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Abstracts from the 5th Annual NYC RING Convocation of Practices December 2, 2008 NYC RING Selected Abstracts 5th Annual Convocation of Practices Table of Contents Information about NYC RING……………………………………………………….Page 2 NYC RING Website Information……………………………………………………Page 3 Introduction to NYC RING’s 5th Annual Convocation of Practices….…...................Page 4 Convocation Agenda………….…………………………..………………………….Page 5 Selected Abstracts from the Convocation……………………………………………Page 6 Authors’ Email Addresses……………………………………………………………Page 57 1 NYC RING ABOUT US The New York City Research and Improvement Networking Group (NYC RING) was formed in 2003. It is a practice based research network sponsored by the Department of Family and Social Medicine of Albert Einstein College of Medicine. NYC RING has built to date a partnership of 33 practices in the Bronx and Manhattan sponsored by six medical centers, and one private practice, providing over 500,000 visits to primarily low-income, minority primary care patients. WHAT IS A PRACTICE BASED RESEARCH NETWORK (PBRN)? • A voluntary association of practicing clinicians collaborating to improve quality of care through research or quality improvement in their offices. OUR UNIQUE GOAL To focus on the issues of underserved urban communities through quality improvement projects and research initiatives. CRITICAL ELEMENTS OF NYC RING PROJECTS • Clinically relevant to urban primary care • Potential to change practice • Respectful of clinician time and practice realities • Results fed back to practices • Opportunity for clinician and staff input at all phases PARTICIPATION We welcome both new member practices and collaborators working on research topics appropriate for the practice based setting. NYC RING WEBSITE Please visit our website at www.nycring.org to learn more about our goals and projects. NYC RING MEMBERS Bronx-Lebanon Hospital Center Fulton Family Practice Center Ogden Family Medical & Dental Crotona Park Family Practice Wellness Center Institute for Family Health Mt. Hope Family Practice Parkchester Family Practice Urban Horizons Family Health Center/ River Counseling Center Walton Family Health Westchester Avenue Amsterdam Center East 13th Street Family Practice Phillips Family Practice Sidney Hillman Family Practice Montefiore Medical Center Castle Hill Comprehensive Family Care Center (CFCC) Comprehensive Health Care Center (CHCC) Family Health Center Fordham Family Practice Marble Hill Family Practice University Ave. Family Practice West Farms Family Practice Williamsbridge Family Practice South Bronx Health Center for Children and Families 2 North Bronx Healthcare Network Health Care Center at Gun Hill Healthcare Center at Tremont Health Center at Glebe Private Practice Riverdale Family Practice Saint Joseph's Medical Center Family Health Center Urban Health Plan Inc. El Nuevo San Juan Health Center Bella Vista Health Center Plaza Del Castillo Health Center NYC RING WEBSITE Please visit our website at www.nycring.org to learn more about our goals and projects, or to view abstracts of posters from our convocation. 3 NYC RING’s Fifth Annual Convocation of Practices Clinicians, Residents and Researchers Gather to Share their Work We want to thank everyone who attended the 5th Annual NYC RING Convocation on, Tuesday December 2nd at the Price Center. Over 100 NYC RING participating clinicians, researchers and investigators attended the event. Attendees came from all our partners - Bronx Lebanon Hospital Center, the Institute for Family Health, the North Bronx Healthcare Network, Urban Health Plan, Riverdale Family Practice, St Joseph's Medical Center and from throughout the Montefiore system. Thanks as well to all those who presented their posters and story boards at the convocation. We were excited to see the wide range of topics that are important to urban primary care practice and health. This year 46 poster presentations and story boards were presented by teams from participating sites, residents, and investigators working in NYC RING practices. The wide range of topics important to primary care practice in the urban setting included chronic disease, health promotion, mental health, reproductive health, screening and prevention, and health systems and other topics. Congratulations to Jose Lopez, Sabesan Karuppiah, Anele Manfredini, Eduardo Hidalgo and Marcella Scaccia from the Bronx Lebanon Hospital Center for winning the best poster competition for their poster entitled, "Patient Perceived Barriers for Colorectal Cancer Screening". Dr. Karuppiah’s enthusiasm for explaining the work he did was very engaging, the topic was interesting, and we are sure that standing next to the wine helped in making this the poster acknowledged by the vast majority of his peers as the best. This book contains abstracts of these posters. We hope that by creating a book of abstracts from these posters and storyboards, we can help share this work among interested parties. If you find an abstract interesting, feel free to contact the author, (email addresses are on pages 57-59). We look forward to hearing from you about how we can help you and others to further build on this work. Diane McKee, MD, MS NYC RING Director Phone: 718-430-2750 Email: [email protected] Paul Meissner, MSPH NYC RING Administrator Phone: 718-920-7802 Email: [email protected] Stacia Maher, MPH NYC RING Coordinator Phone: 718-430-2749 Email: [email protected] 4 5th Annual Convocation of Practices December 2, 2008 Agenda Poster Session 4:30- 7:30 pm Welcome 5:30 pm Roundtable Discussions 6:30-7:30 pm Roundtable 1: Behavior Change in Primary Care: Where Are We? Where Do We Go From Here? • Darwin Deen, MD, MS: Family Lifestyle Assessment of Initial Risk Project • Jessica Rieder, MD, MS: B’Healthy, B’Fit, B’Yourself: The Bronx Nutrition and Fitness Initiative for Teens • Elizabeth Walker, PhD, RN & Diane McKee, MD, MS: A Collaborative Approach to Control Hypertension in Diabetes (COACH-D): Implementation Experience • Alan Shapiro, MD: Community Pediatric Programs-Obesity Initiative Roundtable 2: Patient Centered Medical Home: The Research Perspective • Arturo Brito, MD, MPH & Roy Grant, MA: The Enhanced Medical Home: A model for underserved children • Bruce Soloway & Jonathan Swartz: Moving Toward the Patient Center Medical Home at MMG II Roundtable 3: Exploring Integrated Mental Health Care Models • Joanna Dognin, PsyD: Mental Health Screening Card Paper • Doug Reich, MD & Jeff Levine: Wellness Center at Bronx Lebanon • Virna Little, PsyD, LCSW-R: Integrated Models of Care at the Institute for Family Health • Barabara Hackely, MS, RN, CNM: Integrated Models of Care at South Bronx 5 NYC RING 5 Annual Convocation of Practices December 2, 2008 th Selected Abstracts Chronic Disease Abstract # 1 A Collaborative Approach to Control Hypertension in Diabetes (COACH-D): Implementation Experience Diane McKee, Elizabeth Walker, Irina Segal, Stacia Maher, Alex Ramirez Abstract # 2 “Voy a Viajar; The Effects of Circular Migration on Diabetes Control Among Latinos of Caribbean Origin”: A Project Proposal Gretchen Mockler, Jean Burg, Diane McKee, Arthur Blank Abstract # 3 Acupuncture to Decrease Disparities in Outcomes of Pain Treatment (ADDOPT) Diane McKee, Ben Kligler, Arthur E. Blank, Francesca Biryulov, Sheila George Abstract # 4 Proyecto Sabiduria (Project Wisdom) Improves Assessment and Outcomes for Geriatric Patients Mildred Casiano Abstract # 5 Intensive Case Management: A Multidisciplinary Team and Resident Education Approach to "Not at Target" Diabetics Victoria Gorski, Sandra Barnaby, Amy Osorio, Fabienne Daguilh, Jennifer Klein Abstract # 6 Care Improvement through a Five Year Diabetes Registry Implementation in a Small Urban Practice Akiko S.Hosler, Rachael Ruberto, Janet Sullivan, Alan Silver, Joan Cerniglia, Kim Kelly, Robert Morrow, Laura Shea, Maureen Spence, John Jacoby 6 Abstract # 7 CMO Chronic Care Management Advanced Technology in Diabetes Care Sandra Barnaby, Rosalyn Collado-Abreu, Pat Farrell, Bruce Feldman, Sheila Felleman Rhonda Figueira, Lea Gould, Karen Wauchope Abstract # 8 Staffing the Medical Home: Using Patient Educators Beyond Chronic Disease Management Darwin Deen, Arthur E. Blank, Diane McKee, Stacia Maher Health Promotion Abstract # 9 The Feeding Young Children Study (FYCS): Development of a WIC-Based Bottle Weaning Counseling Tool Christel Hyden, Karen Bonuck, Richard Kahn Abstract # 10 Family Lifestyle Assessment of Initial Risk (FLAIR): Evaluation of Lifestyle Counselor Consults Stacia Maher, Alice Fornari, Patricia Lopez, Diane McKee Abstract # 11 Can We Improve Resident Management of Obesity? Nichola Davis, Bernice Forbes, Clyde Schechter Abstract # 12 Zumba Bronx: An Intervention to Increase Physical Activity Among Health Center Users in the Bronx Renee Shanker, Miriam Shapiro, Earle Chambers, Michele Vaca Abstract # 13 B'Healthy..B'Fit...B'Yourself at the the Bronx Nutrition and Fitness Initiative for Teens at the Children's Hospital at Montefiore Jessica Rieder, Unab Khan Abstract # 14 Fit For Life-Preventing Childhood Obesity and Type 2 Diabetes Shamiza Ally Abstract # 15 Acceptability of Primary Care-Based Lifestyle Change: Counseling to Prevent Obesity Among Pre-School Children Darwin Deen, Diane McKee, Stacia Maher, Arthur E. Blank 7 Abstract # 16 Patient-Physician Perceptions Regarding Breastfeeding Counseling at Two Community Health Centers in the Bronx: A Pilot Study Elizabeth Natal, Rebecca Williams Abstract # 17 A Creative Collaboration to Improve Health Care Delivery: The South Bronx Community Health Worker- Montefiore Clinic Collaboration S. Doorley, A. Soto, R. Asgary, L. Smith, J. Deluca, J. Paccione Abstract # 18 Intervening with Primary Care Physicians and Parent(s) to Prevent Childhood Obesity: Planning and Enhancing Interventions using A Socio-Ecological Framework Arthur E. Blank, Darwin Deen, Jason Fletcher, Alice Fornari, Diane McKee, Stacia Maher Mental Health Abstract # 19 Exploration of Mental Health Need at the Family Health Center: Results of a One Week Card Study Joanna Dognin, Eliana Korin, Paul Meissner Abstract # 20 Increasing Assessment and Treatment of Depression in Community Health Kwame Kitson, Virna Little Abstract # 21 Psychosocial Characteristics of High Utilizing Inner City Hospital Patients JM Levine, Y Martin, D Reich, L Ladogana, M Gordon, A Khadivi, J Billings Abstract # 22 Ethnic Differences in Views of Psychotherapy among Depressed Primary Care Patients Lucia Ferri, Alison Karasz Abstract # 23 Westchester Square Partnership: Community-based Participatory Research in the Bronx Jean Burg, Rosy Chhabra, Kabita Ma, Alison Karasz, Runi Mukherji, Diana Rodrigue Reproductive Health Abstract # 24 An Effective Service Delivery Model for Expanding the Utilization of Reproductive Health Care Services in Community Health Care Settings Virna Little, Cynthia Kernahan, Laura Leone 8 Abstract # 25 Confidential Care & Health Concerns in Urban Adolescent Males: A Focus Group Study Diane McKee, Susan Rubin, Giselle Campos, Lucia O’Sullivan Abstract # 26 Vaginal Hygiene and Douching: Perspectives of Hispanic Males Diane McKee, Maria Baquero, Matt Anderson, and Alison Karasz Abstract # 27 Changing the Face of Reproductive Health Care: Discussions of Contraception and Pregnancy with Men Emily Jackson, Marissa Harris, Tara Stein, Marji Gold Abstract # 28 Interviews with Women of Caribbean Descent at Williamsbridge Family Practice: their Attitudes Towards Reproductive Health Marji Gold, Marissa Harris Abstract # 29 “Up In Me”: Urban Female Family Medicine Patients’ Perceptions around Intrauterine Contraception Susan E Rubin, Ilana Winrob Abstract # 30 Promoting Maternal Pap Testing during a Child Visit William B Jordan, Marian S Krauskopf, Diane McKee Abstract # 31 Improving Pap Smear Follow-up Compliance in Montefiore Medical Group Ambulatory Practices Maureen Warner, Pio Paunon, Arthur Hopkins, Jonathan Swartz, Noel Brown, ZhongWei Lu Abstract # 32 Is a Pelvic Exam Necessary for Women with Vaginal complaints? (Pilot RCT Study) Andreas Cohrssen, Matthew Anderson, Gina Foster, Danit Brahver Abstract # 33 The role of Health Care Trust in Contraceptive Practices Among Low-income AfricanAmerican Women Oni Blackstock, Adamma Mba-Jonas, Hillary Kunins, Galit Sacajiu Screening and Prevention Abstract # 34 Collaborative HIV Primary Care in the Bronx: Evaluation of the CICERO Program Carolyn Chu, Galina Moskaleva, Arthur Blank, Robert Beil, Robert Grossberg, Peter Selwyn 9 Abstract # 35 Improving Use of Oral Health Services Among HIV+ Patients: Project TEETH Niko Verdecias, Arthur E. Blank, Joan Grcevic, Alison Karasz, Robert Beil, Paul Meissner Abstract # 36 Patient Perceived Barriers for Colorectal Cancer Screening Jose Lopez, Sabesan Karuppiah, Anele Manfredini, Eduardo Hidalgo, Marcella Scaccia Abstract # 37 How Family Medicine Residents Conducted a Continuous Quality Improvement Program in an Outpatient Setting-Identifying and Targeting Smokers for Smoking Cessation using the Fax-To-Quit Program Betsy Mathew, Sybil Hodgson, David Herszenson, Rebecca Middleton, Victoria Gorski, Karen Becker, Fabienne Daquilh, Belinda Johnson Abstract # 38 Hep CAT: Hepatitis C Assessment & Testing Project Mari-Lynn Drainoni, Lisa Koppelman, Cindy L. Christiansen, Allen Gifford, Alain Litwin, Diane McKee, Stacia Maher, Tamara Maynard, Will Southern Abstract # 39 ACTS (Advise, Consent, Test, Support): A Paradigm Shift in HIV Testing that Strengthens Healthcare Services by Reorganizing Existing Personnel Donna Futterman, Stephen Stafford, Michelle Lyle, Paul Meissner Health Systems and Other Abstract # 40 Medical Conditions Affecting Employment Capacity Michael Ward, Fernando Diaz-Mori, Paula Parkerson Abstract # 41 CARE CONNECT, Investigating the Value of Generic Telemonitoring in Management of a Frail Elderly Population Bruce L. Feldman, Kathe Byrne, Ana Goulborne, Roselyn Collado-Abreu, Myriam VilliariniHarris Abstract # 42 Kerr White in the Bronx: The Use of Census Data and Electronic Information Systems to Describe Community and Clinic Populations Arthur E. Blank, Vincent Huang Abstract # 43 Impact of Incarceration in Primary Care Settings in the Bronx: A Card Study Minesh Shah, Sadiqa Edmonds-Myles, Carolyn Chu, Miriam Shapiro, Matt Anderson 10 Abstract # 44 Analysis of Patient Satisfaction Improvements in a Medical Practice Pio Paunon Abstract # 45 A Comparison of Integrated HIV and Buprenorphine Treatment in Primary Care C.O. Cunningham, A.G. Giovanniello, G. Sacajiu , S. Whitley, N.L. Sohler Abstract # 46 Improving Health Care Outcomes in Homebound High Risk Vulnerable Elders in the South Bronx: An Enhanced Interdisciplinary Model of Home Based Primary Care Marcella Scaccia, Jose A. Lopez, John Forney, Isabella Jankowska, Doug Reich 11 Abstract 1 A Collaborative Approach to Control Hypertension in Diabetes (COACH-D): Implementation Experience Diane McKee, MD, MS; Elizabeth Walker, PhD, RN; Irina Segal, RN; Stacia Maher, MPH; Alex Ramirez Objective: To develop a novel intervention to improve blood pressure and other intermediate outcomes of diabetes management (HbA1c and cholesterol) in a multi-ethnic, low-income primary care population. Patients: English or Spanish speaking patients from the Family Health Center with Type 2 Diabetes, any level of A1c, and a blood pressure reading > 140/90 at their last visit and at least one other visit in the past year. Additionally, a touch tone home phone is required for compatibility with the intervention. Methods: Diabeaters Registry data was used to identify BP eligibility and the Primary Care Provider screened patient data for ineligibility. A PCP signed letter was mailed and a follow-up phone call from the research team was made for eligibility verification. Following an initial interview and clinical assessment (including home BP), patients were randomized to usual care or home telemetry intervention with home nurses assessing self management activities and medication adherence. Home nurses were trained in motivational interviewing-based counseling. Home telemetry units transmitted daily blood pressure and glucose results to home health and these reports were forwarded to the PCP to facilitate intensified treatment. Results: 44.4% of visits in CareCast had no BP recorded. Eligible by visit in last 6 months and BP criteria: n = 171 (23% of patients with diabetes seen during interval). Ineligible by physician or research team: n=28 (16.4%). Opted out of contact: n=9 (5.3%). Refused: n = 24 (14%). To date there have been a total of 11 usual care patients and 15 intervention patients (mean age: 61.4 + 8.8y, range: 44-79y, 75% female, insurance: 75% Medicaid, 7% Private, Mean A1C: 7.9, LDL>100: 50%). Currently active on protocol: n = 17, completed intervention: n = 6, and withdrawn: n = 3 (10.7%). Conclusions: Early results suggest that intervention is acceptable to PCPs, HHNs and patients. We are identifying barriers to implementation that will be considered in the design of an R18 intervention. It is expected that the intervention will be effective in reducing BP (to below 130/80), reducing HbA1c, and reducing LDL cholesterol. 