Hospital Capabilities Associated With Behavioral Health Integration Within Emergency Departments.

OBJECTIVES: To identify hospital capabilities associated with behavioral health (BH) processes in emergency departments (EDs). RESEARCH DESIGN: Six hundred two hospital responses to the 2017/2018 National Survey of Healthcare Organizations and Systems were linked to 2017 American Hospital Association Annual Survey data. Separate multivariable regressions estimated how hospital capabilities (the use of quality improvement methods, approaches to disseminate best patient-care practices, barriers to using care delivery innovations, and inpatient beds for psychiatric or substance use) were associated with each of 4 ED-based BH processes: mental health and substance use disorder screening, team-based approaches to BH, telepsychiatry, and direct referrals to community-based BH clinicians. Models controlled for hospital structural characteristics and area-level socioeconomic factors. RESULTS: Most hospitals screened for BH conditions and provided direct referrals to community-based BH clinicians. Approximately half of the hospitals used a team approach to BH. A minority had implemented telepsychiatry. Each additional process used to disseminate best patient-care practices was associated with more screening for BH conditions (an increase of 4.07 points on the screening index, P <0.01) and greater likelihood of using a team approach to BH [4.41 percentage point ( P <0.01) increase]. Hospitals reporting more barriers to the use of care delivery innovations reported less screening and use of a team approach [a decrease of 0.15 points on the screening index ( P <0.01) and 0.28 percentage points reduction in likelihood of team approach use ( P <0.001) for 1-point increase in the barrier index]. CONCLUSIONS: Research and interventions focused on removing innovation barriers or adding processes to disseminate best practices offer a path to accelerate BH integration in hospital EDs.

Primary Care Practice Characteristics Associated With Medical Assistant Staffing Ratios.

This study characterized adult primary care medical assistant (MA) staffing. National Survey of Healthcare Organizations and Systems (n = 1,252) data were analyzed to examine primary care practice characteristics associated with MA per primary care clinician (PCC) staffing ratios. In 2021, few practices (11.4%) had ratios of 2 or more MAs per PCCs. Compared with system-owned practices, independent (odds ratio [OR] = 1.76, P <0.05) and medical group-owned (OR = 2.09, P <0.05) practices were more likely to have ratios of 2 or more MAs per PCCs, as were practices with organizational cultures oriented to innovation (P <0.05). Most primary care practices do not have adequate MA staffing.

Conjoint Analysis of Telemedicine Preferences for Hypertension Management Among Adult Patients.

Background: Telemedicine has been differentially utilized by different demographic groups during COVID-19, exacerbating inequities in health care. We conducted conjoint and latent class analyses to understand factors that shape patient preferences for hypertension management telemedicine appointments. Methods: We surveyed 320 adults, oversampling participants from households that earned <$50K per year (77.2%) and speak a language other than English at home (68.8%). We asked them to choose among 2 hypothetical appointments through 12 conjoint tasks measuring 6 attributes. Individual utilities for attributes were constructed using logit estimation, and latent classes were identified and compared by demographic and clinical characteristics. Results: Respondents preferred in-person visits (0.353, standard error [SE] = 0.039) and video appointments conducted through a secure patient portal (0.002, SE = 0.040). Respondents also preferred seeing a clinician with whom they have an established relationship (0.168, SE = 0.021). We found four latent classes: "in-person" (26.5% of participants) who strongly weighted in-person appointments, "cost conscious" (8.1%) who prioritized the lowest copay ($0 to $10), "expedited" (19.7%) who prioritized getting the earliest appointment possible (same/next day or at least within the next week), and "comprehensive" (45.6%) who had preferences for in-person care and telemedicine appointments through a secure portal, low copayments, and the ability to see a familiar clinician. Conclusions: Appointment preferences for hypertension management can be segmented into four groups that prioritize (1) in-person care, (2) low copayments, (3) expedited care, and (4) balanced preferences for in-person and telemedicine appointments. Evidence is needed to clarify whether aligning appointment offerings with patients' preferences can improve care quality, equity, and efficiency.

Telemedicine Implementation for Safety Net Populations: A Systematic Review.

