North Carolina's Medicaid Transformation: the Early Enrollee Experience.

INTRODUCTION: On July 1, 2021, North Carolina's Medicaid Transformation mandatorily switched 1.6 million Medicaid beneficiaries from fee-for-service to managed care plans. We examined the early enrollee experience in terms of engagement in plan selection, provider continuity, use of primary care visits, and assistance with social needs. METHODS: Using electronic health records (EHR) covering pre- and post-transition periods (1/1/2019-5/31/2022) from the largest provider network in western North Carolina, we identified all children and adults under age 65 with continuous Medicaid or private coverage. We conducted primary surveys of a random sample of Medicaid-covered enrollees and obtained self-reported rates of engagement in plan selection, continuity of provider access, and receipt of social need assistance. We used comparative interrupted time series models to estimate the relative change in primary care visits associated with the transition. RESULTS: Our EHR-based study cohorts included 4859 Medicaid and 5137 privately insured enrollees, with 398 Medicaid enrollees in the primary surveys. We found that 77.3% of survey participants reported that the managed care plan they were on was not chosen but automatically assigned to them, 13.1% reported insufficient information about the transition, and 19.2% reported lacking assistance with plan choice. We found that 5.9% were assigned to a different primary care provider. Over 29% reported not receiving any additional social need assistance. The transition was associated with a 7.1% reduction (95% CI, -11.5 to -2.7%) in the volume of primary care visits among Medicaid enrollees relative to privately insured enrollees. CONCLUSIONS: Medicaid enrollees in North Carolina may have had limited awareness and engagement in the transition process and experienced a reduction in primary care visits. As the state's transition process gains a foothold, future policy needs to improve enrollee engagement and develop evidence on healthcare utilization and patient outcomes.

Perceptions of North Carolina's Medicaid Transformation: A Qualitative Study.

BACKGROUND: In 2021, North Carolina switched 1.6 million beneficiaries from a fee-for-service Medicaid model to a managed care system. The state prepared beneficiaries with logistical planning and a communications plan. However, the rollout occurred during the COVID-19 pandemic, creating significant challenges. Little is known about how Medicaid Transformation impacted the experience of Medicaid enrollees. METHODS: We conducted four focus groups (N = 22) with Medicaid beneficiaries from January to March 2022 to gain insight into their experience with Medicaid Transformation. A convenience sample was recruited. Focus groups were recorded, transcribed verbatim, and verified. A codebook was developed using inductive and deductive codes. Two study team members independently coded the transcripts; discrepancies were resolved among the research team. Themes were derived by their prevalence and salience within the data. RESULTS: We identified four major themes: 1) Participants expressed confusion about the signup process; 2) Participants had a limited understanding of their new plans; 3) Participants expressed difficulty accessing services through their plans; and 4) Participants primarily noted negative changes to their care. These findings suggest that Medicaid enrollees felt unsupported during the enrollment process and had difficulty accessing assistance to gain a better understanding of their plans and new services. LIMITATIONS: Participants were recruited from a single institution in the Southeastern United States; results may not be transferable to other institutions. Participants were likely not representative of all Medicaid Transformation beneficiaries; only English-speaking participants were included. CONCLUSION: As the transition process continues, the North Carolina Medicaid program can benefit from integrating recommendations identified by member input to guide strategies for addressing whole-person care.

Transitional care following a skilled nursing facility stay: Utilization of nurse practitioners to reduce readmissions in high risk older adults.

This quality improvement project's goal was to identify older adults who were at high risk for readmission following a skilled nursing facility (SNF) admission and evaluate the impact of a nurse practitioner (NP) visit within 72 hours of SNF discharge. The aims of this project were to reduce 30-day readmissions, identify gaps in care, and address care needs for patients recently discharged from a SNF. High readmission risk was estimated through use of readmission risk prediction and frailty tools. Results of the project revealed several gaps in care including medication discrepancies, delays in start of home health services, and lack of follow up with a primary care provider. Of the patients seen for a transitional care visit (TCV), none were readmitted. Project findings indicate there is value in seeing patients in their home soon after SNF discharge. Further work is indicated to improve care transitions in this area.

Development of a screening tool to identify patients likely to benefit from clinical pharmacist review in a home-based primary care population.