12 Abstract 2 “Voy a Viajar; The Effects of Circular Migration on Diabetes Control Among Latinos of Caribbean Origin” Gretchen Mockler, MD; Jean Burg, MD; Diane McKee, MD, MS; Arthur Blank, PhD Context: In the US, Latino adults have up to two times the incidence of T2DM as non-Hispanic adults and have higher rates of end-stage complications of diabetes. To date, it has not been clearly demonstrated how much of this difference can be attributed to genetic vs. socioeconomic and/or cultural/linguistic factors. Objective: To assess whether the frequency of Latino patients’ visits to their home country and the nature of their health care practices while away impact on diabetes clinical outcome measures. Design: The study will include a retrospective chart review segment and a patient questionnaire to be administered verbally. Participants: An estimated 300 Hispanic, adult, outpatient patients with type 2 diabetes who are of Dominican, Puerto Rican or Cuban descent. Instrument: The patient questionnaire will include questions to study participants regarding: 1) Dates and frequency of travel to their native country over the past 2 years, 2) Whether they have an identified PCP in NYC and/or abroad, 3) If so, whether they saw their PCP in NYC prior to travel and whether their travel plans were discussed at the visit/s, 4) Whether they were seen by any medical personnel, hospitalized or had their medications changed while they were away, 5) Whether they ran out of medication while away, 6) Whether self-monitoring habits and/or diet differed while away, 7) Four-question acculturation scale. Setting: The Health Center at Tremont, a community clinic in the East Tremont section of the Bronx. Anticipated Results: Key Measures based on chart review will include average Hba1c, fasting glucose, lipids and blood pressure among patients in the highest- vs. lowest-frequency of travel groups; a comparison of these same parameters prior to and subsequent to travel dates; an analysis of the impact of medical attention while abroad; and a comparison of the frequency of travel to patients’ acculturation scale scores. Implications: If clinically significant differences in outcomes can be demonstrated among the two groups described, potential interventions might include a standardized visit format to discuss diet, medication refill plans and to review PCP contact information between countries prior to patient travel, and the establishment of a medical record exchange or sister clinic arrangement with health practitioners abroad. 13 Abstract 3 Acupuncture to Decrease Disparities in Outcomes of Pain Treatment (ADDOPT) Diane McKee, MD, MS; Ben Kligler, MD; Arthur E. Blank, PhD; Francesca Biryulov; Sheila George Context: The importance of identifying and effectively treating pain has gained recognition in the last decade. Chronic pain, defined as pain that is persistent or recurs frequently for at least 3 months, is common in the general population. Chronic pain is associated with impairments of physical and psychological functioning. Low income and minority samples experience disparities in the prevalence of chronic pain, in perceived access to effective pain treatment, and in consultations for pain. A great deal of literature suggests that acupuncture offers potential benefit in the management of chronic pain, but is rarely available to low income patients. Objectives: To assess the adoption and implementation of acupuncture as a treatment for chronic pain due to osteoarthritis, neck and back pain among minority low income patients in primary care practice. To determine whether adding acupuncture services to routine management of chronic pain in the community health center setting results in improvements in the following outcomes: pain, pain free days, and health-related quality of life. Setting: Acupuncture will be offered weekly at each practice by a student/faculty team from the Swedish Institute Program in Acupuncture. The practices involved include the Family Health Center, Williamsbridge, and Castle Hill. Patients and Methods: Patients 21 and are eligible if they have chronic pain due to a qualifying diagnosis of osteoarthritis, neck, or back pain. The design is quasi-experimental (repeated measures design) with multiple settings across baseline. Multiple pre and post measures to be used during a 6 week pre-treatment phase for baseline measures repeated 6 times post intervention, at 2, 4, 8, 12, and 16 weeks. The key measures to be used are: the Brief Pain Inventory/Short Form (BPI): nine item measure which asks patients to indicate, over the past 24 hours, the level of pain they are feeling, the intensity of pain, and how their pain influences select aspects of their everyday life, Pain Free Days: self-report measure asking patients to report the number of pain free days in the previous 2 weeks, a Health Related Quality of Life (SF-12), and the Patient Global Impression of Change (PGIC): a single question 7-point categorical scale. A final assessment will also be conducted at 6 months from initiation of acupuncture. Expected Outcomes: Data collection is expected to begin in 03/2009. We hypothesize that: 1) At least 30% of eligible minority patients who are referred to acupuncture clinicians by primary care providers can be recruited and retained in treatment. 2) Patients treated with acupuncture in addition to routine management of chronic pain will show a 2 point improvement in their reports of pain, and a 3 to 6 point change in their health-related functional status, compared to preacupuncture routine care. Conclusions: Pain is often under treated, especially in minority populations. Acupuncture can be efficacious in the treatment of many common pain disorders however little is known about the use of acupuncture for chronic pain in primary care settings, especially in low income and minority communities. There will be an evaluation not only on effectiveness but on a variety of process measures to understand barriers to implementing acupuncture for low income minority patients. Moreover, collection of preliminary cost data related to the intervention will assist in the design of a larger trial examining cost effectiveness as well as clinical outcomes of acupuncture for chronic pain conditions. 14 Abstract 4 Proyecto Sabiduria (Project Wisdom) Improves Assessment and Outcomes for Geriatric Patients Mildred Casiano, LCSW; Deborah Lester, LMSW Context: In 2007, UHP obtained a grant from the Fan Fox Leslie R. Adams Samuels Foundation to expand our discrete Geriatric Clinic, Proyecto Sabiduria, to better serve our patients over 65 years of age. Objective: To create a discrete clinic that better serves the unique needs of our geriatric patients, prevent institutionalization, and improve their health and quality of life. Design: Evidence based and internally developed questionnaires were utilized to assess patients’ health, mental health, and social needs at intake including the PHQ-9 to screen for depression, Folstein fall risk assessment, mini mental status exam, adult activities of daily living, abuse and neglect screening and social services needs assessment. Setting: Urban Health Plan Inc. is a Federally Qualified Health Center located in the South Bronx, New York. Participants: Currently, the discrete clinic has 451 patients. A retrospective analysis was conducted utilizing a random sample of patients in the geriatric clinic (N=95) and in the general primary care population (N=66) was compared to ascertain whether or not medical and psychosocial assessment and outcomes were improved for patients served in the discrete clinic. Intervention: Upon intake, a case manager conducts aforementioned screenings and provides follow-up to assure patients obtain needed services. Results: A retrospective analysis was conducted on a random sample of geriatric and nongeriatric clinic patients. The case managers performed the aforementioned screenings on patients in the discrete geriatric clinic and provided follow-up case management; (89% screened) with the following results: 98% live in the home, 67% live with family members, 90% of those that live alone have home care, only 16% were clinically depressed (less than the general adult population), and less than 2% reported neglect or abuse in the home. In comparison, geriatric patients seen in the general clinic were not proactively screened and only 18% received minimal case management services. In addition, patients with diabetes in the discrete clinic had an average Hba1c of 7.2, while the general geriatric population had an average Hba1c of 7.7. Conclusion: Proactive screening and provision of case management services improves assessment, health and psycho-social outcomes for geriatric patients. 15 Abstract 5 Intensive Case Management: A Multidisciplinary Team and Resident Education Approach to 'Not at Target' Diabetics Victoria Gorski, MD, FAAFP; Sandra Barnaby, RN, CDE; Amy Osorio, MPH; Fabienne Daguilh, MD; Jennifer Klein, RD Context: One of two continuity practice sites of the Montefiore Medical Center/Albert Einstein College of Medicine residency program in family medicine. The clinical practice team was inspired by participation in the American Association of Medical Colleges Chronic Care Collaborative. The practice is 66% Afro-Caribbean and 12% Latino. Objectives: 1) To provide individualized, interdisciplinary diabetes education to high-risk patients with an A1C>9 and LDL > 100 or BP > 130/80. 2) To provide clinical services to meet the needs of patients not meeting A, B, C targets for diabetes. 3) To reinforce resident education in the Chronic Care Model by providing experience in the intensification of diabetes treatment as part of a care team. 4) To reinforce the importance of taking a biopsychosocial approach to people struggling with chronic illness. Design: 1) Multidisciplinary team with physicians, RN/certified diabetes educator, health educators, and social worker convened and established protocol for assessment (including a PHQ-9 and quality of life tool) and approximately six-week program of intervention. Clinical care occurs once weekly with a sub-set of the team. Interventions include selfmanagement support using a motivational interviewing approach, education using visual tools, medication adjustment, and social work referral for depression treatment or referral when indicated. Inter visit phone calls support medication and behavior changes. 2) The protocol includes follow up at three and six months after completion of the program and a yearly “reunion”. 3) The whole team meets for planning and evaluation on a monthly basis. 4) Second and third year family medicine residents join the team for four weeks while on their cardiology rotation. ACGME competency oriented goals and objectives were established for the resident learning experience. Results: The first cohort of fifteen patients started with an initial average A1C of 10.8. At graduation from the program, the average A1C was 8.8. At six to twelve months after graduation from the program, the average A1C was 8.2. Qualitative data gathered from comments of patients at the diabetes reunion highlight the sense of enthusiasm and support generated by the different members of the intervention team, knowledge gained about diabetes and behavior changes related to nutrition, exercise and medication adherence that patients were able to sustain. Informal interviews with the family medicine residents who have completed the rotation reveal high levels of satisfaction with the rotation, which allows them to learn about intensification of treatment and self-management support. Conclusions: Guided by the principles of the Chronic Care Model, a multidisciplinary team is able to improve clinical parameters in diabetics not at target for A1C, BP, LDL cholesterol in an urban predominantly Afro-Caribbean practice although a structured program of intensification of education, medication adjustment/adherence and social support. The improvements are sustained at six to twelve months following the intervention. Family medicine residents’ value time spent with the team and it increases their comfort with diabetes medications, patient education and support. 16 Abstract 6 Care Improvement through a Five Year Diabetes Registry Implementation in a Small Urban Practice Akiko S.Hosler, PhD; Rachael Ruberto, MPH; Janet Sullivan, MD; Alan Silver, MD; Joan Cerniglia, RN, MPA, FACHE; Kim Kelly; Robert Morrow, MD; Laura Shea, MS, RN; Maureen Spence, MS, RD; John Jacoby, MD Context: Key to improving chronic care in a practice setting is the creation of accurate data registries. We implemented a computer-based diabetes registry in a [private] primary care practice to test both its practicability [could it be done in this setting], and its effect on patient care measures. Objectives: To evaluate the impact of adopting a personal computer based diabetes management registry. The implementation was supported by the NYS Department of Health and the New York Diabetes Coalition. Setting: An urban setting, 2.5 MDs and I NP family practice serving a mixed income population. Methods: We assessed annual changes of the proportions of adult (≥18 years) patients who had at least 2 visits in a given year and met selected National Quality Forum (NQF) endorsed diabetes performance measures during 2002 to 2006. (n=214) We also assessed changes among a subset of patients who had at least 2 visits in every year during the same period (5-year cohort, n=45). Results: Patient population was 58% female, with the median age of 61. From baseline to 2006, all indicators improved, including annual A1C (61.5 to 75.0%), A1C in good control (<7%) (22.8 to 33.9%), lipid profile (58.3% to 78.6%), lipids controlled (LDL<100mg/dl) (16.5% to 23.2%), and blood pressure (BP) controlled (<80/130) (30.7 to 35.7%). All indicators except BP control had a statistically significant (p<0.05) improvement. The 5-year cohort saw similar improvements. Registry patients showed significantly larger improvement compared to referent state managed care populations (5-20% vs. -3-7% Medicaid/commercial), suggesting improvement beyond the secular trend. Conclusion: A registry in a small practice is feasible and can lead to significant improvement in diabetes clinical management processes. 17 Abstract 7 Use of Advanced Technology in Diabetes Care in the CMO Disease Management Program Bruce L. Feldman, MD; Shelia Felleman RN, MPA; Sandra Barnaby RN, MPH, CDE; Patricia Farrell RN, MSN, CDE; Rhonda Figueira RN, NP, MSN; Karen Wauchope RN, BSN, CDE; Lea Gould, RN, BSN; Roselyn Collado-Abreu, MPA Context: CMO Diabetes Disease Management Program members were offered a device, the Auto-Link, to facilitate electronic monitoring of capillary blood glucose (CBG) results by the Disease Management (DM) team. The program first piloted in January 2007, was implemented in January 2008. Approximately 30 members were enrolled during the 2008 calendar year. Objectives: To closely monitor and promptly respond to uncontrolled hyperglycemia and significant hypoglycemic events, leading to reduction in ED visits and hospitalizations, improvements in glucose management, increased staff effectiveness, and decreased health care costs for members. Participants: Montefiore CMO members with HIP insurance, a confirmed diagnosis of Diabetes Type II, an available standard (analog) land-line telephone service, capability of using technology and the clinician’s belief that the member would benefit from closely managed blood sugars. Design: CMO RN identifies appropriate members and obtains agreement to participate in the program. CMO Coordinator then orders device and telephonically assists the member with the initial set-up. Setting: The member, in their own home, tests and transmits their CBG readings via Auto-Link. Those CBG results are viewed daily on a secure web interface by a CMO Coordinator and escalated to a RN when outside of normal parameters (70-240 mg/dl in most instances). Members are contacted if they do not submit CBG's over 2 days. Program Evaluation: Members’ experience during the first three months (first quarter) of program participation is compared to the next three quarters of participation. Key measures include the number of hyperglycemic/hypoglycemic events, ED visits, hospital admissions, and overall member satisfaction with the program. Preliminary Conclusions: Program participation allowed for the early identification of 2 infections with actions taken to prevent hospitalization. Member hospitalizations and ED visits suggest a downward trend. Greater program experience with membership growth is necessary for effective measurement of program outcomes. The program is slated to continue and expand. 