Service supply chains for population health: Overcoming fragmentation of service delivery ecosystems

Assessing experts' perspectives on challenges in substance misuse prevention, harm reduction, and treatment to shape funding priorities in New York State

BACKGROUND

Drug overdose is a leading cause of death and opioid-related deaths increased by more than 300% from 2010 to 2020 in New York State. Experts holding a range of senior leadership positions from across New York State were asked to identify the greatest challenges in substance misuse prevention, harm reduction, and treatment continuum of care. Expert input was used to shape funding priorities.

METHOD

Individual semi-structured interviews of sixteen experts were conducted in April and May 2023. Experts included academics, medical directors, leaders of substance misuse service agencies, administrators of a state agency, a county mental health commissioner, the president of a pharmacy chain, and a senior vice president of an addiction-related national non-profit. Zoom interviews were conducted individually by an experienced qualitative interviewer and were recorded, transcribed, and coded for content. An initial report, with the results of the interviews organized by thematic content, was reviewed by the research team and emailed to the expert interviewees for feedback.

RESULTS

The research team identified five major themes: 1. Siloed and fragmented care delivery systems; 2. Need for a skilled workforce; 3. Attitudes towards addiction (stigma); 4. Limitations in treatment access; and 5. Social and drug related environmental factors. Most experts identified challenges in each major theme; over three-quarters identified issues related to siloed and fragmented systems and the need for a skilled workforce. Each expert mentioned more than one theme, three experts mentioned all five themes and six experts mentioned four themes.

CONCLUSIONS

Research, educational, and programmatic agendas should focus on identified topics as a means of improving the lives of patients at risk for or suffering from substance use-related disorders. The results of this project informed funding of pilot interventions designed to address the identified care challenges.

Perspectives from gambling expert stakeholders in relation to electronic gaming machines in New Zealand

Electronic gaming machines (EGMs) are one of the most addictive and harmful forms of gambling. Gaming machine characteristics, easy accessibility of EGMs and normalisation of gambling behaviour have exacerbated these effects. We conducted a pilot study investigating the perspectives of gambling expert stakeholders on gambling harm and effective harm-minimisation policies regarding EGMs. In-depth individual interviews were undertaken with 14 health professionals working in the addiction sector, academics in the field of gambling and individuals from a range of government and non-government organisations who have an impact on gambling policy making in New Zealand. Five major themes were identified: the need to shift focus from problematic people to the problematic product, the need for a holistic approach to gambling intervention, focus on creating an empowered population, and improving protective factors and refining public health initiatives to gambling harm. The results suggest the need to challenge current narratives of EGM-related gambling harm and have wide-ranging implications for EGM harm minimisation and health promotion policies.

Screening Families in Primary Care for Social and Economic Needs: Patients' Urgency and Activation for Social Care Navigation

INTRODUCTION

Social determinants of health (SDoH) screening and intervention in primary care aim to alleviate adverse influences on health, but its efficacy may be diluted when offered supports are not well matched to families' desire for such services. The purpose of this prospective cohort study was to provide guidance to social care navigation teams regarding which families would be most likely to make use of services.

METHODS

Analysis of registry data collected in April 1-September 30, 2021 from a social care navigation program embedded in a medical home was conducted. Multivariable regression models explored (1) whether family-reported urgency of needs, number of needs, and/or specific types of needs predicted completing program intake and (2) whether the degree of family activation regarding social needs predicted subsequent interactions with the navigation team.

RESULTS

Of the 1,483 families reporting any social care needs (38% of all screens completed, mean of 2.5 needs per screen), 31% indicated that their needs were urgent. Accounting for program factors and the number and type of needs reported, families whose needs were urgent were more likely to complete intake (OR=1.34; 95% CI=1.01, 1.82; p=0.04) and remain engaged with the program over time (OR=2.25; 95% CI=1.62, 3.12; p<0.01). Those who were self-advocates were substantially less likely to desire follow-up or stay engaged (OR=0.40; 95% CI=0.17, 0.93; p<0.01).

CONCLUSIONS

Family-reported urgency of needs and activation for social care assistance predicted engagement with the navigation team. SDoH interventions should prioritize outreach to those families expressing an interest in help with any of their identified needs.

Outpatient care fragmentation in Veterans Affairs patients at high-risk for hospitalization

OBJECTIVE

To examine outpatient care fragmentation and its association with future hospitalization among patients at high risk for hospitalization.

DATA SOURCES

Veterans Affairs (VA) and Medicare data.

STUDY DESIGN

We conducted a longitudinal study, using logistic regression to examine how outpatient care fragmentation in FY14 (as measured by number of unique providers, Breslau's Usual Provider of Care (UPC), Bice-Boxerman's Continuity of Care Index (COCI), and Modified Modified Continuity Index (MMCI)) was associated with all-cause hospitalizations and hospitalizations related to ambulatory care sensitive conditions (ACSC) in FY15. We also examined how fragmentation varied by patient's age, gender, race, ethnicity, marital status, rural status, history of homelessness, number of chronic conditions, Medicare utilization, and mental healthcare utilization.

