Leveraging Accountable Care Organization infrastructure for rapid pandemic response in independent primary care practices.

BACKGROUND: Population risk segmentation and technology-enabled preventive care workflows are core competencies for Accountable Care Organizations (ACOs) that may also have relevance for public health emergencies. METHODS: During the early weeks of the COVID-19 pandemic, we aimed to leverage existing ACO capabilities to support 467 primary care practices across 27 states with pandemic response. We used Medicare claims and electronic health records to identify patients with increased COVID-19 vulnerability, for proactive outreach and guidance for "Staying Well at Home." RESULTS: 302,125 patients met intervention criteria; 45% were reached within the first 6 weeks. Engagement in the initiative was uneven among ACO-participating practices. ACO staff identified prior practice engagement in core ACO workflows as a major facilitator of success and staffing shortages as a major barrier. Small practice size, non-metropolitan location, penetration of value-based payment models in the practice, and pre-pandemic Annual Wellness Visit completion rates were independently associated with successful outreach to COVID-vulnerable patients. CONCLUSIONS: Rapid adaptation of ACO infrastructure assisted independent practices across the country to reach vulnerable patients with proactive guidance for staying well at home. The initiative was most successful in smaller, non-metropolitan practices and those with greater engagement in core ACO initiatives pre-pandemic. IMPLICATIONS: Our experience suggests that primary care participation in accountable care models can contribute to preparedness for future public health crises.

Duration of medical home participation and quality of care for patients with chronic conditions.

OBJECTIVE: To examine whether the length of participation in a patient-centered medical home (PCMH), an evidence-based practice, leads to higher quality care for Medicaid enrollees with multiple co-morbid chronic conditions and major depressive disorder (MDD). DATA SOURCES: This analysis uses a unique data source that links North Carolina Medicaid claims and enrollment data with other administrative data including electronic records of state-funded mental health services, a state psychiatric hospital utilization database, and electronic records from a five-county behavioral health carve-out program. STUDY DESIGN: This retrospective cohort study uses generalized estimating equations (GEEs) on person-year-level observations to examine the association between the duration of PCMH participation and measures of guideline-concordant care, including the receipt of minimally adequate care for MDD, defined as 6 months of antidepressant use or eight psychotherapy visits each year. DATA COLLECTION/EXTRACTION METHODS: Adults with two or more chronic conditions reflected in administrative data, including MDD. PRINCIPAL FINDINGS: We found a 1.7 percentage point increase in the likelihood of receiving guideline-concordant care at 4 months of PCMH participation, as compared to newly enrolled individuals with a single month of participation (p < 0.05). This effect increased with each additional month of PCMH participation; 12 months of participation was associated with a 19.1 percentage point increase in the likelihood of receiving guideline-concordant care over a single month of participation (p < 0.01). CONCLUSIONS: The PCMH model is associated with higher quality of care for patients with multiple chronic conditions and MDD over time, and these benefits increase the longer a patient is enrolled. Providers and policy makers should consider the positive effect of increased contact with PCMHs when designing and evaluating initiatives to improve care for this population.

Medical home effects on enrollees with mental and physical illness.

OBJECTIVES: To assess the effect of medical home enrollment on acute care use and healthcare spending among Medicaid beneficiaries with mental and physical illness. STUDY DESIGN: Retrospective cohort analysis of administrative data. METHODS: We used 2007-2010 Medicaid claims and state psychiatric hospital data from a sample of 83,819 individuals diagnosed with schizophrenia or depression and at least 1 comorbid physical condition. We performed fixed-effects regression analysis at the person-month level to examine the effect of medical home enrollment on the probabilities of emergency department (ED) use, inpatient admission, and outpatient care use and on amount of Medicaid spending. RESULTS: Medical home enrollment had no effect on ED use in either cohort and was associated with a lower probability of inpatient admission in the depression cohort (P <.05). Medical home enrollees in both cohorts experienced an increase in the probability of having any outpatient visits (P <.05). Medical home enrollment was associated with an increase in mean monthly spending among those with schizophrenia ($65.8; P <.05) and a decrease among those with depression (-$66.4; P <.05). CONCLUSIONS: Among Medicaid beneficiaries with comorbid mental and physical illness, medical home enrollment appears to increase outpatient healthcare use and has mixed effects on acute care use. For individuals in this population who previously had no engagement with the healthcare system, use of the medical home model may represent an investment in providing improved access to needed outpatient services with cost savings potential for beneficiaries with depression.

