Program Implementation Strategies Associated With Reduced Acute Care Utilization for Medicaid Beneficiaries in California's Whole Person Care Pilot Program.

Public health care policymakers and payers are increasingly investing in efforts to address patients' health-related social needs (HRSNs) as a strategy for improving health while controlling or reducing costs. However, evidence regarding the implementation and impact of HRSN interventions remains limited. California's Whole Person Care Pilot program (WPC) was a Medicaid Section 1115 waiver demonstration program focused on the provision of care coordination and other services to address eligible beneficiaries' HRSN. In this study, we examine pilot-level variation in impact on acute care utilization and identify factors associated with differential outcomes. The majority of pilots reduced emergency department (ED) visits for enrollees relative to matched controls; however, only four pilots reduced both ED visits and hospitalizations. Coincidence analysis results highlight the importance of cross-sector partnerships, field-based outreach and engagement, and adequate program investment in differentiating pilots that reduced acute care utilization from those that did not.

Selective Hydrodeoxygenation of Lignin-Derived Phenolic Monomers to Cyclohexanol over Tungstated Zirconia Supported Ruthenium Catalysts.

The selective hydrodeoxygenation (HDO) of lignin-derived methoxyphenols to cyclohexanol is one of the most significant transformation in biomass conversion since cyclohexanol is an important industrial raw material. This study has disclosed a series of tungstated zirconia with different Zr/W ratio supported Ru catalysts (Ru/xZrW, x means the molar ration of Zr/W) for the hydrodeoxygenation (HDO) of guaiacol to cyclohexanol. Among these catalysts, Ru/16ZrW has the best catalytic activity, which can achieve 92 % yield of cyclohexanol under the conditions of 180 °C and 1 MPa H2 pressure for 2 h (TOF 231 h-1). Compared with Ru/ZrO2, Ru/16ZrW has smaller particles, more dispersed and electron-rich Ru species, significant hydrogen spillover and more acid sites, which are the main reason for its excellent performance on this reaction. Apart from guaiacol, other methoxy substitution phenols and organosolv lignin can also be converted into cyclohexanol via hydrodeoxygenation reactions over this catalyst.

Associations of Homelessness With Primary Care and Acute Care Utilization Among Medicaid-Enrolled Youth.

BACKGROUND: Youth comprise one-third of the US homeless population. However, little is known about how homelessness affects health care utilization. OBJECTIVE: Examine associations of homelessness with hospitalization, primary care, and ED visits, varying by race/ethnicity, among Medicaid-enrolled youth. RESEARCH DESIGN: A cross-sectional analysis was conducted using California Medicaid claims data on youth beneficiaries with complex needs. We examined the number of hospitalizations, preventable and nonpreventable ED, and primary care visits using a multivariate regression. We further explored the differential associations by race/ethnicity. RESULTS: Approximately 17% of our sampled youth experienced homelessness in 2018 (N=90,202). Compared with their housed counterparts, youth experiencing homelessness had a 1.9 percentage point (pp) higher likelihood of frequent ED visits (95% CI: 1.7-2.2) but a 2.9 pp lower probability of any primary care visits (95% CI: -3.9 to -1.9). Homelessness was associated with 221 more ED visits (95% CI: 182-260), 100 more preventable ED visits (95% CI: 84-116), 19.9 more hospitalizations (95% CI: 12-27), but 56 fewer primary care visits (95% CI: -104 to -7), per 1000 youth. The associations of homelessness with total ED visits, preventable ED visits, and needed and nonpreventable ED visits were all higher among Whites and, particularly, Blacks than for Hispanics and Asians. CONCLUSIONS: Medicaid-enrolled youth who experienced homelessness had more overall ED, preventable ED, and hospital visits, but fewer primary care visits than their housed peers. Our results suggest promoting primary care use should be considered among strategies to improve health and reduce costs.

Simulating PDT of port-wine stains in the in vivo chicken wattle model using Hemoporfin and radiation at 532 nm: Comparison of a LED and a laser source.

