The effect of technology-supported, multidisease care management on the mortality and hospitalization of seniors

The Medical Home and Care Coordination in Disaster Recovery: Hypothesis for Interventions and Research

In postdisaster settings, health care providers encounter secondary surges of unmet primary care and mental health needs that evolve throughout disaster recovery phases. Whatever a community’s predisaster adequacy of health care, postdisaster gaps are similar to those of any underserved region. We hypothesize that existing practice and evidence supporting medical homes and care coordination in primary care for the underserved provide a favorable model for improving health in disrupted communities. Elements of medical home services can be offered by local or temporary providers from outside the region, working out of mobile clinics early in disaster recovery. As repairs and reconstruction proceed, local services are restored over weeks or years. Throughout recovery, major tasks include identifying high-risk patients relative to the disaster and underlying health conditions, assisting displaced families as they transition through housing locations, and tracking their evolving access to health care and community services as they are restored. Postdisaster sources of financial assistance for the disaster-exposed population are often temporary and evolving, requiring up-to-date information to cover costs of care until stable services and insurance coverage are restored. Evidence to support disaster recovery health care improvement will require research funding and metrics on structures, processes, and outcomes of the disaster recovery medical home and care coordination, based on adaptation of standard validated methods to crisis environments. (Disaster Med Public Health Preparedness. 2015;9:337–343)

Racial Differences in Chronic Conditions and Sociodemographic Characteristics Among High-Utilizing Veterans

PURPOSE

African-Americans are disproportionally represented among high-risk, high-utilizing patients. To inform program development for this vulnerable population, the current study describes racial variation in chronic conditions and sociodemographic characteristics among high-utilizing patients in the Veterans Affairs Healthcare System (VA).

METHODS

We identified the 5 % most costly Veterans who used inpatient or outpatient care at the VA during fiscal year 2010 (N = 237,691) based on costs of inpatient and outpatient care, pharmacy services, and VA-sponsored contract care. Patient costs and characteristics were abstracted from VA outpatient and inpatient data files. Racial differences in sociodemographic characteristics (age, sex, marital support, homelessness, and health insurance status) were assessed with chi-square tests. Racial differences in 32 chronic condition diagnoses were calculated as relative risk ratios.

RESULTS

African-Americans represented 21 % of high-utilizing Veterans. African-Americans had higher rates of homelessness (26 vs. 10 %, p < 0.001) and lower rates of supplemental health insurance (44 vs. 58 %, p < 0.001). The mean number of chronic conditions was similar across race. However, there were racial differences in the prevalence of specific chronic conditions, including a higher prevalence of HIV/AIDS (95 % confidence interval (CI) 4.86, 5.50) and schizophrenia (95 % CI 1.94, 2.07) and a lower prevalence of ischemic heart disease (95 % CI 0.57, 0.59) and bipolar disorder (95 % CI 0.78, 0.85) among African-American high-utilizing Veterans.

CONCLUSION

Racial disparities among high-utilizing Veterans may differ from those found in the general population. Interventions should devote attention to social, environmental, and mental health issues in order to reduce racial disparities in this vulnerable population.

Effectiveness of chronic care models: opportunities for improving healthcare practice and health outcomes: a systematic review

Background

The increasing prevalence of chronic disease and even multiple chronic diseases faced by both developed and developing countries is of considerable concern. Many of the interventions to address this within primary healthcare settings are based on a chronic care model first developed by MacColl Institute for Healthcare Innovation at Group Health Cooperative.

Methods

This systematic literature review aimed to identify and synthesise international evidence on the effectiveness of elements that have been included in a chronic care model for improving healthcare practices and health outcomes within primary healthcare settings. The review broadens the work of other similar reviews by focusing on effectiveness of healthcare practice as well as health outcomes associated with implementing a chronic care model. In addition, relevant case series and case studies were also included.

Results

Of the 77 papers which met the inclusion criteria, all but two reported improvements to healthcare practice or health outcomes for people living with chronic disease. While the most commonly used elements of a chronic care model were self-management support and delivery system design, there were considerable variations between studies regarding what combination of elements were included as well as the way in which chronic care model elements were implemented. This meant that it was impossible to clearly identify any optimal combination of chronic care model elements that led to the reported improvements.

Conclusions

While the main argument for excluding papers reporting case studies and case series in systematic literature reviews is that they are not of sufficient quality or generalizability, we found that they provided a more detailed account of how various chronic care models were developed and implemented. In particular, these papers suggested that several factors including supporting reflective healthcare practice, sending clear messages about the importance of chronic disease care and ensuring that leaders support the implementation and sustainability of interventions may have been just as important as a chronic care model’s elements in contributing to the improvements in healthcare practice or health outcomes for people living with chronic disease.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0854-8) contains supplementary material, which is available to authorized users.