18 Abstract 8 Staffing the Medical Home: Using Patient Educators Beyond Chronic Disease Management Darwin Deen, MD, MS; Arthur E. Blank, PhD; Diane McKee, MD, MS; Stacia Maher, MPH Context: Obesity rates have increased dramatically over the past two decades particularly impacting urban minority children. This represents a critical public health issue for our time. Objective: To reframe the preventive care visits for 2-4 year olds to focus on family lifestyle behaviors that put children at risk of excess weight gain. Design: A self-administered screening form was introduced into practices And providers were trained in brief motivational interviewing methods to engage caregivers in goal setting. A health educator was made available to follow-up with patients who expressed interest in changing behaviors. Setting: Six urban primary care practices providing care for children, three served as intervention sites and three and control. Participants: Low-income inner city parents/guardians, 94% of those referred were mothers, 61% identified themselves as ethnically Hispanic Instrument/ Intervention: FLAIR screening form and goal setting form. Goal setting was done by primary care providers and referral to a health educator was provided when indicated. Results: Parents are interested in identifying changes that they can make to assure the future health of their children. Physician advice is critical but parents really appreciated the practical advice provided by the health educator. Conclusions: Health educators have been used in a variety of chronic disease management roles but their skills are equally applicable to primary prevention. 19 Abstract 9 The Feeding Young Children Study (FYCS): Development of a WIC Based Flipchart for Bottle Weaning Christel Hyden, MS, CHES; Karen Bonuck, PhD; Richard Kahn, MS, RD Context: Excess bottles of whole milk and sweet beverages beyond the advised weaning age of 12 months (i.e. “inappropriate bottle feeding”) has been linked to overweight. The Feeding Young Children Study (FYCS) aims to reduce the risk of early childhood overweight by reducing their use of bottles. Objective: To describe the development an educational flipchart to help parents appreciate the full gamut of potential risks of bottle use past age 1 as well as the potential benefits of timely weaning. Design: The FYCS consists of three components: (1) Randomized controlled trial to test a bottle weaning intervention; (2) Observational study to collect 24 hour dietary recalls on 12-24 month olds enrolled in the study; (3) Extension and dissemination activities. Bottle use, anthropometrics, dietary intake & nutrient density to be assessed at baseline (12 months) and at 15, 18, 21, and 24 months of age. Participants: FYCS will enroll 464 12-month olds at two WIC sites in the Bronx who are currently consuming two or more non-water bottles per day. Instrument/ Intervention: The intervention is delivered by WIC nutritionists during the 12 month recertification visit at WIC. A one-on-one conversation with parents and caregivers is supported by the educational flipchart. The flipchart’s primary functions are to: (1) Relate to the negative sequalae of inappropriate bottle feeding (e.g. overweight, dental caries, iron deficiency; (2) adapt a systematic weaning approach that woks for them; (3) problem-solve family/child reactions to weaning. Support for self-efficacy is promoted through anticipatory guidance and client initiated solutions to potential challenges. Next Steps: The intervention for which this flipchart was developed was launched in October 2008 and recruitment will continue through December 2010. As part of the extension activities, the final flipchart will be submitted for publication at WIC Works, American Academy of Pediatrics, National Center for Education in Maternal & Child Health and the National Maternal & Child Oral Health Resource Center. 20 Abstract 10 Family Lifestyle Assessment of Initial Risk (FLAIR): Evaluation of Lifestyle Counselor Consults Stacia Maher, MPH; Alice Fornari, EdD; Patricia Lopez, MA; Diane McKee, MD, MS Context: The prevalence of overweight among 2-5 year olds is a growing concern, especially in low-income communities. Objective: To assess whether a brief goal setting process between the patient’s parent/guardian and the physician, followed by a lifestyle counselor (LC) consult is effective in producing meaningful lifestyle change. Design: Three intervention site clinics in the Bronx (1 Peds, 1 Family Med, 1 Mixed) and 3 matched controls. The “Family Lifestyle Assessment of Initial Risk” (FLAIR) study: 1) reframed 2 to 3 year old well child visits to focus on family lifestyle risk assessment and behavior change, 2) encouraged primary care providers (PCP) to help families set behavior change goals, and 3) augmented clinician counseling by referral to a LC trained in motivational interviewing (MI). Lifestyle Counselor’s Intervention: The LC contacted each referred family for an appointment. Using the principals of MI, the LC developed strategies to address the barriers identified by the parent. Notes were placed in the patient’s chart. Participants: All families counseled as part of the intervention. Measures: 1) Screener: Assessed the health habits of the family & child. 2) Goal Setting Form: Facilitated a conversation between the PCP and the patient to set one or two goals. 3) Family Action Plan Form: Assessed overall importance and confidence for achieving behavior change goals. 4) LC’s Notes: Recorded the discussion between the LC and parents, and the specific goals that were set and accomplished by the family. Data Analysis: Two readers compared their identified themes and came to an agreement on final themes with assistance from the principal investigator. Within themes, patient barriers and strategies to overcome these barriers were identified. Demographics: Low-income inner city parents/guardians, 94% of those referred were mothers, 61% identified themselves as ethnically Hispanic. Results: Three themes were found during the intervention: 1) poor parenting skills 2) poor knowledge and skills regarding healthy eating, and 3) psycho/social contextual issues acting as barriers to healthy eating. For each theme and subtheme a strategy was developed by the LC to help families overcome barriers. The majority of the barriers were based on poor parenting skills, which exasperated parents’ ability to deal with issues around picky eating, their child’s ability to achieve milestones, and a lack of knowledge about healthy food. Psycho/social contextual barriers such as unstable housing, parental depression, unemployment and intergerational and/or partner conflict regarding food choices were barriers to achieving goals and adopting healthier behaviors. Conclusions: Parents are open to improving the health of their families and in many instances were already exercising healthy nutritional habits, such as diluting their children’s juice with water and switching to low fat milk. Interventions of this nature should focus on the family not just the individual child. We need to shift toward a more holistic conception of what it means to be healthy, taking into consideration the social, emotional, and spiritual as well as the physical aspects of the human experience. 21 Abstract 11 Can We Improve Resident Management of Obesity? Nichola Davis, MD, MS; Bernice Forbes, MD; Clyde Schechter, MD, MA Context: Resident physicians report feelings of incompetence in treating obesity and do not routinely counsel patients or refer patients for weight management. Many training programs do not emphasize training in obesity management. Objective: To determine the effect of a resident educational intervention on resident knowledge and management of obesity. Setting & Participants: The educational intervention involves 80 Internal Medicine and Family Medicine residents. Intervention: The resident educational intervention is a 2 hour educational session which instructs residents on how to counsel obese patients, demonstrates use of counseling tools, and how to use motivational interviewing techniques to assess patients’ motivation for change. Residents are given an opportunity to practice counseling techniques. Outcome Measures: The primary outcome is change in resident knowledge assessed by 20 item questionnaire (10-items on knowledge and 10 items on beliefs and feelings of confidence) done prior to and immediately after educational intervention. Resident management of obesity was assessed by chart reviews which determined documentation of BMI, diagnosis of overweight or obesity, and weight loss recommendations pre and post intervention. Results: Mean (±SD) knowledge increased from 5.9± pre intervention to 6.6±post intervention. (p=.001). There was a significant increase in the number of residents reporting confidence in using the 5As approach (from 24% to 54%) and using motivational interviewing techniques (from 38% to 75%). There was no significant change in the documentation of BMI, diagnosis of overweight or obesity, or weight loss recommendations after the intervention. Conclusions: A 3 hour educational intervention integrated into the ambulatory curriculum improved knowledge slightly and had greater effects on confidence with using the 5 As and motivational interviewing for nutritional counseling. We did not detect any change in physician behavior based on chart review. 22 Abstract 12 ZumbaBronx: An intervention to increase physical activity among health center users in the Bronx Renee Shainker, MSW, MPH; Miriam Shapiro, BA; Earle Chambers, PhD; Michele Vaca, MD Conext: The Bronx is the NYC borough with the highest rate of obesity and diabetes. Thirty five percent of Bronx residents are overweight, 30% are obese, and over 12% suffer from diabetes. Objective: To investigate the feasibility and sustainability of a 12-week salsa dance exercise program at community health centers in the Bronx, including level of participation and increase in level of physical activity of health center users. Methods: Health educators, nutritionists, and physicians at community health centers served as instructors. They completed a 1-day Zumba® Gold Instructor Workshop and a 6-week postcertificate skill development series. Participants were enrolled health center patients at least 18 years of age referred by their medical providers. The intervention consisted of weekly 45 minute Zumba® Gold exercise classes. Results and Discussion: Attendance at classes was consistent and there is much interest in Zumba classes among health center users. A fun and culturally relevant salsa dance exercise program is sustainable, feasible and popular in the Bronx community. This project is just getting started. In the coming months we intend to extend the program to a pediatric population and more health centers and community locations in the Bronx, offer classes continually throughout the year, and add a weight-loss component to program. Additionally, we hope to develop a Peer Leadership Model by training community residents as fitness instructors. 23 Abstract 13 B’Healthy, B’Fit, B’Yourself: The Bronx Nutrition and Fitness Initiative for Teens Jessica Rieder, MD, MS; Unab Khan, MD Context: There are few published evaluations of successful weight reduction programs for overweight adolescents and data on interventions targeting low-income and minority populations are scarce. For an inner-city, minority population of teens, the Bronx Nutrition and Fitness Initiative for Teens (B’N Fit) Program offers an individually-tailored, medical, nutritional, and psychosocial assessment and a comprehensive community-based weight loss management program. Objective: To preliminarily evaluate the short term effect of the B’N Fit Program on anthropometric measures such as weight and body mass index, biochemical indices, and lifestyle behaviors such as fruit/vegetable intake, sugared beverages, time watching TV. Design: Adolescent subjects ages 12 to 21 years underwent a baseline evaluation consisting of: 1) physical examination and anthropometric assessment ( including height and weight assessments); 2) comprehensive nutrition and physical activity assessment; 3)fitness evaluation; and 4)laboratory evaluation consisting of fasting insulin, fasting LDL, HDL, triglycerides, total cholesterol, and a 2-hour oral glucose tolerance test. Subjects then participated in an initial 12week intensive intervention which consists of ongoing medical, nutritional, psychosocial surveillance, weekly group sessions to introduce basic principles of nutrition and behavioral techniques, physical activity sessions, and family-tailored skills-developing sessions to provide specific suggestions and techniques that will assist youth and families as they adopt healthy nutrition and physical activity practices. A subsequent 6-month weekly maintenance program offered long-term support of healthy lifestyle behaviors. Follow-up evaluations were done at 9 months after starting the program. Results: Of the 46 subjects that completed the baseline and follow-up 9-month evaluations, 53% are females, the mean age is 15.1 +2.3 years, 67% are African American and 55% self-report Hispanic ethnicity. The mean baseline weight was 104.5 +19.8 kg, mean baseline BMI was 37.5+5.7, and mean baseline BMI z-score was 2.5+0.3. There was a significant linear trend toward decreasing BMI z-score over the 9-month time interval (p=0.039 for linear trend). Further, 38% lost at least 3% of their baseline weight, 36% maintained weight (with a weight loss or gain of less than 3%) and 27% gained at least 3% of their baseline weight. There was a significant increase (improvement) in mean HDL cholesterol levels (42.4 mg/dl versus 46.8 mg/dl, p=0.031). Although not significant, at nine-months, there were increases in the proportion of youth consuming less than one sugared beverage per day, vegetables more than once per day, and fruits more than once per day, and increases in the proportion of youth watching 3 or less hours of TV per day and engaging in three or more days of vigorous physical activity per day. Conclusions: Sustained access to a community-based adolescent weight loss program may result in improved healthy lifestyle behaviors which may precede significant weight loss and improved cardiovascular risk profiles in predominantly sedentary, severely overweight inner city, minority adolescents. 24 Abstract 14 Prevention of TYPE II Diabetes and Obesity in Children: The Fit for Life Collaborative Shamiza Ally, MD, FAAP Project Objective: Childhood Obesity has increased over the past three decades. To minimize the risk of becoming overweight or obese, parents of children age 0-36 months will be targeted for intervention. Design: An interdisciplinary team based approach is utilized using Ed Wagner’s Chronic Care Model. The program design is centered on physician and nutritionist intervention for parents of children who are over the 85th percentile for weight for length or Body mass index (BMI) as well as focusing on preventing them from becoming overweight or obese. The provider engages the parent and conducts brief education, and a referral to the nutritionist, who is stationed at point of care. A follow-up is conducted in 2-4 weeks. Setting: Urban Health Plan (UHP) is a Federally Qualified Health Center located in the South Bronx New York. Participants: of 426 patients ages 0-36 months. Intervention: The Medical Assistant shares the child’s growth chart with the parent regardless of the child’s weight. The physician engages with the parent of the overweight or obese or at risk child adopting a direct, non-judgmental, and blame-free approach. Parents are encouraged to set achievable self management goals with the nutritionist. Goal follow-up is conducted via phone or in person. Point of care nutrition education is provided using low literacy visual aids emphasizing consistent messages focused on juice reduction, switching to low fat milk, portion control and physical activity. Results: 64% of the population of focus patients are healthy weight compared to NYCDOHMH statistics for NYC of 53% and the South Bronx (UHP catchment area) of 49%. In comparing our outcomes internally, 10.6% of the group that had benefit of the intervention were overweight (N=64) while 20% (N=60) of the group that did not have the benefit of intervention were overweight. Conclusion: Though in the early stages of investigation, provider engagement and education of parents of children who are overweight or obese or at risk of becoming overweight, appear to be effective, especially when early follow-up is conducted and point of care nutrition and physical activity education are offered. Through the process of educating the parents – as well as the patients – early, this has been crucial to keeping the patients healthy. 