Risk Stratification Methods and Provision of Care Management Services in Comprehensive Primary Care Initiative Practices.

PURPOSE: Risk-stratified care management is essential to improving population health in primary care settings, but evidence is limited on the type of risk stratification method and its association with care management services. METHODS: We describe risk stratification patterns and association with care management services for primary care practices in the Comprehensive Primary Care (CPC) initiative. We undertook a qualitative approach to categorize risk stratification methods being used by CPC practices and tested whether these stratification methods were associated with delivery of care management services. RESULTS: CPC practices reported using 4 primary methods to stratify risk for their patient populations: a practice-developed algorithm (n = 215), the American Academy of Family Physicians' clinical algorithm (n = 155), payer claims and electronic health records (n = 62), and clinical intuition (n = 52). CPC practices using practice-developed algorithm identified the most number of high-risk patients per primary care physician (282 patients, P = .006). CPC practices using clinical intuition had the most high-risk patients in care management and a greater proportion of high-risk patients receiving care management per primary care physician (91 patients and 48%, P =.036 and P =.128, respectively). CONCLUSIONS: CPC practices used 4 primary methods to identify high-risk patients. Although practices that developed their own algorithm identified the greatest number of high-risk patients, practices that used clinical intuition connected the greatest proportion of patients to care management services.

Practice transformation in the safety net medical home initiative: a qualitative look.

BACKGROUND: Transformation of primary care to patient-centered medical homes (PCMH) is challenging. Progress in transformation varied widely among practices involved in the Safety Net Medical Home Initiative. OBJECTIVE: To study 3 successful practices to identify common characteristics and approaches. RESEARCH DESIGN: We selected 3 diverse practices based on their improvement on the PCMH-A, a self-assessment instrument measuring progress toward becoming a PCMH. We interviewed 2-3 leaders from the each of 3 practices seeking information about their motivations for transforming, the methods used to make changes, and challenges and facilitators. Interview data were coded, themes developed, and conclusions drawn using qualitative research methods. RESULTS: For these successful practices, the major motivators were a desire to improve quality of care, patient experience, or provider experience. Financial incentives played a minor role. All practices had engaged, visible leaders driving change, and all ultimately developed an effective quality improvement/practice change strategy that included the provision of trusted performance data at the provider level and an explicit process change strategy. Sequencing the work of PCMH transformation was important, and developing defined provider patient panels and building effective clinical teams facilitated making improvements to access and care delivery. CONCLUSIONS: Practice transformation is disruptive. To be successful, organizations need to have the will or motivation to change, explicit ideas or models on which to base change, and a culture and infrastructure that enables the execution of system changes.

Improving Wildfire Readiness Among Patients With Chronic Obstructive Pulmonary Disease and Asthma: Applying a Population Health Approach to Climate Change.

As a result of climate change, wildfire frequency, duration, and severity are increasing in the United States. Exposure to wildfire-related air pollutants can lead to negative health outcomes, particularly among patients with preexisting respiratory diseases (e.g., asthma and chronic obstructive pulmonary disease) and those who are at higher risk for developing these conditions. Underserved communities are disproportionately affected for multiple reasons, including lack of financial and social resources, increased exposure to air pollutants at home and at work, and impaired access to health care. To best serve clinically high-risk and underserved populations, health systems must leverage community public health data, develop and mobilize a wildfire preparedness action plan to identify populations at high risk, and implement interventions to mitigate the consequences of poor air quality. University of California, Davis Health, located at the epicenter of the largest wildfires in California's history, has developed the 5 pillar Wildfire Population Health Approach: (1) identify clinically at-risk and underserved patient populations using well-validated, condition-targeted registries; (2) assemble multidisciplinary care teams to understand the needs of these communities and patients; (3) create custom analytics and wildfire-risk stratification; (4) develop care pathways based on wildfire-risk tiers by disease, risk of exposure, and health care access; and (5) identify outcome measures tailored to interventions with a commitment to continuous, iterative improvement efforts. The Wildfire Population Health Approach provides an action plan for health systems and care teams to meet the needs of clinically at-risk and underserved patients affected by the increasing health threat posed by climate change-related wildfires.

