Medicaid Integrated Purchasing for Physical and Behavioral Health: Early Adopters' Perceptions of Payment Reform Implementation in Washington State.

The Centers for Medicare and Medicaid Innovation (CMMI) gave rise to the State Innovation Models (SIMs). Medicaid Integrated Purchasing for Physical and Behavioral Health, referred to as Payment Model 1 (PM1), was a core payment redesign area of the Washington State SIM project under which our research team was contracted to provide an evaluation. In doing so, we leveraged an open systems conceptual model to assess qualitatively Early Adopter stakeholders' perceived effects of implementation. Between 2017 and 2019, we conducted three rounds of interviews, examining themes of care coordination, common facilitators and barriers to integration, and potential concerns for sustaining the initiative into the future. Further, we noted the initiative's complexity may require the establishment of enduring partnerships, secure funding sources, and committed regional leadership to ensure longer-term success.

Evaluation of a Multilevel Laboratory Stewardship Intervention Targeted to Cardiac and Thoracic Surgical Services at an Academic Medical Center.

CONTEXT.­: Unnecessary laboratory tests are ordered because of factors such as preselected orders on order sets, clinician habits, and trainee concerns. Excessive use of laboratory testing increases patient discomfort via unnecessary phlebotomy, contributes to iatrogenic anemia, increases risk of bloodstream infections, and increases the cost of care. OBJECTIVE.­: To address these concerns, we implemented a multilevel laboratory stewardship intervention to decrease unnecessary laboratory testing, measured by laboratory tests per day attributed to service, across 2 surgical divisions with high laboratory use. DESIGN.­: The multilevel intervention included 5 components: stakeholder engagement, provider education, computerized provider order entry modification, performance feedback, and culture change supported by leadership. The primary outcome of the study was laboratory tests ordered per patient-day. Secondary outcomes included the number of blood draws per patient-day, total lab-associated costs, length of stay, discharge to a nursing facility, 30-day readmissions, and deaths. A difference-in-differences analytic approach assessed the outcome measures in the intervention period, with other surgical services as controls. RESULTS.­: The primary outcome of laboratory tests per patient-day showed a significant decrease across both thoracic and cardiac surgery services, with between 1.5 and 2 fewer tests ordered per patient-day for both services and an estimated 20 000 fewer tests performed during the intervention period. Blood draws per patient-day were also significantly decreased on the thoracic surgery service but not for cardiac surgery. CONCLUSIONS.­: A multilevel laboratory stewardship intervention targeted to 2 surgical services resulted in a significant decrease in laboratory test use without negatively impacting length of stay, readmissions, or mortality.

Barriers and facilitators to the use of personal information documents in health and social care settings for people living with dementia: A thematic synthesis and mapping to the COM-B framework.

INTRODUCTION: People living with dementia experience communication difficulties. Personal information documents, or healthcare passports, enable communication of information essential for the care of a person with dementia. Despite the potential for providing person-centred care, personal information documents are not ubiquitously used. The Capability Opportunity Motivation-Behaviour (COM-B) model can be used to understand factors determining individuals' behaviours. OBJECTIVES: This study aimed to identify the barriers to and facilitators of the use of healthcare passports for people living with dementia through a systematic review methodology. METHODS: A systematic search of six electronic databases was undertaken. Grey literature was searched using three databases. All study types reporting barriers to or facilitators of the use of personal information documents in the care of adults living with dementia in high-income countries were included. Study quality was assessed using the NICE Quality Appraisal Checklist. Thematic synthesis was used to develop descriptive themes, which were subsequently mapped to the COM-B framework. RESULTS: Nineteen papers were included. Themes included training, awareness, embedding the process in norms and appreciating the value of the personal information documents. A broad range of barriers and facilitators was identified within each COM-B domain. CONCLUSION: This framework provides a starting point for evidence-informed initiatives to improve the use of personal information documents in the care of people with dementia. PATIENT AND PUBLIC CONTRIBUTION: This is a review of studies and did not involve patients or the public. Review results will guide evaluation of a local personal information document, which will be designed with input from the Dementia Champions Network (includes carers and other stakeholders).

State-Level Evaluation of Washington's State Innovation Models (SIM) Initiative.

The Washington State Innovation Models (SIM) $65 million Test Award from the Center for Medicare & Medicaid Services' Innovation Center is a statewide intervention expected to improve population health, quality of care, and cost growth through four initiatives: 1) regional accountable communities of health linking health and social services to address local needs; 2) a practice transformation support hub; 3) four value-based payment reform pilot projects mainly in state employee and Medicaid populations; and 4) data and analytic infrastructure development to support system transformation with common measures. We develop a conceptual model based on diffusion theory and apply the RE-AIM evaluation framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance) to structure our evaluation. We find that in three years (2016-2018), SIM built the infrastructure for system transformation and increased Washington's readiness for health system change in the next decade. However, the initiatives have not spread statewide, which may take over 10 years.

