Impact of dementia care training on nurse care managers' interactions with family caregivers.

BACKGROUND: Nurse care managers (NCM) operate through care management programs to provide care for persons living with dementia (PLWD) and interact regularly with their family caregivers; however, most do not receive formal instruction in dementia care or caregiver support. CRESCENT (CaReEcoSystem primary Care Embedded demeNtia Treatment) is a telephone-based dementia care intervention adapted from the Care EcoSystem model designed to equip NCMs with these tools. For this study, we aimed to measure intervention fidelity and understand how dementia care training impacted NCMs' provision of dementia care management services during interactions with caregivers of PLWD. METHODS: We recruited 30 active NCMs; 15 were randomly assigned to receive training. For each nurse, we randomly selected 1-3 patients with a diagnosis of dementia in each nurse's care during January-June 2021 for a total of 54 medical charts. To assess training uptake and fidelity, we identified documentation by NCMs of CRESCENT protocol implementation in the medical records. To understand how the training impacted the amount and types of dementia care management services provided in interactions with family caregivers, we compared attention to key dementia topic areas between trained NCMs (intervention) and untrained NCMs (control). RESULTS: Within the trained group only, community resources for PLWD, followed by safety, medication reconciliation, and advanced care planning topic areas were addressed most frequently (> 30%), while behavior management was addressed least frequently (12%). Trained NCMs were more likely to document addressing aspects of caregiver wellbeing (p = 0.03), community resources (p = 0.002), and identification of behavior (p = 0.03) and safety issues (p = 0.02) compared to those without training. There was no difference between groups in the amount of care coordination provided (p = 0.64). CONCLUSION: Results from this study demonstrate that focused dementia care training enriches care conversations in important topic areas for PLWD and family caregivers. Future research will clarify how best to sustain and optimize high quality dementia care in care management programs with special attention to the NCM-family caregiver relationship. TRIAL NUMBER: NCT04556097.

Prevalence of social risk factors and social needs in a Medicaid Accountable Care Organization (ACO).

BACKGROUND: Health-related social needs (HRSN) are associated with higher chronic disease prevalence and healthcare utilization. Health systems increasingly screen for HRSN during routine care. In this study, we compare the differential prevalence of social risk factors and social needs in a Medicaid Accountable Care Organization (ACO) and identify the patient and practice characteristics associated with reporting social needs in a different domain from social risks. METHODS: Cross-sectional study of patient responses to HRSN screening February 2019-February 2020. HRSN screening occurred as part of routine primary care and assessed social risk factors in eight domains and social needs by requesting resources in these domains. Participants included adult and pediatric patients from 114 primary care practices. We measured patient-reported social risk factors and social needs from the HRSN screening, and performed multivariable regression to evaluate patient and practice characteristics associated with reporting social needs and concordance to social risks. Covariates included patient age, sex, race, ethnicity, language, and practice proportion of patients with Medicaid and/or Limited English Proficiency (LEP). RESULTS: Twenty-seven thousand four hundred thirteen individuals completed 30,703 screenings, including 15,205 (55.5%) caregivers of pediatric patients. Among completed screenings, 13,692 (44.6%) were positive for ≥ 1 social risk factor and 2,944 (9.6%) for ≥ 3 risks; 5,861 (19.1%) were positive for social needs and 4,848 (35.4%) for both. Notably, 1,013 (6.0%) were negative for social risks but positive for social needs. Patients who did not identify as non-Hispanic White or were in higher proportion LEP or Medicaid practices were more likely to report social needs, with or without social risks. Patients who were non-Hispanic Black, Hispanic, preferred non-English languages or were in higher LEP or Medicaid practices were more likely to report social needs without accompanying social risks. CONCLUSIONS: Half of Medicaid ACO patients screened for HRSN reported social risk factors or social needs, with incomplete overlap between groups. Screening for both social risks and social needs can identify more individuals with HRSN and increase opportunities to mitigate negative health outcomes.

Epilepsy Among Elderly Medicare Beneficiaries: A Validated Approach to Identify Prevalent and Incident Epilepsy.