Background: Telemedicine systems were rapidly implemented in response to COVID-19. However, little is known about their effectiveness, acceptability, and sustainability for safety net populations. This study systematically reviewed primary care telemedicine implementation and effectiveness in safety net settings. Methods: We searched PubMed for peer-reviewed articles on telemedicine implementation from 2013 to 2021. The search was done between June and December 2021. Included articles focused on health care organizations that primarily serve low-income and/or rural populations in the United States. We screened 244 articles from an initial search of 343 articles and extracted and analyzed data from N = 45 articles. Results: Nine (20%) of 45 articles were randomized controlled trials. N = 22 reported findings for at least one marginalized group (i.e., racial/ethnic minority, 65 years+, limited English proficiency). Only n = 19 (42%) included African American/Black patients in demographics descriptions, n = 14 (31%) LatinX/Hispanic patients, n = 4 (9%) Asian patients, n = 4 (9%) patients aged 65+ years, and n = 4 (9%) patients with limited English proficiency. Results show telemedicine can provide high-quality primary care that is more accessible and affordable. Fifteen studies assessed barriers and facilitators to telemedicine implementation. Common barriers were billing/administrative workflow disruption (n = 9, 20%), broadband access/quality (n = 5, 11%), and patient preference for in-person care (n = 4, 9%). Facilitators included efficiency gains (n = 6, 13%), patient acceptance (n = 3, 7%), and enhanced access (n = 3, 7%). Conclusions: Telemedicine is an acceptable care modality to deliver primary care in safety net settings. Future studies should compare telemedicine and in-person care quality and test strategies to improve telemedicine implementation in safety net settings.

Assessing the Impact of Telemedicine Implementation in Diverse Health Care Systems.

Health care organizations and systems can have a large impact on how extensively telemedicine and virtual visits are used by medical practices and individual clinicians. This supplemental issue of medical care aims to advance evidence about how health care organizations and systems can best support telemedicine and virtual visit implementation. This issue includes 10 empirical studies examining the impact of telemedicine on quality of care, utilization, and/or patient care experiences, of which 6 are studies of Kaiser Permanente patients; 3 are studies of Medicaid, Medicare, and community health center patients; and 1 is a study of PCORnet primary care practices. The Kaiser Permanente studies find that ancillary service orders resulting from telemedicine encounters were not placed as often as in-person encounters for urinary tract infections, neck, and back pain, but there were no significant changes in patient fulfillment of ordered antidepressant medications. Studies focused on diabetes care quality among community health center patients and Medicare and Medicaid beneficiaries highlight that telemedicine helped maintain continuity of primary care and diabetes care quality during the COVID-19 pandemic. The research findings collectively demonstrate high variation in telemedicine implementation across systems and the important role that telemedicine had in maintaining the quality of care and utilization for adults with chronic conditions when in-person care was less accessible.

Hospital Characteristics Associated With Clinically Integrated Network Participation.

BACKGROUND: Increased integration of physician organizations and hospitals into health systems has not necessarily improved clinical integration or patient outcomes. However, federal regulators have issued favorable opinions for clinically integrated networks (CINs) as a way to pursue coordination between hospitals and physicians. Hospital organizational affiliations, including independent practice associations (IPA), physician-hospital organizations (PHOs), and accountable care organizations (ACOs), may support CIN participation. No empirical evidence, however, exists about factors associated with CIN participation. METHODS: Data from the 2019 American Hospital Association survey (n = 4405) were analyzed to quantify hospital CIN participation. Multivariable logistic regression models were estimated to examine whether IPA, PHO, and ACO affiliations were associated with CIN participation, controlling for market factors and hospital characteristics. RESULTS: In 2019, 34.6% of hospitals participated in a CIN. Larger, not-for-profit, and metropolitan hospitals were more likely to participate in CINs. In adjusted analyses, hospitals participating in CINs were more likely to have an IPA (9.5% points, P < 0.001), a PHO (6.1% points, P < 0.001), and ACO (19.3% points, P < 0.001) compared with hospitals not participating in a CIN. CONCLUSIONS: Over one-third of hospitals participate in a CIN, despite limited evidence about their effectiveness in delivering value. Results suggest that CIN participation may be a response to integrative norms. Future work should attempt to better define CIN participation and strive to disentangle overlapping organizational participation.

