The Comprehensive Primary Care Plus Model and Health Care Spending, Service Use, and Quality.

Importance: Implemented in 18 regions, Comprehensive Primary Care Plus (CPC+) was the largest US primary care delivery model ever tested. Understanding its association with health outcomes is critical in designing future transformation models. Objective: To test whether CPC+ was associated with lower health care spending and utilization and improved quality of care. Design, Setting, and Participants: Difference-in-differences regression models compared changes in outcomes between the year before CPC+ and 5 intervention years for Medicare fee-for-service beneficiaries attributed to CPC+ and comparison practices. Participants included 1373 track 1 (1 549 585 beneficiaries) and 1515 track 2 (5 347 499 beneficiaries) primary care practices that applied to start CPC+ in 2017 and met minimum care delivery and other eligibility requirements. Comparison groups included 5243 track 1 (5 347 499 beneficiaries) and 3783 track 2 (4 507 499 beneficiaries) practices, matched, and weighted to have similar beneficiary-, practice-, and market-level characteristics as CPC+ practices. Interventions: Two-track design involving enhanced (higher for track 2) and alternative payments (track 2 only), care delivery requirements (greater for track 2), data feedback, learning, and health information technology support. Main Outcomes and Measures: The prespecified primary outcome was annualized Medicare Part A and B expenditures per beneficiary per month (PBPM). Secondary outcomes included expenditure categories, utilization (eg, hospitalizations), and claims-based quality-of-care process and outcome measures (eg, recommended tests for patients with diabetes and unplanned readmissions). Results: Among the CPC+ patients, 5% were Black, 3% were Hispanic, 87% were White, and 5% were of other races (including Asian/Other Pacific Islander and American Indian); 85% of CPC+ patients were older than 65 years and 58% were female. CPC+ was associated with no discernible changes in the total expenditures (track 1: $1.1 PBPM [90% CI, -$4.3 to $6.6], P = .74; track 2: $1.3 [90% CI, -$5 to $7.7], P = .73), and with increases in expenditures including enhanced payments (track 1: $13 [90% CI, $7 to $18], P < .001; track 2: $24 [90% CI, $18 to $31], P < .001). Among secondary outcomes, CPC+ was associated with decreases in emergency department visits starting in year 1, and in acute hospitalizations and acute inpatient expenditures in later years. Associations were more favorable for practices also participating in the Medicare Shared Savings Program and independent practices. CPC+ was not associated with meaningful changes in claims-based quality-of-care measures. Conclusions and Relevance: Although the timing of the associations of CPC+ with reduced utilization and acute inpatient expenditures was consistent with the theory of change and early focus on episodic care management of CPC+, CPC+ was not associated with a reduction in total expenditures over 5 years. Positive interaction between CPC+ and the Shared Savings Program suggests transformation models might be more successful when provider cost-reduction incentives are aligned across specialties. Further adaptations and testing of primary care transformation models, as well as consideration of the larger context in which they operate, are needed.

Effects of the Million Hearts Model on Myocardial Infarctions, Strokes, and Medicare Spending: A Randomized Clinical Trial.