Port-wine stain (PWS) birthmarks are congenital capillary malformations occurring in 0.3 %∼0.5 % of newborns. Hemoporfin-mediated vascular-acting photodynamic therapy (Hemoporfin PDT) is an emerging option for treating PWS. This in vivo study aimed to compare laser and light-emitting diodes (LED) as light source for Hemoporfin PDT. Chicken wattles were used as the animal model. Color and histopathological changes were evaluated after combining Hemoporfin with KTP laser or LED light source of 532 nm at the same doses. Both PDT approaches could induce significant vascular injury and color bleaching. Although the use of the laser resulted in a greater vascular clearance, the LED showed more uniform distribution both in the beam profiles and tissue reaction and exhibited better safety. This in vivo study suggests that the LED is a favorable choice for larger PWS lesion.

Chitosan oligosaccharide improves intestinal homeostasis to achieve the protection for the epithelial barrier of female Drosophila melanogaster via regulating intestinal microflora.

Chitosan oligosaccharide (COS) is a new type of marine functional oligosaccharide with biological activities such as regulating intestinal microflora and improving intestinal immunity. In this study, female Drosophila melanogaster was used as a model organism to evaluate the effect of COS on intestinal injury by H2O2 induction, and its mechanism was explored through the analysis of intestinal homeostasis. The results showed that 0.25% of COS could effectively prolong the lifespan of stressed female D. melanogaster by increasing its antioxidant capacity and maintaining intestinal homeostasis, which included protecting the mechanical barrier, promoting the chemical barrier, and regulating the biological barrier by affecting its autophagy and the antioxidant signaling pathway. Additionally, the protective effect of COS on the intestinal barrier and homeostasis of D. melanogaster under oxidative stress status is directly related to its regulation of the intestinal microflora, which could decrease excessive autophagy and activate the antioxidant system to promote health. IMPORTANCE: The epithelial barrier plays an important role in the organism's health. Chitosan oligosaccharide (COS), a new potential prebiotic, exhibits excellent antioxidant capacity and anti-inflammatory effects. Our study elucidated the protective mechanisms of COS on the intestinal barrier of Drosophila melanogaster under oxidative stress, which could provide new insights into COS application in various industries, such as food, agriculture, and medicine.

Differences in Health Care Utilization of High-Need and High-Cost Patients of Federally Funded Health Centers Versus Other Primary Care Providers.

BACKGROUND: Primary care providers (PCP) differ in their ability to address the needs and reduce use of costly services among complex Medicaid beneficiaries. Among PCPs, Health Resources and Services Administration (HRSA)-funded health centers (HCs) are shown to provide high-value care. OBJECTIVE: We compared health care utilization of complex Medicaid managed care beneficiaries whose PCPs were HCs versus 3 other groups. RESEARCH DESIGN: Cross-sectional study using propensity score matching comparing health care use by provider type, controlling for demographics, health status, and other covariates. SUBJECTS: California Medicaid administrative data for complex adult managed care beneficiaries with at least 1 primary care visit in 2018. MEASURES: Primary and specialty care evaluation & management visits and services; emergency department (ED) visits; and hospitalizations. PCPs included HCs, clinics not funded by HRSA, solo, and group practice providers. RESULTS: HRSA-funded HCs had lower predicted rates of specialty evaluation & management and other services than all others; lower predicted probability of any ED visits than clinics not funded by HRSA [54% (95% CI: 53%-55%) vs. 56% (95% CI: 55%-57%)] and group practice providers [51% (95% CI: 51%-52%) vs. 52% (95% CI: 52%-53%)]; and lower PP of any hospitalizations than solo [20% (95% CI: 19%-20%) vs. 23% (95% CI: 22%-24%)] and group practice providers [21% (95% CI: 20%-21%) vs. 24% (95% CI: 23%-24%)]. CONCLUSIONS: Differences in HC care delivery and practices were associated with lower use of specialty, ED, and hospitalization visits compared with other PCPs for complex Medicaid managed care beneficiaries. Understanding the underlying reasons for these utilization differences may promote better outcomes among these patients.

Phylogenetic analysis of wall associated kinase genes in Triticum and characterization of TaWAK7.