BACKGROUND: Uncertain validity of epilepsy diagnoses within health insurance claims and other large datasets have hindered efforts to study and monitor care at the population level. OBJECTIVES: To develop and validate prediction models using longitudinal Medicare administrative data to identify patients with actual epilepsy among those with the diagnosis. RESEARCH DESIGN, SUBJECTS, MEASURES: We used linked electronic health records and Medicare administrative data including claims to predict epilepsy status. A neurologist reviewed electronic health record data to assess epilepsy status in a stratified random sample of Medicare beneficiaries aged 65+ years between January 2012 and December 2014. We then reconstructed the full sample using inverse probability sampling weights. We developed prediction models using longitudinal Medicare data, then in a separate sample evaluated the predictive performance of each model, for example, area under the receiver operating characteristic curve (AUROC), sensitivity, and specificity. RESULTS: Of 20,945 patients in the reconstructed sample, 2.1% had confirmed epilepsy. The best-performing prediction model to identify prevalent epilepsy required epilepsy diagnoses with multiple claims at least 60 days apart, and epilepsy-specific drug claims: AUROC=0.93 [95% confidence interval (CI), 0.90-0.96], and with an 80% diagnostic threshold, sensitivity=87.8% (95% CI, 80.4%-93.2%), specificity=98.4% (95% CI, 98.2%-98.5%). A similar model also performed well in predicting incident epilepsy (k=0.79; 95% CI, 0.66-0.92). CONCLUSIONS: Prediction models using longitudinal Medicare data perform well in predicting incident and prevalent epilepsy status accurately.

Prioritizing Primary Care Patients for a Communication Intervention Using the "Surprise Question": a Prospective Cohort Study.

BACKGROUND: Communication about priorities and goals improves the value of care for patients with serious illnesses. Resource constraints necessitate targeting interventions to patients who need them most. OBJECTIVE: To evaluate the effectiveness of a clinician screening tool to identify patients for a communication intervention. DESIGN: Prospective cohort study. SETTING: Primary care clinics in Boston, MA. PARTICIPANTS: Primary care physicians (PCPs) and nurse care coordinators (RNCCs) identified patients at high risk of dying by answering the Surprise Question (SQ): "Would you be surprised if this patient died in the next 2 years?" MEASUREMENTS: Performance of the SQ for predicting mortality, measured by the area under receiver operating curve (AUC), sensitivity, specificity, and likelihood ratios. RESULTS: Sensitivity of PCP response to the SQ at 2 years was 79.4% and specificity 68.6%; for RNCCs, sensitivity was 52.6% and specificity 80.6%. In univariate regression, the odds of 2-year mortality for patients identified as high risk by PCPs were 8.4 times higher than those predicted to be at low risk (95% CI 5.7-12.4, AUC 0.74) and 4.6 for RNCCs (3.4-6.2, AUC 0.67). In multivariate analysis, both PCP and RNCC prediction of high risk of death remained associated with the odds of 2-year mortality. LIMITATIONS: This study was conducted in the context of a high-risk care management program, including an initial screening process and training, both of which affect the generalizability of the results. CONCLUSION: When used in combination with a high-risk algorithm, the 2-year version of the SQ captured the majority of patients who died, demonstrating better than expected performance as a screening tool for a serious illness communication intervention in a heterogeneous primary care population.

What Do High-Risk Patients Value? Perspectives on a Care Management Program.

