The association between care management and neonatal outcomes: the role of a Medicaid-managed pregnancy medical home in North Carolina.

BACKGROUND: Preterm birth is a significant clinical and public health issue in the United States. Rates of preterm birth have remained unchanged, and racial disparities persist. Although a causal pathway has not yet been defined, it is likely that a multitude of clinical and social risk factors contribute to a pregnant person's risk. State-based public health and provider programmatic partnerships have the potential to improve care during pregnancy and reduce complications, such as preterm birth. In North Carolina, a state-based Medicaid-managed Pregnancy Medical Home Program screens pregnant individuals for psychosocial and medical risk factors and utilizes community-based care management, to offer support to those at highest risk. OBJECTIVE: This study aimed to examine the association between care-management and birth outcomes (low birthweight and preterm birth rates) among high-risk non-Hispanic White and Black pregnant people enrolled in the North Carolina Pregnancy Medical Home. STUDY DESIGN: This was a quasi-experimental study of people in the Medicaid-managed North Carolina Pregnancy Medical Home who had singleton pregnancies and who enrolled in the program between January 2016 and December 2017. Black and White pregnant people were included in the analysis if they had singleton pregnancies, were enrolled in the Pregnancy Medical Home, and for whom there were data regarding care management involvement. Preterm birth and low birthweight were chosen as the outcomes of interest. Two different methodologies were used to test the effect of care management on outcomes: Method 1 evaluated the effect of intensive care management (≥5 face-to-face visits from a care manager) and Method 2 evaluated the effect of the implementation of a specific risk-stratification system. Chi-squared and multivariate logistic regressions were performed as appropriate. RESULTS: From January 1, 2016 to December 31, 2017, a total of 3564 singleton pregnancies occurred among non-Hispanic Black and White pregnant Medicaid beneficiaries, who were a part of the Pregnancy Medical Home in North Carolina. White pregnant people comprised 57% and Black pregnant people comprised 43% of the sample. In the Method 1 analysis, intensive care management was significantly associated with reductions in preterm birth and low birthweight among Black and White pregnant people whereas in the Method 2 analysis, the implementation of a risk-stratification score only resulted in a significant reduction among Black pregnant people. In multivariable logistic modeling, race, number of prenatal visits, and intensive care management were all significantly associated with the outcomes of interest. CONCLUSION: Care management is associated with reductions in preterm birth and low birthweight in the Medicaid-managed Pregnancy Medical Home in North Carolina. This study contributes to a growing body of literature on the role of state-based initiatives in reducing perinatal morbidity. These results are significant as it demonstrates the importance of care coordination and management, in identifying and providing resources for high-risk pregnant people. In the United States, where pregnancy-related outcomes are poor, programs that address the multitude of economic, social, and clinical complexities are becoming increasingly crucial and necessary.

Randomized trial comparing caregiver-only family-focused treatment to standard health education on the 6-month outcome of bipolar disorder.

OBJECTIVES: Caregivers of people with bipolar disorder often have depression and health problems. This study aimed to evaluate the sustained effects of a 12-15 week psychoeducational intervention on the health and mental health of caregivers of persons with bipolar disorder. We also evaluated the effects of the intervention on patients' mood symptoms over 6 months post-treatment. METHODS: Caregivers of 46 persons with bipolar disorder were randomized to 12-15 weeks of a caregiver-only adaptation of family-focused treatment (FFT), in which caregivers were instructed on self-care strategies and ways to assist the patient in managing the illness, or to 8-12 sessions of standard health education. Independent evaluators assessed caregivers' depression and physical health and patients' mood symptoms before treatment, immediately after the treatment, and at 6 months post-treatment. RESULTS: Randomization to FFT was associated with greater decreases in depression for both caregivers and patients over a 6-month follow-up period post-treatment. Reductions in patients' depression scores over 6 months post-treatment were mediated by reductions in caregivers' depression scores (z = -2.74, P < .01). CONCLUSIONS: Interventions that are effective in reducing mood symptoms and improving health behavior in caregivers may have important health and mental health benefits for patients with bipolar disorder. Specifically, a treatment focused on caregiver education about bipolar disorder and the need for the caregiver to attend to his/her own health and mental health can benefit patients, even without their direct participation.

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.

Readmission Patterns and Effectiveness of Transitional Care Among Medicaid Patients With Schizophrenia and Medical Comorbidity.

