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Johnson C, Ingraham MK, Stafford SR, Guilamo-Ramos V. Adopting a nurse-led model of care to advance whole-person health and health equity within Medicaid. Nurs Outlook 2024; 72:102191. [PMID: 38781773 DOI: 10.1016/j.outlook.2024.102191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 04/18/2024] [Accepted: 04/27/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Medicaid payment reforms and delivery model innovations are needed to fully transform U.S. healthcare structuring and provision. PURPOSE To synthesize nurse-led models of care and their implications for improving health care access, quality, and reducing costs for Medicaid recipients. METHODS A critical review of the literature regarding nurse-led models and implications for addressing social determinants of health (SDOH), adopting population health approaches, managing complex care, and integrating behavioral and physical health care within Medicaid. DISCUSSION Three interrelated findings emerged (a) investing in dynamic nurse-led models is important for mitigating SDOH and adopting value-based care, (b) regulations preventing nurses from practicing at the fullest extent of their training and licensure limit clinical impact and value, and (c) directed payments can establish value-based expectations for Medicaid managed care. CONCLUSION Adoption of a nurse-led model of care has the potential to advance the goals of reducing inequity and promoting whole-person health within Medicaid and nationally.
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Affiliation(s)
- Celia Johnson
- Institute for Policy Solutions, Johns Hopkins School of Nursing, Washington, DC; Center for Latino Adolescent and Family Health, Johns Hopkins School of Nursing, Baltimore, MD
| | | | - Stephen R Stafford
- Institute for Policy Solutions, Johns Hopkins School of Nursing, Washington, DC; Center for Latino Adolescent and Family Health, Johns Hopkins School of Nursing, Baltimore, MD
| | - Vincent Guilamo-Ramos
- Institute for Policy Solutions, Johns Hopkins School of Nursing, Washington, DC; Center for Latino Adolescent and Family Health, Johns Hopkins School of Nursing, Baltimore, MD; Presidential Advisory Council on HIV/AIDS, U.S. Department of Health and Human Services, Washington, DC.
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2
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Li S, Gulley J, Booty M, Firchow B, McGladrey ML. Using Photovoice to Improve Engagement in Community Health Assessments Addressing Behavioral Health. J Behav Health Serv Res 2024:10.1007/s11414-024-09885-4. [PMID: 38710979 DOI: 10.1007/s11414-024-09885-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2024] [Indexed: 05/08/2024]
Abstract
Behavioral health disorders are well-known to have close links with the social determinants of health, yet little is known about how impacted communities perceive these links. Qualitative participatory methods can not only provide insight into how communities conceptualize these relationships but also empower those with lived experience to contextualize their perspectives and formulate calls to action. This study used Photovoice as a participatory method to supplement the Clark County Health Department Community Health Assessment and determine priority facilitators and barriers contributing to the behavioral health of Clark County, KY, residents. A secondary aim was to gain a greater understanding of how the Photovoice methodology impacts community engagement efforts in Community Health Assessments. Twenty-three Clark County residents participated in four Photovoice groups involving five weekly sessions, which included photograph "show and tell," critical group dialogue, participatory analysis, and planning for dissemination. Secondary analysis of Photovoice focus group discussions revealed behavioral health facilitators and barriers were most influenced by (1) public sector unresponsiveness, (2) strong partnerships formed between community and grassroots organizations, and (3) the siloed division of responsibility between agencies and across sectors. The authors also found the Photovoice method successfully enhanced engagement and empowered those with lived experience to frame their perspectives of the behavioral health landscape. This project has implications for enhancing community engagement and empowerment in behavioral health-focused public health assessments and shaping policy to promote multi-sector collaboration.
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Affiliation(s)
- Stacey Li
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, 70118, USA.
| | | | - Marisa Booty
- University of Kentucky College of Arts and Sciences, Lexington, KY, 40506, USA
| | - Bradley Firchow
- University of Kentucky College of Medicine, Lexington, KY, 40506, USA
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Chuang E, Safaeinili N. Addressing Social Needs in Clinical Settings: Implementation and Impact on Health Care Utilization, Costs, and Integration of Care. Annu Rev Public Health 2024; 45:443-464. [PMID: 38134403 DOI: 10.1146/annurev-publhealth-061022-050026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
In recent years, health care policy makers have focused increasingly on addressing social drivers of health as a strategy for improving health and health equity. Impacts of social, economic, and environmental conditions on health are well established. However, less is known about the implementation and impact of approaches used by health care providers and payers to address social drivers of health in clinical settings. This article reviews current efforts by US health care organizations and public payers such as Medicaid and Medicare to address social drivers of health at the individual and community levels. We summarize the limited available evidence regarding intervention impacts on health care utilization, costs, and integration of care and identify key lessons learned from current implementation efforts.