Wall-associated kinases (WAKs), a group of receptor-like kinases (RLKs), have been found to play important roles in defending against pathogens and in various developmental processes. However, the importance of this family in wheat remains largely unknown. Wheat powdery mildew is caused by Blumeria graminis f. sp. tritici (Bgt) which initiates infection on the cell surface and forms haustoria inside the cell, therefore, the defense to Bgt involves extracellular and subsequently intracellular signals. In this study, WAKs were identified genome-wide and phylogenetically analyzed, then a transmembrane WAK gene putatively participated in pathogen-associated molecular patterns (PAMPs)-triggered immunity (PTI) and effector-triggered immunity (ETI) to Bgt was functionally and evolutionarily investigated. In total, 1,193 WAKs were identified from wheat and its Gramineae relatives. Phylogenetic analysis indicated that WAKs expanded through tandem duplication or segment duplication. TaWAK7, from chromosome 2A, was identified as a Bgt-inducible gene both in susceptible and resistant materials but showed distinct responsive patterns. Functional analysis showed that TaWAK7 was involved in both the basal and resistance (R)-gene mediated resistances. The specific gene structures and protein characteristics of TaWAK7 together with its orthologs were characterized both in subgenomes of Triticum and in the A genome of multiple wheat accessions, which revealed that TaWAK7 orthologs underwent complex evolution with frequent gene fusion and domain deletion. In addition, three cytoplasmic proteins interacting with TaWAK7 were indicated by yeast-two-hybrid and BiFC assays. Binding of TaWAK7 with these proteins could change the subcellular localization of TaWAK7 from the plasma membrane to the cytoplasm. This study provides a better understanding of the evolution of WAKs at the genomic level and TaWAK7 at the gene level, and provides useful clues for further investigation of how WAKs transmit the extracellular signals to the cytoplasm to activate defense responses.

An innovative virtual reality training tool for the pre-hospital treatment of cranialmaxillofacial trauma.

Virtual reality (VR) surgery using the High Technology Computer Corporation Very Immersive Virtual Experience professional 2(HTC VIVE Pro2) suite is a multi-sensory, holistic surgical training experience. A multimedia combination including videos and three-dimensional interaction in VR has been developed to enable trainees to experience a realistic battlefield environment. The innovation allows trainees to interact with the individual components of the cranialmaxillofacial(CMF) anatomy and apply surgical instruments while watching close-up stereoscopic three-dimensional videos of the surgery. In this study, a novel training tool for the pre-hospital treatment of CMF trauma based on immersive virtual reality (iVR) was developed and validated. Twenty-five CMF surgeons evaluated the application for face and content validity. Using a structured assessment process, the surgeons commented on the content of the developed training tool, its realism and usability and the applicability of VR surgery for CMF trauma rescue simulation training. The results confirmed the applicability of VR for delivering training in the pre-hospital treatment of CMF trauma. Modifications were suggested to improve the user experience and interactions with the surgical instruments. This training tool is ready for testing with surgical trainees.

Weight management practices of health center providers in the United States.

BACKGROUND: We examined weight management counseling practices of Health Resources and Services Administration-funded health center (HC) providers for patients with overweight (POW) and obesity (POB) status, focusing on weight-related conditions, risk factors, and health care utilization. METHOD: We used a nationally representative cross-sectional survey of HC patients and multilevel generalized structural equation logistic regression models to assess the association of provider counseling practices for POW and POB and by three obesity classes. Dependent variables included being told by the HC provider that weight was a problem, receiving a diet or exercise recommendation, referral to a nutritionist, or receiving weight loss prescriptions. Independent variables included weight-related conditions such as diabetes and hypertension, risk factors such as smoking, and health service utilization such as five or more primary care visits. RESULTS: All POB classes had higher odds of receiving all five counseling interventions than POW. Patients with diabetes and high cholesterol had higher odds of diet recommendations (OR = 1.8) and nutritionist referrals (OR = 2.3), while patients with cardiovascular disease had higher odds of nutritionist referral (OR = 2.0) and receiving weight loss prescriptions (OR = 2.6). Respondents with POB class III and diabetes had higher odds of receiving exercise recommendations (OR = 3.4), while POB class 1 and had hypertension had lower odds of nutritionist referral (OR = 0.3). CONCLUSIONS: Variations in HC primary care providers' weight management counseling practices between POW and POB present missed opportunities for consistent practice and early intervention. Assessing providers' counseling practices for patients with comorbid conditions is essential to the successful management of the obesity crisis.

