Implementation strategies to improve adoption of unmet social needs screening and referrals in care management using enabling technologies: study protocol for a cluster randomized trial.

Background: Adverse social determinants of health contribute to health inequities. Practice guidelines now recommend incorporating patient unmet social needs into patient care, and payors increasingly reimburse for screening and providing related referrals to community organizations. Emergent electronic health record (EHR)-based tools can enable clinical-community linkages, but their adoption commonly faces workflow and infrastructure barriers.

Patient-Reported Social Risks and Clinician Decision Making: Results of a Clinician Survey in Primary Care Community Health Centers.

Purpose: To assess the extent that patients' social determinants of health (SDOH) influence safety-net primary care clinicians' decisions at the point of care; examine how that information comes to the clinician's attention; and analyze clinician, patient, and encounter characteristics associated with the use of SDOH data in clinical decision making.

Methods: Thirty-eight clinicians working in 21 clinics were prompted to complete 2 short card surveys embedded in the electronic health record (EHR) daily for 3 weeks. Survey data were matched with clinician-, encounter-, and patient-level variables from the EHR.

Designing and Implementing an Electronic Health Record-Embedded Card Study in Primary Care: Methods and Considerations.

Card studies-short surveys about the circumstances within which patients receive care-are traditionally completed on physical cards. We report on the development of an electronic health record (EHR)-embedded card study intended to decrease logistical challenges inherent to paper-based approaches, including distributing, tracking, and transferring the physical cards, as well as data entry and respondent prompts, while simultaneously decreasing the complexity for participants and facilitating rich analyses by linking to clinical and demographic data found in the EHR. Developing the EHR-based programming and data extraction was time consuming, required specialized expertise, and necessitated iteration to rectify issues encountered during implementation.

Adjusting for Patient Economic/Access Issues in a Hypertension Quality Measure.

Introduction: The American Heart Association and American College of Cardiology have proposed adjusting hypertension-related care quality measures by excluding patients with economic/access issues from the denominator of rate calculations. No research to date has explored the methods to operationalize this recommendation or how to measure economic/access issues. This study applied and compared different approaches to populating these denominator exceptions.

Results of a Social Network Testing Intervention for HIV in Infectious Disease Clinics.

Social networks can be leveraged to identify undiagnosed HIV-infected individuals. The NC-LINK clinic-based testing initiative utilized these networks to achieve a 5% (95% CI 1.1-8.

Characteristics of Out-of-Care Patients Who Required a Referral for Re-engagement Services by Public Health Bridge Counselors Following a Brief Clinic-Based Retention Intervention.

The NC-LINK Project initiated both clinic-based retention services and state public health bridge counselor-based (SBCs) re-engagement services to retain and re-engage people living with HIV infection (PLWH) in care. The goal of this project is to compare efforts between clinic-based retention and SBC re-engagement services to determine whether patients are more or less likely to remain in HIV care services. Clinic appointment data were used to identify patients who were last seen more than 6-9 months prior.

Past Care Predicts Future Care in Out-of-Care People Living with HIV: Results of a Clinic-Based Retention-in-Care Intervention in North Carolina.

Poor retention in care is associated with higher viral load (VL) results and decreased rates of viral load suppression (VS) in people living with HIV (PLWH). Therefore, improving retention in HIV care is a priority of national significance. The NC-LINK Retention Project utilized a systematic approach to identify, locate, and attempt to return to care patients who did not attend a clinic appointment for 6-9 months.

The North Carolina HIV Bridge Counselor Program: Outcomes From a Statewide Level Intervention to Link and Reengage HIV-Infected Persons in Care in the South.

Background: To improve the HIV continuum of care, a team of field service interventionists (State Bridge Counselors, SBC) was developed through a state public health system and provided brief (1-2) contacts for linkage of newly diagnosed persons with HIV and reengagement of persons living with HIV (PLWH) who were not in care.

Setting: North Carolina, United States.

Methods: Service data from January 2013 to June 2015 were analyzed to determine characteristics of clients referred to SBCs, proportions linked or reengaged in care, and/or achieved viral load suppression (VLs).

HIV patient retention: the implementation of a North Carolina clinic-based protocol.

Decreased visit attendance leads to poor health outcomes, decreased viral suppression, and higher mortality rates for persons living with HIV. Retention in care is an important factor in improving health status for people living with HIV but continues to be a challenge in clinical settings. This paper details the development and implementation of the NC-LINK Retention Protocol, a clinic-based protocol to locate and reengage out-of-care patients, as part of overall clinic retention efforts.