Examining Social Determinates of Health in Adult Sickle Cell Disease Patients

Background:Patients with Sickle Cell Disease (SCD) experiencing vaso-occlusive pain crisis in the U.S., have hospitalization readmission rates of 33% within 30 days, and 50% within 90 days. Vaso-occlusive crises (VOC) creates a healthcare burden on a vulnerable population plagued by pain, mental illness, social determinants of health, and racial disparities. Patients often present depressed, withdrawn, oppositional and guarded with severe pain that makes it challenging to screen, treatment plan and coordinate outpatient follow-up care after discharge. Treating providers can experience apprehension when engaging patient attitudes of anger and depression while managing complex diagnoses (e.g., acute chest syndrome, avascular necrosis, anemia, cerebrovascular accidents)and meeting patient's opioid pain needs. We created an institutional inpatient interprofessional team to provide behavioral health and lifestyle medicine consultations for SCD patients while admitted to the inpatient unit. The Lifestyle Medicine (LM) Intensivist Fellow and Psychology doctoral students providing integrated behavioral health (IBH) worked with physician team to create a comprehensive approach to treatment for patients admitted for SCD. The aim of this project was to demonstrate the impact of these consultations in addressing social determinants of health (SDOH) and mental health challenges in SCD, in order to optimize discharge planning and continued outpatient support.

Methods:All patients with SCD in Spring, 2024 received an automatic request for a LM Consult. The LM Fellow then alerted the IBH team. Both consultations happened for the patients before discharge. Consults included review and discussion of reported SDOH that was assessed by nursing staff. The PHQ-2 depression screening tool and nursing intake interview indicated LM concerns (physical activity, smoking, alcohol use, sleep) as well as mental health concerns (social connections, depression, stress). The patient concerns were examined in a chart audit of all patients seen on the inpatient service in one year (2023-2024) before and after the integrated consults were implemented. Data included demographics, consults placed with LM and IBH, SDOH risk factor and referrals to the SCD Center on campus for further care coordination with support groups, socials, and low-cost psychotherapy. After the consultations, treatment plans were created to reflect LM pillars (nutrition, sleep, physical activity, stress management, substance use abstinence, and healthy social connections) to reduce disease progression and burden by treating the whole person.

Results:A chart review on the 22 SCD patients admitted to the inpatient service during a 12-month period. Each patient had 2 to 3 readmissions in a year. The SDOH risks reported were transportation (15%), food insecurity (25%), substance use (30%), financial strains (40%), stress management (45%), deficits in healthy social connections (60%), and impairments in physical activity (70%). After implemented the automatic consultations for the integrated team there was a 61.5% increase in consults and a 30% increase in referrals to the SCD Center for outpatient care.

Conclusion:Our study found that there was underutilization of integrated consultations and high rates of readmissions on this service. Referrals to IBH initially was a verbal request that was not trackable. With a single automatic LM consultation both LM and IBH consultations could be completed and tracked in the EMR. This allowed us to dramatically increase integrated consultations and to understand the needs of patients admitted for SCD crisis on our service. Future studies should track outpatient follow-up and readmission rates over time of this patient population. Additional goals will incorporate increased screening for depression, anxiety, stress of somatic complaints to improve referrals for care as well as increased use of buprenorphine transdermal patches over excessive oral opioid use with increased risk of mortality.This project was funded by the HRSA PCTE-RTMB grant.

References:

Colombatti, R., Hoppe, C., Vichinsky, E., Hamdy, M., Akinsete, A., Davis, M., Bello-Manga, H., Okpala, I., Silva Pinto, A., Inati, A. (2022). Insights into vaso-occlusive rises-related readmissions in patients with SCD across geographic regions. Blood; 140 (Supplement 1): 5453-5455. https://doi.org/10.1182/blood-2022-167948

No relevant conflicts of interest to declare.