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This field report describes the accessibility and perceived effectiveness of a free acupuncture program among a group of predominantly low-income Hispanic/Latino adults. Surveys, developed based on the Levesque Conceptual Framework of Access to Health Care, were administered to clients. Baseline (n = 245) and 6-week follow-up (n = 79) surveys were analyzed to document early program findings. A majority of clients were Hispanic/Latino (72.7%) and female (73.1%). Most reported their original pain complaint was treated very well/well (98.7%). Clients reported an average 1.2 points pain level decrease (scale 1-10) at follow-up (p < 0.0001). Early program results suggest this acupuncture program was accessible and well received by low-income Hispanics/Latinos.

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Treating patients with uncontrolled hypertension is a powerful intervention for reducing the risk of heart attack and stroke. Leveraging health information technology to identify patients with undiagnosed hypertension using algorithmic logic can be an effective approach for reaching hypertensive patients who may otherwise be overlooked. Despite evidence that this strategy can support favorable cardiovascular health outcomes in the safety-net healthcare setting, little is known about its implementation outside of targeted practice and research environments. In 2021-2022, Community Clinic Association of Los Angeles County and the Los Angeles County Department of Public Health collaborated on a mixed methods, organizational assessment of community health centers to better understand their practices and attitudes toward the use of algorithmic logic to identify patients with undiagnosed hypertension. Results from the assessment suggest that awareness and use of this approach are limited; numerous challenges are associated with its adoption and implementation.

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Demand for scaling and sustaining clinical services to improve health outcomes while minimizing costs is rising, particularly for patients dealing with major cardiovascular disease and stroke risk factors such as hypertension. Consequently, there is growing national and local interest in engaging pharmacists as part of the solution through the implementation of comprehensive medication management. To capitalize on this momentum, a team from the University of Southern California led the establishment of the California Right Meds Collaborative (CRMC) in 2019. CRMC aims to reduce the burden of uncontrolled chronic disease by advancing the role of pharmacists as team members in the health care system. This case study describes CRMC's structure and approach to developing value-based payment models and advancing the competency of pharmacists through training, continuous quality improvement, and technical assistance. In addition, this case study provides an overview of a CRMC pilot project wherein a local health plan tested a value-based payment model to deliver comprehensive medication management. The pilot underwent many iterative changes throughout its duration but ultimately was considered a success and adopted as part of standard practice. Lessons learned from this effort can help others leverage the availability of pharmacists to assist vulnerable populations in their communities.

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CONTEXT: In fall 2020, Community Clinic Association of Los Angeles County, in collaboration with the Los Angeles County Department of Public Health, launched a 3-year, cohort-based quality improvement (QI) coaching program to assist Federally Qualified Health Centers (FQHCs) in improving their clinical management of hypertension, high blood cholesterol, diabetes, and chronic kidney disease. PROGRAM: The QI program utilized a cohort-based coaching model in which 5 FQHCs were each assigned a practice transformation coach who provided them with guidance and support to monitor clinical quality measures. These measures were then used to facilitate changes and improvements in clinical workflows and approaches to patient care. To encourage peer learning and promote inter-organizational collaboration, the coaching team hosted quarterly cohort check-ins and an online group messaging board where the participating FQHCs could share lessons learned. Throughout the program, the FQHCs were provided trainings and resources to advance their clinical quality measures of choice. IMPLEMENTATION: To implement the program, each FQHC selected 2 clinical quality measures to focus on, completing a minimum of 1 Plan-Do-Study-Act cycle per year for each measure. Throughout, the coaches met regularly with FQHC staff to discuss progress, strategize on how best to address challenges encountered, and identify training or resource needs for their clinic sites. EVALUATION: To drive implementation of QI interventions and monitor overall progress, the FQHCs reported quarterly on the clinical quality measures being addressed. By program's end, all 5 FQHCs reached their 10% improvement goals. DISCUSSION: This QI coaching program allowed participating FQHCs to build new competencies and achieve measurable improvements in how they managed their patients' chronic diseases. This model of practice serves as a promising approach for achieving sustainable clinical improvements in these FQHCs.

