Technology-facilitated care coordination in rural areas: What is needed?

Responsible coordination of municipal health and care services for individuals with serious mental illness: a participatory qualitative study with service users and professionals

BACKGROUND

Care coordination is crucial to ensure the health of individuals with serious mental illness. The aim of this study was to describe and analyze an inclusive innovation process for coordinating municipal health and care services for individuals with serious mental illness.

METHODS

We conducted café dialogues with professionals and service users with serious mental illness. The café dialogues engaged participants in conversation and knowledge exchange about care coordination, adressing topics of efficiency, challenges, and improvement. We used a responsible innovation framework to analyze the innovation process.

RESULTS

Responsible coordination requires promoting service users' health and ensuring communication and mutual awareness between professionals. Individual-level factors supporting responsible coordination included service users knowing their assigned professionals, personalized healthcare services, and access to meaningful activities. Provider-level factors included effective coordination routines, communication, information exchange, and professional familiarity. Results reflect professionals' and service users' perspectives on efficient care coordination, existing challenges, and measures to improve care coordination.

CONCLUSION

Café dialogues are an inclusive, participatory method that can produce insights into the responsible coordination of municipal health and care services for individuals with serious mental illness. The responsible innovation framework is helpful in identifying care coordination challenges and measures for responsible coordination.

Comparing "Meaningful Use" of Health Information Technology in Pennsylvania: Electronic Prescription Rates of Metropolitan and Rural Counties

The Health Information Technology for Economic and Clinical Health Act incentivized the adoption of electronic health records (EHRs). Health systems looked to leverage technology to assist in serving populations in health professional shortage areas. Qualitative research points to EHR usability as a source of health inequities in rural settings, making the challenges of EHR usage a subject of interest. Pennsylvania offers a model for investigating rural health infrastructure with it having the third largest rural population in the United States. This study analyzed the adoption of Electronic Prescribing in the 67 Pennsylvania (PA) counties. Physician adoption and usage data for PA and the United States were compared using a t-test to establish a basis for comparison. PA counties were categorized using the United States Department of Agriculture (USDA)'s Rural-Urban Commuting Areas (RUCAs) system. Surescript use percentages were plotted against the RUCA scores of each PA county to create a polynomial regression model. PA office-based physicians, on average, utilize e-prescription tools at the same rate as the national average with 59% of practices utilizing Surescripts as of 2013. There was no significant correlation between Surescript usage and the rural/urban classification of counties in Pennsylvania (R-squared value of 0.06). Pennsylvania was able to adopt health information technology (HIT) infrastructure at the same rate as the national average. Rural and metropolitan definitions do not correlate to meaningful use of HIT, thus usability of HIT cannot be tied to health outcomes. Future studies looking at specific forms of HIT and their ability to decrease the burden of administrative work for clinicians.

Practice Perspectives on Care Coordination in Rural Settings

PURPOSE

Social needs and nonmedical health determinants are increasingly incorporated into care coordination models. However, little is known about the practice of operationalizing enhanced care coordination, particularly in rural settings. The objective of this study was to determine care coordination practices in rural settings that integrate social services with health care.

PRIMARY PRACTICE SETTINGS

Staff and administrators in rural Missouri health and health care settings were interviewed about their organization's implementation of enhanced care coordination practices.

METHODOLOGY AND SAMPLE

This is a mixed-methods study; 16 key informant structured interviews were conducted across 14 organizations.

RESULTS

Organizations reported a median care coordination population of 800 (range: 50-21,500) across a median of 11 case managers (range: 3-375). The percentage of organizations reporting social determinants of health services included the following: 100% transportation, 86% mental health, 79% food, 71% housing, and 50% dental. Implementation of the essential indicators of care coordination quality ranged from 41.7% to 100%. We report organizations' innovative solutions to care coordination barriers.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

This study contributes to a very limited literature on the practice of rural care coordination by assessing the quality of care provided compared with a recommended standard. This study also contributes an in-depth reporting on the variety of service models being implemented. Finally, this study uniquely contributes innovative interprofessional examples of enhanced care coordination initiatives. These examples may provide inspiration for rural health care organizations. As the care coordination landscape evolves to include social determinants of health, there remain important fundamental barriers to ensuring quality of care.

