A Hospice Transitions Program for Patients in the Emergency Department.

Importance: Patients often visit the emergency department (ED) near the end of life. Their common disposition is inpatient hospital admission, which can result in a delayed transition to hospice care and, ultimately, an inpatient hospital death that may be misaligned with their goals of care. Objective: To assess the association of hospice use with a novel multidisciplinary hospice program to rapidly identify and enroll eligible patients presenting to the ED near end of life. Design, Setting, and Participants: This pre-post quality improvement study of a novel, multifaceted care transitions program involving a formalized pathway with email alerts, clinician training, hospice vendor expansion, metric creation, and data tracking was conducted at a large, urban tertiary care academic medical center affiliated with a comprehensive cancer center among adult patients presenting to the ED near the end of life. The control period before program launch was from September 1, 2018, to January 31, 2020, and the intervention period after program launch was from August 1, 2021, to December 31, 2022. Main Outcome and Measures: The primary outcome was a transition to hospice without hospital admission and/or hospice admission within 96 hours of the ED visit. Secondary outcomes included length of stay and in-hospital mortality. Results: This study included 270 patients (median age, 74.0 years [IQR, 62.0-85.0 years]; 133 of 270 women [49.3%]) in the control period, and 388 patients (median age, 73.0 years [IQR, 60.0-84.0 years]; 208 of 388 women [53.6%]) in the intervention period, identified as eligible for hospice transition within 96 hours of ED arrival. In the control period, 61 patients (22.6%) achieved the primary outcome compared with 210 patients (54.1%) in the intervention period (P < .001). The intervention was associated with the primary outcome after adjustment for age, race and ethnicity, primary payer, Charlson Comorbidity Index, and presence of a Medical Order for Life-Sustaining Treatment (MOLST) (adjusted odds ratio, 5.02; 95% CI, 3.17-7.94). In addition, the presence of a MOLST was independently associated with hospice transition across all groups (adjusted odds ratio, 1.88; 95% CI, 1.18-2.99). There was no significant difference between the control and intervention periods in inpatient length of stay (median, 2.0 days [IQR, 1.1-3.0 days] vs 1.9 days [IQR, 1.1-3.0 days]; P = .84), but in-hospital mortality was lower in the intervention period (48.5% [188 of 388] vs 64.4% [174 of 270]; P < .001). Conclusions and Relevance: In this quality improvement study, a multidisciplinary program to facilitate ED patient transitions was associated with hospice use. Further investigation is needed to examine the generalizability and sustainability of the program.

Misaligned Pharmacy Incentives in Value-Based Care.

This Viewpoint explains some ways in which the alignment of incentives between payers and clinicians in value-based care (VBC) arrangements can be interrupted and proposes a multifaceted approach to realigning incentives for drug spending within VBC contracts to better provide value-based care and improve patient outcomes.

Sex Differences in Primary Care-Based Chronic Kidney Disease Management.

This retrospective study uses electronic health record data to investigate the sex differences in guideline-based management outcomes between male and female patients with chronic kidney disease.

Optimization of Patient Progression in a New Era: A Comprehensive Framework.

