Health Equity Adjustment and Hospital Performance in the Medicare Value-Based Purchasing Program.

Importance: Medicare's Hospital Value-Based Purchasing (HVBP) program will provide a health equity adjustment (HEA) to hospitals that have greater proportions of patients dually eligible for Medicare and Medicaid and that offer high-quality care beginning in fiscal year 2026. However, which hospitals will benefit most from this policy change and to what extent are unknown. Objective: To estimate potential changes in hospital performance after HEA and examine hospital patient mix, structural, and geographic characteristics associated with receipt of increased payments. Design, Setting, and Participants: This cross-sectional study analyzed all 2676 hospitals participating in the HVBP program in fiscal year 2021. Publicly available data on program performance and hospital characteristics were linked to Medicare claims data on all inpatient stays for dual-eligible beneficiaries at each hospital to calculate HEA points and HVBP payment adjustments. Exposures: Hospital Value-Based Purchasing program HEA. Main Outcomes and Measures: Reclassification of HVBP bonus or penalty status and changes in payment adjustments across hospital characteristics. Results: Of 2676 hospitals participating in the HVBP program in fiscal year 2021, 1470 (54.9%) received bonuses and 1206 (45.1%) received penalties. After HEA, 102 hospitals (6.9%) were reclassified from bonus to penalty status, whereas 119 (9.9%) were reclassified from penalty to bonus status. At the hospital level, mean (SD) HVBP payment adjustments decreased by $4534 ($90 033) after HEA, ranging from a maximum reduction of $1 014 276 to a maximum increase of $1 523 765. At the aggregate level, net-positive changes in payment adjustments were largest among safety net hospitals ($28 971 708) and those caring for a higher proportion of Black patients ($15 468 445). The likelihood of experiencing increases in payment adjustments was significantly higher among safety net compared with non-safety net hospitals (574 of 683 [84.0%] vs 709 of 1993 [35.6%]; adjusted rate ratio [ARR], 2.04 [95% CI, 1.89-2.20]) and high-proportion Black hospitals compared with non-high-proportion Black hospitals (396 of 523 [75.7%] vs 887 of 2153 [41.2%]; ARR, 1.40 [95% CI, 1.29-1.51]). Rural hospitals (374 of 612 [61.1%] vs 909 of 2064 [44.0%]; ARR, 1.44 [95% CI, 1.30-1.58]), as well as those located in the South (598 of 1040 [57.5%] vs 192 of 439 [43.7%]; ARR, 1.25 [95% CI, 1.10-1.42]) and in Medicaid expansion states (801 of 1651 [48.5%] vs 482 of 1025 [47.0%]; ARR, 1.16 [95% CI, 1.06-1.28]), were also more likely to experience increased payment adjustments after HEA compared with their urban, Northeastern, and Medicaid nonexpansion state counterparts, respectively. Conclusions and Relevance: Medicare's implementation of HEA in the HVBP program will significantly reclassify hospital performance and redistribute program payments, with safety net and high-proportion Black hospitals benefiting most from this policy change. These findings suggest that HEA is an important strategy to ensure that value-based payment programs are more equitable.

Financing Approaches to Social Prescribing Programs in England and the United States.

Policy Points The number of social prescribing practices, which aim to link patients with nonmedical services and supports to address patients' social needs, is increasing in both England and the United States. Traditional health care financing mechanisms were not designed to support social prescribing practices, and flexible payment approaches may not support their widespread adoption. Policymakers in both countries are shifting toward developing explicit financing streams for social prescribing programs. Consequently, we need an evaluation of them to assess their success in supporting both the acceptance of these programs and their impacts. Investment in community-based organizations and wider public services will likely be crucial to both the long-term effectiveness and the sustainability of social prescribing.

Addressing the Social Determinants of Health During the COVID-19 Pandemic: Ensuring Equity, Quality, and Sustainability.

The COVID-19 pandemic has highlighted the importance of social determinants of health in affecting health outcomes. Populations with high social risk are disproportionately impacted by the virus and its economic consequences. Primary care practices have a unique opportunity to implement interventions to mitigate their patients' unmet social needs, such as food and income insecurity. In this commentary, we outline key considerations for clinics implementing programs that identify and address patients' social needs in a way that promotes equity, quality, and sustainability. We provide examples from our own experience at a federally qualified health center.