Medicare Annual Wellness Visit association with healthcare quality and costs.

OBJECTIVES: Although use of the Medicare Annual Wellness Visit (AWV) is increasing nationally, it remains unclear whether it can help contain healthcare costs and improve quality. In the context of 2 primary care physician-led accountable care organizations (ACOs), we tested the hypothesis that AWVs can improve healthcare costs and clinical quality. STUDY DESIGN: A retrospective cohort study using propensity score matching and quasi-experimental difference-in-differences regression models comparing the differential changes in cost, emergency department (ED) visits, and hospitalizations for those who received an AWV versus those who did not from before until after the AWV. Logistic regressions were used for quality measures. METHODS: Between 2014 and 2016, we examined the association of an AWV with healthcare costs, ED visits, hospitalizations, and clinical quality measures. The sample included Medicare beneficiaries attributed to providers across 44 primary care clinics participating in 2 ACOs. RESULTS: Among 8917 Medicare beneficiaries, an AWV was associated with significantly reduced spending on hospital acute care and outpatient services. Patients who received an AWV in the index month experienced a 5.7% reduction in adjusted total healthcare costs over the ensuing 11 months, with the greatest effect seen for patients in the highest hierarchical condition category risk quartile. AWVs were not associated with ED visits or hospitalizations. Beneficiaries who had an AWV were also more likely to receive recommended preventive clinical services. CONCLUSIONS: In a setting that prioritizes care coordination and utilization management, AWVs have the potential to improve healthcare quality and reduce cost.

Do Medical Homes Improve Quality of Care for Persons with Multiple Chronic Conditions?

OBJECTIVE: To examine the association between medical home enrollment and receipt of recommended care for Medicaid beneficiaries with multiple chronic conditions (MCC). DATA SOURCES/STUDY SETTING: Secondary claims data from fiscal years 2008-2010. The sample included nonelderly Medicaid beneficiaries with at least two of eight target conditions (asthma, chronic obstructive pulmonary disease, diabetes, hypertension, hyperlipidemia, seizure disorder, major depressive disorder, and schizophrenia). STUDY DESIGN: We used linear probability models with person- and year-level fixed effects to examine the association between patient-centered medical home (PCMH) enrollment and nine disease-specific quality-of-care metrics, controlling for selection bias and time-invariant differences between enrollees. DATA COLLECTION METHODS: This study uses a dataset that links Medicaid claims with other administrative data sources. PRINCIPAL FINDINGS: Patient-centered medical home enrollment was associated with an increased likelihood of receiving eight recommended mental and physical health services, including A1C testing for persons with diabetes, lipid profiles for persons with diabetes and/or hyperlipidemia, and psychotherapy for persons with major depression and persons with schizophrenia. PCMH enrollment was associated with overuse of short-acting ß-agonists among beneficiaries with asthma. CONCLUSIONS: The PCMH model can improve quality of care for patients with multiple chronic conditions.

Primary Care Practices' Abilities And Challenges In Using Electronic Health Record Data For Quality Improvement.

Federal value-based payment programs require primary care practices to conduct quality improvement activities, informed by the electronic reports on clinical quality measures that their electronic health records (EHRs) generate. To determine whether EHRs produce reports adequate to the task, we examined survey responses from 1,492 practices across twelve states, supplemented with qualitative data. Meaningful-use participation, which requires the use of a federally certified EHR, was associated with the ability to generate reports-but the reports did not necessarily support quality improvement initiatives. Practices reported numerous challenges in generating adequate reports, such as difficulty manipulating and aligning measurement time frames with quality improvement needs, lack of functionality for generating reports on electronic clinical quality measures at different levels, discordance between clinical guidelines and measures available in reports, questionable data quality, and vendors that were unreceptive to changing EHR configuration beyond federal requirements. The current state of EHR measurement functionality may be insufficient to support federal initiatives that tie payment to clinical quality measures.

Active Redesign of a Medicaid Care Management Strategy for Greater Return on Investment: Predicting Impactability.

