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The Institute for Family Health’s 7th Annual Research and Innovation Symposium “Celebrating Achievements in Community Health”


Dear Colleagues, It is my honor to welcome you to the Institute’s Seventh Annual Research and Innovation Symposium at the New York Academy of Medicine. Each year I am thrilled to read about the innovative scholarly activity being carried out across our organization, representing almost every type of clinic, program, and department under our roof. I believe symposia like ours are essential to engender the clever thinking, proactive problem solving, and productive dialogue that coalesce to drive systemic improvements for our patients and communities. I encourage you to view every presentation, speak with the authors, and learn what we as an organization are doing through research and advocacy to address the barriers to healthy lives our patients encounter every day.

Neil S. Calman, MD President and CEO, The Institute for Family Health & System Chair, The Alfred and Gail Engelberg Department of Family Medicine and Community Health at the Icahn School of Medicine at Mount Sinai

The Institute for Family Health, founded in 1983, is committed to high-quality, affordable health care and accepts all patients, regardless of their ability to pay, at all of its practices. The Institute uses its expertise and resources to address racial and ethnic disparities in health, advance use of health information technology, and find innovative ways to improve care for diabetes, depression, women’s health, HIV, and other priorities in the communities it serves. It is committed to improving the health care system, particularly for individuals and communities who historically have had limited access to care. It also engages in research to improve health care services and participates in policy development at local, state, and national levels. The Institute operates the Department of Family Medicine and Community Health in affiliation with the Icahn School of Medicine at Mount Sinai.


Table of Contents Agenda .................................................................................................3

Abstract Categories Research ...............................................................................................4 Continuous Quality Improvement (CQI) ............................................13 Innovative Projects ............................................................................21


2018 Institute for Family Health Research and Innovation Symposium The New York Academy of Medicine 1216 5th Ave, New York, NY 10029

Wednesday, April 25th, 2018

Agenda 5:00pm

Check-in and Registration


Poster and Storyboard presentation


Welcoming Remarks Dr. Neil Calman – President and CEO of the Institute for Family Health


Awards Ceremony Best in category awards for Research, CQI, and Innovative Projects, as well as the “People’s Choice” award 3

RESEARCH A Comparison of Tricyclic Antidepressant Prescriptions between Patients with and without Identified Suicidal Ideation Authors: Anna Blazejowskyj, BS, Virna Little, PsyD, Abigail Herron, DO, Andrea Cole, PhD Background: Research has demonstrated the toxicity of Tricyclic Antidepressants (TCAs) and has identified that TCAs are implicated in intentional self-poisoning deaths. Objective: Limited data exists on current trends in TCA prescribing, specifically among primary care providers and for patients with identified suicidal ideation (SI). This study aimed to fill this gap. Design: A retrospective secondary data analysis of electronic health record data for 6535 TCA prescription orders was performed. Differences in prescriptions were compared between patients with and without identified Suicidal Ideation (SI) for indication, drug type, dose, quantity, number of refills, and specialty of provider. Analyses were completed using SPSS statistical software, and the Pearson Chi-Square Statistic or Test for Linear Trend was utilized as appropriate. Setting/Participants: Data included orders for 1805 patients across all IFH sites who received TCA prescriptions between July 2013 to July 2016. Instrumentation/Intervention/Data Collection: This is a retrospective analysis of EPIC data that was recorded during standard clinical practices. Results and Conclusions: In total, 127 patients with a history of SI received TCAs. Patients with identified SI were primarily prescribed TCAs for mental health reasons (67%), while non-suicidal patients were prescribed TCAs most often for pain (51%). Patients with identified SI received fewer refills and were less likely to receive prescriptions for 90 days or more. Psychiatrists prescribed fewer refills and smaller quantities of TCAs than other providers (all comparisons, P < 0.001). Overall, providers at IFH prescribe TCAs with fewer refills and reduced quantities when prescribing to patients with identified suicidal ideation. However, non-psychiatry providers seem to be less likely than psychiatrists to consider safety concerns when prescribing TCAs. These results suggest additional education may be needed for primary care providers around the dangers of prescribing TCAs to individuals with SI.

Reducing sugar-sweetened beverage consumption among youth in the South Bronx through an innovative counter marketing curriculum Author: Moria Byrne-Zaaloff, MPH Background: In the last 30 years, marketing for sugar sweetened beverages (SSBs) has increased in the United States, disproportionately targeting low income and minority communities. In the Bronx, where residents drink the most SSBs in NYC (up to four or more daily), exposure to SSB marketing places them at greater risk for developing chronic dietrelated illnesses. Objective: The purpose of this study was to implement a “counter marketing” curriculum to middle school students in South Bronx schools to reduce youth demand for SSBs and evaluate the curriculum’s efficacy. Design: The study utilized pre and post surveys and focus groups to measure attitude and behavior change before and after exposure and gain student feedback on the curriculum. Setting: The curriculum was implemented during after school programs at 4 Bronx public schools: CS211/CS318, CS323, CS467, and CS448. Participants: Seventh grade students from the schools took the curriculum and completed pre and post-surveys. 15 students took part in a focus group at Bronx Helpers Program, New Settlement Community Center. Instrumentation/Intervention: The eight-week course was adapted from CUNY Urban Food Policy Institute’s Youth Food Educators (YOFE) model. Pre/post-surveys and focus group questions were taken from the Boston Youth Survey, NYC Community Health Survey, Self-Rated Health Survey, the Stanford Patient Education Research


Center, and 2010 Healthy Eating Index. Results and Conclusions: 75 students participated in the SSB counter marketing course. Most reported increasing water consumption and decreasing soda consumption, along with changing their views on water, believing it to be part of a healthy lifestyle. After taking the curriculum many students felt that they would not be criticized by their peers for not drinking SSBs, however, they cited SSBs as a large part of their community’s identity, thereby making it difficult to completely abstain from SSB consumption. Future school-wide SSB counter marketing campaigns must be student-led with teacher and parent support.

Patient and Provider Preferences for Reproductive Intention Screening in Primary Care Authors: Cynthia Calixte, MD, Meredith Manze, PhD, Lynn Roberts, PhD, Michele Perlman, MPH, Susan Rubin, MD, Aileen Langston, MD, Diana Romero, PhD, Heidi E Jones, PhD, There have been efforts underway to include reproductive intention screening in primary care in United States. One Key Question ©, “Do you want to get pregnant in one year?” has been one initiative. However, little is known about patients’ and providers’ preferences for reproductive intention screening in primary care. The objective of this study was to describe patient and provider perspectives on reproductive intention screening. Cross-sectional anonymous surveys were done of patients and providers. Descriptive analyses of preferences by patient and provider characteristics were done using chi-squared/Fisher’s exact. The results showed that participants preferred a question that did not just focus on reproductive intentions but reproductive services. By having a question that focuses on reproductive services it allows for broader discussions beyond pregnancy prevention or pregnancy planning alone. A question about reproductive services is also more inclusive across genders, ages and sexual orientations.

Effects of Patient Education on Patient Outcomes in Osteopathic Manipulative Treatment Author: Bridget Foy, DO, Jincy Cherian, DO, Jessica King, DO, Amanda Chen, DO, Jennifer Eaton, DO Background: Osteopathic manipulative Medicine (OMM) is a known tool to help with musculoskeletal problems, lymphatic issues, and pain. Studies have shown that patients perceive OMM to be beneficial for musculoskeletal disorders. However, in our practice, patients are often referred to osteopathic treatment with little information about OMM. We aimed to conduct a study to investigate whether education of OMM prior to treatment would improve outcomes for patients, specifically their pain level. Objective: To determine if patient education regarding OMM prior to treatment reduces pain to a greater degree when compared to no patient education prior to treatment. Design: Randomized non-blinded controlled survey based study. Patients were randomized into the intervention or control arm based on the month they sought care. Setting: Participants were new patients to OMM clinic in Kingston, NY. Participants: Eligibility criteria included all new patients to the OMM clinic who are able to able to read English. All those with prior knowledge of OMM were excluded. Data Collection: Surveys were collected after being completed the day of visit. A phone survey was conducted with the patient 3 days following the visit. All surveys were uniquely numbered and each participant received one survey. Results and Conclusions: 19 patients were enrolled in the study. Of these 5 (26%) were unaware they were receiving OMM care at their visit. Adjusting for baseline differences, patients who were aware of their OMM treatment reported a significant improvement in pain three days after their care (p= 0.06). The receipt of educational materials showed no independent impact on improving pain in this sample. From these results, we can


conclude that when patients understand their treatment, they have better outcomes. However, patient handouts are not the pathway to this understanding.

Views of Primary Care Providers on Testing Diverse Patients for Genetic Risks for Common, Chronic Diseases Authors: Diane Hauser, MPA, Carol Horowitz, MD, Michelle Ramos, MPH, Kezhen Fei, Aniwaa Owusu-obeng, PharmD Background: Widespread adoption of genetic medicine by PCPs will depend, in part, on their ability to interpret and act on relevant genetic information. Little is known about PCP’s preparedness to use genetic testing for common, chronic disease risk, diagnosis and therapy, or their views related to race and genetics. Objective: We surveyed PCPs to assess their knowledge, attitudes, and beliefs about genetic testing in general, and for common, chronic diseases. Our objective is to generate insights for sustainable adoption and dissemination of genomic medicine as a whole, and specifically for translation in diverse clinical settings and ancestral populations. Design: Pre-post survey – presenting baseline data only. Setting: We invited PCPs at Mount Sinai and IFH practice to complete the survey. Participants: The PCPs were general internists, family physicians, nurse practitioners, physician assistants, and residents. Instrumentation/Intervention/Data Collection: We developed a 45-item survey that queried PCPs about their perceptions of genomic medicine, associations between ancestry and genetic risk for common disease, perceived knowledge of genetics and genomics, clinical utility of genomic medicine, their own genetics education, experience and concerns with genetic testing for chronic disease risk, perceived impact on patients, and preferred genetic tools for the EHR. Results and Conclusions: The majority of PCPs surveyed have had formal genetics education and have positive views of the utility of genetic testing. However, they feel unprepared to work with patients at high-risk for genetic conditions and are not confident interpreting test results. PCPs are concerned that genetic testing may lead to insurance discrimination and lack trust in companies that offer genetic tests. These findings point to some of the attitudes and knowledge gaps among PCPs that should be considered in clinical