Telehealth Use, Care Continuity, and Quality: Diabetes and Hypertension Care in Community Health Centers Before and During the COVID-19 Pandemic.

BACKGROUND: Community health centers (CHCs) pivoted to using telehealth to deliver chronic care during the coronavirus COVID-19 pandemic. While care continuity can improve care quality and patients' experiences, it is unclear whether telehealth supported this relationship. OBJECTIVE: We examine the association of care continuity with diabetes and hypertension care quality in CHCs before and during COVID-19 and the mediating effect of telehealth. RESEARCH DESIGN: This was a cohort study. PARTICIPANTS: Electronic health record data from 166 CHCs with n=20,792 patients with diabetes and/or hypertension with ≥2 encounters/year during 2019 and 2020. METHODS: Multivariable logistic regression models estimated the association of care continuity (Modified Modified Continuity Index; MMCI) with telehealth use and care processes. Generalized linear regression models estimated the association of MMCI and intermediate outcomes. Formal mediation analyses assessed whether telehealth mediated the association of MMCI with A1c testing during 2020. RESULTS: MMCI [2019: odds ratio (OR)=1.98, marginal effect=0.69, z=165.50, P<0.001; 2020: OR=1.50, marginal effect=0.63, z=147.73, P<0.001] and telehealth use (2019: OR=1.50, marginal effect=0.85, z=122.87, P<0.001; 2020: OR=10.00, marginal effect=0.90, z=155.57, P<0.001) were associated with higher odds of A1c testing. MMCI was associated with lower systolic (ß=-2.90, P<0.001) and diastolic blood pressure (ß=-1.44, P<0.001) in 2020, and lower A1c values (2019: ß=-0.57, P=0.007; 2020: ß=-0.45, P=0.008) in both years. In 2020, telehealth use mediated 38.7% of the relationship between MMCI and A1c testing. CONCLUSIONS: Higher care continuity is associated with telehealth use and A1c testing, and lower A1c and blood pressure. Telehealth use mediates the association of care continuity and A1c testing. Care continuity may facilitate telehealth use and resilient performance on process measures.

Shared Decision-making Lowers Medical Expenditures and the Effect Is Amplified in Racially-Ethnically Concordant Relationships.

BACKGROUND: Racial-ethnic disparities are pervasive in health care. One mechanism that may underlie disparities is variation in shared decision-making (SDM), which encompasses high-quality clinician-patient communication, including deliberative discussions about treatment options. OBJECTIVES: To determine whether SDM has causal effects on outcomes and whether these effects are stronger within racial-ethnic concordant clinician-patient relationships. RESEARCH DESIGN: We use instrumental variables to estimate the causal effect of SDM on outcomes. SUBJECTS: A total of 60,584 patients from the 2003-2017 Integrated Public Use Microdata Series Medical Expenditure Panel Survey. Years 2018 and 2019 were excluded due to changes in the Medical Expenditure Panel Survey that omitted essential parts of the SDM index. MEASURES: Our key variable of interest is the SDM index. Outcomes included total, outpatient, and drug expenditures; physical and mental health; and the utilization of inpatient and emergency services. RESULTS: SDM lowers annual total health expenditures for all racial-ethnic groups, but this effect is only moderated among Black patients seen by Black clinicians, more than doubling in size relative to Whites. A similar SDM moderation effect also occurs for both Black patients seen by Black clinicians and Hispanic patients seen by Hispanic clinicians with regard to annual outpatient expenditures. There was no significant effect of SDM on self-reported physical or mental health. CONCLUSIONS: High-quality SDM can reduce health expenditures without negatively impacting overall physical or mental health, supporting a business case for health care organizations and systems to improve racial-ethnic clinician-patient concordance for Black and Hispanic patients.

Racial-Ethnic Composition of Primary Care Practices and Comprehensive Primary Care Plus Initiative Participation.