A Multisite Electronic Health Record Integrated Remote Monitoring Intervention for Hypertension Improvement: Protocol for a Randomized Pragmatic Comparative Effectiveness Trial.

BACKGROUND: Hypertension is a major contributor to various adverse health outcomes. Although previous studies have shown the benefits of home blood pressure (BP) monitoring over office-based measurements, there is limited evidence comparing the effectiveness of whether a BP monitor integrated into the electronic health record is superior to a nonintegrated BP monitor. OBJECTIVE: In this paper, we describe the protocol for a pragmatic multisite implementation of a quality improvement initiative directly comparing integrated to nonintegrated BP monitors for hypertension improvement. METHODS: We will conduct a randomized, comparative effectiveness trial at 3 large academic health centers across California. The 3 sites will enroll a total of 660 participants (approximately n=220 per site), with 330 in the integrated BP monitor arm and 330 in the nonintegrated BP control arm. The primary outcome of this study will be the absolute difference in systolic BP in mm Hg from enrollment to 6 months. Secondary outcome measures include binary measures of hypertension (controlled vs uncontrolled), hypertension-related health complications, hospitalizations, and death. The list of possible participants will be generated from a central data warehouse. Randomization will occur after enrollment in the study. Participants will use their assigned BP monitor and join site-specific hypertension interventions. Cross-site learning will occur at regular all-site meetings facilitated by the University of California, Los Angeles Value-Based Care Research Consortium. A pre- and poststudy questionnaire will be conducted to further evaluate participants' perspectives regarding their BP monitor. Linear mixed effects models will be used to compare the primary outcome measure between study arms. Mixed effects logistic regression models will be used to compare secondary outcome measures between study arms. RESULTS: The study will start enrolling participants in the second quarter of 2023 and will be completed by the first half of 2024. Results will be published by the end of 2024. CONCLUSIONS: This pragmatic trial will contribute to the growing field of chronic care management using remote monitoring by answering whether a hypertension intervention coupled with an electronic health record integrated home BP monitor improves patients' hypertension better than a hypertension intervention with a nonintegrated BP monitor. The outcomes of this study may help health system decision makers determine whether to invest in integrated BP monitors for vulnerable patient populations. TRIAL REGISTRATION: ClinicalTrials.gov NCT05390502; clinicaltrials.gov/study/NCT05390502. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/45915.

Key Factors that Promote Low-Value Care: Views of Experts From the United States, Canada, and the Netherlands.

BACKGROUND: Around the world, policies and interventions are used to encourage clinicians to reduce low-value care. In order to facilitate this, we need a better understanding of the factors that lead to low-value care. We aimed to identify the key factors affecting low-value care on a national level. In addition, we highlight differences and similarities in three countries. METHODS: We performed 18 semi-structured interviews with experts on low-value care from three countries that are actively reducing low-value care: the United States, Canada, and the Netherlands. We interviewed 5 experts from Canada, 6 from the United States, and 7 from the Netherlands. Eight were organizational leaders or policy-makers, 6 as low-value care researchers or project leaders, and 4 were both. The transcribed interviews were analyzed using inductive thematic analysis. RESULTS: The key factors that promote low-value care are the payment system, the pharmaceutical and medical device industry, fear of malpractice litigation, biased evidence and knowledge, medical education, and a 'more is better' culture. These factors are seen as the most important in the United States, Canada and the Netherlands, although there are several differences between these countries in their payment structure, and industry and malpractice policy. CONCLUSION: Policy-makers and researchers that aim to reduce low-value care have experienced that clinicians face a mix of interdependent factors regarding the healthcare system and culture that lead them to provide low-value care. Better awareness and understanding of these factors can help policy-makers to facilitate clinicians and medical centers to deliver high-value care.

Creating value for communities: Los Angeles County's investment in Housing for Health.