BACKGROUND: There is growing interest in coordinating care for high-risk patients through care management programs despite inconsistent results on cost reduction. Early evidence suggests patient-centered benefits, but we know little about how participants engage with the programs and what aspects they value. OBJECTIVE: To explore care management program participants' awareness and perceived utility of program offerings. DESIGN: Cross-sectional telephone survey administered December 2015-January 2016. PARTICIPANTS: Patients enrolled in a Boston-area primary care-based care management program. MAIN MEASURES: Our main outcome was the number of topics in which patients reported having "very helpful" interactions with their care team in the past year. We analyzed awareness of one's care manager as an intermediate outcome, and then as a primary predictor of the main outcome, along with patient demographics, years in the program, attitudes, and worries as secondary predictors. KEY RESULTS: The survey response rate was 45.8% (n = 1220); non-respondents were similar to respondents. More respondents reported worrying about family (72.8%) or financial issues (52.5%) than about their own health (41.6%). Seventy-four percent reported care manager awareness, particularly women (OR 1.33, 95% CI 1.01-1.77) and those with more years in the program (OR 1.16, 95% CI 1.03-1.30). While interaction rates ranged from 19.8% to 72.4% across topics, 81.3% rated at least one interaction as very helpful. Those who were aware of their care manager reported very helpful interactions on more topics (OR 2.77, 95% CI 2.15-3.56), as did women (OR 1.25, 95% CI 1.00-1.55), younger respondents (OR 0.98 for older age, 95% CI 0.97-0.99), and those with higher risk scores (OR 1.04, 95% CI 1.02-1.06), preference for deferring treatment decisions to doctors (OR 2.00, 95% CI 1.60-2.50), and reported control over their health (OR 1.67, 95% CI 1.33-2.10). CONCLUSIONS: High-risk patients reported helpful interactions with their care team around medical and social determinants of health, particularly those who knew their care manager. Promoting care manager awareness may help participants make better use of the program.

Using a Self-Reported Global Health Measure to Identify Patients at High Risk for Future Healthcare Utilization.

BACKGROUND: Research studies have shown that patient-reported outcome measures (PROMs) that assess global health are helpful for predicting health care utilization, but less evidence exists that collection of PROMs in routine care can identify patients with high health care needs. OBJECTIVE: To investigate the association between the PROMIS Global Health (PGH) scores and subsequent health care utilization among patients in a large accountable care organization (ACO). DESIGN: Retrospective cohort study of individuals in the Partners HealthCare ACO who completed at least one PGH during a primary care visit. PARTICIPANTS: A total of 2639 individuals who completed at least one PGH and who also had 12 months of ACO membership and/or claims data prior to the PROM completion and at least one month of claims data post-PGH completion. MAIN MEASURES: The main outcomes were the rates of emergency department (ED) visits and hospitalizations by quartile of PGH physical and mental health scores. We also compared the predictive accuracy of administrative data models with and without the PGH scores to identify the highest utilizers. KEY RESULTS: The group with the worst (lowest) physical and mental health scores had significantly higher rates of hospitalization (RR 5.14, 95% CI 2.37, 11.15; and 2.27, 95% CI 1.06, 4.85, respectively) than those with higher scores. After adjustment for demographic and clinical factors, only the group with lower physical health scores had higher rates of hospitalization (RR 3.15, 95% CI 1.30, 7.90). The addition of the physical health subscore to administrative data increased the sensitivity to detect the top 5% of hospital utilizers compared with administrative data alone (44.0% vs. 36.0% respectively). CONCLUSIONS: Worse self-reported physical health, measured during routine primary care, is associated with significantly higher rates of hospitalization. It is not associated with increased rates of ED visits. Self-reported physical health modestly increases the sensitivity to detect the highest hospital utilizers.

The quality of hospital care for Medicaid and private pay patients.

CONTEXT: Understanding Medicaid performance relative to private payers and among other states may lead to better value. DESIGN, SETTING, AND PARTICIPANTS: Hospital Quality Alliance data from 2007-2008 were used to create composite "all-or-none" quality scores for nearly 900,000 nonelderly adult patients hospitalized with acute myocardial infarction (AMI), congestive heart failure (CHF), or pneumonia. MAIN OUTCOME MEASURES: Differences in the quality of care received by Medicaid compared with privately insured patients at the national and state levels. RESULTS: Nationally, 88% of Medicaid beneficiaries received all appropriate processes of care when hospitalized for AMI, compared with 73% for CHF and 77% for pneumonia. Private patients received higher quality of care than Medicaid patients, but differences were small (1.3 percentage point difference, pneumonia; 2.7, AMI; 2.9, CHF; all P<0.05). At the state level, the differences averaged <3 percentage points across all conditions, but some states (2-8 states depending on the condition) exhibited significant (P<0.05) differences of >5 percentage points in favor of private patients. Two states exhibited significantly better quality of care for their Medicaid patients in excess of 5 percentage points. Quality scores for both Medicaid and private patients varied significantly by state but were highly correlated (correlations for AMI=0.80, CHF=0.84, pneumonia=0.80; all P<0.001). CONCLUSIONS: Small national differences in quality between hospitalized Medicaid and private patients are promising, although merit close monitoring as states are forced to curb Medicaid reimbursements. Although quality for Medicaid patients varied by state, high correlations with private patients suggest that the factors driving quality have more to do with geographic factors in the delivery of hospital services than with state-established Medicaid policies.