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Affiliation(s)
- Emmeline Chuang
- School of Social Welfare, Mack Center on Public and Nonprofit Management in the Human Services, University of California, Berkeley, California, USA;
| | - Nadia Safaeinili
- Division of Primary Care and Population Health, Stanford University, Stanford, California, USA
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Park M, Choi E, Jeong M, Seo HJ, Kim J, Seo E. Interprofessional Educational Needs for Shared Governance of Integrated Care. Int J Integr Care 2024; 24:15. [PMID: 38736721 PMCID: PMC11086590 DOI: 10.5334/ijic.7674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 04/17/2024] [Indexed: 05/14/2024] Open
Abstract
Introduction This study investigated the educational needs of integrated care among professionals in the public sector of healthcare and social care services in South Korea. Methods A cross-sectional secondary data analysis was performed. Original data were obtained from 10 metropolitan communities with a convenience sample of 210 integrated care professionals. The Borich Needs Assessment Model and the Locus for Focus Model were used to examine the priority educational needs of each integrated care professional. Results This study analyzed the key details of educational needs in integrated care by focusing on the competencies of integrated care approaches for person-centered care, interprofessional collaboration, and community involvement. The core educational needs of community care administrators, care coordinators, healthcare and social care providers, and community health champions, which are common to all professionals, and the specific educational needs for each type of professional were demonstrated, which contained specific content to implement integrated care. Conclusion This study provides an opportunity to comprehensively understand the educational needs of integrated care professionals based on their competencies. They want better interprofessional cooperation through networking and collaborative strategies. The results of this study may be utilized as fundamental data by future instructors to provide evidence-based education programs.
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Affiliation(s)
- Myonghwa Park
- College of Nursing, Chungnam National University, Daejeon, Republic of Korea
| | - Eunjeong Choi
- Department of Public Health, Graduate School, Yonsei University, Seoul, Republic of Korea
| | - Miri Jeong
- Department of nursing, Joongbu University, Geumsan-gun, Chungnam-do, Republic of Korea
| | - Hyun-Ju Seo
- College of Nursing, Chungnam National University, Daejeon, Republic of Korea
| | - Jahyeon Kim
- College of Nursing, Chungnam National University, Daejeon, Republic of Korea
- Chung-ang University Gwangmyeong Hospital, Gwangmyeong-si, Gyeonggi-do, Republic of Korea
| | - Eunkyung Seo
- College of Nursing, Chungnam National University, Daejeon, Republic of Korea
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Matthews EB. The Impact of Delivery Reform on Health Information Exchange with Behavioral Health Providers: Results from a National Representative Survey of Ambulatory Physicians. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2024:10.1007/s10488-024-01367-1. [PMID: 38512556 DOI: 10.1007/s10488-024-01367-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2024] [Indexed: 03/23/2024]
Abstract
Health information exchange (HIE) is an effective way to coordinate care, but HIE between health and behavioral health providers is limited. Recent delivery reform models, including the Accountable Care Organization (ACO) and Patient Centered Medical Home (PCMH) prioritize interprofessional collaboration, but little is known about their impact on behavioral health HIE. This study explores whether delivery reform participation affects behavioral health HIE among ambulatory health providers using pooled 2015-2019 data from the National Electronic Health Record Survey, a nationally representative survey of ambulatory physicians' technology use (n = 8,703). The independent variable in this analysis was provider participation in ACO, PCMH, Hybrid ACO-PCMH, or standard care. The dependent variable was HIE with behavioral health providers. Chi square analysis estimated unweighted rates of behavioral health HIE across reform models. Logistic regression estimated the impact of delivery reform participation on rates of behavioral health HIE. Unweighted estimates indicated that Hybrid ACO-PCMH providers had the highest rates of HIE (n = 330, 33%). In the fully adjust model, rates of HIE were higher among ACO (AOR = 2.66, p < .01), PCMH (AOR = 4.73, p < .001) and Hybrid ACO-PCMH participants (AOR = 5.55, p < .001) compared to standard care, but they did not significantly vary between delivery models. Physicians infrequently engage in HIE with behavioral health providers. Compared to standard care, higher rates of HIE were found across all models of delivery reform. More work is needed to identify common elements of delivery reform models that are most effective in supporting this behavior.
