Project ACHIEVE (Achieving Patient-Centered Care and Optimized Health In Care Transitions by Evaluating the Value of Evidence)—Funded by Patient Centered Outcome Research Institute (PCORI), nationally recognized leaders in healthcare and research methods are partnering with patients and caregivers to evaluate the effectiveness of current efforts at improving care transitions and develop recommendations on best practices for patient-centered care transitions and guidance for spreading them across the U.S.
Patients in the U.S. suffer harm too often as they move between sites of health care, and their caregivers experience significant burden. Poorly managed patient care transitions can lead to worsening symptoms, adverse effects from medications, unaddressed test results, and excess re-hospitalizations and emergency visits. Project ACHIEVE is a collaboration among patients, family caregivers, and nationally recognized leaders in health care transitions and research to evaluate the effectiveness of current efforts at improving care transitions. Funded by the Patient Centered Outcome Research Institute (PCORI), the ACHIEVE team aims to develop recommendations on best practices for patient-centered care transitions and guidance for dissemination.
1. Identify the transitional care outcomes and components that matter most to patients and caregivers.
2. Determine which evidence-based transitional care (TC) strategies or clusters most effectively yield patient and caregiver desired outcomes overall and among diverse patient and caregiver populations in different types of care settings and communities.
3. Identify barriers and facilitators to the implementation of specific TC strategies or clusters of TC strategies for different types of care settings and communities.
4. Develop recommendations for dissemination and implementation of the findings on the best evidence regarding how to achieve optimal TC services and outcomes for patients, caregivers and providers.
Project BOOST®—The Project BOOST® Mentored Implementation Program is a yearlong initiative wherein hospitals receive expert mentoring and peer support to aid in improving the care of patients as they transition from hospital to home. BOOST mentors help hospital teams to map current processes and create and implement action plans for organizational change. BOOST provides a suite of evidence-based clinical interventions that can be easily adapted and integrated into each unique hospital environment.
Tracking and Evaluation Core of UK's Center for Clinical and Translational Science—CHSR is implementing a comprehensive evaluation plan to engage CCTS leadership, researchers, and staff in examining progress and impact in the field of translational science. Using internal resources and expertise gleaned from our ongoing work in the areas of healthcare transformation, community outreach and engagement, and quality improvement and evaluation, our CCTS T&E plan employs validated methods designed to accomplish tracking and performance monitoring, continuous quality improvement, process and implementation evaluation, and assessment of outcomes and impact indicators.
Kentucky Consortium for Accountable Health Communities (KC-AHC)—Funded by the Centers for Medicare & Medicaid Services, CHSR has established the KC-AHC to address the health-related social needs of vulnerable patients across the Commonwealth. KC-AHC will implement and test an Alignment model, which seeks to determine whether providing a combination of tailored community service referrals and patient navigation services assistance, as well as clinical and community partner alignment, will yield improvement in patient outcomes, health care utilization and costs.
The AHC model recognizes that social and community-level need factors are key drivers of pervasive health inequalities, contributing to elevated disease burden and healthcare utilization costs among vulnerable populations of community dwelling Medicaid and Medicare beneficiaries. The University of Kentucky Center for Health Services Research (CHSR) has designed the Kentucky Consortium for Accountable Health Communities (KC-AHC) to reach the most vulnerable community-dwelling beneficiaries in the State of Kentucky by targeting a diverse range of economically depressed and medically underserved geographic areas across the Commonwealth.
Our KC-AHC proposal will address a number of important service gaps in Kentucky, including the absence of a standardized system to universally screen community-dwelling Medicare and Medicaid beneficiaries to identify health-related social needs that can be served through access to targeted services. We seek to implement Track 3 (Alignment) of the AHC model, to determine whether providing a combination of tailored community service referrals and navigation services assistance at the individual beneficiary level, as well as clinical partner alignment at the community level, impacts patient outcomes, health care utilization and costs. This intervention incorporates structural supports and financial sustainability planning to foster community-wide realignment of resources to more effectively address health-related social needs for all community-dwelling beneficiaries.
