A proposed conceptual model of nursing and population health

"Organizing practice": The hidden work of homecare nurses in fighting health inequity and advancing social justice

The nursing profession has a long history of advocating for social justice and health equity, and both values profoundly infuse nursing ethics, theory, and education. Homecare nursing occurs between the patient's daily life at home and the public health care system. Therefore, homecare nurses ideally possess insight into the living conditions and social determinants of health that their patients experience. This interpretive phenomenological study explores the strategies employed by homecare nurses to fight health inequity and advance social justice. Data were collected through participant observations, situational interviews, and small group interviews with 12 homecare nurses from two municipalities. Three analytical approaches were used: paradigm cases, exemplars, and thematic analysis. The data identified two primary strategies homecare nurses use to circumvent, solve, and mitigate the negative consequences of social determinants of health on patients' care and treatment: "Negotiating practice" and "Aligning practice." "Negotiating practice" ensures that care and treatment are delivered in a way acceptable to all involved. "Aligning practice" ensures cohesion, progression in the treatment and care trajectory, and support for patients and relatives in navigating the system. Both strategies are part of nurses' largely hidden work, reflecting the nursing profession's position as nested between the individual patient and the system.

Unlocking Population-Specific Treatments to Render Equitable Approaches and Management in Cardiovascular Disease: Development of a Situation-Specific Theory for African American Emerging Adults

BACKGROUND

Emerging adulthood (18-25 years old) is a distinct developmental period in which multiple life transitions pose barriers to engaging in healthy lifestyle behaviors that reduce cardiovascular disease risk. There is limited theory-based research on African American emerging adults.

OBJECTIVE

This article introduces a synthesized empirically testable situation-specific theory for cardiovascular disease prevention in African American emerging adults.

METHODOLOGY

Im and Meleis' integrative approach was used to develop the situation-specific theory.

RESULTS

Unlocking Population-Specific Treatments to Render Equitable Approach and Management in Cardiovascular Disease is a situation-specific theory developed based on theoretical and empirical evidence and theorists' research and clinical practice experiences.

DISCUSSION

African American emerging adults have multifaceted factors that influence health behaviors and healthcare needs. Unlocking Population-Specific Treatments to Render Equitable Approaches and Management in Cardiovascular Disease has the potential to inform theory-guided clinical practice and nursing research. Recommendations for integration in nursing practice, research, and policy advocacy are presented. Further critique and testing of the theory are required.

Ready or Not: A Conceptual Model of Organizational Readiness for Embedded Pragmatic Dementia Research

The National Institute on Aging Alzheimer's Disease/Alzheimer's Disease and Related Dementias Research Implementation Milestones emphasize the need for implementation research that maximizes up-take and scale-up of evidence-based dementia care practices across settings, diverse populations, and disease trajectories. Organizational readiness for implementation is a salient consideration when planning and conducting embedded pragmatic trials, in which interventions are implemented by provider staff. The current article examines the conceptual and theoretical underpinnings of organizational readiness for implementation and the operationalization of this construct. We offer a preliminary conceptual model for explicating and measuring organizational readiness and describe the unique characteristics and demands of implementing evidence-based interventions targeting persons with dementia and/or their care partners. [Research in Gerontological Nursing, 17(3), 149-160.].

Food Insecurity, Neighborhood Disadvantage, and Hospital Readmission in Health System Adults: A Population Health Study

PURPOSE

The purpose of the study was to examine the relationship between food insecurity, neighborhood disadvantage, and hospital readmission within 90 days of discharge for health system patients.

DESIGN

The study used a retrospective, correlational design with a single cohort.

METHODS

Records of adult patients with a health system primary care provider and discharged from hospital to home were included. Data were obtained from health system billing database, medical record, and publicly available population databases. A time-to-readmission analysis was conducted with a Kaplan-Meier plot, log-rank test, and Cox regression analysis.

RESULTS

The final sample included 41 566 records; the rate of food insecurity was 1.45%, and 90-day readmission rate was 16.7%. The mean area deprivation index score was 54.4 (SD, 26.0). After adjusting for patient demographics, comorbidity, and length of stay, food insecurity resulted in 1.94 times higher risk of readmission (hazard ratio, 1.94; 95% confidence interval, 1.69-2.23; P < .001). Neighborhood disadvantage and lower food access were not significant in final models.