Easy to use and validated predictive models to identify beneficiaries experiencing homelessness in Medicaid administrative data.

OBJECTIVE: To develop easy to use and validated predictive models to identify beneficiaries experiencing homelessness from administrative data. DATA SOURCES: We pooled enrollment and claims data from enrollees of the California Whole Person Care (WPC) Medicaid demonstration program that coordinated the care of a subset of Medicaid beneficiaries identified as high utilizers in 26 California counties (25 WPC Pilots). We also used public directories of social service and health care facilities. STUDY DESIGN: Using WPC Pilot-reported homelessness status, we trained seven supervised learning algorithms with different specifications to identify beneficiaries experiencing homelessness. The list of predictors included address- and claims-based indicators, demographics, health status, health care utilization, and county-level homelessness rate. We then assessed model performance using measures of balanced accuracy (BA), sensitivity, specificity, positive predictive value, negative predictive value, and area under the receiver operating characteristic curve (area under the curve [AUC]). DATA COLLECTION/EXTRACTION METHODS: We included 93,656 WPC enrollees from 2017 to 2018, 37,441 of whom had a WPC Pilot-reported homelessness indicator. PRINCIPAL FINDINGS: The random forest algorithm with all available indicators had the best performance (87% BA and 0.95 AUC), but a simpler Generalized Linear Model (GLM) also performed well (74% BA and 0.83 AUC). Reducing predictors to the top 20 and top five most important indicators in a GLM model yields only slightly lower performance (86% BA and 0.94 AUC for the top 20 and 86% BA and 0.91 AUC for the top five). CONCLUSIONS: Large samples can be used to accurately predict homelessness in Medicaid administrative data if a validated homelessness indicator for a small subset can be obtained. In the absence of a validated indicator, the likelihood of homelessness can be calculated using county rate of homelessness, address- and claim-based indicators, and beneficiary age using a prediction model presented here. These approaches are needed given the rising prevalence of homelessness and the focus of Medicaid and other payers on addressing homelessness and its outcomes.

Ensuring Equitable Care in Diabetes Management Among Patients of Health Resources & Services Administration-Funded Health Centers in the United States.

Aim: To explore whether there are racial/ethnic differences in diabetes management and outcomes among adult health center (HC) patients with type 2 diabetes. Methods: We analyzed data from the 2014 Health Center Patient Survey, a national sample of HC patients. We examined indicators of diabetes monitoring (A1C testing, annual foot/eye doctor visits, and cholesterol checks) and care management (specialist referrals, individual treatment plan, and receipt of calls/appointments/home visits). We also examined diabetes-specific outcomes (blood glucose levels, diabetes-related emergency department [ED] visits/hospitalizations, and diabetes self-management confidence) and general outcomes (number of doctor visits, ED visits, and hospitalizations). We used multilevel logistic regression models to examine racial/ethnic disparities by the above indicators. Results: We found racial/ethnic parity in A1C testing, eye doctor visits, and diabetes-specific outcomes. However, Hispanics/Latinos (odds ratio [OR] 0.26), non-Hispanic African Americans (OR 0.25), and Asians (OR 0.11) were less likely to receive a cholesterol check than Whites. Non-Hispanic African Americans (OR 0.43) were less likely to have frequent doctor visits, while Hispanic/Latino patients (OR 0.45) were less likely to receive an individual treatment plan. Conclusion: HCs largely provide equitable diabetes care but have room for improvement in some indicators. Tailored efforts such as culturally competent care and health education for some racial/ethnic groups may be needed to improve diabetes management and outcomes.

Factors associated with frequent emergency department visits among health centre patients receiving primary care.