Recovery experiences of younger stroke survivors who are parents: A qualitative content analysis.

AIMS AND OBJECTIVES: To explore the experience of parenting for younger stroke survivors (aged 18 to 64 years at the time of the stroke). BACKGROUND: Stroke among younger adults increased 43% between 2000 and 2010. The social, emotional and physical functioning of younger adults affects multiple aspects of their lives including parenting. There is limited research on the experience of parenting after stroke. DESIGN: This is a qualitative descriptive study. METHODS: We conducted individual semi-structured interviews with 10 younger adults who were actively parenting children under the age of 18 years at the time of stroke. Conventional content analysis was used to analyse the data. We report the methods and results using the COREQ checklist. RESULTS: Impairments from stroke disrupted participants' identity, relationships and roles as a parent. The degree to which parenting abilities and behaviours were affected by stroke was contingent upon the type and severity of impairments as well as the children's age. Participants also observed emotional and behavioural changes in their children in response to their stroke. Support from family, friends, healthcare providers and children's school/day care was crucial to participants throughout their stroke recovery. Two major themes emerged: (a) finding a new normal; and (b) support for parenting post-stroke. CONCLUSIONS: Findings enable a deeper understanding of the distinct parenting challenges younger stroke survivors face and can inform future research on this population. RELEVANCE FOR CLINICAL PRACTICE: Study findings highlight the need for continual and tailored follow-up by nurses and other allied healthcare professionals to decrease the difficulty stroke survivors experience when trying to resume their role as parents.

Integrating a Machine Learning System Into Clinical Workflows: Qualitative Study.

BACKGROUND: Machine learning models have the potential to improve diagnostic accuracy and management of acute conditions. Despite growing efforts to evaluate and validate such models, little is known about how to best translate and implement these products as part of routine clinical care. OBJECTIVE: This study aims to explore the factors influencing the integration of a machine learning sepsis early warning system (Sepsis Watch) into clinical workflows. METHODS: We conducted semistructured interviews with 15 frontline emergency department physicians and rapid response team nurses who participated in the Sepsis Watch quality improvement initiative. Interviews were audio recorded and transcribed. We used a modified grounded theory approach to identify key themes and analyze qualitative data. RESULTS: A total of 3 dominant themes emerged: perceived utility and trust, implementation of Sepsis Watch processes, and workforce considerations. Participants described their unfamiliarity with machine learning models. As a result, clinician trust was influenced by the perceived accuracy and utility of the model from personal program experience. Implementation of Sepsis Watch was facilitated by the easy-to-use tablet application and communication strategies that were developed by nurses to share model outputs with physicians. Barriers included the flow of information among clinicians and gaps in knowledge about the model itself and broader workflow processes. CONCLUSIONS: This study generated insights into how frontline clinicians perceived machine learning models and the barriers to integrating them into clinical workflows. These findings can inform future efforts to implement machine learning interventions in real-world settings and maximize the adoption of these interventions.

Hospital Characteristics Associated With Social Needs Activities in the US.

This study assesses what hospital characteristics, including hospital participation in payment and delivery reform, are associated with activities related to health-related social needs.

Awareness, Adjustment, Assistance, Alignment, and Advocacy: Operationalizing Social Determinants of Health Topics in Undergraduate Medical Education Curricula.

Social and economic factors, such as those related to food, housing, and transportation, are major drivers of health and health inequities. Multiple national professional organizations have articulated roles for physicians in identifying and addressing social determinants of health (SDOH) and the need to include SDOH in all stages of physician education. Despite encouragement from these professional organizations, medical schools still do not routinely offer SDOH education alongside basic and clinical sciences curricula. A recent national expert consensus process identified priority SDOH knowledge domains and professional skills for medical students but lacked an organizing schema and specific pedagogical examples to help translate prioritized skills into routine pedagogical practice. One such schema is the 5As framework developed by the National Academies of Sciences, Engineering, and Medicine, which elaborates on 5 strategies to strengthen social care: awareness, adjustment, assistance, alignment, and advocacy. In this article, the authors highlight and provide examples of how mapping SDOH skills to the 5As framework can help educators meaningfully operationalize SDOH topics into specific curricular activities during the preclinical and clinical stages of undergraduate medical education. As a foundational first step in this direction, medical schools should conduct an internal curricular review of social care content (ideally mapped to the 5As framework) and identify opportunities to integrate these topics into existing courses when relevant (e.g., in social medicine, population health, and health systems science courses). Given that health and social care integration is highly context dependent, each medical school will likely need to tailor curricular changes based on their own institutional needs, mission, patient populations, and ties to the community. To increase interinstitutional alignment, medical schools might consider using or adapting peer-reviewed materials and assessments curated and centralized by the National Collaborative for Education to Address the Social Determinants of Health.

