DIGITAL HEALTH EQUITY PARTNERSHIP EVALUATION
Vinfen is the Lead Applicant for the Digital Equity Partnership on behalf of the Human Services Alliance for Digital Equity (“the Alliance”), a network of organizations that provide mental health, disability and homeless services across the Commonwealth. The goal of the Alliance is to increase digital inclusion among low-income people with physical, behavioral or cognitive disabilities and people who are homeless. The Alliance organizations provides a wide range of services including outpatient mental health, skill development and employment programs, group homes, substance use treatment, community support teams, homeless programs, transitional housing and drop-in resource centers. The main approach was to deploy 15 regionally based Technology Navigators (TN) who supported people with disabilities to obtain devices, learn how to use them and enroll in the Affordable Connectivity Program (ACP). The Health Equity Research Lab assessed the TN program, the challenges, successes and lessons learned to facilitate its replication by other human service organizations in Massachusetts. The evaluation included key informant interviews with stakeholders, including clients, to assess various intervention components during project implementation. The goal of the Digital Equity Partnership program is to increase digital inclusion among low-income people with disabilities and people with unstable housing by supporting participating organization to develop Tech Navigator programs that include the below scope of services.
PI: Dharma Cortes
ASSESSING SUICIDAL BEHAVIOR USING DIGITAL PHENOTYPING AMONG ADOLESCENTS AND TRANSITIONAL AGE YOUTH
The purpose of this study was to refine and pilot a smartphone app for the study of suicidal behavior among a group of youth representing a diversity of race, ethnicity, language, SES, and gender. We envisioned a research program that aims to unify data from electronic health records, smartphone apps, and neighborhood datasets to better understand suicidal predictors and behaviors in the context of dramatic changes wrought by the COVID pandemic on vulnerable families. We studied how suicidal behavior among youth could be identified and predicted using multi-level patterns of individual behavior, family interactions, and social context elicited via smartphones. We also advanced digital phenotyping science by analyzing data from an app for youth and their caregiver that measures real-time changes in mental health, family conflict and discrimination. This app was developed and studied in other clinical settings (e.g. adult liver disease, adolescent mental health) and needed stakeholder-based refinement to improve acceptability among youth in mental health treatment. To place the app data from this small pilot in a larger socioeconomic context, we drew on available large datasets of “volunteered geographic information” that can reveal zones of inequity, which may help improve suicide prevention using digital phenotyping with disadvantaged families.
PI: Nicholas Carson
Impact of State Policies on Smoking among Individuals with Substance Use Disorder (NCI)
This project was funded by the National Cancer Institute (NCI) and it directly responded to concerns raised by clinical stakeholders about the difficulty of reducing smoking in the Substance Use Disorder (SUD) population. It also contributed to realizing the vision of NCI to eliminate smoking, and the cancers and other harms it causes, through research on tobacco prevention and cessation interventions, especially those aimed at vulnerable populations at increased risk of tobacco use. The project examined the impact of tobacco control policies, specifically looking at whether expanding coverage for tobacco dependence treatment (TDT) and raising cigarette excise taxes increase TDT use and decrease smoking among the SUD population. It also explored whether states with rising taxes would further reduce smoking if they also had generous Medicaid coverage of TDT, which allows for more actionable information to state policymakers. Results were disseminated to clinicians and policymakers and directly informed coverage and taxation policies that address smoking behaviors in this high-risk population. This project was the first to examine the smoking behaviors and factors affecting TDT and cessation among individuals with SUD who are not in SUD treatment.
PI: Benjamin Lê Cook
RISE (LEAP): Recovery In Shared Experiences
Cambridge Health Alliance launched the RISE program in 2014 to provide evidence-based early intervention, in order to help teens and young adults build resiliency and skills vital to recovery. With group therapy (based on NAVIGATE model) as the foundation, RISE clients also received individualized medication management, psychological assessment, peer and employment support, opportunities to hang out with each other before and after appointments in our Community Room, and other services as needed. RISE is well-integrated within the larger CHA network, including inpatient psychiatry (child and adult), emergency departments (with medical and psychiatric providers), primary care (pediatrics, family and internal medicine), and active presence in local communities and public schools.