EMPOWER-support of patient empowerment by an intelligent self-management pathway for patients: study protocol

Background

Diabetes education together with patient empowerment has shown to be key to effective self-management behavior. When delivered through information and communication technologies (ICT), this solution has shown to lead to better health outcomes. However, the potential of ICT and their integration into the healthcare environment have not yet been fully exploited. ICT should be in particular used to facilitate communication and information exchange between patient and healthcare providers. In addition, systems should include components facilitating behavior change using empowerment approaches such as goal-setting.

Methods/Design

Funded by the European Commission (FP7-ICT-2011-288209) a web/mobile based platform (EMPOWER) has been developed, which aims at supporting self-management activities of diabetes patients and their treating physicians in Germany and Turkey. The platform semantically integrates multiple information sources, such as electronic and personal health records (EHR/PHR). Patients can register patterns of daily living, record blood glucose levels, design disease management plans and set long- and short-term goals. The project actively involves the treating physician, who has the possibility to set recommendations for the patient and to monitor his/her progress on the platform.

In the test-phase of EMPOWER, patients will be assigned to an intervention group and a control group. Data will be collected at baseline and three months after the intervention started. In addition, qualitative interviews will be conducted to collect extra information on usability and usefulness.

Outcome measures include amongst others the Problem Areas in Diabetes questionnaire (PAID), the Summary of Diabetes Self-Care Activities and scales evaluating doctor-patient interaction. Physiological parameters, such as physical activity or blood glucose levels will be collected via the platform. Further, log files and number of logins will serve as independent variables.

Discussion

The interplay between multiple sources, including EHR, patients’ own registered information and physicians’ recommendations on one platform can have important practice implications. It might not only improve self-management activities in diabetes patients but it will also facilitate physician’s work, and ultimately the physician patient relationship.

Trial registration

The trial has been registered with Deutsches Register Klinischer Studien (German register of clinical trials) under DRKS00007699 on January 30, 2015.

Study protocol: transforming outcomes for patients through medical home evaluation and redesign: a cluster randomized controlled trial to test high value elements for patient-centered medical homes versus quality improvement

Background

Health care in the United States is in the midst of a near perfect storm: strong cost pressures, dramatic redesign efforts like patient-centered medical homes and accountable care organizations, and a broad series of payment and eligibility reforms. To date, alternative models of care intended to reduce costs and improve outcomes have shown mixed effects in the U.S., in part due to the difficulty of performing rigorous evaluation studies that control for the broader transformation while avoiding other biases, such as organizational or clinic effect on individual patient outcomes. Our objective is to test whether clinics assigned to achieve high value elements (HVEs) of practice redesign are more likely than controls to achieve improvements in patient health and satisfaction with care and reduction in costs.

Methods/Design

To prepare, we interview stakeholders, align with health reform, and propose a pilot. Participants are primary care clinics engaged in reform. Study protocol requires that both arms receive monthly practice facilitation, IT-based milestone reporting, and small financial incentives based on self-determined quality improvement (QI) goals; intervention receives additional prompting to choose HVEs. Design is a cluster randomized controlled trial over 1 year with pre- and post-washout periods. Outcomes are unplanned utilization and costs, patient experience of care, quality, and team performance. Analysis is a multivariate difference-in-difference with adjustments for patient risk, intraclinic correlation, and other confounders.

Discussion

The TOPMED study is a cluster randomized controlled trial focused on learning how primary care practices can transform within health reform guidelines to achieve outcomes related to the Triple Aim.

Trial registration

ClinicalTrials.gov registration: NCT02106221.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-015-0204-6) contains supplementary material, which is available to authorized users.

Cost analysis of a home-based nurse care coordination program

Objectives

To determine whether a home-based care coordination program focused on medication self-management would affect the cost of care to the Medicare program and whether the addition of technology, a medication-dispensing machine, would further reduce cost.

Design

Randomized, controlled, three-arm longitudinal study.

Setting

Participant homes in a large Midwestern urban area.

Participants

Older adults identified as having difficulty managing their medications at discharge from Medicare Home Health Care (N = 414).

Intervention

A team consisting of advanced practice nurses (APNs) and registered nurses (RNs) coordinated care for two groups: home-based nurse care coordination (NCC) plus a pill organizer group and NCC plus a medication-dispensing machine group.

Measurements

To measure cost, participant claims data from 2005 to 2011 were retrieved from Medicare Part A and B Standard Analytical Files.