Statewide Evaluation of Washington's State Innovation Model Initiative: A Mixed-Methods Approach.

The Washington State Innovation Model (SIM) $65 million Test Award from the Center for Medicare and Medicaid Innovation is a statewide intervention expected to improve population health, quality of care, and cost growth through 4 initiatives in 2016-2018: (1) regional accountable communities of health linking health and social services to address local needs; (2) a practice transformation support hub; (3) four value-based payment reform pilot projects mainly in state employee and Medicaid populations; and (4) data and analytic infrastructure development to support system transformation with common measures. A mixed-methods study design and data from the 2013-2018 Behavioral Risk Factor Surveillance System Surveys are used to estimate whether SIM resulted in changes in access to care, health behaviors, and health status in Washington's adult population. Semi-structured qualitative interviews also were conducted to assess stakeholder perceptions of SIM performance. SIM may have reduced binge drinking, but no effects were detected for heavy drinking, physical activity, smoking, having a regular doctor checkup, unmet health care needs, and fair or poor health status. Complex interventions, such as SIM, may have unintended consequences. SIM was associated unexpectedly with increased unhealthy days, but whether the association was related to the Initiative or other factors is unclear. Over 3 years, stakeholders generally agreed that SIM was implemented successfully and increased Washington's readiness for system transformation but had not yet produced expected outcomes, partly because SIM had not spread statewide. Stakeholders perceived that scaling up SIM statewide takes time to achieve and remains challenging.

The one-year impact of accountable care networks among Washington State employees.

OBJECTIVE: To estimate the impact of a new, two-sided risk model accountable care network (ACN) on Washington State employees and their families. DATA SOURCES/STUDY SETTING: Administrative data (January 2013-December 2016) on Washington State employees. STUDY DESIGN: We compared monthly health care utilization, health care intensity as measured through proxy pricing, and annual HEDIS quality metrics between the five intervention counties to 13 comparison counties, analyzed separately by age categories (ages 0-5, 6-18, 19-26, 18-64). DATA COLLECTION/EXTRACTION METHODS: We used difference-in-difference methods and generalized estimating equations to estimate the effects after 1 year of implementation for adults and children. PRINCIPAL FINDINGS: We estimate a 1-2 percentage point decrease in outpatient hospital visits due to the introduction of ACNs (adults: -1.8, P < .01; age 0-5: -1.2, P = .07; age 6-18: -1.2, P = .06; age 19-26; -1.2, P < .01). We find changes in primary and specialty care office visits; the direction of impact varies by age. Dependents age 19-26 were also responsive with inpatient admissions declines (-0.08 percentage points, P = .02). Despite changes in utilization, there was no evidence of changes in intensity of care and mixed results in the quality measures. CONCLUSIONS: Washington's state employee ACN introduction changed health care utilization patterns in the first year but was not as successful in improving quality.

Organizational factors affecting successful physician-system integration: A qualitative study of Washington State health executives.

BACKGROUND: Health care delivery is moving toward a value-based environment, which calls for increased integration between physician groups and health systems. Health executives sit at a key nexus point for determining how and when physician-system integration occurs. PURPOSE: The objective of this study was to identify the organizational factors that health executives perceived to have made physician-system integration successful. METHODOLOGY/APPROACH: We used a multiple-case study research design. We conducted semistructured, qualitative interviews with 25 health executives in the roles of CEO, chief medical officer, chief financial officer and physician group chief executives from eight of Washington State's largest integrated delivery systems. To guide our analysis, we employed open systems theory and Porter's Value Chain to identify physician group and hospital factors that were integral to successful integration. RESULTS: Using the executives' perspectives, the factors grouped into three themes: (1) organizational structure-a mix of integration contracts united by common structural characteristics between physician groups and hospitals); (2) organizational culture-alignment of leadership between physician groups and hospitals; and (3) strategic resources-designated resources to establish and support care coordination activities. CONCLUSION: Our work indicates that health systems should focus on the pathway to integration success through the alignment of structure (not just the integration contract), culture, and resources and not on an end goal of the physician employment model. PRACTICE IMPLICATIONS: Health system executives are key drivers for when and how physician groups are integrated into health services organizations. This article provides executives with an evidence-based model to aid in formulating integration approaches that combine elements of organizational structure, organizational culture, and strategic resources.

