What can we do when the smoke rolls in? An exploratory qualitative analysis of the impacts of rural wildfire smoke on mental health and wellbeing, and opportunities for adaptation

Background Extreme, prolonged wildfire smoke (WFS) events are becoming increasingly frequent phenomena across the Western United States. Rural communities, dependent on contributions of nature to people’s quality of life, are particularly hard hit. While prior research has explored the physical health impacts of WFS exposure, little work has been done to assess WFS impacts on mental health and wellbeing, or potential adaptation solutions. Methods Using qualitative methods, we explore the mental health and wellbeing impacts experienced by community members in a rural Washington State community that has been particularly hard hit by WFS in recent years, as well as individual, family, and community adaptation solutions. We conducted focus groups with residents and key informant interviews with local health and social service providers. Results Participants identified a variety of negative mental health and wellbeing impacts of WFS events, including heightened anxiety, depression, isolation, and a lack of motivation, as well as physical health impacts (e.g., respiratory issues and lack of exercise). Both positive and negative economic and social impacts, as well as temporary or permanent relocation impacts, were also described. The impacts were not equitably distributed; differential experiences based on income level, outdoor occupations, age (child or elderly), preexisting health conditions, housing status, and social isolation were described as making some residents more vulnerable to WFS-induced physical and mental health and wellbeing challenges than others. Proposed solutions included stress reduction (e.g., meditation and relaxation lessons), increased distribution of air filters, development of community clean air spaces, enhancing community response capacity, hosting social gatherings, increasing education, expanding and coordination risk communications, and identifying opportunities for volunteering. Findings were incorporated into a pamphlet for community distribution. We present a template version herein for adaptation and use in other communities. Conclusions Wildfire smoke events present significant mental health and wellbeing impacts for rural communities. Community-led solutions that promote stress reduction, physical protection, and community cohesion have the opportunity to bolster resilience amid this growing public health crisis.

Exploring the Experiences of Transgender and Gender Diverse Adults in Accessing a Trans Knowledgeable Primary Care Physician

Transgender and gender diverse individuals face a variety of barriers when attempting to access healthcare, from discrimination to lack of access to lack of knowledgeable providers. Using data from the 2015 United States Trans Survey (N = 27,715), this study looks at the differences within the TGD population regarding having seen a doctor in the past year, having a primary care provider, and having a primary care provider who is knowledgeable about trans health. Logistic regressions indicate that even within an all transgender and gender diverse sample, a variety of identities and experiences are related to increased or decreased likelihood of each of these outcomes, with significant differences across gender, race/ethnicity, age, sexual orientation, disability status, educational attainment, annual income, disability status, religiosity, military status, overall health, housing status, and insurance coverage. Not only should there be an effort to support transgender and gender diverse individuals in accessing care, but there is a clearly indicated need for additional education for healthcare providers, especially those doing primary care, on how to offer knowledgeable, affirming, and intersectional care to their patients.

Examining Mental and Physical Health Status Among Sandwich Generation Caregivers

With a sample of 54,076 caregivers, the Behavioral Risk Factor Surveillance System (BRFSS, 2015-2017) provides an opportunity to assess the impact of caregiving on U.S. adults varying in age, gender, and race. We focused on sandwich generation (SG) caregivers, aged 30-59, with childcare and eldercare responsibilities (n=8,805). In multivariate regression models of mental and physical health, we evaluated the association of age, gender, race and caregiving factors controlling for marital status, education, housing status, income, employment status, and self-rated health status. SG caregivers were predominantly female (65.6%), white (69.6%), black (13%) and were caring for a parent/parent-in-law (50%) or another relative (26.4%). Age, gender, and race were associated with mental health outcomes such that SG caregivers who were younger (aged 30-39), female, and white reported poorer mental health during the past month (p<.05). Older (aged 50-59), female, and white SG caregivers reported poorer physical health during the past month (p<.05). Caregiving factors were not associated with mental health, but SG caregivers who had been providing care for a longer period of time were more likely to report poor physical health in the past month. Finally, education, income, employment, housing status, and self-rated health status were statistically significant covariates in both models (p<.05). These findings demonstrate that young caregivers are at risk for poor mental health; older caregivers for poor physical health. Being female, white, with lower socioeconomic status is associated with poor mental and physical health. Future research should address the unique needs of SG caregivers with dual caregiving responsibilities.

