Socioeconomic and other factors such as race, ethnicity, income, education, and place of residence are associated with reduced access to and poorer quality healthcare. Clinicians serving disadvantaged populations are often overloaded, and have little chance to gather a comprehensive biomedical and psychosocial (biopsychosocial, BPS) evaluation of patients. This situation is unfortunate because many physical symptoms are medically unexplained, reflecting a pattern of high symptom reporting or underlying psychosocial issues, such as depression, trauma, or poorly-tolerated stress. These BPS factors are particularly problematic for patients from disadvantaged populations. Lastly, severe, medically unexplained symptoms, psychosocial issues, and poor quality of life (QOL) occur together in a subset of at-risk individuals (ARI), which comprises about 20% of typical clinic populations. ARI are at risk for poor outcomes and high costs from inappropriate care, a problem that is compounded in disadvantaged and minority populations where access to primary care is limited and urgent care is more prevalent than preventive care. SOLUTION: Our objective is to deploy a clinical methodology and infrastructure to ensure delivery of patient-centered care to minority and disadvantaged patients. Our work builds on an online, patient self-assessment system called CarePrep, now operational in clinic. CarePrep allows patients to easily enter and track BPS and QOL data over the Internet from home or clinic. However, just handing a diagnosis of depression, for example, to a clinician does not change outcomes. Therefore, we will also deploy an integrated intervention to support BPS care. APPROACH: 1) We will adapt, enhance cultural sensitivity, deploy, refine, and initially validate CarePrep in a primary care setting. Our goals are to meet the needs of patients and clinicians for enhancing communication and patient- centered care, ensuring that BPS issues are uncovered. Patients will be asked to do CarePrep before clinic. We will assess validity, feasibility, and CarePrep's ability to accurately identify patients who warrant extra attention (ARI) by findings such as severe symptoms, psychosocial issues, impaired QOL, or substance abuse. 2) We will analyze and develop a plan for supporting culturally competent, BPS care using some combination of automated CarePrep functionality, training and supporting care managers or existing clinic staff in delivering simple, brief BPS interventions, and telehealth support. IMPACT stems from 1) creating a system that generates sufficient value to patients, clinicians, and administrators to warrant routine use;2) creating a streamlined, branching assessment that minimizes redundancy and maximizes relevance, thereby supporting collection of the full spectrum of relevant data and delivery of context-relevant education and guidance;3) using this technology and clinical methodology to transcend barriers to care for minorities and disadvantaged populations, and 4) identifying, characterizing, and targeting care to the patients with the greatest need and highest utilization within such populations, thereby facilitating cost-effective use of limited healthcare dollars.
This work adapts an online, patient self-assessment system now in operation in clinic to support delivery of patient-centered care for minority and disadvantaged patients. We focus on helping clinicians care for patients with multiple, severe physical symptoms, psychosocial, and health behavioral issues that interfere with their quality of life and ability to function, because these patients now have the poorest outcomes and consume a disproportionate share of resources. These outcomes are likely to be worse in disadvantaged and minority populations where access to primary care is limited and urgent care more prevalent than preventive care. Our online system gathers a comprehensive assessment and presents the data so that clinicians can rapidly identify the most important issues. However, simply delivering this information is not enough;we also propose to support care by a combination of the online system offloading clinician tasks, training and supporting care managers or clinicians to help in assessment and treatment, and delivering telehealth support where needed.