The Contribution of Physician-System Integrating Structure to Select Health System Outcomes.

Physician groups are increasingly being vertically integrated with hospitals and health systems; yet, the evidence on the impact of physician-system integration on health system outcomes is mixed. The objective of this study was to examine the impact of increased physician-system integration on select health system outcomes. We used a mixed-methods approach: (1) a fixed-effects multivariate mediation analysis; and (2) a qualitative analysis of interviews with health executives (n = 25). Our findings showed that hospitals spent $633 375.22 to $827 110.24 for each "level" increase in integration. This relationship was attenuated, however, by the presence of care coordination mechanisms.

RE-AIM Evaluation Plan for Washington State Innovation Models Project.

The State of Washington received a State Innovation Models (SIM) $65 million award from the federal Centers for Medicare & Medicaid Services to improve population health and quality of care and reduce the growth of health care costs in the entire state, which has over 7 million residents. SIM is a "complex intervention" that implements several interacting components in a complex, decentralized health system to achieve goals, which poses challenges for evaluation. Our purpose is to present the state-level evaluation methods for Washington's SIM, a 3-year intervention (2016-2018). We apply the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) evaluation framework to structure our evaluation. We create a conceptual model and a plan to use multiple and mixed methods to study SIM performance in the RE-AIM components from a statewide, population-based perspective.

Means restriction for the prevention of suicide by jumping.

BACKGROUND: Jumping from a height is an uncommon but lethal means of suicide. Restricting access to means is an important universal or population-based approach to suicide prevention with clear evidence of its effectiveness. However, the evidence with respect to means restriction for the prevention of suicide by jumping is not well established. OBJECTIVES: To evaluate the effectiveness of interventions to restrict the availability of, or access to, means of suicide by jumping. These include the use of physical barriers, fencing or safety nets at frequently-used jumping sites, or restriction of access to these sites, such as by way of road closures. SEARCH METHODS: We searched the Cochrane Library, Embase, MEDLINE, PsycINFO, and Web of Science to May 2019. We conducted additional searches of the international trial registries including the World Health Organization International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov, to identify relevant unpublished and ongoing studies. We searched the reference lists of all included studies and relevant systematic reviews to identify additional studies and contacted authors and subject experts for information on unpublished or ongoing studies. We applied no restrictions on date, language or publication status to the searches. Two review authors independently assessed all citations from the searches and identified relevant titles and abstracts. Our main outcomes of interest were suicide, attempted suicide or self-harm, and cost-effectiveness of interventions. SELECTION CRITERIA: Eligible studies were randomised or quasi-randomised controlled trials, controlled intervention studies without randomisation, before-and-after studies, or studies using interrupted time series designs, which evaluated interventions to restrict the availability of, or access to, means of suicide by jumping. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies for inclusion and three review authors extracted study data. We pooled studies that evaluated similar interventions and outcomes using a random-effects meta-analysis, and we synthesised data from other studies in a narrative summary. We summarised the quality of the evidence included in this review using the GRADE approach. MAIN RESULTS: We included 14 studies in this review. Thirteen were before-and-after studies and one was a cost-effectiveness analysis. Three studies each took place in Switzerland and the USA, while two studies each were from the UK, Canada, New Zealand, and Australia respectively. The majority of studies (10/14) assessed jumping means restriction interventions delivered in isolation, half of which were at bridges. Due to the observational nature of included studies, none compared comparator interventions or control conditions. During the pre- and postintervention period among the 13 before-and-after studies, a total of 742.3 suicides (5.5 suicides per year) occurred during the pre-intervention period (134.5 study years), while 70.6 suicides (0.8 suicides per year) occurred during the postintervention period (92.4 study years) - a 91% reduction in suicides. A meta-analysis of all studies assessing jumping means restriction interventions (delivered in isolation or in combination with other interventions) showed a directionality of effect in favour of the interventions, as evidenced by a reduction in the number of suicides at intervention sites (12 studies; incidence rate ratio (IRR) = 0.09, 95% confidence interval (CI) 0.03 to 0.27; P < 0.001; I2 = 88.40%). Similar findings were demonstrated for studies assessing jumping means restriction interventions delivered in isolation (9 studies; IRR = 0.05, 95% CI 0.01 to 0.16; P < 0.001; I2 = 73.67%), studies assessing jumping means restriction interventions delivered in combination with other interventions (3 studies; IRR = 0.54, 95% CI 0.31 to 0.93; P = 0.03; I2 = 40.8%), studies assessing the effectiveness of physical barriers (7 studies; IRR = 0.07, 95% CI 0.02 to 0.24; P < 0.001; I2 = 84.07%), and studies assessing the effectiveness of safety nets (2 studies; IRR = 0.09, 95% CI 0.01 to 1.30; P = 0.07; I2 = 29.3%). Data on suicide attempts were limited and none of the studies used self-harm as an outcome. There was considerable heterogeneity between studies for the primary outcome (suicide) in the majority of the analyses except those relating to jumping means restriction delivered in combination with other interventions, and safety nets. Nevertheless, every study included in the forest plots showed the same directional effects in favour of jumping means restriction. Due to methodological limitations of the included studies, we rated the quality of the evidence from these studies as low. A cost-effectiveness analysis suggested that the construction of a physical barrier on a bridge would be a highly cost-effective project in the long term as a result of overall reduced suicide mortality. AUTHORS' CONCLUSIONS: The findings from this review suggest that jumping means restriction interventions are capable of reducing the frequency of suicides by jumping. However, due to methodological limitations of included studies, this finding is based on low-quality evidence. Therefore, further well-designed high-quality studies are required to further evaluate the effectiveness of these interventions, as well as other measures at jumping sites. In addition, further research is required to investigate the potential for suicide method substitution and displacement effects in populations exposed to interventions to prevent suicide by jumping.

