Effect of Social Needs Case Management on Hospital Use Among Adult Medicaid Beneficiaries : A Randomized Study.

BACKGROUND: Case management programs assisting patients with social needs may improve health and avoid unnecessary health care use, but little is known about their effectiveness. OBJECTIVE: This large-scale study assessed the population-level impact of a case management program designed to address patients' social needs. DESIGN: Single-site randomized encouragement design with administrative enrollment from an eligible population and intention-to-treat analysis. Study participants were enrolled between August 2017 and December 2018 and followed for 1 year. (ClinicalTrials.gov: NCT04000074). SETTING: Contra Costa County, an economically and culturally diverse community in the San Francisco Bay Area. PARTICIPANTS: 57 972 randomized enrollments of adult Medicaid patients at elevated risk for health care use (top 15%) to the intervention or control group. INTERVENTION: Enrollees were offered 12 months of social needs case management, which provided more intensive services to patients with higher demonstrated needs. MEASUREMENTS: Medical use was measured via emergency department (ED) visits and inpatient admissions, some of which were classified as avoidable. RESULTS: Participants in the intervention group visited the ED at ratios of 0.96 (95% CI, 0.91 to 1.00) for all visits and 0.97 (CI, 0.92 to 1.03) for avoidable visits relative to the control group. The intervention group was hospitalized at ratios of 0.89 (CI, 0.81 to 0.98) for all admissions and 0.72 (CI, 0.55 to 0.88) for avoidable admissions. LIMITATIONS: Only 40% of the intervention group engaged with the program. The program was in continual development during the trial period. CONCLUSION: Although social needs case management programs may reduce health care use, these savings may not cover full program costs. More work is needed to identify ways to increase patient uptake and define characteristics of successful programs. PRIMARY FUNDING SOURCE: Contra Costa Health Services via the Medicaid waiver program.

Conceptualizing the effective mechanisms of a social needs case management program shown to reduce hospital use: a qualitative study.

BACKGROUND: Social needs case management programs are a strategy to coordinate social and medical care for high-risk patients. Despite widespread interest in social needs case management, not all interventions have shown effectiveness. A lack of evidence about the mechanisms through which these complex interventions benefit patients inhibits effective translation to new settings. The CommunityConnect social needs case management program in Contra Costa County, California recently demonstrated an ability to reduce inpatient hospital admissions by 11% in a randomized study. We sought to characterize the mechanisms through which the Community Connect social needs case management program was effective in helping patients access needed medical and social services and avoid hospitalization. An in-depth understanding of how this intervention worked can support effective replication elsewhere. METHODS: Using a case study design, we conducted semi-structured, qualitative interviews with case managers (n = 30) and patients enrolled in social needs case management (n = 31), along with field observations of patient visits (n = 31). Two researchers coded all interview transcripts and observation fieldnotes. Analysis focused on program elements identified by patients and staff as important to effectiveness. RESULTS: Our analyses uncovered three primary mechanisms through which case management impacted patient access to needed medical and social services: [1] Psychosocial work, defined as interpersonal and emotional support provided through the case manager-patient relationship, [2] System mediation work to navigate systems, coordinate resources, and communicate information and [3] Addressing social needs, or working to directly mitigate the impact of social conditions on patient health. CONCLUSIONS: These findings highlight that the system mediation tasks which are the focus of many social needs assistance interventions offered by health care systems may be necessary but insufficient. Psychosocial support and direct assistance with social needs, enabled by a relationship-focused program, may also be necessary for effectiveness.

Comparing health care system and physician practice influences on social risk screening.