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Affiliation(s)
- Elizabeth B Matthews
- Graduate School of Social Service, Fordham University, 113 W. 60th st. 7th Fl, New York, NY, 10023, USA.
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Ng IK. Physicians, know thy patient. J R Coll Physicians Edinb 2024; 54:84-88. [PMID: 38523064 DOI: 10.1177/14782715241240510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024] Open
Abstract
Person-centered care is presently the standard healthcare model, which emphases shared clinical decision-making, patient autonomy and empowerment. However, many aspects of the modern-day clinical practice such as the increased reliance on medical technologies, artificial intelligence, and teleconsultation have significantly altered the quality of patient-physician communications. Moreover, many countries are facing an aging population with longer life expectancies but increasingly complex medical comorbidities, which, coupled with medical subspecialization and competing health systems, often lead to fragmentation of clinical care. In this article, I discuss what it truly means for a clinician to know a patient, which is, in fact, a highly intricate skill that is necessary to meet the high bar of person-centered care. I suggest that this can be achieved through the implementation of a holistic biopsychosocial model of clinical consultation at the physician level and fostering coordinated and continuity of care at the health systems level.
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Affiliation(s)
- Isaac Ks Ng
- Department of Medicine, National University Hospital, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Mostafa N, Sayed A, Rashad O, Baqal O. Malnutrition-related mortality trends in older adults in the United States from 1999 to 2020. BMC Med 2023; 21:421. [PMID: 37936140 PMCID: PMC10631109 DOI: 10.1186/s12916-023-03143-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 10/30/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND Malnutrition mortality in older adults is underrepresented in scientific literature. This obscures any recent changes and hinders needed social change. This study aims to assess malnutrition mortality trends in older adults (≥ 65 years old) from 1999 to 2020 in the United States (U.S.). METHODS Mortality data from the Centers for Disease Control and Prevention's (CDC) Wide-Ranging Online Data for Epidemiology Research (WONDER) database were extracted. The ICD-10 Codes E40 - E46 were used to identify malnutrition deaths. Crude mortality rates (CMR) and age-adjusted mortality rates (AAMR) were extracted by gender, age, race, census region, and urban-rural classification. Joinpoint regression analysis was used to calculate annual percentage changes (APC) of AAMR by the permutation test and the parametric method was used to calculate 95% confidence intervals. Average Annual Percentage Changes (AAPC) were calculated as the weighted average of APCs. RESULTS Between 1999 and 2020, 93,244 older adults died from malnutrition. Malnutrition AAMR increased from 10.7 per 100,000 in 1999 to 25.0 per 100,000 in 2020. The mortality trend declined from 1999 to 2006 (APC = -8.8; 95% CI: -10.0, -7.5), plateaued till 2013, then began to rise from 2013 to 2020 with an APC of 22.4 (95% CI: 21.3, 23.5) and an overall AAPC of 3.9 (95% CI: 3.1, 4.7). Persons ≥ 85 years of age, females, Non-Hispanic Whites, residents of the West region of the U.S., and urban areas had the highest AAPCs in their respective groups. CONCLUSION Despite some initial decrements in malnutrition mortality among older adults in the U.S., the uptrend from 2013 to 2020 nullified all established progress. The end result is that malnutrition mortality rates represent a historical high. The burden of the mortality uptrends disproportionately affected certain demographics, namely persons ≥ 85 years of age, females, Non-Hispanic Whites, those living in the West region of the U.S., and urban areas. Effective interventions are strongly needed. Such interventions should aim to ensure food security and early detection and remedy of malnutrition among older adults through stronger government-funded programs and social support systems, increased funding for nursing homes, and more cohesive patient-centered medical care.