PURPOSE/OBJECTIVES: The onset of the coronavirus disease 2019 pandemic increased the demand for inpatient services and led to widespread staffing shortages in the acute and post-acute setting, contributing to delayed inpatient throughput and leading to capacity crises. Novel strategies are needed to facilitate the efficient progression of hospitalized patients when medically ready for lower levels of care. The authors have developed a foundational strategic framework for patient progression to ensure capture of patient progression data, enhance efficiency, and optimal utilization of post-acute resources in increasingly complex and resource-constrained acute and post-acute environments. PRIMARY PRACTICE SETTINGS: Interventions were implemented, and metrics of success tracked as part of an overarching framework to test new models of care or optimize existing assets related to barriers to patient progression. Brigham and Women's Hospital (BWH) and Brigham and Women's Faulkner Hospital (BWFH) comprise an academic medical center and a community hospital, respectively, that are affiliated with Massachusetts General Brigham (MGB), a nonprofit health care system in Massachusetts. Key interventions include (1) screening to prioritize patients needing case management services through a modified early screening for discharge planning tool and process; (2) communicating, documenting, identifying patient progression status, barriers to discharge and post-acute needs through interdisciplinary care optimization rounds, a novel tool in the electronic health record, and an associated dashboard; (3) managing active high-risk patients through a novel complex care team and post-acute strategy development; (4) developing novel transportation and hospice pathways; and (5) establishing community hospital repatriation and a physical therapy "Why Not Home" campaign. FINDINGS: Key metrics of success were (1) modified discharge planning tool resulting in screening out low-risk patients (53%) and impacting length of stay (0.55-day reduction, p = .083) during a 3-month intervention versus control study; (2) documentation adherence in more than 98% of patients 10 months postimplementation; (3) complex care team achieving a 2.5% reduction in Case Mix Index-adjusted length of stay 6 months postimplementation; (4) use of care van offsetting ambulance/chair car in 10% of cases, and earlier discharge time/length of stay in 21% of cases 3 months postimplementation; and (5) implementation of community repatriation impacting delay days to discharge (10-month pilot, 40 patients accounting for 1,000 delay days). CONCLUSIONS: Implementation of a novel comprehensive framework focusing on optimizing patient progression resulted in increased operational efficiency and positively impacted length of stay at our academic and community hospitals. Additional study is actively ongoing to understand long-term benefit of the innovations that the authors have developed. Further interventions are needed to wholly mitigate evolving capacity challenges in the acute and post-acute settings. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: The authors' implementation of the Brigham framework for progression demonstrates that innovative approaches to case management can help address the evolving challenges in care transitions planning. Notable opportunities include approaches that empower case managers as multidisciplinary team leaders, improve workflow, utilize patient progression data, prioritize patients with complex care needs support key patient populations, and promote post-acute collaboration.

Cost, Utilization, and Patient and Family Experience With ACO-Based Pediatric Care Management.

BACKGROUND AND OBJECTIVES: Children and Youth with Special Health Care Needs have high healthcare utilization, fragmented care, and unmet health needs. Accountable Care Organizations (ACOs) increasingly use pediatric care management to improve quality and reduce unnecessary utilization. We evaluated effects of pediatric care management on total medical expense (TME) and utilization; perceived quality of care coordination, unmet needs, and patient and family experience; and differential impact by payor, risk score, care manager discipline, and behavioral health diagnosis. METHODS: Mixed-methods analysis including claims using quasi-stepped-wedge design pre and postenrollment to estimate difference-in-differences, participant survey, and semistructured interviews. Participants included 1321 patients with medical, behavioral, or social needs, high utilization, in Medicaid or commercial ACOs, and enrolled in multidisciplinary, primary care-embedded care management. RESULTS: TME significantly declined 1 to 6 months postenrollment and continued through 19 to 24 months (-$645.48 per member per month, P < .001). Emergency department and inpatient utilization significantly decreased 7 to 12 months post-enrollment and persisted through 19 to 24 months (-29% emergency department, P = .012; -82% inpatient, P < .001). Of respondents, 87.2% of survey respondents were somewhat or very satisfied with care coordination, 56.1% received education coordination when needed, and 81.5% had no unmet health needs. Emergency department or inpatient utilization decreases were consistent across payors and care manager disciplines, occurred sooner with behavioral health diagnoses, and were significant among children with above-median risk scores. Satisfaction and experience were equivalent across groups, with more unmet needs and frustration with above-median risk scores. CONCLUSIONS: Pediatric care management in multipayor ACOs may effectively reduce TME and utilization and clinically provide high-quality care coordination, including education and family stress, with high participant satisfaction.

Survey Study of a Hospital-Based Bereavement Program During COVID-19: Insights to Improve Support of the Bereaved.

Background: The COVID-19 pandemic has highlighted that bereavement care is under-recognized with few hospitals offering universal bereavement services. Methods: One hundred sixty-nine bereaved individuals, whose loved ones died at our hospital during 2021 and 2022, completed a survey about their experience with the bereavement program. Results: Of respondents who recalled receiving bereavement outreach, 79% rated speaking to a team member soon after the death as having a positive impact on their bereavement, and 75% rated receiving a condolence call or note from the team positively. Feedback also identified opportunities for improvements in care: (1) importance of compassionate communication and connection with family members after a death; (2) more flexible hospital visitation policies; and (3) additional support for families during the end-of-life (EOL) period. Conclusions: The findings demonstrated that a hospital-based bereavement program can positively impact an individual's bereavement experience with a formal letter of condolence, psychoeducation information, and direct outreach from team members soon after death, being positively evaluated.