Results

Ordinary least squares regression with covariate adjustment was used to estimate monthly dollar savings. Total Medicare costs were $447 per month lower in the NCC plus pill organizer group (P = .11) than in a control group that received usual care. For participants in the study at least 3 months, total Medicare costs were $491 lower per month in the NCC plus pill organizer group (P = .06) than in the control group. The cost of the NCC plus pill organizer intervention was $151 per month, yielding a net savings of $296 per month or $3,552 per year. The cost of the NCC plus medication-dispensing machine intervention was $251 per month, and total Medicare costs were $409 higher per month than in the NCC plus pill organizer group.

Conclusion

Nurse care coordination plus a pill organizer is a cost-effective intervention for frail elderly Medicare beneficiaries. The addition of the medication machine did not enhance the cost effectiveness of the intervention.

Partnered research in healthcare delivery redesign for high-need, high-cost patients: development and feasibility of an Intensive Management Patient-Aligned Care Team (ImPACT)

OBJECTIVES

We employed a partnered research healthcare delivery redesign process to improve care for high-need, high-cost (HNHC) patients within the Veterans Affairs (VA) healthcare system.

METHODS

Health services researchers partnered with VA national and Palo Alto facility leadership and clinicians to: 1) analyze characteristics and utilization patterns of HNHC patients, 2) synthesize evidence about intensive management programs for HNHC patients, 3) conduct needs-assessment interviews with HNHC patients (n = 17) across medical, access, social, and mental health domains, 4) survey providers (n = 8) about care challenges for HNHC patients, and 5) design, implement, and evaluate a pilot Intensive Management Patient-Aligned Care Team (ImPACT) for a random sample of 150 patients.

RESULTS

HNHC patients accounted for over half (52 %) of VA facility patient costs. Most (94 %) had three or more chronic conditions, and 60 % had a mental health diagnosis. Formative data analyses and qualitative assessments revealed a need for intensive case management, care coordination, transitions navigation, and social support and services. The ImPACT multidisciplinary team developed care processes to meet these needs, including direct access to team members (including after-hours), chronic disease management protocols, case management, and rapid interventions in response to health changes or acute service use. Two-thirds of invited patients (n = 101) enrolled in ImPACT, 87 % of whom remained actively engaged at 9 months. ImPACT is now serving as a model for a national VA intensive management demonstration project.

CONCLUSIONS

Partnered research that incorporated population data analysis, evidence synthesis, and stakeholder needs assessments led to the successful redesign and implementation of services for HNHC patients. The rigorous design process and evaluation facilitated dissemination of the intervention within the VA healthcare system.

IMPACT STATEMENT

Employing partnered research to redesign care for high-need, high-cost patients may expedite development and dissemination of high-value, cost-saving interventions.

Expert knowledge elicitation using computer simulation: the organization of frail elderly case management as an illustration

BACKGROUND

Various elderly case management projects have been implemented in Belgium. This type of long-term health care intervention involves contextual factors and human interactions. These underlying complex mechanisms can be usefully informed with field experts' knowledge, which are hard to make explicit. However, computer simulation has been suggested as one possible method of overcoming the difficulty of articulating such elicited qualitative views.

METHODS

A simulation model of case management was designed using an agent-based methodology, based on the initial qualitative research material. Variables and rules of interaction were formulated into a simple conceptual framework. This model has been implemented and was used as a support for a structured discussion with experts in case management.

RESULTS

The rigorous formulation provided by the agent-based methodology clarified the descriptions of the interventions and the problems encountered regarding: the diverse network topologies of health care actors in the project; the adaptation time required by the intervention; the communication between the health care actors; the institutional context; the organization of the care; and the role of the case manager and his or hers personal ability to interpret the informal demands of the frail older person.

CONCLUSION

The simulation model should be seen primarily as a tool for thinking and learning. A number of insights were gained as part of a valuable cognitive process. Computer simulation supporting field experts' elicitation can lead to better-informed decisions in the organization of complex health care interventions.

The medical home transformation in the Veterans Health Administration: an evaluation of early changes in primary care delivery

OBJECTIVE

To evaluate the effect of medical home implementation on primary care delivery in the Veterans Health Administration (VHA).

DATA SOURCES/STUDY SETTING/STUDY DESIGN

We link interview-based qualitative data on medical home implementation to quantitative outcomes from VHA clinical encounter data. We use a longitudinal analysis with provider fixed effects (taking advantage of variation in timing of implementation and allowing each provider to serve as a control for him or herself) to test whether patient-aligned care team (PACT) implementation was associated with changes in organizational processes and patient outcomes.