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Affiliation(s)
| | - Ahmed Sayed
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Omar Rashad
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Omar Baqal
- Department of Internal Medicine, Mayo Clinic Arizona, Phoenix, AZ, USA
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Matthews EB, Stanhope V, Hu Y. Barriers to Health Information Exchange Among Ambulatory Physicians: Results From a Nationally Representative Sample. J Healthc Qual 2023; 45:352-358. [PMID: 37919957 DOI: 10.1097/jhq.0000000000000404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
PURPOSE Health information exchange (HIE) improves healthcare quality, but is underutilized by providers. This study used a nationally representative survey of ambulatory physicians to examine barriers to HIE, and identify which barriers have the greatest impact on providers' use of HIE. METHODS A pooled sample of 1,292 physicians from the 2018-2019 National Electronic Health Record Survey was used. Univariate statistics described rates and patterns of eight common barriers to HIE. Multivariate logistic regression examined the relationship between each barrier and the use of HIE. RESULTS Barriers to HIE were common and diverse. Negative attitudes toward HIE's ability to improve clinical quality significantly decreased HIE use (OR = .44, p < .01). CONCLUSIONS To increase adoption of HIE, efforts should focus on addressing providers' negative attitudes toward HIE. These findings can guide targeted implementation strategies to improve HIE adoption.
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Verma A, Madrigal J, Coaston T, Ascandar N, Williamson C, Benharash P. Care Fragmentation Following Hospitalization for Atrial Fibrillation in the United States. JACC. ADVANCES 2023; 2:100375. [PMID: 38938260 PMCID: PMC11198211 DOI: 10.1016/j.jacadv.2023.100375] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 02/15/2023] [Accepted: 03/10/2023] [Indexed: 06/29/2024]
Abstract
Background Despite the high prevalence of atrial fibrillation (AF), the incidence and impact of care fragmentation (CF) following hospitalization for this condition remain unstudied. Objectives The present study used a national database to determine the incidence of and risk factors associated with CF. Outcomes following CF were also examined. Methods All adults who were discharged alive following hospitalization for AF (index facility) were identified within the 2016 to 2019 Nationwide Readmissions Database. Patients requiring nonelective rehospitalization within 30 days of discharge were categorized into 2 groups. The CF cohort included those readmitted to a nonindex facility, while others were classified as noncare fragmentation. Multivariable regression was used to evaluate factors associated with CF, as well as its impact on in-hospital mortality, length of stay, and costs at rehospitalization. Results Of an estimated 686,942 patients who met study criteria and survived to discharge, 13.6% (n = 93,376) experienced unplanned readmission within 30 days. Among those readmitted, 21.3% (n = 19,906) were readmitted to a nonindex facility. Patients who experienced CF were younger, more commonly male and less frequently readmitted for AF. Upon multivariable adjustment, male sex, Medicaid insurance (ref: private), and transfer status were associated with increased odds of CF. Upon readmission, CF was associated with a 18% increment in relative odds of in-hospital mortality, a 0.3-day increment in length of stay, and an additional $1,500 in hospitalization costs. Conclusions CF was associated with significant clinical and financial burden. Further studies are needed to address factors which contribute to increased mortality and resource use following CF.