Assessing the Prevalence of Surrogateless Patients and Advance Care Planning in an Outpatient, Urban Adult Homeless Population Authors: Sara Sansone, RN, Eve Waltermaurer, PhD, Casey Crump, MD, PhD, and Laura Kaplan-Weisman, MD Research shows that homeless adults, who experience increased morbidity and mortality compared to their housed peers, rarely have the opportunity to discuss and document advance care plans. Patients who are unable to appoint a Health Care Proxy (HCP) are referred to as “surrogateless” and surrogateless patients who lack capacity for medical decision making as “unbefriended.” The size of the surrogateless and unbefriended homeless populations in the US is unclear; the unbefriended rate is ~3-10% in hospital and long-term care settings. Advance care planning is ideally discussed in advance of a healthcare crisis to preserve patient dignity and autonomy. To our knowledge there are no studies examining feasibility of advance care planning in homeless primary care. From April 2016-June 2017, we sought to complete advance care directives for active patients > age 45 during primary care visits and focused visits with an APN/MPH student at the IFH adult homeless sites. In August 2017, we conducted a retrospective chart review of documented


advance care plans. We found a high prevalence of surrogatelessness (36%), suggesting that homeless patients are at increased risk for becoming unbefriended. Our study engagement rate and advance care preferences are similar to those of our colleaguesâ&#x20AC;&#x2122; work with homeless patients in research settings. Barriers to initiating advance care counseling included perceived lack of clinical time or patient lack of interest, not viewed as a priority compared to more immediate needs, and concern that plans will not be available if needed. Our study shows that advance care planning is essential and feasible in homeless primary care. We hope to inspire others to document advance care plans during routine care, undertake larger studies to ascertain the prevalence of surrogatelessness in the US, improve transmission of records between healthcare systems, and initiate effective policy solutions for surrogateless and unbefriended adults.

The CHANGE Challenge: A Pediatric Obesity Group Intervention Authors: Migdalia Morel, BS, Yomiuri Ortiz, BA, Donna Martinez, Tiffany Diaz, Margaret Walsh, FNP, Alexandra Aarons, MD, Monalisa Ghose, MD, Miriam Serrano, MSED, RDN, Sandra Arevalo, MPH, RD, Laura Kaplan-Weisman, MD Pediatric obesity is a significant public health problem in the United States. At the Institute for Family Health, there is a high prevalence of pediatric obesity despite providersâ&#x20AC;&#x2122; best efforts at routine visits. The gold standard treatment for pediatric obesity is centered around comprehensive, intensive behavioral interventions. We sought to determine whether an intensive group intervention in a primary care setting would help obese children in our clinic improve their BMI percentiles. The CHANGE (Community, Health, Activity, and Nutrition Group Education) Challenge, an IRB approved pediatric obesity intervention adapted from Montefioreâ&#x20AC;&#x2122;s Starting Right program, met weekly for two hours at Walton Family Practice for ten weeks in the fall 2016 and for twelve weeks in the spring 2017. Using a culturally sensitive, interactive, and flexible curriculum, each session incorporated hands-on activities conducive to promoting healthy dietary and lifestyle modifications, including nutrition education, physical fitness, and the children, parents, and session leaders working together to prepare a healthy meal or snack. To improve attendance, we modified our marketing, group structure, and incentive prizes for the 2nd cohort. With these changes, attendance and BMI percentiles at the conclusion of the group improved in Cohort 2 compared to Cohort 1. In both cohorts, families were actively engaged and discussions in shared medical visits showed that they had increased knowledge about pediatric obesity and begun dietary and lifestyle changes. Our initial CHANGE Challenge groups have been successful first steps in addressing pediatric obesity at the IFH. Going forward, we plan to improve our retention of patients in group sessions as well as post-group follow-up outreach. Future steps include replication and expansion to other IFH sites and publication of our findings.

Clinic-Based vs. Home-Based Support to Improve Care and Outcomes for Older Asthmatics Authors: Joseph Lurio, MD, Alex Federman, MD, MPH, Juan Wisnivesky, MD, MPH, Samantha Udondem, MPH, Diane Hauser, MPA, Michaela Frazier, LMSW, CCM, Mirta Milanes, MPH, June Futterman, BS, Nandini Shroff, MPH Background: In the U.S., African-Americans, Latinos, low-income individuals, and the elderly suffer disproportionately from asthma compared to younger asthmatics. Older minority adults with asthma experience higher rates of hospitalization and worse asthma-related quality of life


than Whites. Very few asthma interventions have been specifically designed for older adults or comprehensively address the barriers to asthma control commonly found in this population. Objective: To compare the effectiveness of clinic and home-based asthma care coordination and self- management support on asthma-related outcomes for older asthmatics. Design: A 3arm (clinic-based, home-based, and usual care) randomized controlled trial was conducted among elderly patients with poorly controlled asthma. Setting: Participants were recruited from Mount Sinai Hospital (IMA), St. Lukeâ&#x20AC;&#x2122;s Roosevelt Hospital (SLR), and Institute for Family Health (IFH). Participants: A total of 405 patients were recruited from IMA, SLR, and IFH and randomized into the three arms. To be eligible, participants had to be aged 60 years and older, and have uncontrolled asthma diagnosis, no history of other chronic lung conditions, less than 15 pack-years, and the ability to manage their own care. Instrumentation/Intervention/Data Collection: Asthma control, quality of life, resource utilization, medication adherence, inhaler use, use of peak flow meter and asthma action plan, appointment keeping, and spirometry were assessed during the four clinical interviews (baseline, 3-months, 6-months, and 12-months) and monthly ACC sessions. Results and Conclusions: Preliminary results demonstrate that overall, patients receiving asthma care coaching had higher asthma control test scores compared to usual care patients (p=0.03). Therefore, continued provision of IFH ACC services for elderly asthmatics should be seriously considered. As there is no statistically significant difference between clinic and home-based care coach outcomes, ACC service assignment should be based on patient preference.

Electronic Health Records in Integrated Behavioral Health Practice: The Impact of Collaborative Computer Use on the Therapeutic Alliance Authors: Liz Matthews, MSW, PhD Candidate Background: Efforts to integrate health and behavioral health care have dramatically increased EHR adoption. As a result, technology and social work practice are becoming increasingly intertwined. Despite this trend, little is known about how these systems impact core clinical processes, such as the therapeutic alliance Objective: This study describes the nature and extent of computer use within integrated behavioral health care, and explores the impact of collaborative computer use on the therapeutic alliance. Design: The stated research objectives were addressed through a quantitative analysis of video recorded therapy sessions and survey data from participating clients and behavioral health providers Setting: This study took place in a large, urban integrated health and behavioral health center. Participants: A targeted sampling approach was used to recruit 13 behavioral health providers using electronic health records. A convenience sample of 53 English-speaking, adult clients was then recruited from the caseloads of participating providers. Instrumentation/Intervention/Data Collection: Video recorded sessions (n=53) were coded for total amount of computer use and the presence of collaborative computing. After each session, survey data was collected from clients and providers to measure therapeutic alliance and perceptions of collaborative computing from both perspectives. Bivariate correlations explored the relationship between client and provider perceptions of computer use and alliance. OLS regression tested the association between total computer use, collaborative computing, and the therapeutic alliance. Results and Conclusions: Findings suggest that client rate their alliance and experience of collaborative computer more favorably than providers. Among clients, collaborative computer was positively associated with the therapeutic alliance.


Feasibility, Acceptability and Outcome of a Screening Program for Complicated Grief at the Institute Authors: Sapana Patel, PhD, Andrea Cole, PhD, LCSW, Virna Little, PsyD, LCSW-R, Natalia Skritskaya, PhD, Elizabeth Lever, MSW, Lisa Dixon, MD, Katherine Shear, MD Background: Complicated grief is associated with impaired functioning and behavioral and physical comorbidity. Individuals experiencing complicated grief may not seek behavioral health treatment, rather, they may be identified as needing help in primary care. Objectives: 1) To examine the feasibility and acceptability of a screening protocol to identify complicated grief among adult patients at IFH, and 2) To explore the demographic, health, and service-use variables associated with complicated grief. Design: This is a cross-sectional survey and feasibility and acceptability study of a screening protocol to identify complicated grief among patients at IFH. Setting & Participants: A screening protocol to identify complicated grief was integrated into EPIC between September 2014 and March 2017 at six IFH sites: Mt. Hope, Walton, Sidney Hillman, Kingston, Ellenville, and New Paltz. IFH clinicians were trained in the protocol and invited to complete a survey regarding feasibility and acceptability. Instrumentation/Intervention/Data Collection: Patients were administered the Brief Grief Questionnaire (BGQ) and, if positive, the Inventory of Complicated Grief (ICG). Data were extracted from EPIC on the BGQ, ICG, demographic, health, and service-use variables. Associations between demographic, health, and service-use variables were analyzed with t-tests and Spearman correlations using SPSS version 24. Acceptability data from clinicians were collected via survey monkey. Results and Conclusions: Of the 2425 patients screened, 1015 reported a loss more than six months ago. Of these patients, 22% (N = 228) endorsed symptoms of complicated grief (ICG > 25). Unemployment, lower levels of education, receiving public assistance, being single, and a history of suicidal ideation were associated with complicated grief. Clinicians (N = 14) reported they found the screening protocol feasible and acceptable. Results suggest that integrated primary care settings may have elevated rates of complicated grief and primary care providers should consider systematic screening.

Experiences of treatment decision making for African Americans and Latinos diagnosed with depressive disorders: a qualitative study in primary care Author: Sapana R. Patel, PhD, Andrea Cole, PhD, LCSW, Virna Little, PsyD, LCSW-R, Harold Pincus, MD, Roberto Lewis-Fernandez, MD Background: Shared decision making is a process that allows individuals and their care teams to make treatment decisions together. Understanding the treatment decision making process of minorities in primary care may improve the quality of communication and activate patient involvement in decision-making. Objective: The purpose of this study is to examine patient and family member perspectives on the decision making process for depression treatment in primary care. Design: Three focus groups (two in English and one in Spanish) with 16 African American and Latino primary care patients with major depressive disorder and their family members were analyzed qualitatively to identify key themes and components of a depression care decision aid. Setting: Data were collected from two IFH clinics: Parkchester and Walton Family Practice. Participants: Primary care patients who self-identify as African American or Latino and scored a 10 or above on the PHQ-9 and for whom depression treatment was deemed appropriate were invited to participate. Among those who agreed, their friends/relatives were also invited to participate. The final sample is 63% African American, 63% English-speaking, 88% female, mean age = 48. Instrumentation/Intervention/Data Collection: Qualitative data were collected from patients and their friends/relatives as part of a focus group. Focus group recordings were transcribed and analyzed by coders using grounded thematic analysis. Results


and Conclusions: Study participants identified physical symptoms as a central component of their experience with depression. Patients also felt a fear of stigma from their family, their community, and providers, and cited these as reasons for delaying treatment. Participants noted the importance of effective communication with providers and shared decision-making. Results suggest that providers should enlist patient opinion when developing a course of treatment with regard to familial involvement, communication preferences, and types of treatment.

