Barriers and Facilitators to Establishing Partnerships for Substance Use Disorder Care Transitions Between Safety-Net Hospitals and Community-Based Organizations.

BACKGROUND: The effectiveness of hospital-based transitional opioid programs (TOPs), which aim to connect patients with substance use disorders (SUD) to ongoing treatment in the community following initiation of medication for opioid use disorder (MOUD) treatment in the hospital, hinges on successful patient transitions. These transitions are enabled by strong partnerships between hospitals and community-based organizations (CBOs). However, no prior study has specifically examined barriers and facilitators to establishing SUD care transition partnerships between hospitals and CBOs. OBJECTIVE: To identify barriers and facilitators to developing partnerships between hospitals and CBOs to facilitate care transitions for patients with SUDs. DESIGN: Qualitative study using semi structured interviews conducted between November 2022-August 2023. PARTICIPANTS: Staff and providers from hospitals affiliated with four safety-net health systems (n=21), and leaders and staff from the CBOs with which they had established partnerships (n=5). APPROACH: Interview questions focused on barriers and facilitators to implementing TOPs, developing partnerships with CBOs, and successfully transitioning SUD patients from hospital settings to CBOs. KEY RESULTS: We identified four key barriers to establishing transition partnerships: policy and philosophical differences between organizations, ineffective communication, limited trust, and a lack of connectivity between data systems. We also identified three facilitators to partnership development: strategies focused on building partnership quality, strategic staffing, and organizing partnership processes. CONCLUSIONS: Our findings demonstrate that while multiple barriers to developing hospital-CBO partnerships exist, stakeholders can adopt implementation strategies that mitigate these challenges such as using mediators, cross-hiring, and focusing on mutually beneficial services, even within resource-limited safety-net settings. Policymakers and health system leaders who wish to optimize TOPs in their facilities should focus on adopting implementation strategies to support transition partnerships such as inadequate data collection and sharing systems.

An observational, sequential analysis of the relationship between local economic distress and inequities in health outcomes, clinical care, health behaviors, and social determinants of health.

BACKGROUND: Socioeconomic status has long been associated with population health and health outcomes. While ameliorating social determinants of health may improve health, identifying and targeting areas where feasible interventions are most needed would help improve health equity. We sought to identify inequities in health and social determinants of health (SDOH) associated with local economic distress at the county-level. METHODS: For 3,131 counties in the 50 US states and Washington, DC (wherein approximately 325,711,203 people lived in 2019), we conducted a retrospective analysis of county-level data collected from County Health Rankings in two periods (centering around 2015 and 2019). We used ANOVA to compare thirty-three measures across five health and SDOH domains (Health Outcomes, Clinical Care, Health Behaviors, Physical Environment, and Social and Economic Factors) that were available in both periods, changes in measures between periods, and ratios of measures for the least to most prosperous counties across county-level prosperity quintiles, based on the Economic Innovation Group's 2015-2019 Distressed Community Index Scores. RESULTS: With seven exceptions, in both periods, we found a worsening of values with each progression from more to less prosperous counties, with least prosperous counties having the worst values (ANOVA p < 0.001 for all measures). Between 2015 and 2019, all except six measures progressively worsened when comparing higher to lower prosperity quintiles, and gaps between the least and most prosperous counties generally widened. CONCLUSIONS: In the late 2010s, the least prosperous US counties overwhelmingly had worse values in measures of Health Outcomes, Clinical Care, Health Behaviors, the Physical Environment, and Social and Economic Factors than more prosperous counties. Between 2015 and 2019, for most measures, inequities between the least and most prosperous counties widened. Our findings suggest that local economic prosperity may serve as a proxy for health and SDOH status of the community. Policymakers and leaders in public and private sectors might use long-term, targeted economic stimuli in low prosperity counties to generate local, community health benefits for vulnerable populations. Doing so could sustainably improve health; not doing so will continue to generate poor health outcomes and ever-widening economic disparities.

Association of Medicaid expansion and 1115 waivers for substance use disorders with hospital provision of opioid use disorder services: a cross sectional study.