CONCLUSIONS

Food insecurity should be identified and addressed as part of transitional care to improve patient outcomes. Future research should focus on models of care that ensure connection to community resources to resolve food insecurity and evaluate the impact on patient outcomes.

End-of-Life Care Planning in Diverse Individuals Across Age Groups: A Proposed Conceptual Model of Nursing

BACKGROUND

End-of-life planning helps nurses meet the needs of their patients at a crucial time of life.

PURPOSE

This article presents a conceptual model of end-of-life care planning for nurses, especially those in palliative and hospice care, focusing on holistic nursing views.

METHODS

Based on a literature review, we developed a new conceptual model illustrating the concepts and dimensions of end-of-life care planning among diverse individuals across countries, life spans and age groups, ethnographies, and residential statuses.

RESULTS

This conceptual model includes 3 concepts: personal factors, stakeholders, and environmental and social factors. Each concept encompasses multiple dimensions. The concepts are interrelated and directly related to end-of-life care planning.

CONCLUSION

This work addresses the need for a comprehensive end-of-life care planning model and can help enhance the quality of end-of-life care. This article identifies implications for nursing education, practice, and research.

Population Health: A New Essential in Nursing

BACKGROUND

Nursing education is engaged in efforts to respond and adapt to the dynamic fluctuations of health care in the United States. Population health has been revived in this venue of health care involvement in the community and social determinants of health.

PURPOSE

The purpose of the study was to define population health and identify topics to include in the undergraduate curriculum, teaching strategies, and skills and competencies needed by new nurses for implementation of population health to improve health outcomes.

METHODS

The study had a mixed-methods design with a survey and an interview distributed to public/community health faculty across the United States.

RESULTS

Extensive population health topics were suggested for the curriculum, but a significant lack of a structured framework and consistent concepts was noted.

CONCLUSIONS

Topics identified in the survey and through the interviews are illustrated in the tables. These will assist in integrating and scaffolding population health throughout a nursing curriculum.

Teaching nursing within a population health context: From concept to exemplars

As researchers in the health sciences improve their understanding of the underlying causes of poor health to include non-medical factors, nursing practice must expand and adapt to enable nurses to effectively contribute to population health improvement. The concept of population health has been incorporated into the current American Association of Colleges of Nursing (AACN) The Essentials: Core Competencies for Professional Nursing Education (2021) as a set of competencies for nurses at entry and advanced levels. This article provides a description of these competencies, and exemplars of how to include them meaningfully in nursing curricula at the entry level.

Climate Change, Environmental Health, and Challenges for Nursing Discipline

Current data and scientific predictions about the consequences of climate change are accurate in suggesting disaster. Since 2019, climate change has become a threat to human health, and major consequences on health and health systems are already observed. Climate change is a central concern for the nursing discipline, even though nursing theorists' understanding of the environment has led to problematic gaps that impact the current context. Today, nursing discipline is facing new challenges. Nurses are strategically placed to respond to the impacts of climate change through their practice, research, and training in developing, implementing, and sustaining innovation towards climate change mitigation and adaptation. It is urgent for them to adapt their practice to this reality to become agents of change.

Population health in a global society: Preparing nurses for the future

BACKGROUND

The COVID-19 pandemic has reinforced awareness that the health of populations is inextricably linked around the globe. Nurses require increased knowledge and preparation in global health. Nursing educators need examples of how to improve content in the curriculum.

AIMS

The purpose of this paper is to describe reconceptualization of a master's level nursing course entitled "Population Health in a Global Society" to include global health competencies.

METHODS

We identified four global health competencies within the following three domains: globalization of health and healthcare; collaboration, partnering, and communication; and sociocultural and political awareness.

IMPLEMENTATION

We utilized guest lectures, a panel discussion, discussion forums and an independent research assignment. The methods used were well received by students, and the content delivered improved their perceived knowledge in global population health.

DISCUSSION

The global health domains and competencies provided a roadmap for improving our course to focus on population health from a global perspective.

CONCLUSION

In order to prepare nurses to contribute to global population health, population health courses should integrate global health competencies. The content of the revised course will better prepare nurses who will practice in a wide variety of settings and is designed for interdisciplinary education.

