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Griesemer I, Palmer JA, MacLaren RZ, Harvey KLL, Li M, Garikipati A, Linsky AM, Mohr DC, Gurewich D. Rural Veterans' Experiences with Social Risk Factors: Impacts, Challenges, and Care System Recommendations. J Gen Intern Med 2024; 39:782-789. [PMID: 38010459 PMCID: PMC11043235 DOI: 10.1007/s11606-023-08530-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 11/08/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Social risk factors, such as food insecurity and financial needs, are associated with increased risk of cardiovascular diseases, health conditions that are highly prevalent in rural populations. A better understanding of rural Veterans' experiences with social risk factors can inform expansion of Veterans Health Administration (VHA) efforts to address social needs. OBJECTIVE To examine social risk and need from rural Veterans' lived experiences and develop recommendations for VHA to address social needs. DESIGN We conducted semi-structured interviews with participants purposively sampled for racial diversity. The interview guide was informed by Andersen's Behavioral Model of Health Services Use and the Outcomes from Addressing Social Determinants of Health in Systems framework. PARTICIPANTS Rural Veterans with or at risk of cardiovascular disease who participated in a parent survey and agreed to be recontacted. APPROACH Interviews were recorded and transcribed. We analyzed transcripts using directed qualitative content analysis to identify themes. KEY RESULTS Interviews (n = 29) took place from March to June 2022. We identified four themes: (1) Social needs can impact access to healthcare, (2) Structural factors can make it difficult to get help for social needs, (3) Some Veterans are reluctant to seek help, and (4) Veterans recommended enhancing resource dissemination and navigation support. CONCLUSIONS VHA interventions should include active dissemination of information on social needs resources and navigation support to help Veterans access resources. Community-based organizations (e.g., Veteran Service Organizations) could be key partners in the design and implementation of future social need interventions.
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Affiliation(s)
- Ida Griesemer
- Veterans Affairs Boston Healthcare System, Center for Healthcare Organization and Implementation Research, Boston, MA, USA.
| | - Jennifer A Palmer
- Veterans Affairs Boston Healthcare System, Center for Healthcare Organization and Implementation Research, Boston, MA, USA
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Risette Z MacLaren
- Veterans Affairs Boston Healthcare System, Center for Healthcare Organization and Implementation Research, Boston, MA, USA
| | - Kimberly L L Harvey
- Veterans Affairs Boston Healthcare System, Center for Healthcare Organization and Implementation Research, Boston, MA, USA
| | - Mingfei Li
- Veterans Affairs Boston Healthcare System, Center for Healthcare Organization and Implementation Research, Boston, MA, USA
- Department of Mathematical Sciences, Bentley University, Waltham, MA, USA
| | | | - Amy M Linsky
- Veterans Affairs Boston Healthcare System, Center for Healthcare Organization and Implementation Research, Boston, MA, USA
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - David C Mohr
- Veterans Affairs Boston Healthcare System, Center for Healthcare Organization and Implementation Research, Boston, MA, USA
- Department of Health Law, Policy & Management, School of Public Health, Boston University, Boston, MA, USA
| | - Deborah Gurewich
- Veterans Affairs Boston Healthcare System, Center for Healthcare Organization and Implementation Research, Boston, MA, USA
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
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Gurewich D, Linsky AM, Harvey KL, Li M, Griesemer I, MacLaren RZ, Ostrow R, Mohr D. Relationship Between Unmet Social Needs and Care Access in a Veteran Cohort. J Gen Intern Med 2023:10.1007/s11606-023-08117-3. [PMID: 37340267 DOI: 10.1007/s11606-023-08117-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 02/24/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND The association between unmet social needs (e.g., food insecurity) and adverse health outcomes is well-established, especially for patients with and at risk for cardiovascular disease (CVD). This has motivated healthcare systems to focus on unmet social needs. Yet, little is known about the mechanisms by which unmet social needs impact health, which limits healthcare-based intervention design and evaluation. One conceptual framework posits that unmet social needs may impact health by limiting care access, but this remains understudied. OBJECTIVE Examine the relationship between unmet social needs and care access. DESIGN Cross-sectional study design using survey data on unmet needs merged with administrative data from the Veterans Health Administration (VA) Corporate Data Warehouse (September 2019-March 2021) and multivariable models to predict care access outcomes. Pooled and separate rural and urban logistic regression models were utilized with adjustments from sociodemographics, region, and comorbidity. SUBJECTS A national stratified random sample of VA-enrolled Veterans with and at risk for CVD who responded to the survey. MAIN MEASURES No-show appointments were defined dichotomously as patients with one or more missed outpatient visits. Medication non-adherence was measured as proportion of days covered and defined dichotomously as adherence less than 80%. KEY RESULTS Greater burden of unmet social needs was associated with significantly higher odds of no-show appointments (OR = 3.27, 95% CI = 2.43, 4.39) and medication non-adherence (OR = 1.59, 95% CI = 1.19, 2.13), with similar associations observed for rural and urban Veterans. Social disconnection and legal needs were especially strong predictors of care access measures. CONCLUSIONS Findings suggest that unmet social needs may adversely impact care access. Findings also point to specific unmet social needs that may be especially impactful and thus might be prioritized for interventions, in particular social disconnection and legal needs.
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Affiliation(s)
- Deborah Gurewich
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA.