Manual Vacuum Aspiration in the Family Medicine Setting is Safe Authors: Olivia Perlmutt MD, Martha Simmons MD, Gabrielle deFiebre MPH, Eve Waltermaurer PhD, Susan Rubin MD MPH, Kelly Kirkpatrick DO, Nina Ragaz MD, Linda Prine MD Background: Manual Vacuum Aspiration (MVA) done in the outpatient setting is safe and can be offered in the family medicine (FM) setting but rarely is. One barrier to integrating MVA into FM practices is the lack of data demonstrating safety within this setting. Thus we evaluated the complication rate of MVA conducted by FM providers in the FM setting. Objectives: For patients who had a Manual Vacuum Aspiration (MVA) done at a New York family medicine (FM) health center network from 2004 â&#x20AC;&#x201C; 2016, to quantify and describe the 1) MVA complication rate 2) type of complication and 3) associations with patient and provider factors. Methods: Retrospective chart review of MVA procedures done at a New York FM health center network. Charts evaluated for MVA complications within 28 days of the procedure; patient/provider demographic information abstracted. In order to capture complications lost to follow-up in our network, we searched the New York State Medicaid Database for claims on MVA-related hospitalizations, ER visits and ambulatory care visits. Results: From 2004-2016, 1,499 MVA procedures (93% for elective termination, 7% for miscarriage) were conducted at the FM network. Of these, 692 (46%) procedures had Medicaid coverage at the time of MVA. We identified a total of 47 (3.3%) MVA related complications. The most common were retained products of conception (n=16), mild-to-moderate hemorrhage requiring outpatient management (n=14), and endometritis (n=13). One hospitalization for hemorrhage requiring repeat D&C occurred, and no deaths. No significant differences in complication rates existed regarding provider type, reason for MVA, and gestational age. The majority (74%) of MVAs were conducted by providers-in-training. Conclusion: The MVA complication rate we found is comparable to national averages. We conclude that MVA for abortion and miscarriage management can safely be conducted in the FM health center and training setting.

PurpLE Clinic: A Descriptive Analysis of the Population Authors: Anita Ravi, MD, MPH, Saskia Shuman, MHS, Nandini Shroff, MPH Background: Survivors of sexual violence, particularly sex trafficking, face multiple barriers to accessing health care, particularly primary care. While current literature is focused on victim identification, literature is sparse with regard to understanding the long-term health needs of sexual violence survivors, particularly those who have experienced sex trafficking. The Institute for Family Healthâ&#x20AC;&#x2122;s PurpLE Clinic, launched in 2015, was designed to delivery longitudinal primary care services for people who have experienced sexual violence and human rightsrelated abuses. Objective: To identify prevalent medical, mental and social determinants of health issues and describe the health care utilization of patients who have experienced sexual violence. Design & Setting: A retrospective chart review was conducted using data from the PurpLE Clinic. Participants: PurpLE Clinic patients who had at least 1 visit between July 2015


and Jan 31, 2017. Instrumentation/Intervention/Data Collection: Using a combination of automated reporting and chart reviews, demographic information, healthcare problems and utilization and social determinants of health was collected. Results and Conclusions: A total of 109 patients were seen at the PurpLE Clinic; eighty-seven percent of whom were females. Nearly 80% of PurpLE Clinic patients are people of color and about 40% speak a language other than English. A majority of the patients are either uninsured or publicly insured. Furthermore, patients made an average of 9 visits overall, an average of 2.75 visits specifically with the PurpLE Clinic primary care provider, and an average of 5.5 psychosocial visits. Nearly all patients received preventive care services and chronic disease management; referral to mental health and case management services was common. As one of the very few programs in the country that serves this population located in a primary care setting, the results from this descriptive research on the PurpLE Clinic can be used to replicate the work at other primary care settings.

Effectiveness of family planning services screening and support intervention at an urban Federally Qualified Health Center network Authors: Seema Shah, MD, MPH, Linda Prine, MD, Eve Waltermaurer, PhD, Susan E. Rubin, MD, MPH Objective: To improve provision of family planning services (FPS) among female patients of reproductive age in our Federally Qualified Health Center network. Methods: The FPS intervention includes an electronic medical record clinical decision support consisting of a reproductive intention screening for females 13-44 years who are coming for a medical visit asked by the medical assistant/nurse (support staff) with a linked provider documentation tool, and clinic/staff capacity building. From Mar-Sep 2017, the intervention was rolled out in a phased manner at 7 sites; evaluation period extended through Jan 13, 2018. We evaluated the intervention using the RE-AIM framework, with pre/post surveys of the support staff and a quasi-experimental interrupted time-series analysis of the main effectiveness outcome, contraception and/or preconception utilization among all females 13-44 who came for a medical visit. Results: 84% (85/101) of support staff responded to the pre-survey and 90% (83/92) to the post-survey. At baseline, support staff reported high level of comfort (63.5% very, 22% somewhat) asking the CDS-based reproductive intention screening question, and more shifted to the â&#x20AC;&#x2DC;very comfortableâ&#x20AC;&#x2122; category in the post-survey. From Mar 2017-Jan 2018 implementation at all sites, the screening question was triggered for 17,078 female patient visits and 75% had a documented response, ranging from 60-90% at individual sites. The time series analysis of the overall outcome of family planning utilization documentation rates (pre-intervention 16-week period n=14,172, intervention 16-week period n=14,290) demonstrates no appreciable change of the intervention-period linear models compared to the pre-intervention period. Conclusion: FPS intervention CDS screening had adequate adoption and implementation at the 7 FQHC sites. Yet, there was no appreciable effect on overall family planning utilization documentation rates in visits of females age 13-44 years. Limitations include challenges of capturing accurate clinical information from EMR data and using all females as a denominator rather than a denominator of females at risk of pregnancy. Implications: Implementation of the FPS intervention requires further tailoring by sites, a more accurate way to assess clinician performance and patient outcome data, and a longer time for assessment.


Measuring the Intersection of Social Determinants of Health and Chronic Health in a Primary Care Setting Authors: Nandini Shroff, MPH, Elizabeth Lever, MS, Eve Waltermaurer, PhD, Diane Hauser, MPA, Maxine Golub, MPH, Virna Little, PsyD, Neil Calman, MD Background: There is a growing body of research correlating social factors with health status and articulating the contribution of social factors to persistent health disparities. In 2015, the Institute piloted a systematic process to screen for and respond to social determinants of health (SDH) in patients of a federally qualified health center that provides care to an underserved community in the Bronx. Objective: To examine the factors associated with reporting SDH in a primary care setting. Design: We used a cross-sectional study design. Participants & Setting: All patients aged 18 and older completed the SDH-screening annually at the Urban Horizons Family Health Center. Instrumentation: We implemented a 5-item screening tool to identify patient concerns regarding housing, food, financial, domestic/relationship violence, and community violence. Results and Conclusions: 3,043 patients (98% of 3,097 eligible patients) completed the SDH screening; 17% affirmed at least one SDH. Health insecurity was strongly associated with each of the other SDHs raising the risk of dual determinants to three to six times an increased risk. Reporting domestic/relationship violence was associated with documented depression (PR 2.6) and diabetes (PR 1.8). Reports of food insecurity were associated with a 50% reduced prevalence of hypertension. The rates of patient reported SDH identified through the process were lower than known rates of poverty and unemployment in the community. That said, for the patients who do report one SDH the likelihood to report another is higher; this is particularly noteworthy given the high association of each SDH with health insecurity. Screening and responding to SDHs in primary care will further allow greater examination of the impact of responding to these challenges on improving patient health outcomes in the near future.

Testing the Efficacy of Difference in Differences for Non-Randomized Medical Interventions: Exploring the Effects of a Diabetes Intervention Authors: Eve Waltermaurer, PhD, Leah Mancini, BA Background: Interventions in a primary care setting are often conducted for medical treatment rather than research, making it difficult to test the causal impact between that intervention and health outcomes. Difference in differences is a statistical design that allows for causal hypothesis testing when a randomized control trial is not feasible. While these methods have been used in social science research to a small degree, these approaches have rarely been applied to medical research. Objective: This study applies a difference of differences (DID) analysis to assess the impact of enhanced diabetes care on HgbA1c. Design: Difference in difference estimations were applied to compare two level of diabetes care: “usual care” where a patient was only seen by physician and “intervention care” where a patient was seen by a physician as well as at least one of the following: outreach worker, diabetes educator, and/or psycho-social provider. Setting: The setting is institute-wide. The implications of this setting are that patients seen at IFH are not directly generalizable to the full population of diabetics. Participants: 2,168 Diabetic patients seen at least once between 2003 and 2008 and once between 2008 and 2013. Data Collection: Secondary data-analysis Results and Conclusions: All patients showed improvement in HgbA1c from the baseline to follow-up periods particularly when patients received intervention care, with the exception of non-Hispanic White patients and


patients over 60. While no statistically significant effects were noted, an increased improvement among females and non-Hispanic Blacks approached significance (p=0.09 and p=0.14 accordingly). DID was feasible for testing effects.

CQI CQI: Improving the Depression Screening Rate at a Federally Qualified Health Center (FQHC) Authors: Dimitri Alvarez, MD, Sarah Baden, MD, Laura Leone, LCSW, Jason Rapaport, MD Depression is the most common mental health condition among patients seen in primary care in the United States. However, it is estimated only about 50% of patients with depression are identified. Untreated depression is associated with decreased quality of life as well as increased mortality and economic burden. The United States Preventive Services Task Force (USPSTF) recommends screening all adult patients (>18 years of age) during routine visits when enhanced, staff assisted, depression care programs are in place so to improve the rates of diagnosis and improve outcomes. The Patient Health Questionnaire-2 (PHQ-2), an easy and efficient screening tool for depression, is used at the Institute for Family Health, an FQHC. Although it typically takes less than one minute to complete and despite an electronic medical record best practice alert reminder in place, the PHQ-2 is completed less than 50% of the time. This quality improvement project seeks to increase the depression screening rate at this FQHC using a behavioral modification intervention that encourages staff to complete the PHQ-2 with every adult patient at every visit. Targeted informational email messages were sent, team performance was then audited, and feedback was provided weekly to the care teams, including: meeting oneon-one with the lower performers and public recognition of top screeners. Analysis of the data reveals that the screening rate did improve over the five-month period that this study was conducted. This was a simple intervention that can easily be replicated in other primary care settings, resulting in a profound change in the identification of depression, with the potential to save life.