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Despite the availability of effective treatments, hypertension control rates remain inadequate in the United States and locally in Los Angeles County. To address this health condition, QueensCare Health Centers developed and launched a team-based hypertension management program that was led by clinical pharmacists and designed to mitigate treatment barriers encountered at the system, provider, and patient levels. System- and provider-focused strategies included incorporating self-monitored blood pressure values into the electronic health record and retraining clinicians to regularly review these values; adding a community health worker to the disease management team; and utilizing clinical pharmacists to assess and titrate medications. Patient-focused strategies included tailoring education materials to reduce literacy and linguistic barriers; providing tailored one-on-one education and support; and providing blood pressure cuffs and pedometers. This multilevel intervention serves as a practical example of how team-based care can be optimized at a Federally Qualified Health Center.

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INTRODUCTION: Community-based health interventions often demonstrate efficacy in clinical trial settings but fail to be implemented in the real-world. We sought to identify the key operational and contextual elements of the Los Angeles Barbershop Blood Pressure Study (LABBPS), an objectively successful community-based health intervention primed for real-world implementation. LABBPS was a cluster randomized control trial that paired the barbers of Black-owned barbershops with clinical pharmacists to manage uncontrolled hypertension in Black male patrons, demonstrating a substantial 21.6 mmHg reduction in systolic blood pressure. Despite this success, the LABBPS intervention has not expanded beyond the original clinical trial setting. The aim of this study was to determine the facilitating and limiting factors to expansion of the LABBPS intervention. METHODS: We undertook a qualitative assessment of semi-structured interviews with study participants performed after trial completion. Interviews included a total of 31 participants including 20 (6%) of the 319 LABBPS program participants ("patrons"), 10 (19%) barbers, and one (50%) clinical pharmacist. The semi-structured interviews were focused on perceptions of the medical system, study intervention, and influence of social factors on health. RESULTS: Several common themes emerged from thematic analysis of interview responses including: importance of care provided in a convenient and safe environment, individual responsibility for health and health-related behaviors, and engagement of trusted community members. In particular, patrons reported that receiving the intervention from their barber in a familiar environment positively influenced the formation of relationships with clinical pharmacists around shared efforts to improve medication adherence and healthy habits. All interviewee groups identified the trust diad, comprising the familiar environment and respected community member, as instrumental in increasing health-related behaviors to a degree not usually achieved by traditional healthcare providers. DISCUSSION: In conclusion, participants of an objectively successful community-based intervention trial consistently identified key features that could facilitate wider implementation and efficacy: social trust relationships, soliciting insights of trust bearers, and consistent engagement in a familiar community setting. These findings can help to inform the design and operations of future community-based studies and programs aiming to achieve a broad and sustainable impact.

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BACKGROUND: The recent coronavirus pandemic accelerated the need to deliver pharmacy-related services remotely. OBJECTIVE: To describe experiences with providing comprehensive medication management (CMM) and other clinical services via telehealth by pharmacy type, before and during the COVID-19 pandemic. METHODS: An online survey of pharmacists, representing 27 pharmacies, was conducted to capture telehealth usage in three pharmacy types: independently owned, integrated into a clinical setting, and retail chain. A sub-analysis was performed to assess if providing CMM services via telehealth helped, resulted in no change, or worsened the care of different patient groups (e.g., those with diabetes, were low-income, aged 65+ years). RESULTS: During the pandemic, telehealth usage among independently owned pharmacies and those integrated into a clinical setting increased, but no change occurred among retail chain pharmacies. This usage increase in the first two pharmacy types occurred despite limited investments in connectivity-related resources to support telehealth services. Pharmacists from both independently owned pharmacies (63%) and those integrated into a clinical setting (89%) reported CMM via telehealth reached patients they would not otherwise have been able to reach during the pandemic. Most pharmacists/pharmacies found telehealth to be a feasible and acceptable method of delivering CMM. CONCLUSION: Pharmacists and pharmacies are now experienced with and have interest in continuing CMM via telehealth, even as the pandemic recedes. However, investments in telecommunications resources, training support, technical assistance, and continued telehealth reimbursement from health plans are needed to sustain this service delivery model.