Importance: The Million Hearts Model paid health care organizations to assess and reduce cardiovascular disease (CVD) risk. Model effects on long-term outcomes are unknown. Objective: To estimate model effects on first-time myocardial infarctions (MIs) and strokes and Medicare spending over a period up to 5 years. Design, Setting, and Participants: This pragmatic cluster-randomized trial ran from 2017 to 2021, with organizations assigned to a model intervention group or standard care control group. Randomized organizations included 516 US-based primary care and specialty practices, health centers, and hospital-based outpatient clinics participating voluntarily. Of these organizations, 342 entered patients into the study population, which included Medicare fee-for-service beneficiaries aged 40 to 79 years with no previous MI or stroke and with high or medium CVD risk (a 10-year predicted probability of MI or stroke [ie, CVD risk score] ≥15%) in 2017-2018. Intervention: Organizations agreed to perform guideline-concordant care, including routine CVD risk assessment and cardiovascular care management for high-risk patients. The Centers for Medicare & Medicaid Services paid organizations to calculate CVD risk scores for Medicare fee-for-service beneficiaries. CMS further rewarded organizations for reducing risk among high-risk beneficiaries (CVD risk score ≥30%). Main Outcomes and Measures: Outcomes included first-time CVD events (MIs, strokes, and transient ischemic attacks) identified in Medicare claims, combined first-time CVD events from claims and CVD deaths (coronary heart disease or cerebrovascular disease deaths) identified using the National Death Index, and Medicare Parts A and B spending for CVD events and overall. Outcomes were measured through 2021. Results: High- and medium-risk model intervention beneficiaries (n = 130 578) and standard care control beneficiaries (n = 88 286) were similar in age (median age, 72-73 y), sex (58%-59% men), race (7%-8% Black), and baseline CVD risk score (median, 24%). The probability of a first-time CVD event within 5 years was 0.3 percentage points lower for intervention beneficiaries than control beneficiaries (3.3% relative effect; adjusted hazard ratio [HR], 0.97 [90% CI, 0.93-1.00]; P = .09). The 5-year probability of combined first-time CVD events and CVD deaths was 0.4 percentage points lower in the intervention group (4.2% relative effect; HR, 0.96 [90% CI, 0.93-0.99]; P = .02). Medicare spending for CVD events was similar between the groups (effect estimate, -$1.83 per beneficiary per month [90% CI, -$3.97 to -$0.30]; P = .16), as was overall Medicare spending including model payments (effect estimate, $2.11 per beneficiary per month [90% CI, -$16.66 to $20.89]; P = .85). Conclusions and Relevance: The Million Hearts Model, which encouraged and paid for CVD risk assessment and reduction, reduced first-time MIs and strokes. Results support guidelines to use risk scores for CVD primary prevention. Trial Registration: ClinicalTrials.gov Identifier: NCT04047147.

Medicare beneficiaries with more comprehensive primary care physicians report better primary care.

OBJECTIVE: To examine whether primary care physician (PCP) comprehensiveness is associated with Medicare beneficiaries' overall rating of care from their PCP and staff. DATA SOURCES: We linked Medicare claims with survey data from Medicare beneficiaries attributed to Comprehensive Primary Care Plus (CPC+) physicians and practices. STUDY DESIGN: We performed regression analyses of the associations between two claims-based measures of PCP comprehensiveness in 2017 and beneficiaries' rating of care from their PCP and practice staff in 2018. DATA COLLECTION/EXTRACTION METHODS: The analytic sample included 6228 beneficiaries cared for by 3898 PCPs. Regressions controlled for beneficiary, physician, practice, and market characteristics. PRINCIPAL FINDINGS: Beneficiaries with more comprehensive PCPs rated care from their PCP and practice staff higher than did those with less comprehensive PCPs. For each comprehensiveness measure, beneficiaries whose PCP was in the 75th percentile were more likely than beneficiaries whose PCP was in the 25th percentile to rate their care highly (2 percentage point difference, p = 0.02). CONCLUSIONS: Medicare beneficiaries with more comprehensive PCPs rate overall care from their PCPs and staff higher than those with less comprehensive PCPs.

Maternal and Child Mortality: Analysis of Nurse Home Visiting in 3 RCTs.

INTRODUCTION: The impact of intensive prenatal and infant/toddler nurse home visiting on low-income mothers' and children's survival was examined in 3 RCTs following participants over 2-decade periods after trial registration during pregnancy (data gathered between 1978 and 2015 and analyzed between 2016 and 2020). METHODS: All-cause and external-cause maternal mortality and preventable-cause child mortality were examined using National Death Index data. Survival rates were calculated for all the 1,138 mothers randomized and 1,076 live-born children in the second RCT (conducted in Memphis, TN) and for all the 1,135 mothers randomized and 1,087 live-born children in the first and third RCTs combined (conducted in Elmira, NY and Denver, CO). RESULTS: There were no significant nurse home visiting-control differences in maternal mortality in Memphis or Elmira and Denver. Posthoc analysis, combining all 3 trials, suggested a reduction in external-cause maternal mortality among nurse-visited mothers (p=0.054). There was a marginally significant nurse home visiting-control difference in preventable-cause child mortality (p=0.09) in Memphis. CONCLUSIONS: These results support examining maternal and child mortality in additional nurse home visiting trials with larger samples living in disadvantaged contexts. Intensive prenatal and infant/toddler home visiting by nurses for mothers and children living in poverty may decrease premature death.

Effect of the Million Hearts Cardiovascular Disease Risk Reduction Model on Initiating and Intensifying Medications: A Prespecified Secondary Analysis of a Randomized Clinical Trial.