DATA EXTRACTION METHODS

We extracted data for 130,704 VA patients ≥65 years old with a hospitalization risk ≥90th percentile and ≥ four outpatient visits in the baseline year.

PRINCIPAL FINDINGS

Mean (standard deviation) of FY14 outpatient visits was 13.2 (8.6). Fragmented care (more providers, less care with a usual provider, more dispersed care based on COCI) was more common among patients with more chronic conditions and those receiving mental health care. In adjusted models, most fragmentation measures were not associated with all-cause hospitalization, and patients with low levels of fragmentation (more concentrated care based on UPC, COCI, and MMCI) had a higher likelihood of an ACSC-related hospitalization (AOR, 95% CI = 1.21 (1.09-1.35), 1.27 (1.14-1.42), and 1.28 (1.18-1.40), respectively).

CONCLUSIONS

Contrary to expectations, outpatient care fragmentation was not associated with elevated all-cause hospitalization rates among VA patients in the top 10th percentile for risk of admission; in fact, fragmented care was linked to lower rates of hospitalization for ACSCs. In integrated settings such as the VA, multiple providers and dispersed care might offer access to timely or specialized care that offsets risks of fragmentation, particularly for conditions that are sensitive to ambulatory care.

Evaluation of a Commercial Mobile Health App for Depression and Anxiety (AbleTo Digital+): Retrospective Cohort Study

BACKGROUND

Digital solutions, such as web-based and mobile interventions, have the potential to streamline pathways to mental health services and improve access to mental health care. Although a growing number of randomized trials have established the efficacy of digital interventions for common mental health problems, less is known about the real-world impact of these tools. AbleTo Digital+, a commercially available mental health app for depression and anxiety, offers a unique opportunity to understand the clinical impact of such tools delivered in a real-world context.

OBJECTIVE

The primary aim of this study is to examine the magnitude of change in depression and anxiety symptoms among individuals who used AbleTo Digital+ programs. The secondary aim is to evaluate Digital+ module completion, including the use of 1:1 coaching.

METHODS

In this retrospective cohort study, we analyzed previously collected and permanently deidentified data from a consecutive cohort of 1896 adults who initiated using one of the three Digital+ eight-module programs (depression, generalized anxiety, or social anxiety) between January 1 and June 30, 2020. Depression, generalized anxiety, and social anxiety symptoms were assessed within each program using the Patient Health Questionnaire-9, the Generalized Anxiety Disorder-7, and the Social Phobia Inventory, respectively. Linear mixed effects models were built to assess the association between module completion and symptom change among users who completed at least four modules and had at least mild baseline symptom elevations, controlling for age, gender, and baseline symptom severity. Digital+ use, including module completion, 1:1 coaching calls, and in-app coach messaging, was also evaluated.

RESULTS

Significant effects were observed among depression (Cohen d=1.5), generalized anxiety (Cohen d=1.2), and social anxiety (Cohen d=1.0) program participants who completed at least four modules and had mild baseline elevations (n=470). Associations between module completion and change in depression (β=-1.2; P<.001), generalized anxiety (β=-1.1; P<.001), and social anxiety (β=-2.4; P<.001) symptom scores retained significance with covariate adjustment. Participants completed an average of 2.6 (SD 2.7) modules. The average total length of app use was 52.2 (SD 83.5) days. Approximately two-thirds of the users engaged in at least 1 coaching call (66.82%, 1267/1896) or in-app text messaging (66.09%, 1253/1896). Participants who completed at least four modules participated in significantly more coaching calls per module (mean 1.1, SD 0.7) than users who completed fewer than four modules (mean 1.0, SD 1.2; t1407=-2.1; P=.03).

CONCLUSIONS

This study demonstrated that AbleTo Digital+ users experienced significant reductions in depression, generalized anxiety, and social anxiety symptoms throughout the program.

Out-of-hours primary care in 26 European countries: an overview of organizational models

BACKGROUND

Various models exist to organize out-of-hours primary care (OOH-PC). We aimed to provide an up-to-date overview of prevailing organizational models in the European Union (EU), implemented changes over the last decade and future plans. This baseline overview may provide information for countries considering remodelling their OOH-PC system.

METHODS

A cross-sectional web-based questionnaire among 93 key informants from EU countries, Norway and Switzerland. Key informants with expertise in the field of primary health care were invited to participate. Themes in the questionnaire were the existing organizational models for OOH-PC, model characteristics, major organizational changes implemented in the past decade and future plans.

RESULTS

All 26 included countries had different coexisting OOH-PC models, varying from 3 to 10 models per country. 'GP cooperative was the dominant model in most countries followed by primary care centre and rota group'. There was a large variation in characteristics between the models, but also within the models, caused by differences between countries and regions. Almost all countries had implemented changes over the past 10 years, mostly concerning the implementation of telephone triage and a change of organizational model by means of upscaling and centralization of OOH-PC. Planned changes varied from fine-tuning the prevailing OOH-PC system to radical nationwide organizational transitions in OOH-PC.

CONCLUSIONS

Different organizational models for OOH-PC exist on international and national level. Compared with a decade ago, more primary care-oriented organizational models are now dominant. There is a trend towards upscaling and centralization; it should be evaluated whether this improves the quality of health care.