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Callahan CM, Carter A, Carty HS, Clark DO, Grain T, Grant SL, McElroy-Jones K, Reinoso D, Harris LE. Building the Infrastructure to Integrate Social Care in a Safety Net Health System. Am J Public Health 2024; 114:619-625. [PMID: 38574317 PMCID: PMC11079822 DOI: 10.2105/ajph.2024.307602] [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: 04/06/2024]
Abstract
A recent National Academies report recommended that health systems invest in new infrastructure to integrate social and medical care. Although many health systems routinely screen patients for social concerns, few health systems achieve the recommended model of integration. In this critical case study in an urban safety net health system, we describe the human capital, operational redesign, and financial investment needed to implement the National Academy recommendations. Using data from this case study, we estimate that other health systems seeking to build and maintain this infrastructure would need to invest $1 million to $3 million per year. While health systems with robust existing resources may be able to bootstrap short-term funding to initiate this work, we conclude that long-term investments by insurers and other payers will be necessary for most health systems to achieve the recommended integration of medical and social care. Researchers seeking to test whether integrating social and medical care leads to better patient and population outcomes require access to health systems and communities who have already invested in this model infrastructure. (Am J Public Health. 2024;114(6):619-625. https://doi.org/10.2105/AJPH.2024.307602).
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Affiliation(s)
- Christopher M Callahan
- Christopher M. Callahan, Amy Carter, Hannah S. Carty, Tedd Grain, Seth L. Grant, Kimberly McElroy-Jones, Deanna Reinoso, and Lisa E. Harris are with Eskenazi Health, Indianapolis, IN. Daniel O. Clark is with the Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Amy Carter
- Christopher M. Callahan, Amy Carter, Hannah S. Carty, Tedd Grain, Seth L. Grant, Kimberly McElroy-Jones, Deanna Reinoso, and Lisa E. Harris are with Eskenazi Health, Indianapolis, IN. Daniel O. Clark is with the Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Hannah S Carty
- Christopher M. Callahan, Amy Carter, Hannah S. Carty, Tedd Grain, Seth L. Grant, Kimberly McElroy-Jones, Deanna Reinoso, and Lisa E. Harris are with Eskenazi Health, Indianapolis, IN. Daniel O. Clark is with the Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Daniel O Clark
- Christopher M. Callahan, Amy Carter, Hannah S. Carty, Tedd Grain, Seth L. Grant, Kimberly McElroy-Jones, Deanna Reinoso, and Lisa E. Harris are with Eskenazi Health, Indianapolis, IN. Daniel O. Clark is with the Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Tedd Grain
- Christopher M. Callahan, Amy Carter, Hannah S. Carty, Tedd Grain, Seth L. Grant, Kimberly McElroy-Jones, Deanna Reinoso, and Lisa E. Harris are with Eskenazi Health, Indianapolis, IN. Daniel O. Clark is with the Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Seth L Grant
- Christopher M. Callahan, Amy Carter, Hannah S. Carty, Tedd Grain, Seth L. Grant, Kimberly McElroy-Jones, Deanna Reinoso, and Lisa E. Harris are with Eskenazi Health, Indianapolis, IN. Daniel O. Clark is with the Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Kimberly McElroy-Jones
- Christopher M. Callahan, Amy Carter, Hannah S. Carty, Tedd Grain, Seth L. Grant, Kimberly McElroy-Jones, Deanna Reinoso, and Lisa E. Harris are with Eskenazi Health, Indianapolis, IN. Daniel O. Clark is with the Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Deanna Reinoso
- Christopher M. Callahan, Amy Carter, Hannah S. Carty, Tedd Grain, Seth L. Grant, Kimberly McElroy-Jones, Deanna Reinoso, and Lisa E. Harris are with Eskenazi Health, Indianapolis, IN. Daniel O. Clark is with the Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Lisa E Harris
- Christopher M. Callahan, Amy Carter, Hannah S. Carty, Tedd Grain, Seth L. Grant, Kimberly McElroy-Jones, Deanna Reinoso, and Lisa E. Harris are with Eskenazi Health, Indianapolis, IN. Daniel O. Clark is with the Department of Medicine, Indiana University School of Medicine, Indianapolis
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Vessa B, Malhotra R, Chemerinski A, Howard D, Morelli S. One Result, Many Eyes: Creating a Results Safety Net in a University Hospital-Based Reproductive Endocrinology and Infertility Clinic. Am J Med Qual 2024; 39:135-136. [PMID: 38713603 DOI: 10.1097/jmq.0000000000000170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2024]
Affiliation(s)
- Blake Vessa
- PGY4 Obstetrics and Gynecology Resident, Rutgers Health/Cooperman Barnabas Medical Center, Newark and Livingston, NJ
| | - Radhika Malhotra
- PGY1 Internal Medicine Resident, New Jersey Medical School, Newark, NJ
| | - Anat Chemerinski
- PGY7 Reproductive Endocrinology and Infertility Fellow, New Jersey Medical School/University Reproductive Associates, Newark and Hasbrouk Heights, NJ
| | - David Howard
- Department of Obstetrics, Gynecology and Reproductive Health, Rutgers New Jersey Medical School, Newark, NJ
| | - Sara Morelli
- Reproductive Endocrinology and Infertility Fellowship New Jersey Medical School/University Reproductive Associates, Newark and Hasbrouk Heights, NJ
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Gore R, Engelberg RS, Johnson D, Jebb O, Schwartz MD, Islam N. Integrating Community Health Workers' Dual Clinic-Community Role in Safety-Net Primary Care: Implementation Lessons from a Pragmatic Diabetes-Prevention Trial. J Gen Intern Med 2024; 39:774-781. [PMID: 37973708 PMCID: PMC11043246 DOI: 10.1007/s11606-023-08512-w] [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: 07/09/2023] [Accepted: 10/24/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Over a third of US adults carry a diagnosis of prediabetes, 70% of whom may progress to type 2 diabetes mellitus ("diabetes"). Community health workers (CHWs) can help patients undertake healthy behavior to prevent diabetes. However, there is limited guidance to integrate CHWs in primary care, specifically to address CHWs' dual clinic-based and community-oriented role. OBJECTIVE Using evidence from CHWs' adaptations of a diabetes-prevention intervention in safety-net hospitals in New York City, we examine the nature, intent, and possible consequences of CHWs' actions on program fidelity. We propose strategies for integrating CHWs in primary care. DESIGN Case study drawing on the Model for Adaptation Design and Impact (MADI) to analyze CHWs' actions during implementation of CHORD (Community Health Outreach to Reduce Diabetes), a cluster-randomized pragmatic trial (2017-2022) at Manhattan VA and Bellevue Hospital. PARTICIPANTS CHWs and clinicians in the CHORD study, with a focus in this analysis on CHWs. APPROACH Semi-structured interviews and focus group discussion with CHWs (n=4); semi-structured interviews with clinicians (n=17). Interpretivist approach to explain CHWs' adaptations using a mix of inductive and deductive analysis. KEY RESULTS CHWs' adaptations extended the intervention in three ways: by extending social assistance, healthcare access, and operational tasks. The adaptations were intended to improve fit, reach, and retention, but likely had ripple effects on implementation outcomes. CHWs' focus on patients' complex social needs could divert them from judiciously managing their caseload. CONCLUSIONS CHWs' community knowledge can support patient engagement, but overextension of social assistance may detract from protocolized health-coaching goals. CHW programs in primary care should explicitly delineate CHWs' non-health support to patients, include multiprofessional teams or partnerships with community-based organizations, establish formal communication between CHWs and clinicians, and institute mechanisms to review and iterate CHWs' work to resolve challenges in their community-oriented role.
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Affiliation(s)
- Radhika Gore
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA.
| | - Rachel S Engelberg
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Danielle Johnson
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
- Bellevue Hospital Center, New York, NY, USA
| | - Olivia Jebb
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
- Bellevue Hospital Center, New York, NY, USA
| | - Mark D Schwartz
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
- VA NY Harbor Health Care System, New York, NY, USA
| | - Nadia Islam
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
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Gasperino J. Safety-net Hospitals in Brooklyn, New York: A Review. J Health Care Poor Underserved 2023; 34:1452-1465. [PMID: 38661767] [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
Safety-net hospitals (SNHs) provide health care services to individuals regardless of their ability to pay. These hospitals serve Medicaid recipients, the uninsured, and people with limited access to health care due to their socioeconomic status, race, or ethnicity. In addition to providing health care to the most vulnerable, SNHs are crucial in training the next generation of clinicians. Hospitals serving Medicaid patients and the uninsured have low operating margins because of a dated State Medicaid financial model, and as a result, many now face closure. This review provides historical context for the financial challenges facing SNHs in Brooklyn, New York. In addition, it examines how New York State's Medicaid reimbursement methodology threatens the viability of hospitals that serve low-income communities. Finally, the article suggests a solution to the health care crisis in Brooklyn, capitalizing on structural payment reform successes in other states.
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Cross DA, Stevens MA, Spivack SB, Murray GF, Rodriguez HP, Lewis VA. Survey of Information Exchange and Advanced Use of Other Health Information Technology in Primary Care Settings: Capabilities In and Outside of the Safety Net. Med Care 2022; 60:140-148. [PMID: 35030563 PMCID: PMC8966676 DOI: 10.1097/mlr.0000000000001673] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Advanced use of health information technology (IT) functionalities can support more comprehensive, coordinated, and patient-centered primary care services. Safety net practices may benefit disproportionately from these investments, but it is unclear whether IT use in these settings has kept pace and what organizational factors are associated with varying use of these features. OBJECTIVE The aim was to estimate advanced use of health IT use in safety net versus nonsafety net primary care practices. We explore domains of patient engagement, population health management (decision support and registries), and electronic information exchange. We examine organizational characteristics that may differentially predict advanced use of IT across these settings, with a focus on health system ownership and/or membership in an independent practice network as key factors that may indicate available incentives and resources to support these efforts. RESEARCH DESIGN We conduct cross-sectional analysis of a national survey of physician practices (n=1776). We use logistic regression to predict advanced IT use in each of our domains based on safety net status and other organizational characteristics. We then use interaction models to assess whether ownership or network membership moderate the relationship between safety net status and advanced use of health IT. RESULTS Health IT use was common across primary care practices, but advanced use of health IT functionalities ranged only from 30% to 50% use. Safety net settings have kept pace with adoption of features for patient engagement and population management, yet lag in information exchange capabilities compared with nonsafety net practices (odds ratio=0.52 for federally qualified health centers, P<0.001; odds ratio=0.66 for other safety net, P=0.03). However, when safety net practices are members of a health system or practice network, health IT capabilities are comparable to nonsafety net sites. CONCLUSIONS All outpatient settings would benefit from improved electronic health record usability and implementation support that facilitates advanced use of health IT. Safety net practices, particularly those without other sources of centralized support, need targeted resources to maintain equitable access to information exchange capabilities.