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Affiliation(s)
- Arjun Verma
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Josef Madrigal
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Troy Coaston
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Nameer Ascandar
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Catherine Williamson
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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Hudon C, Bisson M, Chouinard MC, Delahunty-Pike A, Lambert M, Howse D, Schwarz C, Dumont-Samson O, Aubrey-Bassler K, Burge F, Doucet S, Ramsden VR, Luke A, Macdonald M, Gaudreau A, Porter J, Rubenstein D, Scott C, Warren M, Wilhelm L. Implementation analysis of a case management intervention for people with complex care needs in primary care: a multiple case study across Canada. BMC Health Serv Res 2023; 23:377. [PMID: 37076851 PMCID: PMC10116737 DOI: 10.1186/s12913-023-09379-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 04/08/2023] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND Case management is one of the most frequently performed interventions to mitigate the negative effects of high healthcare use on patients, primary care providers and the healthcare system. Reviews have addressed factors influencing case management interventions (CMI) implementation and reported common themes related to the case manager role and activities, collaboration with other primary care providers, CMI training and relationships with the patients. However, the heterogeneity of the settings in which CMI have been implemented may impair the transferability of the findings. Moreover, the underlying factors influencing the first steps of CMI implementation need to be further assessed. This study aimed to evaluate facilitators and barriers of the first implementation steps of a CMI by primary care nurses for people with complex care needs who frequently use healthcare services. METHODS A qualitative multiple case study was conducted including six primary care clinics across four provinces in Canada. In-depth interviews and focus groups with nurse case managers, health services managers, and other primary care providers were conducted. Field notes also formed part of the data. A mixed thematic analysis, deductive and inductive, was carried out. RESULTS Leadership of the primary care providers and managers facilitated the first steps of the of CMI implementation, as did the experience and skills of the nurse case managers and capacity development within the teams. The time required to establish CMI was a barrier at the beginning of the CMI implementation. Most nurse case managers expressed apprehension about developing an "individualized services plan" with multiple health professionals and the patient. Clinic team meetings and a nurse case managers community of practice created opportunities to address primary care providers' concerns. Participants generally perceived the CMI as a comprehensive, adaptable, and organized approach to care, providing more resources and support for patients and better coordination in primary care. CONCLUSION Results of this study will be useful for decision makers, care providers, patients and researchers who are considering the implementation of CMI in primary care. Providing knowledge about first steps of CMI implementation will also help inform policies and best practices.
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Affiliation(s)
- Catherine Hudon
- Department of Family Medicine and Emergency Medicine, University of Sherbrooke, Pavillon Z7-Room 3007, 3001, 12E Avenue Nord, Sherbrooke, QC, J1H 5N4, Canada.
- Centre Hospitalier Universitaire de Sherbrooke Research Centre, Sherbrooke, QC, Canada.
| | - Mathieu Bisson
- Department of Family Medicine and Emergency Medicine, University of Sherbrooke, Pavillon Z7-Room 3007, 3001, 12E Avenue Nord, Sherbrooke, QC, J1H 5N4, Canada
| | | | | | - Mireille Lambert
- Department of Family Medicine and Emergency Medicine, University of Sherbrooke, Pavillon Z7-Room 3007, 3001, 12E Avenue Nord, Sherbrooke, QC, J1H 5N4, Canada
| | - Dana Howse
- Primary Healthcare Research Unit, Memorial University, St-John's, NL, Canada
| | - Charlotte Schwarz
- Department of Nursing and Health Sciences, University of New Brunswick, Fredericton, NB, Canada
| | - Olivier Dumont-Samson
- Department of Family Medicine and Emergency Medicine, University of Sherbrooke, Pavillon Z7-Room 3007, 3001, 12E Avenue Nord, Sherbrooke, QC, J1H 5N4, Canada
| | - Kris Aubrey-Bassler
- Primary Healthcare Research Unit, Memorial University, St-John's, NL, Canada
| | - Fred Burge
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Shelley Doucet
- Department of Nursing and Health Sciences, University of New Brunswick, Fredericton, NB, Canada
| | - Vivian R Ramsden
- Department of Academic Family Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Alison Luke
- Department of Nursing and Health Sciences, University of New Brunswick, Fredericton, NB, Canada
| | - Marilyn Macdonald
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | | | - Judy Porter
- Nova Scotia Health Authority, Halifax, NS, Canada
| | | | - Cathy Scott
- Canadian Cancer Society, Toronto, ON, Canada
| | - Mike Warren
- Patient Advisory Council, Newfoundland and Labrador SPOR SUPPORT Unit, St. John's, NL, Canada
| | - Linda Wilhelm
- Canadian Arthritis Patient Alliance, Ottawa, ON, Canada