INTRODUCTION: Opioid-related hospitalizations have risen dramatically, placing hospitals at the frontlines of the opioid epidemic. Medicaid expansion and 1115 waivers for substance use disorders (SUDs) are two key policies aimed at expanding access to care, including opioid use disorder (OUD) services. Yet, little is known about the relationship between these policies and the availability of hospital based OUD programs. The aim of this study is to determine whether state Medicaid expansion and adoption of 1115 waivers for SUDs are associated with hospital provision of OUD programs. METHODS: We conducted a cross-sectional study of a random sample of hospitals (n = 457) from the American Hospital Association's 2015 American Hospital Directory, compiled with the most recent publicly available community health needs assessment (2015-2018). RESULTS: Controlling for hospital characteristics, overdose burden, and socio-demographic characteristics, both Medicaid policies were associated with hospital adoption of several OUD programs. Hospitals in Medicaid expansion states had significantly higher odds of implementing any program related to SUDs (OR: 1.740; 95% CI: 1.032-2.934) as well as some specific activities such as programs for OUD treatment (OR: 1.955; 95% CI: 1.245-3.070) and efforts to address social determinants of health (OR: 6.787; 95% CI: 1.308-35.20). State 1115 waivers for SUDs were not significantly associated with any hospital-based SUD activities. CONCLUSIONS: Medicaid expansion was associated with several hospital programs for addressing OUD. The differential availability of hospital-based OUD programs may indicate an added layer of disadvantage for low-income patients with SUD living in non-expansion states.

Generational differences in beliefs about COVID-19 vaccines.

Vaccine uptake variation across demographic groups remains a public health barrier to overcome the coronavirus pandemic despite substantial evidence demonstrating the effectiveness of COVID-19 vaccines against severe illness and death. Generational cohorts differ in their experience with historical and public health events, which may contribute to variation in beliefs about COVID-19 vaccines. Nationally representative longitudinal data (December 20, 2020 to July 23, 2021) from the Understanding America Study (UAS) COVID-19 tracking survey (N = 7279) and multilevel logistic regression were used to investigate whether generational cohorts differ in COVID-19 vaccine beliefs. Regression models adjusted for wave, socioeconomic and demographic characteristics, political affiliation, and trusted source of information about COVID-19. Birth-year cutoffs define the generational cohorts: Silent (1945 and earlier), Boomer (1946-1964), Gen X (1965-1980), Millennial (1981-1996), and Gen Z (1997-2012). Compared to Boomers, Silents had a lower likelihood of believing that COVID-19 vaccines have many known harmful side effects (OR = 0.52, 95%CI = 0.35-0.74) and that they may lead to illness and death (OR = 0.53, 95%CI = 0.37-0.77). Compared to Boomers, Silents had a higher likelihood of believing that the vaccines provide important benefits to society (OR = 2.27, 95%CI = 1.34-3.86) and that they are useful and effective (OR = 1.97, 95%CI = 1.17-3.30). Results for Gen Z are similar to those reported for Silents. Beliefs about COVID-19 vaccines markedly differ across generations. This is consistent with the idea of generational imprinting-the idea that some beliefs may be resistant to change through adulthood. Policy strategies other than vaccine education may be needed to overcome this pandemic and future public health challenges.

Aligning Health Care and Social Services to Reduce Hospitalizations and Emergency Department Visits: An Evaluation of the Community Care Connections Program.

BACKGROUND: Integration of social services in health care delivery is increasingly recognized as a potential strategy for improving health and reducing the use of acute care services. Collaborative models that provide older adults with case management, linkages to social services, and assistance with health care navigation have emerged as promising strategies. OBJECTIVE: The objective of this study was to evaluate the Community Care Connections (CCC) program, a cross-sector collaboration designed to align social and health care services for older adults. RESEARCH DESIGN: We compared hospitalizations and emergency department (ED) visits 90 days after enrollment with a propensity score-matched group of non-CCC patients. Subgroup analyses were also conducted for adults with hypertension, diabetes, and high cholesterol. SUBJECTS: A total of 1004 patients enrolled in CCC between June 1, 2016, and November 15, 2018, and 1004 matched patients from the same metropolitan area. MEASURES: Mean hospitalizations and ED visits per patient 90 days after CCC enrollment. RESULTS: Mean hospitalizations were lower among CCC patients 90 days after enrollment than among non-CCC adults [difference=-0.039, 95% confidence interval (CI): -0.077 to -0.001, P=0.044]. They were also lower among CCC patients with hypertension (difference=-0.057, 95% CI: -0.103 to -0.010, P=0.017). However, 90 days after enrollment mean ED visits were higher among CCC patients relative to non-CCC adults (difference=0.238, 95% CI: 0.195-0.281, P<0.001). CONCLUSIONS: Connecting older adults to social services while being served by the health care system may lead to decreases in hospitalizations. Cross-sector partnerships that address social and economic needs may reduce the use of costly health care services.