OBJECTIVE: To create a novel screening tool that identified patients who were most likely to benefit from pharmacist in-home medication reviews. DESIGN: Single-center, retrospective study. SETTING AND PARTICIPANTS: A total of 25 homebound patients in Forsyth County, NC, aged 60 years or older with physical or cognitive impairments and enrolled in home-based primary care or transitional and supportive care programs participated in the study. Pharmacy resident-provider pairs conducted home visits for all patients in the study. Pharmacy residents assessed the subjective risk (high, medium, low) of medication nonadherence using information obtained from home visits (health literacy, support network, medications, and detection of something unexpected related to medications). An electronic medical record-based risk score was simultaneously calculated using screening tool components (i.e., electronic frailty index score, LACE+ index [length of stay in the hospital, acuity of admission, comorbidity, emergency department utilization in the 6 months before admission], and 2015 American Geriatric Society Beers Criteria). OUTCOME MEASURES: The electronic medical record-based screening tool numerical risk scores were compared with pharmacy resident subjective risk assessments using tree-based classification models to determine screening tool components that best predicted pharmacy residents' subjective assessment of patients' likelihood of benefit from in-home pharmacist medication review. Following the study, satisfaction surveys were given to providers and pharmacy residents. RESULTS: The best predictor of high-risk patients was an electronic frailty index score greater than 0.32 (indicating very frail) or LACE+ index greater than or equal to 59 (at high risk for hospital readmission). Pharmacy residents and providers agreed that homebound patients at high-risk for medication noncompliance benefited from pharmacist time and attention in home visits. CONCLUSION: In homebound older persons, this screening tool allowed for the identification of patients at high-risk for medication nonadherence through targeted in-home pharmacist medication reviews. Further studies are needed to validate the accuracy of this tool internally and externally.

The Integration of Community Voice in the Implementation of a Mobile Health Program.

BACKGROUND: Health care access is vital to advancing health equity. The purpose of this paper was to use a community-based participatory research approach to engage underserved communities in the development of a new mobile health clinic (MHC) program and to discuss the lessons learned from the conversations. Community conversations helped identify barriers to access to health care, community strengths, and health concerns. They also helped the MHC leaders develop programming. METHODS: The community-based participatory research approach guided five community conversations conducted (N = 51 participants) from 2018 to 2019. Participants provided input on their personal experiences with a) existing facilitators and barriers to health, b) priority health issues and needs, and c) recommendations for MHC program development. RESULTS: Barriers to health care access were identified, as were many community strengths. Recommendations directly informed MHC program development and implementation, including availability of services at no cost, mammogram referrals, mental health screening, eye exams, and nutrition counseling. CONCLUSIONS: This project highlights the importance of collaboration between academic partners and communities to inform health care programs and the implementation of a MHC based on community voice and input.

Qualitative Perceptions of an Anticipated Fresh Food Prescription Program.

Objective: Food insecurity (FI) is a growing public health problem. Produce prescriptions are known to improve healthy eating and decrease FI; however, few studies have incorporated community voice prior to its implementation. In this study, we aimed to elicit perspectives of individuals at risk for FI and the potential impact of a fresh food prescription (FFRx) program. Methods: We conducted this qualitative descriptive study through an academic medical center in collaboration with community partners. We conducted focus groups involving Latinx (N = 16) and African-American (N = 8) adults in community settings. Data were interpreted using an inductive thematic analysis. Results: Three overarching themes emerged: (1) fresh food accessibility was limited by cost, household size, and transportation but enhanced by food pantries, budgeting, and education; (2) cooking behaviors were curbed by time constraints and unfamiliarity but propagated by passion, traditions, and communal practices; and (3) health and wellness deterrents included unhealthy diets driven by cultural and familial norms; however, weight loss and awareness of comorbidities were positive motivators. Participants shared their preference for local produce and cooking classes as components of a FFRx program while raising concerns about low participation due to the stigma of receiving aid. Conclusions: Our findings illuminated interest in engaging in a FFRx program and learning ways to prepare healthy foods. A program distributing fresh produce and healthy lifestyle education could close gaps identified in African-American and Latinx communities at risk for FI.

Exploring Perceptions of a Fresh Food Prescription Program during COVID-19.