BACKGROUND: It remains unclear whether the racial-ethnic composition or the socioeconomic profiles of eligible primary care practices better explain practice participation in the Centers for Medicare and Medicaid Services' (CMS) Comprehensive Primary Care Plus (CPC+) program. OBJECTIVE: To examine whether practices serving high proportions of Black or Latino Medicare fee-for-service (FFS) beneficiaries were less likely to participate in CPC+ in 2021 compared to practices serving lower proportions of these populations. DESIGN: 2019 IQVIA OneKey data on practice characteristics was linked with 2018 CMS claims data and 2021 CMS CPC+ participation data. Medicare FFS beneficiaries were attributed to practices using CMS's primary care attribution method. PARTICIPANTS: 11,718 primary care practices and 7,264,812 attributed Medicare FFS beneficiaries across 18 eligible regions. METHODS: Multivariable logistic regression models examined whether eligible practices with relatively high shares of Black or Latino Medicare FFS beneficiaries were less likely to participate in CPC+ in 2021, controlling for the clinical and socioeconomic profiles of practices. MAIN MEASURES: Proportion of Medicare FFS beneficiaries attributed to each practice that are (1) Latino and (2) Black. KEY RESULTS: Of the eligible practices, 26.9% were CPC+ participants. In adjusted analyses, practices with relatively high shares of Black (adjusted odds ratio, aOR = 0.62, p < 0.05) and Latino (aOR = 0.32, p < 0.01) beneficiaries were less likely to participate in CPC+ compared to practices with lower shares of these beneficiary groups. State differences in CPC+ participation rates partially explained participation disparities for practices with relatively high shares of Black beneficiaries, but did not explain participation disparities for practices with relatively high shares of Latino beneficiaries. CONCLUSIONS: The racial-ethnic composition of eligible primary care practices is more strongly associated with CPC+ participation than census tract-level poverty. Practice eligibility requirements for CMS-sponsored initiatives should be reconsidered so that Black and Latino beneficiaries are not left out of the benefits of practice transformation.

Adoption of Patient Engagement Strategies by Physician Practices in the United States.

BACKGROUND: Patient engagement strategies can equip patients with tools to navigate treatment decisions and improve patient-centered outcomes. Despite increased recognition about the importance of patient engagement, little is known about the extent of physician practice adoption of patient engagement strategies nationally. METHODS: We analyzed data collected from the National Survey of Healthcare Organizations and Systems (NSHOS) on physician practice adoption of patient engagement strategies. Stratified-cluster sampling was used to select physician practices operating under different organizational structures. Multivariable linear regression models estimated the association of practice ownership, health information technology functionality, use of screening activities, patient responsiveness, chronic care management processes, and the adoption of patient engagement strategies, including shared decision-making, motivational interviewing, and shared medical appointments. All regression models controlled for participation in payment reforms, practice size, Medicaid revenue percentage, and geographic region. RESULTS: We found modest and varied adoption of patient engagement strategies by practices of different ownership types, with health system-owned practices having the lowest adoption of ownership types. Practice capabilities, including chronic care management processes, routine screening of medical and social risks, and patient care dissemination strategies were associated with greater practice-level adoption of patient engagement strategies. CONCLUSIONS: This national study is the first to characterize the adoption of patient engagement strategies by US physician practices. We found modest adoption of shared decision-making and motivational interviewing, and low adoption of shared medical appointments. Risk-based payment reform has the potential to motivate greater practice-level patient engagement, but the extent to which it occurs may depend on internal practice capabilities.

Survey of Information Exchange and Advanced Use of Other Health Information Technology in Primary Care Settings: Capabilities In and Outside of the Safety Net.