With U.S. healthcare expenditures leading and social service spending trailing other developed nations, patients, caregivers, and employers are insisting on improved value in health and healthcare for communities. Yet, health systems struggle to understand how to best invest existing funding or savings to reach these goals. We share the experience of Los Angeles County's health system that has invested in housing through their Housing for Health Program (HFH) to address the needs of high cost populations within communities. The approach rested on four key program strategies including having partnerships with various housing facilities, a whole person approach with broad community-based resources, a local footprint in community health services, and a robust jail and prison transitions program. HFH also relied on three key implementation strategies including having dynamic funding sources, stakeholder alignment, and continuous improvement. This case report describes these program and implementation strategies plus challenges and lessons learned navigating homeless individuals through the regulations of various funding contracts, maintaining service provider capacity, maintaining local culture in implementation, and persistent gaps in affordable housing availability. Future policies can incentivize similar efforts and infrastructure to transfer healthcare dollars into public services to improve housing and value for communities.

Health Care Value: Relationships Between Population Health, Patient Experience, and Costs of Care.

Health care delivery in the United States has become complex and inefficient. With national health care gross domestic product and out-of-pocket expenses increasing, the nation has not yet improved the quality of health care compared with similar nations. As a result, the public asks for greater population health, improved patient experience, and reduced expenses. In this article, the author discuss how key stakeholders, including policy makers, health systems, patients, and employers, understand how these components of health care value are defined, interlink, and provide opportunities for improvement. The author also outlines concrete improvement opportunities from across the country.

Aligning Delivery System and Training Missions in Academic Medical Centers to Promote High-Value Care.

Academic medical centers (AMCs) are transforming to improve their care delivery and learning environments so that they build a culture that fosters high-value care. However, AMCs struggle to create learning environments where trainees are part of the reason for institutional success and their initiatives have high impact and are sustainable. The authors believe that AMCs can reach these goals if they codevelop strategic priorities and provide infrastructure to support alignment between the missions of health delivery systems and graduate medical education (GME).They outline four steps for AMCs and policy makers to create an infrastructure that supports this alignment to deliver value-based care. First, AMCs can align strategic priorities between delivery systems and educators by creating a common understanding of why initiatives require priorities within the health care system. Second, AMCs can support alignment with data from multiple sources that are reliable, valid, and actionable for trainees. Third, resident initiatives can create sustained impact by linking trainees to the institutional staff and infrastructure supporting value improvement efforts. Fourth, incentive payment programs through medical education could augment current system incentives to propel further alignment between education and delivery systems. The authors support their recommendations with concrete examples from emerging models created by GME and health delivery system leaders at AMCs across the country.

Association between Hospitalist Productivity Payments and High-Value Care Culture.

BACKGROUND: Given the national emphasis on affordability, healthcare systems expect that their clinicians are motivated to provide high-value care. However, some hospitalists are reimbursed with productivity bonuses, and little is known about the effects of these reimbursements on the local culture of high-value care delivery. OBJECTIVE: To evaluate if hospitalist reimbursement models are associated with high-value culture in university, community, and safety-net hospitals. DESIGN, SETTING, PATIENTS: Internal medicine hospitalists from 12 hospitals across California completed a cross-sectional survey assessing their perceptions of high-value care culture within their institutions. Sites represented university, community, and safety-net centers with different performances as reflected by the Centers of Medicare and Medicaid Service's Value-based Purchasing (VBP) scores. MEASUREMENT: Demographic characteristics and High-Value Care Culture Survey (HVCCSTM) scores were evaluated using descriptive statistics, and associations were assessed through multilevel linear regression. RESULTS: Of the 255 hospitalists surveyed, 147 (57.6%) worked in university hospitals, 85 (33.3%) in community hospitals, and 23 (9.0%) in safety-net hospitals. Across all 12 sites, 166 (65.1%) hospitalists reported payment with salary or wages, and 77 (30.2%) with salary plus productivity adjustments. The mean HVCCS score was 50.2 (SD 13.6) on a 0-100 scale. Hospitalists reported lower mean HVCCS scores if they reported payment with salary plus productivity (ß = -6.2, 95% CI -9.9 to -2.5) than if they reported payment with salary or wages. CONCLUSIONS: Hospitalists paid with salary plus productivity reported lower high-value care culture scores for their institutions than those paid with salary or wages. High-value care culture and clinician reimbursement schemes are potential targets of strategies for improving quality outcomes at low cost.