This qualitative study aimed to elicit the perspectives of individuals with food insecurity (FI) who were enrolled in a Fresh Food Prescription (FFRx) delivery program through a collaboration between an academic medical center and multiple community partners in the southeastern United States. Semi-structured interviews and open-ended survey responses explored the experiences of participants enrolled in a FFRx delivery program during the COVID-19 pandemic. The interviews probed the shopping habits, food security, experience, and impact of the program on nutrition, health, and well-being; the surveys explored the perceptions of and satisfaction with the program. A coding scheme was developed inductively, and a thematic analysis was conducted on raw narrative data using Atlas.ti 8.4 to sort and manage the data. The themes included that the program promoted healthy dietary habits, improved access to high-quality foods, improved well-being, enhanced financial well-being, and alleviated logistical barriers to accessing food and cooking. Participants provided suggestions for FFRx improvement. Future studies may facilitate improved clinical-community partnerships to address FI.

Strategies and Lessons Learned from a Home Delivery Food Prescription Program for Older Adults.

Food insecurity (FI) is a growing health problem, worsening during the COVID-19 pandemic. Fresh food prescription programs (FFRx) have been shown to increase healthy eating and decrease FI, but few FFRx are community-informed, or theory based. Our FFRx was a delivery program developed to alleviate FI for older adults. It was implemented in an academic medical center and guided by the Capabilities, Opportunities, Motivations, and Behaviors and Theoretical Domains Framework. We tested impacts of the program on FI, Fruit and Vegetable (FV) intake, depression, and loneliness at six-month intervals. During the FFRx, 31 people completed surveys every six months. FI decreased by an average of 2.03 points (p = <.001) while FV intake increased from a mean of 2.8 servings per day to 2.9 servings per day (p = .53). Depression and loneliness scores stayed stable. Preliminary data from this FFRx program, a partnership between an academic medical center and community partners, had positive impacts on FI.

What a city eats: Examining the dietary preferences of families living in communities at high risk for food insecurity.

INTRODUCTION: Food insecurity (FI) is the lack of consistent access to enough food for an active and healthy life. Community-based hunger relief programs often serve as emergency food sources for families with FI. However, these programs may not provide foods that diverse populations of people prefer. We sought to evaluate the dietary patterns and preferences of families living in food-insecure neighborhoods and utilizing a community-based hunger relief program, in order to improve the utilization of local nutritional programs. METHODS: We examined the Help Our People Eat (HOPE) community-based mobile meal program. Free-listing interviews (n = 63) were conducted with English-(66%) and Spanish-speaking (34%) participants of the program. Participants were asked about FI risk, food preferences, and dietary behaviors at home. RESULTS: The majority of participants (90%) had children in the household. About 60% reported not being able to afford the type of food they enjoyed. Most participants reported using stoves for cooking (80%). Participants overwhelmingly cooked with chicken, beef, and pork. The most common side dishes included potatoes, rice, and salad. Most participants reported no interest in cooking differently or learning new recipes. CONCLUSIONS: A common theme throughout interviews was that families prefer similar meals, but may prepare them differently based on the language spoken. Food preferences consisted of a high intake of carbohydrate-rich meals, perhaps because these foods may be cheaper and easier to access. Notably, new recipes and cooking methods were not a priority for these families, possibly due to the time and effort needed to learn them.

Ten Things Every Geriatrician Should Know About House Calls.

Home-based primary care (HBPC) is experiencing a reemergence to meet the needs of homebound older adults. This brief review based on existing literature and expert opinion discusses 10 key facts about HBPC that every geriatrician should know: (1) the team-based nature of HBPC is key to its success; (2) preparations and after-hour access for house calls are required; (3) home safety for the clinician and patient must be considered; (4) being homebound is an independent mortality risk factor with a high symptom burden; (5) home care medicine presents unique benefits and challenges; (6) a systems-based approach to care is essential; (7) HBPC is a sustainable model within value-based care proven by the Department of Veterans Affairs and the Independence at Home Medicare Demonstration Project; (8) HBPC has an educational mission; (9) national organizations for HBPC include American Academy of Home Care Medicine and Home Centered Care Institute; and (10) practicing HBPC is a privilege. HBPC is a dynamic and unique practice model that will continue to grow in the future. J Am Geriatr Soc 67:139-144, 2019.