BACKGROUND: Patients with chronic medical and mental health comorbidities are at increased risk of hospital admission, but little is known about their hospital utilization patterns or whether nurse-directed transitional care interventions have any appreciable impact on future hospitalizations. METHOD: Using paid Medicaid claims and a care management database, we examined patterns of hospital utilization for adults with multiple chronic conditions where one of the conditions was schizophrenia. Patients were enrolled in Community Care of North Carolina's medical home program and were discharged from 100 different hospitals throughout the state from July 1, 2010 through June 30, 2011. We examined readmission rates after psychiatric and nonpsychiatric hospital discharges, and we compared patients who received community-based, nurse-directed, transitional care management services to patients who received usual care. RESULTS: A total of 1,717 patients were included in the final analysis. Patients in this study experienced 980 readmissions over the course of 1 year, with 20% of readmissions for a different reason than the primary hospitalization, and 36% of readmissions occurring at a different hospital. Controlling for demographic, clinical, and hospital characteristics, patients receiving transitional care (n = 1,104) were as much as 30% less likely to experience a readmission during the year following discharge compared to patients receiving usual care (n = 613). LIMITATIONS: This descriptive study reports on a nonrandomized intervention and its impact on service utilization for Medicaid patients with complex illnesses in North Carolina. CONCLUSIONS: Regardless of the reason for hospitalization, patients with chronic medical and psychiatric conditions may benefit from transitional care support that addresses both conditions. This holds true even when the patient is already receiving intensive outpatient psychiatric care.

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.

With "big data" comes big responsibility: outreach to North Carolina Medicaid patients with 10 or more computed tomography scans in 12 months.

BACKGROUND: Patients are being exposed to increasing levels of ionizing radiation, much of it from computed tomography (CT) scans. METHODS: Adults without a cancer diagnosis who received 10 or more CT scans in 2010 were identified from North Carolina Medicaid claims data and were sent a letter in July 2011 informing them of their radiation exposure; those who had undergone 20 or more CT scans in 2010 were also telephoned. The CT scan exposure of these high-exposure patients during the 12 months following these interventions was compared with that of adult Medicaid patients without cancer who had at least 1 CT scan but were not in the intervention population. RESULTS: The average number of CT scans per month for the high-exposure population decreased over time, but most of that reduction occurred 6-9 months before our interventions took place. At about the same time, the number of CT scans per month also decreased in adult Medicaid patients without cancer who had at least 1 CT scan but were not in the intervention population. LIMITATIONS: Our data do not include information about CT scans that may have been performed during times when patients were not covered by Medicaid. Some of our letters may not have been received or understood. Some high-exposure patients were unintentionally excluded from our study because organization of data on Medicaid claims varies by setting of care. CONCLUSION: Our patient education intervention was not temporally associated with significant decreases in subsequent CT exposure. Effecting behavior change to reduce exposure to ionizing radiation requires more than an educational letter or telephone call.

Niños Sanos, Familia Sana: Mexican immigrant study protocol for a multifaceted CBPR intervention to combat childhood obesity in two rural California towns.

BACKGROUND: Overweight and obese children are likely to develop serious health problems. Among children in the U.S., Latino children are affected disproportionally by the obesity epidemic. Niños Sanos, Familia Sana (Healthy Children, Healthy Family) is a five-year, multi-faceted intervention study to decrease the rate of BMI growth in Mexican origin children in California's Central Valley. This paper describes the methodology applied to develop and launch the study. METHODS/DESIGN: Investigators use a community-based participatory research approach to develop a quasi-experimental intervention consisting of four main components including nutrition, physical activity, economic and art-community engagement. Each component's definition, method of delivery, data collection and evaluation are described. Strategies to maintain engagement of the comparison community are reported as well. DISCUSSION: We present a study methodology for an obesity prevention intervention in communities with unique environmental conditions due to rural and isolated location, limited infrastructure capacity and limited resources. This combined with numerous cultural considerations and an unstable population with limited exposure to researcher expectations necessitates reassessment and adaptation of recruitment strategies, intervention delivery and data collection methods. Trial registration # NCT01900613. TRIAL REGISTRATION: NCT01900613.

Implementation of a weight loss program for Latino outpatients with severe mental illness.

To determine feasibility of implementation of a weight loss program for overweight Latinos with severe mental illness. In this quasi-experimental study, a 14-week behavioral weight loss course (extended) was implemented at one clinic. A one-time nutrition class (brief) was given at a sister clinic. Implementation feasibility was assessed by consent and participation rates. Weight was followed for 6 months. Consent rates were high [77 % (49/64) extended; 68 % (39/57) brief], and 88 % (43/49) of extended subjects participated and 88 % (38/43) completed follow-up. Weight loss did not differ between groups. A behavioral weight loss course is feasible to implement for this population.

Collaborative accountability for care transitions: the community care of North Carolina transitions program.

Community Care of North Carolina initiated efforts to improve care transitions for North Carolina Medicaid recipients in 2008. The transitions program is now statewide, serving more than 4,000 patients every month, virtually every North Carolina hospital, and more than 1,400 primary care practices. This commentary describes program components, early outcomes, and future challenges.

High Rates of Multimorbidity Reported Among People of Color Despite Healthy Weight.