Views on the need to implement restriction policies to be able to address COVID-19 in the United States.

Several restriction policies implemented in many states in the United States have demonstrated their effectiveness in mitigating the spread of the coronavirus disease (COVID-19), but less is known about the differences in views on the restriction policies among different population segments. This study aimed to understand which different population groups of adults in the United States consider several key restriction policies as necessary to combat COVID-19. Survey data from Wave 64 (March 19-24, 2020) of the Pew Research Center's American Trends Panel (n=10,609) and logistic regression were used to evaluate the association between socioeconomic and demographic characteristics, employment status, political party affiliation, news exposure, census region, and opinions about COVID-19 restriction policies. The policies included restricting international travel, imposing business closures, banning large group gatherings, cancelling entertainment events, closing schools, limiting restaurants to carry-out only, and postponing state primary elections. Most survey respondents viewed COVID-19 restriction policies as necessary. Views on each restriction policy varied substantially across some population segments such as age, race, and ethnicity. Regardless of population segments, those who followed news closely or considered themselves Democrat/lean Democrat were more likely to consider all the policies as necessary than those not following the news closely or those who considered themselves Republican/lean Republican. The effectiveness of key COVID-19 restriction policies is likely to vary substantially across population groups given that views on the need to implement these policies vary widely. Tailored health messages may be needed for some population segments given divergent views on COVID-19 restriction policies.

A decision-making model to optimize the impact of community-based health programs.

Hospitals and clinics are increasingly interested in building partnerships with community-based organizations to address the social determinants of health. Choosing among community-based health programs can be complex given that programs may have different effectiveness levels and implementation costs. This study develops a decision-making model that can be used to evaluate multiple key factors that would be relevant in resource allocation decisions related to a set of community-based health programs. The decision-making model compares community-based health programs by considering funding limitations, program duration, and participant retention until program completion. Specifically, the model allows decision makers to select the optimal mix of community-based health programs based on the profiles of the population given the above constraints. The model can be used to improve resource allocation in communities, ultimately contributing to the long-term goal of strengthening cross-sector partnerships and the integration of services to improve health outcomes.

Aligning social and health care services: The case of Community Care Connections.

The Community Care Connections (CCC) program aims to align social and healthcare services to improve health outcomes in older adults with complex medical and social needs. This study assessed changes in healthcare utilization before and after CCC program participation. Between June 2016 and March 2019, 1214 adults with complete data who provided informed consent participated in the CCC program. CCC client data were linked with data on hospitalizations, emergency department (ED) visits, and observation stays 90 days before and after program start. Data analysis examined changes in health care utilization 90 days after program start, compared to 90 days before. Hospitalizations decreased by 30% (Change = -0.029, 95% Confidence Interval (CI) = -0.053, -0.005), ED visits decreased by 29% (Change = -0.114, 95% CI = -0.163, -0.066), and observation stays decreased by 23% (Change = -0.041, 95% CI = -0.073, -0.009) during the post period. ED visits decreased by 37% (Change = -0.140, 95% CI = -0.209, -0.070) for those with hypertension and by 30% (Change = -0.109, 95% CI = -0.199, -0.020) for those with high cholesterol, while observation stays decreased by 46% (Change = -0.118, 95% CI = -0.185, -0.052) for those with diabetes and by 44% (Change = -0.082, 95% CI = -0.150, -0.014) for those with high cholesterol during the post period. Connecting older adults with social services through the healthcare delivery system may lead to decreases in hospitalizations, ED visits, and observation stays. Implementation of cross-sector partnerships that address non-clinical factors that impact the health of older adults may reduce the use of costly healthcare services.

