The Role of Telehealth in Improving Care Connections and Outcomes for Community Health Center Patients with Diabetes.

INTRODUCTION: Does telehealth decrease health disparities by improving connections to care or simply result in new barriers for vulnerable populations who often lack access to technology? This study aims to better understand the role of telehealth and social determinants of health in improving care connections and outcomes for Community Health Center patients with diabetes. METHODS: This retrospective analysis of Electronic Health Record (EHR) data examined the relationship between telehealth utilization and glycemic control and consistency of connection to the health care team ("connectivity"). EHR data were collected from 20 Community Health Centers from July 1, 2019 through December 31, 2021. Descriptive statistics were calculated, and multivariable linear regression was used to assess the associations between telehealth use and engagement in care and glycemic control. RESULTS: The adjusted analysis found positive, statistically significant associations between telehealth use and each of the 2 primary outcomes. Telehealth use was associated with 0.89 additional months of hemoglobin A1c (HbA1c) control (95% confidence interval [CI], 0.73 to 1.04) and 4.49 additional months of connection to care (95% CI, 4.27 to 4.70). DISCUSSION: The demonstrated increased engagement in primary care for telehealth users is significant and encouraging as Community Health Center populations are at greater risk of lapses in care and loss to follow up. CONCLUSIONS: Telehealth can be a highly effective, patient-centered form of care for people with diabetes. Telehealth can play a critical role in keeping vulnerable patients with diabetes connected to their care team and involved in care and may be an important tool for reducing health disparities.

Implementing and Enhancing Social and Economic Needs Screening at a Federally Qualified Health Center.

BACKGROUND: Programs to screen for social and economic needs (SENs) are challenging to implement. AIM: To describe implementation of an SEN screening program for patients obtaining care at a federally qualified health center (FQHC). SETTING: Large Chicago-area FQHC where many patients are Hispanic/Latino and insured through Medicaid. PROGRAM DESCRIPTION: In the program's phase 1 (beginning April 2020), a prescreening question asked about patients' interest in receiving community resources; staff then called interested patients. After several refinements (e.g., increased staffing, tailored reductions in screening frequency) to address challenges such as a large screening backlog, program phase 2 began in February 2021. In phase 2, a second prescreening question asked about patients' preferred modality to learn about community resources (text/email versus phone calls). PROGRAM EVALUATION: During phase 1, 8925 of 29,861 patients (30%) expressed interest in community resources. Only 40% of interested patients were successfully contacted and screened. In phase 2, 5781 of 21,737 patients (27%) expressed interest in resources; 84% of interested patients were successfully contacted by either text/email (43%) or phone (41%). DISCUSSION: Under one-third of patients obtaining care at an FQHC expressed interest in community resources for SENs. After program refinements, rates of follow-up with interested patients substantially increased.

Association Between ICD-10 Codes for Social Needs and Subsequent Emergency and Inpatient Use.

BACKGROUND: International Classification of Diseases, 10th revision Z codes capture social needs related to health care encounters and may identify elevated risk of acute care use. OBJECTIVES: To examine associations between Z code assignment and subsequent acute care use and explore associations between social need category and acute care use. RESEARCH DESIGN: Retrospective cohort study. SUBJECTS: Adults continuously enrolled in a commercial or Medicare Advantage plan for ≥15 months (12-month baseline, 3-48 month follow-up). OUTCOMES: All-cause emergency department (ED) visits and inpatient admissions during study follow-up. RESULTS: There were 352,280 patients with any assigned Z codes and 704,560 sampled controls with no Z codes. Among patients with commercial plans, Z code assignment was associated with a 26% higher rate of ED visits [adjusted incidence rate ratio (aIRR) 1.26, 95% CI: 1.25-1.27] and 42% higher rate of inpatient admissions (aIRR 1.42, 95% CI: 1.39-1.44) during follow-up. Among patients with Medicare Advantage plans, Z code assignment was associated with 42% (aIRR 1.42, 95% CI: 1.40-1.43) and 28% (aIRR 1.28, 95% CI: 1.26-1.30) higher rates of ED visits and inpatient admissions, respectively. Within the Z code group, relative to community/social codes, socioeconomic Z codes were associated with higher rates of inpatient admissions (commercial: aIRR 1.10, 95% CI: 1.06-1.14; Medicare Advantage: aIRR 1.24, 95% CI 1.20-1.27), and environmental Z codes were associated with lower rates of both primary outcomes. CONCLUSIONS: Z code assignment was independently associated with higher subsequent emergency and inpatient utilization. Findings suggest Z codes' potential utility for risk prediction and efforts targeting avoidable utilization.