Increasing Resident Engagement and Reporting of Adverse Events Authors: Michelle Bejar, MD, MPH, Michael Berman, MD Background: Residents and Fellows work on the front line of patient care and have a unique opportunity to recognize and report patient safety events. Although residents have this opportunity, many do not take advantage of it. The Mount Sinai Hospital received 10,574 patient safety event reports in the 2016 calendar year. Residents submitted only 405 (3.8%) of those reports. According to a recent survey of current residents at Mount Sinai Beth Israel Hospital, house staff face a variety of barriers to reporting events with the most reported barrier was that house staff do not know how to report the event followed by lack of time to report. This project is aimed to address these issues by instituting an online reporting form to reveal compromises in patient safety to the administration. Objective: The purpose was to increase resident engagement in reporting adverse events at the hospital. The administration will get a report of the reported events and can address the issues during their morning leadership safety meeting. Design: We created an online portal hyperlinked to the hospitalâ&#x20AC;&#x2122;s home webpage through which residents can fill out a simple form to report adverse events. The portal was


continuously updated according to feedback from house staff and administration. Setting: This intervention was done at Mount Sinai Beth Israel hospital. Participants: We involved house staff from all residency programs and specifically connected with their chiefs at Mount Sinai Beth Israel. We focused within the whole patient population within the hospital that received care from our staff. Instrumentation/Intervention/Data Collection: Emails were sent to house staff introducing ESTER and posted flyers in resident work rooms that delineate the new adverse event reporting workflow and emphasize its non-punitive, accessible, responsive design. A demo of the website was presented to different groups of residents, highlighting different features of the portal. Results and Conclusions: We found that residents and administration were very excited about having access to the portal. Since going live on December 15th, 2017 we have had 78 events reported, with 14 (17.95%) events reported by residents.

Improving Flu Vaccination Rates at the Institute for Family Health at 17th Street the OldFashioned Way Authors: Anup Bhandiwad, MD, Andrew Chen, MD, Rebecca Giusti, MD, Ines Teuma, MD Background: Influenza is a very common and contagious viral illness that can lead to severe illness and death. The flu, however, can be easily preventable or its symptoms relatively diminished with the help of the seasonal flu vaccine. The vaccine is easily obtainable for free or at very low cost in order to reach the most people possible. Unfortunately, the flu continues to be a major cause of morbidity and mortality during the winter months in the United States. Several previous studies have shown improvement in flu vaccine compliance among patients who receive written communication from their providers regarding the flu vaccine. Objective: The purpose of this project is to increase the number of patients in the panel of participating resident physicians who have received the flu shot. Our collective goal is 90% compliance. Design: Reviewed monthly quality metrics of participating providers for flu vaccination rates. Target eligible patients through written letters informing them they are due for their annual shot. Setting: The setting is an urban community health center in the Chelsea neighborhood of Manhattan. Participants: All patients eligible to receive the flu vaccine (patients 6 months of age or older) in the respective panels of the four participating resident physicians. Intervention and Data Collection: The four resident physicians mailed out English and Spanish letters including patient education regarding the flu to all eligible patients No additional avenues of contact (e.g. MyChart messages or phone calls) were made to these patients regarding the flu vaccine. Results and Conclusions: Only 2.4% (3 out of 123) patients who received the mailing came into the clinic to get their flu shot by February 2018. Last year over the same time frame, 2.7% (2 out of 75) patients got their flu shot. Findings showed no statistically significant difference between the comparison group and the intervention. Any change noted likely represented a secular trend, meaning a certain number of patient would have received the flu vaccine over a period of time, regardless of whether an intervention was performed given a similar change in the comparison group.

Beyond the Report: Effective Panel Management through Targeted Data Collection in an Electronic Medical Record Authors: Laura Bazhdari LMSW, Katie Bierlein LMSW, MPH, Monica Debride LMSW, Michaela Frazier LMSW, CCM Background: The Care Management team at IFH developed the â&#x20AC;&#x2DC;Active Care Team Reportâ&#x20AC;&#x2122; (ACTR) in early 2017 to assist staff in meeting contact and documentation requirements that


were often going uncompleted. Developed with input from staff themselves, the implementation of the report was part of a continuous quality improvement initiative aimed at improving patient contact and quality of care. Objective: The project’s primary purpose was to improve panel management and documentation completion of patients enrolled in care management services. Measures of improvement included services provided to patients, assessment completion, and care plan completion. Design: The ACTR was added to Care Navigator dashboards in EPIC to be easily run on a daily basis beginning in January 2017. Patient contact included both non-face to face and face to face, prompting a green dot if contact was completed within the month. Assessment and Care Plan dates were also gathered in the report, which highlighted those not yet completed, coming due soon, and overdue. Care Navigators filter the report to organize and prioritize their work each month. Setting: The project was conducted for patients enrolled in Care Management programs across all IFH locations. Participants: Participants of this project were the care navigators in the care management programs across all Institute locations. The patients enrolled in Care Management have two or more chronic conditions and are struggling to manage the symptoms and/or effects of these conditions. Instrumentation/Intervention/Data Collection: Manual tracking of care plan completion was first monitored beginning in July 2016. The Active Care Team Report was first implemented in December 2016 to include data on contact and assessment completion in addition to care plans. Care navigators received training on utilization of the report in December 2016 and the report is utilized in supervision as well as for performance evaluation measures. The report is available real time as well for daily utilization by care navigators. Results and Conclusions: From July 2016 to January 2018, the percentage of invalid care plans decreased over 50% from 75% to 24%. The rate of incomplete comprehensive assessments decreased from 41% to 22% between December 2016 and January 2018. Pt contact increased from 65% to 92% within the same time period. We hope to continue this momentum through 2018.

Falls Risk Clinical Quality Improvement Project Authors: Katie O’Grady, MD, Sarah Chang, MD, Margaret Glausser, MD Background Falls occur in over 1/3 of the community-dwelling elderly (age 65 years and above) and are the leading cause of injury-related hospitalizations in this population. 10% of these falls lead to serious outcomes, including death. In an effort to prevent/reduce the number of elderly falls, the USPSTF has a grade B recommendation to identify elderly patients of increased risk who would benefit from exercise and vitamin D supplementation. In order to identify patients at an increased fall risk, the American Geriatrics Society recommends physicians annually assess their patients’ fall risk, balance or gait problems. Objective Our CQI was focused on increasing the percentage of community-dwelling elderly patients who had a fall risk screening assessment completed from 3/1/2017 to 3/1/2018. Design =Patients age 65 or older that had one of the 3 providers (Katie O’Grady, Sarah Chang, Margaret Glausser) listed as their PCP and were seen at least once by that PCP who had not had a fall risk assessment in 12 months (3/1/2017) were included in this study (16 out of 44 patients total*). Instrumentation/Intervention/Data Collection Each patient was contacted via phone or MyChart (if available) to make an appointment for a fall risk evaluation in the office. The March 2018 quality metric was used to determine if physician outreach increased the percentage of Falls Risk completed in the quality metric. *number to change once patients of Margaret Glausser added (she will return in 1 week from maternity leave) Results and Conclusions: We will find out on March 1, 2018 with those quality metrics.


Effect of Additional Reminder Phone Calls on Specialty Referral Attendance in an Urban Free Clinic Authors: Ryan Corbo, BS, Riana B. Jumamil,BA, Kea Alexa Moncada, BA, Steven Flamer, BA, Samuel Nemiroff, BA, Howard Herman, BS, Juan Lin, PhD, Ellie Schoenbaum, MD, Sarah C. Nosal, MD, Amarylis Cortijo, MD Background: The Einstein Community Health Outreach (ECHO) Free Clinic is run by students of Albert Einstein College of Medicine and the Institute for Family Health in the Bronx, NY. Specialty appointments are referred to NYC public hospitals, which have an income-based sliding scale. Mammograms, ultrasounds, X-Rays, and colonoscopy screenings are free. The average referral attendance rate in 2016 was only 47%, although colonoscopy attendance rates were higher at 58.2%. Patients had received two reminder calls, two Saturdays before their appointment. Colonoscopy patients were additionally called 1-2 days before to begin their colon prep. Our study assessed whether a new reminder protocol would improve attendance rates. Objectives: Determine whether an additional reminder call during the week increases attendance rates for referral specialties. Analyze differences in attendance rates based on successful call attempts, demographic data, chronic disease status, hospital location, and referral specialty. Design: A comparison study analyzed data between original protocol A (October 2016-March 2016) and updated protocol B (April 2017-October 2017). Student’s T-test (p<0.05) was used. Setting: Student volunteers called patients during Saturday clinic hours. Referral coordinators called patients on the weekdays. Participants: Protocol A – 205 patients; Protocol B – 259 patients Intervention/Data Collection: For patients not successfully reached during the two Saturday attempts, a third reminder call was made on a weekday after 5pm at least 1-2 days before their appointment. All phone calls were documented in the electronic health record and in a password-protected Microsoft Excel sheet. Descriptive information included age, sex, language, chronic disease status, referral location, and referral specialty. Results and Conclusions: Under the new protocol, the percentage of patients contacted within 2 weeks significantly increased (59% vs. 42%, p-value < 0.001), however overall attendance rates were not affected (p=0.8372). Differences were observed based on appointment location (North Bronx, South Bronx, or Manhattan), cost (free or sliding-scale), and referral type (Colonoscopy, Women’s Health Services, Diabetes Specialties, or Other specialties). Future work can target more specific barriers of access, such as finding more convenient referral sites and resources for reduced payments.