25 Abstract 15 Acceptability of Primary Care-Based Lifestyle Change: Counseling to Prevent Obesity Among Pre-School Children Darwin Deen, MD, MS; Diane McKee, MD, MS; Stacia Maher, MPH; Arthur E. Blank, PhD Context: Childhood overweight/obesity has grown three-fold since the early 1990’s and today’s children face burdens and shortened life spans. Objectives: 1) To explore the acceptability of a pilot primary care-based intervention designed to address risk behaviors for overweight among preschool children. 2) To understand what urban parents liked and disliked about the intervention as a step toward designing larger primary care-based interventions. Setting: Three intervention sites in the Bronx (1 Peds, 1 Family Med, 1 Mixed Model) and 3 matched controls. Design: Multi-component Intervention: Encouraged primary care providers (PCP) to help families set behavior change goals. Reframed 2 to 3 year old well child visits to focus on family lifestyle risk assessment and behavior change. Clinician counseling was augmented by contact with a health educator who was trained in motivational interviewing. Participants: Parents of 2 to 5 year olds exposed to intervention. Children were 2 to 5 years old and parents’ mean age was 28. 11 children were male and 6 were female. 11 child/parent pairs were Hispanic and 4 were Black Data Collection: Three focus groups (2 in English, 1 in Spanish) that explored completion of the new pre-visit tool for family risk assessment (the FLAIR screener), discussion of risk behaviors by physicians, goal setting for behavior change and referral to and contacts with a lifestyle change counselor. Data Analysis: Team- 2 family physician investigators, a master’s level project coordinator trained in health education, and a social psychologist. Focus groups were audio-taped, transcribed. Analysis was conducted by using an editing approach to identify themes. Results: 1) Importance of Behavior Change: Parents expressed strong desire to change family diet for healthier families. Described little previous attention to nutrition from their PCPs 2) Physician Counseling: Parents saw the screener as a good way to get nutrition on the clinician’s agenda. Parents expressed some fear of being judged to be bad parents. Parents expressed frustration with physicians for: offering advice about what to do but not how to achieve it, dismissing their concerns about picky or under-eating labels of overweight they felt were inappropriately applied. 3) Goal Setting: Parents described mutual goal setting consistent with our intent. Parents were more willing to set nutrition goals than physical activity goals, citing lack of access to safe outdoor places and benefits low cost of television watching. 4) Contacts with Lifestyle Counselor: Counseling focused on strategies to achieve change not just advice, on change for whole family not just individual child and was sensitive to cultural heritage. 5) Efforts at Behavior Change: Parents struggled to overcome sociological barriers to behavior change because of family dynamics, generational conflict about food and control of resources. Conclusions: Parents welcomed efforts to address family lifestyle change in pediatric visits. Model of physician goal setting with referral for behavior change counseling is highly acceptable to families. Lifestyle counselor successfully changed the focus from the parent-child dynamic to the entire family in sociological context. Behavior change discussions must acknowledge positives rather than negatives and focus on strengths the families can build on. Future interventions should acknowledge parents’ concerns about undereating and perceived benefit of television watching. 26 Abstract 16 Patient-Physician Perceptions Regarding Breastfeeding Counseling at Two Community Health Centers in the Bronx: A Pilot Study Elizabeth Natal, MD; Rebecca Williams, MD, MHPE Research question: What are physician and patient perspectives about breastfeeding counseling at two residency community health centers located in an urban center of the Bronx? Context: Many studies have documented the benefits of breastfeeding for mothers and infants. As a result, the American Academy of Pediatrics, the World Health Organization, UNICEF and other leading organizations recommend at least six months of exclusive breastfeeding, with continued breastfeeding and complimentary foods thereafter for at least one year or more.2 Objectives: To identify mothers’ and clinicians’ perspectives about breastfeeding counseling during routine prenatal and preventive visits, including exploring gaps in communication, barriers to effective breastfeeding counseling and levels of physician confidence. Setting: Two community health centers located in the Bronx, New York, affiliated with Montefiore Medical Center – Albert Einstein College of Medicine’s Family Medicine Residency Program. Participants: The participants were patients and clinicians from two Bronx community health centers, the resident training sites for the Montefiore Medical Center Family Medicine Residency Program in Social Medicine. Between the two sites they serve a predominantly Hispanic, African American, Caribbean and Asian population. Methods: The study involved administering a one-time email survey to clinicians and conducting a one time telephone survey with mothers. Both surveys consisted of multiple closed-ended questions. An introductory letter was sent to all eligible patients, which included an “opt out” option. The physician survey focused on issues of knowledge, attitudes, skills and practices. The patient survey focused on issues of personal experiences, beliefs, practices, and clinic breastfeeding support. Results: Of 234 eligible mothers 51 participated. Of 67 eligible physicians, 59 returned completed surveys, 29 residents and 30 attendings. 83.1% clinicians recommended exclusive breastfeeding (BF), 6.8% recommended mixed feeding and 8.5% recommended exclusive formula feeding. 62.7% reported their advice regarding breastfeeding was somewhat important and 30.5% reported it was very important. Of 59 mothers surveyed, 11.1% reported physician advice to be somewhat important and 88.9% reported it very important. Physicians perceived barriers to breastfeeding counseling were lack of breastfeeding support (73%), lack of consultant services (68%), lack of time to address breastfeeding issues (44%), lack of time to give breastfeeding advice (42%) or limited skills (31%). Physicians reported on confidence in BF teaching (54%), evaluation of latch on (54%), advice on BF pain (49%), advice on adequate milk (42%), advice on return to work (42%) and referral to BF services (15%). Mothers recommended future needed services. Physicians requested additional BF education. Discussion: It appears that physician advice matters to patients. Physicians should engage patients and promote BF. Patients reported various breastfeeding complications and less than half of all physicians reported addressing specific breastfeeding issues. More time should be spent education patients about common breastfeeding complications. The majority of the physicians indicated low confidence levels in addressing various breastfeeding problems and desired more training/education in BF. Physicians want more training/education in BF and many modalities can be used (resident/faculty breastfeeding workshop created). Patients are also interested in additional BF support. Clinics should work towards providing this support (BF classes, Nurse Family Partnership, Videos, Reading Materials, etc). 27 Abstract 17 A Creative Collaboration to Improve Health Care Delivery: The South Bronx Community Health Worker- Montefiore Clinic Collaboration Sara Doorley, MD; Nilda Soto, MPH; Ramin Asgary, MD; Cylde L. Smith, MD; Joseph Deluca, MD; Jerry Paccione, MD Context: There is underutilization of the Comprehensive Health Care Center Center (CHCC) services by the foreign-born population in the South Bronx. Objectives: 1) Increase utilization of health care services by the uninsured immigrant population in the South Bronx. 2) Create a collaborative team of Community Health Workers (CHW), resident physicians, and Community Based Organizations (CBO) to facilitate access to care among new immigrants. Program Description: The Montefiore CHCC is federally qualified health center in the Highbridge-Morrisania (HM) section of the South Bronx where 30% of the population is foreign born and 45% do not have a personal doctor. The CHCC established the OPEN-IT Clinic (Opportunities Pro-Immigrant Elderly Newcomers-International Travel) to provide culturally appropriate clinical services to immigrants, and educate resident physicians in immigration/travel medicine. The multiple barriers for HM residents to access available health care services include language, cultural differences, fear of retribution (for undocumented residents), and lack of knowledge regarding available services. To address these barriers, the CHW-OPEN-IT clinic collaboration recruited and trained Community Health Workers (CHWs). The training began with bilingual health classes led by Montefiore medical residents and progressed to a biweekly â health promoter certificationâ for interested participants. In collaboration with CBOs, the CHWs conducted outreach to places of worship, businesses, immigrant organizations, and schools. The CHWs accompanied interested new immigrant patients to the OPEN-IT clinic to facilitate the registration, visit, and follow-up processes. The CHWs also arranged for home visits to clients by physicians when necessary and conducted follow-up phone calls to the patients. The CHWs were available to assist residents in providing cross-cultural care and facilitate communication between patient and physician. Results & Discussion: 1) Increased utilization of health care services by the foreign-born population. Via our collaboration, 57 new immigrant patients have received health care at the Montefiore CHCC OPEN-IT clinic. 2) Discovery of barriers to receiving health care services at the CHCC.We learned that uninsured patients erroneously received bills from the clinic and were hesitant to return for follow up. Although prescriptions are available to uninsured patients on a sliding-fee basis, we learned that some OPEN-IT clinic patients were charges full prices for medications. 3) Novel feelings of provider trust and service satisfaction by the new patients. 28 Abstract 18 Intervening with Primary Care Physicians and Parent(s)To Prevent Childhood Obesity: Planning and Enhancing Interventions using a Socio-Ecological Framework Arthur E. Blank, PhD; Darwin Deen, MD, MS; Jason Fletcher, MA, MS; Alice Fornari, EdD; Diane McKee, MD, MS; Stacia Maher, MPH Context: The prevalence of childhood overweight/obesity has grown three-fold since the 1990’s, and today’s children face increased health burdens and shortened life spans. Objective: NYCRING -a practice based research network (PBRN) in Montefiore Medical Center’s Department of Family and Social Medicine - introduced a simple clinic based intervention to: (1) increase screening in primary care for young children at risk of obesity, and (2) influence short-term parent and child activity and nutrition. Intervention: The Family Lifestyle Assessment of Initial Risk (FLAIR) project encouraged primary care providers (PCP) to help families set behavior change goals. At the 3 intervention sites, the 2-to-3 year old well child visit was reframed to focus on family lifestyle risk assessment and behavior change. Clinician counseling was augmented by a health educator. At the 2 control sites families received usual care (brief PCP advice without enhanced screening or a health educator). Results: There were 1102 well child visits at the intervention sites, and 32% (N=354) were screened (“FLAIRED”). Of these 59% participated in goal setting, and 55% were referred to a health educator. Sixteen out of 17 clinicians participated in screening. In comparing intervention and control sites, there were no changes between initial and final assessments in adult nutrition or physical activity practices, no changes in children’s physical activities, but a statistically significant decrease in the unhealthy food children ate (11.7 vs 10. 7; p < .05). Challenges: Screening patients required office staff to take on a new task. Even with a short screener which was self-administered and simple to complete, fewer families completed the screener than expected. Lessons Learned: The socio-ecological recognizes the perspective of individuals, patients and physicians, are nested in a variety of organizational and interpersonal contexts. To effectively translate research into clinical practice we need to design strategies that can apply theory-based interventions at the appropriate socio-ecological levels, provide practical, local strategies for implementation, and tailored evaluations. This will mean involving patients as well as physicians when planning interventions. 29 Abstract 19 Exploration of Mental Health Need at the Family Health Center: Results of a One Week Card Study Joanna Dognin, PsyD; Eliana Korin, Dipl, Psic; Paul Meissner, MSPH Context: Medical and psychosocial problems are often intertwined, putting primary care physicians in a unique position to detect emotional difficulties and to refer their patients to appropriate mental health services. Yet, this process is often complicated by a serious lack of resources in our communities. Objective: To address this gap, we developed and implemented a needs assessment, in the form of a card study. Participants: 37 primary care providers participated in the study for one week. Design: Providers were asked to complete one card per patient for 10 consecutive adult patients. Outcomes Measures: The card contained 4 questions asking the provider's perception of whether their patient had a psychosocial problem, were in distress, were in mental health treatment, whether they had referred their patient to services, and whether they would refer in house if appropriate services were available. Setting: A primary care health center located in an impoverished section of the Bronx. Results: 238 cards were completed and used in the analysis. Providers identified a mental health need in 42% of the cards returned. The majority of patients (73%) were currently in distress, and 22% had been given a mental health referral in the past year. The vast majority (92%) had providers who would have made an in-house referral if appropriate services were available, and 26% were currently receiving any mental health services. Providers believed they were receiving all necessary services in 54% of these cases. Insurance status may be related to who was currently receiving services. Compared to those with a needs-based policy, fewer patients with commercial insurance, and no uninsured patients, were currently in mental health care. Conclusions: Access to appropriate mental health services are indeed lacking at our health center. Increased resources and tailored approaches are needed to meet the mental health needs of our patients. 