Importance: The Million Hearts Cardiovascular Disease (CVD) Risk Reduction Model pays provider organizations for measuring and reducing Medicare patients' cardiovascular risk. Objective: To assess whether the model increases the initiation or intensification of antihypertensive medications or statins among patients with blood pressure or low-density lipoprotein (LDL) cholesterol levels above guideline thresholds for treatment intensification. Design, Setting, and Participants: This prespecified secondary analysis of a cluster-randomized, pragmatic trial included primary care and cardiology practices, health care centers, and hospital-based outpatient departments across the US. Participants included Medicare patients who were enrolled into the model in 2017 by participating organizations and who were at high risk and at medium risk of a myocardial infarction or stroke in 10 years. Patient outcomes were analyzed for 1 year postenrollment (through December 2018) using an intent-to-treat design. Analysis began November 2019. Interventions: US Centers for Medicare & Medicaid Services paid organizations for risk stratifying Medicare patients and reducing CVD risk among high-risk patients through discussing risk scores, developing individualized risk reduction plans, and following up with patients twice yearly. Main Outcomes and Measures: Initiating or intensifying statin or antihypertensive therapy within 1 year of enrollment, measured in Medicare Part D claims, and LDL cholesterol and systolic blood pressure levels approximately 1 year after enrollment, measured in usual care and reported to Centers for Medicare & Medicaid Services via a data registry (data complete for 51% of high-risk enrollees). The study's primary outcome (incidence of first-time myocardial infarction and stroke) is not reported because the trial is ongoing. Results: A total of 330 primary care and cardiology practices, health care centers, and hospital-based outpatient departments and 125 436 Medicare patients were included in this analysis. High-risk patients in the intervention group had a mean (SD) age of 74 (4.1), 15 213 (63%) were male, 21 657 (90%) were receiving antihypertensive medication at baseline, and 16 558 (69%) were receiving statins. Almost all (21 791 [91%]) high-risk intervention group patients had above-threshold systolic blood pressure level (>130 mm Hg), LDL cholesterol level (>70 mg/dL), or both. Patients in the intervention group with these risk factors were more likely than control patients (8127 [37.3%] vs 4753 [32.4%]; adjusted difference in percentage points, 4.8; 95% CI, 2.9-6.7; P < .001) to initiate or intensify statins or antihypertensive medication. Centers for Medicare & Medicaid Services did not pay for CVD risk reduction for medium-risk enrollees, but initiation or intensification rates for these enrollees were also higher in the intervention vs control groups (12 668 [27.9%] vs 7544 [24.8%]; adjusted difference in percentage points, 3.1; 95% CI, 1.9-4.3; P < .001). Among high-risk enrollees with clinical data approximately 1 year after enrollment, LDL cholesterol level was slightly lower in the intervention vs control groups (mean [SD], 89 [31.8] vs 91 [32.1] mg/dL; adjusted difference in percentage points, -1.8; 95% CI, -2.9 to -0.6; P = .002), as was systolic blood pressure (mean [SD], 133 [15.7] vs 135 [16.4] mm Hg; adjusted difference in percentage points, -1.7; 95% CI, -2.8 to -0.6; P = .003). Conclusions and Relevance: In this study, a pay-for-performance model led to modest increases in the use of CVD medications in a range of organizations, despite high medication use at baseline.

Development of claims-based measures of unplanned acute care with superior power for assessing the effectiveness of interventions following acute care.

OBJECTIVE: To develop outcome measures that are more sensitive than current measures for evaluating primary or transitional care after hospitalizations, emergency department (ED) visits, or observation stays. DATA SOURCES: Medicare claims data from January 1, 2015, to October 31, 2017, for 1 261 707 Medicare fee-for-service beneficiaries served by (a) primary care practices participating in Track 1 of the Comprehensive Primary Care Plus (CPC+) initiative, and (b) their matched comparison practices. STUDY DESIGN: Given the poor statistical power in many studies to detect effects on readmissions, we developed two novel claims-based measures of unplanned acute care (UAC) following an index acute care event. The first measure assesses the proportion of hospitalizations followed by an unplanned readmission, ED visit, or observation stay within 30 days of discharge; the second assesses the proportion of ED visits and observation stays followed by a hospitalization, ED visit, or observation stay within 30 days. We calculate minimum detectable effects (MDEs) for both measures and for a conventional measure of 30-day unplanned readmissions, using CPC+ data. PRINCIPAL FINDINGS: Repeat UAC events are common among Medicare beneficiaries served by the CPC+ practices. In 2017, 22% of discharges and 21% of ED visits and observation stays had a UAC event within 30 days. Readmissions were the most common UAC event following discharge, whereas ED visits were most common following index ED visits or observation stays. MDEs are 25%-40% lower for the new measures than for the standard 30-day readmissions measure, indicating better statistical power to detect impacts of primary or transitional care interventions. CONCLUSIONS: This study introduces two new claims-based measures to assess quality of care during a patient's vulnerable period following acute care. The new measures complement existing measures, covering a broader range of UAC events than the standard 30-day readmissions measure, and yielding greater statistical power.

