P-O11 Surgical Ambulatory Care: Reducing surgical admissions whilst maintaining patient satisfaction. Experiences over a four year period

Background The tri-association document; The future of Emergency General Surgery (2015) has a number of key recommendations for the provision of emergency general surgical care. Key recommendations include for senior surgeons to triage referrals and to utilise a “hot clinic” model. Prior to 2016 in the authors’ hospital, all General Practitioner/community referrals were formally admitted to General Surgery. A consultant led ambulatory clinic with dedicated Advanced Nurse Practitioner support was instituted in October 2016. It offers preliminary assessment, phlebotomy and priority access to routine imaging modalities. The clinic is located in a tertiary hospital serving a population of 500,000. Methods A retrospective audit of prospectively collected referral and outcome lists for the Surgical Ambulatory clinic was conducted for the time periods of October 2016 to June 2021. The two primary outcomes were defined as admission to the General Surgical ward and discharge to the community/non-general surgical specialty. Secondary outcomes for patient satisfaction were measured by randomly distributing over a six week period a patient satisfaction survey. The survey was designed in accordance with trust guidance, was anonymous and would cover multiple lead Consultant encounters as a cohort. Results In total, 9069 patients presented to the surgical ambulatory clinic over a period of 44 months. 2347 (26%) were admitted to the General Surgical ward whilst 6717 (74%) were discharged directly from the clinic. 71% of survey responders rated their experiences of the ambulatory clinic as “Excellent”, 19% “Very Good”, 0.5% “Good” and 0.5% “Poor.” Conclusions The introduction of an ambulatory care model has demonstrated a marked reduction in surgical admissions whilst remaining favourable to the patient populace. This has a direct impact on overall bed occupancy rates. In the age of COVID-19, efforts must me made to reduce the the number of potential inpatient interactions to protect those most at risk. A reduced admission and bed occupancy rate will contribute to the reduction of this risk.

Evaluation of a social determinants of health screening questionnaire and workflow pilot within an adult ambulatory clinic

Background There is increased recognition in clinical settings of the importance of documenting, understanding, and addressing patients’ social determinants of health (SDOH) to improve health and address health inequities. This study evaluated a pilot of a standardized SDOH screening questionnaire and workflow in an ambulatory clinic within a large integrated health network in Northern California. Methods The pilot screened for SDOH needs using an 11-question Epic-compatible paper questionnaire assessing eight SDOH and health behavior domains: financial resource, transportation, stress, depression, intimate partner violence, social connections, physical activity, and alcohol consumption. Eligible patients for the pilot receiving a Medicare wellness, adult annual, or new patient visits during a five-week period (February-March, 2020), and a comparison group from the same time period in 2019 were identified. Sociodemographic data (age, sex, race/ethnicity, and payment type), visit type, length of visit, and responses to SDOH questions were extracted from electronic health records, and a staff experience survey was administered. The evaluation was guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Results Two-hundred eighty-nine patients were eligible for SDOH screening. Responsiveness by domain ranged from 55 to 67%, except for depression. Half of patients had at least one identified social need, the most common being stress (33%), physical activity (22%), alcohol (12%), and social connections (6%). Physical activity needs were identified more in females (81% vs. 19% in males, p < .01) and at new patient/transfer visits (48% vs. 13% at Medicare wellness and 38% at adult wellness visits, p < .05). Average length of visit was 39.8 min, which was 1.7 min longer than that in 2019. Visit lengths were longer among patients 65+ (43.4 min) and patients having public insurance (43.6 min). Most staff agreed that collecting SDOH data was relevant and accepted the SDOH questionnaire and workflow but highlighted opportunities for improvement in training and connecting patients to resources. Conclusion Use of evidence-based SDOH screening questions and associated workflow was effective in gathering patient SDOH information and identifying social needs in an ambulatory setting. Future studies should use qualitative data to understand patient and staff experiences with collecting SDOH information in healthcare settings.

