Appendix 1.
The Evidence-Based Strategies Patients Selected to Improve the Top 3 Unhealthy Behavior, Mental Health, and Social Needs Risks.
| Care plan topic | Number of patients who created a care plan | Number of evidence-based strategies selected | Number of evidence-based strategies | Frequency of top strategies (%) | Top strategies selected |
|---|---|---|---|---|---|
| Mean (SD) | Min, max | ||||
| Unhealthy behaviors | |||||
| Nutrition | 67 | 7.2 (4.7) | (0, 21) | 49/67 (73.1) 36/67 (53.7) 35/67 (52.2) 35/67 (52.2) |
Eat more vegetables Find healthy recipes online Research more about nutrition on your own Stop or eat fewer unhealthy snacks |
| Physical activity | 100 | 5.8 (3.2) | (0, 16) | 61/100 (61) 55/100 (55) 52/100 (52) |
Develop an exercise routine Walk more every day Make exercise part of every day |
| Weight loss | 57 | 9.5 (5.1) | (1, 25) | 37/57 (64.9) 33/57 (57.9) 32/57 (56.1) |
Eat more vegetables Walk more every day Stop or eat fewer unhealthy snacks |
| Smoking | 4 | 5 (2.9) | (2, 9) | 2/4 (50) 2/4 (50) 2/4 (50) 2/4 (50) 2/4 (50) 2/4 (50) |
Figure out your pitfalls (what makes you smoke) and come up with a plan to not smoke when you encounter a pitfall Get help from a telephone counselor by calling 1-800-quit-now Make a quit plan at https://smokefree.gov/build-your-quit-plan Set a quit date Talk with your doctor about nicotine replacement Talk with your doctor about options |
| Alcohol use | 7 | 2.3 (2.0) | (0, 5) | 4/7 (57.1) 2/7 (28.6) 2/7 (28.6) |
Plan for more days when you have no drinks *Connect with a case manager for increased support Set a goal and keep track of how much you drink |
| Drug use | 1 | 0 | (0, 0) | n/a | n/a |
| Any unhealthy behavior | 173 | 9.4 (7.3) | (0, 46) | ||
| Social needs | |||||
| Financial | 5 | 4.4 (7.1) | (0, 17) | 3/5 (60) 3/5 (60) 2/5 (40) |
*Learn from a financial counselor Build a financial plan *Get free legal information about money and debt |
| Food security | 0 | n/a | n/a | n/a | n/a |
| Transportation | 1 | 0 | (0, 0) | n/a | n/a |
| Housing | 1 | 8 | (8, 8) | 1/1 (100) 1/1 (100) 1/1 (100) |
*Apply for assistance with your bills - gas, electric, phone, internet *Apply for public housing voucher to help with rent *Connect with a case manager or housing counselor for help |
| 1/1 (100) 1/1 (100) 1/1 (100) 1/1 (100) 1/1 (100) |
*Enroll in a program to find permanent housing *Find transitional housing *Get guidance on reducing housing costs and maintenance *Get help with a loan, mortgage, or subsidy to buy a home *Learn how to better manage your finances |
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| Dental | 3 | 6.7 (2.5) | (4, 9) | 3/3 (100) 3/3 (100) 2/3 (66.7) 2/3 (66.7) 2/3 (66.7) 2/3 (66.7) |
*Find a dentist *Find free or reduced fee dental care near you *Get help paying a dental bill Stop or drink less soda Talk to your doctor or dentist about options to help you Visit the dentist at least twice a year |
| Safety | 2 | 3 (4.2) | (0, 6) | 1/2 (50) 1/2 (50) 1/2 (50) 1/2 (50) 1/2 (50) 1/2 (50) |
*Call a hotline *Create a safety plan *Find a shelter near you *Get a referral for counseling to cope with what happened to you *Learn about ways to improve financial security Change where or who you live with |
| Any social | 12 | 4.7 (5.1) | (0, 17) | ||
| Mental health | |||||
| Anxiety or depression | 10 | 7.1 (3.5) | (3, 13) | 7/10 (70) 7/10 (70) 6/10 (60) |
Practice putting things in perspective and recognize what you can and cannot control Talk to your doctor about whether you might benefit from a medication *Try meditation or mindfulness |
| Loneliness | 8 | 4.4 (2.7) | (2, 9) | 5/8 (62.5) 4/8 (50.0) 3/8 (37.5) 3/8 (37.5) 3/8 (37.5) 3/8 (37.5) 3/8 (37.5) 3/8 (37.5) |
Call, text, or email people in your life Make time every day to get together with friends and family *Get a referral for counseling *Join a social or service club *Try meditation or mindfulness Adopt a pet Find an organization you want to help and volunteer Talk to your doctor about ways to reduce loneliness |
| Sleep | 11 | 7.1 (4.7) | (2, 16) | 7/11 (63.6) 6/11 (54.5) 6/11 (54.5) |
*Get more exercise Do a calming routine every night before you go to bed Use a Fitbit or wearable to track your sleep |
| Any mental | 29 | 6.3 (3.9) | (2, 16) | ||