The following services are provided: Psychiatric assessment, Psychopharmacology, individual therapy, Group therapy, Cognitive Behavior Therapy, Social skills training, Substance abuse counseling, Social milieu activities, Family education and engagement, Co-located primary care and lab, Employment and education support, Peer Support Specialist, and Health education & wellness coaching.
HERLab supplied the Assessment Coordinator position, which conducts assessment (currently, the EPINET battery) in a clinical capacity.
COVID-19’S IMPACT ON ECONOMICALLY VULNERABLE CHILDREN AND THEIR PARENTS
Consistent evidence suggests that severe adversity in early life—stemming from stressors such as deep and persistent poverty, abuse or neglect, exposure to community violence, and/or the cumulative burdens of racial or ethnic discrimination—is a risk to healthy child development, and can lead to physiological disruptions that contribute to lifelong problems in learning, behavior, and both physical and mental health. Importantly, much of this research is being conducted in the absence of comprehensive information about the social and physical environments that create adverse circumstances for young children. The Center on the Developing Child at Harvard University (the Center) has convened a group of scientists who are actively developing a multidimensional but brief battery of the biological indicators of “toxic stress” in children (i.e., chronic or excessive activation of stress response systems). The ultimate goal of the research on both the biological indicators and the social and behavioral triggers of toxic stress was to generate novel interventions to reduce the development of toxic stress and to ameliorate its adverse consequences for health. In addition to the original surveys, our team readministered a second set of surveys to identify different social factors that contribute to toxic stress and to advance the measurement of social risks that affect young children and their parents in the context of the COVID-19 pandemic. We hoped this study would help us to come up with ways to reduce the development of toxic stress and lower its negative health outcomes and identify the needs of parents and their children in the context of the pandemic.
Investigators: David Williams (HSPH), Benjamin Lê Cook
MEDICAID PAYMENT POLICY AND ACCESS TO CARE FOR DUAL ELIGIBLE INDIVIDUALS (NIMHD R01)
Dr. Cook and Dr. Vicki Fung at Massachusetts General Hospital (MGH) were granted a NIMHD R01 grant for 5 years with the aim to assess the impact of recent Medicare policy changes on racial/ethnic disparities in mental health care. The Lab assessed the effects of policy changes on racial/ethnic minorities in medical care use, quality process measures, clinical events and total and component medical spending. Racial/ethnic minorities are less likely to receive mental health care than Whites and these Medicare policies have the potential for reducing these disparities. Data used were a 20% sample of fee-for-service beneficiaries linked to provider and area-level data implementing difference-in-difference and within-person statistical analysis.
Investigators: Benjamin Lê Cook, Vicki Fung (MGH)
RIZE: Innovations in Anti-Racism to Address the Opioid Overdose Crisis
The HERLab at CHA was selected as an evaluator to partner with RIZE and the four grantee sites to support implementation and mixed methods evaluation of their efforts:
Boston Public Health Commission: Used the grant to create a comprehensive awareness and information initiative on smoking and inhaling safer, specifically targeting African-American, Latino, and Indian drug users.
Casa Esperanza: funds were to expand the use of the language access application of the Comprehensive Healthcare Improvement Support System – Spanish (CASA-CHESS) to address racial and ethnic disparities in access to treatment for the Disorder. Substance Use (SUD), reduce isolation among Spanish speakers, strengthen recovery networks and disseminate information about COVID-19.
Codman Square Health Center: Used the grant to conduct a comprehensive needs assessment of its SUD services through the lens of racial justice, including examining how workflows and protocols are determined; what services may be missing; and to what extent the community they serve is involved.
Prisoner Legal Services: Used the funds to plan an innovative state project that will advocate for evidence-based access to SUD for incarcerated individuals as a necessary model of public health treatment and racial equity. The project was a medical advocacy partnership with residents and the Boston Medical Center School of Internal Medicine.