Pathways to reduced emergency department and urgent care center use: Lessons from the comprehensive primary care initiative.

OBJECTIVE: To determine the association between a large-scale, multi-payer primary care redesign-the Comprehensive Primary Care (CPC) Initiative-on outpatient emergency department (ED) and urgent care center (UCC) use and to identify the types of visits that drive the overall trends observed. DATA SOURCES: Medicare claims data capturing characteristics and outcomes of 565 674 Medicare fee-for-service (FFS) beneficiaries attributed to 497 CPC practices and 1 165 284 beneficiaries attributed to 908 comparison practices. STUDY DESIGN: We used an adjusted difference-in-differences framework to test the association between CPC and beneficiaries' ED and UCC use from October 2012 through December 2016. Regression models controlled for baseline practice and patient characteristics and practice-level clustering of standard errors. Our key outcomes were all-cause and primary care substitutable (PC substitutable) outpatient ED and UCC visits, and potentially primary care preventable (PPC preventable) ED visits, categorized by the New York University Emergency Department Algorithm. We used a propensity score-matched comparison group of practices that were similar to CPC practices before CPC on multiple dimensions. Both groups of practices had similar growth in ED and UCC visits in the two-year period before CPC. PRINCIPAL FINDINGS: Comprehensive Primary Care practices had 2% (P = .06) lower growth in all-cause ED visits than comparison practices. They had 3% (P = .02) lower growth in PC substitutable ED visits, driven by lower growth in weekday PC substitutable visits (4%, P = .002). There was 3% (P = .04) lower growth in PPC preventable ED visits with no weekday/nonweekday differential. As expected, our falsification test showed no difference in ED visits for injuries. UCC visits had 9% lower growth for both all-cause (P = .08) and PC substitutable visits (P = .07). CONCLUSIONS: Our results suggest that greater access to the practice and more effective primary care both contributed to the lower growth in ED and UCC visits during the initiative.

The Impact of a Preventive Intervention on Persistent, Cross-Situational Early Onset Externalizing Problems.

The Nurse-Family Partnership (NFP) home visiting intervention for low-income first-time mothers was evaluated for its preventive impact on persistent, cross-situational early-onset externalizing problems (EXT). Seven hundred thirty-five women in the Denver, CO, area were randomly assigned into one of two active conditions (nurse or paraprofessional home visiting from pregnancy through child age 2) or a control group in which children were screened and referred for behavioral and developmental problems. Externalizing behavior was assessed by parent report when the children were 2, 4, 6, and 9 years old; teachers provided reports at ages 6 and 9. Latent profile analyses suggested the presence of persistent, cross-situational early onset EXT in approximately 6 to 7% of girls and boys. The intervention deflected girls away from these EXT and toward a pattern marked by a persistent moderate elevation of externalizing behavior that was evident at home and not at school. This finding should be interpreted cautiously given the small number of girls with the elevated EXT. Surprisingly, the intervention also moved girls away from stable low level externalizing behavior toward the moderately elevated pattern. Both of the significant effects on girls' externalizing behavior were modest. No statistically significant effects were found for boys' externalizing behaviors, which exhibited a somewhat different patterning across time and reporter. Effect sizes were generally similar for the nurse and paraprofessional-visited groups. The results are discussed in the context of prior efforts to prevent early EXT and emerging evidence on the normative development of externalizing behavior.

Patient Experiences with Chronic Care Management Services and Fees: a Qualitative Study.