- Section of General Internal Medicine, Boston University School of Medicine (BUSM), Boston, MA, USA.
| | - Amy M Linsky
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
- Section of General Internal Medicine, Boston University School of Medicine (BUSM), Boston, MA, USA
- Section of General Internal Medicine, VA Boston Healthcare System, Boston, MA, USA
| | - Kimberly L Harvey
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
| | - Mingfei Li
- CHOIR, VA Bedford Healthcare System, Bedford, MA, USA
- Department of Mathematical Sciences, Bentley University, Waltham, MA, USA
| | - Ida Griesemer
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
| | - Risette Z MacLaren
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
| | - Rory Ostrow
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
| | - David Mohr
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
- Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, USA
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Shwartz M, Rosen AK, Beilstein-Wedel E, Davila H, Harris AH, Gurewich D. Using the Kitagawa Decomposition to Measure Overall-and Individual Facility Contributions to-Within-facility and Between-facility Differences: Analyzing Racial and Ethnic Wait Time Disparities in the Veterans Health Administration. Med Care 2023; 61:392-399. [PMID: 37068035 PMCID: PMC10175195 DOI: 10.1097/mlr.0000000000001849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
Abstract
BACKGROUND Identifying whether differences in health care disparities are due to within-facility or between-facility differences is key to disparity reductions. The Kitagawa decomposition divides the difference between 2 means into within-facility differences and between-facility differences that are measured on the same scale as the original disparity. It also enables the identification of facilities that contribute most to within-facility differences (based on facility-level disparities and the proportion of patient population served) and between-facility differences. OBJECTIVES Illustrate the value of a 2-stage Kitagawa decomposition to partition a disparity into within-facility and between-facility differences and to measure the contribution of individual facilities to each type of difference. SUBJECTS Veterans receiving a new outpatient consult for cardiology or orthopedic services during fiscal years 2019-2021. MEASURES Wait time for a new-patient consult. METHODS In stage 1, we predicted wait time for each Veteran from a multivariable model; in stage 2, we aggregated individual predictions to determine mean adjusted wait times for Hispanic, Black, and White Veterans and then decomposed differences in wait times between White Veterans and each of the other groups. RESULTS Noticeably longer wait times were experienced by Hispanic Veterans for cardiology (2.32 d, 6.8% longer) and Black Veterans for orthopedics (3.49 d, 10.3% longer) in both cases due entirely to within-facility differences. The results for Hispanic Veterans using orthopedics illustrate how positive within-facility differences (0.57 d) can be offset by negative between-facility differences (-0.34 d), resulting in a smaller overall disparity (0.23 d). Selecting 10 facilities for interventions in orthopedics based on the largest contributions to within-in facility differences instead of the largest disparities resulted in a higher percentage of Veterans impacted (31% and 12% of Black and White Veterans, respectively, versus 9% and 10% of Black and White Veterans, respectively) and explained 21% of the overall within-facility difference versus 11%. CONCLUSIONS The Kitagawa approach allows the identification of disparities that might otherwise be undetected. It also allows the targeting of interventions at those facilities where improvements will have the largest impact on the overall disparity.
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Affiliation(s)
| | - Amy K Rosen
- VA Boston Healthcare System, Boston, MA
- Boston University School of Medicine, Boston, MA
| | | | - Heather Davila
- VA Iowa City Health Care System, Iowa City, IA
- University of Iowa Carver College of Medicine, Iowa City, IA
| | - Alex Hs Harris
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA
- Department of Surgery, Stanford-Surgery Policy Improvement Research and Education Center, Palo Alto, CA
| | - Deborah Gurewich
- VA Boston Healthcare System, Boston, MA
- Boston University School of Medicine, Boston, MA
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Gurewich D, Shoushtari SI, Ostrow R, MacLaren RZ, Li M, Harvey K, Linsky A, Mohr D. Prevalence and Determinants of Unmet Social Needs Among Rural and Urban Veterans. J Health Care Poor Underserved 2023. [DOI: 10.1353/hpu.2023.0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
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Gurewich D, Beilstein-Wedel E, Shwartz M, Davila H, Rosen AK. Disparities in Wait Times for Care Among US Veterans by Race and Ethnicity. JAMA Netw Open 2023; 6:e2252061. [PMID: 36689224 PMCID: PMC9871804 DOI: 10.1001/jamanetworkopen.2022.52061] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 11/30/2022] [Indexed: 01/24/2023] Open
Abstract
Importance Prior studies indicate that Black and Hispanic vs White veterans wait longer for care. However, these studies do not capture the COVID-19 pandemic, which caused care access disruptions, nor implementation of the US Department of Veterans Affairs (VA) Maintaining Internal Systems and Strengthening Integrated Outside Networks Act (MISSION), which is intended to improve care access by increasing veterans' options to use community clinicians. Objective To determine whether wait times increased differentially for Black and Hispanic compared with White veterans from the pre-COVID-19 to COVID-19 periods given concurrent MISSION implementation. Design, Setting, and Participants This cross-sectional study used data from the VA's Corporate Data Warehouse for fiscal years 2019 to 2021 (October 1, 2018, to September 30, 2021). Participants included Black, Hispanic, and White veterans with a new consultation for outpatient cardiology and/or orthopedic services during the study period. Multivariable mixed-effects models were used to estimate individual-level adjusted wait times and a likelihood ratio test of the significance of wait time disparity change over time. Main Outcomes and Measures Overall mean wait times and facility-level adjusted relative mean wait time ratios. Results The study included 1 162 148 veterans (mean [SD] age, 63.4 [14.4] years; 80.8% men). Significant wait time disparities were evident for orthopedic services (eg, Black veterans had wait times 2.09 [95% CI, 1.57-2.61] days longer than those for White veterans) in the pre-COVID-19 period, but not for cardiology services. Mean wait times increased from the pre-COVID-19 to COVID-19 periods for both services for all 3 racial and ethnic groups (eg, Hispanic wait times for cardiology services increased 5.09 [95% CI, 3.62-6.55] days). Wait time disparities for Black veterans (4.10 [95% CI, 2.44-5.19] days) and Hispanic veterans (4.40 [95% CI, 2.76-6.05] days) vs White veterans (3.75 [95% CI, 2.30-5.19] days) increased significantly from the pre-COVID-19 to COVID-19 periods (P < .001). During the COVID-19 period, significant disparities were evident for orthopedic services (eg, mean wait times for Hispanic vs White veterans were 1.98 [95% CI, 1.32-2.64] days longer) but not for cardiology services. Although there was variation in wait time ratios across the 140 facilities, only 6 facility wait time ratios were significant during the pre-COVID-19 period and 26 during the COVID-19 period. Conclusions and Relevance These findings suggest that wait time disparities increased from the pre-COVID-19 to COVID-19 periods, especially for orthopedic services for both Black and Hispanic veterans, despite MISSION's goal to improve access. Facility-level analyses identified potential sites that could be targeted to reduce disparities.