CQI - Improving Blood Pressure Control and Goals at Kingston Family Practice Authors: Megan McMullan, MD, William House, MD Background: Blood pressure control has historically been difficult for many primary care practices. Helping patients to understand the need for control and helping providers to consistently communicate and monitor this goal has been central to the problem. Objective: The purpose of this CQI was to measure how well our practice was communicating the blood pressure goal to patients and how well we were equipping patients to measure and report their own blood pressure. Design: There were two arms of this intervention. Staff Education: We presented basic information in PowerPoint format on hypertension at a nursing/MOA meeting and a provider meeting for our center, updating guidelines and treatment options. A similar presentation focusing more on medication regimens was given at the time to providers. Particular attention was paid to the patients with upcoming scheduled appointments with parameters out of range at a prior appointment for medication titration. Patient Education: A smartphrase (.kfpbp) was created that stated, “Kingston Family Practice – Blood Pressure Goal.


The smartphrase was also used in MyChart messaging between providers and patients. Per the smartphrase above the patients carried out the BP readings at home and reported back to clinic in person or via MyChart. The smartphrase was placed in Patient Instructions in Epic during clinic visits for appropriate patients. Setting: We performed the intervention of staff education at the Kingston Family Practice of IFH. Participants: Patients 18-85 years of age with current diagnosis of hypertension and who’s BP was not adequately controlled at Kingston Family Health Center. Results and Conclusions: Baseline measurement in 2016 for the goal was 59%. Measurement in December 2017 was 69%. This is a +14% change from baseline. Improvements are being made in reaching goal of 75% of patients at <140/90mmHg BP readings at Kingston Family Practice. The CQI smartphrase may be beneficial, as may additional resources developed in both English and Spanish at IFH. This phrase could easily be implemented at other sites by both practitioners as well as other medical and support staff in communicating appropriate BP goals to target patients.

You Are Not Alone: A Group Intervention to Increase Confidence in Suicide Safety Planning Authors: Warren “Jay” Pires, LCSW, Sarah Bernes, LMSW, MPH, Marianne Goodman MD, Deena Levine LCSW Background: More than 44,000 people die by suicide in the U.S each year. The Institute has pledged to support the Zero Suicide initiative and made safety planning central to mitigating the risk and occurrence of suicide. The most effective safety plans reflect patients’ unique strengths and risk factors. The intervention used group experience and distress tolerance skills to build safety plans that patients would feel confident in employing to reduce the risk of suicide. Objective: The purpose of the CQI project was to assess whether a group intervention could increase confidence in safety planning. Design: At the Center for Counseling of Harlem patients who reported suicidal ideation were offered referral to a 90-minute weekly safety planning group. The group comprised 9-sessions in 2 cycles and ending with an additional review session. Setting: The group took place in the Center for Counseling of Harlem. Participants: Adult patients of the Center for Counseling of Harlem who had experienced thoughts of suicide. Instrumentation/Intervention/Data Collection: Originally created by Dr. Marianne Goodman at the Veterans Administration as “Project Life Force (PLF),” the intervention combines skills from cognitive behavior therapy (CBT) and dialectical behavior therapy (DBT) with psychoeducation to maximize safety planning development and implementation. The group setting offers support, relatedness and a forum for difficult, taboo or stigmatized feelings. Assessment tools included PHQ-9, GAD-7, Beck Suicide Scale, Beck Hopelessness Scale, Reasons for Living Scale and the Stanley Suicide Scale. Purpose made numerical scales and an open-ended questionnaire provided qualitative data. Results and Conclusions: 15 patients attended the group at least once during the 19-weeks. Pre-test to post-test, the 6 patients that filled out the Suicide-Related Coping Measure at least twice indicated an average increase of 21.12% and the Reasons for Living survival coping beliefs subscale an increase of 34.23%. Week-to-week, patients indicated greater comfort with their safety plan and that sessions were helpful. Adoption of the intervention at the 4 other centers for counseling to collect further data on the effectiveness of the Safety Planning group is recommended.


Who Completes Follow-up Mental Health Assessments? A Demographic Analysis of Successful Mental Health Referrals from the NYC Free Clinic Authors: William Plowe, BA, Christina Boada, BA, Sarah Nosal, MD, Amarylis Cortijo, MD, Lucia McClendon, MD, Melanie Raffoul, MD Background: One of the many challenges facing an attending supervised student-run free clinic is connecting patients to specialist care when they have medical problems that cannot be addressed in the clinic. At the NYC Free Clinic, all psychiatry referrals are made to the Behavioral Health clinic at The Institute for Family Health. Objective: To better evaluate and improve the referral process as measured by attendance of first appointment, we examined the patient characteristics associated with attendance. Design, Setting, Participants, Instrumentation/Intervention/Data Collection: A retrospective chart review was conducted for all patients seen at the free clinic between September 2016 and September 2017 who received a referral to the behavioral health clinic at The Institute, n=99. We collected the time and date of their free clinic appointments; and the demographic factors of age, gender, race, ethnicity, and language and compared the characteristics of those who did and did not attend a mental health follow-up appointment. Results and Conclusions: We did not note any significant differences. However, 61% of those who did not attend referral appointments were women, while 49% of those that did attend were women. We could not directly compare sameday and non-same-day appointments because patients who declined a same-day referral were not captured in our data. Instead, we used time of free clinic appointment as a proxy for the possibility of a same-day appointment. While we expected to find that those with earlier appointments were more likely to attend their mental health referral, this was not the case. Further analysis on specific mental health diagnoses was not possible due to inconsistencies in documentation.

Cervical Cancer Screening in a Fragmented Electronic Medical Record Authors: Alexandra Aarons, MD, Shanti Leon Guerrero, MD, Cleopatra McGovern, MD, Rachel Rosenberg, MD Background: Every year in the US, more than 13,000 women are diagnosed with cervical cancer. Women of color are disproportionately affected by cervical cancer. This is thought to be largely due to disparities in cervical cancer screening, or Pap smears. The Family Health Center of Harlem (FHCH) views cervical cancer screening as a top priority in its mission to reduce health disparities. One barrier to accurately assessing which of our patients are due for cervical cancer screening is fragmentation of the Electronic Medical Record, which results in patients who are in fact up-to-date on their cervical cancer screening at another institution being flagged as due for a Pap smear in the IFH medical record. Objective: The purpose of this project was to search the Mount Sinai Hospital electronic medical record for Pap smear results for a selection of the FHCH patients who were thought to be behind on cervical cancer screening. Design: Four team members were each assigned patients from the IFH Pap smear â&#x20AC;&#x153;GAPS listâ&#x20AC;? (the list of patients who are identified as being due for cervical cancer screening.) Each team member searched the Mount Sinai Electronic Medical record for Pap smear results for those patients. Chart review in the Mount Sinai system was attempted for 600 patients with no Pap smear on record in the IFH electronic medical record. Instrumentation/Intervention/Data Collection: Members of the CQI team searched the Mount Sinai Electronic Medical Record for Pap smears for their assigned patients. Patients with confidential charts were excluded. Only up-to-date Pap smears were included. If Pap smears were found in the Mount Sinai system, they were printed and uploaded to the IFH medical record. Results and Conclusions: Of the 598 patient charts


reviewed in the Mount Sinai system, 57 patients were identified who were in fact up to date with their cervical cancer screening. This represents 9.5% of the IFH patients reviewed. This CQI project allows IFH to better target our outreach to patients who are actually due for Pap smears, and also allows our IFH medical record to accurately reflect Quality Metrics, which has implications for health center funding.

Improving the Adult BMI Quality Metric at Kingston Family Practice (KFP) Authors: Anna Samedova, DO, MPH, MBS, Sharanya Visakan, MD Background: Many clinical guidelines recommend that physicians screen for overweight and obesity in their practices and provide intensive behavioral counseling to patients with risk factors for cardiovascular disease. Sadly, the rates of screening and counseling for obesity in the primary care setting are only 30%. At the IFH sites, this measure is met by completing an Adult BMI Best Practice Advisory (BPA) and documenting the counseling and any referrals made during the visit. The KFP Adult BMI BPA completion rate for 2017 was less than 50%, with a goal of 90% completion. It is possible, that the actual rates of screening and counseling are higher and are simply not documented by physicians. Objective: To improve physician documentation of adult BMI at the KFP site by providing brief group and individual educational sessions on how to meet the measure requirement in EPIC. Design: A single group and multiple individual educational sessions on the Adult BMI BPA. Setting: Weekly resident conference and outpatient family practice clinic. It is unlikely that setting mattered for the project. Participants: Resident and attending physicians at the KFP site. Instrumentation/Intervention/Data Collection: For group educational session, we provided a brief 5-10-minute demonstration of addressing the Adult BMI BPA in EPIC during a weekly resident conference in January 2018. To educate physicians not at that session, we provided a brief individual demonstration during the researchersâ&#x20AC;&#x2122; clinic days in January 2018 at the KFP. Results and Conclusions: We estimate that >75% of the KFP providers participated in educational sessions and that the improved adult BMI measures were applied to at least 100 adult (>18 yo) patients at the KFP in January 2018. To measure the impact of this intervention, we will analyze the monthly IFH Quality Metrics for December 2017, January 2018, and February 2018.

Improving Blood Pressure Control in Diabetics Patients at the Family Health Center of New Paltz Authors: Hilary Schroeder, MD, Shahrukh Mustafa, MD Background: Hypertension and diabetes mellitus are extremely prevalent conditions in the United States. In fact, hypertension is twice more common in Diabetes than non-diabetics. Coexistence increases risk for coronary artery disease, cerebrovascular disease, renal failure and congestive heart failure, hence, early diagnosis and treatment is essential in reducing morbidity and mortality. Both pharmacological and non-pharmacological methods have been successful in achieving target blood pressures in diabetics. As Family Medicine physicians, we encounter many diabetics with uncontrolled hypertension, and chose to focus our research project on our own clinic patients in New Paltz. Objective: The purpose of our study was to identify patients with diabetes and uncontrolled blood pressure and propose a way to improve their blood pressure control. Design: Using our Electronic Medical Record (EMR) system, we searched for patients using multiple filters, to identify which patients fit our study purpose. From there, we reviewed their list of medications, last four documented blood pressures, most recent A1c level,


and then contacted the patient, along with their Primary Care Physician (PCP) to inform them of our study. Next, we proposed ways of improving their blood pressure, and then followed up with them every three months to reassess. Setting: New Paltz Family Health Center in New Paltz, New York. Our patient population is diverse, with multiple chronic medical conditions, and high rates of non-compliance. Our Continuous Quality Improvement project was an attempt to improve patient outcomes and decrease morbidity and mortality. Participants: Known patients of NPFHC with a known history of diabetes and uncontrolled blood pressure, and their Providers. Instrumentation/Intervention/Data Collection: Accessed patients via EMR- called patients and emailed the associated Provider. Results and Conclusions: Initially, there was difficulty with follow up from Providers and not much improvement. Slowly, patients started to improve their blood pressure control. This is an on-going study and will take time to truly see a significant difference. Our goal is for at least 50% of patients to have blood pressures at goal: 140/90.