BACKGROUND: As of 2015, the Centers for Medicare & Medicaid Services (CMS) pays for chronic care management (CCM) services for Medicare beneficiaries with two or more chronic conditions. CMS requires eligible providers to first obtain patients' verbal (and, prior to 2017, written) consent, to ensure that patients who participate in CCM services understand their rights and agree to any applicable cost sharing. CCM providers must also enhance patients' access to continuous and coordinated care, including ongoing care management. OBJECTIVE: To understand patients' perceptions of the consent process, their reasons for choosing to participate, and their experiences receiving CCM services. DESIGN: Qualitative study using semi-structured interviews with Medicare beneficiaries who had two or more CCM claims submitted by an eligible provider. Beneficiaries were selected from a sampling frame of Medicare claims submitted between January and September 2015. KEY RESULTS: Most patients reported no concerns about being asked to participate in CCM. The majority of patients had secondary insurance (or Medicaid) that covered any coinsurance for CCM and therefore could not say with certainty whether they would participate if they had to pay for CCM services out-of-pocket. Reasons for participating included having insurance that covered the copay and peace of mind about having access to the CCM team. Patients reported multiple benefits of participating in CCM services, including better access to their primary care team, improved continuity of care, and improved care coordination. Most patients reported no downside to participating in CCM services, although some felt they were relatively healthy and questioned whether they needed CCM services. CONCLUSIONS: These findings on patients' experiences participating in CCM services during the first 9 months of the policy's implementation can help providers and policymakers understand their perceived benefits and unintended consequences. Our findings also have implications for providers when approaching patients about CCM services.

Provider Experiences with Chronic Care Management (CCM) Services and Fees: A Qualitative Research Study.

BACKGROUND: Support for ongoing care management and coordination between office visits for patients with multiple chronic conditions has been inadequate. In January 2015, Medicare introduced the Chronic Care Management (CCM) payment policy, which reimburses providers for CCM activities for Medicare beneficiaries occurring outside of office visits. OBJECTIVE: To explore the experiences, facilitators, and challenges of practices providing CCM services, and their implications going forward. DESIGN: Semi-structured telephone interviews from January to April 2016 with 71 respondents. PARTICIPANTS: Sixty billing and non-billing providers and practice staff knowledgeable about their practices' CCM services, and 11 professional society representatives. KEY RESULTS: Practice respondents noted that most patients expressed positive views of CCM services. Practice respondents also perceived several patient benefits, including improved adherence to treatment, access to care team members, satisfaction, care continuity, and care coordination. Facilitators of CCM provision included having an in-practice care manager, patient-centered medical home recognition, experience developing care plans, patient trust in their provider, and supplemental insurance to cover CCM copayments. Most billing practices reported few problems obtaining patients' consent for CCM, though providers felt that CMS could better facilitate consent by marketing CCM's goals to beneficiaries. Barriers reported by professional society representatives and by billing and non-billing providers included inadequacy of CCM payments to cover upfront investments for staffing, workflow modification, and time needed to manage complex patients. Other barriers included inadequate infrastructure for health information exchange with other providers and limited electronic health record capabilities for documenting and updating care plans. Practices owned by hospital systems and large medical groups faced greater bureaucracy in implementing CCM than did smaller, independent practices. CONCLUSIONS: Improving providers' experiences with and uptake of CCM will require addressing several challenges, including the upfront investment for CCM set-up and the time required to provide CCM to more complex patients.

Reducing Inpatient Hospital and Emergency Room Utilization Among Nursing Home Residents.

OBJECTIVE: To examine the association among nursing home residents between strength of relationship with a primary care provider (PCP) and inpatient hospital and emergency room (ER) utilization. METHOD: Medicare administrative data for beneficiaries residing in a nursing home between July 2007 and June 2009 were used in multivariate analyses controlling for beneficiary, nursing home, and market characteristics to assess the association between two measures-percentage of months with a PCP visit and whether the patient maintained the same usual source of care after nursing home admission-and hospital admissions and ER visits for all causes and for ambulatory care sensitive conditions (ACSCs). RESULTS: Both measures of strength of patient-provider relationships were associated with fewer inpatient admissions and ER visits, except regularity of PCP visits and ACSC ER visits. DISCUSSION: Policy makers should consider increasing the strength of nursing home resident and PCP relationships as one strategy for reducing inpatient and ER utilization.

Emergency department and inpatient hospital use by Medicare beneficiaries in patient-centered medical homes.