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Affiliation(s)
- Deborah Gurewich
- Center for Health Care Organization and Implementation Research, Veterans Affairs (VA) Boston Healthcare System, Boston, Massachusetts
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Erin Beilstein-Wedel
- Center for Health Care Organization and Implementation Research, Veterans Affairs (VA) Boston Healthcare System, Boston, Massachusetts
| | - Michael Shwartz
- Center for Health Care Organization and Implementation Research, Veterans Affairs (VA) Boston Healthcare System, Boston, Massachusetts
| | - Heather Davila
- Center for Access & Delivery Research and Evaluation, VA Iowa City Health Care System, Iowa City, Iowa
- General Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Amy K. Rosen
- Center for Health Care Organization and Implementation Research, Veterans Affairs (VA) Boston Healthcare System, Boston, Massachusetts
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
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Griesemer I, Li M, Tsai J, Harvey K, Hausmann LRM, Linsky AM, Mohr DC, Gurewich D. Interaction between Legal and Social Needs in Their Association with Self-rated Health in a National Sample of Veterans. J Health Care Poor Underserved 2023; 34:1221-1233. [PMID: 38661752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
Many health-related social needs, such as financial insecurity, are interconnected with legal needs. However, little is known about which social needs are more likely to be associated with legal needs, or whether legal and other needs interact to affect health. Using data from a 2020 national mailed survey assessing social needs among Veterans who had or were at risk for cardiovascular disease (N=2,801) and linked administrative data, linear regression models tested interactions between legal and other social needs, and their associations with self-rated health. In a model examining the interaction of financial and legal needs, experiencing financial but not legal needs was as strongly associated with worse health (b=-0.58, 95% CI -0.69, -0.46) as experiencing both financial and legal needs (b= -0.55, 95% CI -0.70, -0.40). Financial needs are important to Veterans' health and further research is needed to determine how financial and legal needs should be triaged by providers.
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Clements KM, Kunte PS, Clark MA, Gurewich D, Greenwood BC, Sefton L, Pratt C, Person SD, Wessolossky MA. Uptake of hepatitis C virus treatment in a multi-state Medicaid population, 2013-2017. Health Serv Res 2022; 57:1312-1320. [PMID: 35466398 PMCID: PMC9643082 DOI: 10.1111/1475-6773.13994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE To examine trends in the direct acting antiviral (DAA) uptake in a multi-state Medicaid population with hepatitis C virus (HCV) prior to and after ledipasvir/sofosbuvir (LDV/SOF) approval and changes in prior authorization (PA) requirements. DATA SOURCES Analyses utilized enrollment, medical, and pharmacy claims in four states, December 2013-December 2017. STUDY DESIGN An interrupted time series examined trends in uptake (1+ claim for a DAA) before and after two events: LDV/SOV approval (October 2014) and lifting of PA requirements for 40% of members (July 2016). Analyses were also performed in subgroups defined by the number and dates of change in PA requirements in members' Medicaid plans. DATA COLLECTION/EXTRACTION METHODS Members aged 18-64 years with an ICD code for HCV were included in the sample from diagnosis date until treatment initiation or Medicaid disenrollment. PRINCIPAL FINDINGS The annual sample size ranged from 38,302 to 45,005 with approximately 30% ages 18-34 years and 40% female. In December 2013, 0.08% was treated, rising to 0.74% in December 2017 (p < 0.001). Uptake increased from 0.34%/month in October 2014 to 0.70%/month after LDV/SOF approval, (p < 0.001), and increased relative to the pre-LDV/SOV trend through June 2016 (p = 0.04). Uptake increased to 1.18%/month after PA change, (p < 0.001) and remained flat through 2017 (p = 0.64). Cumulatively, 20.1% were treated by December 2017. In plans with few/no requirements through 2017, uptake increased to 1.19%/month after LDV/SOF approval (p < 0.001) and remained flat through 2017 (p = 0.11), with 22.2% cumulatively treated. Among plans that lifted PA requirements from three to zero in mid-2016, uptake did not increase after LDV/SOF approval (p = 0.36) but did increase to 1.41%/month (p < 0.001) after PA change, with 18.1% cumulatively treated. CONCLUSIONS HCV Treatment increased through 2017. LDV/SOF approval and lifting PA requirements led to an increase in uptake followed by flat monthly utilization. Cumulative uptake was higher in plans with few/no PA requirements relative to those with three requirements through mid-2016.