BACKGROUND: Advanced use of health information technology (IT) functionalities can support more comprehensive, coordinated, and patient-centered primary care services. Safety net practices may benefit disproportionately from these investments, but it is unclear whether IT use in these settings has kept pace and what organizational factors are associated with varying use of these features. OBJECTIVE: The aim was to estimate advanced use of health IT use in safety net versus nonsafety net primary care practices. We explore domains of patient engagement, population health management (decision support and registries), and electronic information exchange. We examine organizational characteristics that may differentially predict advanced use of IT across these settings, with a focus on health system ownership and/or membership in an independent practice network as key factors that may indicate available incentives and resources to support these efforts. RESEARCH DESIGN: We conduct cross-sectional analysis of a national survey of physician practices (n=1776). We use logistic regression to predict advanced IT use in each of our domains based on safety net status and other organizational characteristics. We then use interaction models to assess whether ownership or network membership moderate the relationship between safety net status and advanced use of health IT. RESULTS: Health IT use was common across primary care practices, but advanced use of health IT functionalities ranged only from 30% to 50% use. Safety net settings have kept pace with adoption of features for patient engagement and population management, yet lag in information exchange capabilities compared with nonsafety net practices (odds ratio=0.52 for federally qualified health centers, P<0.001; odds ratio=0.66 for other safety net, P=0.03). However, when safety net practices are members of a health system or practice network, health IT capabilities are comparable to nonsafety net sites. CONCLUSIONS: All outpatient settings would benefit from improved electronic health record usability and implementation support that facilitates advanced use of health IT. Safety net practices, particularly those without other sources of centralized support, need targeted resources to maintain equitable access to information exchange capabilities.

Adoption of Patient-Reported Outcomes by Health Systems and Physician Practices in the USA.

BACKGROUND: Patient-reported outcome measures (PROs) can help clinicians adjust treatments and deliver patient-centered care, but organizational adoption of PROs remains low. OBJECTIVE: This study examines the extent of PRO adoption among health systems and physician practices nationally and examines the organizational capabilities associated with more extensive PRO adoption. DESIGN: Two nationally representative surveys were analyzed in parallel to assess health system and physician practice capabilities associated with adoption of PROs of disability, pain, and depression. PARTICIPANTS: A total of 323 US health system and 2,190 physician practice respondents METHODS: Multivariable regression models separately estimated the association of health system and physician practice capabilities associated with system-level and practice-level adoption of PROs. MAIN MEASURES: Health system and physician practice adoption of PROs for depression, pain, and disability. KEY RESULTS: Pain (50.6%) and depression (43.8%) PROs were more commonly adopted by all hospitals and medical groups within health systems compared to disability PROs (26.5%). In adjusted analyses, systems with more advanced health IT functions were more likely to use disability (p<0.05) and depression (p<0.01) PROs than systems with less advanced health IT. Practice-level advanced health IT was positively associated with use of depression PRO (p<0.05), but not disability or pain PRO use. Practices with more chronic care management processes, broader medical and social risk screening, and more processes to support patient responsiveness were more likely to adopt each of the three PROs. Compared to independent physician practices, system-owned practices and community health centers were less likely to adopt PROs. CONCLUSIONS: Chronic care management programs, routine screening, and patient-centered care initiatives can enable PRO adoption at the practice level. Developing these practice-level capabilities may improve PRO adoption more than solely expanding health IT functions.

Cigarettes smoked among daily and non-daily smokers following CVS Health's tobacco-free pharmacy policy.

INTRODUCTION: In September 2014, CVS Health ceased tobacco sales in all of its 7700 pharmacies nationwide. We investigate the impact of the CVS policy on the number of cigarettes smoked per day among metropolitan daily and non-daily smokers, who may respond to the availability of smoking cues in different manners. METHODS: Data are from the US Census Bureau Tobacco Use Supplement to the Current Population Survey 2014-2015 and the Blue Cross and Blue Shield Institute Community Health Management Hub. Adjusted difference-in-difference (DID) regressions assess changes in the number of cigarettes smoked per day among daily smokers (n=10 759) and non-daily smokers (n=3055), modelling core-based statistical area (CBSA) level CVS pharmacy market share continuously. To assess whether the policy had non-linear effects across the distribution of CVS market share, we also examine market share using tertiles. RESULTS: CVS's tobacco-free pharmacy policy was associated with a significant reduction in the number of cigarettes smoked by non-daily smokers in the continuous DID (rate ratio=0.985, p=0.022), with a larger reduction observed among non-daily smokers in CBSAs in the highest third of CVS market share compared with those living in CBSAs with no CVS presence (rate ratio=0.706, p=0.027). The policy, however, was not significantly associated with differential changes in the number of cigarettes by daily smokers. CONCLUSION: The removal of tobacco products from CVS pharmacies was associated with a reduction in the number of cigarettes smoked per day among non-daily smokers in metropolitan CBSAs, particularly those in which CVS had a large pharmacy market share.