PRINCIPAL FINDINGS

Among 683 PCPs, caring for 321,295 patients, the uptake of eight of nine PACT structural changes significantly increased from July 2010 to June 2012 as did the percentage of primary care appointments occurring by telephone and hospital discharges contacted within 2 days of discharge. We found that PACT implementation was associated with significant improvements in 2-day post-hospital discharge contact, but not primary care visits occurring by telephone or within 3 days of the requested date. We found no association between medical home implementation and rates of emergency department use by patients.

CONCLUSIONS

Medical home implementation at the VHA resulted in large changes in the structure of care but few changes in patient-level outcomes. These results highlight both the complexity of studying the effect of the medical home as well as implementing this model to change primary care delivery.

About half of the states are implementing patient-centered medical homes for their Medicaid populations

Public and private payers are testing the patient-centered medical home model by shifting resources to enhance primary care as an important component of improving the quality and cost-effectiveness of the US health care delivery system. Medicaid has been at the forefront of this movement. Since 2006 twenty-five states have implemented new payment systems or revised existing ones so that primary care providers can function as patient-centered medical homes. State Medicaid programs are taking a variety of approaches. For example, Minnesota's reforms focus on chronically ill populations, while in Missouri a 90 percent federal match under the Affordable Care Act is helping integrate primary and behavioral health care and address issues of long-term services and supports. These reforms have led to better alignment of payments with performance metrics that emphasize health outcomes, patient satisfaction, and cost containment. This article focuses on trends in Medicaid patient-centered medical home payment that can inform public and private payment strategies more broadly.

Health information technologies in geriatrics and gerontology: a mixed systematic review

OBJECTIVE

To review, categorize, and synthesize findings from the literature about the application of health information technologies in geriatrics and gerontology (GGHIT).

MATERIALS AND METHODS

This mixed-method systematic review is based on a comprehensive search of Medline, Embase, PsychInfo and ABI/Inform Global. Study selection and coding were performed independently by two researchers and were followed by a narrative synthesis. To move beyond a simple description of the technologies, we employed and adapted the diffusion of innovation theory (DOI).

RESULTS

112 papers were included. Analysis revealed five main types of GGHIT: (1) telecare technologies (representing half of the studies); (2) electronic health records; (3) decision support systems; (4) web-based packages for patients and/or family caregivers; and (5) assistive information technologies. On aggregate, the most consistent finding proves to be the positive outcomes of GGHIT in terms of clinical processes. Although less frequently studied, positive impacts were found on patients' health, productivity, efficiency and costs, clinicians' satisfaction, patients' satisfaction and patients' empowerment.

DISCUSSION

Further efforts should focus on improving the characteristics of such technologies in terms of compatibility and simplicity. Implementation strategies also should be improved as trialability and observability are insufficient.

CONCLUSIONS

Our results will help organizations in making decisions regarding the choice, planning and diffusion of GGHIT implemented for the care of older adults.

The role of mental and behavioral health in the application of the patient-centered medical home in the Department of Veterans Affairs

The patient-centered medical home, which is termed the Patient Aligned Care Team (PACT) in the Department of Veterans Affairs (VA), is a transformational initiative with mental and behavioral health as integral components. Funding has been provided to VA medical facilities to assist with the transformation and process redesign of primary care into interdisciplinary teams focused on increased access, Veteran-centered care, and active incorporation of collaborative expertise from specialists within primary care. Primary care clinics are not simple machines that change by merely replacing parts or colocating additional resources. Rather, they are complex systems with a relationship infrastructure among members of the team that is critically important to the change process. Mental health professionals are integral, mandated members of the PACTs providing needed mental and behavioral health care to Veterans as an integrated component of primary care. They also work to catalyze a quality improvement process that encourages collaboration, innovation, and adoption of best practices that promote transformation based on patient-centered principles of care. The purpose of this article is to describe the evolution of VA primary care settings toward interdisciplinary teams that provide patient-centered care in collaboration with Primary Care-Mental Health Integration providers and Health Promotion Disease Prevention team members.

Quality and efficiency in small practices transitioning to patient centered medical homes: a randomized trial

BACKGROUND

There is growing evidence that even small and solo primary care practices can successfully transition to full Patient Centered Medical Home (PCMH) status when provided with support, including practice redesign, care managers, and a revised payment plan. Less is known about the quality and efficiency outcomes associated with this transition.

OBJECTIVE

Test quality and efficiency outcomes associated with 2-year transition to PCMH status among physicians in intervention versus control practices.

DESIGN

Randomized Controlled Trial.

PARTICIPANTS

Eighteen intervention practices with 43 physicians and 14 control practices with 24 physicians; all from adult primary care practices.