RATIONALE, AIMS AND OBJECTIVES: We sought to examine specific care-seeking behaviours and experiences, access indicators, and patient care management approaches associated with frequency of emergency department (ED) visits among patients of Health Resources and Services Administration-funded health centres that provide comprehensive primary care to low-income and uninsured patients. METHOD: We used cross-sectional data of a most recent nationally representative sample of health centre adult patients aged 18-64 (n = 4577) conducted between October 2014 and April 2015. These data were merged with the 2014 Uniform Data System to incorporate health centre characteristics. We measured care-seeking behaviours by whether the patient called the health centre afterhours, for an urgent appointment, or talked to a provider about a concern. Access to care indicators included health centre continuity of care and receipt of transportation or translation services. We included receipt of care coordination and specialist referral as care management indicators. We used a multilevel multinomial logistic regression model to identify the association of independent variables with number of ED visits (4 or more visits, 2-3 visits, 1 visit, vs. 0 visits), controlling for predisposing, enabling, and need characteristics. RESULTS: Calling the health centre after-hours (OR = 2.41) or for urgent care (OR = 2.53), and being referred to specialists (OR = 2.36) were associated with higher odds of four or more ED visits versus none. Three or more years of continuity with the health centre (OR = 0.32) was also associated with lower odds of four or more ED visits versus none. CONCLUSIONS: Findings underscore opportunities to reduce higher frequency of ED visits in health centres, which are primary care providers to many low-income populations. Our findings highlight the potential importance of improving patient retention, better access to providers afterhours or for urgent visits, and access to specialist as areas of care in need of improvement.

Staffing transformation following Patient-Centered Medical Home recognition among Health Resources & Services Administration-funded health centers.

INTRODUCTION: Patient-Centered Medical Home (PCMH) recognition is designed to promote whole-person team-based and integrated care. PURPOSE: Our goal was to assess changes in staffing infrastructure that promoted team-based and integrated care delivery before and after PCMH recognition in Health Resources & Services Administration (HRSA)-funded health centers (HCs). METHODOLOGY/APPROACH: We identified changes in staffing 2 years before and 3 years after PCMH recognition using 2010-2019 Uniform Data System data among three cohorts of HCs that received PCMH recognition in 2013 ( n = 346), 2014 ( n = 207), and 2015 ( n = 115). Our outcomes were team-based ratio (full-time equivalent medical and nonmedical providers and staff to one primary care physician) and a multidisciplinary staff ratio (allied medical and nonmedical staff to 1,000 patients). We used mixed-effects Poisson regression models. RESULTS: The earlier cohorts served fewer complex patients and were larger before PCMH recognition. Three years following recognition, the 2013 and 2014 cohorts had significantly larger team-based ratios, and all three cohorts had significantly larger multidisciplinary staff ratios. Cohorts varied, however, in the type of staff that drove this change. Both ratios increased in the longer term. CONCLUSION: Our study suggests that growth in team-based and multidisciplinary staff ratios in each cohort may have been due to a combination of HCs' perceptions of need for specific services, HRSA funding, and technical assistance opportunities. POLICY IMPLICATIONS: Further research is needed to understand barriers such as costs of employing a multidisciplinary staff, particularly those that cannot directly bill for services as well as whether such changes lead to practice transformation and improved quality of care.

Mechanical Performance Study of Beam-Column Connection with U-Shaped Steel Damper.

The article proposes the use of a semi-rigid energy-dissipation connection combined with a U-shaped metal damper to avoid brittle failure of rigid steel beam-column connections under seismic loading. The U-shaped metal damper connects the H-section column and the H-section beam to form a new energy-dissipation connection as an energy-dissipation member. Compared with the existing research, this connection has a stable energy-dissipation performance and great ductility. To clarify the mechanism of energy dissipation, mechanical models under two U-shaped damping deformation modes are established. The calculation formulas for the yield load and stiffness are derived for the corresponding deformation mode using the unit load method. Taking the T-shaped beam-column connection and the application of U-shaped steel damper in the beam-column connection as an example, the mechanical model of the connection is established and the calculation formulas for the yield load and stiffness are derived. At the same time, the connection is subjected to a quasi-static test under cyclic loading. The results show that the hysteretic curve of the test is complete and that the skeleton curve is accurate compared to the theory. The error range of the initial stiffness and yield load obtained by the test and the theoretical formula is kept within 20%, indicating that the theoretical formula is reasonable and feasible. In addition, the correctness of the finite element model is verified by establishing a finite element model and comparing it with the test. The mechanical responses of purely rigid connections and rigid semi-rigid composite connections are compared and analyzed using a multi-story and multi-span plane frame as an example. The results show that the model with semi-rigid connections, compared to the model with rigid connections, avoids the gradual loss of bearing capacity caused by the failure of the connection area of the second floor of the main structure and improves the seismic performance of the main structure.