Community Readiness for Increasing Older Adult Physical Activity Levels in Kazakhstan.

Introduction: Physical activity is proven to be a significant element of successful aging, but many seniors worldwide fail to achieve the recommended levels. This study aimed to assess the readiness of the community in Nur-Sultan, Kazakhstan, to act on the issue of physical inactivity among older adults. Methods: In order to achieve this purpose, we conducted qualitative interviews with key informants in the community and applied a validated community readiness tool. Results: The results suggest that the local community is at early stages of readiness to act on the issue of older adult physical inactivity. We identified a number of barriers that prevented seniors from leading active lifestyles, which included community misconceptions about older adult physical activity, family centeredness in older adulthood, scarcity of resources, passive support from the leadership, and lack of efforts in the community. Research findings also highlighted the importance of conducting in-depth analysis of key informant responses in addition to calculating readiness scores, when using the community readiness tool. Conclusions: Community-specific strategies for enhancing the level of physical activity among seniors are required to offset the disease burden associated with aging and to prolong life expectancy in Kazakhstan, and it is of paramount importance to tailor potential efforts as to address the current readiness of the community and its needs.

From Volume- to Value-Based Payment System in Washington State Federally Qualified Health Centers: Innovation for Vulnerable Populations.

The reimbursement system at 16 Federally Qualified Health Centers in Washington State transformed to a per-member-per-month model with a prospective adjustment for quality performance. The results of this qualitative study suggest that 3 to 5 years would be required to achieve significant progress in the Triple Aim goals of the initiative and also demonstrate that Federally Qualified Health Centers are potentially more advanced in their readiness to offer value-based care. By providing positive financial incentives without downside risk, the state is stimulating replicable models of care, and in longer term such reforms may lead to a greater care coordination and a whole person-centered care.

Enhancing Access to Quality Online Training to Strengthen Public Health Preparedness and Response.

OBJECTIVES: To improve access to quality online training materials developed from 2010 to 2015 by 14 Preparedness and Emergency Response Learning Centers (PERLCs) by creating quality standards and enhancing searchability through a new Web-based public health training catalog. METHODS: The PERLC-developed training materials (n = 530) were evaluated for their capability to support development of preparedness competencies as established by 2 evidence-based competency frameworks. Inclusion/exclusion criteria and evaluation guidelines regarding training quality (design, technology, and instructional components) were systematically applied to PERLC products to create a training catalog. Twenty emergency preparedness professionals pilot tested content and provided feedback to improve catalog design and function. RESULTS: Seventy-eight percent of PERLC resources (n = 413) met our quality standards for inclusion in the catalog's searchable database: 358 self-paced courses, 55 informational briefs, and other materials. Twenty-one training bundles were curated. DISCUSSION: We established quality guidelines, identified strengths and weaknesses in PERLC resources, and improved accessibility to trainings. Guidelines established by this work can be generalized to trainings outside the preparedness domain. Enhancing access to quality training resources can serve as a valuable tool for increasing emergency preparedness competence.

Accountable Care Program Implementation and Effects on Participating Health Care Systems in Washington State: A Conceptual Model.