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Bi-directional communication and referral pathways (BCRPs) between clinics and community-based organizations could promote well-being among vulnerable populations with complex and overlapping health and social needs. While BCRPs are promising, establishing them is complex, involving system and process changes across diverse organizational settings. To date, few models have been implemented or empirically tested. This article describes an innovation and planning project to build a BCRP, linking patients in safety net primary care clinics to a comprehensive suite of community-based health and wellness supports in Los Angeles. During a year-long process, a multi-sector team iteratively engaged data to facilitate learning and improvement. The project proceeded through three distinct, but overlapping, phases: (1) Discovery, (2) Systems Mapping, and (3) BCRP Re-design and Testing, which were coordinated through frequent collaborative meetings. By using a stepwise systems-informed approach to collect and examine data, the team was able to generate new change ideas, dispel assumptions, and make transparent and informed decisions. It was critical to have engagement from both internal partners with knowledge of "on-the-ground" practice realities, and external stakeholders with the fresh perspective needed to identify opportunities and define an improvement agenda. These efforts represent first steps towards implementing sustainable BCRPs and realizing their full potential to dynamically bridge the community-clinic divide and improve population health. Other jurisdictions can learn from and adapt the practical data-driven approach used in Los Angeles to build BCRPs that will be thoroughly operationalized, consistently implemented, and optimized within their own unique contexts.

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CONTEXT: The coupling of health care services with complementary resources that address unmet social needs is a progressively popular approach for improving health outcomes among low-income populations. Community health workers are increasingly recognized as a helpful intermediary for clients navigating community and clinical services. PROGRAM: The Wellness Center at the Historic General Hospital in East Los Angeles employs a team of community health workers, referred to as Health Navigators, who are trained to link low-income clients to resources such as chronic disease management programs, food pantries, free or low-cost legal aid, health insurance enrollment, group fitness classes, and counseling and peer support services. IMPLEMENTATION: The Center's model of practice has evolved over time, continuously increasing the breadth and depth of services provided by the Health Navigator team. Its goal has been to address clients' unmet social needs while optimizing their health outcomes through the building of stronger community-clinical linkages. EVALUATION: A program review showed that Health Navigators serve as a critical bridge for clients navigating a complex network of health and social services. They actively engage, recruit, and deliver services to clients. Since 2014, the Health Navigator team has connected more than 28 000 unique clients to resources for health and well-being. DISCUSSION: By using Health Navigators to assist clients with community resource engagement, the Center has prototyped and promoted an approach that complements clinical care, strengthening the community-clinical linkages that are needed to meaningfully manage chronic disease outside of the hospital or clinic setting.

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As part of federal and local efforts to increase access to high quality, clinical preventive services (CPS) in underserved populations, the Los Angeles County Department of Public Health (DPH) partnered with six local health system and community organization partners to promote the use of team care for CPS delivery. Although these partners were at different stages of organizational capacity, post-program review suggests that each organization advanced team care in their clinical or community environments, potentially affecting >250,000 client visits per year. Despite existing infrastructure and DPH's funding support of CPS integration, partner efforts faced several challenges. They included lack of sustainable funding for prevention services; limited access to community resources that support disease prevention; and difficulties in changing health-care provider behavior. Although team care can serve as a catalyst or vehicle for delivering CPS, downstream sustainability of this model of practice requires further state and national policy changes that prioritize prevention. Public health is well positioned to facilitate these policy discussions and to assist health system and community organizations in strengthening CPS integration.

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In 2014, the Los Angeles County Department of Public Health received federal funding to improve the prevention and control of hypertension in the population through team-based health care delivery models, such as pharmacist-led medication therapy management. To inform this work, the department conducted a 3-part needs assessment consisting of 1) a targeted context scan of regional policies and efforts, 2) a key stakeholder survey, and 3) a public opinion internet-panel survey of Los Angeles residents. Results suggest that political will and professional readiness exists for expansion of pharmacist-led medication management strategies in Los Angeles. However, several infrastructure and economic barriers, such as a lack of sufficient payment or reimbursement mechanisms for these services, impede progress. The department is using assessment results to address barriers and shape efforts in scaling up pharmacist-led programming in Los Angeles.