30 Abstract 20 Increasing Assessment and Treatment of Depression in Community Health Centers: A PBRN Study Kwame Kitson, MD; Virna Little, PsyD, LCSW-R Context: Only about half of depressed adults are treated. Untreated depression worsens comorbid condition outcomes (i.e. Diabetes, HIV, Heart Disease). Only 20 – 40 % show substantial improvement over 12 months. There is increasing use of antidepressants but treatment is often not effective because of early treatment dropout, staying on ineffective meds too long, and little access to evidence-based psychosocial treatments Objective: The purpose of the study was to research what interventions would improve the identification and treatment of patients with depression in a community health center. Design: A retrospective study which looks at eelectronic Best Practice Alerts (BPA’s) targeted to intake nursing personnel to administer initial depression screening utilizing PHQ-2 screening tool. Initial site targeted was Parkchester Family Practice (PKFP) in Bronx, New York in January 2005. Participants: The sample population included all adults at PKFP who had office visits between January 1, 2003 and December 31, 2007. Results: There was a statistically significant increase (p<0.0001, Chi2 = 273.6) in depression screening rate at PKFP from 22% to 79% within one year after having the BPA turned on within the electronic medical record system. Increases in screening rates have also led to increases in the number of visits coded for depression at the center. There was a statistically significant increase in the % of total visits for adults 19 and over where an ICDM code for depression was used from 4% in 2003 to 17% in the first four months of 2008 (p<0.001). Lastly, among primary care providers, a statistically significant increase occurred in visits where antidepressants were used from 1.4% to 2.0% between 2003 and 2007 at PKFP (P value = 0.002). Implications: Increasing the screening for depression will improve the identification and treatment of depression in primary care centers, consistent with the HRSA recommendations. Next Steps: To continue to demonstrate that depression programs in primary care centers can not only be implemented but be effective. Continue to develop the work to improve all of the measures currently being tracked such as PHQ9 follow ups, self management goals and significant phq9 reductions in patients who are identified with depression. Continue to share and collaborate with other organizations to develop evidence-based practices. Ensure Phase II Spread is successful via a coordinated administrative and clinical effort. Improved 3 month Positive PHQ-9 Reassessment Rate is needed via social work outreach. Low rate of reassessment is linked to timely follow-up. Further analysis needed of patients whose PHQ-9 scores fail to improve. Medication management vs. access to and utilization of mental health care: more detailed reporting needed to track depression outcomes 31 Abstract 21 Psychosocial Characteristics of High Utilizing Inner City Hospital Patients Jeff Levine MD; Yolanda Martin MA; Doug Reich MD; Dana Ladogana MD; Michael Gordon MD; Ali Khadivi PhD; John Billings, JD Context: A relatively small proportion of patients account for a disproportionate share of healthcare utilization and cost with, on average, 1% of patients responsible for 20-25% of cost, 5% of patients for 40% and 10% for two thirds. These “high-utilizers” frequently suffer from comorbid medical and psychiatric illnesses, but they are not well characterized in terms of diagnoses, current treatment patterns, or long-term outcomes. Objective: We sought to characterize further such patients at a large inner city acute care hospital. Design: We applied a validated tool, Patients At Risk for Re-hospitalization, to the entire hospital population and then performed a mixed methods (quantitative/qualitative) study of 100 patients judged to be at high risk (>67%) of re-hospitalization during the ensuing year. Results: Of over 130,000 patients, 6,000 were identified. These individuals were overwhelmingly non-elderly adults (96% ages 18-64). Most common medical diagnoses were hypertension (49%), asthma (41%), diabetes (33%), and HIV/AIDS (32%). Schizophrenia, bipolar illness, or other psychosis was found in 48%. Over two-thirds had substance abuse diagnoses. Although 56% had made at least one emergency department visit in the past two years, only 37% had seen a primary care provider. Patient interviews revealed high rates of unstable housing, social isolation, and failure to appreciate the severity of health problems. Conclusion: High utilizers of general health care have very high rates of serious mental illness and substance abuse. Interviews suggest need for improved medical/psychiatric coordination with community outreach. Although such interventions are resource intense, the economic and health benefits may be large. 32 Abstract 22 Ethnic Differences in Views of Psychotherapy among Depressed Primary Care Patients Lucia Ferri; MA; Alison Karasz PhD Context: Despite high rates of depression among ethnic minority populations in the United States, likelihood of adherence to professional psychotherapy is low among these groups. Recommendations for improving treatment of ethnic minority populations emphasize the importance of understanding a patient’s cultural background and being open to modifying treatment approaches to fit patient perspectives. Objective: The present study sought to address how beliefs about mental illness inform specific attitudes and expectations regarding psychotherapy in African American, Hispanic American, and European American populations. Results: Analysis of in-depth qualitative interviews revealed common expectations for psychotherapy among all ethnic groups including the importance of listening and empathy. However, key differences emerged. African American and Hispanic American individuals were more likely to attribute their distress to external or situational causes. This attributional pattern shaped preferences for more directive and cathartic approaches to therapy. European Americans presented more internal and individual views of distress, which resulted in preferences for therapeutic approaches that emphasized individual changes in thoughts, behaviors, and selfawareness. Conclusions: The influence of life context, attitudes towards distress, and preferences for psychotherapy is considered. 33 Abstract 23 Westchester Square Partnership: Community-based Participatory Research in the Bronx Jean Burg, MD; Rosy Chhabra, PhD; Kabita Ma, Alison Karasz, PhD; Runi Mukherji, PhD; Diana Rodrigue, MD Context: South Asians are one of the largest immigrant groups in the New York metropolitan region, numbering close to two million and growing rapidly. The Bangladeshi population in the Bronx has grown ten fold over the past two decades. Bangladeshi’s in the Bronx are a high need group, reporting poor access to social and health services. A variety of structural and cultural barriers constrain access, including low income, low health literacy, lack of insurance, language problems, and among women, cultural practices tending to devalue women and restricting freedom of movement. Objective: The Westchester Square Partnership is an academic-community collaboration founded to address service needs and conduct participatory research aimed at health needs, empowerment, and building social capital. Discussion & Future Direction: Two projects are currently underway. The Glebe Avenue project provides language classes, health fairs, and a community health worker’s program. The Bondhu project is an NIMH-funded planning grant in which researchers and a group of Bangladeshi partners are working together to design a community intervention to improve women’s emotional health and well-being. 34 Abstract 24 An Effective Service Delivery Model For Expanding the Utilization of Reproductive Health Care Services In Community Health Care Settings Virna Little, PsyD, LCSW-R; Cynthia Kernahan, LMSW; Laura Leone, LMSW Context: High rates of teen pregnancy in the South Bronx have been correlated to a number of negative outcomes that include poor health, poor educational outcomes, with high drop-out rates, persistent intergenerational poverty, and an increased dependence on social resources. Objective: The study was sponsored by the Department of Health and Mental Hygiene and was designed to link a local high school with a community health center to provide reproductive health care to teens in the Bronx. Design: Data on students seen at the family practices before and after implementation of the school-linked program were collected using Crystal Reports, a reporting format based on an electronic medial record (EMR) system. EMR data were reviewed for a pre-implementation period of January 2004 -August 2006. Pre-implementation data were compared with a postimplementation phase of September 2006-August 2008 for participants, who consisted of students aged 12-19 years. Data reflected the average monthly number of reproductive services delivered for pregnancy tests, contraception visits, contraceptive orders, and emergency contraceptive orders. Results: There was a statistically significant increase in utilization of reproductive health care services following the implementation of the school-linked program. Additional outcomes indicate positive benefits for the practices involved, such as increased collaboration between providers, support staff, and patients, and the selection of each family practice involved to participate in other DOHMH programs providing training and free supplies for enhancement of on-site adolescent reproductive health care. Conclusions: Results indicate significant increases in utilization of reproductive health care services following the implementation of the school-linked program. Additional outcomes indicate positive benefits for the practices involved as well as an increased collaboration between providers, support staff, and patients. Selection of each family practice to participate in other DOHMH programs providing training and supplies for adolescent reproductive health care. 35 Abstract 25 Confidential Care & Health Concerns in Urban Adolescent Males: A Focus Group Study Diane McKee, MD MS; Susan E. Rubin, MD MPH; Lucia O’Sullivan, PhD Context: Adolescents in poor, urban neighborhoods are at considerable risk for pregnancy and sexually transmitted infections (STIs). Confidential care (CC) is critical to meeting adolescent’s health needs, but many youth report they have not spent time alone with health care providers, and few are aware of the right to confidential care. Concerns around confidentiality impact teenage males accessing health services. Objective: Obtain the perspective of adolescent males and their mothers/female guardians regarding health care concerns and needs of teenage boys, the role of the providers in meeting those needs, and the teen’s experiences obtaining CC. Participants: Mother-son dyads. Adolescent males (16-19 years old) seen at any of the 6 study sites in the last 6 months, and have a “mother” listed as next of kin. Design: Mother/son dyads identified from clinic data. Letter sent from son’s PCP to mom and son inviting them to participate followed by outreach phone calls. Focus groups held first with moms, then sons and used experienced, gender concordant facilitators. The focus group guide covered health concerns, communication about sexual health with family and providers, confidentiality, trust and disclosure in the medical visit, clinic systems issues; provider’s role, view on confidential care, and parents partnering with doctors to meet teen’s needs. Preliminary Results: • Health concerns: o Mothers’ first concern is STI. A broad range of issues were mentioned and included violence, allure of the street, emotional/mental health, peer pressure, and substance use. Pregnancy prevention is low in their list o Sons’ major concerns are STIs and pregnancy prevention. Other issues mentioned were genital health/hygiene and weight/obesity. • Role of health care provider o Mothers want providers to address a broad range of issues, reflecting their concerns, as well as a strong “harm reduction” message. o Sons felt provider role was primarily secondary prevention (STI testing). PCP demeanor and connection with teen is critical for comfort and disclosure. • Experience & attitude toward confidential care o Mothers see the utility of private time for education. Conflict arises if the teen is diagnosed with a serious illness. The mother feels usurped in her role as protector, and as the person ultimately responsible for the teen. o Sons were concerned about diagnosis being revealed to parent, not sexual activity. They have heard the harm reduction message from many other places, so repeating this with their provider is perceived to have no added value. They have a limited idea of how PCPs could be useful, especially if there’s no continuity of care. 36 Abstract 26 Vaginal Hygiene and Douching: Perspectives of Hispanic Males Diane McKee, MD, MS; Maria Baquero, MPH; Matt Anderson, MD, MS; Alison Karasz, PhD Context: 75% of adolescent males prefer partners who douche. Women may douche to please male partners because they feel odor and wetness repellant to men and it will enhance male sexual pleasure (“tightening”) Objective: To identify the culturally and socially shaped beliefs that influence douching practices from the perspective of Latino males Setting: One urban community health center Eligibility: Present for care, between the ages of 18 and 60, self-identifies as Latino and Age >18-60, and Sample: (n=13): Primarily of Puerto Rican and Dominican backgrounds, age 24-56 (mean 39) 6 conducted in Spanish, 10 born outside mainland US, 11 currently married or living with partner. The refusal for qualitative interview was 5 out of 18 women. Methods: Interviewed at health center (12 to 46 minutes), audiotaped and transcribed verbatim, then translated into English Editing approach (some core codes were anticipated in advance) 2 team members read all data and independently applied provisional codes, new codes added NVivo used for coding and retrieval. Interview assessed familiarity with douching and other hygiene practices, concepts of vaginal health, disease, and perceptions of attractiveness, preferences related to women’s hygiene, and men’s role in promoting partner’s vaginal health Results: Men unanimous about importance of cleanliness; essential to vaginal health. The vagina is considered to be inherently dirty part of body, a repository of sperm, blood, sweat and is particularly prone to infection. Pre-coital practices included washing, shaving, or douching For post-coital douching is used to remove sperm and prevent infection. Odor is considered the most reliable sign of uncleanliness and infection. The role of douching is primarily to remove blood and sperm, was endorsed as necessary by 9/13 women, and about half aware of some risk from douching, mostly focused on “overdrying”. The male role in vaginal health was to provide “advice” about the importance of hygiene, practice good hygiene themselves, serve as role model, use protection with non-primary partner, and to treat women well, so they are “confident” and want to “take care of themselves”. There are multiple meanings of cleanliness. It is valued for perceived role in preventing infection; it makes attractiveness easier because it removes the odor that is “repugnant”. It is closely linked to perceptions of social status and desirability. Discussion: The vagina is inherently flawed and unclean in its natural state. Vaginal health is a state attained through proactive hygiene measures that remove contaminants. Given internal “hidden” nature of the vagina, men rely on odor or external signs to determine if women engage in proactive measures that are in essence acts of purification. Implications for Practice: Counseling should acknowledge that the decision to douche is grounded in social context and not merely individual behavior. Women are responding to cues from male partners. They perceive douching as providing health and social benefits. Alternatives to douching must address odor control. A role for intervening directly with male partners should be considered. 