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Affiliation(s)
- Karen M. Clements
- Commonwealth MedicineUniversity of Massachusetts Chan Medical SchoolShrewsburyMassachusettsUSA
| | - Parag S. Kunte
- Commonwealth MedicineUniversity of Massachusetts Chan Medical SchoolShrewsburyMassachusettsUSA
| | - Melissa A. Clark
- Quantitative Health SciencesUniversity of Massachusetts Chan Medical SchoolWorcesterMassachusettsUSA
| | - Deborah Gurewich
- Center for Healthcare Organization and Implementation ResearchVA Boston Health Care System Jamaica Plain CampusBostonMassachusettsUSA
| | - Bonnie C. Greenwood
- Commonwealth MedicineUniversity of Massachusetts Chan Medical SchoolShrewsburyMassachusettsUSA
| | - Laura Sefton
- Commonwealth MedicineUniversity of Massachusetts Chan Medical SchoolShrewsburyMassachusettsUSA
| | - Carter Pratt
- Commonwealth MedicineUniversity of Massachusetts Chan Medical SchoolShrewsburyMassachusettsUSA
| | - Sharina D. Person
- Quantitative Health SciencesUniversity of Massachusetts Chan Medical SchoolWorcesterMassachusettsUSA
| | - Miryea A. Wessolossky
- Department of MedicineUniversity of Massachusetts Chan Medical SchoolWorcesterMassachusettsUSA
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Evans L, Fabian MP, Charns MP, Gurewich D, Stopka TJ, Cabral HJ. Medicaid Expansion and Change in Federally Qualified Health Center Accessibility From 2008 to 2016. Med Care 2022; 60:743-749. [PMID: 35948346 DOI: 10.1097/mlr.0000000000001762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Affordable Care Act expanded health coverage for low-income residents through Medicaid expansion and increased funding for Health Center Program New Access Points from 2009 to 2015, improving federally qualified health center (FQHC) accessibility. The extent to which these provisions progressed synergistically as intended when states could opt out of Medicaid expansion is unknown. OBJECTIVE To compare change in FQHC accessibility among census tracts in Medicaid expansion and nonexpansion states. RESEARCH DESIGN Tract-level FQHC accessibility scores for 2008 and 2016 were estimated applying the 2-step floating catchment area method to American Community Survey and Health Resources and Services Administration data. Multivariable linear regression compared changes in FQHC accessibility between tracts in Medicaid expansion and nonexpansion states, adjusting for sociodemographic and health system factors and accounting for state-level clustering. SUBJECTS In total, 7058 census tracts across 10 states. RESULTS FQHC accessibility increased comparably among tracts in Medicaid expansion and nonexpansion states (coef: 0.3; 95% CI: -0.3, 0.8; P -value: 0.36). FQHC accessibility increased more in tracts with higher poverty and uninsured rates, and those with lower proportions of non-English speakers and Black or African American residents. CONCLUSION Similar gains in FQHC accessibility across Medicaid expansion and nonexpansion states indicate improvements progressed independently from Medicaid expansion, rather than synergistically as expected. Accessibility increases appeared consistent with HRSA's goal to improve access for individuals experiencing economic barriers to health care but not for those experiencing cultural or language barriers to health care.
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Affiliation(s)
- Leigh Evans
- Division of Health and Environment, Abt Associates, Cambridge, MA
| | - M Patricia Fabian
- Department of Environmental Health, Boston University School of Public Health, Boston, MA
| | - Martin P Charns
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA
| | - Deborah Gurewich
- Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Thomas J Stopka
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA
| | - Howard J Cabral
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
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Gurewich D, Kressin N, Bokhour BG, Linsky AM, Dichter ME, Hunt KJ, Fix GM, Niles BL. Randomised controlled trial evaluating the effects of screening and referral for social determinants of health on Veterans' outcomes: protocol. BMJ Open 2022; 12:e058972. [PMID: 36153033 PMCID: PMC9511545 DOI: 10.1136/bmjopen-2021-058972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 08/12/2022] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Health policy leaders recommend screening and referral (S&R) for unmet social needs (eg, food) in clinical settings, and the American Heart Association recently concluded that the most significant opportunities for reducing cardiovascular disease (CVD) death and disability lie with addressing the social determinants of CVD outcomes. A limited but promising evidence base supports these recommendations, but more rigorous research is needed to guide health care-based S&R efforts. Funded by the Veteran Health Administration (VA), the study described in this paper will assess the efficacy of S&R on Veterans' connections to new resources to address social needs, reduction of unmet needs and health-related outcomes (adherence, utilisation and clinical outcomes). METHODS AND ANALYSIS We will conduct a 1-year mixed-methods randomised controlled trial at three VA sites, enrolling Veterans with CVD and CVD-risk. 880 Veterans experiencing one or more social needs will be randomised within each site (n=293 per site) to one of three study arms representing referral mechanisms of varying intensity (screening only, screening and provision of resource sheet(s), screening and provision of resource sheet(s) plus social work assistance). For each Veteran, we will examine associations of unmet social needs with health-related outcomes at baseline, and longitudinally compare the impact of each approach on connection to new resources (primary outcome) and follow-up outcomes over a 12-month period. We will additionally conduct qualitative interviews with key stakeholders, including Veterans to identify potential explanatory factors related to the relative success of the interventions. ETHICS AND DISSEMINATION Ethics approval was obtained from the VA Central Internal Review Board on 13 July 2021 (reference #: 20-07-Amendment No. 02). Findings will be disseminated through reports, lay summaries, policy briefs, academic publications, and conference presentations. TRIAL REGISTRATION NUMBER NCT04977583.
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Affiliation(s)
- Deborah Gurewich
- Center for Healthcare Organization and Implementation Research, VA Boston Health Care System, Boston, Massachusetts, USA
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Nancy Kressin
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan School of Medicine, Worcester, MA, USA
| | - Amy M Linsky
- Center for Healthcare Organization and Implementation Research, VA Boston Health Care System, Boston, Massachusetts, USA
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
- General Internal Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Melissa E Dichter
- Center for Health Equity Research and Promotion (CHERP), Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- School of Social Work, Temple University, Philadelphia, Pennsylvania, USA
| | - Kelly J Hunt
- Charleston Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H Johnson VAMC, Charleston, South Carolina, USA
| | - Gemmae M Fix
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Barbara L Niles
- National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
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Abstract
BACKGROUND Care coordination is critical for patients with multiple chronic conditions, but fragmentation of care persists. Providers' perspectives of facilitators and barriers to coordination are needed to improve care. OBJECTIVES We sought to understand providers' perspectives on care coordination for patients having multiple chronic diseases served by multiple providers. RESEARCH DESIGN Based upon our earlier survey of patients with multiple chronic conditions, we selected 8 medical centers having high and low coordination. We interviewed providers to identify facilitators and barriers to coordination and compare them between patient-rated high sites and low sites and between primary care (PC)-mental health (MH) and PC-medical/surgical specialty care. SUBJECTS Physicians, nurses and other clinicians in PC, cardiology, and MH (N=102) in 8 Veterans Affairs medical centers. RESULTS We identified warm handoffs, professional relationships, and physical proximity as facilitators, and service agreements, reporting relationships and staffing as barriers. PC-MH coordination was reported as better than PC-medical/surgical specialty coordination. Facilitators were more prevalent and barriers less prevalent in sites rated high by patients than sites rated low, and between PC-MH than between PC-specialty care. DISCUSSION We noted that professional relationships were highly related to coordination and both affected other facilitators and barriers and were affected by them. We suggested actions to improve relationships directly, and to address other facilitators and barriers that affect relationships and coordination. Among these is the use of the Primary Care Mental Health Integration model.