Optimal Care for Kidney Health: Development of a Merit-based Incentive Payment System (MIPS) Value Pathway.

The Merit-based Incentive Payment System (MIPS) is a mandatory pay-for-performance program through the Centers for Medicare & Medicaid Services (CMS) that aims to incentivize high-quality care, promote continuous improvement, facilitate electronic exchange of information, and lower health care costs. Previous research has highlighted several limitations of the MIPS program in assessing nephrology care delivery, including administrative complexity, limited relevance to nephrology care, and inability to compare performance across nephrology practices, emphasizing the need for a more valid and meaningful quality assessment program. This article details the iterative consensus-building process used by the American Society of Nephrology Quality Committee from May 2020 to July 2022 to develop the Optimal Care for Kidney Health MIPS Value Pathway (MVP). Two rounds of ranked-choice voting among Quality Committee members were used to select among nine quality metrics, 43 improvement activities, and three cost measures considered for inclusion in the MVP. Measure selection was iteratively refined in collaboration with the CMS MVP Development Team, and new MIPS measures were submitted through CMS's Measures Under Consideration process. The Optimal Care for Kidney Health MVP was published in the 2023 Medicare Physician Fee Schedule Final Rule and includes measures related to angiotensin-converting enzyme inhibitor and angiotensin receptor blocker use, hypertension control, readmissions, acute kidney injury requiring dialysis, and advance care planning. The nephrology MVP aims to streamline measure selection in MIPS and serves as a case study of collaborative policymaking between a subspecialty professional organization and national regulatory agencies.

Reframing Value-Based Care Management: Beyond Cost Reduction and Toward Patient Centeredness.

Importance: Care management programs are increasingly being utilized by health systems as a new foundational strategy to advance value-based care. These programs offer the promise of improving patient outcomes while decreasing health care utilization and costs. However, as these programs proliferate in number and specialization, the field of care management is increasingly at risk of fragmentation, inefficiency, and failure to meet the core needs of the patient. Observations: This review of the current state of care management identifies several key challenges for the field, including an unclear value proposition, a focus on system- vs patient-centered outcomes, increased specialization by private and public entrants that produces care fragmentation, and lack of coordination among health and social service entities. A framework is proposed for reorienting care management to truly address the needs of patients through acknowledging the dynamic nature of patient care needs, providing a continuum of need-targeted programming, coordinating care among all involved entities and staff, and performing regular evaluations of outcomes that include patient-centered and health equity measures. Guidance on how this framework can be implemented within a health system and an outline of recommendations is provided for how policymakers may incentivize the development of high value and more equitable care management programs. Conclusions and Relevance: With increased focus on care management as a cornerstone of value-based care, value-based health leaders and policymakers can improve the effectiveness and value of care management programs, reduce patient financial burden for care management services, and promote stakeholder coordination.

Tacking upwind: reducing spending among high-risk commercially insured patients.

OBJECTIVES: The study examined a commercial accountable care organization (ACO) population and then assessed the impact of an integrated care management program on medical spending and clinical event rates. STUDY DESIGN: Retrospective cohort study of high-risk individuals (n = 487) in a population of 365,413 individuals aged 18 to 64 years within the Mass General Brigham health system who were part of commercial ACO contracts with 3 large insurers between 2015 and 2019. METHODS: Using medical spending claims and other enrollment data, the study assessed the demographic and clinical characteristics, medical spending, and clinical event rates of patients in the ACO and its high-risk care management program. The study then examined the impact of the program using a staggered difference-in-difference design with individual-level fixed effects and compared outcomes of those who had entered the program with those of similar patients who had not entered. RESULTS: The commercially insured ACO population was healthy on average but included several hundred high-risk patients (n = 487). After adjustment, patients within the ACO's integrated care management program for high-risk patients had lower monthly medical spending (by $1361 per person per month) as well as lower emergency department visit and hospitalization rates compared with similar patients who had yet to start the program. Accounting for early ACO departure decreased the magnitude of the program effects as expected. CONCLUSIONS: Commercial ACO populations may be healthy on average but still include some high-risk patients. Identifying which patients might benefit from more intensive care management could be critical for reaping the potential savings.

