SRFP034: Enhanced Care Planning Study: Barriers to Successful Community Referrals for Patients with Multiple Chronic Conditions

Grace Smith; Kristen O'Loughlin, MA, MS; Jacqueline Britz, MD, MSc; Jennifer Hinesley, PsyD; Alex Krist, MD, MPH; Benjamin Webel, BA; Paulette Lail Kashiri, MPH; Marshall Brooks, PhD

Abstract

Context: Existing literature recognizes that social context, health behaviors, and mental health play as much—if not more—of a role in patient health outcomes as access to quality medical assistance. Needs in these areas are common for people struggling with chronic diseases. In order to address these risk factors, it has become increasingly common for primary care providers (PCPs) to refer patients to community resources to receive supportive services. However, these referrals vary in their success rate. Chronic conditions can introduce difficulties in daily life and their management can be complex. These difficulties are more pronounced for those who have multiple chronic conditions (MCC). Therefore, patients with MCC may face additional barriers to accessing community resources, however little is known about this group's experiences with referrals. Objective: To describe the different barriers to accessing community resources for patients with multiple chronic conditions. Study Design: This project is a part of the ongoing Enhanced Care Planning (ECP) study. The ECP study aims to examine the effects of a care planning intervention with community referral support on the health outcomes of patients with MCC. For the current analysis, we will report patient barriers to accessing community referrals. Thematic analysis will be used to identify themes among patients with MCC. Setting: Primary care clinics in the Greater Richmond area. Population Studied: Adult patients with MCC, where at least one chronic condition is uncontrolled. Main Outcome Measures: Barriers with accessing community resources as identified by field notes from the community health worker. Preliminary Results: Preliminary data suggests that patients fail to connect with resources due to factors such as cost of services, family responsibilities, and work schedule conflicts. More barriers are expected to arise due to similar factors as more patients join the study. Conclusions: There is limited research describing the barriers patients face when seeking community resources, especially for patients with MCC. MCC affect many aspects of a patient's life and are expected to introduce unique barriers to accessing necessary community resources. These findings will increase our knowledge of barriers to community resource referrals and may be used to inform primary care referral processes.
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Jack Westfall
jwestfall@aafp.org 11/21/2021

Terrific poster and presentation. Thanks for your work.

Bill Kerns
11/21/2021

Agree with Jack. Important work, well presented. Thank you!

Diane Harper
harperdi@med.umich.edu 11/22/2021

Present your results in Phoenix next year! Thank you for sharing your work with NAPCRG!

William R. Phillips
wphllps@uw.edu 11/22/2021

Great poster.  Nicely presented poster.  Attractive and effective poster Important research question. Very important research question. Pilot work like this is key to study and implementation success. Thanks for the video. Hope you continue on this important line of inquiry. Thanks for sharing your work here at NAPCRG. - Bill Phillips

Andy Pasternak
avpiv711@sbcglobal.net 11/28/2021

Well done poster- gets a the complexity of primary care

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