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Affiliation(s)
- Dori A Cross
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN
| | - Maria A Stevens
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, NC
| | - Steven B Spivack
- Center for Outcomes and Evaluation, Yale School of Medicine, New Haven, CT
| | - Genevra F Murray
- Department of General Internal Medicine, Boston Medical Center, Boston, MA
| | - Hector P Rodriguez
- Department of Health Policy and Management, University of California-Berkeley School of Public Health, Berkeley, CA
| | - Valerie A Lewis
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, NC
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Pathman DE, Sonis J, Harrison JN, Sewell RG, Fannell J, Overbeck M, Konrad TR. Experiences of Safety-Net Practice Clinicians Participating in the National Health Service Corps During the COVID-19 Pandemic. Public Health Rep 2022; 137:149-162. [PMID: 34694922 PMCID: PMC8721684 DOI: 10.1177/00333549211054083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES The impact of the COVID-19 pandemic has been particularly harsh for low-income and racial and ethnic minority communities. It is not known how the pandemic has affected clinicians who provide care to these communities through safety-net practices, including clinicians participating in the National Health Service Corps (NHSC). METHODS In late 2020, we surveyed clinicians who were serving in the NHSC as of July 1, 2020, in 20 states. Clinicians reported on work and job changes and their current well-being, among other measures. Analyses adjusted for differences in subgroup response rates and clustering of clinicians within practices. RESULTS Of 4263 surveyed clinicians, 1890 (44.3%) responded. Work for most NHSC clinicians was affected by the pandemic, including 64.5% whose office visit numbers fell by half and 62.5% for whom most visits occurred virtually. Fewer experienced changes in their jobs; for example, only 14.9% had been furloughed. Three-quarters (76.6%) of these NHSC clinicians scored in at-risk levels for their well-being. Compared with primary care and behavioral health clinicians, dental clinicians much more often had been furloughed and had their practices close temporarily. CONCLUSIONS The pandemic has disrupted the work, jobs, and mental health of NHSC clinicians in ways similar to its reported effects on outpatient clinicians generally. Because clinicians' mental health worsens after a pandemic, which leads to patient disengagement and job turnover, national programs and policies should help safety-net practices build cultures that support and give greater priority to clinicians' work, job, and mental health needs now and before the next pandemic.
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Affiliation(s)
- Donald E. Pathman
- Department of Family Medicine, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jeffrey Sonis
- Department of Family Medicine, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Robert G. Sewell
- Office of Healthcare Access, Section on Rural and Community Health Systems, Division of Public Health, Alaska Department of Health and Social Services, Anchorage, AK, USA
| | - Jackie Fannell
- Provider Retention and Information System Management Collaborative, National Rural Recruitment and Retention Network (3RNET), Jefferson City, MO, USA
| | - Marc Overbeck
- Oregon Primary Care Office, Oregon Health Authority, Portland, OR, USA
| | - Thomas R. Konrad
- Department of Family Medicine, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Health Workforce Analytics, Chapel Hill, NC, USA
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Affiliation(s)
- Janine Knudsen
- From the New York City Department of Health and Mental Hygiene (J.K., D.A.C.), New York University Grossman School of Medicine (J.K., D.A.C.), and New York City Health and Hospitals (J.K.) - all in New York
| | - Dave A Chokshi
- From the New York City Department of Health and Mental Hygiene (J.K., D.A.C.), New York University Grossman School of Medicine (J.K., D.A.C.), and New York City Health and Hospitals (J.K.) - all in New York
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Abstract
BACKGROUND Clerical burdens have strained primary care providers already facing a shifting health care landscape and workforce shortages. These pressures may cause burnout and job dissatisfaction, with negative implications for patient care. Medical scribes, who perform real-time electronic health record documentation, have been posited as a solution to relieve clerical burdens, thus improving provider satisfaction and other outcomes. OBJECTIVE The purpose of this study is to identify and synthesize the published research on medical scribe utilization in primary care and safety net settings. RESEARCH DESIGN We conducted a review of the literature to identify outcomes studies published between 2010 and 2020 assessing medical scribe utilization in primary care settings. Searches were conducted in PubMed and supplemented by a review of the gray literature. Articles for inclusion were reviewed by the study authors and synthesized based on study characteristics, medical scribe tasks, and reported outcomes. RESULTS We identified 21 publications for inclusion, including 5 that examined scribes in health care safety net settings. Scribe utilization was consistently reported as being associated with improved productivity and efficiency, provider experience, and documentation quality. Findings for patient experience were mixed. CONCLUSIONS Published studies indicate scribe utilization in primary care may improve productivity, clinic and provider efficiencies, and provider experience without diminishing the patient experience. Further large-scale research is needed to validate the reliability of study findings and assess additional outcomes, including how scribes enhance providers' ability to advance health equity.
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Nadjarian A, LeClair J, Mahoney TF, Awtry EH, Bhatia JS, Caruso LB, Clay A, Greer D, Hingorani KS, Horta LFB, Ibrahim M, Ieong MH, James T, Kulke MH, Lim R, Lowe RC, Moses JM, Murphy J, Nozari A, Patel AD, Silver B, Theodore AC, Wang RS, Weinstein E, Wilson SA, Cervantes-Arslanian AM. Validation of a Crisis Standards of Care Model for Prioritization of Limited Resources During the Coronavirus Disease 2019 Crisis in an Urban, Safety-Net, Academic Medical Center. Crit Care Med 2021; 49:1739-1748. [PMID: 34115635 PMCID: PMC8439631 DOI: 10.1097/ccm.0000000000005155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The coronavirus disease 2019 pandemic has overwhelmed healthcare resources even in wealthy nations, necessitating rationing of limited resources without previously established crisis standards of care protocols. In Massachusetts, triage guidelines were designed based on acute illness and chronic life-limiting conditions. In this study, we sought to retrospectively validate this protocol to cohorts of critically ill patients from our hospital. DESIGN We applied our hospital-adopted guidelines, which defined severe and major chronic conditions as those associated with a greater than 50% likelihood of 1- and 5-year mortality, respectively, to a critically ill patient population. We investigated mortality for the same intervals. SETTING An urban safety-net hospital ICU. PATIENTS All adults hospitalized during April of 2015 and April 2019 identified through a clinical database search. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 365 admitted patients, 15.89% had one or more defined chronic life-limiting conditions. These patients had higher 1-year (46.55% vs 13.68%; p < 0.01) and 5-year (50.00% vs 17.22%; p < 0.01) mortality rates than those without underlying conditions. Irrespective of classification of disease severity, patients with metastatic cancer, congestive heart failure, end-stage renal disease, and neurodegenerative disease had greater than 50% 1-year mortality, whereas patients with chronic lung disease and cirrhosis had less than 50% 1-year mortality. Observed 1- and 5-year mortality for cirrhosis, heart failure, and metastatic cancer were more variable when subdivided into severe and major categories. CONCLUSIONS Patients with major and severe chronic medical conditions overall had 46.55% and 50.00% mortality at 1 and 5 years, respectively. However, mortality varied between conditions. Our findings appear to support a crisis standards protocol which focuses on acute illness severity and only considers underlying conditions carrying a greater than 50% predicted likelihood of 1-year mortality. Modifications to the chronic lung disease, congestive heart failure, and cirrhosis criteria should be refined if they are to be included in future models.