High-Value Care Culture Among the Future Physician Workforce in Internal Medicine.

PURPOSE: Training in high-spending regions correlates with higher spending patterns among practicing physicians. This study aimed to evaluate whether trainees' exposure to a high-value care culture differed based on type of health system in which they trained. METHOD: In 2016, 517 internal medicine residents at 12 California graduate medical education programs (university, community, and safety-net medical centers) completed a cross-sectional survey assessing perceptions of high-value care culture within their respective training program. The authors used multilevel linear regression to assess the relationship between type of medical center and High-Value Care Culture Survey (HVCCS) scores. The correlation between mean institutional HVCCS and Centers for Medicare and Medicaid Services' Value-Based Purchasing (VBP) scores was calculated using Spearman rank coefficients. RESULTS: Of 517 residents, 306 (59.2%), 83 (16.1%), and 128 (24.8%) trained in university, community, and safety-net programs, respectively. Across all sites, the mean HVCCS score was 51.2 (standard deviation [SD] 11.8) on a 0-100 scale. Residents reported lower mean HVCCS scores if they were from safety-net-based training programs (ß = -4.4; 95% confidence interval: -8.2, -0.6) with lower performance in the leadership and health system messaging domain (P < .001). Mean institutional HVCCS scores among university and community sites positively correlated with institutional VBP scores (Spearman r = 0.71; P < .05). CONCLUSIONS: Safety-net trainees reported less exposure to aspects of high-value care culture within their training environments. Tactics to improve the training environment to foster high-value care culture include training, increasing access to data, and improving open communication about value.

Continuity Clinic Practice Feedback Curriculum for Residents: A Model for Ambulatory Education.

BACKGROUND: There is an unmet need for formal curricula to deliver practice feedback training to residents. OBJECTIVE: We developed a curriculum to help residents receive and interpret individual practice feedback data and to engage them in quality improvement efforts. METHODS: We created a framework based on resident attribution, effective metric selection, faculty coaching, peer and site comparisons, and resident-driven goals. The curriculum used electronic health record-generated resident-level data and disease-specific ambulatory didactics to help motivate quality improvement efforts. It was rolled out to 144 internal medicine residents practicing at 1 of 4 primary care clinic sites from July 2016 to June 2017. Resident attitudes and behaviors were tracked with presurveys and postsurveys, completed by 126 (88%) and 85 (59%) residents, respectively. Data log-ins and completion of educational activities were monitored. Group-level performance data were tracked using run charts. RESULTS: Survey results demonstrated significant improvements on a 5-point Likert scale in residents' self-reported ability to receive (from a mean of 2.0 to 3.3, P < .001) and to interpret and understand (mean of 2.4 to 3.2, P < .001) their practice performance data. There was also an increased likelihood they would report that their practice had seen improvements in patient care (13% versus 35%, P < .001). Run charts demonstrated no change in patient outcome metrics. CONCLUSIONS: A learner-centered longitudinal curriculum on ambulatory patient panels can help residents develop competency in receiving, interpreting, and effectively applying individualized practice performance data.

The Population Health Value Framework: Creating Value by Reducing Costs of Care for Patient Subpopulations With Chronic Conditions.

PROBLEM: With the growth in risk-based and accountable care organization contracts, creating value by redesigning care to reduce costs and improve outcomes and the patient experience has become an urgent priority for health care systems. APPROACH: In 2016, UCLA (University of California, Los Angeles) Health implemented a system-wide population health approach to identify patient populations with high expenses and promote proactive, value-based care. The authors created the Patient Health Value framework to guide value creation: (1) identify patient populations with high expenses and reasons for spending, (2) create design teams to understand the patient story, (3) create custom analytics and spending-based risk stratification, and (4) develop care pathways based on spending risk tiers. Primary care patients with three chronic conditions-dementia, chronic kidney disease (CKD), and cancer-were identified as high-cost subpopulations. OUTCOMES: For each patient subpopulation, a multispecialty, multidisciplinary design team identified reasons for spending and created care pathways to meet patient needs according to spending risk. Larger, lower-risk cohorts received necessary but less intensive interventions, while smaller, higher-risk cohorts received more intensive interventions. Preliminary analyses showed a 1% monthly decrease in inpatient bed day utilization among dementia patients (incident rate ratio [IRR] 0.99, P < .03) and a 2% monthly decrease in hospitalizations (IRR 0.98, P < .001) among CKD patients. NEXT STEPS: Use of the Patient Health Value framework is expanding across other high-cost subpopulations with chronic conditions. UCLA Health is using the framework to organize care across specialties, build capacity, and grow a culture for value.