Investigators: Benjamin Lê Cook, Dharma Cortes, Ana Progovac, Michael Flores, Valeria Chambers
CMS DISPARITIES (ACOS) BY RACE/ ETHNICITY, GENDER, AND GENDER IDENTITY STATUS (CMS OFFICE OF MINORITY HEALTH)
The Health Equity Research Lab was awarded one of the 5 Office of Minority Health seats with the CMS Virtual Research Data Center. This project studied the differences in ACO participation by race/ ethnicity, gender (including gender minority status), and mental health status beneficiaries. This project also studied disparities within ACO’s by dual eligibility status, race/ ethnicity and gender/gender identity in access, utilization, and quality of mental health services, and also compared access, utilization, and quality of disparities for beneficiaries treated within ACOs to those not treated in ACO’s by race/ethnicity and gender.
CENTER FOR MINDFULNESS AND COMPASSION EVALUATIONS
The Center for Mindfulness and Compassion (CMC) is an interdisciplinary center within Cambridge Health Alliance, CMC is an organization grounded in current scientific understanding of mindfulness and compassion, and the promotion of empirically supported theory and practice. CMC is committed to using mindfulness and compassion to foster an inclusive and caring community that ensures access on the basis of intersecting factors such as race, gender, sexuality, language, mental and physical ability, and economic status. The HER Lab partnered with CMC on multiple projects that aligned both center’s focus on improving physical and mental health in diverse communities. These projects included:
“Effect of Mindfulness Training on Opioid Use and Anxiety During Primary Care Buprenorphine Treatment.” This study pilot-tested the Mindful Recovery OBOT Care Continuum model and demonstrate capacity for a multi-sites Randomized Control Trial (RCT) comparing Group-Based Opioid Treatment versus M-ROCC in primary care office-based opioid treatment (OBOT).
“Effects of Remote Motivational Enhancement and MySafeRx via Video on Post-Detox Engagement and Retention in Buprenorphine Treatment.” This study investigated the effects of starting remote motivational enhancement during inpatient detoxification on rates of engagement in during inpatient detoxification, on rates of engagement in buprenorphine treatment and evaluated the impacts of MySafeRx, a mobile device application which integrated remote motivational coaching with daily observed dosing from secure electronic pill dispensers at home via video-conference on treatment retention and overdose prevention.
“Mindfulness Influences on Self-Regulation: Mental and Physical Health Implications, and Effects of Remote Motivational Enhancement.” This study sought to understand the impact of mindfulness training on the underlying neural mechanisms of self-regulation for patients who are participating in mindful primary care at CHA.
Alcohol treatment in Medicaid managed care plans: Disparities in policies and outcomes
Fewer than 10% of those with alcohol use disorder (AUD) receive evidence-based treatment, and racial/ethnic minorities and women are less likely to access any treatment at all. Medicaid programs are among the most important payers for AUD treatment and rates of AUD in the Medicaid population are especially high. Medicaid provides health insurance for more than 77 million Americans, including a large and disproportionate share of racial/ethnic minorities, women, and rural Americans. Almost all state Medicaid programs contract with Medicaid managed care organizations (MMCOs) to deliver and manage health care services and nearly 70% of Medicaid enrollees are now in managed care. However, there is almost no information or transparency on MMCO policies related to alcohol treatment services. This study systematically examined AUD treatment policies in MMCOs, an under-explored area of research with potentially large influence on disparities in AUD treatment access and outcomes.
PI: Maureen Stewart
Improving Limited English Proficient Patient Safety through Patient Portal Accessibility (crico)
Language barriers a risk for poor clinical outcomes, medical errors, and liability across the spectrum of care. We have partnered with Dr. Robert Marlin, a strong advocate of vulnerable populations, to assess the effects of implementing a Spanish-language patient online portal that accurately sends messages to low English proficiency patients in their native language with the aim to improve communication with the care team and mitigate risks that result from miscommunication. The project evaluated patient satisfaction and clinical outcomes.