Care management of high-cost/high-needs patients is an increasingly common strategy to reduce health care costs. A variety of targeting methodologies have emerged to identify patients with high historical or predicted health care utilization, but the more pertinent question for program planners is how to identify those who are most likely to benefit from care management intervention. This paper describes the evolution of complex care management targeting strategies in Community Care of North Carolina's (CCNC) work with the statewide non-dual Medicaid population, culminating in the development of an "Impactability Score" that uses administrative data to predict achievable savings. It describes CCNC's pragmatic approach for estimating intervention effects in a historical cohort of 23,455 individuals, using a control population of 14,839 to determine expected spending at an individual level, against which actual spending could be compared. The actual-to-expected spending difference was then used as the dependent variable in a multivariate model to determine the predictive contribution of a multitude of demographic, clinical, and utilization characteristics. The coefficients from this model yielded the information required to build predictive models for prospective use. Model variables related to medication adherence and historical utilization unexplained by disease burden proved to be more important predictors of impactability than any given diagnosis or event, disease profile, or overall costs of care. Comparison of this approach to alternative targeting strategies (emergency department super-utilizers, inpatient super-utilizers, or patients with highest Hierarchical Condition Category risk scores) suggests a 2- to 3-fold higher return on investment using impactability-based targeting.

Evaluating the potential for primary care to serve as a mental health home for people with schizophrenia.

OBJECTIVE: Primary care-based medical homes could improve the coordination of mental health care for individuals with schizophrenia and comorbid chronic conditions. The objective of this paper is to examine whether persons with schizophrenia and comorbid chronic conditions engage in primary care regularly, such that primary care settings have the potential to serve as a mental health home. METHOD: We examined the annual primary care and specialty mental health service utilization of adult North Carolina Medicaid enrollees with schizophrenia and at least one comorbid chronic condition who were in a medical home during 2007-2010. Using a fixed-effects regression approach, we also assessed the effect of medical home enrollment on utilization of primary care and specialty mental health care and medication adherence. RESULTS: A substantial majority (78.5%) of person-years had at least one primary care visit, and 17.9% had at least one primary care visit but no specialty mental health services use. Medical home enrollment was associated with increased use of primary care and specialty mental health care, as well as increased medication adherence. CONCLUSIONS: Medical home enrollees with schizophrenia and comorbid chronic conditions exhibited significant engagement in primary care, suggesting that primary-care-based medical homes could serve a care coordination function for persons with schizophrenia.

Do primary care medical homes facilitate care transitions after psychiatric discharge for patients with multiple chronic conditions?

OBJECTIVE: Primary-care-based medical homes may facilitate care transitions for persons with multiple chronic conditions (MCC) including serious mental illness. The purpose of this manuscript is to assess outpatient follow-up rates with primary care and mental health providers following psychiatric discharge by medical home enrollment and medical complexity. METHODS: Using a quasi-experimental design, we examined data from North Carolina Medicaid-enrolled adults with MCC hospitalized with an inpatient diagnosis of depression or schizophrenia during 2008-2010. We used inverse-probability-of-treatment weighting and assessed associations between medical home enrollment and outpatient follow-up within 7 and 30 days postdischarge. RESULTS: Medical home enrollees (n=16,137) were substantially more likely than controls (n= 11,304) to receive follow-up care with any provider 30 days post discharge. Increasing patient complexity was associated with a greater probability of primary care follow-up. Medical complexity and medical home enrollment were not associated with follow-up with a mental health provider. CONCLUSIONS: Hospitalized persons with MCC including serious mental illness enrolled in a medical home were more likely to receive timely outpatient follow-up with a primary care provider but not with a mental health specialist. These findings suggest that the medical home model may be more adept at linking patients to providers in primary care rather than to specialty mental health providers.

Incremental Benefit of a Home Visit Following Discharge for Patients with Multiple Chronic Conditions Receiving Transitional Care.