Transforming Health Data to Actionable Information: Recent Progress and Future Opportunities in Health Information Exchange

OBJECTIVES

Provide a systematic review of literature pertaining to health information exchange (HIE) since 2018. Summarize HIE-associated literature for most frequently occurring topics, as well as within the context of the COVID-19 pandemic and health equity. Finally, provide recommendations for how HIE can advance the vision of a digital healthcare ecosystem.

METHODS

A computer program was developed to mediate a literature search of primary literature indexed in MEDLINE that was: (1) indexed with "Health Information Exchange" MeSH descriptor as a major topic; and (2) published between January 2018 and December 2021. Frequency of MeSH descriptors was then used to identify and to rank topics associated with the retrieved literature. COVID-19 literature was identified using the general COVID-19 PubMed Clinical Query filter. Health equity literature was identified using additional MeSH descriptor-based searches. The retrieved literature was then reviewed and summarized.

RESULTS

A total of 256 articles were retrieved and reviewed for this survey. The major thematic areas summarized were: (1) Information Dissemination; (2) Delivery of Health Care; (3) Hospitals; (4) Hospital Emergency Service; (5) COVID-19; (6) Health Disparities; and (7) Computer Security and Confidentiality. A common theme across all areas examined for this survey was the maturity of HIE to support data-driven healthcare delivery. Recommendations were developed based on opportunities identified across the reviewed literature.

CONCLUSIONS

HIE is an essential advance in next generation healthcare delivery. The review of the recent literature (2018-2021) indicates that successful HIE improves healthcare delivery, often resulting in improved health outcomes. There remain major opportunities for expanded use of HIE, including the active engagement of clinical and patient stakeholders. The maturity of HIE reflects the maturity of the biomedical informatics and health data science fields.

Perspectives on Coordinating Health Services for Individuals with Serious Mental Illness - A Qualitative Study

PURPOSE

Individuals with serious mental illness (SMI) might require coordinated health services to meet their healthcare needs. The overall aim of this study was to describe the perspectives of professionals (registered nurses, medical doctors, social educators, and social workers) on care coordination and measures to ensure proper and coordinated follow-up of the healthcare needs of individuals with SMI. More specifically, we investigated which measures are taken by employees in municipal health and care services to prevent the deterioration of health conditions and which measures are taken in cases where deterioration occurs despite preventive efforts.

METHOD

The study comprised individual qualitative interviews with professionals employed in municipal health and care services in two Norwegian municipalities. The interview material was analyzed using systematic text condensation.

RESULTS

Three categories and seven subcategories were created in the data analysis: 1) Maintain a stable and meaningful home life, including ensuring proper housing and access to services and assistance in receiving healthcare; 2) Measures to prevent deterioration of the health condition, including close monitoring of symptoms, emergency psychiatric care plans and emergency room calls and visits; and 3) Inpatient care to stabilize acute and severe symptoms, including municipal inpatient care, returning home after inpatient care and a need for shared responsibility for treatment and care.

CONCLUSION

Professionals employed in municipal health and care services coordinate health services to ensure proper and coordinated follow-up of the healthcare needs of individuals with SMI by ensuring housing services and access to the required healthcare. Measures taken when deterioration occurs include monitoring symptoms, use of emergency psychiatric care plans, emergency room contacts, or inpatient care.

The Role of Community Health Workers in Developing Multidimensional Organizational Relationships

Effective care coordination relies on organizations working collaboratively to meet medically and socially complex participants' needs. This study examines community health workers' (CHWs') roles in developing the organizational relationships on which care coordination efforts depend. Semistructured interviews (n = 13) were conducted with CHWs, CHWs' supervisors, and executive staff at organizations participating in a Washington State care coordination program. Interviewees described how CHWs developed and furthered multidimensional relationships in service of participants between and within participating organizations, as well as external organizations. Relationship-building challenges included COVID-19, geographic context, and staffing. The study concludes with considerations for care coordination efforts to support CHWs.