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Affiliation(s)
- Albert Nadjarian
- Department of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, MA
- Boston University School of Medicine, Boston, MA
- Boston Medical Center, Boston, MA
| | - Jessica LeClair
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Taylor F Mahoney
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Eric H Awtry
- Boston University School of Medicine, Boston, MA
- Boston Medical Center, Boston, MA
- Department of Medicine, Section of Cardiology, Boston Medical Center, Boston, MA
| | - Jasvinder S Bhatia
- Boston University School of Medicine, Boston, MA
- Boston Medical Center, Boston, MA
- Department of Medicine, Section of Nephrology, Boston Medical Center, Boston, MA
| | - Lisa B Caruso
- Department of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, MA
- Boston University School of Medicine, Boston, MA
- Boston Medical Center, Boston, MA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
- Department of Medicine, Section of Cardiology, Boston Medical Center, Boston, MA
- Department of Medicine, Section of Nephrology, Boston Medical Center, Boston, MA
- Department of Neurology, Boston Medical Center, Boston, MA
- Department of Medicine, Section of Pulmonary, Allergy, and Critical Care Medicine, Boston Medical Center, Boston, MA
- Department of Emergency Medicine, Boston Medical Center, Boston, MA
- Department of Medicine, Section of Hematology and Oncology, Boston Medical Center, Boston, MA
- Department of Medicine, Section of Gastroenterology, Boston Medical Center, Boston, MA
- Department of Pediatrics, Boston Medical Center, Boston, MA
- Department of Quality and Patient Safety, Boston Medical Center, Boston, MA
- Department of Anesthesiology, Boston Medical Center, Boston, MA
- Office of the General Counsel, Boston Medical Center, Boston, MA
- Department of Family Medicine, Boston Medical Center, Boston, MA
- Department of Medicine, Section of Infectious Disease, Boston Medical Center, Boston, MA
- Department of Neurosurgery, Boston Medical Center, Boston, MA
| | - Alexis Clay
- Boston Medical Center, Boston, MA
- Department of Neurology, Boston Medical Center, Boston, MA
| | - David Greer
- Boston University School of Medicine, Boston, MA
- Boston Medical Center, Boston, MA
- Department of Neurology, Boston Medical Center, Boston, MA
| | - Karan S Hingorani
- Boston Medical Center, Boston, MA
- Department of Neurology, Boston Medical Center, Boston, MA
| | - L F B Horta
- Boston Medical Center, Boston, MA
- Department of Neurology, Boston Medical Center, Boston, MA
| | - Michel Ibrahim
- Boston University School of Medicine, Boston, MA
- Boston Medical Center, Boston, MA
- Department of Medicine, Section of Cardiology, Boston Medical Center, Boston, MA
| | - Michael H Ieong
- Boston University School of Medicine, Boston, MA
- Boston Medical Center, Boston, MA
- Department of Medicine, Section of Pulmonary, Allergy, and Critical Care Medicine, Boston Medical Center, Boston, MA
| | - Thea James
- Boston University School of Medicine, Boston, MA
- Boston Medical Center, Boston, MA
- Department of Emergency Medicine, Boston Medical Center, Boston, MA
| | - Matthew H Kulke
- Boston University School of Medicine, Boston, MA
- Boston Medical Center, Boston, MA
- Department of Medicine, Section of Hematology and Oncology, Boston Medical Center, Boston, MA
| | | | - Robert C Lowe
- Boston University School of Medicine, Boston, MA
- Boston Medical Center, Boston, MA
- Department of Medicine, Section of Gastroenterology, Boston Medical Center, Boston, MA
| | - James M Moses
- Boston University School of Medicine, Boston, MA
- Boston Medical Center, Boston, MA
- Department of Pediatrics, Boston Medical Center, Boston, MA
- Department of Quality and Patient Safety, Boston Medical Center, Boston, MA
| | - Jaime Murphy
- Boston University School of Medicine, Boston, MA
- Boston Medical Center, Boston, MA
- Department of Medicine, Section of Pulmonary, Allergy, and Critical Care Medicine, Boston Medical Center, Boston, MA
- Department of Quality and Patient Safety, Boston Medical Center, Boston, MA
| | - Ala Nozari
- Boston University School of Medicine, Boston, MA
- Boston Medical Center, Boston, MA
- Department of Anesthesiology, Boston Medical Center, Boston, MA
| | - Anuj D Patel
- Boston Medical Center, Boston, MA
- Department of Neurology, Boston Medical Center, Boston, MA
| | - Brent Silver
- Boston Medical Center, Boston, MA
- Department of Neurology, Boston Medical Center, Boston, MA
| | - Arthur C Theodore
- Boston University School of Medicine, Boston, MA
- Boston Medical Center, Boston, MA
- Department of Medicine, Section of Pulmonary, Allergy, and Critical Care Medicine, Boston Medical Center, Boston, MA
| | - Ryan Shufei Wang
- Boston Medical Center, Boston, MA
- Department of Neurology, Boston Medical Center, Boston, MA
| | - Ellen Weinstein
- Department of Quality and Patient Safety, Boston Medical Center, Boston, MA
- Office of the General Counsel, Boston Medical Center, Boston, MA
| | - Stephen A Wilson
- Boston University School of Medicine, Boston, MA
- Boston Medical Center, Boston, MA
- Department of Family Medicine, Boston Medical Center, Boston, MA
| | - Anna M Cervantes-Arslanian
- Boston University School of Medicine, Boston, MA
- Boston Medical Center, Boston, MA
- Department of Neurology, Boston Medical Center, Boston, MA
- Department of Medicine, Section of Infectious Disease, Boston Medical Center, Boston, MA
- Department of Neurosurgery, Boston Medical Center, Boston, MA
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Balasubramanian BA, Higashi RT, Rodriguez SA, Sadeghi N, Santini NO, Lee SC. Thematic Analysis of Challenges of Care Coordination for Underinsured and Uninsured Cancer Survivors With Chronic Conditions. JAMA Netw Open 2021; 4:e2119080. [PMID: 34387681 PMCID: PMC8363913 DOI: 10.1001/jamanetworkopen.2021.19080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
IMPORTANCE Although a majority of underinsured and uninsured patients with cancer have multiple comorbidities, many lack consistent connections with a primary care team to manage chronic conditions during and after cancer treatment. This presents a major challenge to delivering high-quality comprehensive and coordinated care. OBJECTIVE To describe challenges and opportunities for coordinating care in an integrated safety-net system for patients with both cancer and other chronic conditions. DESIGN, SETTING, AND PARTICIPANTS This multimodal qualitative study was conducted from May 2016 to July 2019 at a county-funded, vertically integrated safety-net health system including ambulatory oncology, urgent care, primary care, and specialty care. Participants were 93 health system stakeholders (clinicians, leaders, clinical, and administrative staff) strategically and snowball sampled for semistructured interviews and observation during meetings and daily processes of care. Data collection and analysis were conducted iteratively using a grounded theory approach, followed by systematic thematic analysis to organize data, review, and interpret comprehensive findings. Data were analyzed from March 2019 to March 2020. MAIN OUTCOMES AND MEASURES Multilevel factors associated with experiences of coordinating care for patients with cancer and chronic conditions among oncology and primary care stakeholders. RESULTS Among interviews and observation of 93 health system stakeholders, system-level factors identified as being associated with care coordination included challenges to accessing primary care, lack of communication between oncology and primary care clinicians, and leadership awareness of care coordination challenges. Clinician-level factors included unclear role delineation and lack of clinician knowledge and preparedness to manage the effects of cancer and chronic conditions. CONCLUSIONS AND RELEVANCE Primary care may play a critical role in delivering coordinated care for patients with cancer and chronic diseases. This study's findings suggest a need for care delivery strategies that bridge oncology and primary care by enhancing communication, better delineating roles and responsibilities across care teams, and improving clinician knowledge and preparedness to care for patients with cancer and chronic conditions. Expanding timely access to primary care is also key, albeit challenging in resource-limited safety-net settings.
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Affiliation(s)
- Bijal A. Balasubramanian
- University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Dallas
- Harold C. Simmons Comprehensive Cancer Center, Dallas, Texas
| | - Robin T. Higashi
- Harold C. Simmons Comprehensive Cancer Center, Dallas, Texas
- University of Texas Southwestern Medical Center, Dallas
| | | | - Navid Sadeghi
- Harold C. Simmons Comprehensive Cancer Center, Dallas, Texas
- University of Texas Southwestern Medical Center, Dallas
- Parkland Health and Hospital System, Dallas, Texas
| | | | - Simon Craddock Lee
- Harold C. Simmons Comprehensive Cancer Center, Dallas, Texas
- University of Texas Southwestern Medical Center, Dallas
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Cooper Z, Zerden LDS. How COVID-19 has impacted integrated care practice: lessons from the frontlines. Soc Work Health Care 2021; 60:146-156. [PMID: 33749534 DOI: 10.1080/00981389.2021.1904316] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 01/03/2021] [Accepted: 03/12/2021] [Indexed: 06/12/2023]
Abstract
Primary care systems are a mainstay for how many Americans seek health and behavioral health care. It is estimated that almost a quarter of behavioral health conditions are diagnosed and/or treated in primary care. Many clinics treat the whole person through integrated models of care such as the Primary Care Behavioral Health (PCBH) model. COVID-19 has disrupted integrated care delivery and traditional PCBH workflows requiring swift adaptations. This paper synthesizes how COVID-19 has impacted clinical services at one federally qualified health center and describes how care has continued despite the challenges experienced by frontline behavioral health providers.
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Affiliation(s)
- Zachary Cooper
- Behavioral Health Department, Christ Community Health Services, Augusta, Georgia, USA
| | - Lisa De Saxe Zerden
- School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, USA
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Mesa H, Doshi M, Lopez W, Bryce R, Rion R, Rabinowitz E, Fleming PJ. Impact of anti-immigrant rhetoric and policies on frontline health and social service providers in Southeast Michigan, U.S.A. Health Soc Care Community 2020; 28:2004-2012. [PMID: 32462702 DOI: 10.1111/hsc.13012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 03/02/2020] [Accepted: 04/01/2020] [Indexed: 06/11/2023]
Abstract
Rising hostility towards immigrants characterised the 2016 Presidential election in the United States (US) and subsequent policy priorities by the new presidential administration. The political shift towards aggressive policies targeting undocumented immigrants is far-reaching and extends into other communities that convive con-or coexist with-immigrant communities. Our study aims to examine the rippling effects of these anti-immigrant policies and rhetoric on health and social service providers in Southeast Michigan who predominantly serve Latino immigrants. Between April and August 2018, we conducted in-depth individual interviews in two Federally Qualified Health Centers and a non-profit social service agency at a county health department. We interviewed 28 frontline health and social service providers. After coding and thematic analyses, we found that staff members' experiences in supporting immigrant clients was congruent with definitions of secondary trauma stress and compassion fatigue, whereby exposure to clients' trauma combined with job burden subsequently impacted the mental health of providers. Major themes included: (a) frontline staff experienced a mental and emotional burden in providing services to immigrant clients given the restrictive anti-immigrant context; and (b) this burden was exacerbated by the increased difficulties in providing these services to their clients. Staff described psychological and emotional distress stemming from exposure to clients' immigration-related trauma and increased mental health needs. This distress was exacerbated by an increased demand to meet clients' needs, which involved explaining or translating documents into English, assisting with legal paperwork, referring clients to mental health resources, addressing increased transportation barriers, and reestablishing trust with the community. Our findings add qualitative data on the mental health implications for frontline providers who support Latino immigrant clients impacted by immigration and highlights the need for further research and resources that address the workplace-related stress generated by heightened immigration enforcement.
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Affiliation(s)
- Hannah Mesa
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Monika Doshi
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - William Lopez
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Richard Bryce
- Community Health and Social Services Center, Detroit, MI, USA
| | | | - Ellen Rabinowitz
- Washtenaw Health Department, Washtenaw Health Plan, Ypsilanti, MI, USA
| | - Paul J Fleming
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
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Abstract
In the United States, obesity has increased in prevalence over time and is strongly associated with subsequent outcomes such as diabetes mellitus (DM) and nonalcoholic fatty liver disease (NAFLD). It is unclear, however, as to how the magnitude of NAFLD risk from obesity and DM is increased in safety-net health system settings. Among the San Francisco Health Network (SFHN) patients (N = 47,211), we examined the association between Body Mass Index (BMI) and elevated liver enzyme levels, including interaction by DM status. Our findings revealed that 32.2 percent of SFHN patients were obese, and Pacific Islanders in the safety-net had the highest rates of obesity compared to other racial groups, even after using higher race-specific BMI cutoffs. In SFHN, obesity was associated with elevated liver enzymes, with the relationship stronger among those without DM. Our findings highlight how obesity is a stronger factor of NAFLD in the absence of DM, suggesting that practitioners consider screening for NAFLD among safety-net patients with obesity even if DM has not developed. These results highlight the importance of directing efforts to reduce obesity in safety-net health systems and encourage researchers to further examine effect modification between health outcomes in such populations.