Social Needs Identified by Diagnostic Codes in Privately Insured U.S. Adults.

INTRODUCTION: The relationships between healthcare use and social needs are not fully understood. In 2015, International Classification of Diseases, Tenth Revision coding introduced voluntary Z codes for social needs‒related healthcare encounters. This study evaluated early national patterns of Z codes in privately insured adults. METHODS: In 2021, the authors conducted a case-control analysis of national commercial health payer claims from 2016 to 2019. Among adults with ≥6 months of continuous enrollment and ≥1 medical claims, patients with any assigned Z codes were defined as cases. Controls were selected through stratified random sampling. Z codes were organized under 3 categories: socioeconomic, community/social, and environmental. RESULTS: Of 29.5 million adults, 521,334 patients (1.8%) had any assigned Z codes. Among all the Z codes, 53.5% identified community/social issues, 30.3% identified environmental issues, and 16.2% identified socioeconomic issues. Among socioeconomic Z codes, housing needs were frequently identified, but needs for food, utility bills, and transportation were very rarely identified. In multivariable regression analysis, females had higher odds of Z code assignment than males. Depression and chronic pulmonary disease were the 2 common comorbidities (≥5% prevalence in cases and controls) that were highly associated with Z code assignment. Less common comorbidities strongly associated with Z code assignment were drug abuse, alcohol abuse, psychoses, and AIDS/HIV. CONCLUSIONS: In this national study of privately insured patients, many Z codes identified healthcare encounters caused by social stressors, whereas few identified food- or transportation-related causes. Depression and chronic pulmonary disease were highly associated with Z code assignment.

Addressing Medical and Social Needs to Reduce Unnecessary Health Care Utilization and Costs: A Qualitative Study.

This study explored the goals, and care delivery approaches, of 14 interventions to address patients' medical and social needs. In qualitative interviews with clinicians and researchers, several themes emerged. Participants frequently described their overall goal as meeting patients' diverse needs to prevent avoidable acute care utilization. Medical needs were addressed by ensuring patients received primary care and actively coordinating care across clinical settings. Participants perceived social needs as tightly linked with medical needs, as well as a need for interpersonal skills among intervention staff. Descriptions of overall approaches to meeting patients' needs frequently aligned with principles of trauma-informed care and patient-centered care.

Randomized Trial Evaluating Health System Expenditures with Transitional Care Services for Adults with No Usual Source of Care at Discharge.

BACKGROUND: Multidisciplinary transitional care services reduce readmissions for high-risk patients, but it is unclear if health system costs to offer these intensive services are offset by avoidance of higher downstream expenditures. OBJECTIVE: To evaluate net costs for a health system offering transitional care services DESIGN: One-year pragmatic, randomized trial PARTICIPANTS: Adults aged ≥ 18 without a usual source of follow-up care at the time of hospital discharge were enrolled through a high-volume, urban academic medical center in Chicago, IL, USA, from September 2015 through February 2016. INTERVENTIONS: Eligible patients were silently randomized before discharge by an automated electronic health record algorithm allocating them in a 1:3 ratio to receive routine coordination of post-discharge care (RC) versus being offered intensive, multidisciplinary transitional care (TC) services. MAIN MEASUREMENTS: Health system costs were collected from facility administrative systems and transformed to standardized costs using Medicare reference files. Multivariable generalized linear models estimated proportional differences in net costs over one year. KEY RESULTS: Study patients (489 TC; 164 RC) had a mean age of 44 years; 34% were uninsured, 55% had public insurance, and 49% self-identified as Black or Latinx. Over 90 days, cost differences between groups were not statistically significant. Over 180 days, the TC group had 41% lower ED/observation costs (adjusted cost ratio [aCR], 0.59; 95% CI, 0.36-0.97), 50% lower inpatient costs (aCR, 0.50; 95% CI, 0.27-0.95), and 41% lower total healthcare costs (aCR, 0.59; 95% CI, 0.36-0.99) than the RC group. Over 365 days, total cost differences remained of similar magnitude but no longer were statistically significant. CONCLUSIONS: Offering TC services for vulnerable adults at discharge reduced net health system expenditures over 180 days. The promising economic case for multidisciplinary transitional care interventions warrants further research. TRIAL REGISTRATION: National Clinical Trials Registry (NCT03066492).