BACKGROUND: Health care systems can support dissemination of innovations, such as social risk screening in physician practices, but to date, no studies have examined the association of health system characteristics and practice-level adoption of social risk screening. PURPOSE: The aim of the study was to examine the association of multilevel organizational capabilities and adoption of social risk screening among system-owned physician practices. METHODOLOGY: Secondary analyses of the 2018 National Survey of Healthcare Organizations and Systems were conducted. Multilevel linear regression models examined physician practice and system characteristics associated with practice adoption of screening for five social risks (food insecurity, housing instability, utility needs, interpersonal violence, and transportation needs), accounting for clustering of practices within systems using random effects. RESULTS: System-owned practices screened for an average of 1.7 of the five social risks assessed. The intraclass correlation indicated 16% of practice variation in social risk screening was attributable to differences between their health systems owners, with 84% attributable to differences between individual practices. Practices owned by systems with multiple hospitals screened for an additional 0.44 social risks (p = .046) relative to practices of systems without hospitals. Practice characteristics associated with social risk screening included health information technology capacity (ß = 0.20, p = .005), innovation culture (ß = 0.26, p < .001), and patient engagement strategies (ß = 0.57, p < .001). CONCLUSIONS: Health care system capabilities account for less variation in physician practice adoption of social risk screening compared to practice-level capabilities. PRACTICE IMPLICATIONS: Efforts to expand social risk screening among system-owned physician practices should focus on supporting practice capabilities, including enhancing health information technology, promoting an innovative organizational culture, and advancing patient engagement strategies.

Achieving Population Health Impacts Through Health Promotion Programs Offered by Community-based Organizations.

BACKGROUND: Evidence-based health promotion programs can help older adults manage chronic conditions and address behavioral risk factors, and translating these interventions to population-scale impact depends on reaching people outside of clinical settings. Area Agencies on Aging (AAAs) have emerged as important delivery sites for health promotion programs, but the impacts of their expanded role in delivering these interventions remain unknown. OBJECTIVE: The objective of this study was to test whether evidence-based health promotion programs implemented by AAAs from 2008 to 2016 influenced health care use and spending by older adults and to examine how agencies' organizational capacity for implementation influenced these population-level impacts. RESEARCH DESIGN: We used panel regression models to examine how the expansion of health promotion programs offered by AAAs over the course of 2008-2016 was associated with a change in health care use and spending by older adults in counties served by the AAAs. We examined impact separately for high capacity and low capacity agencies. RESULTS: Across the full sample of AAAs, beginning to offer any health promotion program in the AAA was associated a with 0.94% percentage point reduction in potentially avoidable nursing home use in counties covered by the AAA (95% confidence interval=-1.58, -0.29), equivalent to a 6.5% change. Expanding the breadth of programs offered by the AAA was also associated with a significant reduction in potentially avoidable nursing home use. Stratified analysis showed that reductions in potentially avoidable nursing home use were evident only in places where the AAA had high implementation capacity. Expansion of health promotion programs offered by AAAs was not associated with the change in county-level hospital readmission rates, ambulatory care sensitive hospitalizations, or Medicare spending per beneficiary. CONCLUSIONS: AAAs are an example of community-based organizations that can contribute to health care policy goals such as cost containment. Organizational development support may be needed to extend their ability to effect change in more regions of the country.

Resource Brokering: Efforts to Assist Patients With Housing, Transportation, and Economic Needs in Primary Care Settings.

PURPOSE: Clinicians and policy makers are exploring the role of primary care in improving patients' social conditions, yet little research examines strategies used in clinical settings to assist patients with social needs. METHODS: Study used semistructured interviews with leaders and frontline staff at 29 diverse health care organizations with active programs used to address patients' social needs. Interviews focused on how organizations develop and implement case management-style programs to assist patients with social needs including staffing, assistance intensity, and use of referrals to community-based organizations (CBOs). RESULTS: Organizations used case management programs to assist patients with social needs through referrals to CBOs and regular follow-up with patients. About one-half incorporated care for social needs into established case management programs and the remaining described standalone programs developed specifically to address social needs independent of clinical needs. Referrals were the foundation for assistance and included preprinted resource lists, patient-tailored lists, and warm handoffs to the CBOs. While all organizations referred patients to CBOs, some also provided more intense services such as assistance completing patients' applications for services or conducting home visits. Organizations described 4 operational challenges in addressing patients' social needs: (1) effectively engaging CBOs; (2) obtaining buy-in from clinical staff; (3) considering patients' perspectives; and (4) ensuring program sustainability. CONCLUSION: As the US health care sector faces pressure to improve quality while managing costs, many health care organizations will likely develop or rely on case management approaches to address patients' social conditions. Health care organizations may require support to address the key operational challenges.Visual abstract.

The Role of Value-Based Payment in Promoting Innovation to Address Social Risks: A Cross-Sectional Study of Social Risk Screening by US Physicians.