Comparing health care system and physician practice influences on social risk screening.

BACKGROUND: Health care systems can support dissemination of innovations, such as social risk screening in physician practices, but to date, no studies have examined the association of health system characteristics and practice-level adoption of social risk screening. PURPOSE: The aim of the study was to examine the association of multilevel organizational capabilities and adoption of social risk screening among system-owned physician practices. METHODOLOGY: Secondary analyses of the 2018 National Survey of Healthcare Organizations and Systems were conducted. Multilevel linear regression models examined physician practice and system characteristics associated with practice adoption of screening for five social risks (food insecurity, housing instability, utility needs, interpersonal violence, and transportation needs), accounting for clustering of practices within systems using random effects. RESULTS: System-owned practices screened for an average of 1.7 of the five social risks assessed. The intraclass correlation indicated 16% of practice variation in social risk screening was attributable to differences between their health systems owners, with 84% attributable to differences between individual practices. Practices owned by systems with multiple hospitals screened for an additional 0.44 social risks (p = .046) relative to practices of systems without hospitals. Practice characteristics associated with social risk screening included health information technology capacity (ß = 0.20, p = .005), innovation culture (ß = 0.26, p < .001), and patient engagement strategies (ß = 0.57, p < .001). CONCLUSIONS: Health care system capabilities account for less variation in physician practice adoption of social risk screening compared to practice-level capabilities. PRACTICE IMPLICATIONS: Efforts to expand social risk screening among system-owned physician practices should focus on supporting practice capabilities, including enhancing health information technology, promoting an innovative organizational culture, and advancing patient engagement strategies.

FQHC Designation and Safety Net Patient Revenue Associated with Primary Care Practice Capabilities for Access and Quality.

BACKGROUND: Concerns exist about the ability of safety net health care organizations to participate in US health care reform. Primary care practices are key to several efforts, but little is known about how capabilities of primary care practices serving a high share of disadvantaged patients compare to other practices. OBJECTIVE: To assess capabilities around access to and quality of care among primary care practices serving a high share of Medicaid and uninsured patients compared to practices serving a low share of these patients. DESIGN: We analyzed data from the National Survey of Healthcare Organizations and Systems (response rate 46.8%), conducted 2017-2018. PARTICIPANTS: A total of 2190 medical practices with at least three adult primary care physicians. MAIN MEASURES: Our key exposures are payer mix and federally qualified health center (FQHC) designation. We classified practices as safety net if they reported a combined total of at least 25% of annual revenue from uninsured or Medicaid patients; we then further classified safety net practices into those that identified as an FQHC and those that did not. KEY RESULTS: FQHCs were more likely than other safety net practices and non-safety net practices to offer early or late appointments (79%, 55%, 62%; p=0.001) and weekend appointments (56%, 39%, 42%; p=0.03). FQHCs more often provided medication-assisted treatment for opioid use disorders (43%, 27%, 25%; p=0.004) and behavioral health services (82%, 50%, 36%; p<0.001). FQHCs were more likely to screen patients for social and financial needs. However, FQHCs and other safety net providers had more limited electronic health record (EHR) capabilities (61%, 71%, 80%; p<0.001). CONCLUSION: FQHCs were more likely than other types of primary care practices (both safety net practices and other practices) to possess capabilities related to access and quality. However, safety net practices were less likely than non-safety net practices to possess health information technology capabilities.

The Early Impact of the Centers for Medicare & Medicaid Services State Innovation Models Initiative on 30-Day Hospital Readmissions Among Adults With Diabetes.