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Affiliation(s)
- Michael P. Huynh
- School of Public Health, UCLA Center for Health Policy Research, Los Angeles, CA, USA
| | - Patrick T. Bradshaw
- School of Public Health, Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Michele M. Tana
- Department of Medicine, Division of Gastroenterology, University of California, San Francisco, San Francisco, CA, USA
- UCSF Liver Center, San Francisco, CA, USA
| | - Carly Rachocki
- Department of Medicine, Division of Gastroenterology, University of California, San Francisco, San Francisco, CA, USA
| | - Ma Somsouk
- Department of Medicine, Division of Gastroenterology, University of California, San Francisco, San Francisco, CA, USA
- Center for Vulnerable Populations, University of California, San Francisco, San Francisco, CA, USA
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Hsu HE, Wang R, Broadwell C, Horan K, Jin R, Rhee C, Lee GM. Association Between Federal Value-Based Incentive Programs and Health Care-Associated Infection Rates in Safety-Net and Non-Safety-Net Hospitals. JAMA Netw Open 2020; 3:e209700. [PMID: 32639568 PMCID: PMC7344380 DOI: 10.1001/jamanetworkopen.2020.9700] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE In the US, federal value-based incentive programs are more likely to penalize safety-net institutions than non-safety-net institutions. Whether these programs differentially change the rates of targeted health care-associated infections in safety-net vs non-safety-net hospitals is unknown. OBJECTIVE To assess the association of Hospital-Acquired Condition Reduction Program (HACRP) and Hospital Value-Based Purchasing (HVBP) implementation with changes in rates of targeted health care-associated infections and disparities in rates among safety-net and non-safety-net hospitals. DESIGN, SETTING, AND PARTICIPANTS This interrupted time series included all US acute care hospitals enrolled in the Preventing Avoidable Infectious Complications by Adjusting Payment study that participated in mandatory reporting to the National Healthcare Safety Network from January 1, 2013, through June 30, 2018. Hospital characteristics were obtained from the 2015 American Hospital Association annual survey. Penalty statuses for 2015 to 2018 were obtained from Hospital Compare. Data were analyzed between July 9, 2018, and October 1, 2019. EXPOSURES HACRP and HVBP implementation in fiscal year 2015 or 2016. MAIN OUTCOMES AND MEASURES The primary outcomes were rates of 4 health care-associated infections: central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), surgical site infection (SSI) after colon surgical procedures, and SSI after abdominal hysterectomy procedures. Regression models were fit using generalized estimating equations to assess the association of HACRP and HVBP implementation with health care-associated infection rates and disparities in infection rates. RESULTS Of the 618 acute care hospitals included in this study, 473 (76.5%) were non-safety net and 145 (23.5%) were considered safety net. In these hospitals, HACRP and HVBP implementation was not associated with improvements in level or trend for any health care-associated infection examined (eg, CAUTI in safety-net hospitals: incidence rate ratio [IRR] for level change, 0.98 [95% CI, 0.79-1.23; P = .89]; IRR for change in slope, 1.00 [95% CI, 0.97-1.03; P = .80]). Before program implementation, infection rates were statistically significantly higher for safety-net than for non-safety-net hospitals for CLABSI (IRR, 1.23; 95% CI, 1.07-1.42; P = .004), CAUTI (IRR, 1.38; 95% CI, 1.16-1.64; P < .001), and SSI after colon surgical procedure (odds ratio [OR], 1.26; 95% CI, 1.06-1.50; P = .009). The disparity persisted over time when comparing the last year of the study with the first year (CLABSI: ratio of ratios [ROR], 0.93 [95% CI, 0.77-1.13; P = .48]; CAUTI: ROR, 0.90 [95% CI, 0.73-1.10; P = .31]; SSI after colon surgical procedures: ROR, 0.96 [95% CI, 0.78-1.20; P = .75]). Rates of SSI after abdominal hysterectomy procedure were similar in safety-net and non-safety-net hospitals before implementation (OR, 1.13; 95% CI, 0.91-1.40; P = .27) but higher after implementation (OR, 1.43; 95% CI, 1.11-1.83; P = .006), although this change was not significant (ROR, 1.20; 95% CI, 0.91-1.59; P = .20). CONCLUSIONS AND RELEVANCE This study found that HACRP and HVBP implementation was not associated with any improvements in targeted health care-associated infections among safety-net or non-safety-net hospitals or with changes in disparities in infection rates. Given the persistent health care-associated infection rate disparities, these programs appear to function as a disproportionate penalty system for safety-net hospitals that offer no measurable benefits for patients.
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Affiliation(s)
- Heather E. Hsu
- Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts
| | - Rui Wang
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Carly Broadwell
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Kelly Horan
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts
| | - Robert Jin
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts
| | - Chanu Rhee
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Grace M. Lee
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
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Cuevas MA, Wachter ND, Reyes C, Mafi JN, Wei E, Carrillo C, Sarkisian CA. Seeking care for back pain or upper respiratory infections?: Survey results to inform a safety net hospital Choosing Wisely® intervention. Healthc (Amst) 2020; 8:100424. [PMID: 32919578 DOI: 10.1016/j.hjdsi.2020.100424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 02/07/2020] [Accepted: 03/26/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Miguel A Cuevas
- Division of Geriatrics, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA.
| | - Nicole D Wachter
- Division of Geriatrics, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | - Carmen Reyes
- Division of Geriatrics, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | - John N Mafi
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | - Eric Wei
- New York City Health & Hospitals Corporation, New York, NY, USA
| | - Carmen Carrillo
- Division of Geriatrics, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | - Catherine A Sarkisian
- Division of Geriatrics, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
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Abstract
BACKGROUND Magnet hospitals are recognized for nursing excellence and high-value patient outcomes, yet little is known about which and when hospitals pursue Magnet recognition. Concurrently, hospital systems are becoming a more prominent feature of the U.S. health care landscape. PURPOSE The aim of the study was to examine Magnet adoption among hospital systems over time. APPROACH Using American Hospital Association surveys (1998-2012), we characterized the proportion of Magnet hospitals belonging to systems. We used hospital level fixed-effects regressions to capture changes in a given system hospital's Magnet status over time in relation to a variety of conditions, including prior Magnet adoption by system affiliates and nonaffiliates in local and geographically distant markets and whether these relationships varied by degree of system centralization. RESULTS The proportion of Magnet hospitals belonging to a system is increasing. Prior Magnet adoption by a hospital within the local market was associated with an increased likelihood of a given system hospital becoming Magnet, but the effect was larger if there was prior adoption by affiliates (7.4% higher likelihood) versus nonaffiliates (2.7% higher likelihood). Prior adoption by affiliates and nonaffiliates in geographically distant markets had a lesser effect. Hospitals belonging to centralized systems were more reactive to Magnet adoption of nonaffiliate hospitals as compared with those in decentralized systems. CONCLUSIONS Hospital systems take an organizational perspective toward Magnet adoption, whereby more system affiliates achieve Magnet recognition over time. PRACTICE IMPLICATIONS The findings are relevant to health care and nursing administrators and policymakers interested in the diffusion of an empirically supported organizational innovation associated with quality outcomes, particularly in a time of increasing hospital consolidation and system expansion. We identify factors associated with Magnet adoption across system hospitals and demonstrate the importance of considering diffusion of organizational innovations in relation to system centralization. We suggest that decentralized system hospitals may be missing potential benefits of such organizational innovations.
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Affiliation(s)
- Karen B Lasater
- Karen B. Lasater, PhD, RN, is Postdoctoral Fellow, Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia. E-mail: . Michael R. Richards, MD, PhD, MPH, is Assistant Professor, Department of Health Policy, Vanderbilt University, Nashville, Tennessee. Nikila B. Dandapani, BA, is Research Assistant, Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia. Lawton R. Burns, PhD, MBA, is Professor and Director, Wharton Center for Health Management and Economics, University of Pennsylvania, Philadelphia. Matthew D. McHugh, PhD, JD, RN, MPH, CRNP, FAAN, is Associate Professor and Associate Director, Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia
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Abstract
PURPOSE Changing market forces increasingly are leading academic medical centers (AMCs) to form or join health systems. But it is unclear how this shift is affecting the tripartite academic mission of education, research, and high-quality patient care. To explore this topic, the authors identified and characterized the types of health systems that owned or managed AMCs in the United States in 2016. METHOD The authors identified AMCs as any general acute care hospitals that had a resident-to-bed ratio of at least 0.25 and that were affiliated with at least one MD- or DO-granting medical school. Using the Agency for Healthcare Research and Quality 2016 Compendium of U.S. Health Systems, the authors also identified academic-affiliated health systems (AHSs) as those health systems that owned or managed at least one AMC. They compared AMCs and other general acute care hospitals, AHSs and non-AHSs, and AHSs by type of medical school relationship, using health system size, hospital characteristics, undergraduate and graduate medical education characteristics, services provided, and ownership. RESULTS Health systems owned or managed nearly all AMCs (361, 95.8%). Of the 626 health systems, 230 (36.7%) met the definition of an AHS. Compared with other health systems, AHSs included more hospitals, provided more services, and had a lower ratio of primary care doctors to specialists. Most AHSs (136, 59.1%) had a single, shared medical school relationship, whereas 38 (16.5%) had an exclusive medical school relationship and 56 (24.3%) had multiple medical school relationships. CONCLUSIONS These findings suggest that several distinct types of relationships between AHSs and medical schools exist. The traditional vision of a medical school having an exclusive relationship with a single AHS is no longer prominent.
