Achieving Triple Aim Outcomes: An Evaluation of the Texas Medicaid Waiver

Community Health Workers as Trust Builders and Healers: A Cohort Study in Primary Care

PURPOSE

Improving patients' self-care for chronic disease is often elusive in the context of social deprivation. We evaluated whether a practice-integrated community health worker (CHW) intervention could encourage effective long-term self-management of type 2 diabetes mellitus (T2DM).

METHODS

This cohort study, in a safety-net primary care practice, enrolled patients with uncontrolled T2DM and psychosocial risk factors. Patients were identified through a practice diabetes registry or by clinicians' referrals. The CHWs engaged patients in trust building and sensemaking to understand their social context, identify goals, navigate health care, and connect to community resources. Primary outcome was progress through 3 prospectively defined stages of self-care: outreach (meeting face-to-face); stabilization (collaborating to address patients' life circumstances); and self-care generativity (achieving self-care competencies). Secondary outcomes were change in hemoglobin A1c (HbA1c) and need for urgent care, emergency department, or hospital visits.

RESULTS

Of 986 participating patients, 27% remained in outreach, 41% progressed to stabilization, and 33% achieved self-care generativity. Repeated measures ANOVA demonstrates an overall decline in HbA1c, without group differences, through the 4th HbA1c measurement (mean follow-up 703 days). Beginning at the 5th HbA1c measurement (mean 859 days), the self-care generativity group achieved greater declines in HbA1c, which widened through the 10th measurement (mean 1,365 days) to an average of 8.5% compared with an average of 8.8% in the outreach group and 9.0% in the stabilization group (P = .003). Rates of emergency department and hospital visits were lower in the self-care generativity group.

CONCLUSIONS

Practice-linked CHWs can sustainably engage vulnerable patients, helping them advance self-management goals in the context of formidable social disadvantage.

Patient safety from the perspective of quality management frameworks: a review

Patient safety is one of the overarching goals of patient care and quality management. Of the many quality management frameworks, Beauchamp and Childress’s four principles of biomedical ethics presents aspects of patient centeredness in clinical care. The Institute of Medicine’s six aims for improvement encapsulates elements of high-quality patient care. The Institute of Healthcare Improvement’s Triple Aim focuses on three aspects of care, cost, and health. Given the above frameworks, the present review was designed to emphasize the initiatives the system has taken to address various efforts of improving quality and patient safety. We, hereby, present a contemplative review of the concepts of informed consent, informed refusal, healthcare laws, policy programs, and regulations. The present review, furthermore, outlines measures and policies that management and administration implement and enforce, respectively, to ensure patient centered care. We, conclusively, explore prototype policies such as the Delivery System Reform Incentive Payment Program that imbues the elements of quality management frameworks, Hospital-Acquired Conditions Reduction Program that supports patient safety, and Hospital Readmissions Reduction Program that focuses on curbing readmissions.

County-Level Determinants of COVID-19 Testing and Cases: Are there Racial/Ethnic Disparities in Texas?

Reports suggest that COVID-19 affects people of color disproportionately. Texas ranks second in the count of confirmed US cases. This study examined the relationship between county-level racial/ethnic composition and COVID-19 testing/cases in Texas, adjusting for population-level demographic characteristics, health factors, and health care access measures. County-level testing and case data, obtained from the Texas Department of State Health Services, were combined with the 2020 Robert Wood Johnson Foundation County Health Rankings data. Outcome variables were tests per 100,000 population and cases per 100,000 population. The independent variable of interest was percent of racial and ethnic composition. Multivariable linear regression analyses were used. There was a statistically significant increase in COVID-19 testing/100,000 population with every 1% increase in the proportion of African Americans/Blacks (β = 2065.4; P = 0.009), Asians (β = 2056.2; P = 0.015), and Hispanics (β = 1641.1; P = 764.7). After controlling for county characteristics and cases/100,000 population, these relationships were no longer significant. However, primary care physician rate was significantly associated with testing/100,000 population (β = 64.0; P = 0.027), as was the percent of uninsured (β = -469.9; P = 0.024). An analysis of case data showed that African Americans had the largest number of cases/100,000 (β = 432.2; P = 0.001), followed by Hispanics (β = 422.8; P < 0.001) and Asians (β = 415.4; P = 0.004). As in other parts of the United States, African Americans and Hispanics are most affected by COVID-19 in Texas. Community-based strategies to improve access to testing or reduce community spread outside clinical settings should target counties with low primary care physician rates or a high proportion of uninsured residents.