INTRODUCTION: The United States is currently experiencing a shortage of physicians that is projected to worsen substantially over the next decade. Rural regions are most affected by this shortage, with some statistics estimating that the physician-to-patient ratios reach 1 to 2500 in certain areas. While some measures have been taken to help combat this shortage, such as increases in medical school enrollment and the development of more residency training programs, additional interventions are needed that target rural regions specifically. One of the most powerful methods to improve this rural maldistribution of physicians is to make changes in medical education so that it trains and deploys more individuals who wish to practice in rural areas. The Quillen College of Medicine (QCOM) places tremendous focus on training rural physicians, with around 25% of students selecting an alternate educational curriculum that provides them with specific training in rural communities. To further QCOM’s commitment to improving rural healthcare, we hosted a no-cost, week-long camp for high school students. We specifically recruited students from the surrounding rural regions, as studies have demonstrated that students with rural origins are more likely to train in primary care and return to practice in rural areas. We hypothesize that earlier exposure to the medical field through summer camps is an effective method to increase the number of students from rural communities who wish to pursue careers in medicine. METHODS: The 2018 camp was held the week of June 4-8 and hosted 20 students from surrounding high schools. Throughout the week, the students engaged in a variety of fun and engaging activities that taught them about many important aspects of medicine such as proper patient care, communication skills, physical exam techniques, and critical thinking skills. We utilized both the Medical Simulation Lab and Standardized Patient Center at the Quillen College of Medicine, which allowed the students to interview, diagnose, and treat patients with various conditions in a simulated environment. Our objective was not to have the students accurately diagnose and treat the conditions, but rather to utilize teamwork, employ critical thinking skills, and enjoy doing it. Our data was collected pre- and post-surveys which contained closed-ended questions, Likert scales, and free-response questions. The surveys assessed demographic information, previous exposure to the medical field, interest in the medical field, and perceived potential obstacles in pursuing a career in medicine. RESULTS: Student feedback was positive overall. 65% of students stated they were more knowledgeable about the steps they needed to take to become a physician. 55% of participants reported an increased desire to pursue a career in healthcare. 45% of students reported an increased desire to become a physician. CONCLUSIONS: We conclude that earlier medical exposure through summer camps is an effective method for increasing the number of students from rural East Tennessee who are interested in pursuing a career in medicine. We believe that similar opportunities should be offered to a greater degree in other areas to help combat the physician shortage affecting rural regions nationwide.

Background: Ballad Health participates in the Centers for Medicare and Medicaid Services’ (CMS) Accountable Health Communities (AHC) model. The AHC model is evaluating if universal screening, referral, and navigation services for health-related social needs (HRSN) can improve outcomes and reduce unnecessary utilization and costs of health care services. To ensure the evaluation of the model has sufficient statistical power, navigation services are expected to be provided to a minimum number of individuals. The purpose of this study is to analyze the characteristics of Ballad Health’s AHC navigation services that could be modified to improve opt-in rates. Methods: The primary outcome measure was identified as whether a beneficiary contacted via telephone opted-in or –out of the navigation program. Andersen’s Behavioral Model for Health Service Use was used as the conceptual framework for selecting covariates of interest. Enabling factors were of primary interest because alternate interventions may be designed around them. Data was pulled for the time period of November 17, 2018 through February 14, 2019. Where possible, covariates were associated with data from CMS’ AHC Data Template v3.1 to accommodate replication for all AHC bridge organizations, though additional internally-collected data, which may not be available for all bridge organizations, were needed for some variables. Chi-squared tests were performed for each covariate. Results: No statistical differences were found for the primary covariates of interest. Opt-in rates by Navigator were lowest for Navigator 5 and highest for Navigator 4 (67.53% and 88.24%). Opt-in rates by weekday of decision were lowest on Thursdays and highest on Wednesdays (64.91% and 77.42%). Opt-in rates based on time of day were lowest between 8:00am and 9:59am, and highest between 12:00pm and 1:59pm (62.50% and 100%). Opt-in rates were lowest when the decision was made six days after the screening and highest when made the same day (53.57% and 83.33%). Opt-in rates were lowest when there were five weekdays between screening and navigation decision, and highest when there were three weekdays between the screening and decision (60% and 90%). Other non-process covariates of interest that were statistically significant for opt-in rates were the presence of either food, safety, or utility needs. Conclusions: Several groups had higher opt-in rates that were not statistically significant; small sample sizes may have impacted the significance of these differences. For example, opt-in rates were higher when made the same day as the screening than when made one day after (83.33% and 74.79%). However, only 18 beneficiary decisions were made on the same day, while 119 were made one day after. Increasing the number of same-day phone call attempts may be a method to improve opt-in rates. Importantly, date and time data for contact attempts before a beneficiary decides to opt-in or opt-out were unavailable as of the time of the analysis. These data are captured and will be added to the analysis when available, which could provide more insight into whether a beneficiary is more likely to opt-in or opt-out.