"Human as an Embodied Spirit": A Proposed Conceptual Model for Nursing Based on Iranian Mysticism and Wisdom

Most nursing models are developed based on Western philosophy. The conceptual model of "human as an embodied spirit" based on Iranian mysticism and wisdom is presented in this article. This conceptual model was developed in 2 phases: first, using a derivation process, the concepts of the model were developed. Next, in a synthesis process, the conceptual model was constructed. Definitions and descriptions of each of the concepts of the model-the constitution of the physical body, the composition of graded soul, knowledge-based interventions, love-based interventions, balance, and harmony-and the relations between these concepts are presented in the article. This model gives equal value to the art and the science of nursing and integrates all dimensions of human being and related health problems in such a way that they can be explained and approached as a continuum. The next step is the testing of this model followed by the development of guidelines for education and practice.

Defining the social determinants of health for nursing action to achieve health equity: A consensus paper from the American academy of nursing

BACKGROUND

The 2019-2020 American Academy of Nursing (Academy, 2019) policy priorities document states that "they have a clear and distinct focus on social determinants of health and uses this lens to advance policies and solutions within each of the three overarching priorities" PURPOSE: This consensus paper seeks to establish conceptual clarity and consensus for what social determinants of health mean for nursing, with emphasis on examples of health policies that advance planetary health equity and improve planetary health-related quality of life.

METHODS

Volunteers from five Expert Panels of the Academy met via videoconference to determine roles and refine the focus of the paper. After the initial discussion, the first draft of the conceptual framework was written by the first three authors of the paper and, after discussion via videoconference with all the co-authors, successive drafts were developed and circulated for feedback. Consensus was reached when all authors indicated acceptance of what became the final version of the conceptual framework.

DISCUSSION

A conceptual framework was developed that describes how the social determinants of health can be addressed through nursing roles and actions at the individual, family, and population levels with a particular focus on the role of health policy. The paper provides a specific health policy example for each of the six key areas of the social determinants of health to illustrate how nurses can act to improve population health.

CONCLUSION

Nursing actions can support timely health policy changes that focus on upstream factors in the six key areas of the social determinants of health and thus improve population health. The urgent need to eliminate systematic and structural racism must be central to such policy change if equity in planetary health-related quality of life is to be attained.

Upstream Factors in Population Health: A Concept Analysis to Advance Nursing Theory

The assessment of upstream factors is important in population-based nursing practice. The aim of this concept analysis is to enhance understanding of upstream factors and articulate a definition linked to the Conceptual Model for Nursing and Population Health. Upstream factors are thus defined as established conditions related to economic, social, and physical environments that occur outside the health care system, in the communities where people live, and contribute indirectly to the health outcomes for groups of individuals through multiple causal pathways. This concept analysis highlights the need for middle-range theory to guide nursing assessment and contributes to conceptual model evaluation.

Preparing the clinicians of tomorrow: Weaving integrated care across doctor of nursing practice education

In today's changing landscape of health care, integrated health care is essential for best patient outcomes. The number of people with psychiatric conditions in the United States today is staggering, but only half of these people will receive treatment for their condition. By effectively integrating psychiatric and primary health care patients can be connected to appropriate and necessary services that meet the Triple Aim of enhancing patient experience of care while achieving population health goals in a cost-effective manner. Incorporating integrated health care experiences in a DNP program can position future practice leaders to take on these challenges. Guided by DNP essentials and the National Organization of Nurse Practitioner Faculty competencies, integrated health care concepts were weaved across the DNP curriculum. Including robust academic experiences treating mental health conditions in primary care and integrated settings can increase the confidence and effectiveness of clinicians who identify, manage, and refer patients with mental health concerns. Increasing the number of doctorally prepared nurses who are educated in integrated health care helps improve clinical outcomes while transforming the health care landscape.

Transformative Learning in an Online Doctor of Nursing Practice Population Health Course

BACKGROUND

Population health is a critical component of Doctor of Nursing Practice (DNP) education, providing the foundation for clinical prevention, health equity, responsible policy, and practice change. Many DNP learners enter population health courses focused on individual patient care in microsystems. Transformative learning broadens learners' perspectives about health determinants and implications for health system transformation.

METHOD

Transformative learning strategies were imbedded in a 10-week, online population health course. Students engaged with readings and multimedia content and wrote anonymous reflective analyses about population health determinants. Qualitative survey data were explored for transformative content using line-by-line content analysis. The stages of transformative learning were used as a priori codes.

RESULTS

Learners questioned their own beliefs and epistemologies and demonstrated all aspects of transformative learning, although not equally across course topics.