PI: Robert Marlin
BLACK VOICES IN RECOVERY
Black Voices in Recovery was created by and for Massachusetts residents with lived experience of behavioral health, trauma, substance use, and/or addictions as in support of each other’s recovery. Their mission is to promote self-determination, self-empowerment, advocacy, activism, and support in Black communities to promote psychological wellbeing, to educate to reduce mental/health disparities, to mitigate the effects of racism and implicit biases in systems, to reach out in order to reduce alienation, to speak out in order to reduce discrimination, and to emphasize healing, connection, and wellness of mind, body, and spirit. Thirteen years ago, mental health consumers of color in Massachusetts began a peer networking project to meet growing community demands for a space to discuss mental health, trauma, and substance use-related challenges – and their deep disappointment with existing mental health systems that largely failed to meet their needs. Now a statewide advocacy network, Black Voices in Recovery became that “space to talk.” The Health Equity Research Lab has worked closely with Black Voices in Recovery (BVR), led by Valeria Chambers, to raise awareness of the discrimination, racism, and Black community members’ dissatisfaction and resilience in the face of a fragmented mental health care system. We worked in partnership with BVR to document and disseminate their origin, vision, and their established processes for making space, healing, and raising constituent voice.
PI: Valeria Chambers
PATIENT PREFERENCES AND DISCRIMINATION IN THE HEALTHCARE SYSTEM (PCORI)
The Patient Centered Outcomes Research Institute (PCORI) supports research to inform healthcare decisions and improve healthcare delivery and outcomes through integrity and evidence-based information. The Lab was awarded a three year grant to develop an instrument to understand patients’ treatment preferences in their depression and diabetes care. Incorporating patient preferences into treatment plan requires an understanding of patients’ past experiences and preferences, including experiences of discrimination and the influence of peers, family and community members regarding treatment options. A mismatch between treatment and patient preferences worsens health outcomes via lower patient engagement, poorer adherence, and higher attrition. We have developed a survey that combines conjoint analysis with measurement of prior healthcare experiences and socio-cultural factors to describe the influence of preferences among race/ethnic minorities. The survey was sent nationally to more than 1500 patients with either depression, diabetes or both. To further understand treatment preferences and prior experiences, we conducted interviews with patients and providers in person and by phone. We shared these findings with providers and raised awareness of the importance of including preferences as part of treatment planning. These research efforts were developed using community-based participatory research in collaboration with the Primary Care Practice Improvement team and the Volunteer Health Advisers at Cambridge Health Alliance and the Transformation Center, a peer-support organization that seeks to transform policy and practice in communities through the participation of people with mental health diagnoses.
To learn more, visit the PCORI page
Collaborating partners: The Transformation Center
The Cambridge Health Alliance Primary Care Practice Improvement
PI: Benjamin Lê Cook
GENDER MINORITY HEALTH AND HEALTHCARE DISPARITIES USING MEDICARE CLAIMS AND ELECTRONIC HEALTH RECORDS (NIMHD R03)
In 2016, the National Institutes of Health (NIH) formally designated gender minorities (i.e., transgender or gender non-binary persons) as a health disparity population, reflecting mounting evidence that this population has unique unmet health needs and that more research is needed to answer the epidemiological and health services questions which may help reduce disparities for this group. We sought to understand access and utilization of health services by identifying gender minority patients in Medicare claims and in electronic health records. Dr. Progovac has been granted a Harvard Catalyst Award as well as an R03 NIMHD to proceed with the studies. Key outcomes of interest included adequate treatment for depression, treatment for chronic conditions, suicide behavior, victimization from domestic violence, avoidable hospitalizations. We have developed strong collaborations with advocates, policymakers and clinicians who are working closely with and for this population to improve gender minority well-being and health.
PI: Ana Progovac
CAMBRIDGE HEALTH ALLIANCE HEALTH INTEGRATION PROGRAM EVALUATION (HMS KAPLEN FELLOWSHIP)
The Health Integration Program at the Central Street Health Center at CHA is a Behavioral Health Home that offers recovery-oriented care to adults with serious mental illness, including schizophrenia and other psychotic disorders. The project consists of a “reverse integration” program where primary care services are provided in a mental health care setting. It involves the participation of a multidisciplinary team including healthcare providers, nurse practitioners, case managers and administrative personnel. The Lab provided short and long-term evaluation of the program, including barriers/facilitators, appropriateness, acceptability, feasibility, sustainability and replicability. A mixed methods approach from analysis of electronic health records and narratives from semi-structured interviews with providers and patients, has identified that through enhanced training and care coordination, patients have received more screening tests and monitoring of co-morbid chronic and acute medical conditions. Dr. Progovac has earned a Kaplen award to continue with the analysis of the implemented project and defined priorities as well as potential expansion to other CHA sites.