Transitional care management is effective at reducing hospital readmissions among patients with multiple chronic conditions, but evidence is lacking on the relative benefit of the home visit as a component of transitional care. The sample included non-dual Medicaid recipients with multiple chronic conditions enrolled in Community Care of North Carolina (CCNC), with a hospital discharge between July 2010 and December 2012. Using claims data and care management records, this study retrospectively examined whether home visits reduced the odds of 30-day readmission compared to less intensive transitional care support, using multivariate logistic regression to control for demographic and clinical characteristics. Additionally, the researchers examined group differences within clinical risk strata on inpatient admissions and total cost of care in the 6 months following hospital discharge. Of 35,174 discharges receiving transitional care from a CCNC care manager, 21% (N = 7468) included a home visit. In multivariate analysis, home visits significantly reduced the odds of readmission within 30 days (odds ratio = 0.52, 95% confidence interval 0.48-0.57). At the 6-month follow-up, home visits were associated with fewer inpatient admissions within 4 of 6 clinical risk strata, and lower total costs of care for highest risk patients (average per member per month cost difference $970; P < 0.01). For complex chronic patients, home visits reduced the likelihood of a 30-day readmission by almost half compared to less intensive forms of nurse-led transitional care support. Higher risk patients experienced the greatest benefit in terms of number of inpatient admissions and total cost of care in the 6 months following discharge. (Population Health Management 2016;19:163-170).

Advancing heart health in North Carolina primary care: the Heart Health NOW study protocol.

BACKGROUND: The objective of Heart Health NOW (HHN) is to determine if primary care practice support-a comprehensive evidence-based quality improvement strategy involving practice facilitation, academic detailing, technology support, and regional learning collaboratives-accelerates widespread dissemination and implementation of evidence-based guidelines for cardiovascular disease (CVD) prevention in small- to medium-sized primary care practices and, additionally, increases practices' capacity to incorporate other evidence-based clinical guidelines in the future. METHODS/DESIGN: HHN is a stepped wedge, stratified, cluster randomized trial to evaluate the effect of primary care practice support on evidence-based CVD prevention, organizational change process measures, and patient outcomes. Each practice will start the trial as a control, receive the intervention at a randomized time point, and then enter a maintenance period 12 months after the start of the intervention. The intervention will be randomized to practices in one of four strata defined by region of the state (east or west) and degree of practice readiness for change. Seventy-five practices in each region with a high degree of readiness will be randomized 1:1:1 in blocks of 3 sometime prior to month 8 to receive the intervention at month 9, 11, or 12. An additional 75 practices within each region that have a low degree of readiness or are recruited later will be randomized 1:1 in blocks of 2 prior to month 13 to receive the intervention at month 14 or 16. The sites will be ordered within each strata based on time of enrollment with the blocking based on this ordering. Evaluation will examine the effect of primary care practice support on (1) practice-level delivery of evidence-based CVD prevention, (2) patient-level health outcomes, (3) practice-level implementation of clinical and organizational changes that support delivery of evidence-based CVD prevention, and (4) practice-level capacity to implement future evidence-based clinical guidelines. DISCUSSION: Results will indicate whether primary care practice support is an effective strategy for widespread dissemination and implementation of evidence-based clinical guidelines in primary care practices. Discernible reductions in cardiovascular risk in 300 practices covering over an estimated 900,000 adult patients would likely lead to prevention of thousands of cardiovascular events within 10 years. TRIAL REGISTRATION: ClinicalTrials.gov NCT02585557.

Timeliness of outpatient follow-up: an evidence-based approach for planning after hospital discharge.

PURPOSE: Timely outpatient follow-up has been promoted as a key strategy to reduce hospital readmissions, though one-half of patients readmitted within 30 days of hospital discharge do not have follow-up before the readmission. Guidance is needed to identify the optimal timing of hospital follow-up for patients with conditions of varying complexity. METHODS: Using North Carolina Medicaid claims data for hospital-discharged patients from April 2012 through March 2013, we constructed variables indicating whether patients received follow-up visits within successive intervals and whether these patients were readmitted within 30 days. We constructed 7 clinical risk strata based on 3M Clinical Risk Groups (CRGs) and determined expected readmission rates within each CRG. We applied survival modeling to identify groups that appear to benefit from outpatient follow-up within 3, 7, 14, 21, and 30 days after discharge. RESULTS: The final study sample included 44,473 Medicaid recipients with 65,085 qualifying discharges. The benefit of early follow-up varied according to baseline readmission risk. For example, follow-up within 14 days after discharge was associated with 1.5%-point reduction in readmissions in the lowest risk strata (P <.001) and a 19.1%-point reduction in the highest risk strata (P <.001). Follow-up within 7 days was associated with meaningful reductions in readmission risk for patients with multiple chronic conditions and a greater than 20% baseline risk of readmission, a group that represented 24% of discharged patients. CONCLUSIONS: Most patients do not meaningfully benefit from early outpatient follow-up. Transitional care resources would be best allocated toward ensuring that highest risk patients receive follow-up within 7 days.