CONCLUSION

To achieve the promised outcomes of DNP education, population health content should be professionally transformative and integrated across the curriculum. [J Nurs Educ. 2019;58(8):481-484.].

Still More Thoughts About Conceptual Models and Literature Reviews: Focus on Health Policy

This essay is the second of two essays about the use of a conceptual model to guide scoping reviews of literature. The first essay, published in the previous issue of Nursing Science Quarterly, provided examples of the use of the conceptual model of nursing and population health as a starting point for the construction of conceptual-theoretical-empirical structures for scoping reviews. In this essay, the examples are of the use of the conceptual model of nursing and health policy.

Thoughts About the Language of Equity for Population Health

This is the first of two essays addressing equity and social justice, which are interrelated concepts of considerable interest to members of the discipline of nursing. The purpose of this essay is to define equity and related terms, including inequity, inequality, and disparities, within the context of the intersection of nursing and population health science. An essay about social justice will appear in a subsequent issue of Nursing Science Quarterly.

Models and frameworks that enable nurses to develop their public health practice-A scoping study

AIMS AND OBJECTIVES

This scoping review commissioned by the Public Health England, WHO collaborating Centre, aimed to explore the models and frameworks which enable nurses to develop their public health practice and deliver public health interventions to individuals, families and communities.

BACKGROUND

There is a plethora of literature regarding the role, activities and scope of practice undertaken by public health nurses across the world. However, only two reviews have explored the models and frameworks used for public health nursing practice.

DESIGN

The study drew upon an established framework with a narrative review drawing upon five methodological steps.

METHODS

A search of databases, Medline, PsycINFO, Embase, CINHAL and British Nursing Index, was undertaken. The search took place between April 2018 and June 2018 retrieving 9,513 peer-reviewed articles published from 2008.

RESULTS

Ninety-five studies were retrieved and analysed thematically. From an initial review of literature, two themes were identified: public health models used in practice and models used in public health education. Within the first theme, three subthemes were emerged: Characteristics of the interventions; Characteristics of the public health nurse; and Lack of measurable health benefits. Within the second theme, three subthemes were identified: Faculty and Students Working Together; The Experiential Academic Approach, and What works in Educating Nurses for Public Health.

CONCLUSION

The review identified that many models and frameworks are used in practice. However, within public health practice there is a limited evidence base and it fails to demonstrate that the frameworks and models developed for practice result in measurable health benefits on an individual or population level. However, within education innovative models were apparent with collaborative partnerships enabling preregistration nursing students to develop public health nursing competencies.

RELEVANCE TO CLINICAL PRACTICE

Innovative approaches to education of preregistration nursing students could point the way forward for the delivery of public health nursing practice.

The individual focus of nursing research in breastfeeding: Perpetuating a neoliberal perspective

In this paper, I argue for the need to shift the focus of nursing research regarding breastfeeding from that of individual responsibility to include a more system-focused, population health approach. In the 2011, "Call to Action to Support Breastfeeding," the U.S. Surgeon General called attention to the pervasive disparities in breastfeeding outcomes in the United States. A plethora of nursing research exists aimed at addressing these disparities; however, this research leans toward a neoliberal perspective, mainly focusing on individual factors and failing to address the systemic inequities contributing to these disparities. A shift in nursing science that focuses research at a population level would more effectively support addressing disparities in breastfeeding outcomes and embrace a commitment to social justice. In focusing at a population level, specific inequities that must be addressed include the negative history of breastfeeding in the Black population, systemic racism, and gender inequality. Critical research methodologies are proposed as useful approaches to address these inequities. By engaging in this level of research and using a critical lens, nurse scientists broaden their scope of care to include the entire population, motivate needed social and policy change, facilitate the choice to breastfeed, and ultimately eliminate breastfeeding disparities.