Population turnover and leakage in commercial ACOs.

OBJECTIVES: Commercial accountable care organization (ACO) contracts attempt to mitigate spending growth, but past evaluations have been limited to continuously enrolled ACO members in health maintenance organization (HMO) plans, excluding many members. The objective of this study was to examine the magnitude of turnover and leakage within a commercial ACO. STUDY DESIGN: A historical cohort study using detailed information from multiple commercial ACO contracts within a large health care system between 2015 and 2019. METHODS: Individuals insured through 1 of the 3 largest commercial ACO contracts during the study period, 2015-2019, were included. We examined patterns of entry and exit and the characteristics that predicted remaining in the ACO compared with leaving the ACO. We also examined predictors of the amount of care delivered in the ACO compared with outside the ACO. RESULTS: Among the 453,573 commercially insured individuals in the ACO, approximately half left the ACO within the initial 24 months after entry. Approximately one-third of spending was for care occurring outside the ACO. Patients who remained in the ACO differed from those who left earlier, including being older, having a non-HMO plan, having lower predicted spending at entry, and having more medical spending for care performed within the ACO during the initial quarter of membership. CONCLUSIONS: Both turnover and leakage hamper the ability of ACOs to manage spending. Modifications that address potentially intrinsic vs avoidable sources of population turnover and increase patient incentives for care within vs outside of ACOs could help address medical spending growth within commercial ACO programs.

Estimated GFR With Cystatin C and Creatinine in Clinical Practice: A Retrospective Cohort Study.

Rationale & Objective: Estimation of glomerular filtration rate (eGFR) and staging of chronic kidney disease (CKD) are essential to guide management. Although creatinine is routinely used, a recent national task force recommended the use of cystatin C for confirmation. The objective of this study was to examine the following parameters: (1) how cystatin C correlates with creatinine eGFR; (2) how it indicates differences in CKD staging; and (3) how it may affect kidney care delivery. Study Design: Retrospective observational cohort study. Setting & Participants: 1,783 inpatients and outpatients who had cystatin C and creatinine levels drawn within 24 hours at Brigham Health-affiliated clinical laboratories. Predictors: Serum creatinine levels, basic clinical/sociodemographic variables, and reasons for ordering cystatin C from a structured partial chart review. Analytical Approach: Univariate and multivariable linear and logistic regression. Results: Cystatin C-based eGFR was very strongly correlated with creatinine-based eGFR (Spearman correlation ρ = 0.83). Cystatin C eGFR resulted in a change to a later CKD stage in 27%, an earlier stage in 7%, and no change in 66% of patients. Black race was associated with a lower likelihood of change to a later stage (OR, 0.53; 95% CI [0.36, 0.75]; P < 0.001), whereas age (OR per year OR, 1.03; 95% CI [1.02, 1.04]; P < 0.001) and Elixhauser score (OR per point OR, 1.22; 95% CI [1.10, 1.36]; P < 0.001) were associated with a higher likelihood of change to a later stage. Limitations: Single center, no direct measurement of clearance for comparison, and inconsistent self-identification of race/ethnicity. Conclusions: Cystatin C eGFR correlates strongly with creatinine eGFR but can have a substantial effect on CKD staging. As cystatin C is adopted, clinicians must be informed on this impact.

Intensive care management of a complex Medicaid population: a randomized evaluation.