Accelerating health system innovation: principles and practices from the Duke Institute for Health Innovation.

The Duke Institute for Health Innovation (DIHI) was launched in 2013. Frontline staff members submit proposals for innovation projects that align with strategic priorities set by organizational leadership. Funded projects receive operational and technical support from institute staff members and a transdisciplinary network of collaborators to develop and implement solutions as part of routine clinical care, ranging from machine learning algorithms to mobile applications. DIHI's operations are shaped by four guiding principles: build to show value, build to integrate, build to scale, and build responsibly. Between 2013 and 2021, more than 600 project proposals have been submitted to DIHI. More than 85 innovation projects, both through the application process and other strategic partnerships, have been supported and implemented. DIHI's funding has incubated 12 companies, engaged more than 300 faculty members, staff members, and students, and contributed to more than 50 peer-reviewed publications. DIHI's practices can serve as a model for other health systems to systematically source, develop, implement, and scale innovations.

Catalyzing Cross-Sector Collaboration: Lessons from a Virtual Pediatric Complex Care Coalition.

BACKGROUND: Children with complex health needs (CCHN) have intersecting medical, behavioral health, and social needs. Unfortunately, fragmentation across health and social services sectors often results in uncoordinated care for CCHN and their families. OBJECTIVE: The purpose of this article is to describe the creation of a statewide cross-sector partnership, the Children's Complex Care Coalition of North Carolina, to identify and act on opportunities for system-level improvements in the care of CCHN. METHODS: We applied a virtual community engagement approach to form an advisory committee of cross-sector collaborators; systematically identify priorities most important and urgent to collaborators for improving systems of care; and host a series of virtual convenings involving more than 90 attendees from across the state to operationalize collaborator-identified priorities into actionable next steps. LESSONS LEARNED: Key facilitators of success for the Children's Complex Care Coalition of North Carolina partnership were investing time in building trusting relationships, particularly with families of CCHN, and aligning goals and priorities with existing local and regional efforts. Challenges included incorporating traditionally under-represented perspectives, right-sizing virtual convening attendance and number of topics covered, and navigating technological difficulties in a virtual environment. CONCLUSIONS: Health systems can catalyze the formation of cross-sector coalitions and community partnerships to advance complex care. Virtual convenings with interactive activities and participatory structures can be an efficient medium to connect coalition members and elicit actionable recommendations for system-level improvements that address the needs of community members.

Patient Barriers to Accessing Referred Resources for Unmet Social Needs.

INTRODUCTION: Many primary care clinics screen patients for their unmet social needs, such as food insecurity and housing instability, and refer them to community-based organizations (CBOs). However, the ability for patients to have their needs met is difficult to evaluate and address. This study explores patient-reported barriers to accessing referred resources using a conceptual framework that identifies opportunities for intervening to optimize success. METHODS: Patients who participated in a social needs screening and referral intervention at a Federally Qualified Health Center (FQHC) were called 2 weeks after the clinic encounter. We conducted a directed content analysis across 6 domains of access to examine responses from patients who reported barriers. RESULTS: Of the 462 patients that were reached for follow-up, 366 patients reported 537 total barriers. The most frequent challenges related to resource availability (24.6%, eg, patients waiting for submitted application to process) and approachability (23.8%, eg, patients lacking information needed to contact or access resources). Barriers in the domains of acceptability (21.6%, eg, competing life priorities such as medical issues, major life events, or caretaking responsibilities) and appropriateness (17.9%, eg, resource no longer needed) largely represented patient constraints expressed only after the clinical encounter. It was less common for patients to identify accommodation (eg, physical limitations, language barriers, transportation barriers, administrative complexity) or affordability of community resources as barriers (11.2% and 0.9%, respectively). CONCLUSION: Findings suggest opportunities for improvement across the access continuum, from initial referrals from primary care staff during the clinical encounter to patients' attempts to accessing services in the community. Future efforts should consider increased collaboration between health and social service organizations, and advocacy for structural changes that mitigate system-level barriers related to resource availability and administrative complexity.