BACKGROUND: The Centers for Medicare & Medicaid Services (CMS) State Innovation Models (SIM) Initiative funds states to accelerate delivery system and payment reforms. All SIM states focus on improving diabetes care, but SIM's effect on 30-day readmissions among adults with diabetes remains unclear. METHODS: A quasi-experimental research design estimated the impact of SIM on 30-day hospital readmissions among adults with diabetes in 3 round 1 SIM states (N=671,996) and 3 comparison states (N=2,719,603) from 2010 to 2015. Difference-in-differences multivariable logistic regression models that incorporated 4-group propensity score weighting were estimated. Heterogeneity of SIM effects by grantee state and for CMS populations were assessed. RESULTS: In adjusted difference-in-difference analyses, SIM was associated with an increase in odds of 30-day hospital readmission among patients in SIM states in the post-SIM versus pre-SIM period relative to the ratio in odds of readmission among patients in the comparison states post-SIM versus pre-SIM (ratio of adjusted odds ratio=1.057, P=0.01). Restricting the analyses to CMS populations (Medicare and Medicaid beneficiaries), resulted in consistent findings (ratio of adjusted odds ratio=1.057, P=0.034). SIM did not have different effects on 30-day readmissions by state. CONCLUSIONS: We found no evidence that SIM reduced 30-day readmission rates among adults with diabetes during the first 2 years of round 1 implementation, even among CMS beneficiaries. It may be difficult to reduce readmissions statewide without greater investment in health information exchange and more intensive use of payment models that promote interorganizational coordination.

Patient Activation as a Pathway to Shared Decision-making for Adults with Diabetes or Cardiovascular Disease.

BACKGROUND: Shared decision-making (SDM) is widely recognized as a core strategy to improve patient-centered care. However, the implementation of SDM in routine care settings has been slow and its impact mixed. OBJECTIVE: We examine the temporal association of patient activation and patients' experience with the SDM process to assess the dominant directionality of this relationship. DESIGN: Patient activation, or a patients' knowledge, skills, and confidence in self-management, was assessed using the 13-item Patient Activation Measure (PAM). Patient-reported assessment of the SDM process was assessed using the 3-item CollaboRATE measure. Patients at 16 adult primary care practices were surveyed in 2015 and 2016 on PAM (α = 0.92), CollaboRATE (α = 0.90), and demographics. The relationship between PAM and CollaboRATE was estimated using a cross-lagged panel model with clustered robust standard errors and practice fixed effects, controlling for patient characteristics. PARTICIPANTS: 1222 adult patients with diabetes and/or cardiovascular disease with survey responses at baseline (51% response rate) and a 1-year follow-up (73% response rate). RESULTS: PAM (mean 3.27 vs 3.28 on a range of 1 to 4; p = 0.082) and CollaboRATE (mean 3.62 vs 3.63 on a range of 1 to 5; p = 0.14) did not change significantly over time. In adjusted analyses, the path from baseline PAM to follow-up CollaboRATE (ß = 0.35; p < 0.0001) was stronger than the path from baseline CollaboRATE to follow-up PAM (ß = 0.04; p = 0.001). CONCLUSIONS: The relationship between patient activation and patients' experiences of the SDM process is bidirectional, but dominated by baseline patient activation. Rather than promoting the use of SDM for all patients, healthcare organizations should prioritize interventions to promote patient activation and engage patients with relatively high activation in SDM interventions.

Ease of use of electronic health records and relational coordination among primary care team members.

BACKGROUND: Electronic health records (EHRs) have potential to improve quality, health outcomes, and efficiency, but little is known about the mechanisms through which these improvements occur. PURPOSE: One potential mechanism could be that EHRs improve care team communication and coordination, leading to better outcomes. To test this hypothesis, we examine whether ease of EHR use is associated with better relational coordination (RC), a measure of team communication and coordination, among primary care team members. METHODOLOGY: Surveys of adult primary care team members (n = 304) of 16 practices of two accountable care organizations in Chicago and Los Angeles were analyzed. The survey included a validated measure of RC and a measure of ease of EHR use from a national survey. Linear regression models estimated the association of ease of EHR use and RC, controlling for care site and patient demographics and accounting for cluster-robust standard errors. An interaction term tested a differential association of ease of EHR use and RC for primary care providers (PCPs) versus non-PCPs. RESULTS: Ease of EHR use (mean = 3.5, SD = 0.6, range: 0-4) and RC were high (mean = 4.0, SD = 0.7, range: 0-5) but differed by occupation. In regression analyses, a 1-point increase in ease of EHR use was associated with a 0.36 point higher RC score (p = .001). The association of ease of EHR and RC use was stronger for non-PCPs than PCPs. CONCLUSION: Ease of EHR use is associated with better RC among primary care team members, and the benefits accrue more to non-PCPs than to PCPs. PRACTICE IMPLICATIONS: Ensuring that clinicians and staff experience EHRs as easy to use for accessing and integrating data and for communication may produce gains in efficiency and outcomes through high RC. Future studies should examine whether interventions to improve EHR usability can lead to improved RC and patient outcomes.