Conflicting Readmission Rate Trends in a High-Risk Population: Implications for Performance Measurement.

The 30-day readmission rate is a common performance indicator for hospitals and accountable care entities. There is reason to question whether measuring readmissions as a function of hospital discharges is an appropriate measure of performance for initiatives that aim to improve overall cost and quality outcomes in a population. The objectives of this study were to compare trends in 30-day readmission rates per discharge to population-based measures of hospital admission and readmission frequency in a high-risk statewide Medicaid population over a 5-year period of quality improvement and care management intervention. Further, this study aimed to examine case-mix changes among hospitalized beneficiaries over time. This was a retrospective analysis of North Carolina Medicaid paid claims 2008 through 2012 for beneficiaries with multiple chronic or catastrophic conditions. Thirty-day readmission rates per discharge trended upward from 18.3% in 2008 to 18.7% in 2012. However, the rate of 30-day readmissions per 1000 beneficiaries declined from 123.3 to 110.7. Overall inpatient admissions per 1000 beneficiaries decreased from 579.4 to 518.5. The clinical complexity of hospitalized patients increased over the 5-year period. Although rates of hospital admissions and readmissions fell substantially in this high-risk population over 5 years, the 30-day readmission rate trend appeared unfavorable when measured as a percent of hospital discharges. This may be explained by more complex patients requiring hospitalization over time. The choice of metrics significantly affects the perceived effectiveness of improvement initiatives. Emphasis on readmission rates per discharge may be misguided for entities with a population health management focus.

Do medical homes increase medication adherence for persons with multiple chronic conditions?

BACKGROUND: Medications are an integral component of management for many chronic conditions, and suboptimal adherence limits medication effectiveness among persons with multiple chronic conditions (MCC). Medical homes may provide a mechanism for increasing adherence among persons with MCC, thereby enhancing management of chronic conditions. OBJECTIVE: To examine the association between medical home enrollment and adherence to newly initiated medications among Medicaid enrollees with MCC. RESEARCH DESIGN: Retrospective cohort study comparing Community Care of North Carolina medical home enrollees to nonenrollees using merged North Carolina Medicaid claims data (fiscal years 2008-2010). SUBJECTS: Among North Carolina Medicaid-enrolled adults with MCC, we created separate longitudinal cohorts of new users of antidepressants (N=9303), antihypertensive agents (N=12,595), oral diabetic agents (N=6409), and statins (N=9263). MEASURES: Outcomes were the proportion of days covered (PDC) on treatment medication each month for 12 months and a dichotomous measure of adherence (PDC>0.80). Our primary analysis utilized person-level fixed effects models. Sensitivity analyses included propensity score and person-level random-effect models. RESULTS: Compared with nonenrollees, medical home enrollees exhibited higher PDC by 4.7, 6.0, 4.8, and 5.1 percentage points for depression, hypertension, diabetes, and hyperlipidemia, respectively (P's<0.001). The dichotomous adherence measure showed similar increases, with absolute differences of 4.1, 4.5, 3.5, and 4.6 percentage points, respectively (P's<0.001). CONCLUSIONS: Among Medicaid enrollees with MCC, adherence to new medications is greater for those enrolled in medical homes.

Heterogeneity in the quality of care for patients with multiple chronic conditions by psychiatric comorbidity.

BACKGROUND: Little is known about the quality of care received by Medicaid enrollees with multiple chronic conditions (MCCs) and whether quality is different for those with mental illness. OBJECTIVES: To examine cancer screening and single-disease quality of care measures in a Medicaid population with MCC and to compare quality measures among persons with MCC with varying medical comorbidities with and without depression or schizophrenia. RESEARCH DESIGN: Secondary data analysis using a unique data source combining Medicaid claims with other administrative datasets from North Carolina's mental health system. SUBJECTS: Medicaid-enrolled adults aged 18 and older with ≥2 of 8 chronic conditions (asthma, chronic obstructive pulmonary disease, diabetes, hypertension, hyperlipidemia, seizure disorder, depression, or schizophrenia). Medicare/Medicaid dual enrollees were excluded due to incomplete data on their medical care utilization. MEASURES: We examined a number of quality measures, including cancer screening, disease-specific metrics, such as receipt of hemoglobin A1C tests for persons with diabetes, and receipt of psychosocial therapies for persons with depression or schizophrenia, and medication adherence. RESULTS: Quality of care metrics was generally lower among those with depression or schizophrenia, and often higher among those with increasing levels of medical comorbidities. A number of exceptions to these trends were noted. CONCLUSIONS: Cancer screening and single-disease quality measures may provide a benchmark for overall quality of care for persons with MCC; these measures were generally lower among persons with MCC and mental illness. Further research on quality measures that better reflect the complex care received by persons with MCC is essential.

