Human Services and Behavioral Health Integration: A Model for Whole-Person Medicaid Managed Care.

A comprehensive, whole-person approach to individuals' health care can be achieved by aligning, integrating, and coordinating health services with other human services. HealthChoices, Pennsylvania's managed Medicaid program, delegates responsibility for Medicaid-funded behavioral health service management to individual counties or multicounty collaboratives. County administrators' programmatic and fiscal oversight of Medicaid-funded services allows them to create synergies between behavioral health and other human service delivery systems and to set priorities on the basis of local needs. This model supports access to community-based care, integration of general medical and behavioral health services, and programs that address social determinants of health.

Mobilizing a region to redesign a local system of care: lessons from a community-based learning collaborative.

Local efforts to redesign systems of care offer fertile ground for community-based participatory research approaches to take hold and flourish. Drawing on the experiences of a learning collaborative of maternal and child healthcare stakeholders in Allegheny County, Pennsylvania, this article describes 8 action steps for operationalizing key community-based participatory research principles in the context of local systems change. Highlights of the subsequent evolution of the collaborative and its work are provided, as well as comments regarding the generalizability and usefulness of this approach for other public health and community stakeholders who are interested in mobilizing collaborative action for systems change.

Impact of Physician Referral to Health Coaching on Patient Engagement and Health Risks: An Observational Study of UPMC's Prescription for Wellness.

PURPOSE: Evaluate impact of physician referral to health coaching on patient engagement and health risk reduction. DESIGN: Four-year retrospective, observational cohort study with propensity-matched pair comparisons. SETTING: Integrated delivery and finance system in Pittsburgh, Pennsylvania. SAMPLE: 10 457 adult insured members referred to health coaching by their physician; 37 864 other members identified for health coaching through insurer-initiated outreach. INTERVENTION: Practice-based, technology-supported workflow and process for physician prescribing of health coaching during regular office visit, with follow-up on patient's progress and implementation supports. MEASURES: Patient engagement based on completion of pre-enrollment assessment, formal enrollment in health coaching, completion of required sessions, health risk levels, and number of health risks pre- and post-health coaching referral. ANALYSIS: Difference-in-difference analysis to assess change in health risk levels and number of health risks pre- and post-health coaching and probability weighting to control for potential confounding between groups. RESULTS: Members referred by a physician were significantly more likely to enroll in a health coaching program (21.0% vs 6.0%, P < .001) and complete the program requirements (8.5% vs 2.7%, P < .001) than when referred by insurer-initiated outreach; significant within group improvement in health risk levels from baseline (P < .001) was observed for both the groups. CONCLUSIONS: Patients are significantly more likely to engage in health coaching when a referral is made by a physician; engagement in health coaching significantly improves health risk levels.

Using health information technology-related performance measures and tools to improve chronic care.

BACKGROUND: The American Medical Association led a collaborative initiative to explore opportunities for improving the quality of outpatient chronic care through the use of nationally endorsed clinical performance measures and tools. The measures and tools focused on adult diabetes, major depressive disorder, chronic stable coronary artery disease, heart failure, hypertension, and asthma. METHODS: The RAND Corporation conducted an independent, formative assessment of the initiative's four pilot activities using the Context-Input-Process-Product evaluation model. RESULTS: Pilots 1 and 2 demonstrated the feasibility and value of implementing performance measures and tools in practices with electronic health information systems, while highlighting the difficulty of using them in practices with paper-based systems and in community-based models, where multiple stakeholders are expected to share patient data. Pilot 3 illustrated the usefulness of validating performance measures before their use for internal quality improvement or external reporting. Pilot 4 documented the challenges involved in exporting clinical performance data from a physician practice to external entities for multiple potential uses. DISCUSSION: Improving the quality of chronic care through clinical performance measurement, data aggregation, and reporting will require expanded use of clinical performance measures for both internal quality improvement and pay-for-performance; integrating electronic health records (EHRs) or electronic-based registries into more physician offices; more accurate measurement and documentation of diagnoses and care procedures; EHR products that make it easier to capture certain types of information; and simplified, standardized processes for performance data extraction and exporting.

Advancing institutional efforts to support research mentorship: a conceptual framework and self-assessment tool.

