Literature Collection

BACKGROUND: The period following hospital discharge marks a precarious transition for older adults across medical, functional, and social domains. Paramedic-led mobile integrated health (MIH) programs offer a promising approach to bridging gaps in care, though their effectiveness in transitional care remains poorly characterized. The objective of this study was to evaluate the association of the Paramedic Assisted Community Evaluation (after) Discharge (PACED) intervention with 30-day rehospitalization rates among frail older adults. METHODS: In this prospective observational study, the clinical team offered older adults discharged from an urban academic medical center a paramedic-delivered home visit within 72 h. Patients who lived outside the program's geographical catchment area, did not have a system-affiliated primary care doctor, or who declined visits served as a comparator group to create a natural experiment. The primary outcome was 30-day rehospitalization. Secondary outcomes included 30-day emergency department (ED) utilization without admission. The characteristics of the sample and the content of the PACED visits for enrolled patients were presented descriptively. Modified Poisson regressions were used to estimate relative risks (RR) for 30-day rehospitalization and ED utilization, adjusting for demographics, comorbidities, frailty, and prior healthcare use with 95% confidence intervals (CIs). RESULTS: Of 297 subjects, 190 received the PACED intervention (median age 82.7, 66.8% female) and 107 served as comparators (median age 81.3, 58.0% female). Thirty-day rehospitalization was lower among PACED participants (12.6% vs. 21.5%, adjusted RR 0.45, 95% CI: 0.26-0.77, p = 0.003), and they experienced fewer 30-day ED visits (11.5% vs. 18.7%, adjusted RR 0.58, 95% CI: 0.33-0.98, p = 0.05). CONCLUSIONS: An in-home mobile integrated health (MIH) transitional care program for frail older adults after hospital discharge was associated with lower 30-day readmission rates. These findings highlight MIH as a promising model to support aging in place and suggest its potential value for adoption within age-friendly health systems.

OBJECTIVE: To examine how depression screening rates changed after implementation of electronic health record (EHR) clinical decision support tools and medical assistant (MA)-led depression screening at an outpatient pediatric practice. METHODS: We assessed changes in depression screening rates at an urban academic pediatric clinic between September 2016 and December 2020 using interrupted time series analysis. During this time, we implemented 1) EHR clinical decision support tools for depression screening and management (November 2017) and 2) training of MAs to screen for depression (July 2019). RESULTS: Over the study period, 3963 patients received care in the pediatric clinic. Their mean age was 14.9 years (standard deviation, 2.6) and about half were female (n = 2011, 51%). The majority were Black/African American (n = 2852, 72%) and had private insurance (n = 2860, 72%). Depression screening rates increased from 3% to >80%. Preintervention, depression screening rates were not increasing (0.9% per month, 95% confidence interval [CI]: -0.3% to 2.1%; P = .15). After implementing EHR clinical decision support tools, there was a 15.6% (95% CI: 2.5%-28.6%, P = .02) increase in the screening rate. Also, MA-led screening was associated with a 24.6% (95% CI: 9.9%-39.2%, P = .002) screening rate increase. CONCLUSION: This study demonstrates that EHR clinical decision support tools and MA-led screening are likely to increase adolescent depression screening and management in pediatric clinics.

BACKGROUND: Guidelines recommend that individuals with opioid use disorder (OUD) receive pharmacological and psychosocial interventions; however, the most appropriate psychosocial intervention is not known. In collaboration with people with lived experience, clinicians, and policy makers, we sought to assess the relative benefits of psychosocial interventions as an adjunct to opioid agonist therapy (OAT) among persons with OUD. METHODS: A review protocol was registered a priori (CRD42018090761), and a comprehensive search for randomized controlled trials (RCT) was conducted from database inception to June 2020 in MEDLINE, Embase, PsycINFO and the Cochrane Central Register of Controlled Trials. Established methods for study selection and data extraction were used. Primary outcomes were treatment retention and opioid use (measured by urinalysis for opioid use and opioid abstinence outcomes). Odds ratios were estimated using network meta-analyses (NMA) as appropriate based on available evidence, and in remaining cases alternative approaches to synthesis were used. RESULTS: Seventy-two RCTs met the inclusion criteria. Risk of bias evaluations commonly identified study limitations and poor reporting with regard to methods used for allocation concealment and selective outcome reporting. Due to inconsistency in reporting of outcome measures, only 48 RCTs (20 unique interventions, 5,404 participants) were included for NMA of treatment retention, where statistically significant differences were found when psychosocial interventions were used as an adjunct to OAT as compared to OAT-only. The addition of rewards-based interventions such as contingency management (alone or with community reinforcement approach) to OAT was superior to OAT-only. Few statistically significant differences between psychosocial interventions were identified among any other pairwise comparisons. Heterogeneity in reporting formats precluded an NMA for opioid use. A structured synthesis was undertaken for the remaining outcomes which included opioid use (n = 18 studies) and opioid abstinence (n = 35 studies), where the majority of studies found no significant difference between OAT plus psychosocial interventions as compared to OAT-only. CONCLUSIONS: This systematic review offers a comprehensive synthesis of the available evidence and the limitations of current trials of psychosocial interventions applied as an adjunct to OAT for OUD. Clinicians and health services may wish to consider integrating contingency management in addition to OAT for OUD in their settings to improve treatment retention. Aside from treatment retention, few differences were consistently found between psychosocial interventions adjunctive to OAT and OAT-only. There is a need for high-quality RCTs to establish more definitive conclusions. TRIAL REGISTRATION: PROSPERO registration CRD42018090761.

Objective: To evaluate changes in health and health care utilization outcomes for Latinx adults with substance use and mental disorders receiving integrated behavioral and primary health care.Design: Study sample included enrollees who completed baseline, 6-month and 12-month assessments (n = 107). Study outcomes were depression symptom severity, anxiety symptom severity, illicit drug use, emergency department utilization and homelessness status. Pre-post analyses were conducted using paired t-test and McNemar test to examine changes in study outcomes. Multivariable regression model estimated through generalized estimating equations explored the influence of the intervention on study outcomes. Results were presented in adjusted odds ratios (AOR) and 95% confidence intervals (CI).Results: Participants were less likely to report depressive symptoms (AOR: 0.496, 95%CI: 0.296-0.832), less likely to report anxiety symptoms (AOR: 0.539, 95%CI: 0.329-0.884), and less likely to experience homelessness (AOR: 0.556, 95%CI: 0.328-0.943) at 6-month assessment compared to baseline. Participants were also less likely to report depressive symptoms (AOR: 0.378, 95%CI: 0.209-0.684), less likely to report anxiety symptoms (AOR: 0.471, 95%CI: 0.270-0.821), less likely to experience homelessness (AOR: 0.333, 95%CI: 0.189-0.587), and less likely to utilize the emergency department in the past 30 days (AOR: 0.397, 95%CI: 0.188-0.837) at 12-month assessment compared to baseline.Conclusions: Integrating culturally responsive behavioral and primary health care services is critical for addressing the needs of Latinx adults with mental and substance use disorders, and other chronic diseases. This initiative has the potential to reduce disparities in access to and engagement in care for Latinx adults.