STUDY OBJECTIVE: Patient-centered medical homes are primary care practices that focus on coordinating acute and preventive care. Such practices can obtain patient-centered medical home recognition from the National Committee for Quality Assurance. We compare growth rates for emergency department (ED) use and costs of ED visits and hospitalizations (all-cause and ambulatory-care-sensitive conditions) between patient-centered medical homes recognized in 2009 or 2010 and practices without recognition. METHODS: We studied a sample of US primary care practices and federally qualified health centers: 308 with and 1,906 without patient-centered medical home recognition, using fiscal year 2008 to 2010 Medicare fee-for-service data. We assessed average annual practice-level payments per beneficiary for ED visits and hospitalizations and rates of ED visits and hospitalizations (overall and ambulatory-care-sensitive condition) per 100 beneficiaries before and after patient-centered medical home recognition, using a difference-in-differences regression model comparing patient-centered medical homes and propensity-matched non-patient-centered medical homes. RESULTS: Comparing patient-centered medical home with non-patient-centered medical home practices, the rate of growth in ED payments per beneficiary was $54 less for 2009 patient-centered medical homes and $48 less for 2010 patient-centered medical homes relative to non-patient-centered medical home practices. The rate of growth in all-cause and ambulatory-care-sensitive condition ED visits per 100 beneficiaries was 13 and 8 visits fewer for 2009 patient-centered medical homes and 12 and 7 visits fewer for 2010 patient-centered medical homes, respectively. There was no hospitalization effect. CONCLUSION: From 2008 to 2010, outpatient ED visits increased more slowly for Medicare patients being treated by patient-centered medical home practices than comparison non-patient-centered medical homes. The reduction was in visits for both ambulatory-care-sensitive and non-ambulatory-care-sensitive conditions, suggesting that steps taken by practices to attain patient-centered medical home recognition such as improving care access may decrease some of the demand for outpatient ED care.

Total cost of care lower among Medicare fee-for-service beneficiaries receiving care from patient-centered medical homes.

OBJECTIVE: To compare health care utilization and payments between NCQA-recognized patient-centered medical home (PCMH) practices and practices without such recognition. DATA SOURCES: Medicare Part A and B claims files from July 1, 2007 to June 30, 2010, 2009 Census, 2007 Health Resources and Services Administration and CMS Utilization file, Medicare's Enrollment Data Base, and the 2005 American Medical Association Physician Workforce file. STUDY DESIGN: This study used a longitudinal, nonexperimental design. Three annual observations (July 1, 2008-June 30, 2010) were available for each practice. We compared selected outcomes between practices with and those without NCQA PCMH recognition. DATA COLLECTION METHODS: Individual Medicare fee-for-service (FFS) beneficiaries and their claims and utilization data were assigned to PCMH or comparison practices based on where they received the plurality of evaluation and management services between July 1, 2007 and June 30, 2008. PRINCIPAL FINDINGS: Relative to the comparison group, total Medicare payments, acute care payments, and the number of emergency room visits declined after practices received NCQA PCMH recognition. The decline was larger for practices with sicker than average patients, primary care practices, and solo practices. CONCLUSIONS: This study provides additional evidence about the potential of the PCMH model for reducing health care utilization and the cost of care.

HAC-POA policy effects on hospitals, other payers, and patients.

BACKGROUND: Prior to the implementation of the Hospital-Acquired Condition-Present on Admission (HAC-POA) payment policy, concerns regarding its potential impact were raised by a number of organizations and individuals. The purpose of this study was to explore direct and indirect effects of the HAC-POA payment policy on hospitals, patients, and other payers during the policy's first 3 years of implementation. METHODS: The study included semi-structured telephone interviews with representatives of national organizations, hospitals, patient advocacy organizations, and other payers. Interview notes were coded using QSR NVivo qualitative analysis software using inductive and deductive qualitative analysis techniques. We conducted interviews with 106 individuals representing 56 organizations. Hospital staff included physicians, nurses, patient safety officers, coders, and finance, senior management, and information management staff. Individuals from other organizations represented leadership positions. RESULTS: Key changes to hospitals included: cultural shifts involving attention, commitment, and support from hospital leadership for patient safety; hiring new staff to assure the accuracy of clinical documentation and POA oversight structures; increased time burden for physicians, nurses, and coders; need to upgrade or purchase new software; and need to collaborate with hospital departments or staff that did not interface directly in the past. The policy was adopted by a majority of other payers, although the list of conditions and payment penalties varies. The HAC-POA policy is invisible to patients; therefore, the presence or lack of unintended consequences to patients cannot be fully assessed at this time. Understanding of policy effects to all stakeholders is important for maximizing its successful implementation and desired impact.

