• Homelessness: Patient’s history of homelessness
• Outreach: Who else is providing services
• Utilization: How patient uses health care, social services and judicial system
• Salary: Kinds of financial resources
• Eat: Sources of food and access to it
• Drink: Sources of clean water and access to it
• Bathroom: Access to toilet
• Encampment: Sleeping environment
• Daily routine: How to minimize competing priorities
• Substance use: History of usage

This acronym is designed to spur clinicians to ask questions they may not have been trained to ask, which can reveal issues that directly impact a patient’s health.

“Developing an effective treatment plan depends on a complete and accurate patient history,” said Brett Feldman, MSPAS, PA-C, clinical assistant professor of family medicine and director of street medicine at the Keck School. The street medicine program administers care to homeless individuals in Los Angeles County, which is home to nearly 45,000 unsheltered individuals. “Even patients in traditional clinic settings omit information, sometimes unintentionally, that could be relevant to a diagnosis, so it’s important for outreach teams to have a means of understanding each homeless individual’s unique situation,” he added.
 
Understanding the people behind the numbers

• In the 2019 Greater Los Angeles Homeless Count, volunteers found 58,936 people experiencing homelessness in Los Angeles County — a 12% increase over the last year. Countywide, 75% (44,214 people) were unsheltered.
• The City of Los Angeles counted 36,300 homeless people, a 16% increase from last year. Of those, 27,221 were unsheltered.
• In Los Angeles County, the number of people experiencing chronic homelessness, defined as being homeless for 12 consecutive months or on at least four separate occasions in the last three years totaling at least 12 months, increased 17%, from 14,075 in 2018 to 16,529 in 2019. Of these, 1,991 had some form of shelter, but 14,537 were unsheltered.

— Wendy Wolfson

Using a unique source of frontline data — instances of elder abuse reported to the National Center on Elder Abuse (NCEA) resource line, Keck School researchers were able to identify the most common types of elder abuse reported and profile the alleged perpetrators. The NCEA resource line is a source for individuals seeking information regarding how to identify or report elder abuse.

Of the nearly 2,000 calls logged for the study, more than 42% (818 calls) alleged abuse. Financial abuse was the most commonly reported at nearly 55% (449 calls).

Family members were the most frequently identified perpetrators of alleged abuse at nearly 48% of calls in which relationship could be determined. The most common abuse perpetrated by family was financial abuse (61.8%), followed by emotional abuse (35%), neglect (20.1%), physical abuse (12%) and sexual abuse (0.3%). Of the calls that alleged abuse by a family member, more than 32% reported more than one abuse type.

“We expected to find that financial abuse was the most common abuse reported,” said Gali Weissberger, PhD, lead author of the study, and postdoctoral scholar in the Han Research Lab at the Keck School. “But despite the high rates of financial exploitation perpetrated by scammers targeting older adults, we found that family members were the most commonly alleged perpetrators of financial abuse. In fact, across all abuse types, with the exception of sexual abuse and self-neglect, abuse by a family member was the most commonly reported.”

Elder abuse affects an estimated one in 10 older adults annually, but is often underreported. Aside from its physical, psychological and social impact on victims, their families and society, elder abuse attributes to more than $5.3 billion in U.S. annual health care costs.

“This is the first study to characterize elder abuse from calls made to the NCEA resource line, which serves as a public access point for people seeking information and resources about elder abuse,” said Duke Han, PhD, associate professor of family medicine at the Keck School and corresponding author of the study. “Our findings highlight the importance of resource lines for those seeking information on elder abuse, as many calls were made to understand whether certain situations reflected abuse.”

The researchers coded nearly 2,000 calls, emails or messages logged on the NCEA hotline between August 2014 and June 2017, reviewing for any mention of abuse. They categorized type of abuse alleged, whether multiple types of abuse occurred and who perpetrated the alleged abuse.
The researchers added that it is important to incorporate diverse data sources when collecting information regarding alleged abuse. The study was limited by selection bias, as the data was from individuals proactively calling the NCEA line.