INTERVENTIONS

Modeled on 2008 NCQA PPC®-PCMH™, intervention practices received 18 months of tailored practice redesign support; 2 years of revised payment, including up to $2.50 per member per month (PMPM) for achieving quality targets and up to $2.50 PMPM for PPC-PCMH recognition; and 18 months of embedded care management support. Controls received yearly participation payments.

MAIN MEASURES

Eleven clinical quality indicators from the 2009 HEDIS process and health outcomes measures derived from patient claims data; Ten efficiency indicators based on Thomson Reuter efficiency indexes and Emergency Department (ED) Visit Ratios; and a panel of costs of care measures.

KEY RESULTS

Compared to control physicians, intervention physicians significantly improved TWO of 11 quality indicators: hypertensive blood pressure control over 2 years (intervention +23 percentage points, control -2 percentage points, p =0.02) and breast cancer screening over 3 years (intervention +3.5 percentage points, control -0.4 percentage points, p =0.03). Compared to control physicians, intervention physicians significantly improved ONE of ten efficiency indicators: number of care episodes resulting in ED visits was reduced (intervention -0.7 percentage points, control + 0.5 percentage points, p = 0.002), with 3.8 fewer ED visits per year, saving approximately $1,900 in ED costs per physician, per year. There were no significant cost-savings on any of the pre-specified costs of care measures.

CONCLUSIONS

In a randomized trial, we observed that some indicators of quality and efficiency of care in general adult primary care practices transitioning to PCMH status can be significantly, but modestly, improved over 2 years, although most indicators did not improve and there were no cost-savings compared with control practices. For the most part, quality and efficiency of care provided in unsupported control practices remained unchanged or worsened during the trial.

Academic health centers and community health centers partnering to build a system of care for vulnerable patients: lessons from Carolina Health Net

Academic health centers (AHCs) are challenged to meet their core missions in a time of strain on the health care system from rising costs, an aging population, increased rates of chronic disease, and growing numbers of uninsured patients. AHCs should be leaders in developing creative solutions to these challenges and training future leaders in new models of care. The authors present a case study describing the development, implementation, and early results of Carolina Health Net, a partnership between an AHC and a community health center to manage the most vulnerable uninsured by providing access to primary care medical homes and care management systems. This partnership was formed in 2008 to help transform the delivery of health care for the uninsured. As a result, 4,400 uninsured patients have been connected to primary care services. Emergency department use by enrolled patients has decreased. Patients have begun accessing subspecialty care within the medical home. More than 2,200 uninsured patients have been assisted to enroll in Medicaid. The experience of Carolina Health Net demonstrates that developing a system of care with primary care and wrap-around services such as pharmacy and case management can improve the cost-effectiveness and quality of care, thereby helping AHCs meet their broader missions. This project can serve as a model for other AHCs looking to partner with community-based providers to improve care and control costs for underserved populations.

Conformity of pediatric/adolescent HIV clinics to the patient-centered medical home care model

The patient-centered medical home (PCMH) has been introduced as a model for providing high-quality, comprehensive, patient-centered care that is both accessible and coordinated, and may provide a framework for optimizing the care of youth living with HIV (YLH). We surveyed six pediatric/adolescent HIV clinics caring for 578 patients (median age 19 years, 51% male, and 82% black) in July 2011 to assess conformity to the PCMH. Clinics completed a 50-item survey covering the six domains of the PCMH: (1) comprehensive care, (2) patient-centered care, (3) coordinated care, (4) accessible services, (5) quality and safety, and (6) health information technology. To determine conformity to the PCMH, a novel point-based scoring system was devised. Points were tabulated across clinics by domain to obtain an aggregate assessment of PCMH conformity. All six clinics responded. Overall, clinics attained a mean 75.8% [95% CI, 63.3-88.3%] on PCMH measures-scoring highest on patient-centered care (94.7%), coordinated care (83.3%), and quality and safety measures (76.7%), and lowest on health information technology (70.0%), accessible services (69.1%), and comprehensive care (61.1%). Clinics moderately conformed to the PCMH model. Areas for improvement include access to care, comprehensive care, and health information technology. Future studies are warranted to determine whether greater clinic PCMH conformity improves clinical outcomes and cost savings for YLH.