Initiating second-line antidiabetic medication among older adults with type 2 diabetes on Metformin.

BACKGROUND: Antidiabetic medications (ADM), especially sulfonylureas (SFU) and basal insulin (BI), are associated with increased risk of hypoglycemia, which is especially concerning among older adults in poor health. The objective of this study was to investigate prescribing patterns of ADM in older adults according to their health status. METHODS: This case control study analyzed administrative claims between 2013 and 2017 from a large national payer. The study population was derived from a nationwide database of 84,720 U.S. adults aged ≥65, who were enrolled in Medicare Advantage health insurance plans. Participants had type 2 diabetes on metformin monotherapy, and started a second-line ADM during the study period. The exposure was a binary variable for health status, with poor health defined by end-stage medical conditions, dementia, or residence in a long-term nursing facility. The outcome was a variable identifying which second-line ADM class was started, categorized as SFU, BI, or other (i.e. all other ADM classes combined). RESULTS: Over half of participants (54%) received SFU as initial second-line ADM, 14% received BI, and 32% received another ADM. In multivariable models, the odds of filling SFU or BI was higher for participants in poor health than those in good or intermediate health [OR 1.13 (95% CI 1.05-1.21) and OR 2.34 (95% CI 2.14-2.55), respectively]. SFU and BI were also more commonly filled by older adults with poor glycemic control. CONCLUSIONS: Despite clinical consensus to use caution prescribing SFU and BI among older adults in poor health, these medications remain frequently used in this particularly vulnerable population.

Costs for commercially insured adults prescribed second-line diabetes medications.

OBJECTIVES: To examine differences in health care costs associated with choice of second-line antidiabetes medication (ADM) for commercially insured adults with type 2 diabetes. STUDY DESIGN: Retrospective cohort study with multiple pretests and posttests. METHODS: Included patients initiated second-line ADM therapy between 2011 and 2015, with variable follow-up through 2017. The 6 index medication classes were sulfonylureas, dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1 RAs), basal insulin, sodium-glucose cotransporter-2 (SGLT-2) inhibitors, and thiazolidinediones (TZDs). Multivariable regression models compared between-class changes in adjusted quarterly costs after second-line ADM initiation. RESULTS: The study cohort included 34,963 adults. Most were prescribed a sulfonylurea (46.0%) or DPP-4 inhibitor (30.4%). Adjusted quarterly index medication costs were significantly higher for all patients receiving nonsulfonylurea medications, ranging from $108 (95% CI, $99-$118) for TZDs to $742 (95% CI, $720-$765) for GLP-1 RAs. Changes in quarterly total health care costs were significantly higher for all nonsulfonylurea classes. Conversely, changes in quarterly nonpharmacy medical costs were significantly lower for patients receiving DPP-4 inhibitors (-$67; 95% CI, -$92 to -$43), GLP-1 RAs (-$43; 95% CI, -$85 to -$1), and SGLT-2 inhibitors (-$46; 95% CI, -$87 to -$6); changes in all other quarterly costs besides the index medication were significantly lower for patients receiving DPP-4 inhibitors (-$60; 95% CI, -$94 to -$26) and SGLT-2 inhibitors (-$113; 95% CI, -$169 to -$57). CONCLUSIONS: The higher cost of nonsulfonylurea medications was the main driver of relative increases in total costs. Relative decreases in nonpharmacy medical costs among patients receiving newer ADM classes reflect these medications' potential value.

Effect on Health Care Expenditures During Nationwide Implementation of the Diabetes Prevention Program as a Health Insurance Benefit.