Implementation of a Standardized Template as an Electronic Decision Support for Diabetic Care in a Student-Run Free Clinic Authors: Delia Shen, BA, Ankur Srivastava, BA, Howard Herman, BS, Seung Mi Oh, BS, Matthew G. Engel, BS, Ellie Schoenbaum, MD, Sarah C. Nosal, MD Amarilys Cortijo, MD Background: Nearly 7% of the Einstein Community Health Outreach (ECHO) Free Clinicâ&#x20AC;&#x2122;s patient population has Type Two Diabetes Mellitus (T2DM). Previous research has shown a lack of adherence to Diabetes standard of care for which, EMR has served as an effective, computer based decision support. Objective: The purpose of this study is to assess the effectiveness of standardized documentation (ECHO DM SOAP note) serving as clinical decision support to meet standard of care, as established by the America Diabetes Association, for T2DM patients in a student run free clinic. Design: The study is divided into pre and post intervention phases. Retrospective chart review of all T2DM patient visits lasted from October 2016 to September 2017. The SOAP note was introduced in November 2017 and, prospective chart review will last until October 2018. Patient visits were evaluated for completion of requisite labs, physical exam findings and referrals. Setting: This study took place at the ECHO clinic at the Walton Family Health Center. Participants: Third year medical students participated in this study. Instrumentation/Intervention/Data Collection: A SOAP note, in which screening guidelines for appropriate lab work (A1c every three months, LFT, microalbumin to creatinine ratio, serum creatinine and eGFR once a year), physical exam findings (blood pressure at every visit, fundoscopic and foot exam once a year), and referrals (ophthalmology once a year and a nutrition educator, if needed), was created for Third Year Medical Students to use every time they see a T2DM patient at ECHO. Results and Conclusions: Our retrospective chart review has shown that there is room for improvement in adherence to standard of care for T2DM patients. While data collection for the post intervention phase is ongoing, final statistics will be available in the winter of 2018.

Trends in LARC Use During Interconception Care Authors: Dr. Aimee Smith, DO, Joel Panthappattu, MD, William House, MD Background: Rapid repeat pregnancy has potential negative economic, social and health consequences for both mother and child, affecting the motherâ&#x20AC;&#x2122;s education and employment opportunities. A CDC study in 2013 showed that although the prevalence of repeat teen births has declined in recent years, nearly one in five teen births is a repeat birth. Long acting


reversible contraception (LARC) is gaining popularity, as it is for an extended time period, more effective than other methods, and does not require any compliance on part of the patient after initiation. Objective: The purpose of this study is to identify any correlation between age groups or education level in LARC acceptance rates. Design: This pilot study utilized chart review and maternal interviews during well child visits (WCV) to evaluate types of contraception used and maternal demographics. Data was gathered as part of the IMPLICIT (Interventions to Minimize Preterm and Low birth weight Infants through Continuous Improvement Techniques) InterConception Care (ICC) project. Setting: Participants were mothers whose children were seen at Kingston, Port Ewen, New Paltz, Ellenville and the Pediatric Care Center. Participants: Eligibility criteria for study included women whose children are being seen for a WCV from birth to 27 months of age. Intervention: Participants were screened for pregnancy and contraception use. If not using contraception or trying to become pregnant, they were counseled on recommended birth spacing and offered information on contraception options, prescribed contraception or scheduled for an appointment to receive contraception. Results and Conclusions: According to the results of the study, 14.8% of women aged 15 to 17 reported that they used LARC as a form of contraception, 16.3% in women aged 18-19 and 16.1% in women aged 20 to 24, 10.4% in women 25+ and 9.3% in women with an unreported age. 6.5% of women who had LARC had less than a high school degree/GED as compared to 21.2% with a GED and 13.5% with more than a GED. This shows a strong correlation between lower education level and use of LARC, despite relatively equivalent rates in younger women, and is an area that future efforts to decrease rapid repeat pregnancy could be focused.

INNOVATIVE PROJECTS The Process of Developing a PhotoVoice Study to Capture Challenges and Successes in Accessing Health Care for Immigrants: A Participatory Action Project Authors: Guedy Arniella, LCSW, Zaira Hernandez-Cinto, BA, Claudia Calhoon, MPH, Victor Sta. Ana, MD Background: Although New York City and state provide important protections and opportunities to access health care, immigrant communities report ongoing difficulties with a variety of health care access issues, including affordability, finding culturally humble care, navigating large and complex health care facilities, and dealing with barriers to language access. At this time, there is a paucity of qualitative research on New York City populations regarding the specific barriers immigrants, particularly uninsured immigrants, face when trying to access healthcare. Further, there is limited documentation capturing the successes immigrants experience in accessing healthcare. Objective: Through the use of PhotoVoice, a participatory action research project, and working with our community partners, we aim to capture through their eyes, the barriers, concerns and successes immigrants experience in accessing healthcare. We anticipate the results of this project will raise awareness regarding the immigrant experience and assist in advocating with elected officials for continued funding to support immigrant populations in accessing healthcare. This submission illustrates the process of setting up the PhotoVoice project. Design: The development of our project began with having received an Immigrant Health grant from the NYC Council. In linking immigrants to healthcare, we saw the need to capture in their view, the barriers and successes they experienced. We engaged a PhD intern with extensive experience working with immigrant populations and developed a plan to execute a PhotoVoice Project to illustrate their journey to healthcare. Setting: Through phone


calls and in-person outreach to our partners, we assessed interest in working together on this project. Participants: PhD intern, community partners working with immigrant populations, adult immigrants we engage in accessing healthcare Instrumentation/Intervention/Data Collection: We conducted a literature review regarding the PhotoVoice model and are developing focus group and demographic questionnaire. Results and Conclusions: We were able to conceptualize a PhotoVoice Project to explore experiences of immigrants in accessing healthcare. This project is easily replicable.

Increased Follow-up and Teaching: An intervention for increased medication adherence and blood pressure control Authors: Naomi Biviano, RN, BSN, CLC, Amanda R. Stegner Background: The quality metric list/site data shows there is a population of patients who have uncontrolled hypertension. Would these patients be uncontrolled if they were compliant with their medication regimen and their care plans? Objective: The purpose of this research utilization project (RUP) was to increase blood pressure control among patients with known hypertension through medication adherence, education, and increased follow up for reinforcement. Design: This was a quantitative study. Participants came in for three nursing visits, lasting for 15 minutes each, over 9 weeks. Setting: The setting for this quantitative study took place within the primary care setting, during an in-person nursing visit. Participants: Patients with uncontrolled hypertension (age 18-85, diagnosis of hypertension, and had a blood pressure reading of 140/90mmhg), project director, and provider in case medication refills/advisement needed. A total of 11 patients were involved at the New Paltz site. Instrumentation/Intervention/Data Collection: Follow up was also done via phone, where reinforcement of medication adherence and care plan compliance could be addressed. Having the opportunity to be one-on-one with the patient, using the teach-back method and visual aids allows for better comprehension and the opportunity to ask questions. Using telephone to contact also provides convenience, reinforcing information, and allowing further time for patient questions. Results and Conclusions: The interventions support an expected outcome of increased medication adherence of 6% for the identified population. At the conclusion the quantitative study, the actual primary outcome was a 36% increase in medication adherence. Yes, this could be done in any setting.

Integration of Primary Care and Behavioral Health; New Site - New Opportunities Authors: Giorgio Châtelain, LCSW-R, Valentina Ovodenko, RN, Aleksandra Sadej, NP, MSN Background: 16th Street Family Practice relocated to a new location, 230 west 17 th Street. Three differences were noted immediately 1)The 17th Street location is significantly smaller than 16th Street location. Six floors existed at 16th street whereas there are only three floors which are used by IFH at 17th Street. 2) The physical layout of 17th Street combines both primary care and behavioral health in the same clinical space. At 16 th Street FP the behavioral health department was located on different floors. 3) 16th Street FP was the original site for the Institute for Family Health. The relocation is not ideal for some. These potential barriers have generated an opportunity to create new work flows, redefine roles and overcome obstacles all for the purpose of improving patient care through a truly integrated practice. Objective: To implement and improve the effectiveness of primary care and behavioral health care integration in a new clinical environment. Setting: Institute for Family Health at 17th Street. 230 West 17th Street, New York, NY 10011. Participants: For our innovative project, Site leadership, Nursing staff


(RN/LPN/MOA), Providers (MD/DO/NP), Mental Health Clinicians, Psychiatric Providers and patients were involved. Instrumentation/Intervention: The interventions implemented for the improvement of 17th Street FP included creating and training of staff and providers on new workflows for interdisciplinary collaboration, communicating between disciplines through team meetings, huddles and practice wide meetings and following up regarding interdepartmental referrals and positive/negative outcomes. Progress during implementation was monitored on a weekly and monthly basis. Feedback from staff including residents, providers and patients was also collected. Results and Conclusions: The inevitable shared smaller space continues to pose some obstacles for staff who were used to operating out of 16th Street FP but has created the reality of staff knowing more about each department and all the resources available to patients. Within the 4 months following implementation of new workflows, teaching and redefining roles, 17th Street Family Practice has become more organized, collaborative care has increased, integration continues, discussion of patient care between mental health clinicians and clinical staff has improved. 17th Street FP leadership will continue to focus on shared goals and aspirations for the practice.

