Population Health Innovations and Payment to Address Social Needs Among Patients and Communities With Diabetes

Policy Points Population health efforts to improve diabetes care and outcomes should identify social needs, support social needs referrals and coordination, and partner health care organizations with community social service agencies and resources. Current payment mechanisms for health care services do not adequately support critical up-front investments in infrastructure to address medical and social needs, nor provide sufficient incentives to make addressing social needs a priority. Alternative payment models and value-based payment should provide up-front funding for personnel and infrastructure to address social needs and should incentivize care that addresses social needs and outcomes sensitive to social risk.

CONTEXT

Increasingly, health care organizations are implementing interventions to improve outcomes for patients with complex health and social needs, including diabetes, through cross-sector partnerships with nonmedical organizations. However, fee-for-service and many value-based payment systems constrain options to implement models of care that address social and medical needs in an integrated fashion. We present experiences of eight grantee organizations from the Bridging the Gap: Reducing Disparities in Diabetes Care initiative to improve diabetes outcomes by transforming primary care and addressing social needs within evolving payment models.

METHODS

Analysis of eight grantees through site visits, technical assistance calls, grant applications, and publicly available data from US census data (2017) and from Health Resources and Services Administration Uniform Data System Resources data (2018). Organizations represent a range of payment models, health care settings, market factors, geographies, populations, and community resources.

FINDINGS

Grantees are implementing strategies to address medical and social needs through augmented staffing models to support high-risk patients with diabetes (e.g., community health workers, behavioral health specialists), information technology innovations (e.g., software for social needs referrals), and system-wide protocols to identify high-risk populations with gaps in care. Sites identify and address social needs (e.g., food insecurity, housing), invest in human capital to support social needs referrals and coordination (e.g., embedding social service employees in clinics), and work with organizations to connect to community resources. Sites encounter challenges accessing flexible up-front funding to support infrastructure for interventions. Value-based payment mechanisms usually reward clinical performance metrics rather than measures of population health or social needs interventions.

CONCLUSIONS

Federal, state, and private payers should support critical infrastructure to address social needs and incentivize care that addresses social needs and outcomes sensitive to social risk. Population health strategies that address medical and social needs for populations living with diabetes will need to be tailored to a range of health care organizations, geographies, populations, community partners, and market factors. Payment models should support and incentivize these strategies for sustainability.

Correlates of youth smokeless tobacco use

The objectives of this study are to identify knowledge and attitude variables that correlate with smokeless tobacco use and how youth users and non-users differ in their attitudes and knowledge about smokeless tobacco. A randomized cluster sample of 1834 total fifth, eighth, and 11th grade students in West Virginia public schools during the 1996-1997 school year were surveyed on smokeless tobacco knowledge, attitudes and practices. Data from 648 male non-users and 160 male monthly and daily users of smokeless tobacco were compared using chi 2 and two-tailed t-tests. Logistic regression analysis of survey variables revealed the following correlates of smokeless tobacco use: having a family member not living in the home who uses, having a friend who uses, playing football, having tried cigarettes, and having parents who would permit use at home. Important differences exist in knowledge and attitudes regarding smokeless tobacco between users and non-users in fifth, eighth, and 11th grade West Virginia public schools. Correlates of smokeless tobacco use are identified which can be used to target prevention programs.

Assessment of school-based health centers in a rural state: the West Virginia experience

PURPOSE

To assess the capability of school-based health centers (SBHCs) to provide access to health care for rural youth.

METHODS

Review of annual patient records from SBHCs in West Virginia. Ten of 24 SBHCs in West Virginia in operation from July 1994 to June 1997 were selected for the study. Enrollment and utilization rates were generated for each site. A comparison was made between rates of enrollment, utilization, and annual visits among youth with private insurance, those covered by Medicaid, and youth without insurance. Rural and urban SBHCs within West Virginia were compared based on enrollment, utilization, and visit rates. The diagnostic categories were analyzed. Finally, enrollment rates, utilization rates, and insurance status for the West Virginia SBHCs were compared with national norms.

RESULTS

Enrollment rates rose steadily during the study period from 27% in Year 1 to 64% by the end of Year 3. The utilization rate was 67% in Year 3. The youth with either Medicaid or no insurance comprised 52% of enrollees, but they accounted for 63% of all visits. West Virginia SBHCs have a higher rate of Medicaid users than the national average for SBHCs, and the annual visit rate for West Virginia youth is higher than the national average for nonmetropolitan adolescents. The enrollment rate of 64% is slightly higher than the national average for SBHCs. Within West Virginia, the enrollment rate in rural schools was significantly higher, 86% compared to 46% (p < .001), and the utilization rate was 70% in rural centers compared to 63% in the urban centers (p < .001).

CONCLUSION

When SBHCs are available in rural areas, students use them. In West Virginia, SBHCs have contributed to providing access to health care for rural youth.

Dark solitary waves in the nonlinear Schrödinger equation with third order dispersion, self-steepening, and self-frequency shift

We solve the higher order nonlinear Schrödinger equation describing the propagation of ultrashort pulses in optical fibers. By means of the coupled amplitude-phase formulation fundamental (solitary wave) dark soliton solutions are found.

Equivalent-optical-waveguide model for the analysis of optical waveguides by means of an asymptotic effective-index method

We present a theoretical method that makes it possible to analyze three-dimensional (3-D) integrated optical waveguides with arbitrary refractive-index profiles. With this method it is easy to obtain effective indexes, propagation constants, and coupling-switching properties of planar and channel optical waveguides. This theoretical approach involves one's modeling the original optical waveguide by means of an equivalent optical waveguide whose effective index is evaluated by the application of a technique that we call the asymptotic effective-index method. The numerical values show good convergence and accuracy for effective indexes, propagation constants, and coupling-switching characteristics. Theoretical and experimental results are given.

Verification of generalized telegraphist's equations applied to dielectric waveguide problems: comment

In accordance with the paper by So and Lee [Appl. Opt. 31, 6446-6452 (1992)], the efficiency of the Schelkunoff's method as applied to dielectric waveguide problems needs to be clarified. Previous papers have demonstrated the accuracy of the generalized telegraphist's equations in electromagnetic modal analysis on shielded dielectric waveguides as well as their application to electromagnetic-scattering properties. The basic mode-selection process can be clearly improved to get sharp reductions in CPU times and to assure very good solutions of slow, fast, evanescent, and complex waves. As a consequence, to analyze passive devices on dielectric waveguides, the cascaded set of multiple discontinuities model can be used. The modal matching technique has been used to demonstrate this possibility in calculating the generalized scattering matrix. Furthermore, the resulting electromagnetic field in a shielded dielectric waveguide structure can be used to calculate the cross-section dimensions of the metallic walls to simulate the dielectric configuration as in the open air.