Developing a Model to Predict High Health Care Utilization Among Patients in a New York City Safety Net System.

BACKGROUND: Health care facilities use predictive models to identify patients at risk of high future health care utilization who may benefit from tailored interventions. Previous predictive models that have focused solely on inpatient readmission risk, relied on commercial insurance claims data, or failed to incorporate social determinants of health may not be generalizable to safety net hospital populations. To address these limitations, we developed a payer-agnostic risk model for patients receiving care at the largest US safety net hospital system. METHODS: We transformed electronic health record and administrative data from 833,969 adult patients who received care during July 2016-July 2017 into demographic, utilization, diagnosis, medication, and social determinant variables (including homelessness and incarceration history) to predict health care utilization during the following year.We selected the final model by developing and validating multiple classification and regression models predicting 10+ acute days, 5+ acute days, or continuous acute days. We compared a portfolio of performance metrics while prioritizing positive predictive value for patients whose predicted utilization was among the top 1% to maximize clinical utility. RESULTS: The final model predicted continuous number of acute days and included 17 variables. For the top 1% of high acute care utilizers, the model had a positive predictive value of 47.6% and sensitivity of 17.3%. Previous health care utilization and psychosocial factors were the strongest predictors of future high acute care utilization. CONCLUSIONS: We demonstrated a feasible approach to predictive high acute care utilization in a safety net hospital using electronic health record data while incorporating social risk factors.

The Nation's First Publicly Recognized Overdose Prevention Centers: Lessons Learned in New York City.

In November of 2021, multiple factors converged to create a window of opportunity to open overdose prevention centers (OPCs) at two existing syringe service programs (SSPs) in New York City (NYC). Political will exists in NYC, particularly toward the end of the de Blasio administration's term, and the NYC Health Department worked to garner additional support from local and state elected officials given the dire need to address the overdose crisis. This coincided with readiness on the part of one of the NYC SSP providers, OnPoint NYC, to open and operate OPC services. Legal risks were assessed by both the city and the provider. This case study outlines the sequence of events that resulted in NYC supporting OnPoint to open the first two publicly recognized OPCs in the nation, including lessons learned to inform other jurisdictions considering offering such services.

Collateral Impacts of the COVID-19 Pandemic: The New York City Experience.

OBJECTIVE: To adapt an existing surveillance system to monitor the collateral impacts of the COVID-19 pandemic on health outcomes in New York City across 6 domains: access to care, chronic disease, sexual/reproductive health, food/economic insecurity, mental/behavioral health, and environmental health. DESIGN: Epidemiologic assessment. Public health surveillance system. SETTING: New York City. PARTICIPANTS: New York City residents. MAIN OUTCOME MEASURES: We monitored approximately 30 indicators, compiling data from 2006 to 2022. Sources of data include clinic visits, surveillance surveys, vital statistics, emergency department visits, lead and diabetes registries, Medicaid claims, and public benefit enrollment. RESULTS: We observed disruptions across most indicators including more than 50% decrease in emergency department usage early in the pandemic, which rebounded to prepandemic levels by late 2021, changes in reporting levels of probable anxiety and depression, and worsening birth outcomes for mothers who identified as Asian/Pacific Islander or Black. Data are processed in SAS and analyzed using the R Surveillance package to detect possible inflections. Data are updated monthly to an internal Tableau Dashboard and shared with agency leadership. CONCLUSIONS: As the COVID-19 pandemic continues into its third year, public health priorities are returning to addressing non-COVID-19-related diseases and conditions, their collateral impacts, and postpandemic recovery needs. Substantial work is needed to return even to a suboptimal baseline across multiple health topic areas. Our surveillance framework offers a valuable starting place to effectively allocate resources, develop interventions, and issue public communications.

Challenges for immigrant health in the USA-the road to crisis.

The USA is home to more immigrants than any other country-about 46 million, just less than a fifth of the world's immigrants. Immigrant health and access to health care in the USA varies widely by ethnicity, citizenship, and legal status. In recent decades, several policy and regulatory changes have worsened health-care quality and access for immigrant populations. These changes include restrictions on access to public health insurance programmes, rhetoric discouraging the use of social services, aggressive immigration enforcement activities, intimidation within health-care settings, decreased caps on the number of admitted refugees, and rescission of protections from deportation. A receding of ethical norms has created an environment favourable for moral and public health crises, as evident in the separation of children from their parents at the southern US border. Given the polarising immigration rhetoric at the national level, individual states rather than the country as a whole might be better positioned to address the barriers to improved health and health care for immigrants in the USA.

