general population, but successful quitting was lower.

          Implications

          The current study is among the first studies to focus specifically on tobacco use and cessation behaviors among older homeless adults. The high prevalence of smoking and the low rates of successful quitting highlight numerous opportunities to intervene to increase quitting rates among this population. Among these, increasing access to smoke-free living environments and identifying effective cessation therapies will be critical to reducing tobacco-related disease burden among older homeless adults.
            Cover page: Tobacco Cessation Behaviors Among Older Homeless Adults: Results From the HOPE HOME Study.
            • Article
            • Peer Reviewed
            UC San Francisco Previously Published Works (2015)
              • Article
              • Peer Reviewed
              UC San Francisco Previously Published Works (2019)

              Objectives

              To describe the prevalence of and factors associated with oral health measures in a sample of older homeless adults in Oakland, CA.

              Methods

              We conducted a cross-sectional analysis of data from a population-based study of 350 homeless adults aged ≥50 in which trained researchers conducted structured interviews using validated questions regarding sociodemographics, health-related behaviors, healthcare utilization, and health status. We assessed self-reported tooth loss, oral pain, and unmet need for dental care. We used multivariable logistic regression to examine factors associated with missing half or more teeth.

              Results

              Over half 201/350 (57.4 percent) of participants were missing at least half of their teeth. Half 191/350 (54.6 percent) reported oral pain in the past 6 months; 101/350 (28.9 percent) reported that oral pain prevented them from eating and 73/350 (20.9 percent) reported that pain prevented sleeping. Almost half, 141/350 (40.3 percent), had not seen a dentist in over 5 years, and over half 190/350 (54.3 percent) reported being unable to obtain needed dental care. In multivariate models, increased age (AOR = 1.09, 95 percent CI 1.04-1.14), moderate-to-high risk alcohol use (AOR = 2.17, CI = 1.23-3.84), moderate-to-high risk cocaine use (AOR = 1.72, CI = 1.03-2.88), and ever smoking (AOR = 2.87, CI = 1.59-5.18) were associated with an increased odds of having lost half or more teeth.

              Conclusions

              Tooth loss and oral pain are highly prevalent in older homeless adults. Increasing age, alcohol, drug, and tobacco use are associated with tooth loss.
                Cover page: Oral health and access to dental care among older homeless adults: results from the HOPE HOME study
                • Article
                • Peer Reviewed
                UC San Francisco Previously Published Works (2018)
                Older homeless-experienced adults have low engagement in advance care planning (ACP) despite high morbidity and mortality. We conducted a cross-sectional analysis of a cohort of 350 homeless-experienced adults aged 50 and older in Oakland, California. We assessed the prevalence of potential surrogate decision-makers, ACP contemplation, discussions, and ACP documentation (surrogate designation, advance directives). We used multivariable logistic regression to examine factors associated with ACP discussions and documentation. The median age of the cohort was 59 (range 52-82), 75.2% were male, and 82.1% were black. Sixty-one percent reported a potential surrogate, 21.5% had discussed ACP, and 19.0% reported ACP documentation. In multivariable models, having 1 to 5 confidants versus none (adjusted odds ratio (aOR)=5.8, 95% confidence interval (CI)=1.7-20.0), 3 or more chronic conditions versus none (aOR=2.3, 95% CI=0.9-5.6), and a recent primary care visit (aOR=2.1, 95% CI=1.0-4.4) were associated with higher odds of ACP discussions and each additional 5 years of homelessness (aOR=0.7, 95% CI=0.5-0.9) with lower odds. Having 1 to 5 confidants (aOR=5.0, 95% CI=1.4-17.5), being black (aOR=5.5, 95% CI=1.5-19.5), and having adequate versus limited literacy (aOR=7.0, 95% CI=1.5-32.4) were associated with higher odds of ACP documentation and illicit drug use (aOR=0.3, 95% CI=0.1-0.9) with lower odds. Although the majority of older homeless-experienced adults have a potential surrogate, few have discussed or documented their ACP wishes; the odds of both were greater with larger social networks. Future interventions must be customized for individuals with limited social networks and address the instability of homelessness, health literacy, and the constraints of safety-net healthcare settings.
                  Cover page: Advance Care Planning for Older Homeless‐Experienced Adults: Results from the Health Outcomes of People Experiencing Homelessness in Older Middle Age Study
                  • Article
                  • Peer Reviewed
                  UC San Francisco Previously Published Works (2019)

                  Aims

                  To examine the prevalence of and factors associated with unmet need for mental health and substance use treatment in older homeless adults.

                  Methods

                  Among 350 homeless adults aged ≥50, we examined prevalence of mental health and substance use problems and treatment. Using logistic regression, we examined factors associated with unmet treatment need.

                  Results

                  Among those with a mental health problem, being aged ≥65 was associated with an increased odds, while having a regular healthcare provider and case manager were associated with a decreased odds of having unmet need for mental health treatment. A first homelessness episode at age ≥50 was associated with increased, while spending time in jail/prison or having a case manager was associated with decreased odds of unmet needs for substance use treatment.

                  Conclusion

                  Older homeless adults have a high prevalence of unmet behavioral health treatment need. There is a need for targeted services for this population.
                    Cover page: Unmet mental health and substance use treatment needs among older homeless adults: Results from the HOPE HOME Study
                    • Article
                    • Peer Reviewed
                    UC San Francisco Previously Published Works (2019)

                    Background

                    Patient experience surveys are widely used to capture the patient-reported quality of care and are increasingly being used for formal reporting purposes. There is evidence that certain patient subgroups are less likely to respond to traditional CAHPS surveys. As patient-facing technologies become more common, it is important to examine whether tablet-based patient experience surveys have the potential to promote responses from more diverse populations.

                    Objectives

                    To develop, gain perspectives about, and pilot an English and Spanish low-literacy adaptation of the Consumer Assessment of Healthcare Providers & Systems Clinician & Group Survey (CG-CAHPS) administered on a tablet device at the point of care.

                    Research design

                    Cognitive testing and evaluation of a quality improvement pilot comparing a tablet-based adaptation and traditional paper-based versions of the CG-CAHPS survey.

                    Subjects

                    English-speaking and Spanish-speaking patients receiving primary care in an urban community clinic.

                    Measures

                    To compare the acceptability of low-literacy tablet-based and traditional paper-based patient experience surveys, we examined the concordance of responses between survey modes and preferences for modality, as well as perspectives on usability and reporting care experiences. We examined demographic differences in responses to tablet-based versus mailed surveys from a quality improvement pilot.

                    Results

                    The majority of cognitive interview participants preferred a low-literacy, tablet-based survey over a paper-based survey with traditional wording. In a quality improvement pilot comparing tablet-based administration at the point of care versus mailed surveys, respondents to the tablet-based survey were more likely to be younger and Latino.

                    Conclusions

                    If designed with patient input, tablet-based surveys have the potential to improve the collection of patient experience data among diverse populations.
                      Cover page: Adapting Patient Experience Data Collection Processes for Lower Literacy Patient Populations Using Tablets at the Point of Care
                      Top