“The results highlight the importance of developing effective strategies to prevent future abuse,” Weissberger said. “Our next step is to conduct more studies targeting high-risk individuals and to better understand additional risk factors.”

— Wendy Wolfson

Simple measures such as giving patients pillboxes for their medications, helping patients’ family members understand their medication regimen and having patients attend weekly education sessions about managing the disease through lifestyle changes are all ways that patients could improve medication adherence.

The study also points toward specific challenges that underserved Latinos may be facing. Such challenges include having difficulty understanding what their medications are for, keeping track of their medications and feeling that they may take too many medications. Cohorts in this study took an average of 6.5 prescribed medications daily.

“Obtaining patients’ perspectives is key to finding solutions that help improve their medication adherence and health outcomes,” said Andrea Bañuelos Mota, the study’s first and corresponding author. “Not only do our findings suggest several potential approaches to intervention for Latinos with diabetes, but they could also pave the way for the development of future evidence-based guidelines.” Bañuelos Mota is currently enrolled in the Keck School’s Doctor of Medicine/Master of Public Health (MD/MPH) degree program.

Published in the Journal of General Internal Medicine (JGIM) on June 4, the cross-sectional study involved conducting surveys of 120 patients from across four safety net clinics in Los Angeles. Patients were at least 18 years old, self-identified as Latino/Hispanic/Chicano, were diagnosed with diabetes for more than six months, and were taking multiple diabetes medications. Furthermore, the study’s dependent variable was patients with “controlled diabetes” (i.e., having a hemoglobin A1c level of less than 7.5%) versus patients with “uncontrolled diabetes” (i.e., having a hemoglobin A1c level equal to or greater than 7.5%).

“This study is exemplary of excellent primary care research and brings awareness to the language and literacy barriers faced by our immigrant communities, which health care providers must address to deliver quality medical care,” said Jo Marie Reilly, MD, MPH, professor of clinical family medicine (educational scholar). Reilly leads the Keck School’s Primary Care Initiative, a program created to promote careers in primary care and the one through which this study was established.

Conceived and led entirely by a team of five medical students — including Andrea Bañuelos Mota, Emilio Ernesto Feliz Sala, Jennifer M. Perdomo, Joel Alejandro Solis and Walter M. Solorzano — the study also marks an achievement for the Keck School initiative. “JGIM is one of the highest ranked general internal medicine journals, so it is particularly impressive that a student group got a paper accepted,” said Michael Hochman, MD, MPH, a faculty mentor on the project with Reilly. Hochman is an associate professor of clinical medicine and serves as director of the USC Gehr Family Center for Health Systems Science.

— Elyse Blye

• Patient history, from the perspective of both the patient and another trusted source
• The patient’s physical appearance before clean-up or treatment is initiated
• A head-to-toe evaluation for injuries
• All injuries, including minor ones
• Any evidence that might disprove abuse or neglect (pertinent negatives)

“The need to protect our older loved ones from elder abuse is great,” said Alexis Coulourides Kogan, PhD, assistant professor of family medicine at the Keck School and co-author of the study. “But focusing solely on the reason for a patient’s visit seldom tells the whole story, even when you look at the medical chart. If documentation of physical findings is poor, then we may be missing the big picture.”

Study participants also noted the value of photographs and body diagrams to supplement written documentation, the time challenges of thorough documentation in a busy clinical setting and the need to integrate the tool into existing electronic medical records.

“It may be more work for a clinician to use an injury documentation tool, but we believe the value far surpasses the burden placed on physicians,” Kogan explained. “If there is suspected elder abuse, these records can potentially help prosecutors achieve justice and protection for older adults or exonerate innocent caregivers.”
Next, the researchers plan to seek funding to test the Geriatric Injury Documentation Tool in clinical settings.