Does use of primary care-based behavioral health programs differ by race and ethnicity? Evidence from a multi-site collaborative care model.

BACKGROUND: Collaborative care models (CoCM) that integrate mental health and primary care improve outcomes and could help address racial and ethnic mental health disparities. We examined whether use of these programs differs by race/ethnicity. METHODS: This retrospective study examined two CoCM interventions implemented across primary care clinics in a large health system in Massachusetts: 1) a primary care-based behavioral health program for depression or anxiety (IMPACT model) and 2) referral to community-based specialty care services (Resource-finding). Outcomes included enrollment, non-completion, and symptom screening rates, and discharge status for Black, Hispanic and White patients referred for CoCM, 2017-2019. RESULTS: Black and Hispanic vs. White patients referred to CoCM (n = 17,280) were more likely to live in high poverty ZIP codes (34% and 40% vs. 9%). Rates of program enrollment, non-completion, and symptom screening were similar across groups (e.g., 76%, 77%, and 75% of Black, Hispanic, and White patients enrolled). Hispanic vs. White patients were more likely to be enrolled in IMPACT (56%) vs. Resource-finding (43%). Among those completing IMPACT, Hispanic vs. White patients were more likely to be stepped to psychiatry vs. discharged to their primary care provider (51% vs. 20%, aOR = 1.55, 95% CI: 1.02-2.35). CONCLUSIONS: Black and Hispanic patients referred to CoCM were similarly likely to use the program as White patients. Hispanic patients completing IMPACT were more frequently referred to psychiatry. IMPLICATIONS: These results highlight the promise of CoCMs for engaging minority populations in mental healthcare. Hispanic patients may benefit from additional intervention or earlier linkage to specialty care.

The needs of family caregivers of persons living with dementia cared for in primary care practices.

RATIONALE: The informal caregivers who provide unpaid support for persons living with dementia (PLWD) are often unprepared to appropriately manage symptoms and navigate health services to support themselves or the PLWD. AIM: To understand informal caregivers' perceived capabilities of handling dementia symptomology and perceived support from providers. METHODS: We identified and surveyed caregivers of primary care patients in the Mass General Brigham health system. We included a self-efficacy questionnaire to assess caregivers' ability and confidence in access to dementia care, symptom management, and provider support. RESULTS: Respondents indicated that although their provider had knowledge of dementia and memory care, they were least likely to agree (39.2%) that their provider helped them with these challenging symptoms. Those who live with the care recipient were least likely to receive advice about common symptoms (43.6%) and to access community services (63.8%), and in general felt moderately knowledgeable about the progression of the disease (47.9%). CONCLUSIONS: The findings imply that caregivers are aware of disease progression, dementia symptoms, and do not feel supported by their providers in managing care or accessing support services. There is opportunity to support informal caregivers in a primary care setting by appropriately uptraining providers in dementia care.

Reframing Value-Based Care Management: Beyond Cost Reduction and Toward Patient Centeredness.