Policy Points One of the most important possibilities of value-based payment is its potential to spur innovation in upstream prevention, such as attention to social needs that lead to poor health. Screening patients for social risks such as housing instability and food insecurity represents an early step physician practices can take to address social needs. At present, adoption of social risk screening by physician practices is linked with having high innovation capacity and focusing on low-income populations, but not exposure to value-based payment. Expanding social risk screening by physician practices may require standardization and technical assistance for practices that have less innovative capacity. CONTEXT: One of the most important possibilities of value-based payment is its potential to spur innovation in upstream prevention, such as attention to social needs that lead to poor health. However, there is uncertainty about the conditions under which value-based payment will encourage health care providers to innovate to address upstream social risks. METHODS: We used the 2017-2018 National Survey of Healthcare Organizations and Systems (NSHOS), a nationally representative survey of physician practices (n = 2,178), to ascertain (1) the number of social risks for which practices systematically screen patients; (2) the extent of practices' participation in value-based payment models; and (3) measures of practices' capacity for innovation. We used multivariate regression models to examine predictors of social risk screening. FINDINGS: On average, physician practices systematically screened for 2.4 out of 7 (34%) social risks assessed by the survey. In the fully adjusted model, implementing social risk screening was not associated with the practices' overall exposure to value-based payment. Being in the top quartile on any of three innovation capacity scales, however, was associated with screening for 0.95 to 1.00 additional social risk (p < 0.001 for all three results) relative to the bottom quartile. In subanalysis examining specific payment models, participating in a Medicaid accountable care organization was associated with screening for 0.37 more social risks (p = 0.015). Expecting more exposure to accountable care in the future was associated with greater social risk screening, but the effect size was small compared with practices' capacity for innovation. CONCLUSIONS: Our results indicate that implementation of social risk screening-an initial step in enhancing awareness of social needs in health care-is not associated with overall exposure to value-based payment for physician practices. Expanding social risk screening by physician practices may require standardized approaches and implementation assistance to reduce the level of innovative capacity required.

Fast-track Innovation: Area Agencies on Aging Respond to the COVID-19 Pandemic.

Millions of older Americans depend on services provided by Area Agencies on Aging to support their nutritional, social, and health needs. Social distancing requirements and the closure of congregate activities due to COVID-19 resulted in a rapid and dramatic shift in service delivery modes. Area Agencies on Aging were able to quickly pivot due to their long-standing expertise in community needs assessment and cross-sectoral partnerships. The federal Coronavirus relief measures also infused one billion dollars into the Aging Network. As the pandemic response evolves, Area Agencies on Aging are poised to be key partners in a transformed health system.

Collaboration in Health Care and Social Service Networks for Older Adults: Association With Health Care Utilization Measures.

BACKGROUND: Services targeting social determinants of health-such as income support, housing, and nutrition-have been shown to improve health outcomes and reduce health care costs for older adults. Nevertheless, evidence on the properties of effective collaborative networks across health care and social services sectors is limited. OBJECTIVES: The main objectives of this study were to identify features of collaborative networks of health care and social services organizations associated with avoidable health care use and spending for older adults. RESEARCH DESIGN: Through a 2017 survey, we collected data on collaborative ties among health care and social service organizations in 20 US communities with either high or low performance on avoidable health care use and spending for Medicare beneficiaries. Six types of ties were measured: any collaboration, referrals, sharing information, cosponsoring projects, financial contracts, and joint needs assessment. We examined how characteristics of collaborative networks were associated with performance. RESULTS: High-performing networks were distinguished from low-performing networks by 2 features: (1) health care organizations occupied positions of significantly greater centrality (P<0.01), and (2) subnetworks of cosponsorship ties were more cohesive, as measured by centralization (P=0.05) and density (P=0.06). Across all networks, Area Agencies on Aging were more centrally positioned than any other type of organization (P<0.05). CONCLUSIONS: Cross-sector engagement by health care organizations, particularly development of deeper types of collaborative ties such as cosponsorship, may reduce preventable health care use and spending. Efforts to foster effective partnerships could leverage the Area Agencies on Aging, which are already positioned as network brokers.

Links between social environment and health care utilization and costs.