The purpose of this article is to assist institutions in advancing their efforts to support research mentorship. The authors begin by describing how institutions can shape the key domains of research mentorship: (1) the criteria for selecting mentors, (2) incentives for motivating faculty to serve effectively as mentors, (3) factors that facilitate the mentor-mentee relationship, (4) factors that strengthen a mentee's ability to conduct research responsibly, and (5) factors that contribute to the professional development of both mentees and mentors. On the basis of a conceptual analysis of these domains as currently documented in the literature, as well as their collective experience examining mentoring programs at a range of academic medicine institutions and departments, the authors provide a framework that leaders of institutions and/or departments can adapt for use as a tool to document and monitor policies for guiding the mentorship process, the programs/activities through which these policies are implemented, and the structures that are responsible for maintaining policies and implementing programs. The authors provide an example of how one hypothetical institution might use the self-assessment tool to track its policies, programs, and structures across the key domains of research mentorship and, on the basis of this information, identify a range of potential actions to strengthen its research mentoring efforts. The authors conclude with a brief discussion of the limitations of the self-assessment tool, the potential drawbacks and benefits of the overall approach, and proposed next steps for research in this area.

Delivering on the value proposition of precision medicine: the view from healthcare payers.

A long-held assumption and expectation has been that genomics-based precision medicine will provide clinicians with the tools and therapies they need to consistently deliver the right treatment to the right patient while simultaneously reducing waste and yielding cost savings for health systems. The pace of discovery within the field of precision medicine has been remarkable, yet optimal uptake of new genetic tests and genetically targeted therapies will occur only if payers recognize their value and opt to cover them. Coverage decisions require clear evidence of clinical effectiveness and utility and an understanding of how adoption will impact healthcare costs and utilization within a payer's network. Research in precision medicine has often not considered the payer's perspective, and despite demonstrations of clinical effectiveness for many promising precision medicine innovations, coverage determinations have been deferred because relevant findings that payers can use to make informed decisions are lacking. Collaboration among payers, scientists, and clinicians is essential for accelerating uptake and value creation. By pairing clinical outcomes with claims and cost data and collaboratively conducting well-designed pragmatic clinical or observational studies, all stakeholders can learn from more meaningful and relevant outcomes. In turn, there will be a collective understanding of how precision medicine innovations impact the health of populations and care delivery within healthcare systems.

Pittsburgh Regional Healthcare Initiative: a systems approach for achieving perfect patient care.

The Pittsburgh Regional Healthcare Initiative (PRHI) is an innovative model for health system change based on regionwide shared learning. By linking patient outcomes data with processes of care and sharing that information widely, PRHI supports measurable improvements in regionwide clinical practice and patient safety. In addition, through the redesign of problem solving at the front lines of care, PRHI helps health care organizations to evolve toward becoming sustainable systems of perfect patient care. This paper describes PRHI's design for change, reviews the progress and limitations of the shared learning model, and offers a set of broader policy considerations.

Using decision trees to manage hospital readmission risk for acute myocardial infarction, heart failure, and pneumonia.

To improve healthcare quality and reduce costs, the Affordable Care Act places hospitals at financial risk for excessive readmissions associated with acute myocardial infarction (AMI), heart failure (HF), and pneumonia (PN). Although predictive analytics is increasingly looked to as a means for measuring, comparing, and managing this risk, many modeling tools require data inputs that are not readily available and/or additional resources to yield actionable information. This article demonstrates how hospitals and clinicians can use their own structured discharge data to create decision trees that produce highly transparent, clinically relevant decision rules for better managing readmission risk associated with AMI, HF, and PN. For illustrative purposes, basic decision trees are trained and tested using publically available data from the California State Inpatient Databases and an open-source statistical package. As expected, these simple models perform less well than other more sophisticated tools, with areas under the receiver operating characteristic (ROC) curve (or AUC) of 0.612, 0.583, and 0.650, respectively, but achieve a lift of at least 1.5 or greater for higher-risk patients with any of the three conditions. More importantly, they are shown to offer substantial advantages in terms of transparency and interpretability, comprehensiveness, and adaptability. By enabling hospitals and clinicians to identify important factors associated with readmissions, target subgroups of patients at both high and low risk, and design and implement interventions that are appropriate to the risk levels observed, decision trees serve as an ideal application for addressing the challenge of reducing hospital readmissions.

UPMC MyHealth: managing the health and costs of U.S. healthcare workers.