Study on Application of YAG Laser-Assisted Ear Correction Model to Congenital Auricular Deformities.

BACKGROUND: The objective of this study was to compare the clinical effects of a long-pulse-width 1064-nm Nd:YAG laser-assisted ear correction model and a simple ear correction model in the treatment of congenital auricular deformities in children older than 6 weeks. METHODS: A total of 129 children (179 ears) with congenital auricular deformities who were older than 2 months were included. Among them, 84 (119 ears) were treated with the ear correction model after long-pulse-width 1064-nm Nd:YAG laser irradiation (observation group) and 45 (60 ears) were treated with the ear correction model only (control group). The affected ears of the two groups were measured, the correction time was calculated, and the patients' family members filled in the satisfaction questionnaire before and after the treatment. RESULTS: The level of satisfaction of both groups improved after the treatment. The satisfaction level of the observation group was higher than that of the control group. Fewer days of correction were observed in the observation group than in the control group ( p < 0.05). The measurements of the affected ears in the two groups were significantly different after treatment. The difference after treatment of each measurement in the observation group was higher than in the control group. The therapeutic effect of the observation group was significantly better than that of the control group and the differences were statistically significant. CONCLUSION: Long-pulse-width 1064-nm Nd:YAG laser combined with the ear correction model can improve the success rate of correction of congenital auricular deformities in over-aged ears. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Differential associations of homelessness with emergency department visits and hospitalizations by race, ethnicity, and gender.

OBJECTIVE: To investigate the differential associations of homelessness with emergency department (ED) visits and hospitalizations by race, ethnicity, and gender. DATA SOURCES: California Medicaid enrollment and claims. STUDY DESIGN: We identified beneficiaries experiencing homelessness (BEH) and those who did not (NBEH) using diagnosis and place of service codes and residential addresses. Outcomes include four ED visit measures and four hospitalization measures. We compared the use of these services by BEH to NBEH overall and by race, ethnicity, and gender groups in regression models controlling for covariates. DATA COLLECTION: We used a sample of Medicaid beneficiaries who met eligibility criteria for a California Medicaid demonstration program in 2017 and 2018 but were not enrolled in the program. We identified 473,069 BEH, and the rest (1,948,422) were considered NBEH. We used the 2018 data for utilization analyses and most covariates. We constructed lagged measures of health conditions using 2017 data. PRINCIPAL FINDINGS: We found that homelessness was significantly associated with 0.34 more ED visits (p < 0.01) and a higher likelihood of frequent ED visits (2.77 percentage points [pp], p < 0.01), any ED visits due to mental health conditions (0.79 pp, p < 0.01), and any ED visits due to substance use disorders (1.47 pp, p < 0.01). Experiencing homelessness was also significantly associated with 0.03 more hospitalizations (p < 0.01), a higher likelihood of frequent hospitalizations (0.68 pp, p < 0.01) and high frequent hospitalizations (0.28 pp, p < 0.01), and a longer length of stay (0.53 days, p < 0.01). We found a larger association for American Indian and Alaska Native, Black, Native Hawaii or Pacific Islander, and White populations than that for Asian and Hispanic populations. The associations are larger for males than females. CONCLUSIONS: Our findings identified distinct utilization patterns by race, ethnicity, and gender. They indicated the need for developing race, ethnicity, and gender-specific strategies to reduce ED visits and hospitalizations of BEH.

The Relative Contribution of Social Determinants of Health Among Health Resources and Services Administration-Funded Health Centers.