Primary care and specialty providers: an assessment of continuity of care, utilization, and expenditures.

BACKGROUND: Little is known as to whether medical home principles, such as continuity of care (COC), would have the same effect on health service use for individuals whose primary (or predominant) provider is a specialist instead of a primary care provider (PCP). OBJECTIVE: To test associations between health service use and expenditures and (1) beneficiaries' predominant provider type (PCP or specialist) and (2) COC among beneficiaries who primarily see a PCP and those who primarily see a specialist. RESEARCH DESIGN: This is a cross-sectional analysis of Medicare fee-for-service claims data from July 2007 to June 2009. Negative binomial and generalized linear models were used in multivariate regression modeling. SUBJECTS: The study cohort comprised 613,471 community-residing Medicare fee-for-service beneficiaries. MEASURES: Beneficiaries' predominant provider type and COC index during a baseline period (July 2007-June 2008) were studied. All-cause and ambulatory care sensitive condition (ACSC) hospitalizations and emergency department (ED) visits and related expenditures and total expenditures in a 1-year follow-up period (July 2008-June 2009) were also reported. RESULTS: Twenty-five percent of beneficiaries primarily saw a specialist. Having a specialist predominant provider was associated with 9% fewer ED visits, 14% fewer ACSC ED visits, and 8% fewer ACSC hospitalizations (all P<0.001). Regardless of whether the beneficiary's predominant provider was a specialist or a PCP, higher continuity was associated with fewer all-cause hospitalizations and ED visits and lower expenditures for these services. Higher continuity was also associated with lower total expenditures. CONCLUSIONS: Regardless of the predominant provider's specialty, greater continuity was associated with less use of high-cost services and lower expenditures for these services.

Effects of home visits by paraprofessionals and by nurses on children: follow-up of a randomized trial at ages 6 and 9 years.

IMPORTANCE: The Nurse-Family Partnership delivered by nurses has been found to produce long-term effects on maternal and child health in replicated randomized trials. A persistent question is whether paraprofessional home visitors might produce comparable effects. OBJECTIVE: To examine the impact of prenatal and infancy/toddler home visits by paraprofessionals and by nurses on child development at child ages 6 and 9 years. DESIGN, SETTING, AND PARTICIPANTS: Randomized trial in public and private care settings in Denver, Colorado, of 735 low-income women and their first-born children (85% of the mothers were unmarried; 47% were Hispanic, 35% were non-Hispanic white, 15% were African American, and 3% were American Indian/Asian). INTERVENTIONS: Home visits provided from pregnancy through child age 2 years delivered in one group by paraprofessionals and in the other by nurses. MAIN OUTCOMES AND MEASURES: Reports of children's internalizing, externalizing, and total emotional/behavioral problems, and tests of children's language, intelligence, attention, attention dysfunction, visual attention/task switching, working memory, and academic achievement. We hypothesized that program effects on cognitive-related outcomes would be more pronounced among children born to mothers with low psychological resources. We report paraprofessional-control and nurse-control differences with P < .10 given similar effects in a previous trial, earlier effects in this trial, and limited statistical power. RESULTS: There were no significant paraprofessional effects on emotional/behavioral problems, but paraprofessional-visited children born to mothers with low psychological resources compared with control group counterparts exhibited fewer errors in visual attention/task switching at age 9 years (effect size = -0.30, P = .08). There were no statistically significant paraprofessional effects on other primary outcomes. Nurse-visited children were less likely to be classified as having total emotional/behavioral problems at age 6 years (relative risk [RR] = 0.45, P = .08), internalizing problems at age 9 years (RR = 0.44, P = .08), and dysfunctional attention at age 9 years (RR = 0.34, P = .07). Nurse-visited children born to low-resource mothers compared with control-group counterparts had better receptive language averaged over ages 2, 4, and 6 years (effect size = 0.30, P = .01) and sustained attention averaged over ages 4, 6, and 9 years (effect size = 0.36, P = .006). There were no significant nurse effects on externalizing problems, intellectual functioning, and academic achievement. CONCLUSIONS AND RELEVANCE: Children born to low-resource mothers visited by paraprofessionals exhibited improvement in visual attention/task switching. Nurse-visited children showed improved behavioral functioning, and those born to low-resource mothers benefited in language and attention but did not improve in intellectual functioning and academic achievement. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00438282 and NCT00438594.

Improving the nurse-family partnership in community practice.

