Integrating Population Health Strategies into Primary Care: Impact on Outcomes and Hospital Use for Low-Income Adults.

Objective: Our objectives were two-fold: 1) To evaluate the benefits of population health strategies focused on social determinants of health and integrated into the primary care medical home (PCMH) and 2) to determine how these strategies impact diabetes and cardiovascular disease outcomes among a low-income, primarily minority community. We also investigated associations between these outcomes and emergency department (ED) and inpatient (IP) use and costs. Design: Retrospective cohort. Setting: Community-based PCMH: Baylor Scott & White Health and Wellness Center (BSW HWC). Patients/Participants: All patients who attended at least two primary care visits at BSW HWC within a 12-month time span from 2011-2015. Methods: Outcomes for patients participating in PCMH only (PCMH) as compared to PCMH plus population health services (PCMH+PoPH) were compared using electronic health record data. Main Outcomes: Diastolic and systolic blood pressure, hemoglobin A1c, ED visits and costs, and IP hospitalizations and costs were examined. Results: From 2011-2015, 445 patients (age=46±12 years, 63% African American, 61% female, 69.5% uninsured) were included. Adjusted regression analyses indicated PCMH+PoPH had greater improvement in diabetes outcomes (prediabetes HbA1c= -.65[SE=.32], P=.04; diabetes HbA1c= -.74 [SE=.37], P<.05) and 37% lower ED costs than the PCMH group (P=.01). Worsening chronic disease risk factors was associated with 39% higher expected ED visits (P<.01), whereas improved chronic disease risk was associated with 32% fewer ED visits (P=.04). Conclusions: Integrating population health services into the PCMH can improve chronic disease outcomes, and impact hospital utilization and cost in un- or under-insured populations.

Treatment of Chronic Kidney Disease-Related Metabolic Acidosis With Fruits and Vegetables Compared to NaHCO3 Yields More and Better Overall Health Outcomes and at Comparable Five-Year Cost.

OBJECTIVES: Current guidelines recommend treatment of metabolic acidosis in chronic kidney disease (CKD) with Na+-based alkali but base-producing fruits and vegetables (F + V) might yield more and better health outcomes, making the intervention cost-effective. DESIGN AND METHODS: In this post hoc analysis of a clinical trial we randomized 108 macroalbuminuric, nondiabetic CKD stage 3 participants with metabolic acidosis to receive F + V (n = 36) calculated to reduce dietary acid by half, oral NaHCO3 (HCO3-, n = 36) 0.3 mEq/kg body weight/day, or Usual Care (UC, n = 36) assessed annually for 5 years. We calculated a mean overall health score for the groups as follows: 1 for improved, 0 for no change, and -1 for worsened at 5 years for plasma total CO2, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, change in medication dose (reduction = 1, increased = -1, no change = 0), and 1 for met goal and 0 for not meeting goal for estimated glomerular filtration rate (>30 mL/min/1.73 m2) and systolic blood pressure (<130 mm Hg). We also assessed the number of participants with cardiovascular disease events (myocardial infarctions + strokes) and group medication and hospitalization costs. RESULTS: Net plasma total CO2 increase at 5 years was no different between HCO3- and F + V. Average health scores at 5 years differed among groups (P < .01) with F + V (7.4 [mean] ± 1.6 [standard deviation]) being descriptively larger than HCO3- and UC (2.9 ± 1.6 and 1.2 ± 1.6, respectively). The number of participants suffering cardiovascular disease events differed among groups (P = .009) with none (0) in F + V, 6 in UC, and 2 in HCO3-. Total 5-year household cost per beneficial health outcome differed among groups (P = .005) with UC being highest and that for HCO3- and F + V being comparable. CONCLUSIONS: Metabolic acidosis improved comparably with F + V or standard oral NaHCO3, but F + V yielded ancillary beneficial health outcomes, fewer participants with adverse cardiovascular events, and per-household cost that was comparable to NaHCO3.

Innovative Population Health Model Associated With Reduced Emergency Department Use And Inpatient Hospitalizations.

Population health strategies that improve access to health care and address social determinants of health may reduce the use of costly emergency services. Here we describe a strategy adopted by Baylor Scott & White Health to reduce rising rates of emergency department use and inpatient hospitalizations in an underserved Dallas community that is home to many people with low socioeconomic status. Baylor Scott & White partnered with the Dallas Park and Recreation Department to create a level-three primary care clinic integrating wellness and prevention programs in a city recreational center. The clinic, known as the Baylor Scott & White Health and Wellness Center, exemplifies the integration of social determinants of health within a population health strategy. Emergency department (ED) and inpatient care use was examined over twelve months after initiation of services at the center. People who used the center's services showed a reduction in ED use of 21.4 percent and a reduction in inpatient care use of 36.7 percent, with an average cost decrease of 34.5 percent and 54.4 percent, respectively. These data support the use of population health strategies to reduce the use of emergency services.

How Academic Health Systems Can Achieve Population Health in Vulnerable Populations Through Value-Based Care: The Critical Importance of Establishing Trusted Agency.

Improving population health may require health systems to proactively engage patient populations as partners in the implementation of healthy behaviors as a shared value using strategies that incentivize healthy outcomes for the population as a whole. The current reactive health care model, which focuses on restoring the health of individuals after it has been lost, will not achieve the goal of improved population health. To achieve this goal, health systems must proactively engage in partnerships with the populations they serve. Health systems will need the help of community entities and individuals who have the trust of the population being served and are willing to act on behalf of the health system if they are to achieve this effective working partnership. The need for these trusted agents is particularly pertinent for vulnerable and historically underserved segments of the population. In this Invited Commentary, the authors discuss ways by which health systems might identify, engage, and leverage trusted agents to improve the health of the population through value-based care.

Evaluation of diabetes primary care and effects on health care charges in elderly patients with diabeties.

BACKGROUND: This study assessed diabetes out-patient care at a single institution in Medicare patients with significant health care expenditures and correlated the control of these patients with hospital admission rates and charges. METHODS: A retrospective review was performed at a university health sciences center's clinics and affiliated hospital. Medicare patients with Type 2 diabetes, >65 years, and hospitalized >1 in the past year with annual incurred Medicare charges of >$6,000 were included in the study. Data collected over a year period included: hospitalization and emergency department use and charges, and key out-patient diabetes-related quality of care outcomes. These outcomes were compared with national benchmark National Health and Nutrition Examination Survey (NHANES) data. RESULTS: Ninety-three patients were identified (median age of 72). More patients were at goal hemoglobin A1c, low-density lipoprotein cholesterol, and blood pressure than benchmark National Health and Nutrition Examination Survey data. There was a significant correlation between HbA1c and diabetes-related and all cause hospitalizations and ER visits per patient (P < 0.025) and diabetes-related charges (P = 0.0291). There were no differences between an endocrinologist and general practitioners in the quality of care except for documented microalbuminuria and aspirin use. CONCLUSIONS: Diabetes care at this institution was better than national benchmark data. HbA1c correlated with diabetes-related hospitalizations, all-cause combined hospitalizations and emergency department visits and charges. There were no major differences in the care of patients between the endocrinologist and general practitioners.