Care coordination for patients with complex health profiles in inpatient and outpatient settings

Patients with the most complex health profiles consume a disproportionate percentage of health care expenditures, yet often receive fragmented, suboptimal care. Since 2003, Wisconsin-based Gundersen Health has improved the quality of life and reduced the cost burden of patients with complex health profiles with an integrated care coordination program. Those results are consistent with data from the most successful care coordination demonstration projects funded by the Centers for Medicare and Medicaid Services. Specifically, Gundersen's program has been associated with reduced hospital stays, lower costs for inpatients, less use of inpatient services, and increased patient satisfaction. Gundersen's success is rooted in its team-based approach to coordinated care. Teams, led by a subspecialty-trained nurse, have regular, face-to-face contact with patients and their physicians in both inpatient and outpatient settings; involve patients deeply in care-related decisions; access a system-wide electronic medical record database that tracks patients' care; and take a macrolevel view of care-related factors and costs. Gundersen's model offers specific take-home lessons for institutions interested in coordinated care as they design programs aimed at improving quality and lowering costs. This institutional case study provides a window into well-executed care coordination at a large health care system in an era when major changes in health care provision and reimbursement mechanisms are on the horizon.

Six features of Medicare coordinated care demonstration programs that cut hospital admissions of high-risk patients

As policy makers seek to slow the growth in Medicare spending, they have appropriately focused attention on beneficiaries with multiple chronic conditions. Many care coordination and disease management programs designed to improve beneficiaries' care and reduce their need for hospitalizations have been tested, but few have been successful. This study, however, found that four of eleven programs that were part of the Medicare Coordinated Care Demonstration reduced hospitalizations by 8-33 percent among enrollees who had a high risk of near-term hospitalization. The six approaches practiced by care coordinators in at least three of the four programs were as follows: supplementing telephone calls to patients with frequent in-person meetings; occasionally meeting in person with providers; acting as a communications hub for providers; delivering evidence-based education to patients; providing strong medication management; and providing timely and comprehensive transitional care after hospitalizations. When care management fees were included, the programs were essentially cost-neutral, but none of these programs generated net savings to Medicare. Our results suggest that incorporating these approaches into medical homes, accountable care organizations, and other policy initiatives could reduce hospitalizations and improve patients' lives. However, the approaches would save money only if care coordination fees were modest and organizations found cost-effective ways to deliver the interventions.

How changes in Washington University's Medicare coordinated care demonstration pilot ultimately achieved savings

As one of the initial fifteen participants in the Medicare Coordinated Care Demonstration, the Washington University School of Medicine in St. Louis was not able to demonstrate any reduction in hospitalizations or Medicare spending for the patients it served. In fact, the Washington University program increased total Medicare spending by 12 percent. But after a redesign, the results changed. The program stopped conducting care management of most of its patients via telephone from a remote site in California and, instead, served all patients through frequent phone and occasional in-person contact from local care managers in St. Louis. Care management efforts were focused especially on patients deemed at greatest risk of hospitalization, and stronger hospital transition planning and medication reconciliation were provided, among other changes. After that point, the program reduced hospitalizations by 12 percent and monthly Medicare spending by $217 per enrollee-more than offsetting the program's monthly $151 care management fee. The results underscore findings from the overall Medicare Coordinated Care Demonstration that suggest that programs with more in-person contacts were more likely than others to build trusting relationships with patients and providers, improve patient adherence to care plans, and address additional needs and barriers that entirely telephonic contacts had been unable to identify. The results also indicate that programs can be more effective by focusing on the highest-risk patients, for whom the largest savings resulted.

Engaging individuals recently released from prison into primary care: a randomized trial

OBJECTIVES

Individuals released from prison have high rates of chronic conditions but minimal engagement in primary care. We compared 2 interventions designed to improve primary care engagement and reduce acute care utilization: Transitions Clinic, a primary care-based care management program with a community health worker, versus expedited primary care.

METHODS

We performed a randomized controlled trial from 2007 to 2009 among 200 recently released prisoners who had a chronic medical condition or were older than 50 years. We abstracted 12-month outcomes from an electronic repository available from the safety-net health care system. Main outcomes were (1) primary care utilization (2 or more visits to the assigned primary care clinic) and (2) emergency department (ED) utilization (the proportion of participants making any ED visit).

RESULTS

Both groups had similar rates of primary care utilization (37.7% vs 47.1%; P = .18). Transitions Clinic participants had lower rates of ED utilization (25.5% vs 39.2%; P = .04).

CONCLUSIONS

Chronically ill patients leaving prison will engage in primary care if provided early access. The addition of a primary care-based care management program tailored for returning prisoners reduces ED utilization over expedited primary care.

The patient-centered medical home: a review of recent research

The patient-centered medical home is an important innovation in health care delivery. There is a need to assess the scope and substance of published research on medical homes. This article reviews published evaluations of medical home care for the period 2007 to 2010. Chief findings from these evaluations as a whole include associations between the provision of medical home care and improved quality, in addition to decreased utilization associated with medical home care in high-cost areas such as emergency department use. However, fewer associations were found across evaluations between medical home care and enhanced patient or family experiences. The early medical home research appears to reflect both the wide variation in how medical homes are being designed and implemented in practice and in how researchers are choosing to evaluate patient-centered medical home design and implementation. While some aspects of medical home care show promise, continued evolution of medical home evaluative research is needed.