BACKGROUND: Workplace wellness programs hold promise for managing the health and costs of the U.S. workforce. These programs have not been rigorously tested in healthcare worksites. PURPOSE: To evaluate the impact of MyHealth on the health and costs of UPMC healthcare workers. DESIGN: Five-year observational study conducted in 2013 with subgroup analyses and propensity-matched pair comparisons to more accurately interpret program effects. SETTING/PARTICIPANTS: UPMC, an integrated health care delivery and financing system headquartered in Pittsburgh, Pennsylvania. Participants included 13,627 UPMC employees who were continuously enrolled in UPMC-sponsored health insurance during the study period and demonstrated participation in MyHealth by completing a Health Risk Assessment in both 2007 and 2011, as well as 4,448 other healthcare workers employed outside of UPMC who did not participate in the program. INTERVENTION: A comprehensive wellness, prevention, and chronic disease management program that ties achievement of health and wellness requirements to receipt of an annual credit on participants' health insurance deductible. MAIN OUTCOME MEASURES: Health-risk levels, medical, pharmacy, and total healthcare costs, and Healthcare Effectiveness Data and Information Set performance rates for prevention and chronic disease management. RESULTS: Significant improvements in health-risk status and increases in use of preventive and chronic disease management services were observed in the intervention group. Although total healthcare costs increased significantly, reductions in costs were significant for those who moved from higher- to the lowest-risk levels. The contrast differences in costs between reduced- and maintained-risk groups was also significant. Matched pair comparisons provided further evidence of program effects on observed reductions in costs and improvements in prevention, but not improvements in chronic disease management. CONCLUSIONS: Incorporating incentivized health management strategies in employer-sponsored health insurance benefit designs can serve as a useful, though not sufficient, tool for managing the health and costs of the U.S. healthcare workforce.

Mentorship in the context of interdisciplinary geriatric research: lessons learned from the RAND/Hartford Program for Building Interdisciplinary Geriatric Research Centers.

In light of the growing trend toward formalized research mentorship for effectively transmitting the values, standards, and practices of science from one generation of researchers to the next, this article provides the results of an exploratory study. It reports on research mentorship in the context of interdisciplinary geriatric research based on experiences with the RAND/Hartford Program for Building Interdisciplinary Geriatric Research Centers. At the end of the 2-year funding period, staff from the RAND Coordinating Center conducted 60- to 90-minute open-ended telephone interviews with the co-directors of the seven centers. Questions focused on interdisciplinary mentorship activities, barriers to implementing these activities, and strategies for overcoming them, as well as a self-assessment tool with regard to programs, policies, and structures across five domains, developed to encourage research mentorship. In addition, the mentees at the centers were surveyed to assess their experiences with interdisciplinary mentoring and the center. According to the interviewees, some barriers to successful interdisciplinary mentoring included the mentor's lack of time, structural support, and the lack of a clear definition of interdisciplinary research. Most centers had formal policies in place for mentor identification and limited policies on mentor incentives. Mentees uniformly reported their relationships with their mentors as positive. More than 50% of mentees reported having a primary mentor from within their discipline and had more contact with their primary mentor than their secondary mentors. Further research is needed to understand the complexity of institutional levers that emerging programs might employ to encourage and support research mentorship.

Building Bridges: Lessons from a Pittsburgh Partnership to Strengthen Systems of Care for Maternal Depression.

Between January 2007 and June 2010, members of the Allegheny County Maternal and Child Health Care Collaborative designed, implemented, and evaluated the Allegheny County Maternal Depression Initiative, a local system-change effort focused on increasing identification, referrals, and engagement in treatment as needed and appropriate for women at high risk for maternal depression. The collaborative was successful in improving key organizational and clinical processes related to the achievement of its aims. This article describes how and why the initiative was created, the processes through which it was implemented and evaluated, and the results and lessons learned. It concludes with recommendations in four areas for practice and policy change designed to expand and sustain the initiative's achievements: improve identification of maternal depression, enhance access to available resources and services, increase engagement in behavioral health treatment, and improve overall system performance.

Potential benefits of health information technology for integrating physical and behavioral health care: perinatal depression as a case-in-point.

Depression among pregnant and postpartum women (i.e., perinatal depression) is the number one complication of childbirth. The Allegheny County Maternal Depression Initiative aimed to bridge gaps between physical and behavioral health care and improve the capacity of local systems of care for identifying and treating women at high risk for perinatal depression. To achieve these goals, the collaborative adopted a community-based model of systems change focused on women enrolled in the local Medicaid managed care system. Although the systems change protocol included a number of strategies for enhancing communication at all levels of care, variations in health information technology (HIT) capacities and/or capabilities across initiative partners frequently prevented optimal implementation of these strategies. Here, we present an overview of the results of the initiative, share insights from the collaborative regarding how HIT could have improved those results, and offer recommendations related to ways to effectively leverage HIT to integrate physical and behavioral health care.

