Unite Delaware:

Booker, Erin; Coombes, Katie W

doi:10.32481/djph.2020.09.012

Cited by 2 publications

(3 citation statements)

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“…To address the lack of education for community care clinicians, the Office of Integrated Veteran Care could offer trainings and resources on VHA benefits and resources to HHC agencies, community hospitals, and skilled nursing facilities. Another opportunity could be partnering with an SDOH information exchange to give VHA and HHC clinicians the tools to have tailored resources for Veterans easily accessible [ 26 ]. These relationships may increase VHA accessibility through collaborative process improvement to reduce delays in Veteran care.…”

Section: Discussionmentioning

confidence: 99%

Perspectives on supporting Veterans’ social needs during hospital to home health transitions: findings from the Transitions Nurse Program

Daus,

Lee,

Ujano-De Motta

et al. 2024

BMC Health Serv Res

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Background Veterans who need post-acute home health care (HHC) are at risk for adverse outcomes and unmet social needs. Veterans’ social needs could be identified and met by community-based HHC clinicians due to their unique perspective from the home environment, acuity of Veterans they serve, and access to Veterans receiving community care. To understand these needs, we explored clinician, Veteran, and care partner perspectives to understand Veterans’ social needs during the transition from hospital to home with skilled HHC. Methods Qualitative data were collected through individual interviews with Veterans Health Administration (VHA) inpatient & community HHC clinicians, Veterans, and care partners who have significant roles facilitating Veterans’ hospital to home with HHC transition. To inform implementation of a care coordination quality improvement intervention, participants were asked about VHA and HHC care coordination and Veterans’ social needs during these transitions. Interviews were recorded, transcribed, and analyzed inductively using thematic analysis and results were organized deductively according to relevant transitional care domains (Discharge Planning, Transition to Home, and HHC Delivery). Results We conducted 35 interviews at 4 VHA Medical Centers located in Western, Midwestern, and Southern U.S. regions during March 2021 through July 2022. We organized results by the three care transition domains and related themes by VHA, HHC, or Veteran/care partner perspective. Our themes included (1) how social needs affected access to HHC, (2) the need for social needs screening during hospitalization, (3) delays in HHC for Veterans discharged from community hospitals, and (4) a need for closed-loop communication between VHA and HHC to report social needs. Conclusions HHC is an underexplored space for Veterans social needs detection. While this research is preliminary, we recommend two steps forward from this work: (1) develop closed-loop communication and education pathways with HHC and (2) develop a partnership to integrate a social risk screener into HHC pathways.

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Section: Discussionmentioning

confidence: 99%

Perspectives on supporting Veterans’ social needs during hospital to home health transitions: findings from the Transitions Nurse Program

Daus,

Lee,

Ujano-De Motta

et al. 2024

BMC Health Serv Res

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“…The Health Guide screens the referred patients for eligibility, consents eligible and interested patients, and coordinates their referral to and subsequent appointment with the legal aid organization. For those patients, who do not have a qualifying social and/or legal need for the MLP, the Health Guide will provide additional referrals utilizing Unite Delaware, the health systems embedded social prescription platform 10…”

Section: Methodsmentioning

confidence: 99%

“…For those patients, who do not have a qualifying social and/or legal need for the MLP, the Health Guide will provide additional referrals utilizing Unite Delaware, the health systems embedded social prescription platform. 10…”

Section: Description Of the Mlpmentioning

confidence: 99%

Legal Needs, Health, and Health Care Utilization Among Patients Participating in the Delaware Medical Legal Partnership

Mapp

Moore

Booker

et al. 2022

Journal of Public Health Management and Practice

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Context: Unmet legal needs can exacerbate health disparities and contribute to a lack of adherence to treatment plans and medical recommendations for care. Medical legal partnerships (MLPs) are integrated health care and legal aid interventions offered by many health systems in the United States. Although much research has been published regarding the success of MLPs with specific patient groups, there is a gap in literature regarding the nature of MLPs in a more general, at-risk patient population. Objective: We aimed to better understand specific patient characteristics and health outcomes associated with different iHELP legal needs. Design: This is a cross-sectional study of patients who were enrolled in the Delaware MLP (DMLP) from November 2018 to June 2020 (N = 212). Setting: The DMLP is a collaboration between ChristianaCare, a Mid-Atlantic health system, and the Community Legal Aid Society, Inc (CLASI). Participants: Patients must be adults (ie, 18 years or older), below 200% of the federal poverty level (eg, ≤$53 000 for a household of 4 as of 2021), have at least one qualifying legal need, and live in the state. Intervention: The DMLP is designed to address unmet legal needs that fall under a framework called iHELP. iHELP legal domains are income and insurance (i), housing and utilities (H), education and employment (E), legal status (L), and personal and family stability (P). Main Outcome Measures: Outcomes of interest were iHELP legal needs, patient demographics, perceived stress and mental and physical health-related quality of life, comorbidities, and health care utilization. Results: Housing and utilities (46.2%) and income support (41.5%) were the highest reported legal needs. Perceived stress scores were significantly higher for those with income needs (P = .01) as well as those with housing and utilities needs (P = .01). Conclusions: MLP programs offer a value-added service that can address unmet legal needs in vulnerable, at-risk patients.

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Unite Delaware:

Cited by 2 publications

References 0 publications

Perspectives on supporting Veterans’ social needs during hospital to home health transitions: findings from the Transitions Nurse Program

Perspectives on supporting Veterans’ social needs during hospital to home health transitions: findings from the Transitions Nurse Program

Legal Needs, Health, and Health Care Utilization Among Patients Participating in the Delaware Medical Legal Partnership

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