Hepatitis C at W 17th St Family Practice: Identifying population needs and proposing a clinical workflow Authors: Meg Glausser, MD, Regina Ginzburg, Shireen Farzadeh, PharmD candidate, You Jin Chang, PharmD Candidate, Michelle Bejar, MD Background: Due to the recent advent of well-tolerated and curative HCV therapy, we have the opportunity to eliminate HCV from our community. However, in order to effectively treat IFH patients living with chronic HCV infection, we need a clear picture of the affected patient population and a systematic clinical workflow. A useful model for quantification of engagement in HCV care nationally has been called a Cascade of Care. This visual analysis identifies gaps in care, allowing resources to be targeted in useful directions. Steps in the cascade include diagnosing HCV, confirmatory RNA testing, linkage to care, receipt of antiviral therapy, and achievement of sustained virologic response (SVR). A national HCV care cascade was created in 2014 by Yehia, et al.Objective: To identify gaps in HCV care at 17th St IFH clinic, and propose an clinical workflow for primary doctors to engage patients in HCV care. Design: An IFH chart review to extract patient data, creation of an infographic Cascade of Care. Setting: 17th St IFH clinic. This urban setting is important, given high rates of at-risk patients. Participants: Electronic medical records. Instrumentation/Intervention/Data Collection: We searched electronic health records from 2012-2017 for all patients with positive HCV antibody tests, and as well as those with a diagnosis of HCV, and extracted further information from those charts to create a Cascade of Care chart. Included are total antibody positive patients, those who have had at least one viral load (HCV RNA) test performed, those with referrals to GI and those who have been prescribed an anti-HCV medication. Results and Conclusions: Rates of HCV confirmatory diagnosis labs, prescription of HCV medications and sustained virologic response at the 16th St IFH site are lower than national averages. These results show that we need to make a more coordinated effort to outreach and provide treatment to our HCV population at IFH. We propose a clinical workflow that includes internal specialist treatment or referral to GI.


HIV Stigma Reduction at the Institute for Family Health Authors: Rebekah Glushefski, LMSW, Rebecca Green, LMSW, Andrea Cole, PhD, LCSW, Robert Murayama, MD, Mary McGrath, BA Background: Stigma experienced by people living with HIV/AIDS creates a barrier for establishing and remaining engaged in care, which subsequently amplifies existing health disparities and results in poorer physical and mental health outcomes. At the Institute, COMPASS (Comprehensive Outpatient Medical Practice and Supportive Services) attempts to address health disparities in HIV care within the communities we serve. Objective: In 2017, as a funded program of the NYS Department of Health AIDS Institute, COMPASS implemented the Measuring Stigma in Healthcare Settings Survey with the intent of assessing staff knowledge, beliefs, and behaviors that might perpetuate stigma. As well, the COMPASS patient satisfaction survey included questions about experiences with stigma in IFH centers. This project sought to identify the presence of “key population” (people of transgender/gender nonconforming experience, men who have sex with men, people living with mental illness, people of color, and women) and HIV-related stigma in several centers and to develop an appropriate action plan. Design: This is an innovative project that collected quantitative and qualitative cross-sectional data from patients and staff in the summer of 2017. Setting/Participants: Patients from the COMPASS sites - Urban Horizons, Harlem, and 17th St - were invited to take part in the satisfaction survey. Staff members from these three centers and Stevenson, Hyde Park, and the Ali Forney Center were invited to take part in the staff survey. Instrumentation/Intervention/Data Collection: Patient surveys were conducted in person via paper and pencil, and focused on level of trust, perceptions of discrimination, and communication experiences. Staff surveys were conducted via SurveyMonkey and focused on staff perceptions and knowledge around working with key populations. Descriptive analysis of quantitative results was conducted in Excel and SurveyMonkey. Qualitative themes from open ended questions were analyzed using thematic analysis. Results and Conclusions: 166 staff surveys and 77 patient surveys, along with 17 patient interviews, revealed several key findings. Patients reported lack of conversations with staff members regarding PrEP and how to disclose HIV status. Some staff reported they believed HIV infection occurs due to irresponsible behavior and reported hearing staff speaking negatively about trans/gender-nonconforming people. These results suggest additional areas for IFH stigma-reduction initiatives including the U = U campaign.

Enhancing the Nurse Practitioner’s Role in Interdisciplinary Primary Care at The Institute through a Family Nurse Practitioner Fellowship Authors: Aviela Lerner, MSN, APRN, FNP-C, Mark Deguzman, MSN, APRN, FNP-BC, Katrina Organ, BA, Margaret Walsh, MSN, APRN, FNP-BC Background: Nurse practitioner (NP) training programs currently have immense variability in curriculum, required clinical hours, and award of degrees upon graduation. This is especially evident in accelerated NP programs. A number of NP fellowships have been created across the country to address this disparity and allow for more consistent clinical training for primary care providers. Objective: In 2017 The Institute created its own fellowship for the advancement of newly graduated family nurse practitioners (FNPs) in a primary care setting. The fellowship offers an innovative interdisciplinary collaboration with the Harlem Residency in Family Medicine. Design/Setting: The program involves a one-year fellowship focused in outpatient primary care predominantly at the Walton Family Health Center. Components include 10 sessions weekly: three independent patient care sessions, three precepted sessions, two specialty


sessions, one administrative session, and one didactic session with the family medicine residents. Participants: For the inaugural year of the fellowship, two recently graduated FNPs were selected. Designated program staff includes three FNPs and one program coordinator. Instrumentation/Intervention/Data Collection: Preceptors from the specialty rotations and those supervising continuity clinics at Walton evaluate the fellows on their clinical performance. Fellows routinely complete self-evaluations of their confidence level in various clinical areas and evaluate their specialty sessions on usefulness and skills learned. Results and Conclusions: Through independent, precepted, and specialty sessions the FNP fellows have been exposed to substantial clinical training and supported in their initial endeavors as primary care providers. Mentorship with experienced FNPs and clinical guidance from precepting physicians has promoted interdisciplinary education. Additionally, clinical interaction with medical residents had added familiarity for both parties in working on a diverse treatment team. Improvements to this fellowship should include promotion of the fellowship within the Institute to enhance awareness of the program and increased integration with residents within clinical settings for true collaborative practice.

Building a New Maternal Health Infrastructure at the Institute for Family Health Authors: Katrina Organ BA, CLC, Premila Mathews, MD Background: More American women are dying of pregnancy-related complications than any other developed nation in the world. The maternal mortality rate for women of color is higher than for white women. In New York City, black women are 12 times more likely to die than their white counterparts. The Institute had relied on temporary AmeriCorps members to act as prenatal coordinators. In 2016 when the AmeriCorps program ended, the Institute had an opportunity to “renovate” maternal healthcare at the Institute. Objective: To improve outcomes for pregnant and postpartum patients and their children by providing additional staffing and support to providers at the Institute. Design: A small team developed a proposal for the chief medical officer, which was eventually approved by senior leadership at the Institute. Setting: We chose to focus the new staffing model in Institute sites providing the most prenatal care: Kingston Specialty Care Center, Stevenson Family Health Center, Walton Family Health Center, Family Health Center of Harlem, and Sidney Hillman/Phillips (now 17 th Street). Participants: N/A Instrumentation/Intervention/Data Collection: The proposal included a Clinical Director of Maternal Medicine, a Maternal Health and Centering Coordinator, and five full time Maternal Health Advocates. It also identified a provider from each prenatal site as the “Maternal Health Champion”. Results and Conclusions: Preliminary data suggests improvement in patient outcomes with the implementation maternal health program. Women who received services under the new infrastructure (n=12) had, on average, longer pregnancies, heavier babies, lower C-section rates, and higher postpartum visit completion rates compared to women who received services from part-time/temporary staff (n=11). We plan to conduct a study comparing patient outcomes from pre- and post- implementation of the new maternal health infrastructure. We anticipate seeing an increase in number of prenatal visits, number of postpartum visits, and number of CenteringPregnancy enrollees. There could also be a potential decrease in rates of low birth weight and preterm birth.

Background: In Fordham/Bronx Park, where Walton Family Health Center is located, the incidence of low birthweight is higher than New York City (NYC) as a whole (2.8% vs. 2.7%, respectively). Moreover, the preterm birth rate is 10.1% compared to 9.9% in the Bronx and 9.0% in NYC. The Family Medicine Education Consortium developed IMPLICIT


(Interventions to Minimize Preterm and Low Birth Weight Infants using Continuous Improvement Techniques) to address these outcomes. The IMPLICIT-ICC protocol focuses specifically on interconception care (care between pregnancies). Objective: The objective was to successfully implement the IMPLICIT ICC protocol. Design: IMPLICIT ICC was implemented by forming a leadership team, developing a user-friendly workflow, conducting trainings, activating prompts in the electronic health record, tracking progress monthly, and incorporating a new staff position. Setting: The Walton Family Health Center was chosen for two reasons: 1) high rates of preterm birth and low birth weight previously described; and 2) a large pediatric population and high volume of well-child visits completed each year. Participants: The protocol specifically targets mothers of children under the age of two who are present at their child’s well-child medical visits. Instrumentation/Intervention/Data Collection: The IMPLICIT ICC protocol requires screening questions that address four behavioral risks affecting future birth outcomes. They are: 1) smoking 2) depression 3) family planning & birth spacing; and 4) multivitamin with folic acid use. Results and Conclusions: In about eight months, Walton engaged approximately 220 mother/baby dyads in the protocol. The screening rate of 95.7% was higher than the national IMPLICIT ICC Network’s cumulative rate of 84.4%. The implementation strategies for this project could be used at other health centers to initiate the IMPLICIT ICC protocol. Because this project is in early stages, we do not have results for maternal behavior changes or outcome data of subsequent pregnancies. However, given the high screening rate, we anticipate positive results as the project progresses.

Expanding the Reproductive Health Access Project Network: From 2007 to the 2016 election and beyond Authors: Linda Prine, MD, Laura Riker, MSSW, Natalie Kopke, Gabrielle Surick, MD Background: The Network is an organizing effort by the Reproductive Health Access Project connecting family physicians and other primary care clinicians from across the country to work together nationally and locally to expand access to abortion, contraception, and miscarriage care in their clinical and teaching practices. Primary objectives include: 1. Defend and expand access to abortion and other reproductive health care services in community health centers and primary care 2. Provide education, support, and training to primary care clinicians on reproductive health topics and make full-spectrum reproductive health care a core component of family medicine 3. Develop clinical advocates in family medicine and other primary care specialties who will speak up for access to reproductive health care in their professional organizations, clinics, and local/national governments. Design: Innovative Project Setting: Primary care, mostly family medicine settings, in the US. Participants: Family medicine and other primary care providers, including NPs, CNMs, PAs, Internists. There 20 local Network chapters, or Clusters, in 19 states and approximately 1,850 members total. Instrumentation/Intervention/Data Collection: The strategy of the Network is aimed at local and national organizing. Nationally, RHAP supports our members to become pro-choice advocates within their professional organizations, particularly the AAFP. We also connect virtually through the Access List. Clusters are led by local “reproductive health champions” and meet 2-5 times per year to participate in local advocacy and build a supportive community of like-minded providers. Minutes and sign-up sheets are gathered from each meeting. Topics include: resolution writing for the AAFP, plans for presentations at academic meetings, storytelling workshops, legislative advocacy, and general peer support. The meetings often result in cross collaboration of members from different institutions, idea sharing for meeting agendas or resolutions, and expansion of services to new areas. Results and Conclusions: This poster will describe the evolution of the Network’s organizing strategy since its inception in 2007, with a special focus on the effect of the 2016 election on the expansion of the Network in creating a strong network of primary


care/family medicine advocates for reproductive health provision, justice, and integration into family medicine and other primary care education.