Low-Value Proton Pump Inhibitor Prescriptions Among Older Adults at a Large Academic Health System.

BACKGROUND: Older adults are particularly vulnerable to complications from proton pump inhibitor (PPI) drugs. We sought to characterize the prevalence of potentially low-value PPI prescriptions among older adults to inform a quality improvement (QI) intervention. METHODS: We created a cohort of patients, aged 65 years or older, receiving primary care at a large academic health system in 2018. We identified patients currently prescribed any PPI using the electronic health record (EHR) medication list (current defined as September 1, 2018). A geriatrician, a gastroenterologist, a QI expert, and two primary care physicians (PCPs) created multidisciplinary PPI appropriateness criteria based on evidenced-based guidelines. Supervised by a gastroenterologist and PCP, two internal medicine residents conducted manual chart reviews in a random sample of 399 patients prescribed PPIs. We considered prescriptions potentially low value if they lacked a guideline-based (1) short-term indication (gastroesophageal reflux disease [GERD]/peptic ulcer disease/Helicobacter pylori gastritis/dyspepsia) or (2) long-term (>8 weeks) indication (severe/refractory GERD/erosive esophagitis/Barrett esophagus/esophageal adenocarcinoma/esophageal stricture/high gastrointestinal bleeding risk/Zollinger-Ellison syndrome). We used the Wilson score method to calculate 95% confidence intervals (CIs) on low-value PPI prescription prevalence. RESULTS: Among 69 352 older adults, 8729 (12.6%) were prescribed a PPI. In the sample of 399 patients prescribed PPIs, 63.9% were female; their mean age was 76.2 years, and they were seen by 169 PCPs. Of the 399 prescriptions, 143 (35.8%; 95% CI = 31.3%-40.7%) were potentially low value-of which 82% began appropriately (eg, GERD) but then continued long term without a guideline-based indication. Among 169 PCPs, 32 (18.9%) contributed to 59.2% of potentially low-value prescriptions. CONCLUSION: One in eight older adults were prescribed a PPI, and over one-third of prescriptions were potentially low-value. Most often, appropriate short-term prescriptions became potentially low value because they lacked long-term indications. With most potentially low-value prescribing concentrated among a small subset of PCPs, interventions targeting them and/or applying EHR-based automatic stopping rules may protect older adults from harm. J Am Geriatr Soc 67:2600-2604, 2019.

Measuring Value in Internal Medicine Residency Training Hospitals Using Publicly Reported Measures.

Graduate medical education (GME) lacks measures of resident preparation for high-quality, cost-conscious practice. The authors used publicly reported teaching hospital value measures to compare internal medicine residency programs on high-value care training and to validate these measures against program director perceptions of value. Program-level value training scores were constructed using Centers for Medicare & Medicaid Services Value-Based Purchasing (VBP) Program hospital quality and cost-efficiency data. Correlations with Association of Program Directors in Internal Medicine Annual Survey high-value care training measures were examined using logistic regression. For every point increase in program-level VBP score, residency directors were more likely to agree that GME programs have a responsibility to contain health care costs (adjusted odds ratio [aOR] 1.18, P = .04), their faculty model high-value care (aOR 1.07, P = .03), and residents are prepared to make high-value medical decisions (aOR 1.07, P = .09). Publicly reported clinical data offer valid measures of GME value training.

Swimming Upstream: Creating a Culture of High-Value Care.