188. Outcomes After Implementing the OPTIONS-DC Multidisciplinary Care Conference for Patients with Substance Use Disorders and Severe Bacterial Infections

Background Hospitalizations for patients with severe bacterial infections (SBI) and substance use disorders (SUDs) are increasing. To address the unique treatment challenges for these patients and balance appropriate medical therapy with patient goals, we implemented the OPTIONS-DC, a structured multidisciplinary discharge planning conference. All patients with SBI and SUD at our institution qualify for an OPTIONS-DC. Methods We performed a retrospective case-control study to evaluate differences and describe outcomes in patients who received an OPTIONS-DC compared to those who did not. Admissions were included if the patient was diagnosed with a SUD, a SBI requiring at least 2 weeks of antibiotics, consultation by infectious diseases and addiction medicine, and who were admitted between February 2018 and March 2020 (following implementation of OPTIONS-DC conferences). Patients were excluded for infected prosthetic material, pregnancy, or non-bacterial infection. Results 173 admissions qualified for inclusion and 73 had at least one OPTIONS-DC. Unstable housing and psychiatric disease were common (table 1). Opioid and methamphetamine use disorders were most common and almost all SUDs were severe. Patients who received an OPTIONS-DC had less medical comorbidities, less unstable housing, and were more likely to have an opioid use disorder, use more than one substance, start MAT while inpatient, and have vertebral osteomyelitis or epidural abscess (table 2). Patients who had a conference had similar proportions of unexpected discharges (13.7% vs 17%), but a higher proportion of treatment completion (83.6% vs 69%), more days of antibiotic therapy remaining after discharge (13.9 vs 9.8 days), were more likely to discharge to an outpatient setting with family or medical support (30% vs 9%), and more likely to complete their antibiotic course with a long-acting injectable (27.4% vs 9%)(table 3). Conclusion Not all eligible patients received an OPTIONS-DC and there were significant differences in substances used, housing status and type of infections between those groups. Descriptive data suggest that OPTIONS-DC may reduce the duration of inpatient antibiotic treatment and increase likelihood of completion of antibiotic therapy, however this requires further study. Disclosures Amber C. Streifel, PharmD, BCPS, Melinta (Advisor or Review Panel member) Monica K. Sikka, MD, FG2 (Scientific Research Study Investigator)

Connect 2 Care, a Novel Community Outreach Program for Vulnerably Housed Patients With High Acute Care Use: A Mixed-Methods Study Protocol

Introduction: Vulnerably housed individuals, especially those experiencing homelessness, have higher acute care use compared with the general population. Despite available primary care and social services, many face significant challenges accessing needed services. Connect 2 Care (C2C) is a novel transitional case management program that includes registered nurses and health navigators with complementary expertise in chronic disease management, mental health and addictions, social programs, community health, and housing, financial, transportation and legal resources. C2C bridges acute care and community services to improve care coordination.Methods and Analysis: We will perform a mixed-methods evaluation of the C2C program according to the Donabedian framework of structure, process and outcome, to understand how program structure and process, coupled with contextual factors, influence outcomes in a novel intervention. Eligible patients are homeless or unstably housed adults with complex health conditions and high acute care use. Change in emergency department visit rate 12-months after program enrolment is the primary outcome. Secondary outcomes include 12-month post-enrolment hospital admissions, cumulative hospital days, health-related quality of life, housing status, primary care attachment and substance use. Qualitative methods will explore experiences with the C2C program from multiple perspectives and an economic evaluation will assess cost-effectiveness.Discussion: Academic researchers partnered with community service providers to evaluate a novel transitional case management intervention for vulnerably housed patients with high acute-care use. The study uses mixed-methods to evaluate the Connect 2 Care program according to the Donabedian framework of structure, process and outcome, including an assessment of contextual factors that influence program success. Insights gained through this comprehensive evaluation will help refine the C2C program and inform decisions about sustainability and transferability to other settings in Canada.