Frameworks for identifying and assessing social determinants of health (SDOH) are effective for developing long-term societal policies to promote health and well-being, but may be less applicable in clinical settings. The authors compared the relative contribution of a specific set of SDOH indicators with several measures of health status among patients served by health centers (HCs). The 2014 Health Center Patient Survey was used to identify a sample of HC patient adults 18 years and older that reported the HC as their usual source of care (n = 5024). The authors examined the relationship between SDOH indicators organized in categories (health behaviors, access and utilization, social factors, economic factors, quality of care, physical environment) with health status measures (fair or poor health, diabetes, hypertension, cardiovascular disease, depression, or anxiety) using logistic regressions and predicted probabilities. Findings indicated that access to care and utilization indicators had the greatest relative contribution to all health status measures, but the relative contribution of other SDOH indicators varied. For example, access indicators had the highest predicted probability in the model with fair or poor health as the dependent variable (72.4%) and the model with hypertension as the dependent variable (47.4%). However, the second highest predicted probability was for social indicators (54.1%) in the former model and physical environment (44.7%) indicators in the latter model. These findings have implications for HCs that serve as the primary point of access to medical care in underserved communities and to mitigate SDOH particularly for patients with diabetes, depression, or anxiety.

Intersection of complexity and high utilization among health center patients aged 18 to 64 years.

OBJECTIVES: Existing literature indicates that multimorbidity, mental health (MH) conditions, substance use disorders (SUDs), and social determinants of health are hallmarks of high-need, high-cost patients. Health Resources and Services Administration-funded health centers (HCs) provide care to nearly 30 million patients, but data on their patients' complexity and utilization patterns are limited. We identified subgroups of HC patients based on latent concepts of complexity and utilization. STUDY DESIGN: We used cross-sectional national data from the 2014 Health Center Patient Survey and latent class analyses to identify distinct and homogenous groups of complex high-utilizing patients aged 18 to 64 years. METHODS: We included indicators of chronic conditions (CCs), MH, SUD risk, and health behavior to measure complexity. We used number of outpatient and emergency department visits in the past year to measure utilization. RESULTS: HC patients were separated in 9 distinct groups based on 3 complexity latent classes (MH, multiple CCs, and low risk) and 3 utilization classes (low, high, and superutilizers). Conditions associated with each subgroup differed. The highest prevalence of bipolar disorder (45%) and high SUD risk (6%) was observed among MH superutilizers, whereas the highest prevalence of cardiovascular disease (48%) and obesity (96%) was seen among CC superutilizers. Most MH superutilizer patients concurrently had MH conditions and obesity and were smokers, but most CC superutilizer patients concurrently had hypertension, obesity, and cardiovascular disease. CONCLUSIONS: Our examination of complexity and utilization indicated distinct HC patient populations. Managing the care of each group may require different targeted intervention approaches such as multidisciplinary care teams that include MH providers or specialists.

Trends in access to care among rural patients served at HRSA-funded health centers.

PURPOSE: Nearly one-fifth of Americans live in rural areas and experience multiple socioeconomic and health disparities. Health Resources and Services Administration (HRSA)-funded health centers (HCs) provide comprehensive primary care in rural communities. However, no prior research has examined trends in access to care in rural HC patients. We examined the change in access to care among patients served at rural HRSA-funded HCs in the United States between 2009 and 2014. METHODS: We compared patients by year to examine measures of access using multilevel generalized structural equation logistic regression models with random effects. We used the 2009 and 2014 cross-sectional Health Center Patient Surveys and identified 2,625 adult rural HC patients. Dependent variables were subjective (unmet need/delay in medical care, mental health, dental care, and prescription medications) and objective measures (preventive care and other health care utilization) in access to care. Our independent variable of interest was time, comparing access in 2009 and 2014. RESULTS: Rural HC patients reported higher predicted probability of influenza vaccine receipt (37% vs 51%), and lower unmet (25% vs 14%) and delayed medical care (36% vs 18%) between 2009 and 2014. Any emergency department visits in the last year increased (32% vs 46%) and mammogram (70% vs 55%) and Pap test (83% vs 72%) screening rates decreased. CONCLUSIONS: Observed increases in access to care among rural HC patients are positive developments but the challenges to access care still persist. Remote services, such as telehealth, could be cost-effective means of improving access to care among rural patients with limited provider supply.