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Affiliation(s)
- Martin P. Charns
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA
| | - Justin K. Benzer
- VISN 17 Center of Excellence for Research on Returning War Veterans, Central Texas Veterans Healthcare System, Waco, TX
- The University of Texas at Austin, Dell Medical School, Department of Psychiatry & Behavioral Sciences, Austin, TX
| | | | - David C. Mohr
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA
| | - Sara J. Singer
- Stanford School of Medicine and Graduate School of Business, Stanford, CA
| | - Deborah Gurewich
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA
- Department of Medicine, Boston University School of Medicine, Boston, MA
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Davila H, Rosen AK, Beilstein-Wedel E, Shwartz M, Chatelain L, Gurewich D. Rural Veterans' Experiences With Outpatient Care in the Veterans Health Administration Versus Community Care. Med Care 2021; 59:S286-S291. [PMID: 33976078 PMCID: PMC8132914 DOI: 10.1097/mlr.0000000000001552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The 2014 Veterans Access, Choice and Accountability Act was intended to improve Veterans' access to timely health care by expanding their options to receive community care (CC) paid for by the Veterans Health Administration (VA). Although CC could particularly benefit rural Veterans, we know little about rural Veterans' experiences with CC. OBJECTIVE The objective of this study was to compare rural Veterans' experiences with CC and VA outpatient health care services to those of urban Veterans and examine changes over time. RESEARCH DESIGN Retrospective, cross-sectional study using data from the Survey of Healthcare Experiences of Patients (SHEP) and VA Corporate Data Warehouse. Subjects: All Veterans who responded to the SHEP survey in Fiscal Year (FY) 16 or FY19. MEASURES Outcomes were 4 measures of care experience (Access, Communication, Coordination, and Provider Rating). Independent variables included care setting (CC/VA), rural/urban status, and demographic and clinical characteristics. RESULTS Compared with urban Veterans, rural Veterans rated CC the same (for specialty care) or better (for primary care). Rural Veterans reported worse experiences in CC versus VA, except for specialty care Access. Rural Veterans' care experiences improved between FY16 and FY19 in both CC and VA, with greater improvements in CC. CONCLUSIONS Rural Veterans' reported comparable or better experiences in CC compared with urban Veterans, but rural Veterans' CC experiences still lagged behind their experiences in VA for primary care. As growing numbers of Veterans use CC, VA should ensure that rural and urban Veterans' experiences with CC are at least comparable to their experiences with VA care.
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Affiliation(s)
- Heather Davila
- VA Boston Healthcare System
- Boston University School of Medicine
| | - Amy K. Rosen
- VA Boston Healthcare System
- Boston University School of Medicine
| | | | - Michael Shwartz
- VA Boston Healthcare System
- Boston University Questrom School of Business, Boston, MA
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12
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Abstract
BACKGROUND The 2014 Veterans Choice Program aimed to improve care access for Veterans through expanded availability of community care (CC). Increased access to CC could particularly benefit rural Veterans, who often face obstacles in obtaining medical care at the Veterans Health Administration (VHA). However, whether Veterans Choice Program improved timely access to care for this vulnerable population is understudied. OBJECTIVES To examine wait times among rural and urban Veterans for 5 outpatient specialty care services representing the top requests for CC services among rural Veterans. RESEARCH DESIGN Retrospective study using VHA and CC outpatient consult data from VHA's Corporate Data Warehouse in Fiscal Year (FY) 2015 (October 1, 2014 to September 30, 2015) and FY2018 (October 1, 2017 to September 30, 2018). SUBJECTS All Veterans who received a new patient consult for physical therapy, cardiology, optometry, orthopedics, and/or dental services in VHA and/or CC. MEASURES Wait time, care setting (VHA/CC), rural/urban status, sociodemographics, and comorbidities. RESULTS Our sample included 1,112,876 Veterans. Between FY2015 and FY2018, mean wait times decreased for all services for both rural and urban Veterans; declines were greatest in VHA (eg, mean optometry wait times for rural Veterans in VHA vs. CC declined 8.3 vs. 6.4 d, respectively, P<0.0001). By FY2018, for both rural and urban Veterans, CC mean wait times for most services were longer than VHA wait times. CONCLUSIONS Timely care access for all Veterans improved between FY15 and FY18, particularly in VHA. As expansion of CC continues under the MISSION Act, more research is needed to evaluate quality of care across VHA and CC and what role, if any, wait times play.
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Affiliation(s)
| | - Michael Shwartz
- VA Boston Healthcare System
- Richard D. Cohen Professor of Health Care and Operations Management Emeritus, Boston University Questrom School of Business, Boston, MA
| | | | | | - Amy K. Rosen
- VA Boston Healthcare System
- Boston University School of Medicine
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13
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Garvin LA, Pugatch M, Gurewich D, Pendergast JN, Miller CJ. Interorganizational Care Coordination of Rural Veterans by Veterans Affairs and Community Care Programs: A Systematic Review. Med Care 2021; 59:S259-S269. [PMID: 33976075 PMCID: PMC8132902 DOI: 10.1097/mlr.0000000000001542] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In the unique context of rural Veterans' health care needs, expansion of US Department of Veterans Affairs and Community Care programs under the MISSION Act, and the uncertainties of coronavirus disease 2019 (COVID-19), it is critical to understand what may support effective interorganizational care coordination for increased access to high-quality care. OBJECTIVES We conducted a systematic review to examine the interorganizational care coordination initiatives that Veterans Affairs (VA) and community partners have pursued in caring for rural Veterans, including challenges and opportunities, organizational domains shaping care coordination, and among these, initiatives that improve or impede health care outcomes. RESEARCH DESIGN We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to search 2 electronic databases (PubMed and Embase) for peer-reviewed articles published between January 2009 and May 2020. Building on prior research, we conducted a systematic review. RESULTS Sixteen articles met our criteria. Each captured a unique health care focus while examining common challenges. Four organizational domains emerged: policy and administration, culture, mechanisms, and relational practices. Exemplars highlight how initiatives improve or impede rural health care delivery. CONCLUSIONS This is the first systematic review, to our knowledge, examining interorganizational care coordination of rural Veterans by VA and Community Care programs. Results provide exemplars of interorganizational care coordination domains and program effectiveness. It suggests that partners' efforts to align their coordination domains can improve health care, with rurality serving as a critical contextual factor. Findings are important for policies, practices, and research of VA and Community Care partners committed to improving access and health care for rural Veterans.