37 Abstract 27 Changing the Face of Reproductive Health: Discussions of Pregnancy and Contraception with Men Emily Jackson, MD Context: The attitudes and practices of women’s partners are important factors influencing their initiation and compliance with contraception, decision-making surrounding pregnancy intention and continuation or termination of unplanned pregnancy. Studies of contraception and pregnancy have traditionally focused on women. Data regarding the perceptions of men, particularly those who live in neighborhoods with high rates of unintended pregnancy, are lacking. Objective: To explore perceptions of pregnancy, pregnancy decision-making, and contraception use in urban males of reproductive age. Design: In-depth interviews were conducted with 20 English and Spanish speaking men, aged 18-45, in a community health center in the Bronx, New York. Men who had previously conceived a pregnancy were eligible to participate. Interviews were analyzed thematically by two independent reviewers. Results: Most men interviewed had experience with multiple pregnancies. Few subjects had participated in discussions with their partners regarding use of contraception and prevention of pregnancy; most believed that pregnancy prevention responsibility rested with their female partners. In relationships where such conversations did not take place, men underestimated pregnancy risk, assumed their partner was contracepting, or both. Pregnancy, whether planned or unplanned, desired or undesired, represented a signal to men to take responsibility for their actions, although they felt the final decision regarding whether to continue or terminate a pregnancy was their partner’s. In several instances, a partner’s abortion ended the relationship. Conclusions: Men play a role in their own, and their partner’s, reproductive health. Information regarding their interpretation of that role provides insight into effective education and counseling of both men and women in this important topic. In impoverished urban areas, where rates of unintended pregnancy, abortion, and single motherhood exceed those of the nation, interventions developed from such data may prove valuable. 38 Abstract 28 Reproductive Attitudes of Reproductive Aged West-Indian Women residing in New York City Marissa Harris MD; Marji Gold MD Context: The 2000 Census for the United States reports that roughly 640,000 people of West Indian ancestry live in New York City. Groups from Trinidad and Tobago, Haiti, Jamaica, and Guyana represent the largest proportions; namely 11%, 18%, 33%, and 15% respectively. Despite their presence in the New York City area, little is known about the attitudes towards reproductive health and contraceptive use in this population. Reproductive attitudes have been characterized in Latin-American and African-American populations. Some data also exists about the reproductive attitudes of native islander groups such as Jamaica. However, no published studies have been found describing the attitudes or contraceptive behaviors of the West Indian community in the United States. This project will attempt to expand what is known by examining a sample of the general West Indian population based in New York City. Objective: Describe the attitudes toward abortion and contraception of a sample of women in the West Indian population of New York City. Setting: General community and primary care center. Participants: Criteria for selection of subjects are: 1) English-speaking women, 2) aged 18 through 45, 3) have been raised in the West Indies or have both parents of West Indian origin, and specifically are descendents of Jamaica, Guyana or Trinidad and Tobago, and 4) reside in New York City or southern Westchester County. Instrument: Qualitative interviews. Design: We will use individual interviews to investigate contraception and abortion attitudes as well as practices in this population. A convenience sample of reproductive-aged women who self-identify as West Indian will be asked to describe how their community’s attitudes have impacted their own reproductive beliefs and choices. Thirty anonymous semi-structured interviews will be recorded, transcribed and subsequently coded and analyzed for themes. Results/Conclusions: This study is ongoing and results are being analyzed. It is anticipated that attitudes toward contraception and abortion will be described in this population upon completion of this project. Areas for future research and public health programs may emerge from identified themes. 39 Abstract 29 “Up In Me”: Urban Female Family Medicine Patients’ Perceptions around Intrauterine Contraception Susan E Rubin, MD, MPH; Ilana Winrob Context: Improper and inconsistent contraceptive use contributes to the rate of unintended pregnancy. The intrauterine device (IUD) is an effective, safe method of contraception that cannot be used improperly or inconsistently. However, it is relatively underutilized in the United States. Objective: We conducted a qualitative study in order to better understand patient beliefs and attitudes that may act as barrier to their acceptance and use of an IUD. Design: We conducted semi-structured interviews with a convenience sample of 40 reproductive aged women from two Bronx, NY family medicine practices. Self-report of having ‘heard of’ the IUD was the main eligibility criterion. We utilized an iterative process of data collection and analysis. Results: While respondents appreciate the advantages of an IUD, they express a number of “conceptual” concerns and fears about the device. These are primarily related to voluntarily placing a device inside the body for a prolonged period of time and to a knowledge gap about internal female reproductive anatomy. The IUD is viewed as a contraception option to use when other methods have failed or after childbearing. Additionally, respondents report a lack of discussion and information about the IUD from health care providers, the media, and informal networks. Conclusions: Given the high efficacy and safety of IUDs, increasing use could impact rates of unplanned pregnancy. During contraceptive counseling, providers should elicit and discuss patient concerns related to the unique intrauterine placement of the IUD, as well as incorporate education about internal female reproductive anatomy. Directly addressing patient fears that might otherwise be left unsaid could potentially increase patient acceptance of the device. 40 Abstract 30 Promoting Maternal Pap Testing During a Child Visit William B Jordan, MD; Diane McKee, MD, MS; Marian S Krauskopf, MS Context: While cervical cancer mortality in New York City is low, screening disparities of 10 to 20% persist. DOHMH focus groups in 2007 with unscreened women found that many had no provider recommendation but would follow provider recommendations, and many bring children for care even if they neglect themselves. Objective: Pilot an intervention that piggybacks on HPV vaccine conversations during child visits to promote Pap testing among female guardians. Design: Primary care providers questioned female guardians about Pap testing status during the child’s visit. Unscreened women were given a promotional message and materials by the provider, and registered for 3-month follow-up by phone. The rate of Pap testing among these women will be compared to a historical control. Setting: Jacobi and Montefiore primary care settings in the Bronx, and other providers recruited by DOHMH and CDN throughout New York City. Participants: A convenience sample of 60 providers intercepted 10 women each, registering 1 in 10 for 3-month follow-up. Preliminary Results: A baseline survey included 180 providers. More than half rarely or never discussed guardian Pap testing status during a child visit. However, 70% were willing to ask about and 85% were willing to encourage Pap testing. Conclusions: Among this convenience sample, many primary care providers are not discussing guardian Pap testing during child visits, but most would be willing. Results of 3-month follow-up are still pending, but using the child visit as a venue for promoting Pap testing with female guardians seems feasible. 41 Abstract 31 Improving Pap Smear Follow-up Compliance in Montefiore Medical Group Ambulatory Practices Maureen Warner, RN, MS; Pio Paunon, PhD, RN, FCCP, ABQAURP; Arthur Hopkins, MD; Jonathan Swartz, MD, MBA; Noel Brown, MD, MBA; ZhongWei Lu, MS, MA Context: We wanted to ensure that all women diagnosed with an abnormal pap smear (Ascus +HPV positive, LGSIL and HGSIL) that requires follow-up with a colposcopy receives the procedure in a timely manner. Objectives: To update MMG Quality performance initiative on monitoring of abnormal pap smear management in MMG 2 and 4, 2) present updated data on 2008 performance by site and MMG overall, 3) share current performance results, and 4)update on process to ensure continued success. Design: Review of clinical database records. Results: Cervical cancer incidence rates by race and ethnicity, U.S. from 1975–2004: 3.7% decrease per year from 1996 to 2004 among all women, 2.4% decrease per year from 1990 to 2004 among white women. 3.7% decrease per year from 1975 to 2004 among African American women. 5.9% decrease per year from 1995 to 2004 among Asian/Pacific Islander women. 3.6% decrease per year from 1995 to 2004 among Hispanic women. MMG PAP QI: Percent of Abnormal Pap by quarter for 2007: 18% first quarter, 7% second quarter, 4% third quarter, 11% fourth quarter. MMG We created a new pap report format and is defined as cases closed as per protocol and includes a colposcopy not indicated, repeat pap in 6 months, if notification unsuccessful patient is telephoned and mailed three times by certified letter and if no response the case is still tracked, colposcopy in the past, and adolescent patient (see other guidelines).The MMG colposcopy rate increased from 2007-2008 with 72.69% in the first quarter, 88.1% in the second quarter, and 95% in the second quarter. Conclusions: Providers were unfamiliar with pap smear management guidelines. Monthly reconciliation of site’s pap smear log improves compliance. Best practices have multidisciplinary teams that include an LPN, PCT, RN, Ob/Gyn, PMD, and administration. MMG Administration produces quarterly pap reports to ensure accountability. The Director of Nursing is actively involved in the process. Accountability includes deadlines for report submission with timely follow-up, monthly electronic reports that are actionable, and all abnormal pap reports are managed. 42 Abstract 32 Is a Pelvic Exam Necessary for Women with Vaginal complaints? (Pilot RCT Study) Andreas Cohrssen, MD; Matthew Anderson, MD, MS; Gina Foster, MD; Danit Brahver, MD Context: The current protocol for evaluating vaginal symptoms is based on the wet mount diagnosis of candidiasis, trichomoniasis and bacterial vaginosis. Clinicians do not appear to follow this protocol. Objective: To assess if vaginal complaints could be managed on the basis of symptoms alone. Methods: This was a pilot study conducted in two family practice clinics in New York City. 46 premenopausal, non-pregnant women presenting with acute vaginal symptoms were randomized into one of two arms. In the control arm women were managed based on the results of a pelvic examination and wet mount. In the intervention arm women were managed based on symptoms. All women were tested for gonorrhea, chlamydia and trichomonas. Women were called up two weeks after the visit to assess resolution of symptoms, adverse effects of medication, need for revisit, and satisfaction with care. Results: Most women had complete resolution of their symptoms two weeks after the visit, almost all felt better. Both management arms seemed acceptable to patients. There were no differences in clinical outcomes, adverse effects of treatment or patient satisfaction. Three women were diagnosed with sexually transmitted diseases (trichomonas, chlamydia & gonorrhea). Conclusions: The findings from our pilot study suggest that in selected women with vaginal symptoms it may be reasonable to manage their symptoms initially on the basis of symptoms. These results should, however, be confirmed in other, larger trials. 43 Abstract 33 The Role of Health Care Trust in Contraceptive Practices among Low-Income African-American Women Oni Blackstock, MD; Adamma Mba-Jonas, MD, MPH; Hillary Kunins, MD, MPH; Galit Sacajiu, MD, MPH Context: Previous studies suggest that low levels of trust in one’s health care provider are associated with a decreased likelihood of continuity of care and diminished acceptance of health care recommendations. The role of health care trust in contraceptive practices has not been specifically studied. Objective: This hypothesis-generating qualitative study explores participant narratives about the relationship between trust in one’s health care provider and contraceptive practices among low-income African-American women. Methods: This study at an urban community health clinic enrolled 20 African-American women who declared they were heterosexual or bisexual, between 18 and 39 years old, sexually active but not actively trying to become pregnant. Individuals were excluded if they were currently or recently pregnant, or unable to become pregnant. Consecutive patients were approached as they waited to be seen in our Internal Medicine practice. In semi-structured interviews, we operationalized trust by exploring themes including communication, patient comfort and disclosure, and perceptions of provider competence and compassion. Interviews were audio-taped, transcribed, and coded using N-vivo software. Qualitative analysis using grounded theory elicited common themes and developed a typology for trust and contraceptive practices. Results: Of the eligible women approached, 77% agreed to participate. Mean age was 26 years old (range 18 to 37). Eighteen participants were in monogamous relationships. Seventeen participants were employed. Fourteen participants had at least a high school diploma and six had not completed high school. Three participants had never been pregnant. All participants had health care providers who they saw routinely for care. Most participants stated they were satisfied with their relationships with their current health care providers, although some reported negative experiences with previous providers. Participants expressed high satisfaction with providers who were compassionate, communicated well and with whom they felt comfortable. Some participants expressed that their perceived income adversely affected the quality of care they had received in the past. Conversely, participants infrequently believed that race and gender affected care. Reported adverse effects of perceived differential treatment based on income included poor communication and misdiagnosis. Participants said that planning pregnancy was usually discussed only when the participants themselves raised the subject with their providers. In contrast, the topic of contraception was frequently raised by both the participants and providers. Participants who reported high levels of satisfaction with providers, and felt that providers acted in their best interest, also reported extensive conversations about planning pregnancy and contraception with their providers. Conclusion: Our participants reported high levels of satisfaction with current providers. Negative experiences with providers were perceived to be influenced by income as opposed to race or gender. Our results suggest that among participants who believe their providers act beneficently, discussions about planning pregnancy and contraception may be more extensive. This may indicate that patient-provider trust enhances discussions about these issues. Perceptions of differential treatment may undermine this trust. Further research is needed to elucidate the relationship between health care trust and contraceptive practices. 