Improving care coordination and reducing ED utilization through patient navigation.

OBJECTIVES: Our study examines the impact of an emergency department (ED) patient navigation program for patients in a Medicaid accountable care organization across 3 hospitals in a large health system. Our program engages community health workers to (1) promote primary care engagement, (2) facilitate care coordination, and (3) identify and address patients' health-related social needs. STUDY DESIGN: Our study was a retrospective analysis of health care utilization and costs in the 30 days following the index ED visit, comparing individuals receiving ED navigation and matched controls. The primary outcome of interest was all-cause return ED visits, and our secondary outcomes were hospital admissions and completed primary care appointments. METHODS: Patients with ED visits who received navigation were matched to comparable patients with ED visits without an ED navigator interaction. Outcomes were analyzed using fixed effects logistic regression models adjusted for patient demographics, ED visit characteristics, and preceding utilization. Our primary outcome was odds of a return ED visit within 30 days, and our secondary outcomes were odds of a hospitalization within 30 days and odds of having primary care visit within 30 days. RESULTS: In our sample, there were 1117 ED visits by patients meeting our inclusion criteria with an ED navigator interaction, with 3351 matched controls. ED navigation was associated with 52% greater odds of a completed follow-up primary care appointment (odds ratio [OR], 1.52; 95% CI, 1.29-1.77). In patients with no ED visits in the preceding 6 months, ED navigation was associated with 32% decreased odds of repeat ED visits in the subsequent 30 days (OR, 0.68; 95% CI, 0.52-0.90). There was no statistically significant impact on return ED visits in those with higher baseline ED utilization. CONCLUSIONS: Our program demonstrates that high-intensity, short-term patient navigation in the ED can help reduce ED visits in those with low baseline ED utilization and facilitate stronger connections with primary care.

The essential role of population health during and beyond COVID-19.

The coronavirus disease 2019 (COVID-19) pandemic has fundamentally changed how health care systems deliver services and revealed the tenuousness of care delivery based on face-to-face office visits and fee-for-service reimbursement models. Robust population health management, fostered by value-based contract participation, integrates analytics and agile clinical programs and is adaptable to optimize outcomes and reduce risk during population-level crises. In this article, we describe how mature population health programs in a learning health system have been rapidly leveraged to address the challenges of the pandemic. Population-level data and care management have facilitated identification of demographic-based disparities and community outreach. Telemedicine and integrated behavioral health have ensured critical primary care and specialty access, and mobile health and postacute interventions have shifted site of care and optimized hospital utilization. Beyond the pandemic, population health can lead as a cornerstone of a resilient health system, better prepared to improve public health and mitigate risk in a value-based paradigm.

Identification of Racial Inequities in Access to Specialized Inpatient Heart Failure Care at an Academic Medical Center.

BACKGROUND: Racial inequities for patients with heart failure (HF) have been widely documented. HF patients who receive cardiology care during a hospital admission have better outcomes. It is unknown whether there are differences in admission to a cardiology or general medicine service by race. This study examined the relationship between race and admission service, and its effect on 30-day readmission and mortality Methods: We performed a retrospective cohort study from September 2008 to November 2017 at a single large urban academic referral center of all patients self-referred to the emergency department and admitted to either the cardiology or general medicine service with a principal diagnosis of HF, who self-identified as white, black, or Latinx. We used multivariable generalized estimating equation models to assess the relationship between race and admission to the cardiology service. We used Cox regression to assess the association between race, admission service, and 30-day readmission and mortality. RESULTS: Among 1967 unique patients (66.7% white, 23.6% black, and 9.7% Latinx), black and Latinx patients had lower rates of admission to the cardiology service than white patients (adjusted rate ratio, 0.91; 95% CI, 0.84-0.98, for black; adjusted rate ratio, 0.83; 95% CI, 0.72-0.97 for Latinx). Female sex and age >75 years were also independently associated with lower rates of admission to the cardiology service. Admission to the cardiology service was independently associated with decreased readmission within 30 days, independent of race. CONCLUSIONS: Black and Latinx patients were less likely to be admitted to cardiology for HF care. This inequity may, in part, drive racial inequities in HF outcomes.

The Human Rights and Social Justice Scholars Program: a collaborative model for preclinical training in social medicine.

BACKGROUND: Despite the importance of the role social justice takes in medical professionalism, the need to train health professionals to address social determinants of health, and medical trainees' desire to eliminate health disparities, undergraduate medical education offers few opportunities for comprehensive training in social justice. The Human Rights and Social Justice (HRSJ) Scholars Program at the Icahn School of Medicine at Mount Sinai is a preclinical training program in social medicine consisting of 5 components: a didactic course, faculty and student mentorship, research projects in social justice, longitudinal policy and advocacy service projects, and a career seminar series. OBJECTIVES: The aim of this article is to describe the design and implementation of the HRSJ curriculum with a focus on the cornerstone of the HRSJ Scholars Program: longitudinal policy and advocacy service projects implemented in collaboration with partner organizations in East Harlem. Furthermore, we describe the results of a qualitative survey of inaugural participants, now third-year medical students, to understand how their participation in this service-learning component affected their clinical experiences and professional self-perceptions. CONCLUSION: Ultimately, through the implementation and evaluation of the HRSJ Scholars Program, we demonstrate an innovative model for social justice education; the enduring effect of service-learning experiences on participants' knowledge, skills, and attitudes; and the potential to increase community capacity for improved health through a collaborative educational model.

The role of traditional treatment on health care seeking by caregivers for sick children in Sierra Leone: results of a baseline survey.

In Sierra Leone, traditional treatment is at times used in lieu of seeking allopathic healthcare for major illnesses causing child death. This paper describes the nature of traditional treatment for diarrhea and fever (presumed malaria). Weighted analysis and multi-logistic regression was applied to a household cluster survey (n=5951) conducted in 4 districts in June 2010. Using structured questionnaires, heads of households, and caregivers of children under five years of age were interviewed about child morbidity and care seeking. A thematic analysis of qualitative data based on focus group discussions and in-depth interviews with family members from twelve villages in these same four districts, was also done. Illness-specific herbal remedies were described by respondents. Among 1511 children with diarrhea, 31% used traditional treatment. Among 3851 children with fever, 22% used traditional treatment. Traditional treatment for diarrhea was associated with being from a tribe other than the Mende, using government recommended salt sugar solution, not having a vaccine card, having more than two illnesses, and not seeking any allopathic medical treatment for diarrhea. For fever, traditional treatment was associated with being a tribe other than the Mende, having more than two illnesses, not having a vaccine card, Muslim religion, and not seeking any allopathic medical treatment for fever. Qualitatively, respondents describe herbalists as trusted with remedies that are seen to be appropriate due to the perceived cause of illness and due to barriers to seeking care from government providers. The social determinants of traditional treatment use and the prominent role of herbalists in providing them need to be addressed to improve child survival in Sierra Leone.

Availability of over-the-counter emergency contraception in 2 disparate New York City neighborhoods.

We conducted a telephone survey of pharmacies in 2 New York City neighborhoods on same-day availability, type, and cost of over-the-counter emergency contraception. There was no difference in availability of over-the-counter emergency contraception between Upper East Side and East Harlem pharmacies (93% vs 94%; P = .71). Average cost of medication was less in East Harlem than in the Upper East Side ($45.16 vs $51.64; P < .001). Efforts should accentuate overcoming cost and knowledge barriers associated with the use of emergency contraception.