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MESH Headings
- Academic Medical Centers/organization & administration
- Biomedical Research
- Education, Medical, Graduate/organization & administration
- Education, Medical, Undergraduate/organization & administration
- Hospitals, General/organization & administration
- Hospitals, Pediatric/organization & administration
- Hospitals, Proprietary/organization & administration
- Hospitals, Public/organization & administration
- Hospitals, Teaching/organization & administration
- Hospitals, Voluntary/organization & administration
- Humans
- Quality of Health Care
- Safety-net Providers/organization & administration
- Schools, Medical/organization & administration
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Affiliation(s)
- Matthew J Niedzwiecki
- M.J. Niedzwiecki is researcher, Mathematica Policy Research, Oakland, California. R.M. Machta is researcher, Mathematica Policy Research, Oakland, California. J.D. Reschovsky is a senior fellow, Mathematica Policy Research, Washington, DC. M.F. Furukawa is senior economist, Agency for Healthcare Research and Quality, Rockville, Maryland. E.C. Rich is a senior fellow, Mathematica Policy Research, Washington, DC
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Jordan RS, Jones CL, Gallagher TJ. A Mirrored System of Health for the Uninsured: North Carolina's Independent Primary Care Safety Net. N C Med J 2020; 81:141. [PMID: 32132262 DOI: 10.18043/ncm.81.2.141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Randolph S Jordan
- president & CEO, North Carolina Association of Free & Charitable Clinics, Winston-Salem, North Carolina
| | - Cynthia L Jones
- director of quality and clinical support, North Carolina Association of Free & Charitable Clinics, Winston-Salem, North Carolina
| | - Timothy J Gallagher
- executive director, Safety Net Health-NC, Inc., Winston-Salem, North Carolina
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20
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Jacobs BL, Yabes JG, Lopa SH, Heron DE, Chang CCH, Bekelman JE, Nelson JB, Bynum JPW, Barnato AE, Kahn JM. The Development and Validation of Prostate Cancer-specific Physician-Hospital Networks. Urology 2020; 138:37-44. [PMID: 31945379 DOI: 10.1016/j.urology.2019.11.049] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 11/16/2019] [Accepted: 11/26/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To develop prostate cancer-specific physician-hospital networks to define hospital-based units that more accurately group hospitals, providers, and the patients they serve. METHODS Using Surveillance, Epidemiology, and End Results-Medicare, we identified men diagnosed with localized prostate cancer between 2007 and 2011. We created physician-hospital networks by assigning each patient to a physician and each physician to a hospital based on treatment patterns. We assessed content validity by examining characteristics of hospitals anchoring the physician-hospital networks and of the patients associated with these hospitals. RESULTS We identified 42,963 patients associated with 344 physician-hospital networks. Networks anchored by a teaching hospital (compared to a nonteaching hospital) had higher median numbers of prostate cancer patients (117 [interquartile range {71-189} vs 82 {50-126}]) and treating physicians (7 [4-11] vs 4 [3-6]) (both P <0.001). On average, patients traveled farther to networks anchored by a teaching hospital (49 miles [standard deviation] [207] vs 41 [183]; P <.001). Hospitals known as high-volume centers for robotic prostatectomies, proton-beam therapy, and active surveillance had network rates for these procedures well above the mean. Hospitals known as safety net providers served higher proportions of minorities. CONCLUSION We empirically developed prostate-cancer specific physician-hospital networks that exhibit content validity and are relevant from a clinical and policy perspective. They have the potential to become targets for policy interventions focused on improving the delivery of prostate cancer care.
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Affiliation(s)
- Bruce L Jacobs
- Department of Urology, University of Pittsburgh, Pittsburgh, PA; Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA.
| | - Jonathan G Yabes
- Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Samia H Lopa
- Department of Urology, University of Pittsburgh, Pittsburgh, PA
| | - Dwight E Heron
- Department of Radiation Oncology, University of Pittsburgh, Pittsburgh, PA
| | - Chung-Chou H Chang
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA; Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Justin E Bekelman
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA; Division of General Internal Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Joel B Nelson
- Department of Urology, University of Pittsburgh, Pittsburgh, PA
| | - Julie P W Bynum
- Department of Medicine, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, MI
| | - Amber E Barnato
- Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH; Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Jeremy M Kahn
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
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Seay J, Carrasquillo O, Trevil D, Gonzalez M, Brickman A, Amofah A, Pierre L, Koru-Sengul T, Kobetz E. Implementing Two Randomized Pragmatic Trials of HPV Self-sampling among Underserved Women: Challenges and Lessons Learned. Prog Community Health Partnersh 2020; 14:55-62. [PMID: 32280123 DOI: 10.1353/cpr.2020.0008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Haitian and Hispanic immigrant women experience substantial disparities in cervical cancer screening. Recently, our team completed two randomized trials of human papillomavirus (HPV) self-sampling as a cervical cancer screening strategy among Haitian and Hispanic women, using a community-based participatory research (CBPR) approach. OBJECTIVE To reflect on lessons learned in the process of completing two large randomized cancer screening trials within underserved communities. METHODS Haitian and Hispanic women were randomized to HPV self-sampling versus navigation to Pap smear versus standard cervical cancer screening education in the first trial, and HPV self-sampling delivered in-person versus via mail in the second trial. LESSONS LEARNED During the two trials, our team encountered several challenges. The lessons learned from these challenges allowed for the strengthening of our community partnerships, study procedures, and our ability to conduct CBPR within an academic setting. CONCLUSIONS Lessons learned from our trials may be useful to other researchers engaging in CBPR within underserved communities.
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Gardiner P, Luo M, D’Amico S, Gergen-Barnett K, White LF, Saper R, Mitchell S, Liebschutz JM. Effectiveness of integrative medicine group visits in chronic pain and depressive symptoms: A randomized controlled trial. PLoS One 2019; 14:e0225540. [PMID: 31851666 PMCID: PMC6919581 DOI: 10.1371/journal.pone.0225540] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 11/05/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Current treatment options for chronic pain and depression are largely medication-based, which may cause adverse side effects. Integrative Medical Group Visits (IMGV) combines mindfulness techniques, evidence based integrative medicine, and medical group visits, and is a promising adjunct to medications, especially for diverse underserved patients who have limited access to non-pharmacological therapies. OBJECTIVE Determine the effectiveness of IMGV compared to a Primary Care Provider (PCP) visit in patients with chronic pain and depression. DESIGN 9-week single-blind randomized control trial with a 12-week maintenance phase (intervention-medical groups; control-primary care provider visit). SETTING Academic tertiary safety-net hospital and 2 affiliated federally-qualified community health centers. PARTICIPANTS 159 predominantly low income racially diverse adults with nonspecific chronic pain and depressive symptoms. INTERVENTIONS IMGV intervention- 9 weekly 2.5 hour in person IMGV sessions, 12 weeks on-line platform access followed by a final IMGV at 21 weeks. MEASUREMENTS Data collected at baseline, 9, and 21 weeks included primary outcomes depressive symptoms (Patient Health Questionnaire 9), pain (Brief Pain Inventory). Secondary outcomes included pain medication use and utilization. RESULTS There were no differences in pain or depression at any time point. At 9 weeks, the IMGV group had fewer emergency department visits (RR 0.32, 95% CI: 0.12, 0.83) compared to controls. At 21 weeks, the IMGV group reported reduction in pain medication use (Odds Ratio: 0.42, CI: 0.18-0.98) compared to controls. LIMITATIONS Absence of treatment assignment concealment for patients and disproportionate group attendance in IMGV. CONCLUSION Results demonstrate that low-income racially diverse patients will attend medical group visits that focus on non-pharmacological techniques, however, in the attention to treat analysis there was no difference in average pain levels between the intervention and the control group. TRIAL REGISTRATION clinicaltrials.gov NCT02262377.
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Affiliation(s)
- Paula Gardiner
- Department of Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
| | - Man Luo
- Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, United States of America
| | - Salvatore D’Amico
- Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, United States of America
| | - Katherine Gergen-Barnett
- Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, United States of America
| | - Laura F. White
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Robert Saper
- Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, United States of America
| | - Suzanne Mitchell
- Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, United States of America
| | - Jane M. Liebschutz
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
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Piwowarczyk LA, Ona F. BeWell: quality assurance health promotion pilot. Int J Health Care Qual Assur 2019; 32:321-331. [PMID: 31017063 DOI: 10.1108/ijhcqa-08-2017-0152] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this paper is to determine the experience participating in a health promotion program for refugee and asylum seekers and torture survivors in a safety net clinical setting. DESIGN/METHODOLOGY/APPROACH Refugee and asylum seeker torture survivors participated in a seven-week health promotion program at a safety-net clinic. Participants interviewed before, during and after the program was designed to improve and maintain health promotion program quality. FINDINGS Six major themes emerged: social networks; tools/techniques/skills; wellness planning; spiritualism; health maintenance; and social/group interaction. Preliminary results suggest that this multi-pronged approach is feasible and acceptable to foreign-born torture survivors. RESEARCH LIMITATIONS/IMPLICATIONS Torture impacts many facets of one's life. A program which addresses health from a multidisciplinary perspective has promise to facilitate healing. PRACTICAL IMPLICATIONS The impact of torture and human rights violations significantly affects many facets of peoples' lives including emotional, social, physical and spiritual dimensions. Therefore a program which utilizes a multidisciplinary integrated bio-psychosocial and spiritual approach has the potential to simultaneously address many domains facilitating healing. ORIGINALITY/VALUE BeWell, a bio-psychosocio-spiritual health promotion strategy aimed at improving health service quality and increasing patient satisfaction to support positive health outcomes by implementing in-classroom/person modules for patients, to the authors' knowledge is unique in its efforts to encompass multiple domains simultaneously and fully integrate an approach to wellbeing.
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Affiliation(s)
- Linda A Piwowarczyk
- Boston Center for Refugee Health and Human Rights, Boston Medical Center, Boston, Massachusetts, USA
| | - Fernando Ona
- Tufts University School of Medicine , Boston, Massachusetts, USA
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Abstract
PURPOSE The purpose of this paper is to examine the relationship between patients' provider communication effectiveness and courteousness with patients' satisfaction and trust at free clinics. DESIGN/METHODOLOGY/APPROACH This cross-sectional survey (n=507), based on the Consumer Assessment of Healthcare Providers and Systems instrument, was conducted in two Southeastern US free clinics. Latent class analysis (LCA) was used to identify patient subgroups (clusters) with similar but not immediately visible characteristics. FINDINGS Across the items assessing provider communication effectiveness and courteousness, five distinct clusters based on patient satisfaction, trust and socio-demographics were identified. In clusters where communication and courteousness ratings were consistent, trust and satisfaction ratings were aligned with these domains, e.g., 54 percent rated communication and courteousness highly, which was associated with high patient satisfaction and trust. When communication effectiveness and courteousness ratings diverged (e.g., low communication effectiveness but high courteousness), patient trust and satisfaction ratings aligned with communication effectiveness ratings. In all clusters, the association was greater for communication effectiveness than for provider courteousness. Thus, provider courteousness was important but secondary to communication effectiveness. PRACTICAL IMPLICATIONS Investment in patient-centered communication training for providers will improve patient satisfaction and trust. ORIGINALITY/VALUE The study is the first to examine individual provider communication components and how they relate to patient satisfaction and trust in free clinics. LCA helped to more fully examine communication constructs, which may be beneficial for more nuanced quality improvement efforts.