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Affiliation(s)
- Lynn A. Garvin
- United States Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA
| | - Marianne Pugatch
- United States Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA
| | - Deborah Gurewich
- United States Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
- Department of Medicine, Boston University School of Medicine
| | - Jacquelyn N. Pendergast
- United States Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
| | - Christopher J. Miller
- United States Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
- Department of Psychiatry, Harvard Medical School, Boston, MA
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Goff SL, Gurewich D, Alcusky M, Kachoria AG, Nicholson J, Himmelstein J. Barriers and Facilitators to Implementation of Value-Based Care Models in New Medicaid Accountable Care Organizations in Massachusetts: A Study Protocol. Front Public Health 2021; 9:645665. [PMID: 33889558 PMCID: PMC8055830 DOI: 10.3389/fpubh.2021.645665] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 03/05/2021] [Indexed: 12/05/2022] Open
Abstract
Introduction: Massachusetts established 17 new Medicaid accountable care organizations (ACOs) and 24 affiliated Community Partners (CPs) in 2018 as part of a large-scale healthcare reform effort to improve care value. The new ACOs will receive $1.8 billion dollars in state and federal funding over 5 years through the Delivery System Reform Incentive Program (DSRIP). The multi-faceted study described in this protocol aims to address gaps in knowledge about Medicaid ACOs' impact on healthcare value by identifying barriers and facilitators to implementation and sustainment of the DSRIP-funded programs. Methods and analysis: The study's four components are: (1) Document Review to characterize the ACOs and CPs; (2) Semi-structured Key Informant Interviews (KII) with ACO and CP leadership, state-level Medicaid administrators, and patients; (3) Site visits with selected ACOs and CPs; and (4) Surveys of ACO clinical teams and CP staff. The Consolidated Framework for Implementation Research's (CFIR) serves as the study's conceptual framework; its versatile menu of constructs, arranged across five domains (Intervention Characteristics, Inner Setting, Outer Setting, Characteristics of Individuals, and Processes) guides identification of barriers and facilitators across multiple organizational contexts. For example, KII interview guides focus on understanding how Inner and Outer Setting factors may impact implementation. Document Review analysis includes extraction and synthesis of ACO-specific DSRIP-funded programs (i.e., Intervention Characteristics); KIIs and site visit data will be qualitatively analyzed using thematic analytic techniques; surveys will be analyzed using descriptive statistics (e.g., counts, frequencies, means, and standard deviations). Discussion: Understanding barriers and facilitators to implementing and sustaining Medicaid ACOs with varied organizational structures will provide critical context for understanding the overall impact of the Medicaid ACO experiment in Massachusetts. It will also provide important insights for other states considering the ACO model for their Medicaid programs. Ethics and dissemination: IRB determinations were that the overall study did not constitute human subjects research and that each phase of primary data collection should be submitted for IRB review and approval. Study results will be disseminated through traditional channels such as peer reviewed journals, through publicly available reports on the mass.gov website; and directly to key stakeholders in ACO and CP leadership.
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Affiliation(s)
- Sarah L Goff
- Department of Health Promotion and Policy, University of Massachusetts, Amherst, MA, United States
| | - Deborah Gurewich
- Center for Healthcare Organizations and Implementation Research, US Department of Veterans Affairs, Boston, MA, United States
| | - Matthew Alcusky
- Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - Aparna G Kachoria
- Commonwealth Medicine, University of Massachusetts Medical School, Shrewsbury, MA, United States
| | - Joanne Nicholson
- Heller School for Policy and Management, Brandeis University, Waltham, MA, United States
| | - Jay Himmelstein
- Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States.,Commonwealth Medicine, University of Massachusetts Medical School, Shrewsbury, MA, United States
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Blosnich JR, Dichter ME, Gurewich D, Montgomery AE, Kressin NR, Lee R, Hester CM, Hausmann LRM. Health Services Research and Social Determinants of Health in the Nation's Largest Integrated Health Care System: Steps and Leaps in the Veterans Health Administration. Mil Med 2020; 185:e1353-e1356. [PMID: 32592393 DOI: 10.1093/milmed/usaa067] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 03/16/2020] [Indexed: 11/12/2022] Open
Affiliation(s)
- John R Blosnich
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion (CHERP), 151 University Drive C, Building 30, Pittsburgh, PA 15240.,Suzanne Dworak-Peck School of Social Work, University of Southern California, Montgomery Ross Fisher Building, 669 W 34th St, Los Angeles, CA 90089-0411
| | - Melissa E Dichter
- Corporal Michael J. Crescenz VA Medical Center, CHERP, 21 S University Ave, Philadelphia, PA 19104.,School of Social Work, Temple University, 1301 Cecil B. Moore Ave., Philadelphia, PA 19122
| | - Deborah Gurewich
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), 150 South Huntington Avenue (152M), Jamaica Plain Campus, Building 9, Boston, MA 02130
| | - Ann Elizabeth Montgomery
- Birmingham VA Medical Center, 700 19th St S, Birmingham, AL 35233.,School of Public Health, University of Alabama at Birmingham, 1665 University Blvd, Birmingham, AL 35233
| | - Nancy R Kressin
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), 150 South Huntington Avenue (152M), Jamaica Plain Campus, Building 9, Boston, MA 02130.,Department of Medicine, Boston University School of Medicine, 72 E Concord St, Boston, MA 02118
| | - Richard Lee
- Veterans Rural Health Resource Center, 163 Veterans Dr, White River Junction, VT 05009
| | - Christina M Hester
- American Academy of Family Physicians, 11400 Tomahawk Creek Pkwy, Leawood, KS 66211
| | - Leslie R M Hausmann
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion (CHERP), 151 University Drive C, Building 30, Pittsburgh, PA 15240.,Suzanne Dworak-Peck School of Social Work, University of Southern California, Montgomery Ross Fisher Building, 669 W 34th St, Los Angeles, CA 90089-0411.,Division of General Internal Medicine, University of Pittsburgh School of Medicine, 1218 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 1526
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Gurewich D, Beilstein‐Wedel E, Shwartz M, Davila H, Rosen A. What are the Predictors of Wait Times for Veterans Seeking Care in the VA and the Community through VA‐Purchased Care? Health Serv Res 2020. [DOI: 10.1111/1475-6773.13408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- D. Gurewich
- VA Boston Healthcare System Boston MA United States