To the point - Talking points to improve breastfeeding initiation and continuation rates Authors: Umara Saleem, MD, Megan McMullan, MD, Annie Kane-Horrigan, Aimee Smith, DO, Eve Waltermaurer, PhD Background: Women need education during their prenatal care about breastfeeding because knowledge and attitudes about this are formulated early in this realm. Relying on lactation support at the hospital level after birth to alter a woman’s choice of feeding method is not advisable. Our organization has been tracking breastfeeding rates via the traditional method as we have undergone baby friendly accreditation status at Health Alliance Hospital. Our centering groups have shown markedly increased breastfeeding rates, but the patients in conventional care still lag behind the average which currently make up the majority of our patient panel. Despite the push by the hospital setting, we are not seeing initiation rates in concert with Healthy People 2020 goals. Objective: The purpose of this study is to normalize and standardize discussions of feeding choice as well as the benefits of skin to skin in the prenatal setting. The goal of this study is to see how this intervention will change the initial choice and continuation of breastfeeding in the outpatient setting. Design: We intervened at 2 time points in the patient’s prenatal care during their individual care appointments, once in second and once in third trimester to discuss major talking points consistent with the goals of the Baby Friendly initiative and the support for breastfeeding. WE compare these rates to pre intervention rates (standard care) Setting: We did this study in the outpatient setting. Participants: 100 percent of pregnant patients presenting for prenatal care are recruited. Providers and health educators were involved with the intervention. Sites involved are our teaching sites in the Upstate IFH network. Instrumentation/Intervention/Data Collection: We utilized a smarttext to standardize the talking points that are used at the prenatal visits. These are incorporated into the resident smarttext for the prenatal visit, as well as individually accessible to the health educator outside of the medical visit. Results and Conclusions: This project is in progress. We have our preliminary data collected. Others could easily replicate our study.

IMPLICIT Interconception Care and Cigarette Smoking Authors: Aimee Smith, DO, Barbara Oppong, MD, Tiffany Pica, MD, Khurram Farooq, MD Background: Cigarette smoking during pregnancy has been linked to a variety of problems for newborns including cleft lip and palate, low birth weight, premature delivery and heart defects. It is considered the most modifiable risk factor for poor birth outcomes. In the postpartum period, maternal smoking may contribute to decreased infant immunity including a higher predisposition to respiratory infections, as well as many increased risks to the mothers’ own health. Encouraging maternal smoking cessation early in an infant’s life will likely improve overall health of both the mother and child. Objective: The purpose of this study is to determine if there is a correlation between maternal education level and smoking status and cessation efforts after delivery. Design: This study focused on gathering data during the well child visit (WCV) regarding the mother’s demographics and smoking status. Mothers answered questions either on paper or via conversation with healthcare provider. Setting: Participants were mothers whose children were seen at Kingston, Port Ewen, New Paltz, Ellenville and the Pediatric Care Center. Data was gathered as part of the IMPLICIT (Interventions to Minimize Preterm and Low birth weight Infants through Continuous Improvement Techniques) Interconception Care


(ICC) project. Participants: Eligibility criteria for study included women whose children are being seen for a WCV from birth to 27 months of age. Data Collection: If the mother answered yes to being a current smoker, a series of interventions were offered including counseling on smoking cessation, a prescription for smoking cessation aids or a referral to NYS Quit Line. Results and Conclusions: At the most recent WCV, 20.8% of smokers quit after receiving counseling from health care providers. Of those with less than a GED, 21.4% had quit, compared with 35.3% with a GED, 33.3% of those with higher than a GED and 26.1% of those whose education level was unknown. In conclusion, women with a higher education level were more successful at achieving smoking cessation. In the future, targeted or more intensive interventions for those with lower education levels may be more successful.

Ethical Issues, Challenges and Opportunities for Advocacy in Caring for a Detained Undocumented Immigrant Author: Victor Sta. Ana, MD, MSEd Background: Did some sort of problem exist that made you want to do this project? Have others done things like this? Describe the problem and why it was necessary for you to conduct this study. Despite implementation of Performance-Based National Detention Standards by Immigrations and Custom Enforcement (ICE),1 access to and provision of medical and mental health care in detention centers is often inadequate.2 Further, clinicians employed by ICE necessarily face the ethical conflict of “dual loyalty” to their employer and their patient.3 As such, detained undocumented immigrants represent a population vulnerable to health disparities. Objective: The purposes of this project are: 1) To describe barriers encountered while providing care in a detention setting, and 2) To discuss advocacy opportunities for physicians caring for detained patients Design: On 1/10/18, ICE conducted 98 raids of 7-Eleven stores throughout the US. 21 undocumented workers were detained.4 On 1/14/18, I was asked by a community-based organization to assess one such detainee. On 2/9/18, I conducted the assessment and collaborated with attorneys and community organizers to create an advocacy partnership for the patient. Setting: Meetings with lawyers, community organizers, and the detainee’s family occurred in Manhattan. The assessment occurred at the Hudson County Correctional Facility in Kearny, NJ. Participants: Myself, community organizers, lawyers from the Urban Justice Center, the patient and their family. Instrumentation/Intervention/Data Collection: I conducted medical and mental health assessments at the detention center, drafted a letter with my observations and diagnoses, and an opinion regarding the adverse impact of detainment on the patient’s health. These documents, along with a legal argument, were presented in immigration court to advocate for release. Results and Conclusions: Numerous barriers to providing medical and mental health care in detention were observed. Upon assessment, the patient met criteria for both medical and mental illness. Brief counseling and trauma-informed care were provided to the extent possible. On 2/15/18 the patient was released from detention after their immigration court hearing. On 3/4/18 I performed a post-release biopsychosocial assessment of the patient and one of their family members. Despite release, significant biopsychosocial impairments persist in both the patient and their family member as the patient remains at risk of deportation.

Identifying Barriers to Healthcare Experienced by Filipina/o Domestic Workers in New York City and Building a Partnership between the Institute for Family Health and Damayan Migrant Workers Association


Authors: Victor Sta. Ana, MD, MSEd, Guedy Arniella, LCSW, Zaira Hernandez-Cinto, Anita Ravi, MD MPH Background: In the US today, there are approximately 2 million domestic workers. 1 Domestic workers represent a population vulnerable to experiencing health disparities. According to a 3/17 report by the National Domestic Workers Alliance, of 2000 workers surveyed across 14 US cities, “65% reported having no health insurance, 29% reported having some kind of long-term medical problem from their work, [and] 25% of live-in workers reported getting no more than 5 hours of sleep at night.”2 To the presenters’ knowledge, no data exists identifying the specific barriers to accessing care experienced by Filipina/o domestic workers in NYC. Objective: Our objectives are to identify barriers to healthcare experienced by Filipina/o domestic workers in NYC and improve access to care. Design: Since 7/11, an Institute physician has been conducting outreach to Damayan Migrant Workers Association, a Filipina/o domestic worker organization in NYC. From 10-11/17, the physician convened a team of Institute employees to build a more formal partnership with Damayan. The team held several meetings with Damayan to: 1) Elicit barriers to accessing healthcare 2) Assess for and link to eligible benefits 3) Connect members to free and low-cost healthcare services Setting: Meetings with the team occurred at the Family Health Center of Harlem. Meetings with workers occurred at the Damayan office and the Nature Conservancy. Participants: Victor Sta. Ana, Guedy Arniella, Zaira HernandezCinto, Anita Ravi, and Damayan staff and members. 5, 45, 9, 5, and 10 members attended the five meetings, respectively. Instrumentation/Intervention/Data Collection: The team conducted meetings from 12/17-3/18. Workers voiced numerous barriers to accessing healthcare including: concern over large bills, fear of seeking healthcare due to immigration status, PTSD due to possible trafficking, reluctance to start “maintenance” medications, previous negative interactions with healthcare, lack of understanding of recommended health screenings. Zaira Hernandez-Cinto, immigrant health outreach coordinator will convene a group of workers and accompany them to NYC Free and PurpLE Clinic sessions. The team will develop a medical-legal clinic in partnership with Damayan.

The Health Impact of Gentrification Authors: Venis Wilder, MD Anna-Luisa Mirto, BS, Emma Makoba, BS, Guedy Arniella, LCSW Background: There is an observed shift occurring in many of our inner cities where traditionally African-American and Hispanic neighborhoods are becoming whiter and wealthier. In Harlem, New York City (NYC), the population of blacks from 2000 to 2010 decreased by approximately 15,000, while the population of whites increased by approximately 10,000, and the median income of the area has increased by 6%. Traditionally, gentrification has been discussed using the lens of sociology, urban planning, and geography, as opposed to public health. The economic and social effects of gentrification have been well documented, but there has not been substantial study reporting the health implications of these neighborhood level changes. Objective: To explore what is currently known in the literature about gentrification and its impact on health. Design: Literature review. We conducted a systematic review of the medical literature (PubMed) using the search terms: gentrification, health outcome, and displacement over an eight month period. We examined and synthesized evidence of impact of gentrification on the health of the affected community. Forty Four articles were found to be relevant to our discussion Setting: At HFHC and at Mount Sinai School of Medicine. Considering our work was primarily literature review, the setting where it was conducted was not relevant. Participants: None Instrumentation/Intervention/Data Collection: Literature review Results and Conclusions: In conducting the literature review, we found that


gentrification is a very real process affecting individuals and families and warrants further study as a phenomenon impacting population health. Gentrification is a very real neighborhood stressor that displaces individuals and families, reinforces discrimination and racism and creates financial and social pressures for long term residents. As a medical and public health community, we must work toward mitigating the adverse health impacts of gentrification and facilitate social exchange between new and old residents of gentrified communities. This work can be easily replicated


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Thank you to the symposium review team: Matt Beyrouty Andrea Cole Raji Edayathumangalam June Futterman Autumn Henry LaSheandra Hunter Cynthia Kim Mirta Milanes Jessica Neufeld Emily Oppenheimer Janet Park Evelyn Schofield Nandini Shroff Saskia Shuman

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Symposium booklet 2018 online  
Symposium booklet 2018 online