This study is based on key informant interviews with health care executives representing 5 large health systems that had entered into contracts with the Washington State Health Care Authority to provide accountable care network services under the State Innovation Model initiative. The purpose of this study was to explain effects of accountable care program (ACP) implementation on participating health care systems. Between January 2017 and May 2018, we conducted 2 rounds of semistructured interviews (n = 20). Results indicate the need to present a modified conceptual model aligned with ACP implementation in the current context.

Adolescent exposure to Δ9-tetrahydrocannabinol delays acquisition of paired-associates learning in adulthood.

RATIONALE AND OBJECTIVES: Adolescence is a sensitive period of brain development, during which there may be a heightened vulnerability to the effects of drug use. Despite this, the long-term effects of cannabis use during this developmental period on cognition are poorly understood. METHODS: We exposed adolescent rats to escalating doses of Δ9-tetrahydrocannabinol (THC)-the primary psychoactive component of cannabis-or vehicle solution during postnatal days (PND) 35-45, a period of development that is analogous to human adolescence (THC doses: PND 35-37, 2.5 mg/kg; PND 38-41, 5 mg/kg; PND 42-45, 10 mg/kg). After a period of abstinence, in adulthood, rats were tested on an automated touchscreen version of a paired-associates learning (PAL) task to assess their ability to learn and recall object-location associations. Prepulse inhibition (PPI) of the startle response was also measured at three time points (5 days, 4 months, and 6 months after exposure) to assess sensorimotor gating, the ability to filter out insignificant sensory information from the environment. RESULTS: Compared to rats exposed to vehicle alone, rats exposed to THC during adolescence took longer to learn the PAL task when tested in adulthood, even when trials contained visually identical stimuli that differed only in location. Despite this, no differences were observed later in testing, when trials contained visually distinct stimuli in different locations. Rats exposed to THC also displayed impairments in sensorimotor gating, as measured by prepulse inhibition of the startle response, though this deficit did appear to decrease over time. CONCLUSION: Taken together, THC exposure during adolescence produces long-term deficits in associative learning and sensorimotor gating, though the impact of these deficits seems to diminish with time. Thus, adolescence may represent a period of neurocognitive development that is vulnerable to the harms of cannabis use, though the stability of such harms is uncertain.

The Push-Pull Factors of Physician-System Integration: A Qualitative Study of Washington State Healthcare Executives.

EXECUTIVE SUMMARY: The transition from volume- to value-based care calls for closer working relationships between physician groups and health systems. Healthcare executives are in the position of determining when and how physician groups are integrated into healthcare systems. Leveraging the theory of migration, we aim to describe where physician-system integration is headed and offer recommendations on how executives can respond to physician migration to and from integration. We conducted 25 semistructured interviews with CEOs, chief medical officers, chief financial officers, and physician group chief executives from eight of Washington State's largest integrated delivery systems. These executives predicted tighter integration and more forced alignment; however, some clinician executives were skeptical about whether the physician employment model will be the right course despite the growing demand from younger physicians. The results of these interviews suggest that integration will be driven by push and pull factors stemming from five prevailing forces: social (community), social (physicians), economic, political, and technological. Understanding the factors that influence physicians' decisions to migrate can provide insight for and guidance to executives contemplating integration in the current climate.

Building Conceptions of Cognitive Enhancement: University Students' Views on the Effects of Pharmacological Cognitive Enhancers.

BACKGROUND: Use of prescription stimulants for cognitive enhancement in healthy individuals has been of growing interest to the academic community. University students can be prone to use these pharmacological cognitive enhancers (PCEs) for their perceived academic benefits. OBJECTIVES: We aimed to understand university students' beliefs about the factors influencing PCE use, the cognitive and health effects of the drugs, and how these conceptions are interrelated. METHODS: Data were collected through focus groups with 45 students at the University of Toronto in 2015/2016. We used thematic analysis to extract key themes and cooccurrence coefficients to evaluate the overlap between these themes. RESULTS: We found that participants perceived users as either struggling students or high-achieving ones. Alleged benefits of PCEs included enhanced focus, attention, memorization, and grades, but did not include increased intelligence or long-term cognitive enhancement. Participants disagreed on whether ADHD diagnosis would affect how PCEs worked and how "needing the drug" was determined. Mentions of nonspecific side effects were common, as was the possibility of misuse (e.g., addiction, abuse). Though not an initial aim of the study, we uncovered patterns pertaining to whom participants used as sources of information about different themes. We propose that social learning theory provides a useful framework to explain how the experiences of peers may shape the conceptions of our participants. Conclusions/Importance: Our findings highlight that conceptions surrounding PCEs are multileveled, and informed by a variety of sources, including peers. This should be considered in the development of interventions geared toward university students.