Assessing Progress Toward the Vision of a Comprehensive, Shared Electronic Care Plan: Scoping Review

Background

Care plans are central to effective care delivery for people with multiple chronic conditions. But existing care plans—which typically are difficult to share across care settings and care team members—poorly serve people with multiple chronic conditions, who often receive care from numerous clinicians in multiple care settings. Comprehensive, shared electronic care (e-care) plans are dynamic electronic tools that facilitate care coordination and address the totality of health and social needs across care contexts. They have emerged as a potential way to improve care for individuals with multiple chronic conditions.

Objective

To review the landscape of e-care plans and care plan–related initiatives that could allow the creation of a comprehensive, shared e-care plan and inform a joint initiative by the National Institutes of Health and the Agency for Healthcare Research and Quality to develop e-care planning tools for people with multiple chronic conditions.

Methods

We conducted a scoping review, searching literature from 2015 to June 2020 using Scopus, Clinical Key, and PubMed; we also searched the gray literature. To identify initiatives potentially missing from this search, we interviewed expert informants. Relevant data were then identified and extracted in a structured format for data synthesis and analysis using an expanded typology of care plans adapted to our study context. The extracted data included (1) the perspective of the initiatives; (2) their scope, (3) network, and (4) context; (5) their use of open syntax standards; and (6) their use of open semantic standards.

Results

We identified 7 projects for e-care plans and 3 projects for health care data standards. Each project provided critical infrastructure that could be leveraged to promote the vision of a comprehensive, shared e-care plan. All the e-care plan projects supported both broad goals and specific behaviors; 1 project supported a network of professionals across clinical, community, and home-based networks; 4 projects included social determinants of health. Most projects specified an open syntax standard, but only 3 specified open semantic standards.

Conclusions

A comprehensive, shared, interoperable e-care plan has the potential to greatly improve the coordination of care for individuals with multiple chronic conditions across multiple care settings. The need for such a plan is heightened in the wake of the ongoing COVID-19 pandemic. While none of the existing care plan projects meet all the criteria for an optimal e-care plan, they all provide critical infrastructure that can be leveraged as we advance toward the vision of a comprehensive, shared e-care plan. However, critical gaps must be addressed in order to achieve this vision.

The impact of interprofessional communication through ICT on health outcomes of older adults receiving home care in Japan – A retrospective cohort study

Background

Information communication technology (ICT) is crucial to modern communication and information sharing. Effective interprofessional collaboration is essential in the care of elderly people. However, little is known about the effects of ICT on care provision for elderly people in a home setting. This retrospective cohort study examines the impact of interprofessional collaboration using ICT on the health outcomes of elderly home care patients.

Methods

The Team^® mobile application promotes cooperation in local medical health care. It enables providers to obtain and share patient information within a single, cloud‐based platform. We collected and analyzed data from 554 patients from Nagaoka (Niigata prefecture, Japan) who received home care services from 2015 to 2020. We calculated the cumulative hazard ratio (HR) of death or admission to a hospital or nursing home for patients whose information was shared among different professions using the platform, and for those whose information was not shared. We used a Cox proportional hazards model, adjusted for covariates, and applied propensity score matching.

Results

The average age of the study population was 83.5 years; the median follow‐up period was 579.0 days. The risk of death or admission to a hospital or nursing home significantly decreased in the information‐shared group, compared with the control group (adjusted HR: 0.47 [p < 0.01]). Significance remained after propensity score matching (HR: 0.58; p = 0.01).

Conclusions

Interprofessional collaboration using ICT may reduce the risk of death or admission to a hospital or nursing home among elderly home care patients in Japan.

Examining Structural Disparities in U.S. Nursing Homes: A National Survey of Health Information Technology Maturity (Preprint)

Background

There are 15,632 nursing homes (NHs) in the United States. NHs continue to receive significant policy attention due to high costs and poor outcomes of care. One strategy for improving NH care is use of health information technology (HIT). A central concept of this study is HIT maturity, which is used to identify adoption trends in HIT capabilities, use and integration within resident care, clinical support, and administrative activities. This concept is guided by the Nolan stage theory, which postulates that a system such as HIT moves through a series of measurable stages. HIT maturity is an important component of the rapidly changing NH landscape, which is being affected by policies generated to protect residents, in part because of the pandemic.

Objective

The aim of this study is to identify structural disparities in NH HIT maturity and see if it is moderated by commonly used organizational characteristics.