OBJECTIVE: Lifestyle interventions slow development of type 2 diabetes by half, but the impact of health payer reimbursement for delivery of intervention programs is not well known. We evaluated net commercial health payer expenditures when offering reimbursement for access to YMCA's Diabetes Prevention Program (YDPP) in 42 states. RESEARCH DESIGN AND METHODS: We used a nonequivalent comparison group design to evaluate net health care expenditures for adults with prediabetes who attended one or more YDPP visit between 1 July 2009 and 31 May 2013 ("YDPP users"). Rolling, 1:1 nearest neighbor propensity score (PS) matching was used to identify a comparison group of nonusers. Administrative data provided measures of YDPP attendance, body weight at YDPP visits, and health care expenditures. Random effects, difference-in-difference regression was used to estimate quarterly health care expenditures before and after participants' first visit to YDPP. RESULTS: Worksite screening identified 9.7% of the target population; 39.1% of those identified (19,933 participants through June 2015) became YDPP users. Mean weight loss for YDPP users enrolled before June 2013 (n = 1,725) was 7.5 lb (3.4%); 29% achieved ≥5% weight loss. Inclusive of added costs to offer YDPP, there were no statistically significant differences in mean per-person net health care expenditures between YDPP users and PS-matched nonusers over 2 years ($0.2 lower [95% CI $56 lower to $56 higher]). Mean reimbursement to the YMCA was $212 per YDPP user, with 92.8% of all expenditures made for those who attended at a high rate (≥9 completed YDPP visits). CONCLUSIONS: Worksite screening was inefficient for identifying the population with prediabetes, but those identified achieved modest YDPP attendance and clinically meaningful weight loss. Over 2 years, added costs to offer the intervention were modest, with neutral effects on net health care costs.

A pragmatic randomized comparative effectiveness trial of transitional care for a socioeconomically diverse population: Design, rationale and baseline characteristics.

Transitional care programs have been widely used to reduce readmissions and improve the quality and safety of the handoff process between hospital and outpatient providers. Very little is known about effective transitional care interventions among patients who are uninsured or with Medicaid. This paper describes the design and baseline characteristics of a pragmatic randomized comparative effectiveness trial of transitional care. Northwestern Medical Group- Transitional Care (NMG-TC) care model was developed to address the needs of patients with multiple medical problems that required lifestyle changes and were amenable to office-based management. We present the design, evaluation methods and baseline characteristics of NMG-TC trial patients. Baseline demographic characteristics indicate that our patient population is predominantly male, Medicaid insured and non-white. This study will evaluate two methods for implementing an effective transitional care model in a medically complex and socioeconomically diverse population.

Outreach for Annual Colorectal Cancer Screening: A Budget Impact Analysis for Community Health Centers.

INTRODUCTION: Fecal immunochemical testing (FIT) is an attractive approach for colorectal cancer screening at community health centers. This budget impact analysis investigated benefits and costs of FIT outreach-with FIT kits mailed to patients, followed by reminders and phone calls-compared with point-of-care (POC) strategies. METHODS: Five screening and cost outcomes were simulated over 1 year at a "base case" community health center serving 1000 screening-eligible patients: (1) FIT completion among patients due for screening; (2) proportion up-to-date on screening; (3) cost per patient due for screening; (4) cost per completed FIT; and (5) total organizational cost. Uncertainty analysis investigated potential savings from optimizing staff workflows during FIT outreach. Data were collected in 2012-2014, with analysis conducted 2014-2015. RESULTS: Using POC strategies, 24.0% of patients due for screening completed FIT, versus 42.4% under outreach (18.4% absolute difference). When calculations included patients up-to-date on screening from prior colonoscopy, 41.7% were up-to-date via POC, versus 55.8% for outreach (14.1% absolute difference). POC cost $4.93 per patient, versus $30.43 for outreach ($25.50 difference). Cost per patient screened was $20.60 for POC and $71.84 for outreach ($51.24 difference). Total organizational cost was $3,779 for POC distribution and $23,315 for outreach ($19,536 difference). Outreach costs decreased by approximately one fourth under optimized workflows. CONCLUSIONS: Outreach is an effective, practical, relatively low-cost strategy; costs could be reduced further by optimizing staff workflows. Despite its value, outreach costs more than POC distribution and may be difficult for community health centers to implement under current payment models.

Comparative Effectiveness of Multifaceted Outreach to Initiate Colorectal Cancer Screening in Community Health Centers: A Randomized Controlled Trial.