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BACKGROUND: After reaching an all time low in 2000, the rate of syphilis in the United States has been steadily increasing. Parallel benchmarking of the disease's mortality burden has not been undertaken. METHODS: Using ICD-10 classification, all syphilis-related deaths in the national Multiple Cause of Death dataset were examined for the period 2000-2014. Descriptive statistics and age-adjusted mortality rates were generated. Poisson regression was performed to analyze trends over time. A matched case-control analysis was conducted to assess the associations between syphilis-related deaths and comorbid conditions listed in the death records. RESULTS: A total of 1,829 deaths were attributed to syphilis; 32% (n = 593) identified syphilis as the underlying cause of death. Most decedents were men (60%) and either black (48%) or white (39%). Decedents aged ≥85 years had the highest average mortality rate (0.47 per 100,000 population; 95% confidence interval [CI], 0.42-0.52). For the sampled period, the average annual decline in mortality was -2.90% (95% CI, -3.93% to -1.87%). However, the average annual percent change varied across subgroups of interest. CONCLUSIONS: Declines in U.S. syphilis mortality suggest early detection and improved treatment access likely helped attenuate disease progression; however, increases in the disease rate since 2000 may be offsetting the impact of these advancements.

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The Los Angeles County Department of Public Health teamed with a culturally tailored, community-based organization to augment their hepatitis B screening program with blood pressure assessments. During 6 months, 2,298 people were served by the program; descriptive statistics and models were generated to describe demographics and screening and assessment results. Despite the program having good reach, sustainability was challenging. This experience draws attention to the need for invested desire to change at both the organizational and patient levels to sustain interdisciplinary provision of clinical preventive services.

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OBJECTIVE: To examine behavioural intention to reduce soda consumption after exposure to the Choose Health LA 'Sugar Pack' campaign in Los Angeles County, California, USA. DESIGN: A cross-sectional street-intercept survey was conducted to assess knowledge, attitudes, health behaviours and behavioural intentions after exposure to the 'Sugar Pack' campaign. A multivariable regression analysis was performed to examine the relationships between the amount of soda consumed and self-reported intention to reduce consumption of non-diet soda among adults who saw the campaign. SETTING: Three pre-selected Los Angeles County Metro bus shelters and/or rail stops with the highest number of 'Sugar Pack' campaign advertisement placements. SUBJECTS: Riders of the region's Metro buses and railways who were the intended audience of the campaign advertisements. RESULTS: The overall survey response rate was 56 % (resulting n 1041). Almost 60 % of respondents were exposed to the advertisements (619/1041). The multivariable logistic regression analysis suggested that the odds of reporting intention to reduce soda consumption among moderate consumers (1-6 sodas/week) were 1·95 times greater than among heavy consumers (≥1 soda/d), after controlling for clustering and covariates. Respondents with less than a high-school education and who perceived sugary beverage consumption as harmful also had higher odds; in contrast, respondents aged ≥65 years had lower odds. CONCLUSIONS: Results suggest that future campaigns should be tailored differently for moderate v. heavy consumers of soda. Similar tailoring strategies are likely needed for younger groups, for those with less educational attainment and for those who do not perceive consumption of soda as harmful.

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OBJECTIVE: Policies to promote active transportation are emerging as a best practice to increase physical activity, yet relatively little is known about public opinion on utilizing transportation funds for such investments. This study sought to assess public awareness of and support for investments in walking and biking infrastructure in Los Angeles County. METHOD: In the fall of 2013, the Los Angeles County Department of Public Health conducted a telephone survey with a random sample of registered voters in the region. The survey asked respondents to report on the presence and importance of walking and biking infrastructure in their community, travel behaviors and preferences, and demographics. RESULTS: One thousand and five interviews were completed (response rate 20%, cooperation rate 54%). The majority of participants reported walking, biking, and bus/rail transportation investments as being important. In addition, participants reported a high level of support for redirecting transportation funds to active transportation investment - the population average was 3.28 (between 'strongly' and 'somewhat' support) on a 4 point Likert scale. CONCLUSION: Voters see active transportation infrastructure as being very important and support redirecting funding to improve the infrastructure. These findings can inform policy-decisions and planning efforts in the jurisdiction.