Use of medical homes by patients with comorbid physical and severe mental illness.

BACKGROUND: Patients with comorbid severe mental illness (SMI) may use primary care medical homes differently than other patients with multiple chronic conditions (MCC). OBJECTIVE: To compare medical home use among patients with comorbid SMI to use among those with only chronic physical comorbidities. RESEARCH DESIGN: We examined data on children and adults with MCC for fiscal years 2008-2010, using generalized estimating equations to assess associations between SMI (major depressive disorder or psychosis) and medical home use. SUBJECTS: Medicaid and medical home enrolled children (age, 6-17 y) and adults (age, 18-64 y) in North Carolina with ≥2 of the following chronic health conditions: major depressive disorder, psychosis, hypertension, diabetes, hyperlipidemia, seizure disorder, asthma, and chronic obstructive pulmonary disease. MEASURES: We examined annual medical home participation (≥1 visit to the medical home) among enrollees and utilization (number of medical home visits) among participants. RESULTS: Compared with patients without depression or psychosis, children and adults with psychosis had lower rates of medical home participation (-12.2 and -8.2 percentage points, respectively, P<0.01) and lower utilization (-0.92 and -1.02 visits, respectively, P<0.01). Children with depression had lower participation than children without depression or psychosis (-5.0 percentage points, P<0.05). Participation and utilization among adults with depression was comparable with use among adults without depression or psychosis (P>0.05). CONCLUSIONS: Overall, medical home use was relatively high for Medicaid enrollees with MCC, though it was somewhat lower among those with SMI. Targeted strategies may be required to increase medical home participation and utilization among SMI patients.

Health care savings with the patient-centered medical home: Community Care of North Carolina's experience.

This study evaluated the financial impact of integrating a systemic care management intervention program (Community Care of North Carolina) with person-centered medical homes throughout North Carolina for non-elderly Medicaid recipients with disabilities during almost 5 years of program history. It examined Medicaid claims for 169,676 non-elderly Medicaid recipients with disabilities from January 2007 through third quarter 2011. Two models were used to estimate the program's impact on cost, within each year. The first employed a mixed model comparing member experiences in enrolled versus unenrolled months, accounting for regional differences as fixed effects and within physician group experience as random effects. The second was a pre-post, intervention/comparison group, difference-in-differences mixed model, which directly matched cohort samples of enrolled and unenrolled members on strata of preenrollment pharmacy use, race, age, year, months in pre-post periods, health status, and behavioral health history. The study team found significant cost avoidance associated with program enrollment for the non-elderly disabled population after the first years, savings that increased with length of time in the program. The impact of the program was greater in persons with multiple chronic disease conditions. By providing targeted care management interventions, aligned with person-centered medical homes, the Community Care of North Carolina program achieved significant savings for a high-risk population in the North Carolina Medicaid program.

Transitional care cut hospital readmissions for North Carolina Medicaid patients with complex chronic conditions.

Recurrent hospitalizations represent a substantial and often preventable human and financial burden in the United States. In 2008 North Carolina initiated a statewide population-based transitional care initiative to prevent recurrent hospitalizations among high-risk Medicaid recipients with complex chronic medical conditions. In a study of patients hospitalized during 2010-11, we found that those who received transitional care were 20 percent less likely to experience a readmission during the subsequent year, compared to clinically similar patients who received usual care. Benefits of the intervention were greatest among patients with the highest readmission risk. One readmission was averted for every six patients who received transitional care services and one for every three of the highest-risk patients. This study suggests that locally embedded, targeted care coordination interventions can effectively reduce hospitalizations for high-risk populations.