Importance: Care management programs are increasingly being utilized by health systems as a new foundational strategy to advance value-based care. These programs offer the promise of improving patient outcomes while decreasing health care utilization and costs. However, as these programs proliferate in number and specialization, the field of care management is increasingly at risk of fragmentation, inefficiency, and failure to meet the core needs of the patient. Observations: This review of the current state of care management identifies several key challenges for the field, including an unclear value proposition, a focus on system- vs patient-centered outcomes, increased specialization by private and public entrants that produces care fragmentation, and lack of coordination among health and social service entities. A framework is proposed for reorienting care management to truly address the needs of patients through acknowledging the dynamic nature of patient care needs, providing a continuum of need-targeted programming, coordinating care among all involved entities and staff, and performing regular evaluations of outcomes that include patient-centered and health equity measures. Guidance on how this framework can be implemented within a health system and an outline of recommendations is provided for how policymakers may incentivize the development of high value and more equitable care management programs. Conclusions and Relevance: With increased focus on care management as a cornerstone of value-based care, value-based health leaders and policymakers can improve the effectiveness and value of care management programs, reduce patient financial burden for care management services, and promote stakeholder coordination.

When the Process Is the Problem: Racial/Ethnic and Language Disparities in Care Management.

OBJECTIVES: Achieving health equity requires addressing disparities at every level of care delivery. Yet, little literature exists examining racial/ethnic disparities in processes of high-risk care management, a foundational tool for population health. This study sought to determine whether race, ethnicity, and language are associated with patient entry into and service intensity within a large care management program. DESIGN: Retrospective cohort study. METHODS: Subjects were 23,836 adult patients eligible for the program between 2015 and 2018. Adjusting for demographics, utilization, and medical risk, we analyzed the association between race/ethnicity and language and outcomes of patient selection, enrollment, care plan completion, and care management encounters. RESULTS: Among all identified as eligible by an algorithm, Asian and Spanish-speaking patients had significantly lower odds of being selected by physicians for care management [OR 0.74 (0.58-0.93), OR 0.79 (0.64-0.97)] compared with White and English-speaking patients, respectively. Once selected, Hispanic/Latino and Asian patients had significantly lower odds compared to White counterparts of having care plans completed by care managers [OR 0.69 (0.50-0.97), 0.50 (0.32-0.79), respectively]. Patients speaking languages other than English or Spanish had a lower odds of care plan completion and had fewer staff encounters than English-speaking counterparts [OR 0.62 (0.44-0.87), RR 0.87 (0.75-1.00), respectively]. CONCLUSIONS: Race/ethnicity and language-based disparities exist at every process level within a large health system's care management program, from selection to outreach. These results underscore the importance of assessing for disparities not just in outcomes but also in program processes, to prevent population health innovations from inadvertently creating new inequities.

Assessment of the Massachusetts Flexible Services Program to Address Food and Housing Insecurity in a Medicaid Accountable Care Organization.

Importance: Health systems are increasingly addressing health-related social needs. The Massachusetts Flexible Services program (Flex) is a 3-year pilot program to address food insecurity and housing insecurity by connecting Medicaid accountable care organization (ACO) enrollees to community resources. Objective: To understand barriers and facilitators of Flex implementation in 1 Medicaid ACO during the first 17 months of the program. Design, Setting, and Participants: This mixed-methods qualitative evaluation study from March 2020 to July 2021 used the Reach, Efficacy, Adoption, Implementation, Maintenance/Practical, Robust Implementation, and Sustainability Model (RE-AIM/PRISM) framework. Two Mass General Brigham (MGB) hospitals and affiliated community health centers were included in the analysis. Quantitative data included all MGB Medicaid ACO enrollees. Qualitative interviews were conducted with 15 members of ACO staff and 17 Flex enrollees. Main Outcomes and Measures: Reach was assessed by the proportion of ACO enrollees who completed annual social needs screening (eg, food insecurity and housing insecurity) and the proportion and demographics of Flex enrollees. Qualitative interviews examined other RE-AIM/PRISM constructs (eg, implementation challenges, facilitators, and perceived effectiveness). Results: Of 67 098 Medicaid ACO enrollees from March 2020 to July 2021 (mean [SD] age, 28.8 [18.7] years), 38 442 (57.3%) completed at least 1 social needs screening; 10 730 (16.0%) screened positive for food insecurity, and 7401 (11.0%) screened positive for housing insecurity. There were 658 (1.6%) adults (mean [SD] age, 46.6 [11.8] years) and 173 (0.7%) children (<21 years; mean [SD] age, 10.1 [5.5]) enrolled in Flex; of these 831 people, 613 (73.8%) were female, 444 (53.4%) were Hispanic/Latinx, and 172 (20.7%) were Black. Most Flex enrollees (584 [88.8%] adults; 143 [82.7%] children) received the intended nutrition or housing services. Implementation challenges identified by staff interviewed included administrative burden, coordination with community organizations, data-sharing and information-sharing, and COVID-19 factors (eg, reduced clinical visits). Implementation facilitators included administrative funding for enrollment staff, bidirectional communication with community partners, adaptive strategies to identify eligible patients, and raising clinician awareness of Flex. In Flex enrollee interviews, those receiving nutrition services reported increased healthy eating and food security; they also reported higher program satisfaction than Flex enrollees receiving housing services. Enrollees who received nutrition services that allowed for selecting food based on preferences reported higher satisfaction than those not able to select food. Conclusions and Relevance: This mixed-methods qualitative evaluation study found that to improve implementation, Medicaid and health system programs that address social needs may benefit from providing funding for administrative costs, developing bidirectional data-sharing platforms, and tailoring support to patient preferences.