Methods

NHs (n=6123, >20%) were randomly recruited from each state using Nursing Home Compare data. Investigators used a validated HIT maturity survey with 9 subscales including HIT capabilities, extent of HIT use, and degree of HIT integration in resident care, clinical support, and administrative activities. Each subscale had a possible HIT maturity score of 0-100. Total HIT maturity, with a possible score of 0-900, was calculated using the 9 subscales (3 x 3 matrix). Total HIT maturity scores equate 1 of 7 HIT maturity stages (stages 0-6) for each facility. Dependent variables included HIT maturity scores. We included 5 independent variables (ie, ownership, chain status, location, number of beds, and occupancy rates). Unadjusted and adjusted cumulative odds ratios were calculated using regression models.

Results

Our sample (n=719) had a larger proportion of smaller facilities and a smaller proportion of larger facilities than the national nursing home population. Integrated clinical support technology had the lowest HIT maturity score compared to resident care HIT capabilities. The majority (n=486, 60.7%) of NHs report stage 3 or lower with limited capabilities to communicate about care delivery outside their facility. Larger NHs in metropolitan areas had higher odds of HIT maturity. The number of certified beds and NH location were significantly associated with HIT maturity stage while ownership, chain status, and occupancy rate were not.

Conclusions

NH structural disparities were recognized through differences in HIT maturity stage. Structural disparities in this sample appear most evident in HIT maturity, measuring integration of clinical support technologies for laboratory, pharmacy, and radiology services. Ongoing assessments of NH structural disparities is crucial given 1.35 million Americans receive care in these facilities annually. Leaders must be willing to promote equal opportunities across the spectrum of health care services to incentivize and enhance HIT adoption to balance structural disparities and improve resident outcomes.

Evaluation of financial outcomes under a value-based payment program for community pharmacies

BACKGROUND: Value-based payment models have been shown to limit health care spending and waste while improving quality of care. Evidence from value-based pharmacy programs (VBPPs) is needed to guide the use of these mechanisms in health care. OBJECTIVE: To evaluate financial outcomes of a VBPP implemented in 73 community pharmacies for about 40,000 commercial beneficiaries of Wellmark, Inc. METHODS: Beneficiaries were attributed to pharmacies based on the number of prescriptions dispensed. The VBPP paid community pharmacies a per capita payment based on their performance on a set of metrics to deliver care the pharmacists believed was necessary to optimize the beneficiaries' medication therapy and associated outcomes. Financial outcome variables were analyzed for the calendar year of 2018, including total cost of care, hospital admissions, and emergency department (ED) visits. Hospital admissions and ED visits were identified through claims data. Generalized linear models were used to test the effect of the VBPP on each of the outcome variables by comparing outcomes for beneficiaries attributed to the pharmacies participating in the VBPP (73 pharmacies) to Wellmark's beneficiaries attributed to nonparticipating pharmacies (847 pharmacies). Independent variables used in the models to control for possible confounding included beneficiary demographics and complexity scores, region code, accountable care organization (ACO) attribution, beneficiary product type (health maintenance organization (HMO), preferred provider organization (PPO), and several disease indicator variables. RESULTS: Analyses showed in 2018 that the per beneficiary per month total costs of care for the beneficiaries going to the VBPP pharmacies (N = 15,463) was $30.48 (4.5%; 95% CI = -6.2% to -2.7%) lower than that of the non-VBPP group (N = 140,717). The hospital admission rate for the VBPP group was 5.1% lower but was not statistically significant (95% CI = -12.9% to 3.3%). Similarly, the ED visit rate for the VBPP group was 2.1% lower than the non-VBPP group but did not reach statistical significance (95% CI = -8.6% to 3.3%). CONCLUSIONS: With the growing need for solutions to improve quality of care while reducing health care costs and waste, a value-based payment program using performance-determined capitated payments to community pharmacies offering enhanced clinical services significantly reduced total costs of care in a commercial population with one or more chronic conditions. Future work with this promising model is encouraged. DISCLOSURES: No external funding was obtained to support this study. Devolder and Heggen are employed by Wellmark, Inc. Doucette is supported by the Deborah K. Veale Professorship in Healthcare Policy at the University of Iowa. The authors have no other potential conflicts of interest to disclose.