As health system leaders strategize the best ways to encourage the transition toward value-based health care, the underlying culture-defined as a system of shared assumptions, values, beliefs, and norms existing within an environment-continues to shape clinician practice patterns. The current prevailing medical culture contributes to overtesting, overtreatment, and health care waste. Choosing Wisely lists, appropriateness criteria, and guidelines codify best practices, but academic medicine as a whole must recognize that faculty and trainees are all largely still operating within the same cultural climate. Addressing this culture, on both local and national levels, is imperative for engaging clinicians in reforms and creating sustained changes that will deliver on the promise of better health care value. This Perspective outlines four steps for health system leaders to understand, cultivate, and maintain cultural changes toward value-based care: (1) Build the will for change through engaging frontline providers and communicating patient-centered motivations for health care value; (2) create necessary infrastructure to support value improvement efforts; (3) expose physicians to value-based payment structures; and (4) demonstrate leadership commitment and visibility to shared goals. The authors support their recommendations with concrete examples from emerging models and leaders across the country.

Disseminating Innovations in Teaching Value-Based Care Through an Online Learning Network.

BACKGROUND: A national imperative to provide value-based care requires new strategies to teach clinicians about high-value care. OBJECTIVE: We developed a virtual online learning network aimed at disseminating emerging strategies in teaching value-based care. METHODS: The online Teaching Value in Health Care Learning Network includes monthly webinars that feature selected innovators, online discussion forums, and a repository for sharing tools. The learning network comprises clinician-educators and health system leaders across North America. We conducted a cross-sectional online survey of all webinar presenters and the active members of the network, and we assessed program feasibility. RESULTS: Six months after the program launched, there were 277 learning community members in 22 US states. Of the 74 active members, 50 (68%) completed the evaluation. Active members represented independently practicing physicians and trainees in 7 specialties, nurses, educators, and health system leaders. Nearly all speakers reported that the learning network provided them with a unique opportunity to connect with a different audience and achieve greater recognition for their work. Of the members who were active in the learning network, most reported that strategies gleaned from the network were helpful, and some adopted or adapted these innovations at their home institutions. One year after the program launched, the learning network had grown to 364 total members. CONCLUSIONS: The learning network helped participants share and implement innovations to promote high-value care. The model can help disseminate innovations in emerging areas of health care transformation, and is sustainable without ongoing support after a period of start-up funding.

Development of a high-value care culture survey: a modified Delphi process and psychometric evaluation.

BACKGROUND: Organisational culture affects physician behaviours. Patient safety culture surveys have previously been used to drive care improvements, but no comparable survey of high-value care culture currently exists. We aimed to develop a High-Value Care Culture Survey (HVCCS) for use by healthcare leaders and training programmes to target future improvements in value-based care. METHODS: We conducted a two-phase national modified Delphi process among 28 physicians and nurse experts with diverse backgrounds. We then administered a cross-sectional survey at two large academic medical centres in 2015 among 162 internal medicine residents and 91 hospitalists for psychometric evaluation. RESULTS: Twenty-six (93%) experts completed the first phase and 22 (85%) experts completed the second phase of the modified Delphi process. Thirty-eight items achieved ≥70% consensus and were included in the survey. One hundred and forty-one residents (83%) and 73 (73%) hospitalists completed the survey. From exploratory factor analyses, four factors emerged with strong reliability: (1) leadership and health system messaging (α=0.94); (2) data transparency and access (α=0.80); (3) comfort with cost conversations (α=0.70); and (4) blame-free environment (α=0.70). In confirmatory factor analysis, this four-factor model fit the data well (Bentler-Bonett Normed Fit Index 0.976 and root mean square residual 0.056). The leadership and health system messaging (r=0.56, p<0.001), data transparency and access (r=0.15, p<0.001) and blame-free environment (r=0.37, p<0.001) domains differed significantly between institutions and positively correlated with Value-Based Purchasing Scores. CONCLUSIONS: Our results provide support for the reliability and validity of the HVCCS to assess high-value care culture among front-line clinicians. HVCCS may be used by healthcare groups to identify target areas for improvements and to monitor the effects of high-value care initiatives.