Population turnover and leakage in commercial ACOs.

OBJECTIVES: Commercial accountable care organization (ACO) contracts attempt to mitigate spending growth, but past evaluations have been limited to continuously enrolled ACO members in health maintenance organization (HMO) plans, excluding many members. The objective of this study was to examine the magnitude of turnover and leakage within a commercial ACO. STUDY DESIGN: A historical cohort study using detailed information from multiple commercial ACO contracts within a large health care system between 2015 and 2019. METHODS: Individuals insured through 1 of the 3 largest commercial ACO contracts during the study period, 2015-2019, were included. We examined patterns of entry and exit and the characteristics that predicted remaining in the ACO compared with leaving the ACO. We also examined predictors of the amount of care delivered in the ACO compared with outside the ACO. RESULTS: Among the 453,573 commercially insured individuals in the ACO, approximately half left the ACO within the initial 24 months after entry. Approximately one-third of spending was for care occurring outside the ACO. Patients who remained in the ACO differed from those who left earlier, including being older, having a non-HMO plan, having lower predicted spending at entry, and having more medical spending for care performed within the ACO during the initial quarter of membership. CONCLUSIONS: Both turnover and leakage hamper the ability of ACOs to manage spending. Modifications that address potentially intrinsic vs avoidable sources of population turnover and increase patient incentives for care within vs outside of ACOs could help address medical spending growth within commercial ACO programs.

Tacking upwind: reducing spending among high-risk commercially insured patients.

OBJECTIVES: The study examined a commercial accountable care organization (ACO) population and then assessed the impact of an integrated care management program on medical spending and clinical event rates. STUDY DESIGN: Retrospective cohort study of high-risk individuals (n = 487) in a population of 365,413 individuals aged 18 to 64 years within the Mass General Brigham health system who were part of commercial ACO contracts with 3 large insurers between 2015 and 2019. METHODS: Using medical spending claims and other enrollment data, the study assessed the demographic and clinical characteristics, medical spending, and clinical event rates of patients in the ACO and its high-risk care management program. The study then examined the impact of the program using a staggered difference-in-difference design with individual-level fixed effects and compared outcomes of those who had entered the program with those of similar patients who had not entered. RESULTS: The commercially insured ACO population was healthy on average but included several hundred high-risk patients (n = 487). After adjustment, patients within the ACO's integrated care management program for high-risk patients had lower monthly medical spending (by $1361 per person per month) as well as lower emergency department visit and hospitalization rates compared with similar patients who had yet to start the program. Accounting for early ACO departure decreased the magnitude of the program effects as expected. CONCLUSIONS: Commercial ACO populations may be healthy on average but still include some high-risk patients. Identifying which patients might benefit from more intensive care management could be critical for reaping the potential savings.

Cost, Utilization, and Patient and Family Experience With ACO-Based Pediatric Care Management.