Purpose: Weight management is one of the most cited levers for preventing and managing many chronic conditions, particularly those considered to be "lifestyle modifiable." However, it is unclear how much weight is a driver of illness burden among people of color. This article sought to examine whether people of color are more likely to develop "lifestyle-modifiable" conditions, including diabetes, kidney disease, heart disease, lung disease, and hypertension, both individually and in combination (multimorbidity), in the absence of being obese. Methods: Using data from the 2019 Behavioral Risk Factors Surveillance System survey, we examined the risk of having these conditions among Black, Asian, Native American, Latino/a, and White respondents who reported being "normal weight" (n=86,682), while also controlling for age, gender, smoking history, physical activity, and diet. Results: For each individual condition, White respondents almost always had the lowest risk. On the other hand, Latino/a respondents had the highest rates of diabetes and kidney disease. Native American respondents had the highest rates of heart and lung disease. Black respondents had the highest rates of hypertension. Despite an otherwise healthy weight, Native American, Black, and Latino/a people were 2.5, 2.3, and 1.8 times, respectively, more likely to develop multiple chronic conditions that are typically considered "lifestyle modifiable," compared to White people. Conclusion: Disease prevention and management guidelines driven by the clinical experience of White people are insufficient for addressing the considerable illness burden that people of color continue to experience.

Does assertive community treatment increase medication adherence for people with co-occurring psychotic and substance use disorders?

OBJECTIVE: This study analyzed data from a randomized trial to examine the impact on medication adherence of integrated treatment delivered via assertive community treatment (ACT) versus standard clinical case management (SCCM). METHOD: Data from the original study included 198 study participants with co-occurring psychotic and substance use disorders who were randomly assigned to receive integrated treatment via ACT or SCCM and were followed for 3 years. We applied mixed-effects logistic regression to estimate group (ACT vs. SCCM) by time effects on a self-report measure of medication adherence. Adherence was dichotomized as 20% or more missed medication days ("poor adherence") versus less than 20% missed medication days ("adequate adherence"). RESULTS: Participants who were assigned to ACT reported significant improvement in medication adherence compared with those assigned to SCCM. CONCLUSIONS: Integrated treatment delivered via ACT may benefit persons with co-occurring psychotic and substance use disorders who are poorly adherent to medications.

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.

How should we implement psychiatric advance directives? Views of consumers, caregivers, mental health providers and researchers.

The aim of this study was to measure expert consensus on the implementation of Psychiatric Advance Directives (PADs) within the Veterans Health Administration. We conducted a two-round Delphi study with 55 panelists including consumers, caregivers, mental health providers and researchers. For a number of items where no positive or negative consensus was reached we found differences between the views of consumers and non-consumers, reflecting consumer's preferences for nonmedical settings for completion and assistance with completion independent of the treatment team. Thus, the principle of consumer choice that applies to MHAD content should also be applied to the process of completion offered.

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.

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.

Antipsychotic adherence and emergency department utilization among patients with schizophrenia.

This retrospective cohort study evaluated the relationship between antipsychotic medication adherence and emergency department (ED) utilization for 7851 Medicaid patients with schizophrenia enrolled in Community Care of North Carolina (CCNC). Claims and pharmacy data from January to December 2015 were collected. Medication adherence was approximated using the medication possession ratio (MPR). Negative binomial regressions estimated the effect of antipsychotic adherence on rates of medical and psychiatric ED visits. The results demonstrated a statistically significant negative relationship between antipsychotic adherence and medical ED utilization. Non- and partially adherent patients (MPR < 0.80) had 1.61 times the rate of medical ED visits as fully adherent patients (MPR ≥ 0.80) (95% CI: 1.50-1.74, p-value < 0.001). The relationship between adherence and psychiatric utilization was small and not statistically significant. The most common diagnostic categories of ED visits were injuries and poisonings (16%), ill-defined symptoms (14%), and musculoskeletal conditions (12%). This study demonstrates a clear association between antipsychotic adherence and medical ED utilization, suggesting an important link between psychiatric management and medical utilization in patients with schizophrenia.

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.

Relationship between diabetes and mortality among persons with co-occurring psychotic and substance use disorders.

OBJECTIVE: Individuals with diabetes and individuals with serious mental illness are more likely than the general population to die prematurely. The study examined the impact of diabetes on mortality among 197 individuals with co-occurring psychotic and substance use disorders who participated in a randomized controlled study of integrated mental health and substance abuse treatment. METHODS: The authors examined Medicaid claims for evidence of diabetes and applied survival analyses to examine whether time from study entry until death was different for individuals with and without evidence of diabetes. RESULTS: Of individuals with co-occurring psychotic and substance use disorders, 21% had evidence of diabetes. In a 12-year period, 41% of those with evidence of diabetes died compared with 10% of those without evidence of diabetes. CONCLUSIONS: Interventions targeted for diabetes prevention and diabetes management are critical for persons with serious mental illness, particularly among those who also abuse substances.

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.