Substance use disorder (SUD) is a disease that continues to affect the lives of millions of Americans. Access to adequate treatment also continues to be a challenge for many of those suffering from substance use disorder. To better understand the barriers to treatment as well as the social challenges people face in seeking care for their substance use, we designed an observational study to capture demographic data, perceptions of stigma, and self esteem levels at a medication assisted treatment (MAT) facility in Northeast Tennessee. A robust survey was administered to patients at the MAT facility to quantify and analyze these metrics. Results from the survey showed when it came to stigma, respondents felt the highest level of internalized stigma compared to the other two types of measured stigma (enacted and anticipated). This was still the case even after stratifying based on gender. Regarding self esteem, survey results showed that as a whole, most respondents were within the normal range for self esteem, however, differences were appreciated when the data was categorized based on age. Finally, some of the most common reasons respondents selected for not seeking treatment previously were the thought that the problem could be handled alone, the lack of health insurance, and the fact that they were not ready to quit. A greater understanding of these issues is crucial for providers to better serve their patient population and tailor their services to the pertinent issues of the area.

Despite the passage of the Patient Protection and Affordable Care Act (PPACA) in 2010, the Centers for Disease Control and Prevention identified persistent disparities in health care resources as the primary causes of mortality among minority populations. An underexplored resource for affected African American populations is the church, which is not a recognized stakeholder in the implementation of current health care policy. The purpose of this phenomenological case study was to gather perspectives from African American parishioners who lacked sufficient health care insurance on the roles the church could play. Qualitative data management software was used to organize the data (transcripts of interviews) for coding. The purposeful sample of 12 church attendees came from urban, suburban, and rural African American churches. The Andersen behavioral model and Hochbaum's health belief model were used as the conceptual framework for thematic analysis of health care disparities. Kingdon's multiple-stream framework provided theoretical grounds for policy development and revision. Key findings revealed several interrelated health care disparity themes: the significance of insurance coverages, premium costs, financial barriers, family and personal issues, empowerment strategies, religious beliefs, and roles the church could play in promoting quality community health. The study has implications for positive social change: The results include guidance for the development of a bipartisan health care policy that includes the church as a stakeholder. A- partnership between the church and the legislators of health care reform could be a catalyst for improved metrics, trust, accountability, transparency, and opportunities to create tailored health care interventions and thus help alleviate societal health crises.

Interprofessional education (IPE) is essential for enhancing students’ critical thinking skills and ability to integrate other professionals’ knowledge to ensure mutual respect and shared values for patient-centered care. The needs of medically underserved populations (MUPs) to receive behavioral health and nutritional care integrated with primary care services are significant. This research highlights the data outcomes from six offerings of a graduate IPE course on integrated health care. Funding from a Health Resources and Services Administration (HRSA) Behavioral Health Workforce and Education Training (BHWET) grant provided stipends for graduate social work and school counseling students in their final year of field working with MUPs in integrated care settings. Findings indicate significant increases in integrated care knowledge from pre- to post-course. Students reported appreciating the social justice framework of the course including food security and access to care. Students suggest that the course be required of all, not just stipend recipients. This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under Behavioral Health Workforce Education and Training Program Grant No. M01HP313900100. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. Government.

Background: The utilization of telehealth has had a substantial impact on transforming and enhancing the methods by which healthcare is presently delivered. The potential benefits of telehealth in improving the health of vulnerable populations and underserved communities are substantial. The aims of this study were to examine the association between social determinants of health and patient perceptions of their experiences with telehealth. We will analyze how perceptions differ across specialization, race, gender, and other key determinants; examine how patient’s self-rated physical health and mental health influences perceptions and attitudes about telehealth utilization; and evaluate differences in perceptions and attitudes, experience with patient interactions and overall telehealth experiences between mental health providers and non-mental health providers. Methods: A scoping review was completed to explore literature regarding telehealth administration and underserved populations following the PRIMSA-ScR guidelines. Multivariable logistic regression was then conducted to assess the relationship between self-rated mental health and self-rated physical health and the primary predictor variables telehealth usability, telehealth satisfaction, and telehealth experiences. Finally, a mixed-methods study was conducted to evaluate differences in perceptions and attitudes, experience with patient interactions and overall telehealth experiences mental health-care providers and non-mental healthcare providers. Results: The scoping literature review highlights how telehealth is used in diverse settings, but more research needs to be done to determine best practices for both healthcare providers and patients utilizing telehealth. The study focused on self-reported health found significant associations between high mean scores on telehealth usability, telehealth satisfaction, and telehealth experiences and good self-reported mental and physical health. Lastly, the study looking at provider differences highlighted that the reliability of the telemedicine platform, the ability to trust the telemedicine application, and video visits being a convenient form of healthcare delivery was greater for mental healthcare providers than non-mental healthcare providers. Implications: These findings highlight the need for studies examining telehealth satisfaction, telehealth usability and telehealth experiences amongst providers and patients in underserved areas. Further research is needed to gain a deeper understanding of the telehealth access requirements of underserved communities and can aid in the development of evidence-based guidelines for the delivery of telehealth services.