The social environment influences health outcomes for older adults and could be an important target for interventions to reduce costly medical care. We sought to understand which elements of the social environment distinguish communities that achieve lower health care utilization and costs from communities that experience higher health care utilization and costs for older adults with complex needs. We used a sequential explanatory mixed methods approach. We classified community performance based on three outcomes: rate of hospitalizations for ambulatory care sensitive conditions, all-cause risk-standardized hospital readmission rates, and Medicare spending per beneficiary. We conducted in-depth interviews with key informants (N = 245) from organizations providing health or social services. Higher performing communities were distinguished by several aspects of social environment, and these features were lacking in lower performing communities: 1) strong informal support networks; 2) partnerships between faith-based organizations and health care and social service organizations; and 3) grassroots organizing and advocacy efforts. Higher performing communities share similar social environmental features that complement the work of health care and social service organizations. Many of the supportive features and programs identified in the higher performing communities were developed locally and with limited governmental funding, providing opportunities for improvement.

What Works in Readmissions Reduction: How Hospitals Improve Performance.

BACKGROUND: Hospitals across the United States are pursuing strategies to reduce avoidable readmissions but the evidence on how best to accomplish this goal is mixed, with no specific clinical practice shown to reduce readmissions consistently. Changes to hospital organizational practices, a key component of context, also may be critical to improving performance on readmissions, but this has not been studied. OBJECTIVE: The aim of this study was to understand how high-performing hospitals improved risk-stratified readmission rates, and whether their changes to clinical practices and organizational practices differed from low-performing hospitals. DESIGN: This was a qualitative study of 10 hospitals in which readmission rates had decreased (n=7) or increased (n=3). PARTICIPANTS: A total of 82 hospital staff drawn from hospitals that had participated in the State Action on Avoidable Readmissions quality improvement initiative. RESULTS: High-performing hospitals were distinguished by several organizational practices that facilitated readmissions reduction, that is, collective habits of action or interpretation shared by organization members. First, high-performing hospitals reported focused efforts to improve collaboration across hospital departments. Second, they helped postacute providers improve care by sharing the hospital's clinical and quality improvement expertise and data. Third, high performers enthusiastically engaged in trial and error learning to reduce readmissions. Fourth, they emphasized that readmissions represented bad outcomes for patients, de-emphasizing the role of financial penalties. Both high-performing and low-performing hospitals had implemented most clinical practice changes commonly recommended to reduce readmissions. CONCLUSIONS: Our findings highlight several organizational practices that hospitals may be able to use to enhance the effectiveness of their readmissions reduction efforts.

Leadership development programs for physicians: a systematic review.

BACKGROUND: Physician leadership development programs typically aim to strengthen physicians' leadership competencies and improve organizational performance. We conducted a systematic review of medical literature on physician leadership development programs in order to characterize the setting, educational content, teaching methods, and learning outcomes achieved. METHODS: Articles were identified through a search in Ovid MEDLINE from 1950 through November 2013. We included articles that described programs designed to expose physicians to leadership concepts, outlined teaching methods, and reported evaluation outcomes. A thematic analysis was conducted using a structured data entry form with categories for setting/target group, educational content, format, type of evaluation and outcomes. RESULTS: We identified 45 studies that met eligibility criteria, of which 35 reported on programs exclusively targeting physicians. The majority of programs focused on skills training and technical and conceptual knowledge, while fewer programs focused on personal growth and awareness. Half of the studies used pre/post intervention designs, and four studies used a comparison group. Positive outcomes were reported in all studies, although the majority of studies relied on learner satisfaction scores and self-assessed knowledge or behavioral change. Only six studies documented favorable organizational outcomes, such as improvement in quality indicators for disease management. The leadership programs examined in these studies were characterized by the use of multiple learning methods, including lectures, seminars, group work, and action learning projects in multidisciplinary teams. DISCUSSION: Physician leadership development programs are associated with increased self-assessed knowledge and expertise; however, few studies have examined outcomes at a system level. Our synthesis of the literature suggests important gaps, including a lack of programs that integrate non-physician and physician professionals, limited use of more interactive learning and feedback to develop greater self-awareness, and an overly narrow focus on individual-level rather than system-level outcomes.

Hospital strategy uptake and reductions in unplanned readmission rates for patients with heart failure: a prospective study.