44 Abstract 34 Collaborative HIV Primary Care in the Bronx: Evaluation of the CICERO Program Carolyn Chu, MD; Galina Moskaleva, MS; Arthur E. Blank, PhD; Robert Beil, MD; Robert Grossberg; Peter Selwyn, MD, MPH Context: Challenges of access to care, emerging co-morbidities, and chronic disease management suggest key roles for community-based HIV primary care in the current era of HIV/AIDS treatment. Objectives: Our purposes were to: 1) compare the demographic/clinical features of HIV-infected patients at community-based sites to those of patients followed at a hospital specialty center, and 2) determine the effectiveness of HIV and co-morbid disease (hypertension, dyslipidemia, and diabetes) management by evaluating the extent to which guideline-based treatment goals were achieved. Design: This was a retrospective cohort study utilizing standardized chart review of medical records and clinical information systems data. Setting: Nine primary care clinics in Montefiore Medical Group II and the South Bronx Health Center for Children and Families, and the Center for Positive Living at Montefiore were involved. Community-based sites are affiliated with CICERO, the Montefiore/Bronx Community Health Network’s outpatient HIV/AIDS program. Participants: Patients were HIV-positive adults initiating primary medical care between 1/05 and 12/07. Intervention: Collaborative Care Team: Multi-disciplinary teams include a primary care provider, HIV specialist/coordinator, clinical pharmacologist, treatment educator, nutritionist, mental health provider, and social worker. Management follows mentored and/or shared strategies of care. Results: Among community versus hospital-based sites, there were no differences in gender, age, race/ethnicity, or HIV risk factor (53% vs. 58% male, 44 vs. 45 years, 46% vs. 44% African-American and 41% vs. 48% Latino, 53% vs. 56% acquired HIV through heterosexual contact, p = NS for all). Patients at the specialty center presented at more advanced stages of HIV illness, with a higher prevalence of AIDS at initial visit (57% vs. 43%, p < 0.05) and longer time since diagnosis (9.8 vs. 8.8 years, p = NS). Of 118 community and 121 hospital-based patients started on HAART, 78% vs. 64% achieved an undetectable viral load after 16-32 weeks of treatment (p < 0.05); 81% vs. 77% maintained ≥ 95% adherence to HAART (p = NS). Prevalence of co-morbid hypertension, dyslipidemia, and diabetes at community-based sites was 22%, 45%, and 10%. For individuals with hypertension, > 85% of blood pressure measurements were at JNC-7 defined goal. Among patients with dyslipidemia, ~80% of LDL measurements were at ATPIII-defined target. Those with diabetes had poorer treatment outcomes, with < 10% of HbA1c measurements reaching ADA-defined goal. Conclusions: Comprehensive HIV treatment and primary care can be effectively delivered in community-based settings. Diabetes treatment outcomes may be sub-optimal among HIVpositive patients; it is important to determine how these findings affect long-term clinical outcomes for this population. 45 Abstract 35 Improving Use of Oral Health Services Among HIV+ Patients: Project TEETH Niko Verdecias, MPH; Arthur E. Blank, PHD; Joan Grcevic, DDS; Alison Karasz, PhD; Robert Beil, MD; Paul Meissner, MPH Context: Project TEETH, a 5-year HRSA-SPNS funded grant, was designed to increase the number of HIV+ patients referred to and utilizing dental services at ten Montefiore Medical Group (MMG2) sites. Objectives: To accomplish this we delineate three objectives: Design and implement an integrative model of oral health (OH) care; Increase usage rates of OH services in an HIV+ population; and Using a QI orientation and the RE-AIM framework to evaluate our model of dental care with regards to reach, effectiveness, acceptance, implementation and maintenance. Design: Three of the MMG2 sites have existing dental facilities on/near site, while seven are being serviced by mobile dental unit (MDU). Patient Navigators (PNs) have been integrated at the three sites to act as liaisons between medical care and OH services, assist with the dental appointment process and perform educational and follow-up functions. The MDU has integrated a Dental Hygienist (DH) to act as its liaison/link between medical and dental care. Results: Evaluation includes the bilingual DH and PNs conducting ≥300 survey-based patient interviews. We will also conduct frequent QI-based evaluations to monitor the entire program. Currently, we have recorded 30% of patients as routinely receiving OH care off-site; 46.25% of referrals resulted in a dental appointment being made; 18.75% of patients required follow up; and 5% of patients have refused a dental appointment (n=97). Conclusion: We anticipate that the 1000+ HIV+ patients that receive primary care at the MMG2 sites will have been screened, referred, and/or received dental services by the completion of the program. 46 Abstract 36 Patient Perceived Barriers for Colorectal Cancer Screening Jose Lopez, MD,MPH; Sabesan Karuppiah MD, DFM; Anele Manfredini, MD; Eduardo Hidalgo, MD; Marcella Scaccia, MD Context: Warren county colorectal cancer (CRC) mortality and morbidity rates-higher than state and national standards. Objective: To identify economic, psychological, cognitive, and scheduling concerns. Methods: Total of 387 patients between the ages of 51 and 56 identified through medical billing data having seen a PCP in a 12 month period were sent a 21– item patient survey 2005-06 through the mail. Analysis of variance was then performed to review if there was any relationship between screen and no screen and survey-item response: between gender, race, and insurance. Results: Overall response rate to our mailer survey was 11 % (43/387). Population was 58.1% women and 41.9 % men; 79% Caucasian and 4.7 % AA. HMO - 60.8%; No insurance – 11.6%, or Medicaid – 11.3%. 55.8 % reported having had a colonoscopy in the past 5 years; 27.9% of having had a sigmoidoscopy in past 5 years.51.1%- uncomfortable, 39.2%- embarrassment , 26%- cost too much, 25.6%- fear of the unknown, 21%- could not afford, 21%- unaware that it was recommended over the age of 50, 16.3%- ineffective tool for preventing CRC, 11.7%evening schedule, 9.3%- unlikely to get CRC, 8.6% could not get one in the weekends & 7% could not get time off work. Statistical significance for the following constructs: psychological – p<0.016, scheduling – p<0.034, education – p<0.037 Conclusion: Primary prevention for CRC screening could be more effective if patient educational focus is on areas of psychological, cognitive perceptions of testing and if an infrastructure exists to facilitate testing during hours convenient for the working class over the age of 50. We suggest a 5-minute one-on-one patient education session between the physician and patient regarding CRC screening. Tailored educational intervention should address patient perceived embarrassment and discomfort. Larger based studies need to be performed to ascertain statistical significance. 47 Abstract 37 Identifying and Targeting Smokers for Smoking Cessation using the Fax-to-quit Program Betsy Mathew MD; Sybil Hodgson MD; David Herszensen MD; Rebecca Middleton MD; Victoria Gorski MD; Karen Becker MD, MPH; Fabienne Daquilh, MD; Belinda Johnston MD MPH Context: The Montefiore Medical Group, Williamsbridge site embarked on a smoking cessation continuous quality improvement project. A needs assessment ascertained the documentation of smoking status in the medical record from 2004-2006. This chart review identified 17% of our patients as smokers. However, recognition of smokers required reading several patient care notes for each chart. Additionally we only intermittently utilizing a community resource sponsored by the Department of Health, the Fax-to-Quit smoking cessation program. Objective: To develop a system redesign to 1) identify patients who smoke 2) provide easy access to the Fax-to-Quit registration forms 3) sustain our linkage with the Bronx Breathes, a program that analyzes data from the Fax-to-Quit forms. Content: Using the conceptual framework of the Chronic Care Model, we participated in several "Plan Do Study Act" cycles to accomplish our aims. Results: Smokers are identified using a pink label attached to the chart continuing problem list. Fax-to-Quit forms are available in all exam rooms and faxed weekly. 12 providers and 44 patients participated from 11/07 to 5/14/08. Conclusions: Smoking should be viewed as a chronic disease. Our system’s redesign identifies smokers and provides forms to easily register for smoking cessation counseling and obtaining free medications for nicotine addiction. 48 Abstract 38 Optimizing Screening for Hepatitis C in Primary Care: An AHRQ Action Network/ Center for Disease Control-Funded Project Mari-Lynn Drainoni, PhD; Allen Gifford, MD; Lisa Koppelman, MPH; Miriam Sabin, PhD; Cindy Weinbaum, MD; Alain Litwin, MD, MS; Diane McKee, MD, MS; Stacia Maher, MPH; Lery Pointdujour, MPH; Hillary Kunins, MD; Julia Arnsten, MD, MPH Context: Hepatitis C Virus (HCV) is a major health crisis in the United States – the leading cause of chronic liver disease and transplant, and costing $15 billion per year. The Centers of Disease Control and Prevention recommends routine screening and testing for all patients with HCV risk factors, but there is evidence that this has not been widely implemented within primary care. There is a higher prevalence of HCV in New York City compared with the rest of the United States, and the Bronx has the highest reported case rate in New York City. Adults who were born between the years 1945 and 1964 are much more liker to have been infected with HCV than those in other birth cohorts. Objective: to improve HCV screening and testing within primary care centers. Design: cross-sectional program evaluation of HCV screening and testing at three primary care sites involving four phases: 1) assess current practices; 2) develop new screener and train for implementation; 3) implement new screener and targeted testing; and 4) implement routine testing in specified age cohort (1945-1964). Setting: Three Montefiore Medical Center primary care centers located in the Bronx: Comprehensive Health Care Center (CHCC), Comprehensive Family Care Center (CFCC), and Family Health Center (FHC) Participants: Medical and non-medical staff participated in focus groups and structured interviews. All adult patients will participate in both intervention phases: new screener and routine testing in birth cohort (1945-1964). Intervention: Screening and testing was evaluated at baseline in all three clinics. In the first intervention phase, all adult patients are targeted for screening with a HCV risk screener (see figure); in the second intervention phase, all adult patients within the 1945-1964 birth cohort will be targeted for testing. Results: The first two phases are completed, and the first intervention phase is underway. Key qualitative findings from baseline evaluation included: no current standardized procedure in place for HCV screening; physician-led screening was preferred over patient-administered surveys; and physicians favored integration of screener within existing progress notes rather than additional forms. Quantitative results from medical chart and electronic medical record included low percentage of risk factors / key factors documented including injection drug use (2.2%); intranasal drug use (1.4%); homelessness (0.8%); and incarceration (0.4%). Overall, 38% of all patients had been tested for HCV and 4.7% of those tested were HCV-positive. Many (but not all) patients with documented risk factors were tested for HCV including 62% of injection and intranasal drug users and 40% of patients with an elevated alanine aminotransferase level (ALT). Conclusions: Early results demonstrate that there may be areas for improvement including documentation of key risk factors and increased rates testing for patients with these risk factors. Our first intervention phase is well underway, and we are finalizing the intervention for the birth cohort phase. We will investigate whether these interventions lead to increased identification of patients with risk factors; increased HCV testing rates; and increased identification of HCV-infected patients. 49 Abstract 39 ACTS (Advise, Consent, Test, Support): A Successful Model for Routinizing HIV Testing in Clinical and Community Settings Using Existing Resources Diane Futterman, MD; Stephen Stafford, MD; Michelle Lyle, MD; Paul Meissner, MSPH Context: Approximately one-third of HIV+ people in the US have not been tested and thus do not benefit from life-saving treatment and prevention services. In clinical settings, barriers to more routine HIV testing include: lengthy counseling, insufficient counseling staff, HIV testing´s separation from routine health care and risk-based screening. Objective: This report summarizes experiences in scaling up testing in urban community health centers from 2004 through 2007. Design: A streamlined, 5-10 minute approach to HIV testing called ACTS (Advise everyone be tested, obtain Consent, Test and provide Support to HIV+ and HIV- clients) was developed to improve the routine offer of HIV testing to eligible patients (non-pregnant and ages 13-64) in clinical settings. Key innovations of ACTS included task-shifting that charged providers to routinely offer testing and counselors to become more involved in the support of HIV+ patients. Additionally, ACTS addressed key administrative barriers to testing. Ten clinics were randomized with five receiving the ACTS intervention (logistical planning, staff training and follow-up) and 5 serving as lagged controls. Routinely collected lab data was used to monitor results. Results: At baseline (2003) all sites tested less than 10% of eligible patients. By the end of the trial (2005), ACTS clinics were testing 22% of eligible patients while control clinics had only increased to 8%. After the ‘03 - ’05 trial of ACTS, intervention clinics were provided ongoing technical assistance for an additional year (2006). Testing continued to increase to 28% in ACTS clinics vs. 14% in control clinics. In 2006, control sites were trained to implement ACTS and in one year’s time (2007) increased their testing by 50%, from 14% to 21%. Without the ongoing support of technical assistance in 2007, HIV testing declined at the intervention sites from 28% to 26%. No significant change noted in the number of HIV+ patients identified. Providers found ACTS easy to use, but reported that required HIV testing paperwork restricted routine testing achievements. Conclusions: The ACTS approach to streamlined testing, staff training and ongoing data collection and feedback facilitated significant increases in HIV testing, while utilizing existing personnel resources. Doctors, nurses and other health care providers reported that ACTS allowed them to offer a more comprehensive package of routine care, which was worth the extra time added to their clinical encounters. Sustained practice change required intensive support via monthly data reports, site-specific technical assistance and training of new staff. Given the potential clinics have in improving case finding and linking undiagnosed HIV-positive patients to care, ACTS should be utilized to scale-up routine HIV testing in these settings. The success of ACTS in this trial led to it’s use by clinical and community partners in the largest municipal scale up of routine HIV testing in the US, The Bronx Knows HIV Testing Initiative sponsored by the New York City Department of Health and Mental Hygiene and a consortium of Bronx community partners. Additionally, the DOHs in Washington, DC, Oakland and Pennsylvania use ACTS as well as prominent care organizations. Internationally, ACTS is funded by the President’s Emergency Plan for AIDS Relief (PEPFAR) to scale up HIV diagnosis and linkage to care among South African youth in clinic and community settings. Additionally, ACTS formed the basis of the Botswana Ministry of Health’s national policy on routine provider-delivered HIV testing. 50 Abstract 41 Care Connect: Investigating the Value of Generic Telemonitoring in Management of a Frail Elderly Population Bruce L. Feldman, MD; Kathleen Byrne, RN, MPH; Ana Gouldborne, RN, BSN; Roselyn Collado-Abreu, MPA; Myriam Villarini-Harris, BSW Context: Experience with disease-specific telemonitoring suggested that by asking only general health questions, a daily “connection” via a telemonitoring device could have an impact on a study population. A frail elderly population was chosen for study given the potentially broad applicability of technology for this group. Objectives: To closely monitor and promptly respond to health concerns in order to reduce ED visits, hospitalizations, and health care costs for members. Participants: • Approximately 100 Montefiore CMO members over a one year engagement • Average age: 80 years • Average Annual Medical Costs at entry: $ 22 K Design: CMO identifies member via claims/utilization reviews, clinical notes reviews and telephonic interviews/assessments. Criteria varied over the course of the study but centered on suggestion of overall frailty and high medical usage. A CMO Care Coordinator assessed the member for program appropriateness, obtained agreement to participate, and ordered the device. The Coordinator later assisted the member telephonically with the initial set-up. Setting: At home, patients use the Cardiocom FE Commander, a voice generating telemetric device with response buttons, to respond to 10 general health questions on a daily basis. Subjects include appetite, medication adherence, falls, general feeling of wellness and functional status. The patient responses are scored via a web-based desktop interface, potentially triggering “alerts”. CMO Care Coordinators monitor “alerts” Monday-Friday, and call the patient to evaluate. They refer the issue to an RN for a follow-up call as appropriate. Program Evaluation: Members’ experience pre- and post-program participation are compared. Key measures evaluated are ED visits, hospital admissions, medical expenses, and overall member satisfaction with the program. Preliminary Conclusions: Over the period 2007-2008, substantial reductions were recognized in ED visits (-57% PMPY), hospital admissions (-46% PMPY), and medical expenses (-35% PMPY) with a relative savings of over $200K. Patient satisfaction scores demonstrated a 4.4 out of 5 overall rating. Opportunities for better identification of potential candidates and improved engagement strategies remain to be completely explored. 