BACKGROUND: Evidence-based preventive interventions are rarely final products. They have reached a stage of development that warrant public investment but require additional research and development to strengthen their effects. The Nurse-Family Partnership (NFP), a program of nurse home visiting, is grounded in findings from replicated randomized controlled trials. OBJECTIVE: Evidence-based programs require replication in accordance with the models tested in the original randomized controlled trials in order to achieve impacts comparable to those found in those trials, and yet they must be changed in order to improve their impacts, given that interventions require continuous improvement. This article provides a framework and illustrations of work our team members have developed to address this tension. METHODS: Because the NFP is delivered in communities outside of research contexts, we used quantitative and qualitative research to identify challenges with the NFP program model and its implementation, as well as promising approaches for addressing them. RESULTS: We describe a framework used to address these issues and illustrate its use in improving nurses' skills in retaining participants, reducing closely spaced subsequent pregnancies, responding to intimate partner violence, observing and promoting caregivers' care of their children, addressing parents' mental health problems, classifying families' risks and strengths as a guide for program implementation, and collaborating with indigenous health organizations to adapt and evaluate the program for their populations. We identify common challenges encountered in conducting research in practice settings and translating findings from these studies into ongoing program implementation. CONCLUSIONS: The conduct of research focused on quality improvement, model improvement, and implementation in NFP practice settings is challenging, but feasible, and holds promise for improving the impact of the NFP.

Examination of the accuracy of coding hospital-acquired pressure ulcer stages.

OBJECTIVE: Pressure ulcers (PU) are considered harmful conditions that are reasonably prevented if accepted standards of care are followed. They became subject to the payment adjustment for hospitalacquired conditions (HACs) beginning October 1, 2008. We examined several aspects of the accuracy of coding for pressure ulcers under the Medicare Hospital-Acquired Condition Present on Admission (HAC-POA) Program. We used the "4010" claim format as a basis of reference to show some of the issues of the old format, such as the underreporting of pressure ulcer stages on pressure ulcer claims and how the underreporting varied by hospital characteristics. We then used the rate of Stage III and IV pressure ulcer HACs reported in the Hospital Cost and Utilization Project State Inpatient Databases data to look at the sensitivity of PU HAC-POA coding to the number of diagnosis fields. METHODS: We examined Medicare claims data for FYs 2009 and 2010 to examine the degree that the presence of stage codes were underreported on pressure ulcer claims. We selected all claims with a secondary diagnosis code of pressure ulcer site (ICD-9 diagnosis codes 707.00-707.09) that were not reported as POA (POA of "N" or "U"). We then created a binary indicator for the presence of any pressure ulcer stage diagnosis code. We examine the percentage of claims with a diagnosis of a pressure ulcer site code with no accompanying pressure ulcer stage code. RESULTS: Our results point to underreporting of PU stages under the "4010" format and that the reporting of stage codes varied across hospital type and location. Further, our results indicate that under the "5010" format, a higher number of pressure ulcer HACs can be expected to be reported and we should expect to encounter a larger percentage of pressure ulcers incorrectly coded as POA under the new format. CONCLUSIONS: The combination of the capture of 25 diagnosis codes under the new "5010" format and the change from ICD-9 to ICD-10 will likely alleviate the observed underreporting of pressure ulcer HACs. However, as long as coding guidelines direct that Stage III and IV pressure ulcers be coded as POA, if a lower stage pressure ulcer was POA and progressed to a higher stage pressure ulcer during the admission, the acquisition of Stage III and IV pressure ulcers in the hospital will be underreported.

Maternal jail time, conviction, and arrest as predictors of children's 15-year antisocial outcomes in the context of a nurse home visiting program.

Data from the Nurse-Family Partnership intervention program were analyzed to compare the "selection" versus "unique" effects of maternal jail time on adolescent antisocial and health risk outcomes. Data from 320 women and their firstborn children were available from the prenatal, birth, and 15-year assessments. Consistent with a selection perspective, prenatal and demographic risks directly and indirectly related to many adolescent antisocial outcomes. Maternal conviction and arrest were also associated with adolescent contact with the criminal justice system and health risk behaviors. Maternal jail time predicted whether or not children had ever been stopped by police, sent to youth corrections, or run away from home. However, these associations were not significant after controlling for prenatal risk factors and maternal conviction and arrest. The results highlight the importance of maternal criminality and other risk factors in children's environments, including prenatal variables.