Virtual Care during the COVID-19 Pandemic Among Patients with Hematologic Malignancies - a Princess Margaret Cancer Centre Experience

Background: The use of virtual care rapidly increased during the COVID-19 pandemic to provide adequate care for patients while minimizing contact. Studies in solid tumors show high rates of patient satisfaction with virtual care as well as cost-savings. However, little is known about the application of virtual care in malignant hematology, which includes a heterogenous population of patients often at increased risk of infection. Understanding when virtual care or a hybrid model can be used is crucial for comprehensive patient care. Methods: A retrospective review of patients with hematologic malignancies receiving care at Princess Margaret (PM) Cancer Centre in Toronto, Canada from October 2019 to March 2021 was performed. The primary objective was to describe the use of virtual care at three time points: prior to the pandemic, during the initial months of the pandemic, and beyond the initial months. Patients were included in the analysis if they had a clinical visit for their hematologic malignancy. Patients were excluded if they were presenting for treatment-related visits or blood count checks. All methods of virtual care, including phone visits and teleconferencing, were included in the analysis. Patient satisfaction with virtual care was assessed using responses to the Your Voice Matters survey administered from September 2020 to April 2021, a provincial survey of patient-reported experience. Results: A total of 93472 visits for 23162 patients were identified at PM from October 2019 to March 2021 (55% of visits for ambulatory clinic appointments). Mean age was 60 years (range 18-103 years) and 45% of patients were female (N = 23162). Ambulatory clinic appointments for new consultation or follow-up care were done in the following clinics: autologous or allogeneic bone marrow transplant (21%, N = 10 747), cellular therapy (0.2%, N = 82), leukemia (26%, N = 13419), lymphoma (32%, N = 16427) and myeloma (21%, N = 10711). From October 2019 to March 2020, there were 14512 visits, of which nearly 100% were in-person (N = 14511). From March 1 2020 to September 1 2020, there were 19179 total visits, of which 36% were virtual, with the majority of visits by phone (6325 phone visits and 567 video visits). From September 1 2020 to March 1 2021, there was a small decrease in the use of virtual care (p&lt;0.01), but utilization of phone and video visits continued to be used for 30% of patients (N=17695 total visits; 4964 phone visits and 327 video visits). Virtual care was most often used for patients with myeloma (46%) or lymphoma (36%), as shown in Figure 1. A total of 75 survey responses for patients with hematologic malignancies followed at PM were available. 67 responses (89.3%) were from patients, with the remaining from caregivers. 47 visits (62.7%) were in-person, 26 visits (34.7%) were virtual, and 2 visits (2.7%) did not have the visit type available. Survey results are shown in Table 1.Results for in-person and virtual visits were very similar, with both groups reporting that their provider listened to their concerns and involved them in making treatment decisions. There was a trend toward providers discussing physical symptoms more for patients who had virtual visits (mean score of 4.73/5 for virtual visit compared to a mean score of 4.36/5, p=0.10). Data on next visit type preference was available for 25 patients who had a virtual visit and 46 patients who had an in-person visit. For patients who had a virtual visit, 36% preferred a repeat virtual visit with 56% having no preference and only 7.7% preferring an in-person visit. For patients who had an in-person visit, 33% preferred their next visit to be virtual, with only 24% preferring their next visit to be in-person and the remaining 43% having no preference. Conclusion: The use of virtual care increased substantially during the COVID-19 pandemic and persisted into 2021 with high rates of patient and provider satisfaction. The highest uptake of virtual care was for patients with myeloma or lymphoma. There were no significant differences in patient satisfaction scores for virtual visits compared to in-person visits, and one third of patients preferred a virtual visit after an in-person visit. These findings suggest that virtual care is a feasible and preferred tool for delivering care to a substantial proportion of patients with hematologic malignancies. Further work is needed to determine how to optimally integrate virtual care for specific patient populations. Figure 1 Figure 1. Disclosures Prica: Astra-Zeneca: Honoraria; Kite Gilead: Honoraria.