Cities as Platforms for Population Health: Past, Present, and Future.

Policy Points Cities have long driven innovation in public health in response to shifting trends in the burden of disease for populations. Today, the challenges facing municipal health departments include the persistent prevalence of chronic disease and deeply entrenched health inequities, as well as the evolving threats posed by climate change, political gridlock, and surging behavioral health needs. Surmounting these challenges will require generational investment in local public health infrastructure, drawn both from new governmental allocation and from innovative financing mechanisms that allow public health agencies to capture more of the value they create for society. Additional funding must be paired with the local development of public health data systems and the implementation of evidence-based strategies, including community health workers and the co-localization of clinical services and social resources as part of broader efforts to bridge the gap between public health and health care. Above all, advancing urban health demands transformational public policy to tackle inequality and reduce poverty, to address racism as a public health crisis, and to decarbonize infrastructure. One strategy to help achieve these ambitious goals is for cities to organize into coalitions that harness their collective power as a force to improve population health globally.

Redesigning the regulatory framework for ambulatory care services in New York.

UNLABELLED: Policy Points: The landscape of ambulatory care services in the United States is rapidly changing on account of payment reform, primary care transformation, and the rise of convenient care options such as retail clinics. New York State has undertaken a redesign of regulatory policy for ambulatory care rooted in the Triple Aim (better health, higher-quality care, lower costs)-with a particular emphasis on continuity of care for patients. Key tenets of the regulatory approach include defining and tracking the taxonomy of ambulatory care services as well as ensuring that convenient care options do not erode continuity of care for patients. CONTEXT: While hospitals remain important centers of gravity in the health system, services are increasingly being delivered through ambulatory care. This shift to ambulatory care is giving rise to new delivery structures, such as retail clinics and urgent care centers, as well as reinventing existing ambulatory care capacity, as seen with the patient-centered medical home model and the movement toward team-based care. To protect the public's interests, oversight of ambulatory care services must keep pace with these rapid changes. With this purpose, in January 2013 the New York Public Health and Health Planning Council undertook a redesign of the regulatory framework for the state's ambulatory care services. This article describes the principles undergirding the framework as well as the regulatory recommendations themselves. METHODS: We explored and analyzed the regulation of ambulatory care services in New York in accordance with the available gray and peer-reviewed literature and legislative documents. The deliberations of the Public Health and Health Planning Council informed our review. FINDINGS: The vision of high-performing ambulatory care should be rooted in the Triple Aim (better health, higher-quality care, lower costs), with a particular emphasis on continuity of care for patients. There is a pressing need to better define the taxonomy of ambulatory care services. From the state government's perspective, this clarification requires better reporting from new health care entities (eg, retail clinics), connections with regional and state health information technology hubs, and coordination among state agencies. A uniform nomenclature also would improve consumers' understanding of rights and responsibilities. Finally, the regulatory mechanisms employed-from mandatory reporting to licensure to regional planning to the certificate of need-should remain flexible and match the degree of consensus regarding the appropriate regulatory path. CONCLUSIONS: Few other states have embarked on a wide-ranging assessment of their regulation of ambulatory care services. By moving toward adopting the regulatory approach described here, New York aims to balance sound oversight with pluralism and innovation in health care delivery.

Health and political economy: building a new common sense in the United States.

The prevailing economic paradigm, characterized by free market thinking and individualistic cultural narratives, has deeply influenced contemporary society in recent decades, including health in the United States. This paradigm, far from being natural, is iteratively intertwined with politics, social group stratification, and norms, together shaping what is known as political economy. The consequences are starkly evident in health, with millions of lives prematurely lost annually in the United States. Drawing on economic re-thinking happening in fields like climate and law, we argue for a new "common sense" towards a health-focused political economy. Central to this proposed shift is action in 3 interconnected areas: capital, care, and culture. Re-orienting capital to prioritize longer-term investments, such as in public options for health care and baby bonds, can promote health and affirmatively include historically marginalized groups. Recognizing that caregiving is economically valuable and necessary for health, approaches like local cadres of community health workers across the United States would be part of building robust caregiving infrastructures. Advancing momentum in these directions, in turn, will require displacing dominant cultural narratives. As the health arena pursues change in the face of real obstacles, recent efforts reinvigorating industrial policy and addressing concentrated market power can serve as inspiration.