BACKGROUND AND OBJECTIVES: Children and Youth with Special Health Care Needs have high healthcare utilization, fragmented care, and unmet health needs. Accountable Care Organizations (ACOs) increasingly use pediatric care management to improve quality and reduce unnecessary utilization. We evaluated effects of pediatric care management on total medical expense (TME) and utilization; perceived quality of care coordination, unmet needs, and patient and family experience; and differential impact by payor, risk score, care manager discipline, and behavioral health diagnosis. METHODS: Mixed-methods analysis including claims using quasi-stepped-wedge design pre and postenrollment to estimate difference-in-differences, participant survey, and semistructured interviews. Participants included 1321 patients with medical, behavioral, or social needs, high utilization, in Medicaid or commercial ACOs, and enrolled in multidisciplinary, primary care-embedded care management. RESULTS: TME significantly declined 1 to 6 months postenrollment and continued through 19 to 24 months (-$645.48 per member per month, P < .001). Emergency department and inpatient utilization significantly decreased 7 to 12 months post-enrollment and persisted through 19 to 24 months (-29% emergency department, P = .012; -82% inpatient, P < .001). Of respondents, 87.2% of survey respondents were somewhat or very satisfied with care coordination, 56.1% received education coordination when needed, and 81.5% had no unmet health needs. Emergency department or inpatient utilization decreases were consistent across payors and care manager disciplines, occurred sooner with behavioral health diagnoses, and were significant among children with above-median risk scores. Satisfaction and experience were equivalent across groups, with more unmet needs and frustration with above-median risk scores. CONCLUSIONS: Pediatric care management in multipayor ACOs may effectively reduce TME and utilization and clinically provide high-quality care coordination, including education and family stress, with high participant satisfaction.

Using brief clinician and parent measures to track outcomes in outpatient child psychiatry: longer term follow-up and comparative effectiveness.

BACKGROUND: This study explored the feasibility and validity of using brief clinician- and parent-rated measures routinely over 6 months in outpatient child psychiatry. METHOD: All patients under 18 years of age seen for intake in the Child Psychiatry Clinic from 1 August 2007 through 31 July 2010 were eligible for inclusion in the study. Data were collected at intake for 1033 patients and at 3- and 6-month follow-up. RESULTS: ANOVA for repeated measures showed statistically significant improvements in total and subscale scores on all three measures (Brief Psychiatric Rating Scale for Children, Children's Global Assessment Scale, and Pediatric Symptom Checklist) at both second and third assessments. CONCLUSION: The fact that both broadband and narrowband scales showed significant improvements over the first 6 months of care establishes the possibility that these measures could be used in experimental designs studying comparative effectiveness.

Applying embedded program evaluation for care delivery transformation: An analysis of a home-based urgent care program.

Background: In 2014, Mass General Brigham, formerly Partners HealthCare, launched a novel urgent home-based medical care program to provide rapid medical evaluation and treatment to homebound patients and older adults with frailty or limited mobility named the partners mobile observation unit (PMOU) program. Methods: We conducted a pragmatic, embedded evaluation assessing the impact of PMOU on postreferral utilization and total medical expenditure (TME). We used propensity weighting and logistic regression to estimate the 30-day adjusted odds ratios (ORs) of emergency department (ED) utilization and inpatient medical hospitalization for patients enrolled in PMOU (891 episodes of care) relative to those who were referred but not enrolled in the program (57 episodes of care) during the period of April 2017 to June 2018. We additionally conducted a difference-in-differences analysis assessing program impact on TME, comparing claims data 30 days pre/post referral. Results: Despite positive trends, there were no statistically significant differences between the two groups with regard to postreferral ED visits or hospitalizations, with an OR of 0.83 (p = 0.56) and OR of 0.64 (p = 0.21), respectively. There was no statistically significant difference in pre/post referral TME for intervention relative to control episodes (p = 0.64). In post hoc analysis of control episodes, 75% received care elsewhere within 14 days of referral. Conclusion: Although the results suggested positive trends, this analysis of this relatively mature program was unable to identify statistically significant reductions in ED visits, hospitalizations, or TME associated with the PMOU program. Future efforts to build home-based urgent care programs or related programs targeting older adults with frailty or limited mobility should aim to improve patient targeting and identify opportunities to improve program operations and generate meaningful reductions in healthcare utilization and spending.

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.