874. Impact of Telehealth in HIV Ambulatory Clinic during COVID-19 Pandemic Impact of Telehealth in HIV Ambulatory Clinic during COVID-19 Pandemic

Background HIV outpatient in-person (IN-P) visits were limited during the COVID-19 pandemic, and most patients (pts) were cared for remotely through telehealth (TELE). We sought to evaluate the impact of TELE on HIV infected pts during the pandemic compared to the pre-pandemic IN-P care. Methods Retrospective chart review of pts in an outpatient HIV clinic, study period 03/30/2019 to 03/29/2021. Two periods were defined: pre-COVID (Pre-CO) 3/30/2019 to 3/29/2020 and COVID (CO) 3/30/2020 to 3/29/2021. Data was collected on demographics, HIV risk, type of encounter, number of encounters, CD4, HIV Viral loads (VL) at first, and last visit, treatment regimen information. HIV VL &lt; 200 copies/ml was considered as undetectable. Results A total of 607 pts were evaluated. Mean age 51years; (Range-20-84). Male 306 (50.4%), African American 545(90%), Hispanic 50 (8.2%), white 9 (1.5%), Asian 3(0.5%). HIV risk: heterosexual 437(72%), male sex with male 118(19.4%), intravenous drug use 8 (1.3%). In the Pre-CO period, 530 pts were seen as IN-P; in the CO period 606 pts were encountered of which 304 (50.2%) were TELE visits, 89(14.7%) IN-P, 213(35%) had both TELE and IN-P encounters. Mean number of encounters were 2.59 in the Pre-CO and 2.46 during CO. The number of new pts in the Pre-CO were 36 (7%) vs. 52(8.6%) in the CO (p=0.26). During the pre-CO, 373 pts had CD4 measured at first and last visits, 353(95%) at the first visit and 352 (94.3%) at the last visit had CD4 counts ≥ 200/uL (p=.87); 373 pts had a VL done at first and last visits, 330 (88.5%) at the first visit and 337(90.3%) at last visit were undetectable (p=0.41). During CO, 445 pts had CD4 measured at first and last visits, 402 (90.3%) at the first visit and 445(94.2%) at the last visit had CD4 count ≥200/uL (p=0.03); 448 pts had VL measured at first and last encounters, 389(87%) at the first visit and 417(93%) in the last visit were undetectable (p=0.002). Antiretroviral changes occurred in 29% in the Pre-Co compared to 19% in the CO (p=0 .32). Conclusion In our clinic, more pts were cared for during the CO period compared to the Pre-CO period. Significantly, more pts had undetectable HIV VL during CO period. At least one TELE visit was utilized by over ¾ of the pts. TELE has a potentially important role in future HIV care without compromising patient outcomes. Disclosures All Authors: No reported disclosures

EP.FRI.574 Screening tool to improve patient referral to acute surgical care from Emergency Department

Introduction The study aimed to audit the appropriateness of surgical referrals to general surgery; and, secondly, to devise a screening tool for use in the emergency department to screen patients that are safe to be discharged and to be seen in surgical ambulatory clinics. Methods The first phase of the study was an audit to check appropriateness of the surgical referrals (1st-18th February 2020). In the second part, a screening tool questionnaire was prospectively tested (1st February-24th March 2020) on the surgical referrals. The accuracy of the screening tool outcome was compared to actual patient consultation outcomes. The sensitivity and specificity of the questionnaire was assessed using an ROC curve. Results In the first audit, 68.9% patients were discharged on the same day with or without follow up in the ambulatory surgical clinic. In the prospective questionnaire phase of the study, there were 98 patients and the most common presentation was abdominal pain (n = 60) followed by urological symptoms (n = 11), symptoms of hernia complication (n = 10), abscess (n = 7) and testicular pain (n = 2). The sensitivity and specificity of the screening tool was 60.7% and 100%, respectively with overall accuracy being 88.82%. The area under the ROC curve was 0.80. Conclusion A large proportion of the patients referred to the acute surgical unit can be deferred and seen in the ambulatory clinic. The screening tool has the potential to screen patients who can be seen in the ambulatory clinic and safe to identify patients who require urgent surgical admission.

Integrating Interprofessional Trainees into a Complex Care Program for Veterans Experiencing Homelessness: Effects on Health Services Utilization