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Trivedi RB, Rossi FS, Javier SJ, Greene L, Singer SJ, Vanneman ME, Goldstein M, Zulman DM. Association Between Mental Health Conditions and Outpatient Care Fragmentation: a National Study of Older High-Risk Veterans. J Gen Intern Med 2022; 37:4071-4079. [PMID: 35869316 PMCID: PMC9708986 DOI: 10.1007/s11606-022-07705-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 06/16/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Healthcare fragmentation may lead to adverse consequences and may be amplified among older, sicker patients with mental health (MH) conditions. OBJECTIVE To determine whether older Veterans with MH conditions have more fragmented outpatient non-MH care, compared with older Veterans with no MH conditions. DESIGN Retrospective cohort study using FY2014 Veterans Health Administration (VHA) administrative data linked to Medicare data. PARTICIPANTS 125,481 VHA patients ≥ 65 years old who were continuously enrolled in Medicare Fee-for-Service Parts A and B and were at high risk for hospitalization. MAIN OUTCOME AND MEASURES The main outcome was non-MH care fragmentation as measured by (1) non-MH provider count and (2) Usual Provider of Care (UPC), the proportion of care with the most frequently seen non-MH provider. We tested the association between no vs. any MH conditions and outcomes using Poisson regression and fractional regression with logit link, respectively. We also compared Veterans with no MH condition with each MH condition and combinations of MH conditions, adjusting for sociodemographics, comorbidities, and drive-time to VHA specialty care. KEY RESULTS In total, 47.3% had at least one MH condition. Compared to those without MH conditions, Veterans with MH conditions had less fragmented care, with fewer non-MH providers (IRR = 0.96; 95% CI: 0.96-0.96) and more concentrated care with their usual provider (OR = 1.08 for a higher UPC; 95% CI: 1.07, 1.09) in adjusted models. Secondary analyses showed that those with individual MH conditions (e.g., depression) had fewer non-MH providers (IRR range: 0.86-0.98) and more concentrated care (OR range: 1.04-1.20). A similar pattern was observed when examining combinations of MH conditions (IRR range: 0.80-0.90; OR range: 1.16-1.30). CONCLUSIONS Contrary to expectations, having a MH condition was associated with less fragmented non-MH care among older, high-risk Veterans. Further research will determine if this is due to different needs, underuse, or appropriate use of healthcare.
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Affiliation(s)
- Ranak B Trivedi
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Ci2i Bldg 324 B-134, 795 Willow Rd MPD-152, Menlo Park, CA, 94025, USA.
- Division of Public Mental Health and Population Sciences, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA.
| | - Fernanda S Rossi
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Ci2i Bldg 324 B-134, 795 Willow Rd MPD-152, Menlo Park, CA, 94025, USA
- Center for Primary Care and Outcomes Research (PCOR), Stanford University School of Medicine, Stanford, CA, USA
| | - Sarah J Javier
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Ci2i Bldg 324 B-134, 795 Willow Rd MPD-152, Menlo Park, CA, 94025, USA
- Center for Primary Care and Outcomes Research (PCOR), Stanford University School of Medicine, Stanford, CA, USA
| | - Liberty Greene
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Ci2i Bldg 324 B-134, 795 Willow Rd MPD-152, Menlo Park, CA, 94025, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Sara J Singer
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Megan E Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Division of Health System Innovation and Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Mary Goldstein
- Center for Primary Care and Outcomes Research (PCOR), Stanford University School of Medicine, Stanford, CA, USA
- Office of Geriatrics and Extended Care, Department of Veterans Affairs, Washington, DC, USA
| | - Donna M Zulman
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Ci2i Bldg 324 B-134, 795 Willow Rd MPD-152, Menlo Park, CA, 94025, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
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McDermott JH, Wright S, Sharma V, Newman WG, Payne K, Wilson P. Characterizing pharmacogenetic programs using the consolidated framework for implementation research: A structured scoping review. Front Med (Lausanne) 2022; 9:945352. [PMID: 36059837 PMCID: PMC9433561 DOI: 10.3389/fmed.2022.945352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 07/29/2022] [Indexed: 12/11/2022] Open
Abstract
Several healthcare organizations have developed pre-emptive pharmacogenetic testing programs, where testing is undertaken prior to the prescription of a medicine. This review characterizes the barriers and facilitators which influenced the development of these programs. A bidirectional citation searching strategy identified relevant publications before a standardized data extraction approach was applied. Publications were grouped by program and data synthesis was undertaken using the Consolidated Framework for Implementation Research (CFIR). 104 publications were identified from 40 programs and 4 multi-center initiatives. 26 (66%) of the programs were based in the United States and 95% in high-income countries. The programs were heterogeneous in their design and scale. The Characteristics of the Intervention, Inner Setting, and Process domains were referenced by 92.5, 80, and 77.5% of programs, respectively. A positive institutional culture, leadership engagement, engaging stakeholders, and the use of clinical champions were frequently described as facilitators to implementation. Clinician self-efficacy, lack of stakeholder knowledge, and the cost of the intervention were commonly cited barriers. Despite variation between the programs, there were several similarities in approach which could be categorized via the CFIR. These form a resource for organizations planning the development of pharmacogenetic programs, highlighting key facilitators which can be leveraged to promote successful implementation.