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Affiliation(s)
- Elena A Platonova
- Department of Public Health Sciences, University of North Carolina , Charlotte, North Carolina, USA
| | - Haiyan Qu
- Department of Health Services Administration, University of Alabama , Birmingham, Alabama, USA
| | - Jan Warren-Findlow
- Department of Public Health Sciences, University of North Carolina , Charlotte, North Carolina, USA
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Abstract
IMPORTANCE No consensus exists on how to define safety-net hospitals (SNHs) for research or policy decision-making. Identifying which types of hospitals are classified as SNHs under different definitions is key to assessing policies that affect SNH funding. OBJECTIVE To examine characteristics of SNHs as classified under 3 common definitions. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional analysis includes noncritical-access hospitals in the Healthcare Cost and Utilization Project State Inpatient Databases from 47 US states for fiscal year 2015, linked to the Centers for Medicare & Medicaid Services Hospital Cost Reports and to the American Hospital Association Annual Survey. Data were analyzed from March 1 through September 30, 2018. EXPOSURES Hospital characteristics including organizational characteristics, scope of services provided, and financial attributes. MAIN OUTCOMES AND MEASURES Definitions of SNH based on Medicaid and Medicare Supplemental Security Income inpatient days historically used to determine Medicare Disproportionate Share Hospital (DSH) payments; Medicaid and uninsured caseload; and uncompensated care costs. For each measure, SNHs were defined as those within the top quartile for each state. RESULTS The 2066 hospitals in this study were distributed across the Northeast (340 [16.5%]), Midwest (587 [28.4%]), South (790 [38.2%]), and West (349 [16.9%]). Concordance between definitions was low; 269 hospitals (13.0%) or fewer were identified as SNHs under any 2 definitions. Uncompensated care captured smaller (200 of 523 [38.2%]) and more rural (65 of 523 [12.4%]) SNHs, whereas DSH index and Medicaid and uncompensated caseload identified SNHs that were larger (264 of 518 [51.0%] and 158 of 487 [32.4%], respectively) and teaching facilities (337 of 518 [65.1%] and 229 of 487 [47.0%], respectively) that provided more essential services than non-SNHs. Uncompensated care also distinguished remarkable financial differences between SNHs and non-SNHs. Under the uncompensated care definition, median (interquartile range [IQR]) bad debt ($27.1 [$15.5-$44.3] vs $12.8 [$6.7-$21.6] per $1000 of operating expenses; P < .001) and charity care ($19.9 [$9.3-$34.1] vs $9.1 [$4.0-$18.7] per $1000 of operating expenses) were twice as high and median (IQR) unreimbursed costs ($32.6 [$12.4-$55.4] vs $23.6 [$9.0-$42.7] per $1000 of operating expenses; P < .001) were 38% higher for SNHs than for non-SNHs. Safety-net hospitals defined by uncompensated care burden had lower median (IQR) total (4.7% [0%-9.9%] vs 5.8% [1.2%-11.2%]; P = .003) and operating (0.3% [-8.0% to 7.2%] vs 2.3% [-3.9% to 8.9%]; P < .001) margins than their non-SNH counterparts, whereas differences between SNH and non-SNH profit margins generally were not statistically significant under the other 2 definitions. CONCLUSIONS AND RELEVANCE Different SNH definitions identify hospitals with different characteristics and financial conditions. The new DSH formula, which accounts for uncompensated care, may lead to redistributed payments across hospitals. Our results may inform which types of hospitals will experience funding changes as DSH payment policies evolve.
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Affiliation(s)
- Ioana Popescu
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California
- Rand Corporation, Los Angeles, California
| | | | - Eli Cutler
- IBM Watson Health, Sacramento, California
- currently with Qventus, San Jose, California
| | - Jing Guo
- Agency for Healthcare Research and Quality, Rockville, Maryland
| | - H. Joanna Jiang
- Agency for Healthcare Research and Quality, Rockville, Maryland
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Gwede CK, Sutton SK, Chavarria EA, Gutierrez L, Abdulla R, Christy SM, Lopez D, Sanchez J, Meade CD. A culturally and linguistically salient pilot intervention to promote colorectal cancer screening among Latinos receiving care in a Federally Qualified Health Center. Health Educ Res 2019; 34:310-320. [PMID: 30929015 PMCID: PMC7868960 DOI: 10.1093/her/cyz010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 03/24/2019] [Indexed: 06/09/2023]
Abstract
Despite established benefits, colorectal cancer (CRC) screening is underutilized among Latinos/Hispanics. We conducted a pilot 2-arm randomized controlled trial evaluating efficacy of two intervention conditions on CRC screening uptake among Latinos receiving care in community clinics. Participants (N = 76) were aged 50-75, most were foreign-born, preferred to receive their health information in Spanish, and not up-to-date with CRC screening. Participants were randomized to either a culturally linguistically targeted Spanish-language fotonovela booklet and DVD intervention plus fecal immunochemical test [FIT] (the LCARES, Latinos Colorectal Cancer Awareness, Research, Education and Screening intervention group); or a non-targeted intervention that included a standard Spanish-language booklet plus FIT (comparison group). Measures assessed socio-demographic variables, health literacy, CRC screening behavior, awareness and beliefs. Overall, FIT uptake was 87%, exceeding the National Colorectal Cancer Roundtable's goal of 80% by 2018. The LCARES intervention group had higher FIT uptake than did the comparison group (90% versus 83%), albeit not statistically significant (P = 0.379). The LCARES intervention group was associated with greater increases in CRC awareness (P = 0.046) and susceptibility (P = 0.013). In contrast, cancer worry increased more in the comparison group (P = 0.045). Providing educational materials and a FIT kit to Spanish-language preferring Latinos receiving care in community clinics is a promising strategy to bolster CRC screening uptake to meet national targets.
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Affiliation(s)
- Clement K Gwede
- Department of Health Behavior and Outcomes, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
- Department of Oncologic Sciences, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Steven K Sutton
- Department of Oncologic Sciences, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Enmanuel A Chavarria
- Department of Health Promotion and Behavioral Sciences, University of Texas Health Science Center at Houston, Brownsville Regional Campus, Brownsville, TX, USA
| | - Liliana Gutierrez
- Department of Health Behavior and Outcomes, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Rania Abdulla
- Department of Health Behavior and Outcomes, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Shannon M Christy
- Department of Health Behavior and Outcomes, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
- Department of Oncologic Sciences, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Diana Lopez
- Suncoast Community Health Centers, Inc., Brandon, FL, USA
| | - Julian Sanchez
- Department of Health Behavior and Outcomes, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
- Department of Oncologic Sciences, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Cathy D Meade
- Department of Health Behavior and Outcomes, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
- Department of Oncologic Sciences, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
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Joynt Maddox KE, Reidhead M, Hu J, Kind AJH, Zaslavsky AM, Nagasako EM, Nerenz DR. Adjusting for social risk factors impacts performance and penalties in the hospital readmissions reduction program. Health Serv Res 2019; 54:327-336. [PMID: 30848491 PMCID: PMC6407348 DOI: 10.1111/1475-6773.13133] [Citation(s) in RCA: 115] [Impact Index Per Article: 23.0] [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: 12/17/2022] Open
Abstract
OBJECTIVE Medicare's Hospital Readmissions Reduction Program (HRRP) does not account for social risk factors in risk adjustment, and this may lead the program to unfairly penalize safety-net hospitals. Our objective was to determine the impact of adjusting for social risk factors on HRRP penalties. STUDY DESIGN Retrospective cohort study. DATA SOURCES/STUDY SETTING Claims data for 2 952 605 fee-for-service Medicare beneficiaries with acute myocardial infarction (AMI), congestive heart failure (CHF) or pneumonia from December 2012 to November 2015. PRINCIPAL FINDINGS Poverty, disability, housing instability, residence in a disadvantaged neighborhood, and hospital population from a disadvantaged neighborhood were associated with higher readmission rates. Under current program specifications, safety-net hospitals had higher readmission ratios (AMI, 1.020 vs 0.986 for the most affluent hospitals; pneumonia, 1.031 vs 0.984; and CHF, 1.037 vs 0.977). Adding social factors to risk adjustment cut these differences in half. Over half the safety-net hospitals saw their penalty decline; 4-7.5 percent went from having a penalty to having no penalty. These changes translated into a $17 million reduction in penalties to safety-net hospitals. CONCLUSIONS Accounting for social risk can have a major financial impact on safety-net hospitals. Adjustment for these factors could reduce negative unintended consequences of the HRRP.
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Affiliation(s)
- Karen E. Joynt Maddox
- Cardiovascular DivisionDepartment of MedicineWashington University School of MedicineSt. LouisMissouri
| | - Mat Reidhead
- Missouri Hospital AssociationHospital Industry Data InstituteJefferson CityMissouri
| | - Jianhui Hu
- Center for Health Policy and Health Services ResearchHenry Ford Health SystemDetroitMichigan
| | - Amy J. H. Kind
- Division of GeriatricsDepartment of MedicineUniversity of Wisconsin School of Medicine and Public Health, and Department of Veterans Affairs Geriatrics Research Education and Clinical CenterMadisonWisconsin
| | - Alan M. Zaslavsky
- Department of Health Care PolicyHarvard Medical SchoolBostonMassachusetts
| | - Elna M. Nagasako
- Division of General Medical SciencesDepartment of MedicineWashington University School of MedicineSt. LouisMissouri
| | - David R. Nerenz
- Center for Health Policy and Health Services ResearchHenry Ford Health SystemDetroitMichigan
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Jones EA, Linas BP, Truong V, Burgess JF, Lasser KE. Budgetary impact analysis of a primary care-based hepatitis C treatment program: Effects of 340B Drug Pricing Program. PLoS One 2019; 14:e0213745. [PMID: 30870475 PMCID: PMC6417774 DOI: 10.1371/journal.pone.0213745] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 02/27/2019] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Safety-net health systems, which serve a disproportionate share of patients at high risk for hepatitis C virus (HCV) infection, may use revenue generated by the federal drug discount pricing program, known as 340B, to support multidisciplinary care. Budgetary impacts of repealing the drug-pricing program are unknown. Our objective was to conduct a budgetary impact analysis of a multidisciplinary primary care-based HCV treatment program, with and without 340B support. METHODS We conducted a budgetary impact analysis from the perspective of a large safety-net medical center in Boston, Massachusetts. Participants included 302 HCV-infected patients (mean age 45, 75% male, 53% white, 77% Medicaid) referred to the primary care-based HCV treatment program from 2015-2016. Main measures included costs and revenues associated with the treatment program. Our main outcomes were net cost with and without 340B Drug Pricing support. RESULTS Total program costs were $942,770, while revenues totaled $1.2 million. With the 340B Drug Pricing Program the hospital received a net revenue of $930 per patient referred to the HCV treatment program. In the absence of the 340B program, the hospital would lose $370 per patient referred. Ninety-seven percent (68/70) of patients who initiated treatment in the program achieved a sustained virologic response (SVR) at a net cost of $4,150 each, among this patient subset. CONCLUSIONS The 340B Drug Pricing Program enabled a safety-net hospital to deliver effective primary care-based HCV treatment using a multidisciplinary care team. Efforts to sustain the 340B program could enable dissemination of similar HCV treatment models elsewhere.