CHSR’s approach to the KC-AHC involves building a strong and diverse cadre of clinical and community-level partners and other stakeholders, and facilitating structured communications among these stakeholders to drive the processes of KC-AHC model implementation, gap analysis, and quality improvement through an Advisory Board mechanism. The mechanisms for decision-making in the KC-AHC model create ideal conditions for close collaboration between CHSR and its partner agencies; Our partners will be actively engaged to contribute to the development of new screening and assessment tools, to the plans for intervention implementation, and offered opportunities to consider integrating process changes that may ultimately improve services and reduce healthcare costs for high needs beneficiaries. CHSR envisions the KC-AHC as an opportunity to move research innovations into clinical practice to improve health outcomes and costs among our most vulnerable patients.
Examining Social Influences on Syringe Exchange Uptake Among Rural PWID at Risk for HIV—The National Institutes of Health (NIH) awarded the CHSR funding to study the adoption of syringe exchange programs in rural communities in the Appalachian region of Kentucky. Rates of opioid use disorder and injection drug use have risen significantly in Kentucky, especially in rural communities. The two-year National Institute on Drug Abuse-funded study is designed to reach vulnerable injection drug users in Clark, Knox, and Pike counties to understand the multi-level barriers to access syringe exchange programs and to identify priority intervention targets and strategies to increase uptake.
The proposed study will conduct targeted formative research to identify key social-ecological factors influencing the uptake of newly implemented syringe exchange programs (SEPs) among people who inject drugs (PWID) in rural Appalachian Kentucky (KY). The recent initiation of SEPs in this rural, resource poor area provides a unique opportunity to examine social drivers impacting uptake of an evidence-based structural level HIV prevention intervention among a highly vulnerable and understudied population of PWID, and to develop complementary intervention strategies for enhancing SEP utilization. Serious health consequences associated with opioid injection are at crisis levels: KY has the highest rate of acute hepatitis C (HCV) in the nation, particularly among persons aged ≤30 years residing in non-urban areas, with a risk factor of injection drug use. In addition, a recent analysis by the CDC identified 8 counties in Appalachian KY as among the nation’s top 10 most vulnerable to the rapid dissemination of HIV and HCV among PWID. Despite well-documented rural-urban differences in drug use patterns and social characteristics, there is a critical gap in our knowledge of social drivers of SEP uptake and utilization among PWID in rural communities. The implementation of structural level HIV prevention programming has been virtually absent in rural locations, and the applicability of research findings from urban SEPs is largely unknown. Such data are urgently needed to inform the continued refinement of SEP policies and practices for vulnerable rural PWID and to develop complementary multi-level prevention strategies to enhance access and utilization of rurally located SEPs. Guided by Social Ecological Theory, the Specific Aims of this exploratory mixed methods study are to: 1) Examine the uptake of SEPs in three Appalachian county HDs (Clark, Knox and Pike), through structured interviews with 350 PWID (175 SEP utilizers and 175 non-utilizers) to identify and compare the key differences between utilizers and non-utilizers in social ecological domains, including intrapersonal (e.g., HIV /HCV knowledge, rural identity), interpersonal (e.g., kinship, peer norms, social isolation); institutional (e.g., justice system involvement, law enforcement activity); community (e.g., community stigma, geographic distance); and public policy factors (e.g., SEP policies and practices (privacy/anonymity, hours, locations, distribution model, secondary exchange)) that influence SEP uptake and utilization; and, 2) Identify priority intervention targets and develop strategies to enhance uptake of SEPs among rural PWID, by conducting in-depth qualitative interviews with a strategically selected sample of PWID from Aim 1, as well as key health departments directors and SEP staff, local substance treatment providers, law enforcement, and other community stakeholders, to assess multi-level barriers to SEP utilization, acceptability and feasibility of complementary intervention strategies, and to develop recommendations for intervention priorities and practice changes to improve SEP uptake.