The influence of leadership facilitation on relational coordination among primary care team members of accountable care organizations.

BACKGROUND: Teamwork is a central aspect of integrated care delivery and increasingly critical to primary care practices of accountable care organizations. Although the importance of leadership facilitation in implementing organizational change is well documented, less is known about the extent to which strong leadership facilitation can positively influence relational coordination among primary care team members. PURPOSE: The aim of this study was to examine the association of leadership facilitation of change and relational coordination among primary care teams of accountable care organization-affiliated practices and explore the role of team participation and solidarity culture as mediators of the relationship between leadership facilitation and relational coordination among team members. METHODOLOGY/APPROACH: Survey responses of primary care clinicians and staff (n = 764) were analyzed. Multilevel linear regression estimated the relationships among leadership facilitation, team participation, group solidarity, and relational coordination controlling for age, time, occupation, gender, team tenure, and team size. Models included practice site random effects to account for the clustering of respondents within practices. RESULTS: Leadership facilitation (ß = 0.19, p < .001) and team participation (ß = 0.18, p < .001) were positively associated with relational coordination, but solidarity culture was not associated. The association of leadership facilitation and relational coordination was only partially mediated (9%) by team participation. CONCLUSIONS: Leadership facilitation of change is positively associated with relational coordination of primary care team members. The relationship is only partially explained by better team participation, indicating that leadership facilitation has a strong direct effect on relational coordination. Greater solidarity was not associated with better relational coordination and may not contribute to better team task coordination. PRACTICE IMPLICATIONS: Leadership facilitation of change may have a positive and direct impact on high relational coordination among primary care team members.

Early Impact of the State Innovation Models Initiative on Diagnosed Diabetes Prevalence Among Adults and Hospitalizations Among Diagnosed Adults.

BACKGROUND: The State Innovation Models (SIM) Initiative invested $254 million in 6 states in Round 1 to accelerate delivery system and payment reforms. OBJECTIVE: The objective of this study was to examine the association of early SIM implementation and diagnosed diabetes prevalence among adults and hospitalization rates among diagnosed adults. RESEARCH DESIGN: Quasi-experimental design compares diagnosed diabetes prevalence and hospitalization rates before SIM (2010-2013) and during early implementation (2014) in 6 SIM states versus 6 comparison states. County-level, difference-in-differences regression models were estimated. SUBJECTS: The annual average of 4.5 million adults aged 20+ diagnosed with diabetes with 1.4 million hospitalizations in 583 counties across 12 states. MEASURES: Diagnosed diabetes prevalence among adults and hospitalization rates per 1000 diagnosed adults. RESULTS: Compared with the pre-SIM period, diagnosed diabetes prevalence increased in SIM counties by 0.65 percentage points (from 10.22% to 10.87%) versus only 0.10 percentage points (from 9.64% to 9.74%) in comparison counties, a difference-in-differences of 0.55 percentage points. The difference-in-differences regression estimates ranged from 0.49 to 0.53 percentage points (P<0.01). Regression results for ambulatory care-sensitive condition and all-cause hospitalization rates were inconsistent across models with difference-in-differences estimates ranging from -5.34 to -0.37 and from -13.16 to 0.92, respectively. CONCLUSIONS: SIM Round 1 was associated with higher diagnosed diabetes prevalence among adults after a year of implementation, likely because of SIM's emphasis on detection and care management. SIM was not associated with lower hospitalization rates among adults diagnosed with diabetes, but the SIM's long-term impact on hospitalizations should be assessed.