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Use of an Integrated Care Management Program to Uncover and Address Social Determinants of Health for Individuals With Lupus

OBJECTIVE: We studied patients with systemic lupus erythematosus (SLE) enrolled in a nurse‐led, multihospital, primary care–based integrated care management program (iCMP) for complex patients with chronic conditions to understand whether social determinants of health (SDoH), including food insecuri...

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Autores principales: Taber, Kreager A., Williams, Jessica N., Huang, Weixing, McLaughlin, Katherine, Vogeli, Christine, Cunningham, Rebecca, Wichmann, Lisa, Feldman, Candace H.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: John Wiley and Sons Inc. 2021
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8126752/
https://www.ncbi.nlm.nih.gov/pubmed/33779065
http://dx.doi.org/10.1002/acr2.11236
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author Taber, Kreager A.
Williams, Jessica N.
Huang, Weixing
McLaughlin, Katherine
Vogeli, Christine
Cunningham, Rebecca
Wichmann, Lisa
Feldman, Candace H.
author_facet Taber, Kreager A.
Williams, Jessica N.
Huang, Weixing
McLaughlin, Katherine
Vogeli, Christine
Cunningham, Rebecca
Wichmann, Lisa
Feldman, Candace H.
author_sort Taber, Kreager A.
collection PubMed
description OBJECTIVE: We studied patients with systemic lupus erythematosus (SLE) enrolled in a nurse‐led, multihospital, primary care–based integrated care management program (iCMP) for complex patients with chronic conditions to understand whether social determinants of health (SDoH), including food insecurity, housing instability, and financial constraints, were prevalent in this population. METHODS: The academic hospital‐based iCMP enrolls the top 2% of medically and psychosocially complex patients identified on the basis of clinical complexity health care use, and primary care provider referral. A nurse conducts needs assessments and coordinates care. We reviewed the electronic medical records of enrolled patients with SLE to identify SDoH needs and corresponding actions taken 1 year prior to iCMP enrollment using physicians’ and social workers’ notes, and during enrollment using iCMP team members’ notes. RESULTS: Among 69 patients with SLE in the iCMP, in the year prior to enrollment, 57% had documentation of one or more SDoH challenges, compared with 94% during enrollment. iCMP nurses discussed and addressed one or more SDoH issues for 81% of the patients; transportation challenges, medication access, mental health care access, and financial insecurity were the most prevalent. Nurses connected 75% of these patients with related resources and support. CONCLUSION: Although SDoH‐related issues were not used to identify patients for the iCMP, the vast majority of enrolled medically and psychosocially complex patients with SLE had these needs. The iCMP team uncovered and addressed SDoH‐related concerns not documented prior to iCMP participation. Expansion of care management programs like the iCMP would help identify, document, and address these barriers that contribute to disparities in chronic disease care and outcomes.
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spelling pubmed-81267522021-05-21 Use of an Integrated Care Management Program to Uncover and Address Social Determinants of Health for Individuals With Lupus Taber, Kreager A. Williams, Jessica N. Huang, Weixing McLaughlin, Katherine Vogeli, Christine Cunningham, Rebecca Wichmann, Lisa Feldman, Candace H. ACR Open Rheumatol Brief Report OBJECTIVE: We studied patients with systemic lupus erythematosus (SLE) enrolled in a nurse‐led, multihospital, primary care–based integrated care management program (iCMP) for complex patients with chronic conditions to understand whether social determinants of health (SDoH), including food insecurity, housing instability, and financial constraints, were prevalent in this population. METHODS: The academic hospital‐based iCMP enrolls the top 2% of medically and psychosocially complex patients identified on the basis of clinical complexity health care use, and primary care provider referral. A nurse conducts needs assessments and coordinates care. We reviewed the electronic medical records of enrolled patients with SLE to identify SDoH needs and corresponding actions taken 1 year prior to iCMP enrollment using physicians’ and social workers’ notes, and during enrollment using iCMP team members’ notes. RESULTS: Among 69 patients with SLE in the iCMP, in the year prior to enrollment, 57% had documentation of one or more SDoH challenges, compared with 94% during enrollment. iCMP nurses discussed and addressed one or more SDoH issues for 81% of the patients; transportation challenges, medication access, mental health care access, and financial insecurity were the most prevalent. Nurses connected 75% of these patients with related resources and support. CONCLUSION: Although SDoH‐related issues were not used to identify patients for the iCMP, the vast majority of enrolled medically and psychosocially complex patients with SLE had these needs. The iCMP team uncovered and addressed SDoH‐related concerns not documented prior to iCMP participation. Expansion of care management programs like the iCMP would help identify, document, and address these barriers that contribute to disparities in chronic disease care and outcomes. John Wiley and Sons Inc. 2021-03-29 /pmc/articles/PMC8126752/ /pubmed/33779065 http://dx.doi.org/10.1002/acr2.11236 Text en © 2021 The Authors. ACR Open Rheumatology published by Wiley Periodicals LLC on behalf of American College of Rheumatology. https://creativecommons.org/licenses/by-nc-nd/4.0/This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ (https://creativecommons.org/licenses/by-nc-nd/4.0/) License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.
spellingShingle Brief Report
Taber, Kreager A.
Williams, Jessica N.
Huang, Weixing
McLaughlin, Katherine
Vogeli, Christine
Cunningham, Rebecca
Wichmann, Lisa
Feldman, Candace H.
Use of an Integrated Care Management Program to Uncover and Address Social Determinants of Health for Individuals With Lupus
title Use of an Integrated Care Management Program to Uncover and Address Social Determinants of Health for Individuals With Lupus
title_full Use of an Integrated Care Management Program to Uncover and Address Social Determinants of Health for Individuals With Lupus
title_fullStr Use of an Integrated Care Management Program to Uncover and Address Social Determinants of Health for Individuals With Lupus
title_full_unstemmed Use of an Integrated Care Management Program to Uncover and Address Social Determinants of Health for Individuals With Lupus
title_short Use of an Integrated Care Management Program to Uncover and Address Social Determinants of Health for Individuals With Lupus
title_sort use of an integrated care management program to uncover and address social determinants of health for individuals with lupus
topic Brief Report
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8126752/
https://www.ncbi.nlm.nih.gov/pubmed/33779065
http://dx.doi.org/10.1002/acr2.11236
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