INTRODUCTION: Colorectal cancer (CRC) screening rates are low among vulnerable populations. Fecal immunochemical tests (FITs) are one screening modality with few barriers. Studies have shown that outreach can improve CRC screening, but little is known about its effectiveness among individuals with no CRC screening history. We sought to determine whether outreach increases FIT uptake among patients with no CRC screening history compared to usual care. METHODS: This study was a patient-level randomized controlled trial, including 420 patients who had never completed CRC screening and were eligible for FIT; 66% were female, 62.1% were Latino, and 70.7% were uninsured. The main outcome measure was FIT completion within 6 months of the randomization date. We assessed FIT completion at different time points corresponding to receipt of outreach components. All analyses were re-run with 12-month data. RESULTS: Patients who received outreach were more likely to complete FIT than those in usual care (36.7% vs. 14.8%; p < 0.001). FIT completion was more common among patients with increased clinic visits. The difference in FIT completion between the outreach and usual care groups decreased over time. DISCUSSION: The intervention improved FIT uptake among patients with no CRC screening history. However, the intervention was less effective than in a previous trial targeting patients due for repeat screening. Additional research is needed to determine the best methods for improving CRC screening among this hard-to-reach group.

Outcomes among chronically ill adults in a medical home prototype.

OBJECTIVES: To compare quality, utilization, and cost outcomes for patients with selected chronic illnesses at a patient-centered medical home (PCMH) prototype site with outcomes for patients with the same chronic illnesses at 19 nonintervention control sites. STUDY DESIGN: Nonequivalent pretest-posttest control group design. METHODS: PCMH redesign results were investigated for patients with preexisting diabetes, hypertension, and/or coronary heart disease. Data from automated databases were collected for eligible enrollees in an integrated healthcare delivery system. Multivariable regression models tested for adjusted differences between PCMH patients and controls during the baseline and follow-up periods. Dependent measures under study included clinical processes and, outcomes, monthly healthcare utilization, and costs. RESULTS: Compared with controls over 2 years, patients at the PCMH prototype clinic had slightly better clinical outcome control in coronary heart disease (2.20 mg/dL lower mean low-density lipoprotein cholesterol; P <.001). PCMH patients changed their patterns of primary care utilization, as reflected by 86% more secure electronic message contacts (P <.001), 10% more telephone contacts (P = .003), and 6% fewer in-person primary care visits (P <.001). PCMH patients had 21% fewer ambulatory care-sensitive hospitalizations (P <.001) and 7% fewer total inpatient admissions (P = .002) than controls. During the 2-year redesign, we observed 17% lower inpatient costs (P <.001) and 7% lower total healthcare costs (P <.001) among patients at the PCMH prototype clinic. CONCLUSIONS: A clinic-level population-based PCMH redesign can decrease downstream utilization and reduce total healthcare costs in a subpopulation of patients with common chronic illnesses.

Predictors of 1-year change in patient activation in older adults with diabetes mellitus and heart disease.

OBJECTIVES: To identify patterns and predictors of 1-year change in patient activation in chronically ill older adults. DESIGN: Prospective cohort study. SETTING: Integrated healthcare delivery system. PARTICIPANTS: Members of an integrated delivery system from 2007 to 2009 in western Washington state aged 65 and older with diabetes mellitus or heart disease; participants responded to baseline and 1-year follow-up mailed surveys about their health and health care (N = 2,341). MEASUREMENTS: Patient activation was measured using the 13-item Patient Activation Measure (PAM) at baseline and follow-up. Automated diagnoses and procedure data were extracted from databases. Multinomial logistic regression, stratified according to baseline activation stage, was used to estimate the odds ratios for increasing or decreasing activation stage associated with participant characteristics and serious adverse health events. RESULTS: Fifty-two percent of participants changed activation stage between baseline and follow-up. Of people who changed stage, 54% increased, and 46% decreased. Older age and worse baseline self-reported health were independent predictors of activation change in multivariate models. Changes in health status or serious adverse health events such as the occurrence of hospitalizations, new major diagnoses, or procedures were not related to changes in activation in this age group. CONCLUSION: Patient activation, as measured using the PAM, changes over time in elderly adults with chronic diseases. Clinicians and researchers who use the PAM for patient care or as an outcome measure in research studies should be aware of its fluctuation over time in chronically ill older persons.