"Hey, We Can Do This Together": Findings from an Evaluation of a Multi-sectoral Community Coalition.

Multi-sectoral coalitions focused on systemic health inequities are commonly promoted as important mechanisms to facilitate changes with lasting impacts on population health. However, the development and implementation of such initiatives present significant challenges, and evaluation results are commonly inconclusive. In an effort to add to the evidence base, we conducted a mixed-methods evaluation of the Claremont Healthy Village Initiative, a multi-sectoral partnership based in the Bronx, New York City. At an organizational level, there were positive outcomes with respect to expanded services, increased access to resources for programs, improved linkages, better coordination, and empowerment of local leaders-all consistent with a systemic, community building approach to change. Direct impacts on community members were more difficult to assess: perceived access to health and other services improved, while community violence and poor sanitation, which were also priorities for community members, remained important challenges. Findings suggest significant progress, as well as continued need.

Effects of New York's Executive Order on Face Mask Use on COVID-19 Infections and Mortality: A Modeling Study.

There is growing evidence on the effect of face mask use in controlling the spread of COVID-19. However, few studies have examined the effect of local face mask policies on the pandemic. In this study, we developed a dynamic compartmental model of COVID-19 transmission in New York City (NYC), which was the epicenter of the COVID-19 pandemic in the USA. We used data on daily and cumulative COVID-19 infections and deaths from the NYC Department of Health and Mental Hygiene to calibrate and validate our model. We then used the model to assess the effect of the executive order on face mask use on infections and deaths due to COVID-19 in NYC. Our results showed that the executive order on face mask use was estimated to avert 99,517 (95% CIs 72,723-126,312) COVID-19 infections and 7978 (5692-10,265) deaths in NYC. If the executive order was implemented 1 week earlier (on April 10), the averted infections and deaths would be 111,475 (81,593-141,356) and 9017 (6446-11,589), respectively. If the executive order was implemented 2 weeks earlier (on April 3 when the Centers for Disease Control and Prevention recommended face mask use), the averted infections and deaths would be 128,598 (94,373-162,824) and 10,515 (7540-13,489), respectively. Our study provides public health practitioners and policymakers with evidence on the importance of implementing face mask policies in local areas as early as possible to control the spread of COVID-19 and reduce mortality.

Sleep Duration and Health Care Expenditures in the United States.

OBJECTIVE: To estimate the average incremental health care expenditures associated with habitual long and short duration of sleep as compared with healthy/average sleep duration. DATA SOURCE: Medical Expenditure Panel Survey data (2012; N=6476) linked to the 2010-2011 National Health Interview Survey. STUDY DESIGN: Annual differences in health care expenditures are estimated for habitual long and short duration sleepers as compared with average duration sleepers using 2-part logit generalized linear regression models. PRINCIPAL FINDINGS: Habitual short duration sleepers reported an additional $1400 in total unadjusted health care expenditures compared to people with average sleep duration (P<0.01). After adjusting for demographics, socioeconomic factors, and health behavior factors, this difference remained significant with an additional $1278 in total health care expenditures over average duration sleepers (P<0.05). Long duration sleepers reported even higher, $2994 additional health care expenditures over average duration sleepers. This difference in health care expenditures remained significantly high ($1500, P<0.01) in the adjusted model. Expenditure differences are more pronounced for inpatient hospitalization, office expenses, prescription expenses, and home health care expenditures. CONCLUSIONS: Habitual short and long sleep duration is associated with higher health care expenditures, which is consistent with the association between unhealthy sleep duration and poorer health outcomes.

Timely Postpartum Visits for Low-Income Women: A Health System and Medicaid Payer Partnership.

A health care system and a Medicaid payer partnered to develop an educational intervention and payment redesign program to improve timely postpartum visits for low-income, high-risk mothers in New York City between April 2015 and October 2016. The timely postpartum visit rate was higher for 363 mothers continuously enrolled in the program than for a control group matched by propensity score (67% [243/363] and 56% [407/726], respectively; P < .001). An innovative partnership between a health care system and Medicaid payer improved access to health care services and community resources for high-risk mothers.