| | - Erin Beilstein‐Wedel
- Center for Healthcare, Organization and Implementation Research VA Boston Healthcare System Boston MA United States
| | - M. Shwartz
- VA Boston Healthcare System Boston MA United States
| | - H. Davila
- Center for Healthcare Organization and Implementation Research VA Boston Healthcare System Boston MA United States
| | - A. Rosen
- Boston University School of Medicine Boston MA United States
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17
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Miller C, Gurewich D, Garvin L, Pugatch M, Koppelman E, Pendergast J, Harrington K, Clark JA. Veterans Affairs and Rural Community Providers' Perspectives on Interorganizational Care Coordination: A Qualitative Analysis. J Rural Health 2020; 37:417-425. [PMID: 32472724 DOI: 10.1111/jrh.12453] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To investigate challenges in care coordination between US Department of Veterans Affairs (VA) clinics and community providers serving rural veterans. METHODS We completed qualitative interviews in 2017-2018 with a geographically diverse sample of 57 VA and community staff. Interviews were audio-recorded and transcribed verbatim. We used Rapid Qualitative Inquiry (RQI) to guide analyses. RESULTS Results suggested 5 pivotal domains related to interorganizational care coordination at these sites: organizational mechanisms; organizational culture; relational coordination; contextual factors; and the role of the third party administrators charged with management of scheduling and reimbursement of community services through recent legislation. Across these domains, strategies to bridge gaps between organizations (eg, contracts with third party administrators, development of VA-based community care offices, provision of boundary-spanning staff) at times exacerbated coordination challenges. CONCLUSIONS Steps taken to improve interorganizational care coordination between VA and community clinics may inadvertently complicate an already complex process. Our findings emphasize the importance of attending to key contextual barriers in coordinating care for rural veterans, and they illustrate the value of fundamental structural and relational approaches to enhancing such care coordination.
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Affiliation(s)
- Christopher Miller
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), United States Department of Veterans Affairs, Boston, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Deborah Gurewich
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), United States Department of Veterans Affairs, Boston, Massachusetts
| | - Lynn Garvin
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), United States Department of Veterans Affairs, Boston, Massachusetts
- Boston University School of Public Health, Boston, Massachusetts
| | - Marianne Pugatch
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), United States Department of Veterans Affairs, Boston, Massachusetts
| | - Elisa Koppelman
- Boston University School of Public Health, Boston, Massachusetts
| | - Jacquelyn Pendergast
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), United States Department of Veterans Affairs, Boston, Massachusetts
| | - Katharine Harrington
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), United States Department of Veterans Affairs, Boston, Massachusetts
| | - Jack A Clark
- Boston University School of Public Health, Boston, Massachusetts
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18
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Gurewich D, Garg A, Kressin NR. Addressing Social Determinants of Health Within Healthcare Delivery Systems: a Framework to Ground and Inform Health Outcomes. J Gen Intern Med 2020; 35:1571-1575. [PMID: 32076989 PMCID: PMC7210348 DOI: 10.1007/s11606-020-05720-6] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/24/2019] [Accepted: 02/04/2020] [Indexed: 01/08/2023]
Abstract
Social determinants of health (SDoH) are the conditions in which people live and work that shape access to essential social and economic resources. Calls for healthcare systems to intervene on unmet social needs have stimulated several large-scale initiatives across the country. Yet, such activities are underway in the absence of a unifying conceptual framework outlining the potential mechanisms by which healthcare-based unmet social need interventions can improve health outcomes. Drawing on theoretical foundations and empirical evidence about the relationship between unmet social needs and health, the authors developed the OASIS (Outcomes from Addressing SDoH in Systems) conceptual framework to map the known and hypothesized pathways by which unmet social need screening and referral interventions may impact outcomes. The OASIS framework may help guide policy makers, healthcare system leaders, clinicians, and researchers to utilize a more unified approach in their efforts to implement and evaluate unmet social need interventions and thus foster the development of an evidence base to inform healthcare systems to more effectively mitigate the consequences of unmet social needs. Adopting an overarching conceptual framework for addressing unmet social needs by healthcare systems holds promise for better achieving health equity and promoting health at the individual and population levels.
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Affiliation(s)
- Deborah Gurewich
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research, Boston, MA, USA. .,Boston University School of Medicine, Boston Medical Center, Boston, MA, USA.
| | - Arvin Garg
- Boston University School of Medicine, Boston Medical Center, Boston, MA, USA
| | - Nancy R Kressin
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research, Boston, MA, USA.,Boston University School of Medicine, Boston Medical Center, Boston, MA, USA
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Weir RC, Proser M, Jester M, Li V, Hood-Ronick CM, Gurewich D. Collecting Social Determinants of Health Data in the Clinical Setting: Findings from National PRAPARE Implementation. J Health Care Poor Underserved 2020; 31:1018-1035. [PMID: 33410822 DOI: 10.1353/hpu.2020.0075] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences (PRAPARE) is a nationally recognized standardized protocol that goes beyond medical acuity to account for patients' social determinants of health (SDH). AIMS We described the magnitude of patient SDH barriers at health centers. METHODS Health centers across three PRAPARE implementation cohorts collected and submitted PRAPARE data using a standardized data reporting template. We analyzed the scope and intensity of SDH barriers across the cohorts. RESULTS Nationally, patients faced an average of 7.2 out of 22 social risks. The most common SDH risks among all three cohorts were limited English proficiency, less than high school education, lack of insurance, experiencing high to medium-high stress, and unemployment. CONCLUSIONS Findings demonstrated a high prevalence of SDH risks among health center patients that can be critical for informing social interventions and upstream transformation to improve health equity for underserved populations.
