A qualitative study of patient perspectives of care management services in Comprehensive Primary Care Plus.

BACKGROUND: Care management has the potential to improve quality of care and health outcomes for chronic conditions, but questions remain about how patients perceive care management. Understanding patient perceptions is critical for ensuring care management can successfully engage patients and improve management of chronic conditions. OBJECTIVE: To understand high-risk patients' experiences and perceptions of care management. METHODS: We conducted 1-h phone interviews with 40 patients receiving care management at 12 practices participating in the Centers for Medicare & Medicaid Services Comprehensive Primary Care Plus model. Interviews were transcribed verbatim and analysed using a thematic approach. RESULTS: Most patients reported discussing health goals with their providers that aligned with their values and care preferences; a few reported that goal setting did not result in desired action steps. Most reported positive experiences receiving behavioural health support; a few reported unmet behavioural health needs that they had not expressed to their practice. Patients reported financial and transportation barriers to following care managers' recommendations. Care managers' active listening skills, accessibility, and caring personalities facilitated patient engagement. CONCLUSIONS: Practices should consider patient perspectives as they improve care management activities. Future research is needed to confirm our findings about patient perspectives regarding goal setting, behavioural health support, and barriers and facilitators to engagement.

Care management, which involves providing additional support to people with chronic and mental health conditions, has the potential to improve the quality of health care people receive and to improve their overall health. Care management can involve doctors, nurses, and other staff at doctors' offices working with patients to set goals for their health and working with them to manage their physical and mental health. Despite the promise of care management to improve health, the way that patients think about and experience care management is not well known. In our study, we conducted interviews with 40 patients to understand their experiences and thoughts about care management. We found that most patients talk about health goals with their doctor or nurse, and that their health goals were consistent with their values and care preferences. Most patients reported positive experiences receiving support for mental health. Some patients explained that they had difficulty following through on appointments or other services recommended by their doctor or nurse because they could not afford the costs or because they did not have transportation. Nurses' caring personalities and availability outside of appointments helped patients to take actions to improve their health.

Horizontal and Vertical Integration of Health Care Providers: A Framework for Understanding Various Provider Organizational Structures.

INTRODUCTION: Current U.S. policy and payment initiatives aim to encourage health care provider accountability for population health and higher value care, resulting in efforts to integrate providers along the continuum. Providers work together through diverse organizational structures, yet evidence is limited regarding how to best organize the delivery system to achieve higher value care. METHODS: In 2016, we conducted a narrative review of 10 years of literature to identify definitional components of key organizational structures in the United States. A clear accounting of common organizational structures is foundational for understanding the system attributes that are associated with higher value care. RESULTS: We distinguish between structures characterized by the horizontal integration of providers delivering similar services and the vertical integration of providers fulfilling different functions along the care continuum. We characterize these structures in terms of their origins, included providers and services, care management functions, and governance. CONCLUSIONS AND DISCUSSION: Increasingly, U.S. policymakers seek to promote provider integration and coordination. Emerging evidence suggests that organizational structures, composition, and other characteristics influence cost and quality performance. Given current efforts to reform the U.S. delivery system, future research should seek to systematically examine the role of organizational structure in cost and quality outcomes.

TRICARE For Children: Between Medicaid And Marketplace Plans For Comprehensiveness And Cost Sharing.

TRICARE provides health care benefits to nearly two million children of active duty, retired, National Guard, and reserve service members. Child health advocates and congressional reports have raised questions regarding the adequacy of these benefits, compared with other sources of children's health insurance. To help address these questions, we compared TRICARE benefits with benefits from Medicaid and Marketplace plans because they represent alternative sources of coverage for many of the families enrolled in TRICARE. Overall, we found that TRICARE benefits fell in the middle-between Medicaid plans' more comprehensive benefits with no cost sharing and Marketplace plans' more restrictive benefits with higher cost sharing.

The surge in urgent care centers: emergency department alternative or costly convenience?

As the U.S. health care system grapples with strained hospital emergency department (ED) capacity in some areas, primary care clinician shortages and rising health care costs, urgent care centers have emerged as an alterna­tive care setting that may help improve access and contain costs. Growing to 9,000 locations in recent years, urgent care centers provide walk-in care for illnesses and injuries that need immediate attention but don't rise to the level of an emergency. Though their impact on overall health care access and costs remains unclear, hospitals and health plans are optimistic about the potential of urgent care centers to improve access and reduce ED visits, according to a new qualitative study by the Center for Studying Health System Change (HSC) for the National Institute for Health Care Reform. Across the six communities studied--Detroit; Jacksonville, Fla.; Minneapolis; Phoenix; Raleigh-Durham, N.C.; and San Francisco--respon­dents indicated that growth of urgent care centers is driven heavily by con­sumer demand for convenient access to care. At the same time, hospitals view urgent care centers as a way to gain patients, while health plans see opportu­nities to contain costs by steering patients away from costly emergency depart­ment visits. Although some providers believe urgent care centers disrupt coor­dination and continuity of care, others believe these concerns may be over­stated, given urgent care's focus on episodic and simple conditions rather than chronic and complex cases. Looking ahead, health coverage expansions under national health reform may lead to greater capacity strains on both primary and emergency care, spurring even more growth of urgent care centers.