Can integrating health literacy into the patient-centered medical home help us weather the perfect storm?

Improving health literacy is one key to buoying our nation's troubled health care system. As system-level health literacy improvement strategies take the stage among national priorities for health care, the patient-centered medical home (PCMH) model of care emerges as a compelling avenue for their widespread implementation. With a shared focus on effective communication and team-based care organized around patient needs, health literacy principles and the PCMH are well aligned. However, their synergy has received little attention, even as PCMH demonstration projects and health literacy interventions spring up nationwide. While many health literacy interventions are limited by their focus on a single point along the continuum of care, creating a "room" for health literacy within the PCMH may finally provide a multi-dimensional, system-level approach to tackling the full range of health literacy challenges. Increasing uptake coupled with federal support and financial incentives further boosts the model's potential for advancing health literacy. On the journey toward a revitalized health care system, integrating health literacy into the PCMH presents a promising opportunity that deserves consideration.

Health information technology: transforming chronic disease management and care transitions

Adoption of health information technology (HIT) is a key effort in improving care delivery, reducing costs of health care, and improving the quality of health care. Evidence from electronic health record (EHR) use suggests that HIT will play a significant role in transforming primary care practices and chronic disease management. This article shows that EHRs and HIT can be used effectively to manage chronic diseases, that HIT can facilitate communication and reduce efforts related to transitions in care, and that HIT can improve patient safety by increasing the information available to providers and patients, improving disease management and safety.

Interventions for improving outcomes in patients with multimorbidity in primary care and community settings

BACKGROUND

Many people with chronic disease have more than one chronic condition, which is referred to as multimorbidity. While this is not a new phenomenon, there is greater recognition of its impact and the importance of improving outcomes for individuals affected. Research in the area to date has focused mainly on descriptive epidemiology and impact assessment. There has been limited exploration of the effectiveness of interventions for multimorbidity.

OBJECTIVES

To determine the effectiveness of interventions designed to improve outcomes in patients with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual.

SEARCH METHODS

We searched MEDLINE, EMBASE, CINAHL, CAB Health, AMED, HealthStar, The Cochrane Central Register of Controlled Trials (CENTRAL), the EPOC Register and the Database of Abstracts of Reviews of Effectiveness (DARE), and the EPOC Register in April 2011.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs), and interrupted time series analyses (ITS) reporting on interventions to improve outcomes for people with multimorbidity in primary care and community settings. The outcomes included any validated measure of physical or mental health, psychosocial status including quality of life outcomes, well-being, and measures of disability or functional status. We also included measures of patient and provider behaviour including measures of medication adherence, utilisation of health services, and acceptability of services and costs.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for eligibility, extracted data, and assessed study quality. Meta-analysis of results was not possible so we carried out a narrative synthesis of the results from the included studies.

MAIN RESULTS

Ten studies examining a range of complex interventions for patients with multimorbidity were identified. All were RCTs and there was low risk of bias. Two of the nine studies focused on specific co-morbidities. The remaining studies focused on multimorbidity, generally in older patients. All studies involved complex interventions with multiple elements. In six of the ten studies, the predominant intervention element was a change to the organisation of care delivery, usually through case management or enhanced multidisciplinary team work. In the remaining four studies, the interventions were predominantly patient oriented. Overall the results were mixed with a trend towards improved prescribing and medication adherence. The results indicate that it is difficult to improve outcomes in this population but that interventions focusing on particular risk factors or functional difficulties in patients with co-morbid conditions or multimorbidity may be more effective. Cost data were limited with no economic analyses included, though the improvements in prescribing and risk factor management in some studies provided potentially significant cost savings.

AUTHORS' CONCLUSIONS

This review highlights the paucity of research into interventions to improve outcomes for multimorbidity with the focus to date being on co-morbid conditions or multimorbidity in older patients. The limited results suggest that interventions to date have had mixed effects but have shown a tendency to improve prescribing and medication adherence, particularly if interventions can be targeted at risk factors or specific functional difficulties in people with co-morbid conditions or multimorbidity. There is a need for clear definitions of participants, consideration of appropriate outcomes, and further pragmatic studies based in primary care settings.

Effect of a community-based nursing intervention on mortality in chronically ill older adults: a randomized controlled trial

BACKGROUND

Improving the health of chronically ill older adults is a major challenge facing modern health care systems. A community-based nursing intervention developed by Health Quality Partners (HQP) was one of 15 different models of care coordination tested in randomized controlled trials within the Medicare Coordinated Care Demonstration (MCCD), a national US study. Evaluation of the HQP program began in 2002. The study reported here was designed to evaluate the survival impact of the HQP program versus usual care up to five years post-enrollment.