51 Abstract 42 Kerr White in the Bronx: The Use of Census Data and Electronic Information Systems to Describe Community and Clinic Populations Arthur E. Blank, PhD; Vincent Huang, MA Context: Research by Kerr White in the 1960’s, updated by Lawrence Green in the 1990’s use population data to show the relationship between community residents and health care providers. These data are reported on a national level, and use data from secondary data sources. Objective: Our intent here is to conduct a feasibility study with three aims. First, following Kerr White’s, to use existing data sources –national and institutional- to create preliminary estimates of how many patients in the Bronx Community visit Montefiore Medical Center’s Ambulatory Care practices over the course of one year. Second to assess if we could map where our patients lived in relation to where they received ambulatory care. Third to describe the top diagnoses on a population basis. Method: We used 2000 Census data from the Bronx to obtain population estimates of the number of men and women living in the Bronx. We used information extracted from the clinical information system to obtain estimates of the number of unique patients, and the top 10 diagnoses visiting Montefiore Medical Group 2 (MMG2). Third, we used Center’s Clinical Looking Glass (CLG) to geocode where our diabetes patients lived. Results: Approximately, over the course of a year, an estimated 5% of men, and 8% of women living in the Bronx visit our MMG2 primary care clinics. Most of our diabetic patients live close to the MMG2 clinic where they get their care, and using Williamsbridge Family Practice as an example, for patients between the ages of 35-44, the top three diagnoses for men coming in for visits were routine medical exams, benign hypertension, and HIV counseling; for women these were routine medical exams, HIV counseling, and benign hypertension. Conclusions: It was possible to use our clinical information systems to construct and create population data. These information system resources provide an ongoing way to describe and ambulatory care patient population and provide an opportunity to monitor not only who we care for but how well we care for them. 52 Abstract 43 The Impact of Mass Incarceration on Outpatients in the Bronx: A Card Study Minesh P.Shah, MD; Sadiqa Edmonds-Myles, MD; Matthew Anderson, MD, MSc; Miriam E. Shapiro BA; Carolyn Chu MD Context: The term “mass incarceration” has been used to describe the extremely high incarceration rates seen in working class communities of color. There is increasing interest in how this impacts primary care. Objective: To assess the impact of arrest and incarceration on patients attending primary care clinics in the Bronx, New York. Design: Residents and attending physicians working at three primary care clinics in the Bronx asked two patients per clinic session 7-8 questions concerning current involvement in criminal proceedings as well as past or present arrest and incarceration histories. Questions were asked about the patient and family members. Results were written on a card without any identifying information other than age and gender. Results: One hundred eighteen cards were completed during a 2.5 week period. Eleven (9%) patients were currently involved in criminal proceedings. 21 (18%) currently had a family member in jail or prison. 29 (25%) reported having ever been arrested; 65 (55%) reported that they or a family member had been arrested. 21 (18%) had spent time in jail or prison; 60 (51%) reported they or a family member had spent time in jail or prison. For most of the variables, rates were higher for men and for adults accompanying children at pediatric visits. Twenty nine cards had comments. Most of the comments addressed either who had been arrested or the reason for the arrest. Clinicians participating in the study reported positive experiences with discussing incarceration. Discussion: Consistent with the existing literature on mass incarceration we found that involvement with the criminal justice system was common among adults and parents of pediatric patients. Asking questions about incarceration does not appear to have a negative impact on the clinical relationship and may open doors for clinicians to assist their patients. 53 Abstract 44 Analysis of Patient Satisfaction Improvements in a Medical Practice Pio Paunon, PhD, RN, FCCP, ABQAURP (A special thanks to Jonathan Grenier of Press Ganey for the tools and data that made this study possible). Context: Health care organizations and providers have to keep up with the demands of their clients not only by administering “state of the art” health care services but also providing these services to the patients’ highest satisfaction. The 2008 Physician’s Office Pulse Report published by Press Ganey, examined the experience of more than 1.9 million patients treated at 8,483 offices throughout the nation in 2007. Press Ganey’s research findings showed that patients desire high-quality compassionate care from all staff that works in the physician’s office. Issues of great importance to patients ranked according to priority are: staff sensitivity to patient’s needs, a cheerful and caring office environment, the care received during the visit, the comfort and pleasantness of the exam room and waiting time in the exam room before being seen by a care provider. Objective: The goal of this study is to define and utilize a statistical methodology in this quality improvement process in order to assess whether there were significant changes in overall mean patient satisfaction scores between 2007 and 2008. Setting: The analysis of mean scores captured from completed patient satisfaction surveys came from a setting of 21 different medical practice sites of which 16 are non-teaching sites (NT-sites) and 5 are teaching sites (T-sites) with multiple specialty practices that include: Internal Medicine, Family Medicine, Pediatrics and OBGYN. Methodology: A sample of patients is chosen randomly and patient satisfaction questionnaires are administered. Analysis of the data are then posted in a web-based program called ECompass, a database program that can produce reports from a simple descriptive overall mean scores to detailed analyses comparing time periods by domain, by question, by specialty, and comparison with other peer groups. A t-test (2 –tailed) was introduced to compare two patient satisfaction means of different time periods in order to measure statistical difference and significance. Results: The non-teaching (NT) subgroup leads the practice with an overall mean score of 82.8% (n=6167) in CY 2007, which improved, to 86.1% (n=4417) in 2008 YTD. A t-test analysis (p=0) showed that the difference between the two periods was statistically significant. Mean differences for domains such as Access, Visit, Nursing and Care Provider were also significant. Under the care provider domain, all four specialties: Internal Medicine (p=0), Pediatrics (p=0.0029), Family Medicine (p=0.0001) and OB-GYN (p=0.0458) showed significant differences as well. There were 8 non-teaching sites with significant improvements noted. For the teaching subgroup the average mean in 2007 was 78.1 (n=2444), and in 2008 it is at 81 (n=1991). It can be concluded that there was a significant difference between the mean scores. The mean differences for all domains were also significant. Under care provider domain, only Pediatrics (p=0.0425) showed a significant difference in mean scores. Site means were significant in 4 teaching sites. Conclusions: In this study, it is important to note that statistical tools can be used to assess data shifts to make the appropriate decisions in making recommendations as part of the Quality Improvement processes. 54 Abstract 45 A Comparison of Integrated HIV and Buprenorphine Treatment in Primary Care Chinazo Cunningham MD; Angela Giovanniello PharmD; Galet Sacajiu MD MPH; Susan Whitley MD; Nancy Sohler PhD MPH Context: HIV treatment advances, coupled with recent increases in opioid addiction, has lead to an increase in the number of individuals living with HIV and opioid addiction. HIV and drug users have poor access to and utilization of health care services, and poor health outcomes. Legislation was enacted allowing opioid addiction treatment with buprenorphine, a long-acting partial opioid agonist, to occur outside of substance abuse treatment programs. Buprenorphine treatment in HIV primary care settings has the potential to improve access to care and health outcomes among opioid-dependent HIV+ individuals, but this has not been well studied. Objective: To evaluate integrated versus non-integrated HIV and opioid addiction treatment with buprenorphine/naloxone. Design: Although the initial study design was a randomized trial, we discontinued randomization because of substantial cross over from non-integrated to the integrated treatment. Integrated treatment = HIV treatment and opioid addiction treatment with buprenorphine/naloxone by the same physician at a community health center (CHC). Non-integrated treatment = HIV treatment at a CHC and opioid addiction treatment at a nearby affiliated substance abuse treatment program. Patients were HIV+ and opioid dependent, and treatment plans followed national guidelines. An HIV pharmacist closely coordinated care with patients and physicians in the CHC.Data were from ACASI interviews (at 0, 1, 3, and 6 months) and medical records. Interview data included: sociodemographic information, drug use, depressive symptoms, and quality of life. Medical records data included: visits, CD4 counts, and HIV viral loads. The main outcomes were substance use, HIV clinical outcomes, and health care utilization. We analyzed data “per protocol”, where patients were included in the treatment group they received. We used McNemar’s and the Wilcoxin signed-rank tests to examine associations between treatment groups and outcomes. Results: Integration of HIV and opioid addiction treatment with buprenorphine/naloxone in an inner-city, primary care setting is feasible. However, randomization to integrated vs. non-integrated care was not. Heroin, cocaine, alcohol, and injection drug use all substantially decreased over time in both groups. Improvements in HIV outcomes (CD4 counts, HIV viral loads) appeared to improve more substantially among those receiving integrated versus non-integrated treatment. Health services utilization (visits, >2 CD4 counts/6 months) was significantly higher among those receiving integrated versus non-integrated treatment. Limitations: Because of problems with cross-over, we analyzed participants according to the treatment they received (rather than the treatment they were initially assigned). Study findings may have been affected by selection bias. Our small sample size limited the power to detect differences in outcomes between the two treatment groups. Conclusions: Integrated HIV and opioid addiction treatment with buprenorphine/naloxone in an innercity community health center can be successful. Participants had substantial improvements in substance use and HIV outcomes. As expected, individuals with integrated treatment (vs. non-integrated treatment) had substantially higher rates of health care utilization. This finding likely indicates that participants receiving integrated treatment have higher levels of engagement in their health care. Although larger studies are needed to confirm our study findings, our results can help guide the delivery of health care to HIV+ opioid-dependent individuals. 55 Abstract 46 Improving Health Care Outcomes in Homebound High Risk Vulnerable Elders in the South Bronx: An Enhanced Interdisciplinary Model of Home Based Primary Care Marcella Scaccia, MD; Jose A. Lopez, MD; John Forney, MD; Isabella Jankowska, MD; Doug Reich, MD Context: The Department of Family Medicine at Bronx Lebanon Hospital established as Standard of Care the use of the VES-13 Screening tool to screen all adults 60 and older for vulnerability towards functional decline and death. Objective: To assess the feasibility of integrating this tool into a Family Medicine Inpatient Unit to identify high-risk vulnerable elders and offer a home-based primary care program. Design: Patient over the age of 60, admitted to the FM Inpatient Unit, were screened by Family Medicine Residents. Patients with a survey score of 3 or more were offered Home-Based Primary Care. Descriptive Analysis of patient demographics and VES-13 domains will be reported. Qualitative data will reflect feedback from the surveyors. Results: Between October 1, 2007 and June 30, 2008 a total of 50 VES Screenings were completed. 6 were excluded because of incomplete or multiple or inconsistent answers to the functional activity domain. Of the remaining 43, 30 were completed by the PGY1 Class, 10 by an Observer and 3 by Community Health Workers. Average VES Score 5.45+/- 2.7. Summary of the VES-13 Domains: Age: 72% 65-74(Score 0),19% 75-84(Score 1),9 % (Scored 3).SelfReported Health: 65 % reported their health as Good or Excellent (Score =0);35% As Poor or Fair (Score=1). Ability to Perform 6 Physical Activities: 9% Scored 0=No Impairment;16% Scored 1 (Impairment in One Area);65% Scored 2 (Impairment in> 2 Areas). Five Functional Activities: 28% Score 0 (No Impairment) 72% Scored 4 (Impairment in at least on Functional Activity). Age and Self-Reported Health were not significant predictors of functional decline or death as score of 3 or more was mainly contributed by physical and functional disabilities. Barriers to the use of the tool included: incomplete understanding on the part of the patients and the interviewers on the use of the tool. Difficulties were defined as inconsistency in responses among the subset questions in the functional domain of the tool. Conclusions: The tool was useful in recruiting VE for HBPC. Although its use was established as standard of care, residents found it difficult to consistently perform screenings on every patient admitted to the floor. Possible barriers in the inconsistencies in the use of the tool may reflect the literacy level of the tool or the health literacy level of our population. 56 Selected Author’s Email Addresses Abstract Name Email Address 1 Alexander Ramirez [email protected] 2 Gretchen Mockler [email protected] 3 Alexander Ramirez [email protected] 4 Barbara Salcedo [email protected] 5 Victoria Gorski [email protected] 6 Bob Morrow [email protected] 7 Roselyn Collado-Abreu [email protected] 8 Stacia Maher [email protected] 9 Christel Hyden [email protected] 10 Stacia Maher [email protected] 11 Nichola Davis [email protected] 12 Miriam Shapiro [email protected] 13 Jessica Rieder [email protected] 14 Barbara Salcedo [email protected] 15 Stacia Maher [email protected] 16 Elizabeth Natal [email protected] 17 Sara Doorley [email protected] 18 Stacia Maher [email protected] 19 Joanna Dognin [email protected] 20 Leone, Laura [email protected] 57 21 Jeffrey Levine [email protected] 22 Lucia Ferri [email protected] 23 Alison Karasz [email protected] 24 Leone, Laura [email protected] 25 Susan Rubin [email protected] 26 Jennifer Klein [email protected] 27 Diane McKee [email protected] 28 Marissa Harris [email protected] 29 Susan Rubin [email protected] 30 Bill Jordan [email protected] 31 Pio G. Paunon [email protected] 32 Matt Anderson [email protected] 33 Oni Blackstock [email protected] 34 Carolyn Chu [email protected] 35 Niko Verdecias [email protected] 36 Jose Lopez [email protected] 37 Betsy Mathew [email protected] 38 Alain Litwin [email protected] 39 Paul Meissner [email protected] 40 Paula Parkerson [email protected] 41 Roselyn Collado-Abreu [email protected] 42 Arthur Blank [email protected] 43 Miriam Shapiro [email protected] 58 44 Pio G. Paunon [email protected] 45 Chinazo Cunningham [email protected] 46 Marcella Scaccia [email protected] 59