PI: Ana Progovac
NEIGHBORHOOD- LEVEL PREDICTORS OF OPIOID- RELATED MORTALITY (HMS ZINBERG FELLOWSHIP)
In 2017, the Department of Health and Human Services declared the opioid epidemic a “public health emergency.” The Centers for Disease Control and Prevention estimated 63,632 overdose deaths occurred in 2016. Close to two-thirds (66%) of these overdose deaths involved an opioid, either prescribed or illicitly obtained. The specific aims of this project were to identify the neighborhood-level factors that predicted opioid-related mortality among CHA patients, determine the clinical and individual factors that predicted health service use among CHA patients with opioid use and comorbid mental illness, and examine the barriers and facilitators of addiction treatment planning at CHA.
Point Person at the Lab: Michael Flores
SAFETY NET COLLABORATIVE AND CPD MENTAL HEALTH/CRIMINAL JUSTICE INITIATIVES (MILLER FOUNDATION AND DEPARTMENT OF JUSTICE)
Supported by a Department of Justice and the Miller Foundation, the Lab partnered with the Cambridge Police Department (CPD) to conduct evaluation of their diversion program for youth with mental illness (Safety Net) and community policing efforts for adults. In the last 10 years, the CPD has transformed its community policing philosophy to focus more on prevention, intervention, and diversion. Because at least 70% of people in the criminal justice system are mentally ill, the city has been working to connect at risk individuals with mental health care prior to arrest and incarceration. An important part of this initiative was the CPD Community Services Unit, which included officers and sworn personnel who are dedicated to addressing the needs of youth, the elderly, the homeless, and individuals with mental health issues by facilitating information sharing and coordination of care between CPD and partner organizations. We evaluated the current state of these programs, formalized partnerships, and developed toolkits to promote information sharing between law enforcement agencies looking to expand community policing services in their communities.
PI: Jamie Barrett
COMPARATIVE EFFECTIVENESS RESEARCH AND RACIAL/ETHNIC HEALTH CARE EQUITY (AHRQ R01)
We examined whether specific information in FDA warnings influenced disparity trends in psychotropic drug use and mental health care and identified how provider characteristics and HMO enrollment act as mechanisms that underlie the differential diffusion of Comparative Effectiveness Research (CER) via health risk warnings. Identifying the influence of FDA risk warnings on trends in psychotropic drug use and related health care provided a platform to understand how CER influenced disparities and helped us assess whether information regarding the risks and benefits of medications were being equitably disseminated. Our examination of how an increased reliance on CER likely influenced disparities in treatment after health care reform would provide policymakers with actionable information that might avert the negative equity consequences of incorporating CER into routine practice.
PI: Benjamin Lê Cook
THE IMPACT OF A COMPREHENSIVE ELECTRONIC PATIENT PORTAL ON THE HEALTH SERVICE USE OF PATIENTS OBTAINING SERVICES AT FOUR HOSPITALS IN MADRID: AN INTERRUPTED TIME-SERIES ANALYSIS
The objective of this study was to determine the extent to which an electronic patient portal was associated with improvements in health service use. Using a quasi-experimental interrupted time-series approach to analyzing administrative hospital data, we assessed health service use before (April 2012-March 2015) and after (April 2015-December 2016) the implementation of a comprehensive electronic patient portal in four hospitals from the Madrid Health System (Madrid, Spain). Our primary health service use outcomes consisted of number of outpatient visits, any hospital use, any 30-day all-cause readmission, and any emergency department (ED) use.
Point Person at the Lab: Benjamin Lê Cook