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Shepard DS, Gurewich D, Lwin AK, Reed GA, Silverman MM. Suicide and Suicidal Attempts in the United States: Costs and Policy Implications. Suicide Life Threat Behav 2016; 46:352-62. [PMID: 26511788 PMCID: PMC5061092 DOI: 10.1111/sltb.12225] [Citation(s) in RCA: 225] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 08/18/2015] [Indexed: 12/31/2022]
Abstract
The national cost of suicides and suicide attempts in the United States in 2013 was $58.4 billion based on reported numbers alone. Lost productivity (termed indirect costs) represents most (97.1%) of this cost. Adjustment for under-reporting increased the total cost to $93.5 billion or $298 per capita, 2.1-2.8 times that of previous studies. Previous research suggests that improved continuity of care would likely reduce the number of subsequent suicidal attempts following a previous nonfatal attempt. We estimate a highly favorable benefit-cost ratio of 6 to 1 for investments in additional medical, counseling, and linkage services for such patients.
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Affiliation(s)
- Donald S. Shepard
- Heller School for Social Policy and ManagementBrandeis UniversityWalthamMAUSA
| | - Deborah Gurewich
- Family Medicine and Community HealthUniversity of Massachusetts Medical SchoolShrewsburyMAUSA
| | - Aung K. Lwin
- Heller School for Social Policy and ManagementBrandeis UniversityWalthamMAUSA
| | - Gerald A. Reed
- Education Development Center Suicide Prevention and Resource CenterWalthamMAUSA
| | - Morton M. Silverman
- Education Development Center Suicide Prevention and Resource CenterWalthamMAUSA
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Gurewich D, Prottas J, Sirkin JT. Managing care for patients with substance abuse disorders at community health centers. J Subst Abuse Treat 2013; 46:227-31. [PMID: 24007802 DOI: 10.1016/j.jsat.2013.06.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Revised: 05/24/2013] [Accepted: 06/28/2013] [Indexed: 10/26/2022]
Abstract
Coordinating medical and substance use disorder (SUD) services is associated with good health and treatment outcomes but it is not widely practiced. This may be due to a lack of real-world models for coordinating care. This study examined the operational practices associated with a sample of community health centers (CHCs) identified as effectively coordinating SUD services relative to other CHCs. Case studies were used to describe the process of identifying patient need and linking patients with SA treatment services, and to generate propositions about operational approaches for effectively coordinating care. Integrating behavioral health staff within the primary care team was identified as especially critical for facilitating key care transitions. Additional operational approaches that aim to improve care transitions within and across care settings were identified. Future study will be needed to understand the significance of these approaches in terms of health and treatment outcomes. On-going coordination activities among primary care and SUD provided for shared patients remained a challenge for all sites.
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Affiliation(s)
- Deborah Gurewich
- University of Massachusetts Medical School, Center for Health Policy and Research, Shrewsbury, MA, 01545, USA.
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Tyo KR, Gurewich D, Shepard DS. Methodological challenges of measuring primary care delivery to pediatric medicaid beneficiaries who use community health centers. Am J Public Health 2012; 103:273-5. [PMID: 23237184 DOI: 10.2105/ajph.2012.300884] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Efforts to measure quality of care have focused on ambulatory care providers. We examined the performance of community health centers serving children on Medicaid in 3 states. Descriptive analysis showed considerable patient population heterogeneity, and regression analysis demonstrated that variation explained by the assigned provider was small (mean R(2) = 4.3%) compared with the variation explained by patient demographic variables (mean R(2) = 29.9%). The results reinforce the need for caution when one is attributing quality differences to provider performance.
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Affiliation(s)
- Karen R Tyo
- Heller School for Social Policy and Management, Brandeis University, Waltham, MA 02454-9110, USA
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Gurewich D, Capitman J, Sirkin J, Traje D. Achieving excellence in community health centers: implications for health reform. J Health Care Poor Underserved 2012; 23:446-59. [PMID: 22643489 DOI: 10.1353/hpu.2012.0008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Existing studies tell us little about care quality variation within the community health center (CHC) delivery system. They also tell us little about the organizational conditions associated with CHCs that deliver especially high quality care. The purpose of this study was to examine the operational practices associated with a sample of high performing CHCs. METHODS Qualitative case studies of eight CHCs identified as delivering high-quality care relative to other CHCs were used to examine operational practices, including systems to facilitate care access, manage patient care, and monitor performance. RESULTS Four common themes emerged that may contribute to high performance. At the same time, important differences across health centers were observed, reflecting differences in local environments and CHC capacity. CONCLUSIONS In the development of effective, community-based models of care, adapting care standards to meet the needs of local conditions may be important.
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Affiliation(s)
- Deborah Gurewich
- Center for Health Policy and Research, University of Massachusetts Medical School, Shrewsbury, MA 01545, USA.
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Abstract
OBJECTIVE To determine how Community Health Centers (CHCs) perform relative to other primary care providers. RESEARCH DESIGN A retrospective cohort study of Medicaid claims comparing provider groups on the basis of avoidable hospitalizations and costs. RESULTS Avoidable hospitalization rates did not differ significantly across care settings. Hospital outpatient departments and CHCs had comparable total costs, whereas physicians had slightly but significantly lower total costs. CONCLUSIONS Understanding determinants of care cost differences could inform future performance improvement initiatives. Care quality variance within provider groups may be more significant than care quality performance across care settings.
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Affiliation(s)
- Deborah Gurewich
- Schneider Institutes for Health Policy, Brandeis University, Waltham, MA, USA.
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