BACKGROUND: Despite recent reductions in national unplanned readmission rates, we have relatively little understanding of which hospital strategies are most associated with changes in risk-standardized readmission rates (RSRR). OBJECTIVE: We examined associations between the change in hospital 30-day RSRR for patients with heart failure and the uptake of strategies over 12-18 months in a national sample of hospitals. DESIGN: We conducted a prospective study of hospitals using a Web-based survey at baseline (November 2010-May 2011, n = 599, 91.0% response rate) and 12-18 months later (November 2011-October 2012, n = 501, 83.6% response rate), with RSRR measured at the same time points. The final analytic sample included 478 hospitals. PARTICIPANTS: The study included hospitals participating in the Hospital-to-Home (H2H) and State Action on Avoidable Rehospitalizations (STAAR) initiatives. MAIN MEASURES: We examined associations between change in hospital 30-day RSRR for patients with heart failure and the uptake of strategies previously demonstrated to have increased between baseline and follow-up, using unadjusted and adjusted linear regression. KEY RESULTS: The average number of strategies taken up from baseline to follow-up was 1.6 (SE = 0.06); approximately one-quarter (25.3%) of hospitals took up at least three new strategies. Hospitals that adopted the strategy of routinely discharging patients with a follow-up appointment already scheduled experienced significant reductions in RSRR (reduction of 0.63 percentage point, p value < 0.05). Hospitals that took up three or more strategies had significantly greater reductions in RSRR compared to hospitals that took up only zero to two strategies (reduction of 1.29 versus 0.57 percentage point, p value < 0.05). Among the 117 hospitals that took up three or more strategies, 93 unique combinations of strategies were used. CONCLUSIONS: Although most individual strategies were not associated with RSRR reduction, hospitals that took up any three or more strategies showed significantly greater reduction in RSRR compared to hospitals that took up fewer than three strategies.

Strategies to reduce hospital 30-day risk-standardized mortality rates for patients with acute myocardial infarction: a cross-sectional and longitudinal survey.

BACKGROUND: Survival rates after acute myocardial infarction (AMI) vary markedly across U.S. hospitals. Although substantial efforts have been made to improve hospital performance, we lack contemporary evidence about changes in hospital strategies and features of organizational culture that might contribute to reducing hospital AMI mortality rates. We sought to describe current use of several strategies and features of organizational culture linked to AMI mortality in a national sample of hospitals and examine changes in use between 2010 and 2013. METHODS: We conducted a cross-sectional survey of 543 hospitals (70% response rate) in 2013, and longitudinal analysis of a subsample of 107 hospitals that had responded to a survey in 2010 (67% response rate). RESULTS: Between 2010 and 2013, the use of many strategies increased, but the use of only two strategies increased significantly: the percentage of hospitals providing regular training to Emergency Medical Service (EMS) providers about AMI care increased from 36% to 71% (P-value < 0.001) and the percentage of hospitals using computerized assisted physician order entry more than doubled (P-value < 0.001). Most, but not all, hospitals reported having environments conducive to communication, coordination and problem solving. CONCLUSIONS: We found few significant changes between 2010 and 2013 in hospital strategies or in key features of organizational culture that have been associated with lower AMI mortality rates. Findings highlight several opportunities to help close remaining performance gaps in AMI mortality among hospitals.

Organizational and community resilience for COVID-19 and beyond: Leveraging a system for health and social services integration.

OBJECTIVE: To examine how a preexisting initiative to align health care, public health, and social services influenced COVID-19 pandemic response. DATA SOURCES AND STUDY SETTING: In-depth interviews with administrators and frontline staff in health care, public health, and social services in Contra Costa County, California from October, 2020, to May, 2021. STUDY DESIGN: Qualitative, semi-structured interviews examined how COVID-19 response used resources developed for system alignment prior to the pandemic. DATA COLLECTION: We interviewed 31 informants including 14 managers in public health, health care, or social services and 17 social needs case managers who coordinated services across these sectors on behalf of patients. An inductive-deductive qualitative coding approach was used to systematically identify recurrent themes. PRINCIPAL FINDINGS: We identified four distinct components of the county's system alignment capabilities that supported COVID-19 response, including (1) an organizational culture of adaptability fostered through earlier system alignment efforts, which included the ability and willingness to rapidly implement new organizational processes, (2) trusting relationships among organizations based on prior, positive experiences of cross-sector collaboration, (3) capacity to monitor population health of historically marginalized community members, including information infrastructures, data analytics, and population monitoring and outreach, and (4) frontline staff with flexible skills to support health and social care who had built relationships with the highest risk community members. CONCLUSIONS: Prior investments in aligning systems provided unanticipated benefits for organizational and community resilience during the COVID-19 pandemic. Our results illustrate a pathway for investment in system alignment efforts that build capacity within organizations and relationships between organizations to enhance resilience to crisis. Our findings suggest the usefulness of an integrated concept of organizational and community resilience that understands the resilience of systems of care as a vital resource for community resilience during crisis.