Modelo conceptual del manejo del síntoma: evaluación y crítica

Objetivos: evaluar, analizar y criticar el modelo conceptual del manejo del síntoma a partir de los pasos planteados por Fawcett en 2013, y mostrar la relevancia que tiene este ejercicio académico en el área investigativa, tanto a nivel académico como asistencial en enfermería. Materiales y métodos: se realizó una búsqueda sistemática de piezas de investigación, las cuales fueron sometidas a un proceso de lectura crítica por medio de la aplicación de las siguientes herramientas: Critical Appraisal Skills Programme (CAPS) para las piezas de investigación cualitativas, MacMaster University para la piezas de investigación de tipo cuantitativo, el rigor metodológico y la estructura conceptual teórico-empírica planteada por Fawcett en 2013, con lo cual se garantizó la calidad de las piezas de investigación seleccionadas. Resultados: se logró identificar los planteamientos del Modelo conceptual del manejo del síntoma y de investigaciones donde se utilizó este modelo como marco teórico para realizar una evaluación y crítica de este, en la que se tuvieron en cuenta: sus orígenes, el enfoque único del modelo, su congruencia lógica, la generación de teoría, su credibilidad y las contribuciones para la disciplina de enfermería, que corresponden a los pasos recomendados por Fawcett para la evaluación crítica de modelos conceptuales. Conclusión: a pesar de ser un modelo conceptual nuevo cuenta con fuertes bases teóricas y filosóficas que permiten su aplicación a cualquier fenómeno referente a la experiencia de los síntomas; sin embargo, se debe realizar más investigación donde se haga uso de las dimensiones de “los componentes de estrategias de manejo de los síntomas” y “resultados”, ya que un amplio volumen de investigación realizada hasta el momento ha hecho uso de la dimensión “la experiencia de los síntomas”.

More Thoughts About Conceptual Models and Literature Reviews: Focus on Population Health

This essay extends discussion of the ways in which a conceptual model of nursing can guide literature reviews. Emphasis is placed on ways in which the conceptual model of nursing and population health was used to guide and/or categorize the results of scoping reviews of the literature. Examples are presented in the form of diagrams and narrative explanations of the resultant conceptual-theoretical-empirical structures.

Pragmatic dissemination and implementation research models, methods and measures and their relevance for nursing research

BACKGROUND

Pragmatic dissemination and implementation (D&I) research approaches can benefit patient care because they emphasize real-world settings and populations. Nurse scientists have an opportunity to reduce the gap between science and practice by using pragmatic D&I research and sustainability strategies.

PURPOSE

This article discusses pragmatic models, methods, and measures used in D&I research and their relevance for nursing research and enhancing population health.

METHODS

Summary of pragmatic D&I models and related methods for designing a pragmatic studies. We discuss the RE-AIM framework and the PRECIS-2 planning aid and figure in detail. A case study is provided and application to nursing research is discussed.

DISCUSSION

Successful translation of pragmatic D&I research demands an approach that addresses external validity, and customization at multiple levels including the patient, clinician, and setting. Context is critically important, and it is never too early to design for dissemination.

CONCLUSIONS

Pragmatic D&I approaches are needed to speed research translation, reduce avoidable waste of funding, improve clinical care, and enhance population health. Pragmatic D&I research is an area of tremendous opportunity for the nursing science community.

Thinking Upstream: A 25-Year Retrospective and Conceptual Model Aimed at Reducing Health Inequities

Thinking upstream was first introduced into the nursing vernacular in 1990 with the goal of advancing broad and context-rich perspectives of health. Initially invoked as conceptual framing language, upstream precepts were subsequently adopted and adapted by a generation of thoughtful nursing scholars. Their work reduced health inequities by redirecting actions further up etiologic pathways and by emphasizing economic, political, and environmental health determinants. US health care reform has fostered a much broader adoption of upstream language in policy documents. This article includes a semantic exploration of thinking upstream and a new model, the Butterfield Upstream Model for Population Health (BUMP Health).

Thoughts About Population Health Nursing Research Methods: Questions About Participants and Informed Consent

The purpose of this essay is to discuss who participants should be in population health nursing research within the context of the Conceptual Model of Nursing and Population Health. The emphasis is on recruitment of research participants who constitute populations rather than samples drawn from populations and the challenges of obtaining informed consent from populations.

Opportunities in the integration of primary care and public health nursing: Two case exemplars on physical activity and nutrition

OBJECTIVE

The integration of primary care and public health nursing may provide new opportunities for transforming nursing practice that addresses population health. Effective programs emphasize multilevel approaches that include both downstream (education) and upstream (policy change) actions. The purpose of this article is to identify downstream and upstream nursing actions that integrate public health and primary care practice through two case exemplars concerning disparities in physical activity and nutrition.

METHODS

Describe two research case exemplars: (1) a secondary analysis of school physical activity policy for female adolescents in 36 public middle schools and (2) a focus group study of African American adults in a community kitchen program.