Project MISSION (Developing a multicomponent, Multilevel Implementation Strategy for Syncope OptImalCare thrOugh eNgagement)—
Syncope is a complex presenting symptom that requires thoughtful and efficient evaluation to determine the etiology of a patient’s loss of consciousness. Prevalence rates of syncope have been reported as high as 41%, with recurrent syncope occurring in 13.5%. A common symptom, approximately 1% to 3% of all emergency department (ED) visits (as many ED visits as atrial fibrillation) and up to 6% of all hospital admissions are due to syncope. The prognosis among patients with syncope depends on the etiology and underlying cardiovascular condition. A cardiac etiology of syncope is associated with significantly higher rates of morbidity and mortality than other causes such as vasovagal reflex mediated or orthostatic hypotension. The Framingham study documented a doubling of the risk of death among participants with cardiac syncope compared with those with non-cardiac syncope. Notably, experiencing syncope affects patients’ quality of life (QoL), and those with more frequent syncope report poorer QoL with perceptions of low overall physical and mental health and impairment in activities of daily living. The QoL among patients with recurrent syncope appears equivalent to severe rheumatoid arthritis and chronic low-back pain in an adult population. Though research in the past 25 years provides substantial understanding of the pathophysiology of particular etiologies of syncope, the diagnostic approach to such a perplexing symptom remains difficult and efficient diagnosis remains elusive.
The major challenge in the evaluation of patients with syncope is that most patients are asymptomatic at the time of their presentation. Because of concerns that patients presenting with syncope are at risk for an impending catastrophic event, overuse and inappropriate use of testing and hospital admission are common. Aiming to provide guidance on optimizing the evaluation and management of syncope, a collaboration of the American College of Emergency Physicians, Society for Academic Emergency Medicine, American College of Cardiology (ACC), American Heart Association (AHA) and Heart Rhythm Society (HRS) issued a Guideline for the Evaluation and Management of Patients with Syncope in 2017. Adopting a standardized approach to syncope based on this guideline offers an effective opportunity for delivering high value care to patients suffering this distressing and potentially dangerous event. Aiming for more rapid translation from guideline to clinical practice and improved health, the proposed study will identify barriers and facilitators for implementation of an evidence-based, high value approach to diagnosis and management of patients presenting with syncope. The research team will develop a multi-level, multi-component implementation strategy for evidence-based syncope evaluation and management and plan for a subsequent hybrid effectiveness-implementation trial, guided by the Consolidated Framework for Implementation Research (CFIR).
Social Network Analysis and Social Support Intervention for Rural Dwelling Older Adults with T2DM—
Approximately 29.1 million (9.3%) adults in the US have type 2 diabetes (T2DM). T2DM is associated with significant complications including premature coronary artery disease, kidney disease, stroke, and blindness. Estimates show that prevalence of T2DM is 17% higher in rural dwellers compared to their urban counterparts. For example, the prevalence of T2DM for adults in Kentucky’s rural Appalachian counties is 13.6%, compared to the overall state prevalence of 10.6%. Appropriate self-care behaviors are necessary for optimal clinical outcomes in T2DM and account for 90% of the variance in glycemic control. Yet, self-care among T2DM is notoriously poor in general and even worse in rural-dwellers. Without attention to improving self-care in this population, we are facing an epidemic of T2DM complications in rural areas of the US.
The impact of living with T2DM in rural communities is compounded in the aging population. The prevalence of T2DM increases with age and an estimated 25% of older adults (≥65 years) have T2DM. Older adults living with T2DM have more difficulty than younger people adhering to self-care regimens and social/environment factors account for up to 85% of their self-care nonadherence. Notable social/environment factors include competing social demands, lack of social support (SS), and stress. Social support plays a particularly significant role in older adults with T2DM. The extent and type of SS available in rural communities can positively or negatively impact self-care in those diagnosed with T2DM.
To better understand the effects of the social environment in communities where older rural dwelling adults reside and to lay the foundation for interventions, social network analysis (SNA) will be used to determine social support network structures. By using SNA, social support structures can be developed and relationships between individuals within a social network can be evaluated. The overall objective of this study is to improve T2DM self-care regimens in older rural dwelling adults by training influential community members to be community health workers and provide social support strategies within an older adults’ existing social network that promotes T2DM self-care.
The proposed study seeks to:
Aim 1—Use social network analysis to identify key players in a rural community to serve as community health workers for those living with T2DM.
Aim 2—Use mixed methods to evaluate the impact of social support on T2DM self-care and clinical outcomes and evaluate social networks in rural dwelling older adults with T2DM.
Aim 3—Test the feasibility and preliminary effectiveness of a 6-week intervention administered by community health workers with the support of members of older adults’ individual social network.