From community-based pilot testing to region-wide systems change: lessons from a local quality improvement collaborative.

BACKGROUND: A community-based collaborative conducted a 2-year pilot study to inform efforts for improving maternal and child health care practice and policy in Allegheny County, Pennsylvania. OBJECTIVES: (1) To test whether three small-scale versions of an evidence-based, systems improvement approach would be workable in local community settings and (2) to identify specific policy/infrastructure reforms for sustaining improvements. METHODS: A mixed methods approach was used, including quantitative performance measurement supplemented with qualitative data about factors related to outcomes of interest, as well as key stakeholder interviews and a literature review/Internet search. RESULTS: Quantitative performance results varied; qualitative data revealed critical factors for the success and failure of the practices tested. Policy/infrastructure recommendations were developed to address specific practice barriers. This information was important for designing a region-wide quality improvement initiative focused on maternal depression. CONCLUSION: The processes and outcomes provide valuable insights for other communities interested in conducting similar quality improvement initiatives.

Transforming mental healthcare in the Veterans Health Administration: a model for measuring performance to improve access, quality, and outcomes.

In this paper we present the conceptual framework and research design of a national evaluation of the quality of mental healthcare provided to veterans by the Veterans Health Administration, and present results on the reported availability of evidence-based practices. We used the Donabedian paradigm to design a longitudinal evaluation of the quality of mental healthcare. To evaluate the structure of care we used a combination of survey and administrative data and designed a web-based facility survey to examine the availability and characteristics of 12 evidence-based practices and other mental health services. We identified 138 unique facilities that provided mental healthcare to 783,280 veterans. With the exception of opiate substitution therapies, every evidence-based practice was reported in at least one location in each service network. We use maps to estimate the maximum number of veterans that might benefit from expanding the availability of an evidence-based practice. We demonstrate the feasibility of overcoming several major challenges typically associated with measuring the quality of healthcare systems. This framework for evaluation of mental healthcare delivery provides a model upon which other stakeholders can continue to build and expand.

Applying the institute of medicine quality chasm framework to improving health care for mental and substance use conditions.

This article describes the two major phenomena that shaped the overall findings of the Institute of Medicine report Improving the Quality of Health Care for Mental and Substance Use Conditions and that informed its overarching recommendations. These phenomena are (1) the co-occurrence of mental health, substance use, and general health conditions; and (2) differences in the delivery of services for mental health/substance use and general health care. It describes efforts currently underway that address these differences and might significantly improve delivery and outcomes of mental health/substance use services.

Focus on alcohol & drug abuse: improving service delivery for individuals with co-occurring disorders: new perspectives on the quadrant model.

This column summarizes findings of a study that examined the usefulness of the quadrant model for improving service delivery for persons with co-occurring disorders. The authors discuss treatment recommendations, goals and barriers related to delivering care, policy recommendations for implementing evidence-based interventions, and strengths and limitations of the model. They conclude that although the quadrant model is useful for conceptualizing systems-level factors for improving delivery, its further development is unlikely to result in improved care at the clinical level. They call for research to develop and implement evidence-based practices targeted to specific populations of persons with co-occurring disorders.

RAND/Hartford initiative to build interdisciplinary geriatric health care research centers.

A RAND/John A. Hartford Foundation initiative, Building Interdisciplinary Geriatric Health Care Research Centers, seeks to promote such research through developing innovative clinical and health services interventions. Interdisciplinary education, mentoring, and training opportunities, particularly for junior investigators, are the critical components necessary to foster multiprofessional research endeavors.

Emotional and behavioral consequences of bioterrorism: planning a public health response.

Millions of dollars have been spent improving the public health system's bioterrorism response capabilities. Yet relatively little attention has been paid to precisely how the public will respond to bioterrorism and how emotional and behavioral responses might complicate an otherwise successful response. This article synthesizes the available evidence about the likely emotional and behavioral consequences of bioterrorism to suggest what decision makers can do now to improve that response. It examines the emotional and behavioral impact of previous "bioterrorism-like" events and summarizes interviews with experts who have responded to such events or conducted research on the effects of community-wide disasters. The article concludes by reflecting on the evidence and experts' perspectives to suggest actions to be taken now and future policy and research priorities.