Between health care and social services: Boundary objects and cross-sector collaboration.

Health care systems throughout the United States are initiating collaborations with social services agencies. These cross-sector collaborations aim to address patients' social needs-such as housing, food, income, and transportation-in health care settings. However, such collaborations can be challenging as health care and social service sectors are composed of distinct missions, institutions, professional roles, and modes of distributing resources. This paper examines how the "high-risk" patient with both medical and social needs is constructed as a shared object of intervention across sectors. Using the concept of boundary object, we illustrate how the high-risk patient category aggregates and represents multiple types of information-medical, social, service utilization, and cost-in ways that facilitate its use across sectors. The high-risk patient category works as a boundary object, in part, by the differing interpretations of "risk" available to collaborators. During 2019-2021, we conducted 75 semi-structured interviews and 31 field observations to investigate a relatively large-scale, cross-sector collaboration effort in California known as CommunityConnect. This program uses a predictive algorithm and big data sets to assign risk scores to the population and directs integrated health care and social services to patients identified as high risk. While the high-risk patient category worked well to foster collaboration in administrative and policy contexts, we find that it was less useful for patient-level interactions, where frontline case managers were often hesitant or unable to communicate information about the risk-based eligibility process. We suggest that the predominance of health care utilization (and its impacts on costs) in constructing the high-risk patient category may be medicalizing social services, with the potential to deepen inequities.

Multilevel influences on patient engagement and chronic care management.

OBJECTIVES: Physician practices are increasingly owned by health systems, which may support or hinder adoption of innovative care processes for adults with chronic conditions. We examined health system- and physician practice-level capabilities associated with adoption of (1) patient engagement strategies and (2) chronic care management processes for adult patients with diabetes and/or cardiovascular disease. STUDY DESIGN: We analyzed data collected from the National Survey of Healthcare Organizations and Systems, a nationally representative survey of physician practices (n = 796) and health systems (n = 247) (2017-2018). METHODS: Multivariable multilevel linear regression models estimated system- and practice-level characteristics associated with practice adoption of patient engagement strategies and chronic care management processes. RESULTS: Health systems with processes to assess clinical evidence (ß = 6.54 points on a 0-100 scale; P = .004) and with more advanced health information technology (HIT) functionality (ß = 2.77 points per SD increase on a 0-100 scale; P = .03) adopted more practice-level chronic care management processes, but not patient engagement strategies, compared with systems lacking these capabilities. Physician practices with cultures oriented to innovation, more advanced HIT functionality, and with a process to assess clinical evidence adopted more patient engagement strategies and chronic care management processes. CONCLUSIONS: Health systems may be better able to support the adoption of practice-level chronic care management processes, which have a strong evidence base for implementation, compared with patient engagement strategies, which have less evidence to guide effective implementation. Health systems have an opportunity to advance patient-centered care by expanding practice-level HIT functionality and developing processes to appraise clinical evidence for practices.

Sustaining Area Agency on Aging Services During a Pandemic: Innovation Through Community-Based Partnerships.

BACKGROUND AND OBJECTIVES: Area Agencies on Aging (AAAs) have funded, coordinated, and provided services since the 1960s, evolving in response to changes in policy, funding, and the political arena. Many of their usual service delivery programs and processes were severely disrupted with the onset of the coronavirus disease 2019 pandemic. Increasing evidence suggests the importance of partnerships in AAA's capacity to adapt services; however, specific examples of adaptations have been limited. We sought to understand how partnerships may have supported adaptation during the pandemic, from the perspectives of both AAAs and their partners. RESEARCH DESIGN AND METHODS: We conducted a secondary analysis of qualitative data from an explanatory sequential mixed-methods parent study. Data were collected from 12 AAAs diverse in terms of geographic region, governance structure and size, as well as a range of partner organizations. We completed 105 in-depth interviews from July 2020 to April 2021. A 5-member multidisciplinary team coded the data using a constant comparative method of analysis, supported by ATLAS.ti Scientific Software. RESULTS: AAAs and their partners described strategies and provided examples of ways to rapidly transform service delivery including reducing isolation, alleviating food insecurity, adapting program design and delivery, and leveraging partnerships and repurposing resources. DISCUSSION AND IMPLICATIONS: AAAs and partner organizations are uniquely positioned to innovate during times of disruption. Findings may enhance AAA and partner portfolios of evidence-based and evidence-supported programs.