METHODS AND FINDINGS

HQP enrolled 1,736 adults aged 65 and over, with one or more eligible chronic conditions (coronary artery disease, heart failure, diabetes, asthma, hypertension, or hyperlipidemia) during the first six years of the study. The intervention group (n = 873) was offered a comprehensive, integrated, and tightly managed system of care coordination, disease management, and preventive services provided by community-based nurse care managers working collaboratively with primary care providers. The control group (n = 863) received usual care. Overall, a 25% lower relative risk of death (hazard ratio [HR] 0.75 [95% CI 0.57-1.00], p = 0.047) was observed among intervention participants with 86 (9.9%) deaths in the intervention group and 111 (12.9%) deaths in the control group during a mean follow-up of 4.2 years. When covariates for sex, age group, primary diagnosis, perceived health, number of medications taken, hospital stays in the past 6 months, and tobacco use were included, the adjusted HR was 0.73 (95% CI 0.55-0.98, p = 0.033). Subgroup analyses did not demonstrate statistically significant interaction effects for any subgroup. No suspected program-related adverse events were identified.

CONCLUSIONS

The HQP model of community-based nurse care management appeared to reduce all-cause mortality in chronically ill older adults. Limitations of the study are that few low-income and non-white individuals were enrolled and implementation was in a single geographic region of the US. Additional research to confirm these findings and determine the model's scalability and generalizability is warranted.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01071967. Please see later in the article for the Editors' Summary.

Interdisciplinary collaboration in geriatrics: advancing health for older adults

The call for interdisciplinary research, education, and practice is heightened by the recognition of the potential it holds in generating creative solutions to complex problems in health care and to improving quality and effectiveness of care. With the aging of the population and the complex issues in caring for older adults, interdisciplinary collaboration is particularly salient to the field of geriatrics. However, despite interest in this approach for several decades, adoption has been slow and dissemination is not widespread. This article provides examples of recent initiatives and presents driving and restraining forces involved in adoption of interdisciplinary approaches.

Turning on the care coordination switch in rural primary care: voices from the practices--clinician champions, clinician partners, administrators, and nurse care managers

This study sought to understand the acceptability and feasibility of office-based nurse care management in medium to large rural primary care practices. A qualitative assessment of Care Management Plus (a focused medical home model for complex patients) implementation was conducted using semistructured interviews with 4 staff cohorts. Cohorts included clinician champions, clinician partners, practice administrators, and nurse care managers. Seven key implementation attributes were: a proven care coordination program; adequate staffing; practice buy-in; adequate time; measurement; practice facilitation; and functional information technology. Although staff was positive about the care coordination concept, model acceptability was varied and additional study is required to determine sustainability.

The patient-centred medical home in the USA

RATIONALE

The Patient-Centred Medical Home (PCMH) is a new model of health care delivery in the USA at the primary care level that emphasizes integrated and coordinated care around the patients' needs and desires. The PCMH emphasizes a practice-wide team approach to provide high quality, accessible and cost-effective health care for acute, chronic and prevention-oriented problems.

METHOD

This article is a descriptive overview of the PCMH in the USA.

RESULTS

The data on the PCMH have shown decreased mortality, morbidity and increased patient and physician satisfaction with care. Additionally, quality of care and patient access have improved. There has been decreased emergency room utilization, decreased hospitalization and decreased cost per patient.

CONCLUSION

The PCMH in the USA has been an outstanding transformative model change to re-centre health care back to cost-effective, quality, accessible primary care.

Care management's challenges and opportunities to reduce the rapid rehospitalization of frail community-dwelling older adults

Community-based frail older adults, burdened with complex medical and social needs, are at great risk for preventable rapid rehospitalizations. Although federal and state regulations are in place to address the care transitions between the hospital and nursing home, no such guidelines exist for the much larger population of community-dwelling frail older adults. Few studies have looked at interventions to prevent rehospitalizations in this large segment of the older adult population. Similarly, standardized disease management approaches that lower hospitalization rates in an independent adult population may not suffice for guiding the care of frail persons. Care management interventions currently face unique challenges in their attempt to improve the transitional care of community-dwelling older adults. However, impending national imperatives aimed at reducing potentially avoidable hospitalizations will soon demand and reward care management strategies that identify frail persons early in the discharge process and promote the sharing of critical information among patients, caregivers, and health care professionals. Opportunities to improve the quality and efficiency of care-related communications must focus on the effective blending of training and technology for improving communications vital to successful care transitions.