Developing the Next Generation of Leaders in Health Policy and Management: Lessons From an Undergraduate Student-Led Organization.

As health care continues to evolve, training the next generation of healthcare leaders is more important than ever. However, many university undergraduate students are not directly exposed to topics such as health policy and management within their coursework or co-curricular engagements. At Duke University, we developed the Student Collaborative on Health Policy (SCOHP) as an inter-disciplinary health policy hub that offers opportunities for learning, engagement, and leadership in the healthcare-related fields for students of all academic backgrounds. We see opportunity for similar student-led groups to be established by student leaders at other institutions, increasing interaction with experts, mentorship and the accessibility of experiential education, service, and leadership in the health care sector.

Intervention components of link worker social prescribing programmes: A scoping review.

In the United Kingdom (UK), link worker social prescribing has emerged as an option to improve long-term condition management and address primary care patients' non-medical needs by linking patients with community-based activities and support. Social prescribing is a complex, heterogenous intervention, and there is currently no taxonomy of components to guide its implementation and evaluation. This study aimed to identify and categorise the components of link worker social prescribing schemes in the United Kingdom. A scoping review of peer-reviewed literature was conducted. Six databases were used to identify papers that met inclusion criteria. Eligible articles were original research studies in the United Kingdom describing interventions that included (1) initial referral of adults with chronic physical health conditions and/or unmet social needs from primary care to a link worker or equivalent role, (2) consultation with a link worker or equivalent role and (3) referral to a community-based or government service. Of the 1078 articles identified, 32 met study eligibility criteria, representing 22 social prescribing schemes. We drew from the template for intervention description and replication (TIDieR) to identify, organise and report intervention components. We found wide variations in geography, target populations and intervention components such as activities and procedures conducted by primary care staff and link workers, organisational and staffing configurations and use of tools and financing approaches to facilitate adoption. Intervention components are summarised into a taxonomy to guide future research, policy and practice efforts in addition to supporting standardised intervention reporting.

Identifying Priorities to Improve the System of Care for Children With Complex Health Needs in North Carolina: Process and Outcomes of Systematic Stakeholder Engagement.

OBJECTIVE: Children with complex health needs (CCHN) have both medical (eg, chronic conditions) and health-related social needs (eg, potentially adverse social determinants of health) that require ongoing health care and support from multiple community service providers. National standards developed for populations defined by health needs (CYSHCN) provide a framework for stakeholders to plan system-level improvements in care delivery for CCHN, but improvement efforts should reflect the priorities of their families and providers. This article describes a process of prioritizing system-level efforts to improve the health and well-being of CCHN and families in North Carolina (NC), using systematic stakeholder engagement and modified Delphi expert ratings. METHODS: We surveyed stakeholders with experience caring for CCHN using an open-ended, 3-item instrument to identify opportunities to improve systems of care. Using directed qualitative content analysis, we synthesized responses into a master list of potential improvement topics. Using a modified Delphi approach, a 16-member advisory committee rated all topics for importance and urgency, on 9-point Likert scales over 2 rounds; then ratings for each topic were ranked (low, medium, high) to establish relative priority. RESULTS: Forty seven individuals from 31 counties around NC provided survey responses, yielding 59 improvement topics in 10 domains. Through the modified Delphi method process, 21 topics (36%) received the highest rankings, largely representing access to community- and home-based services, equity, and enhancement of the pediatric workforce. CONCLUSIONS: Priorities identified by stakeholders will inform advocacy, policy, and improvement efforts. Next steps for the coalition include developing improvement projects to implement stakeholder-recommended actions for the highest-priority topics.