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PURPOSE: To assess the impact of the Choose Less, Weigh Less portion size health marketing campaign. DESIGN: A mixed-methods, cross-sectional evaluation. SETTING: A quantitative Internet panel survey was administered through an online sampling vendor and qualitative interviews were conducted by street intercept. SUBJECTS: The panel survey included 796 participants, weighted to represent Los Angeles County. Street intercept interviews were conducted with 50 other participants. INTERVENTION: The Choose Less, Weigh Less campaign included print media on transit shelters, bus and rail cars, and billboards; radio and online advertising; and Web site content and social media outreach. MEASURES: The panel survey measured self-reported campaign exposure and outcomes, including knowledge of recommended daily calorie limits, attitudes toward portion sizes, and intent to reduce calories and portion size. Intercept interviews assessed campaign appeal, clarity, and utility. ANALYSIS: Weighted survey data were analyzed using logistic regression to assess the association between campaign exposure and outcomes. Interview data were analyzed for themes. RESULTS: The campaign reached 19.7% of the Los Angeles County population. Significant differences were seen for 2 of the 10 outcomes assessed. Participants who saw the campaign were more likely than those who did not to report fast-food portion sizes as being too large (adjusted odds ratio [Adj. OR]: 1.89; 95% confidence interval [CI]: 1.16, 3.07) and intention to choose a smaller portion (Adj. OR: 1.99; 95% CI: 1.20, 3.31). Qualitative data revealed three themes about appeal, clarity, and utility. CONCLUSION: Health marketing efforts targeting portion size can have relatively broad reach and limited but positive impacts on consumer attitudes and intent to select smaller portions.

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Cryptococcosis is an invasive mycotic infection primarily affecting immunocompromised individuals. The objective of this study was to describe cryptococcosis mortality and associated medical conditions in the US for the period 2000-2010. Cryptococcosis-related deaths were identified from the national multiple-cause-of-death dataset. Mortality trends and comparison analyses were performed on overall cases of cryptococcosis and by subset [i.e. clinical manifestations of disease and human immunodeficiency virus (HIV) status]. A matched case-control analysis was also conducted to describe the associations between this disease and comorbid medical conditions. A total of 3210 cryptococcosis-related deaths were identified. Cerebral cryptococcosis was the most commonly reported clinical manifestation of the disease. Approximately one-fifth of the decedents (n = 616) had a co-diagnosis of HIV. Mortality rates were highest among men, blacks, Hispanics, Native Americans and older adults. Poisson regression analysis indicated a 6.52% annual decrease in mortality rates for the study period. HIV (MOR = 35.55, 95% CI 27.95-45.22) and leukaemia (MOR = 16.10, 95% CI 11.24-23.06) were highly associated with cryptococcosis-related deaths. Cryptococcosis mortality declined significantly during 2000-2010. However, the disease continues to cause appreciable mortality in the US. With the majority of decedents having no HIV co-diagnosis, there is still much to be learned about the epidemiology of this mycosis.

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Although consumption of sugar-sweetened beverages (SSBs) is associated with many negative health outcomes, including obesity, diabetes, and cardiovascular disease, the relationship between consumer nutritional knowledge and the amount consumed is poorly understood. The objective of this study was to examine the relationship between knowledge of daily calorie recommendations and the amount of SSBs consumed in a large, economically and racially diverse sample of adults recruited at selected Metro subway and bus shelters in Los Angeles County. In June 2012, the Los Angeles County Department of Public Health conducted street intercept surveys to assess food attitudes and consumption behaviors and public opinions related to a recent 8-week health marketing campaign targeting SSB consumption. Descriptive and comparative analyses were conducted, including a negative binomial regression model, to examine the relationship between knowledge of the daily calorie recommendations and the amount of SSBs consumed. Among survey respondents (n = 1,041), less than one third correctly identified the daily calorie recommendations for a typical adult. After controlling for sociodemographics and weight status, respondents who correctly identified recommended calorie needs reported, on average, drinking nine fewer SSBs per month than respondents who did not. Results suggest that efforts to reduce SSB consumption might benefit from the inclusion of educational interventions that empower consumers to make healthy choices.

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