PURPOSE High-quality, comprehensive care of vulnerable populations requires interprofessional ambulatory care teams skilled in addressing complex social, medical, and psychological needs. Training health professionals in interprofessional settings is crucial for building a competent future workforce. The impacts on care utilization of adding continuity trainees to ambulatory teams serving vulnerable populations have not been described. We aim to understand how the addition of interprofessional trainees to an ambulatory clinic caring for Veterans experiencing homelessness impacts medical and mental health services utilization. METHODS Trainees from five professions were incorporated into an interprofessional ambulatory clinic for Veterans experiencing homelessness starting in July 2016. We performed clinic-level interrupted time series (ITS) analyses of pre- and post-intervention utilization measures among patients enrolled in this training continuity clinic, compared to three similar VA homeless clinics without training programs from October 2015 to September 2018. RESULTS Our sample consisted of 37,671 patient- months. There was no significant difference between the intervention and comparison groups’ post-intervention slopes for numbers of primary care visits (difference in slopes =−0.16 visits/100 patients/month; 95% CI −0.40, 0.08; p=0.19), emergency department visits (difference in slopes = 0.08 visits/100 patients/month; 95% CI −0.16, 0.32; p=0.50), mental health visits (difference in slopes = −1.37 visits/month; 95% CI −2.95, 0.20; p= 0.09), and psychiatric hospitalizations (−0.005 admissions/100 patients/month; 95% CI −0.02, 0.01; p= 0.62). We found a clinically insignificant change in medical hospitalizations. CONCLUSIONS Adding continuity trainees from five health professions to an interprofessional ambulatory clinic caring for Veterans experiencing homelessness did not adversely impact inpatient and outpatient care utilization. An organized team-based care approach is beneficial for vulnerable patients and provides a meaningful educational experience for interprofessional trainees by building health professionals’ capabilities to care for vulnerable populations.

Associations of Telemedicine vs. In-Person Ambulatory Care Visits on Cancellation Rates and 30-Day Follow-Up Hospitalizations and Emergency Department Visits

Importance: Studies have shown that telemedicine use in specific conditions can promote continuity of care, decreases healthcare costs, and can potentially improve clinical outcomes. The COVID-19 pandemic forced many healthcare systems to expand access for patients using telemedicine, but little is known about cancellation frequencies in telemedicine vs. in-person appointments and its impact on clinical outcomes. Objective: Compare ambulatory clinic cancellation rates, 30-day inpatient hospitalizations rates, and 30-day emergency department visit rates between in-person and video telemedicine appointments, and examine differences in cancellation rates by age, race/ethnicity, gender, and insurance. Design: A retrospective cohort study. Setting: The largest academic healthcare system in the state of Georgia with ambulatory clinics in urban, suburban and rural settings. Participants: Adults scheduled for an ambulatory clinic appointment from June 2020 to December 2020 were included. Each appointment was identified as either a video telemedicine or in-person clinic appointment. Demographics including age, race, ethnicity, gender, primary insurance, and comorbidities were extracted from the electronic medical record. Main Outcomes and Measures: The primary process outcome was ambulatory clinic cancellation rates. The primary clinical outcomes were 30-day hospitalization rates and 30-day emergency department visit rates. Multivariable logistic regression was used to assess differences in the clinical outcomes between appointment types.

Intersectionality and Diabetes in a Population of an Ambulatory Clinic, Quito-Ecuador.

Diabetes Mellitus is a noncommunicable chronic disease, caused by the hormonal imbalance of insulin and glucose; it produces premature mortality, morbidity, and disability. A good metabolic control requires changes of personal habits and attitudes that are affected by social environment.Objective: to identify sociodemographic factors (gender, age, scholarity, civil status and insurance type) that affects metabolic control of type 2 diabetes in a specific population of an ambulatory clinic of Quito-Ecuador.Material and method: This investigation is a cross sectional study from the data taken of the first semester of the year 2018 of patients with Diabetes (ICD-10 E10-E14) from an ambulatory clinic in Quito.Results Among the data analyzed there was found association between age, gender, scholarity and insurance type with metabolic control, despite women have worse metabolic control with higher means of triglycerides, total cholesterol, LDL cholesterol, Systolic blood pressure, diastolic blood pressure and body mass index. There was a statistically significant relationship between the control of glycosylated hemoglobin (HbA1c) with age group under 65 and scholarity.Conclusion DM is a disease that affects the most vulnerable populations: lower socioeconomic status, lower level of education and greater poverty. The prognosis depends on the metabolic control that is influenced by structural and intermediate determinants of health. Traditionally, the vulnerable groups have been exposed to a greater physical and psychosocial risk that increases susceptibility to inadequate metabolic control that are related to intersectionality. Inequalities in disadvantaged population increase the risk factors for complications and premature mortality. The management of this pathology requires an integrative approach.