The prevalence of Hepatitis C Virus (HCV) in the US is estimated at 3.5 million with 18,153 deaths in 2016. It is the most common bloodborne infection, with a higher age-adjusted mortality rate than Hepatitis B Virus or Human Immunodeficiency Virus. Without treatment, nearly 1.1 million people will die from HCV by 2060. About 41,200 new cases of HCV were reported in 41 states in the US in 2016. The reported cases of acute HCV in 2016 is 2.3 per 100,000 in Tennessee, which is more than twice the national goal set by Healthy People 2020. This is a descriptive study to ascertain the HCV prevalence and usefulness of screening in medical outreach settings (MO) compared to indigent healthcare clinics (IHC) in northeast Tennessee. This study period was from April 2017 – February 2019. Participants (n=250), were adults, who engaged in routine, opt-out HCV testing at 4 IHC and 3 MO sites in the Tri-Cities, TN region. During the screening, demographic information- age, gender, race- were collected and the de-identified data were analyzed using Statistical Analysis System (SAS 9.3) to perform a descriptive analysis. Also, several discrete Chi-Square tests of independence between the demographic variables, screening locations, and HCV antibody prevalence was conducted. A total of 250 clients were screened for HCV. The majority of clients screened were non-Hispanic whites 228 (91.20%); females 136 (54.40%); young adults 131 (52.40%) and at IHC clinics 187 (74.80%). Screening showed HCV antibody prevalence of 14.8%. The majority of positive cases were non-Hispanic whites 36 (97.30%; P=0.1561); females 19 (51.35%; P=0.6867) and young adults 23 (62.16%; P=0.286). The prevalence at the IHC clinics and MO settings were 36 (97.30%; P=0.0006) and 1(2.70%) respectively. This analysis shows the higher yield of targeted HCV screening at IHC clinics. Focused HCV screening is critical in the era of opioid epidemic, particularly when direct-acting antiviral agents (DAAs) which offer a Sustained Virologic Response (SVR) rate of more than 90% are available. The use of case control or cohort study designs to establish causality is recommended for improving focused HCV screening.

Adverse Childhood Experiences (ACEs) include childhood exposure to abuse or violence, a parents' divorce, mental illness, substance use disorder, and are identified as risk factors for negative life outcomes. While ACEs screenings are commonly used in mental health and pediatric settings, screening for ACEs in primary care settings is less prevalent. The purpose of this project is to integrate screening for ACEs into a primary care setting and make appropriate referrals for follow-up, thus reducing potential negative life outcomes. The process was designed for a primary care practice located in Winston-Salem, North Carolina. Part one assessed level of awareness and screening history which determined training focus. Each provider and staff member received 30-45 minutes of training on ACEs screening algorithm, a detailed approach to guide treatment. The training was followed by question-and-answer sessions to address concerns. Part two, involved screening using the Center for Youth Wellness, Adverse Childhood Experiences Questionnaire for Children (CYW ACE-Q Child) which was initiated by the front office employee. Front office employee identified patients present for an annual well visit, briefly explained the screening tool, and handed it to the patient on a clipboard. The patient returned the completed form to the Certified Medical Assistant (CMA) when called in from the waiting room. The provider reviewed the ACEs screening and made referrals as appropriate. Part three involved data collection and analysis. Responses were collected weekly for nine weeks. The responses collected will be analyzed using quantitative statistics. The expected outcome is to note progressive increase in screening activities and when appropriate, followed by referrals to community agencies and organizations. The project educated clinicians about ACEs and created awareness among clinicians in a primary care setting to mitigate potential negative life outcomes. Barriers to integrating ACEs screening included employees' absence of training, lack of confidence in the subject matter, limited time frame to complete the screening, and fear of damaging patient-provider relationships. Barriers were mitigated through employee training, repetitive implementation of ACEs screening, and therapeutic communication with patients. The CYW ACE-Q was reserved for those arriving early or on time for their annual wellness visit to allow adequate time for completion. Recommendations include incorporating the CYW ACE-Q into all primary care visits to further intervene with referrals thereby enhancing patients' overall quality of life.