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Affiliation(s)
- Eric A. Jones
- Boston University, School of Public Health, Boston, MA, United States of America
| | - Benjamin P. Linas
- Boston University, School of Medicine, Boston, MA, United States of America
| | - Ve Truong
- Boston Medical Center, Section of General Internal Medicine, Boston, MA, United States of America
| | - James F. Burgess
- Boston University, School of Public Health, Boston, MA, United States of America
| | - Karen E. Lasser
- Boston University, School of Medicine, Boston, MA, United States of America
- Boston Medical Center, Section of General Internal Medicine, Boston, MA, United States of America
- * E-mail:
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Bell Scott B, Doss S, Myers D, Hess B. Addressing externalized behavioral concerns in primary care: Listening to the voices of parents. Soc Work Health Care 2019; 58:14-31. [PMID: 30130473 DOI: 10.1080/00981389.2018.1508114] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 07/23/2018] [Accepted: 07/30/2018] [Indexed: 06/08/2023]
Abstract
This article presents the perceptions parents have of the causative and curative factors for their child's externalized behaviors and what treatment they prefer to receive from their primary care integrated behavioral health team. This is a qualitative study, using interpretative phenomenological analysis. Semi-structured interviews were conducted with a purposive sample of 12 parents representing 14 patients with a disruptive behavior disorder (DBD) who sought care from their primary care physician for treatment of the DBD. Participants spoke of uncertainty of the cause of the DBD and the desire to find parenting approaches that augment the effectiveness of pharmacological intervention provided by the primary care team. Parents' responses suggest that they are eager for more education about their child's DBD and how to engage at-home management of the symptoms. Discussion focused on the import of considering the voices of these parents when implementing brief parent management training programs in integrated behavioral health primary care programs.
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Affiliation(s)
- Becky Bell Scott
- a Garland School of Social Work , Baylor University , Waco , Texas
| | - Susanna Doss
- a Garland School of Social Work , Baylor University , Waco , Texas
| | - Dennis Myers
- a Garland School of Social Work , Baylor University , Waco , Texas
| | - Burrit Hess
- b Waco Family Medicine Residency Program , Waco , Texas
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Colborn KL, Helmkamp L, Bender BG, Kwan BM, Schilling LM, Sills MR. Colorado Asthma Toolkit Implementation Improves Some Process Measures of Asthma Care. J Am Board Fam Med 2019; 32:37-49. [PMID: 30610140 PMCID: PMC6943943 DOI: 10.3122/jabfm.2019.01.180155] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 05/24/2018] [Revised: 09/30/2018] [Accepted: 10/02/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The Colorado Asthma Toolkit Program (CATP) has been shown to improve processes of care with less evidence demonstrating improved outcomes. OBJECTIVE To model the association between pre-and-post-CATP status and asthma-related process and outcome measures among patients ages 5 to 64 years receiving care in safety-net primary care practices. METHODS This is an implementation study involving secondary prepost analysis of existing structured clinical, administrative, and claims data. Nine primary care practices in a federally qualified health center network implemented the CATP. Processes of care and health and utilization outcomes were evaluated prepost implementation in a cohort of patients with asthma using generalized linear mixed models. RESULTS The study cohort included 2678 patients age 5 to 64 years with at least one visit to one of the 9 participating practices during the study period (March 12, 2010 to December 1, 2012). A comparison of 12 months pre- and post-CATP implementation showed improvement in some process measures of asthma care associated with the intervention, including the rate of asthma-severity measurement, although no change in 2 Health care Effectiveness Data and Information Set measures: asthma medication ratio and medication management for people with asthma. We also found no change in asthma outcomes measured across multiple domains: exacerbations, utilization, symptom scores, and pulmonary physiology measures. CONCLUSIONS Implementation of the CATP in a primary care setting led to some improved processes of asthma care, but no changes in measured outcomes. Recommendations for future work include supplemental follow-up training including case review.
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Affiliation(s)
- Kathryn L Colborn
- From the Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Denver, Aurora, Colorado (KLC); Adult & Child Consortium for Health Outcomes Research & Delivery Science, Aurora, CO (LH); Department of Pediatrics, National Jewish Health, Denver (BGB); Department of Medicine, University of Colorado School of Medicine, Aurora (BMK, LMS); Pediatrics, University of Colorado School of Medicine, Aurora (MRS).
| | - Laura Helmkamp
- From the Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Denver, Aurora, Colorado (KLC); Adult & Child Consortium for Health Outcomes Research & Delivery Science, Aurora, CO (LH); Department of Pediatrics, National Jewish Health, Denver (BGB); Department of Medicine, University of Colorado School of Medicine, Aurora (BMK, LMS); Pediatrics, University of Colorado School of Medicine, Aurora (MRS)
| | - Bruce G Bender
- From the Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Denver, Aurora, Colorado (KLC); Adult & Child Consortium for Health Outcomes Research & Delivery Science, Aurora, CO (LH); Department of Pediatrics, National Jewish Health, Denver (BGB); Department of Medicine, University of Colorado School of Medicine, Aurora (BMK, LMS); Pediatrics, University of Colorado School of Medicine, Aurora (MRS)
| | - Bethany M Kwan
- From the Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Denver, Aurora, Colorado (KLC); Adult & Child Consortium for Health Outcomes Research & Delivery Science, Aurora, CO (LH); Department of Pediatrics, National Jewish Health, Denver (BGB); Department of Medicine, University of Colorado School of Medicine, Aurora (BMK, LMS); Pediatrics, University of Colorado School of Medicine, Aurora (MRS)
| | - Lisa M Schilling
- From the Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Denver, Aurora, Colorado (KLC); Adult & Child Consortium for Health Outcomes Research & Delivery Science, Aurora, CO (LH); Department of Pediatrics, National Jewish Health, Denver (BGB); Department of Medicine, University of Colorado School of Medicine, Aurora (BMK, LMS); Pediatrics, University of Colorado School of Medicine, Aurora (MRS)
| | - Marion R Sills
- From the Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Denver, Aurora, Colorado (KLC); Adult & Child Consortium for Health Outcomes Research & Delivery Science, Aurora, CO (LH); Department of Pediatrics, National Jewish Health, Denver (BGB); Department of Medicine, University of Colorado School of Medicine, Aurora (BMK, LMS); Pediatrics, University of Colorado School of Medicine, Aurora (MRS)
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Chan B, Edwards ST, Devoe M, Gil R, Mitchell M, Englander H, Nicolaidis C, Kansagara D, Saha S, Korthuis PT. The SUMMIT ambulatory-ICU primary care model for medically and socially complex patients in an urban federally qualified health center: study design and rationale. Addict Sci Clin Pract 2018; 13:27. [PMID: 30547847 PMCID: PMC6295087 DOI: 10.1186/s13722-018-0128-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [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] [Received: 07/25/2018] [Accepted: 12/05/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Medically complex urban patients experiencing homelessness comprise a disproportionate number of high-cost, high-need patients. There are few studies of interventions to improve care for these populations; their social complexity makes them difficult to study and requires clinical and research collaboration. We present a protocol for a trial of the streamlined unified meaningfully managed interdisciplinary team (SUMMIT) team, an ambulatory ICU (A-ICU) intervention to improve utilization and patient experience that uses control populations to address limitations of prior research. METHODS/DESIGN Participants are patients at a Federally Qualified Health Center in Portland, Oregon that serves patients experiencing homelessness or who have substance use disorders. Participants meet at least one of the following criteria: > 1 hospitalization over past 6 months; at least one medical co-morbidity including uncontrolled diabetes, heart failure, chronic obstructive pulmonary disease, liver disease, soft-tissue infection; and 1 mental health diagnosis or substance use disorder. We exclude patients if they have < 6 months to live, have cognitive impairment preventing consent, or are non-English speaking. Following consent and baseline assessment, we randomize participants to immediate SUMMIT intervention or wait-list control group. Participants receiving the SUMMIT intervention transfer care to a clinic-based team of physician, complex care nurse, care coordinator, social worker, and pharmacist with reduced panel size and flexible scheduling with emphasis on motivational interviewing, patient goal setting and advanced care planning. Wait-listed participants continue usual care plus engagement with community health worker intervention for 6 months prior to joining SUMMIT. The primary outcome is hospital utilization at 6 months; secondary outcomes include emergency department utilization, patient activation, and patient experience measures. We follow participants for 12 months after intervention initiation. DISCUSSION The SUMMIT A-ICU is an intensive primary care intervention for high-utilizers impacted by homelessness. Use of a wait-list control design balances community and staff stakeholder needs, who felt all participants should have access to the intervention, while addressing research needs to include control populations. Design limitations include prolonged follow-up period that increases risk for attrition, and conflict between practice and research; including partner stakeholders and embedded researchers familiar with the population in study planning can mitigate these barriers. Trial registration ClinicalTrials.gov NCT03224858, Registered 7/21/17 retrospectively registered https://clinicaltrials.gov/ct2/show/NCT03224858.
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Affiliation(s)
- Brian Chan
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, 3181 SW Sam Jackson Park Road L475, Portland, OR, 97239-3098, USA.
- Central City Concern, Portland, OR, USA.
| | - Samuel T Edwards
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, 3181 SW Sam Jackson Park Road L475, Portland, OR, 97239-3098, USA
- Portland VA Medical Center, Portland, OR, USA
| | - Meg Devoe
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, 3181 SW Sam Jackson Park Road L475, Portland, OR, 97239-3098, USA
- Central City Concern, Portland, OR, USA
| | - Richard Gil
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, 3181 SW Sam Jackson Park Road L475, Portland, OR, 97239-3098, USA
- Central City Concern, Portland, OR, USA
| | | | - Honora Englander
- Central City Concern, Portland, OR, USA
- Division of Hospital Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Christina Nicolaidis
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, 3181 SW Sam Jackson Park Road L475, Portland, OR, 97239-3098, USA
- School of Social Work, Portland State University, Portland, OR, USA
| | - Devan Kansagara
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, 3181 SW Sam Jackson Park Road L475, Portland, OR, 97239-3098, USA
- Portland VA Medical Center, Portland, OR, USA
| | - Somnath Saha
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, 3181 SW Sam Jackson Park Road L475, Portland, OR, 97239-3098, USA
- Portland VA Medical Center, Portland, OR, USA
| | - P Todd Korthuis
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, 3181 SW Sam Jackson Park Road L475, Portland, OR, 97239-3098, USA
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Abstract
As a population, people who self-identify as lesbian, gay, bisexual, or transgender face significant risks to health and difficulty in obtaining medical and behavioral health care, relative to the general public. These issues are especially challenging in safety-net health care institutions, which serve a range of vulnerable populations with limited access, limited options, and significant health disparities. Safety-net hospitals, particularly public hospitals with fewer resources than academic medical centers and other nonprofit hospitals that also serve as safety nets, are under immense financial pressures. However, with the introduction in 2011 of standards for LGBT inclusion by The Joint Commission, showing progress on LGBT health care has become a compliance issue for hospitals. And because the health care community itself has contributed to LGBT health disparities through prejudice, disrespect, or inadequate knowledge that have made it difficult for LGB and especially T people to seek care or to obtain the care they need, there is a moral case for allocating scarce resources to this population: we owe them some investment in righting wrongs that the health care system itself has produced. So, where to begin in the typical safety-net hospital or clinic? Beyond staff training, which is essential and for which good models now exist, what does justice demand from a service-utilization perspective? Given the range of health care services that an LGBT person in the safety net may need or want, how should we set priorities? And what can't we promise to do for this member of our community?