Human Factors and Organizational Issues in Health Informatics: Innovations and Opportunities

OBJECTIVE

Human factors and ergonomics (HF/E) frameworks and methods are becoming embedded in the health informatics community. There is now broad recognition that health informatics tools must account for the diverse needs, characteristics, and abilities of end users, as well as their context of use. The objective of this review is to synthesize the current nature and scope of HF/E integration into the health informatics community.

METHODS

Because the focus of this synthesis is on understanding the current integration of the HF/E and health informatics research communities, we manually reviewed all manuscripts published in primary HF/E and health informatics journals during 2020.

RESULTS

HF/E-focused health informatics studies included in this synthesis focused heavily on EHR customizations, specifically clinical decision support customizations and customized data displays, and on mobile health innovations. While HF/E methods aimed to jointly improve end user safety, performance, and satisfaction, most HF/E-focused health informatics studies measured only end user satisfaction.

CONCLUSION

HF/E-focused health informatics researchers need to identify and communicate methodological standards specific to health informatics, to better synthesize findings across resource intensive HF/E-focused health informatics studies. Important gaps in the HF/E design and evaluation process should be addressed in future work, including support for technology development platforms and training programs so that health informatics designers are as diverse as end users.

Telehealth in US hospitals: State-level reimbursement policies no longer influence adoption rates

OBJECTIVES

Prior to COVID-19, levels of adoption of telehealth were low in the U.S., though they exploded during the pandemic. Following the pandemic, it will be critical to identify the characteristics that were associated with adoption of telehealth prior to the pandemic as key drivers of adoption and outside of a public health emergency.

MATERIALS AND METHODS

We examined three data sources: The American Telemedicine Association's 2019 state telehealth analysis, the American Hospital Association's 2018 annual survey of acute care hospitals and its Information Technology Supplement. Telehealth adoption was measured through five telehealth categories. Independent variables included seven hospital characteristics and five reimbursement policies. After bivariate comparisons, we developed a multivariable model using logistic regression to assess characteristics associated with telehealth adoption.

RESULTS

Among 2923 US hospitals, 73% had at least one telehealth capability. More than half of these hospitals invested in telehealth consultation services and stroke care. Non-profit hospitals, affiliated hospitals, major teaching hospitals, and hospitals located in micropolitan areas (those with 10-50,000 people) were more likely to adopt telehealth. In contrast, hospitals that lacked electronic clinical documentation, were unaffiliated with a hospital system, or were investor-owned had lower odds of adopting telehealth. None of the statewide policies were associated with adoption of telehealth.

CONCLUSIONS

Telehealth policy requires major revisions soon, and we suggest that these policies should be national rather than at the state level. Further steps as incentivizing rural hospitals for adopting interoperable systems and expanding RPM billing opportunities will help drive adoption, and promote equity.

Rural Perceptions of Acute Care at Home: A Qualitative Analysis

PURPOSE

Hospital-level care at home in urban areas delivers low-cost, high-quality care. Few have attempted to deliver home hospital care in a rural environment, where traditional hospitals are often less equipped to deliver high-quality care. Little is known about rural clinicians' and patients' perceptions regarding rural home hospital care and how the urban model might be adapted to fit rural circumstances.

METHODS

We conducted semistructured qualitative interviews in the United States with a national purposive sample of practicing rural clinicians, a focus group with clinicians who care for rural patients, and interviews with rural patients. We coded these qualitative data into domains and subdomains.

FINDINGS

We identified 4 domains: (1) current state of rural health care, (2) attitudes toward rural home hospital, (3) perceived barriers to implementing rural home hospital, and (4) perceived facilitators to implementing rural home hospital. Participants expressed challenges with current rural health care, including inefficient care coupled with poor access. Most felt rural home hospital care could offer benefits, including comfort, timeliness, and downstream outcomes such as readmission rate reduction. Rural patients were open to receiving acute care in their homes. Potential barriers included geographic accessibility, Internet connectivity, rural hospital politics, the culture of hospitalization, and the availability of skilled human resources.

CONCLUSIONS

Significant interest and optimism exist surrounding rural home hospital despite perceived barriers. Designing for and testing adaptations to the urban model will likely optimize benefits and minimize threats to a potential intervention.