Collaborative Learning Among Health Care Organizations to Improve Quality and Advance Racial Equity.

Background: The study examined stakeholder experiences of a statewide learning collaborative, sponsored and led by Blue Cross Blue Shield of Massachusetts (BCBSMA) and facilitated by the Institute for Healthcare Improvement (IHI) to reduce racial and ethnic disparities in quality of care. Methods: Interviews of key stakeholders (n=44) were analyzed to assess experiences of collaborative learning and interventions to reduce racial and ethnic disparities in quality of care. The interviews included BCBSMA, IHI, provider groups, and external experts. Results: Breast cancer screening, colorectal cancer screening, hypertension management, and diabetes management were focal areas for reducing disparities. Collaborative learning methods involved expert coaching, group meetings, and sharing of best practices. Interventions tested included pharmacist-led medication management, strategies to improve the collection of race, ethnicity, and language (REaL) data, transportation access improvement, and community health worker approaches. Stakeholder experiences highlighted three themes: (1) the learning collaborative enabled the testing of interventions by provider groups, (2) infrastructure and pilot funding were foundational investments, but groups needed more resources than they initially anticipated, and (3) expertise in quality improvement and health equity were critical for the testing of interventions and groups anticipated needing this expertise into the future. Conclusions: BCBSMA's learning collaborative and intervention funding supported contracted providers in enhancing REaL data collection, implementing equity-focused interventions on a small scale, and evaluating their feasibility and impact. The collaborative facilitated learning among groups on innovative approaches for reducing racial disparities in quality. Concerns about sustainability underscore the importance of expertise for implementing initiatives to reduce racial and ethnic disparities.

Greater Covid-19 vaccine uptake among enrollees offered health and social needs case management: Results from a randomized trial.

OBJECTIVE: To investigate Covid-19 vaccination as a potential secondary public health benefit of case management for Medicaid beneficiaries with health and social needs. DATA SOURCES AND STUDY SETTING: The CommunityConnect case management program for Medicaid beneficiaries is run by Contra Costa Health, a county safety net health system in California. Program enrollment data were merged with comprehensive county vaccination records. STUDY DESIGN: Individuals with elevated risk of hospital and emergency department use were randomized each month to a case management intervention or usual care. Interdisciplinary case managers offered coaching, community referrals, healthcare connections, and other support based on enrollee interest and need. Using survival analysis with intent-to-treat assignment, we assessed rates of first-dose Covid-19 vaccination from December 2020 to September 2021. In exploratory sub-analyses we also examined effect heterogeneity by gender, race/ethnicity, age, and primary language. DATA COLLECTION AND EXTRACTION METHODS: Data were extracted from county and program records as of September 2021, totaling 12,866 interventions and 25,761 control enrollments. PRINCIPAL FINDINGS: Approximately 58% of enrollees were female and 41% were under age 35. Enrollees were 23% White, 12% Asian/Pacific Islander, 20% Black/African American, and 36% Hispanic/Latino, and 10% other/unknown. Approximately 35% of the intervention group engaged with their case manager. Approximately 56% of all intervention and control enrollees were vaccinated after 9 months of analysis time. Intervention enrollees had a higher vaccination rate compared to control enrollees (adjusted hazard ratio [aHR]: 1.06; 95% confidence interval [CI]: 1.02-1.10). In sub-analyses, the intervention was associated with stronger likelihood of vaccination among males and individuals under age 35. CONCLUSIONS: Case management infrastructure modestly improved Covid-19 vaccine uptake in a population of Medicaid beneficiaries that over-represents social groups with barriers to early Covid-19 vaccination. Amidst mixed evidence on vaccination-specific incentives, leveraging trusted case managers and existing case management programs may be a valuable prevention strategy.