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Affiliation(s)
- John H. McDermott
- Manchester Centre for Genomic Medicine, St Mary’s Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
- Division of Evolution, Infection and Genomics, School of Biological Sciences, The University of Manchester, Manchester, United Kingdom
- *Correspondence: John H. McDermott,
| | - Stuart Wright
- Division of Population Health, Manchester Centre for Health Economics, Health Services Research and Primary Care, School of Health Sciences, The University of Manchester, Manchester, United Kingdom
| | - Videha Sharma
- Division of Informatics, Centre for Health Informatics, Imaging and Data Science, School of Health Sciences, The University of Manchester, Manchester, United Kingdom
| | - William G. Newman
- Manchester Centre for Genomic Medicine, St Mary’s Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
- Division of Evolution, Infection and Genomics, School of Biological Sciences, The University of Manchester, Manchester, United Kingdom
| | - Katherine Payne
- Division of Population Health, Manchester Centre for Health Economics, Health Services Research and Primary Care, School of Health Sciences, The University of Manchester, Manchester, United Kingdom
| | - Paul Wilson
- Division of Population Health, Centre for Primary Care and Health Services Research, Health Services Research and Primary Care, School of Health Sciences, The University of Manchester, Manchester, United Kingdom
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Makdisse M, Ramos P, Malheiro D, Katz M, Novoa L, Cendoroglo Neto M, Ferreira JHG, Klajner S. Value-based healthcare in Latin America: a survey of 70 healthcare provider organisations from Argentina, Brazil, Chile, Colombia and Mexico. BMJ Open 2022; 12:e058198. [PMID: 35667729 PMCID: PMC9171220 DOI: 10.1136/bmjopen-2021-058198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Value-based healthcare (VBHC) is a health system reform gradually being implemented in health systems worldwide. A previous national-level survey has shown that Latin American countries were in the early stages of alignment with VBHC. Data at the healthcare provider organisations (HPOs) level are lacking. This study aim was to investigate how HPOs in five Latin American countries are implementing VBHC. DESIGN Mixed-methods research was conducted using online questionnaire, semistructured interviews based on selected elements of the value agenda (from December 2018 to June 2020), analyses of aggregated data and documents. Qualitative analysis was performed using NVivo QSR International, 1.6.1 (4830). Quantitative analysis used Fisher's exact test. Univariate analysis was used to compare organisations in relation to the implementation of VBHC initiatives. A p≤0.05 was considered significant. PARTICIPANTS Top and middle-level executives from 70 HPOs from Argentina, Brazil, Chile, Colombia and Mexico. RESULTS The definition of VBHC varied across participating organisations. Although the value equation had been cited by 24% of participants, its composition differed in most case from the original Equation. Most VBHC initiatives were related to care delivery organisation (56.9%) and outcomes measurement (22.4%) but in most cases, integrated practice unit features had not been fully developed and outcome data was not used to guide improvement. Information, stakeholders buy-in, compensation and fragmented care delivery were the most cited challenges to VBHC implementation. Fee-for-service predominated, although one-third of organisations were experimenting with alternative payment models. CONCLUSIONS A wide variation in the definition and level of VBHC implementation existed across organisations. Our finding suggests investments in information systems and on education of key stakeholders will be key to foster VBHC implementation in the region. Further research is needed to identify successful implementation cases that may serve as regional benchmark for other Latin American organisations advancing with VBHC.
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Affiliation(s)
- Marcia Makdisse
- Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Academia VBHC Educacao e Consultoria Ltda, Sao Paulo, Brazil
| | - Pedro Ramos
- Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Medical Management Centre, Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden
| | | | - Marcelo Katz
- Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Luisa Novoa
- Hospital Israelita Albert Einstein, Sao Paulo, Brazil
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