Connecting healthcare professionals in Central America through management and leadership development: a social network analysis.

BACKGROUND: Leadership and management training has become increasingly important in the education of health care professionals. Previous research has shown the benefits that a network provides to its members, such as access to resources and information, but ideas for creating these networks vary. This study used social network analysis to explore the interactions among Central American Healthcare Initiative (CAHI) Fellowship alumni and learn more about information sharing, mentoring, and project development activities among alumni. The CAHI Fellowship provides leadership and management training for multidisciplinary healthcare professionals to reduce health inequities in the region. Access to a network was previously reported as one of the top benefits of the program. RESULTS: Information shared from the work of 100 CAHI fellows from six countries, especially within the same country, was analyzed. Mentoring relationships clustered around professions and project types, and networks of joint projects clustered by country. Mentorship, which CAHI management promoted, and joint project networks, in which members voluntarily engaged, had similar inclusiveness ratios. CONCLUSION: Social networks are strategic tools for health care leadership development programs to increase their impact by promoting interactions among participants. These programs can amplify intergenerational and intercountry ties by organizing events, provide opportunities for alumni to meet, assign mentors, and support collaborative action groups. Collaborative networks have great value to potentiate health professionals' leadership and management capabilities in a resource-constrained setting, such as the Global South.

Diabetes Management Through Remote Patient Monitoring: The Importance of Patient Activation and Engagement with the Technology.

Background: The documented efficacy and promise of telemedicine in diabetes management does not necessarily mean that it can be easily translated into clinical practice. An important barrier concerns patient activation and engagement with telemedicine technology. Objective: To assess the importance of patient activation and engagement with remote patient monitoring technology in diabetes management among patients with type 2 diabetes. Methods: Ordinary least squares and logistic regression analyses were used to examine how patient activation and engagement with remote patient monitoring technology were related to changes in hemoglobin A1c (HbA1c) for 1,354 patients with type 2 diabetes monitored remotely for 3 months between 2015 and 2017. Results: Patients with more frequent and regular participation in remote monitoring had lower HbA1c levels at the end of the program. Compared to patients who uploaded their biometric data every 2 days or less frequently, patients who maintained an average frequency of one upload per day were less likely to have a postmonitoring HbA1c > 9% after adjusting for selected covariates on baseline demographics and health conditions. Conclusions: Higher levels of patient activation and engagement with remote patient monitoring technology were associated with better glycemic control outcomes. Developing targeted interventions for different groups of patients to promote their activation and engagement levels would be important to improve the effectiveness of remote patient monitoring in diabetes management.

Cost-effectiveness analysis of intensive hypertension control in China.

China has the largest population of adults with hypertension in the world. Recent clinical trials have shown that intensive hypertension control can help patients achieve lower blood pressure and reduce the incidence of major cardiovascular disease (CVD) events, but this level of hypertension control also incurs additional costs to patients and society and may result in a substantial increase in adverse events. The objective of this study is to assess the cost-effectiveness of intensive hypertension control to inform health policymakers and health care delivery systems in China in their decision-making regarding hypertension treatment strategies. We developed a Markov based simulation model of hypertension to assess the impact of intensive and standard hypertension control strategies for the Chinese population who are diagnosed with hypertension. Model parameters were estimated based on the best available data and the literature. We projected that intensive hypertension control would avert about 2.2 million coronary heart disease events and 4.4 million stroke events for all hypertensive patients in China in 10 years compared to standard hypertension control. The incremental cost-effectiveness ratio (ICER) for intensive hypertension control was estimated at 7876 CNY per quality-adjusted life year (QALY) compared to standard hypertension control. Intensive hypertension control would be more cost-effective than standard hypertension control in China. Our findings indicated that China should consider expanding intensive hypertension control among hypertensive patients given its great potential in preventing CVD.

Assessing the role of access and price on the consumption of fruits and vegetables across New York City using agent-based modeling.