OBJECTIVES: Care management programs are employed by providers and payers to support high-risk patients and affect cost and utilization, with varied implementation. This study sought to evaluate the impact of an intensive care management program on utilization and cost among those with highest cost (top 5%) and highest utilization in a Medicaid accountable care organization (ACO) population. STUDY DESIGN: Randomized controlled quality improvement trial of intensive care management, provided by a nonprofit care management vendor, for Medicaid ACO patients at 2 academic centers. METHODS: Patients were identified using claims, chart review, and primary care validation, then randomly assigned 2:1 to intervention and control groups. Among 131 patients included in intent-to-treat analysis, 87 and 44 were randomly assigned to the intervention and control groups, respectively. Patients in the intervention group were eligible to receive intensive care management in the community/home setting and, in some cases, home-based primary care. Patients in the control group received standard of care, including practice-based care management. Prespecified primary outcome measures included total medical expense (TME), emergency department (ED) visits, and inpatient utilization. RESULTS: Relative to controls, patients randomly assigned to receive intensive care management had a $1933 smaller increase per member per month in TME (P = .04) and directionally consistent but nonsignificant reductions in ED visits (17% fewer; P = .40) and inpatient admissions (34% fewer; P = .29) in the 12 months post randomization compared with the 12 months prerandomization. CONCLUSIONS: Our study results support that targeted, intensive care management can favorably affect TME in a health system-based high-cost, high-risk Medicaid population. Further research is needed to evaluate the impact on additional clinical outcomes.

Value-Based Care and Kidney Disease: Emergence and Future Opportunities.

The United States health care system has increasingly embraced value-based programs that reward improved outcomes and lower costs. Health care value, defined as quality per unit cost, was a major goal of the 2010 Patient Protection and Affordable Care Act amid high and rising US health care expenditures. Many early value-based programs were specifically designed for patients with end-stage renal disease (ESRD) and targeted toward dialysis facilities, including the ESRD Prospective Payment System, ESRD Quality Incentive Program, and ESRD Seamless Care Organizations. While a great deal of attention has been paid to these ESRD-focused programs, other value-based programs targeted toward hospitals and health systems may also affect the quality and costs of care for a broader population of patients with kidney disease. Value-based care for kidney disease is increasingly relevant in light of the Advancing American Kidney Health initiative, which introduces new value-based payment models: the mandatory ESRD Treatment Choices Model in 2021 and voluntary Kidney Care Choices Model in 2022. In this review article, we summarize the emergence and impact of value-based programs on the quality and costs of kidney care, with a focus on federal programs. Key opportunities in value-based kidney care include shifting the focus toward chronic kidney disease, enhancing population health management capabilities, improving quality measurement, and leveraging programs to advance health equity.

Prescribing Patterns of Sodium-Glucose Cotransporter-2 Inhibitors in Patients with CKD: A Cross-Sectional Registry Analysis.

Background: Sodium-glucose cotransporter-2 inhibitors (SGLT-2i) reduce kidney disease progression and mortality in patients with chronic kidney disease (CKD), regardless of diabetes status. However, the prescribing patterns of these novel therapeutics in the CKD population in real-world settings remain largely unknown. Methods: This cross-sectional study included adults with stages 3-5 CKD included in the Mass General Brigham (MGB) CKD registry in March 2021. We described the adoption of SGLT-2i therapy and evaluated factors associated with SGLT-2i prescription using multivariable logistic regression models in the CKD population, with and without diabetes. Results: A total of 72,240 patients with CKD met the inclusion criteria, 31,688 (44%) of whom were men and 61,265 (85%) White. A total of 22,653 (31%) patients were in the diabetic cohort, and 49,587 (69%) were in the nondiabetic cohort. SGLT-2i prescription was 6% in the diabetic cohort and 0.3% in the nondiabetic cohort. In multivariable analyses, younger Black men with a history of heart failure, use of cardiovascular medications, and at least one cardiologist visit in the previous year were associated with higher odds of SGLT-2i prescription in both diabetic and nondiabetic cohorts. Among patients with diabetes, advanced CKD stages were associated with lower odds of SGLT-2i prescription, whereas urine dipstick test and at least one subspecialist visit in the previous year were associated with higher odds of SGLT-2i prescription. In the nondiabetic cohort, CKD stage, urine dipstick test, and at least one nephrologist visit in the previous year were not significantly associated with SGLT-2i prescription. Conclusions: In this registry study, prescription of SGLT-2i was low in the CKD population, particularly among patients without diabetes.