Taber Kreager A, Williams Jessica N, Huang Weixing, McLaughlin Katherine, Vogeli Christine, Cunningham Rebecca, Wichmann Lisa, Feldman Candace H
Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.
Massachusetts General Hospital and Harvard Medical School, Boston.
ACR Open Rheumatol. 2021 May;3(5):305-311. doi: 10.1002/acr2.11236. Epub 2021 Mar 29.
We studied patients with systemic lupus erythematosus (SLE) enrolled in a nurse-led, multihospital, primary care-based integrated care management program (iCMP) for complex patients with chronic conditions to understand whether social determinants of health (SDoH), including food insecurity, housing instability, and financial constraints, were prevalent in this population.
The academic hospital-based iCMP enrolls the top 2% of medically and psychosocially complex patients identified on the basis of clinical complexity health care use, and primary care provider referral. A nurse conducts needs assessments and coordinates care. We reviewed the electronic medical records of enrolled patients with SLE to identify SDoH needs and corresponding actions taken 1 year prior to iCMP enrollment using physicians' and social workers' notes, and during enrollment using iCMP team members' notes.
Among 69 patients with SLE in the iCMP, in the year prior to enrollment, 57% had documentation of one or more SDoH challenges, compared with 94% during enrollment. iCMP nurses discussed and addressed one or more SDoH issues for 81% of the patients; transportation challenges, medication access, mental health care access, and financial insecurity were the most prevalent. Nurses connected 75% of these patients with related resources and support.
Although SDoH-related issues were not used to identify patients for the iCMP, the vast majority of enrolled medically and psychosocially complex patients with SLE had these needs. The iCMP team uncovered and addressed SDoH-related concerns not documented prior to iCMP participation. Expansion of care management programs like the iCMP would help identify, document, and address these barriers that contribute to disparities in chronic disease care and outcomes.
我们对参与了由护士主导、多医院、基于初级保健的慢性病复杂患者综合护理管理项目（iCMP）的系统性红斑狼疮（SLE）患者进行了研究，以了解包括粮食不安全、住房不稳定和经济困难在内的健康社会决定因素（SDoH）在该人群中是否普遍存在。
基于学术医院的iCMP纳入了根据临床复杂性、医疗保健使用情况以及初级保健提供者转诊确定的医疗和心理社会复杂程度最高的2%的患者。一名护士进行需求评估并协调护理。我们查阅了已登记的SLE患者的电子病历，以使用医生和社会工作者的记录确定iCMP登记前1年的SDoH需求及相应采取的行动，并使用iCMP团队成员的记录确定登记期间的情况。
在iCMP的69例SLE患者中，登记前一年有57%的患者记录了一项或多项SDoH挑战，而登记期间这一比例为94%。iCMP护士为81%的患者讨论并解决了一项或多项SDoH问题；交通困难、药物获取、心理健康护理获取和经济不安全是最普遍的问题。护士为75%的这些患者联系了相关资源和支持。
虽然SDoH相关问题并非用于确定iCMP的患者，但绝大多数已登记的医疗和心理社会复杂的SLE患者有这些需求。iCMP团队发现并解决了参与iCMP之前未记录的SDoH相关问题。扩大像iCMP这样的护理管理项目将有助于识别、记录和解决这些导致慢性病护理和结局差异的障碍。