Most residents in New York City (NYC) do not consume sufficient fruits and vegetables every day. Difficulties with access and high prices of fruits and vegetables in some neighborhoods contribute to different consumption patterns across NYC neighborhoods. We developed an agent-based model (ABM) to predict dietary behaviors of individuals at the borough and neighborhood levels. Model parameters were estimated from the 2014 NYC Community Health Survey, United States Census data, and the literature. We simulated six hypothetical interventions designed to improve access and reduce the price of fruits and vegetables. We found that all interventions would lead to increases in fruit and vegetable consumption but the results vary substantially across boroughs and neighborhoods. For example, a 10% increase in the number of fruit/vegetable vendors combined with a 10% decrease in the prices of fruits and vegetables would lead to a median increase of 2.28% (range: 0.65%-4.92%) in the consumption of fruits and vegetables, depending on neighborhood. We also found that the impact of increasing the number of vendors on fruit/vegetable consumption is more pronounced in unhealthier local food environments while the impact of reducing prices on fruits/vegetable consumption is more pronounced in neighborhoods with low levels of education. An agent-based model of dietary behaviors that takes into account neighborhood context has the potential to inform how fruit/vegetable access and pricing strategies may specifically work in tandem to increase the consumption of fruits and vegetables at the local level.

Who does not reduce their sodium intake despite being advised to do so? A population segmentation analysis.

Excessive sodium intake is linked to an increased risk for hypertension and cardiovascular disease. Although health care providers and other health professionals frequently provide counseling on healthful levels of sodium consumption, many people who consume sodium in excess of recommend levels still do not watch or reduce their sodium intake. In this study, we used a population segmentation approach to identify profiles of adults who are not watching or reducing their sodium intake despite been advised to do so. We analyzed sodium intake data in 125,764 respondents sampled in 15 states, the District of Columbia and Puerto Rico through the Behavioral Risk Factor Surveillance System to identify and segment adults into subgroups according to differences in sodium intake behaviors. We found that about 16% of adults did not watch or reduce their sodium intake despite been told to do so by a health professional. This proportion varied substantially across the 25 different population subgroups identified. For example, about 44% of adults 18 to 44years of age who live in West Virginia were not reducing their sodium intake whereas only about 7.2% of black adults 65years of age and older with diabetes were not reducing their sodium intake. Population segmentation identifies subpopulations most likely to benefit from targeted and intensive public health and clinical interventions. In the case of sodium consumption, population segmentation can guide public health practitioners and policymakers to design programs and interventions that change sodium intake in people who are resistant to behavior change.

Delivery and Payment Redesign to Reduce Disparities in High Risk Postpartum Care.

Purpose This paper describes the implementation of an innovative program that aims to improve postpartum care through a set of coordinated delivery and payment system changes designed to use postpartum care as an opportunity to impact the current and future health of vulnerable women and reduce disparities in health outcomes among minority women. Description A large health care system, a Medicaid managed care organization, and a multidisciplinary team of experts in obstetrics, health economics, and health disparities designed an intervention to improve postpartum care for women identified as high-risk. The program includes a social work/care management component and a payment system redesign with a cost-sharing arrangement between the health system and the Medicaid managed care plan to cover the cost of staff, clinician education, performance feedback, and clinic/clinician financial incentives. The goal is to enroll 510 high-risk postpartum mothers. Assessment The primary outcome of interest is a timely postpartum visit in accordance with NCQA healthcare effectiveness data and information set guidelines. Secondary outcomes include care process measures for women with specific high-risk conditions, emergency room visits, postpartum readmissions, depression screens, and health care costs. Conclusion Our evidence-based program focuses on an important area of maternal health, targets racial/ethnic disparities in postpartum care, utilizes an innovative payment reform strategy, and brings together insurers, researchers, clinicians, and policy experts to work together to foster health and wellness for postpartum women and reduce disparities.

Trends in Reported Health Care Affordability for Men and Women With Employer-Sponsored Health Insurance Coverage in the US, 2000 to 2020.

This study uses National Health Interview Survey data from 2000 to 2020 to examine reported differences between US men and women aged 19 to 64 years with employer-sponsored insurance in obtaining affordable health care.