RESULTS

In exemplar 1, school policies lacked population-based standards and presented structural disadvantages to African American girls who were already obese. In exemplar 2, participants found the community kitchen program to be more effective than the federally funded nutrition program.

DISCUSSION

Integrating primary care and public health nursing could improve the tailoring of physical activity and nutrition programs to local populations by following core principles of community engagement, infrastructural sustainability, aligned leadership, and data sharing for population health improvement.

National nursing science priorities: Creating a shared vision

BACKGROUND

Nursing science is essential to advance population health through contributions at all phases of scientific inquiry. Multiple scientific initiatives important to nursing science overlap in aims and population focus.

PURPOSE

This article focused on providing the American Academy of Nursing and nurse scientists in the Unites States with a blueprint of nursing science priorities to inform a shared vision for future collaborations, areas of scientific inquiry, and resource allocation.

METHODS

The Science Committee convened four times and using Delphi methods identified priorities with empirical evidence and expert opinion for prioritization, state of the science, expert interest, and potential target stakeholders.

DISCUSSION

Nursing science priorities for 2017 were categorized into four themes including: (a) precision science, (b) big data and data analytics, (c) determinants of health, and (d) global health.

CONCLUSION

Nurse scientists can generate new knowledge in priority areas that advances the health of the world's populations.

Perinatal Nurse Home Visiting Referral Patterns Among Women With Diabetes and Hypertension in Philadelphia

OBJECTIVE

To examine access to perinatal nurse home visiting services for high-risk pregnant women who have diabetes or hypertension.

DESIGN

Secondary data analysis.

SETTING

Philadelphia, PA.

PARTICIPANTS

Pregnant women who had a live birth during 2012 and those referred to a community-based agency for perinatal nurse home visiting because of their diagnosis of diabetes or hypertension.

METHODS

Access to services was measured by examining referral information (dosage, diagnosis, gestational age at time of referral, and insurance type) retrieved from administrative logs of the community-based organization that provides perinatal home visiting to high-risk pregnant women. The population-based prevalence rates of hypertension and diabetes were calculated from birth record data provided by the Philadelphia Department of Public Health.

RESULTS

During 2012, 595 pregnant women were referred for perinatal nurse home visiting services. The mean gestational age when referred for services was 24.9 weeks (standard deviation = 8.5) with a mean number of 8.8 authorized visits (standard deviation = 8). Associated with more authorized visits was having Medicaid as the insurance type and medical diagnoses that included hypertension (p < .01). Philadelphia prevalence rates for diabetes and hypertension varied by race and ethnicity (p < .001); Asian mothers had the greatest rates for diabetes and Black mothers the greatest rates for hypertension.

CONCLUSION

Various models of home visiting programs exist to improve maternal and child health outcomes. Because maternal morbidity and mortality rates are rising in the United States, further research about perinatal nurse home visiting programs for pregnant women with diabetes and hypertension is warranted.

The Roles of Chronic Disease Complexity, Health System Integration, and Care Management in Post-Discharge Healthcare Utilization in a Low-Income Population

Economically disadvantaged individuals with chronic disease have high rates of in-patient (IP) readmission and emergency department (ED) utilization following initial hospitalization. The purpose of this study was to explore the relationships between chronic disease complexity, health system integration (admission to accountable care organization [ACO] hospital), availability of care management interventions (membership in managed care organization [MCO]), and 90-day post-discharge healthcare utilization. We used de-identified Medicaid claims data from two counties in western New York. The study population was 114,295 individuals who met inclusion criteria, of whom 7,179 had index hospital admissions in the first 9 months of 2013. Individuals were assigned to three disease complexity segments based on presence of 12 prevalent conditions. The 30-day inpatient (IP) readmission rates ranged from 6% in the non-chronic segment to 12% in the chronic disease complexity segment and 21% in the organ system failure complexity segment. Rehospitalization rates (both inpatient and emergency department [ED]) were lower for patients in MCOs and ACOs than for those in fee-for-service care. Complexity of chronic disease, initial hospitalization in a facility that was part of an ACO, MCO membership, female gender, and longer length of stay were associated with a significantly longer time to readmission in the first 90 days, that is, fewer readmissions. Our results add to evidence that high-value post-discharge utilization (fewer IP or ED rehospitalizations and early outpatient follow-up) require population-based transitional care strategies that improve continuity between settings and take into account the illness complexity of the Medicaid population. © 2016 Wiley Periodicals, Inc.