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Kegler MC, Beasley DD, Liang S, Cotter M, Phillips E, Hermstad A, Williams R, Martinez J, Riehman K. Using the consolidated framework for implementation research to understand safety net health system efforts to increase colorectal cancer screening rates. Health Educ Res 2018; 33:315-326. [PMID: 29982384 DOI: 10.1093/her/cyy019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 06/24/2018] [Indexed: 06/08/2023]
Abstract
Guided by the Consolidated Framework for Implementation Research (CFIR), this study aimed to identify factors that influence implementation of evidence-based provider and client-oriented strategies to promote colorectal cancer (CRC) screening in safety net health systems. Site visits and key informant interviews (n=33) were conducted with project leaders and staff in five health systems funded by an American Cancer Society grants program. Within- and cross-site analyses identified CFIR constructs that influenced implementation of provider and client-oriented strategies to promote CRC screening through colonoscopies and fecal immunochemical tests. Of the five CFIR domains, constructs within four CFIR domains (inner setting, outer setting, individual characteristics and process domains) were particularly salient in discussions of implementation while constructs within one CFIR domain (characteristics of the intervention) were not. This study provides a detailed description of how facilitating and inhibiting factors influenced the implementation of evidence-based practices related to CRC screening within safety net health systems. These findings can inform future efforts to promote evidence-based strategies to increase CRC screening rates in safety net health systems.
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Affiliation(s)
- Michelle C Kegler
- Emory Prevention Research Center, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA, USA
| | - Derrick D Beasley
- Emory Prevention Research Center, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA, USA
| | - Shuting Liang
- Emory Prevention Research Center, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA, USA
| | - Megan Cotter
- Emory Prevention Research Center, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA, USA
| | - Emily Phillips
- Emory Prevention Research Center, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA, USA
| | - April Hermstad
- Emory Prevention Research Center, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA, USA
| | - Rentonia Williams
- Statistics & Evaluation Center, Department of Intramural Research, American Cancer Society, Inc., Atlanta, GA, USA
| | - Jeremy Martinez
- Statistics & Evaluation Center, Department of Intramural Research, American Cancer Society, Inc., Atlanta, GA, USA
| | - Kara Riehman
- Statistics & Evaluation Center, Department of Intramural Research, American Cancer Society, Inc., Atlanta, GA, USA
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Shi L, Wharton MK, Monnette A. Ensuring access to prescription medications in the post-ACA healthcare access landscape: the essential role of FQHCs in the safety net for the underinsured. Am J Manag Care 2018; 24:S67-S73. [PMID: 29620813] [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] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Federally qualified health centers (FQHCs) are essential to underinsured populations in the safety net by offering them several means of access to reduced cost medications. This study employed a 2-pronged approach to evaluate FQHCs' role, estimating both the need for patient assistance and the impact of the safety net. STUDY DESIGN A multiyear panel data study for post-Affordable Care Act (ACA) years 2012 to 2016 and a 2016 cross-sectional analysis design were utilized to analyze FQHCs, their patient populations, and prescription assistance programs. METHODS Publicly available Health Resources and Services Administration (HRSA) Uniform Data System data were merged with HRSA Office of Pharmacy Affairs Information System data on 340B programs. Descriptive statistics were produced to evaluate the need for patient assistance, costs, and conditions treated at FQHCs. RESULTS There were 1337 FQHCs serving more than 2.5 million patients, nearly 29% of whom were uninsured. FQHCs utilized 2 programs to provide affordable, reduced-cost prescriptions for patients without insurance: 1) the HRSA 340B Drug Pricing Program and 2) prescription assistance programs, which rely on pharmaceutical manufacturer donations of reduced-cost medications or coupons. Although these programs were effective at providing affordable prescriptions, program accessibility varied widely by state and FQHC resources. CONCLUSIONS Despite changes in the healthcare access landscape due to the ACA, underinsured populations remain prevalent and the need for financial assistance with medications persists. FQHCs are uniquely situated to provide access to these essential services. Further policy and funding efforts, such as expansion of 340B programs, could assist FQHCs in fulfilling the role of prescription safety-net providers.
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Affiliation(s)
- Lizheng Shi
- Tulane University School of Public Health and Tropical Medicine, 1440 Canal St, Ste 1900, New Orleans, LA 70112.
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Mueller LA, Valentino AS, Clark AD, Li J. Impact of a Pharmacist-Provided Spirometry Service on Access to Results in a Primary Care Setting. J Prim Care Community Health 2018; 9:2150132718759213. [PMID: 29468934 PMCID: PMC5937149 DOI: 10.1177/2150132718759213] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES The primary objective of this study was to determine the effect of a pharmacist-provided spirometry service within a federally qualified health center on the percentage of spirometry referrals completed with results reviewed by the ordering provider. Secondary objectives evaluated differences between internal and external referrals, medication recommendations made by the pharmacist, and revenue brought in by the service. METHODS Chart reviews were completed to determine the referral completion rates between patients who received a spirometry referral before (December 2014-September 2015) and after (January 2016-October 2016) the implementation of the pharmacy-provided spirometry service. Chart reviews were also used to determine the number and completion rate among referrals for internal and external services in the postimplementation time frame. Chart reviews also assessed medication recommendations made by the pharmacist. RESULTS The results demonstrate an increase in referral completion rate from 38.1% to 47.0% ( P = .08) between the pre- and postimplementation time frames. In the postimplementation time frame, there was a statistically significant difference in the percentage of referrals completed between in-house referrals and external referrals (70.0% and 40.9%, respectively, P = .0004). Comparing clinics with and without the spirometry service, there was a statistically significant difference in the total number of spirometry referrals (1.13% and 0.59%, respectively, P < .0001) and the percent of referrals completed (0.55% and 0.27%, respectively, P = .0002). CONCLUSION The results suggest that offering spirometry within the primary care setting helps to increase the rate of completed spirometry tests with results available to the primary care provider. Additionally, the results show that there is an increased completion rate in patients who receive an internal spirometry referral, which may be due to reduced barriers in obtaining this testing. Overall, these results demonstrate that providing spirometry in the primary care setting helps to increase spirometry results obtained and could be beneficial in other primary care settings.
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Affiliation(s)
- Lisa A. Mueller
- Community Health Network, Indianapolis, IN, USA
- The Ohio State University College of Pharmacy, Columbus, OH, USA
- PrimaryOne Health, Columbus, OH, USA
| | - Alexa Sevin Valentino
- The Ohio State University College of Pharmacy, Columbus, OH, USA
- PrimaryOne Health, Columbus, OH, USA
| | - Aaron D. Clark
- The Ohio State University College of Pharmacy, Columbus, OH, USA
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Junan Li
- The Ohio State University College of Pharmacy, Columbus, OH, USA
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Leruth C, Goodman J, Bragg B, Gray D. A Multilevel Approach to Breastfeeding Promotion: Using Healthy Start to Deliver Individual Support and Drive Collective Impact. Matern Child Health J 2017; 21:4-10. [PMID: 29168161 PMCID: PMC5736771 DOI: 10.1007/s10995-017-2371-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [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: 11/24/2022]
Abstract
Purpose Breastfeeding has been linked to a host of positive health effects for women and children. However, disparities in breastfeeding initiation and duration prevent many low-income and African-American women from realizing these benefits. Existing breastfeeding promotion efforts often do not reach women who need support the most. In response, the Westside Healthy Start program (WHS), located in Chicago, Illinois, developed an ongoing multilevel approach to breastfeeding promotion. Description Key elements of our WHS breastfeeding model include individual education and counseling from pregnancy to 6 months postpartum and partnership with a local safety-net hospital to implement the Baby-Friendly Hospital Initiative and provide lactation support to delivering patients. Assessment In the year our model was implemented, 44.6% (49/110) of prenatal WHS participants reported that they planned to breastfeed, and 67.0% (183/273) of delivered participants initiated. Among participants reaching 6 months postpartum, 10.5% (9/86) were breastfeeding. WHS also had 2667 encounters with women delivering at our partner hospital during breastfeeding rounds, with 65.1% of contacts initiating. Community data was not available to assess the efficacy of our model at the local level. However, WHS participants fared better than all delivering patients at our partner hospital, where 65.0% initiated in 2015. Conclusion Healthy Start programs are a promising vehicle to improve breastfeeding initiation at the individual and community level. Additional evaluation is necessary to understand barriers to duration and services needed for this population.
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Affiliation(s)
- Chelsey Leruth
- Access Community Health Network, 600 W Fulton St, Suite 200, Chicago, IL, 60661, USA.
| | - Jacqueline Goodman
- Access Community Health Network, 600 W Fulton St, Suite 200, Chicago, IL, 60661, USA
| | - Brian Bragg
- Access Community Health Network, 600 W Fulton St, Suite 200, Chicago, IL, 60661, USA
| | - Dara Gray
- Access Community Health Network, 600 W Fulton St, Suite 200, Chicago, IL, 60661, USA
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Galbraith AA, Meyers DJ, Ross‐Degnan D, Burns ME, Vialle‐Valentin CE, Larochelle MR, Touw S, Zhang F, Rosenthal M, Balaban RB. Long-Term Impact of a Postdischarge Community Health Worker Intervention on Health Care Costs in a Safety-Net System. Health Serv Res 2017; 52:2061-2078. [PMID: 29130267 PMCID: PMC5682134 DOI: 10.1111/1475-6773.12790] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [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: 11/30/2022] Open
Abstract
OBJECTIVE Patient navigators (PNs) may represent a cost-effective strategy to improve transitional care and reduce hospital readmissions. We evaluated the impact of a PN intervention on health system costs in the 180 days after discharge for high-risk patients in a safety-net system. DATA SOURCE/SETTING Primary and secondary data from an academic safety-net health system. STUDY DESIGN We compared per-patient utilization and costs, overall and by age, for high-risk, medical service patients randomized to the PN intervention relative to usual care between October 2011 and April 2013. Intervention patients received hospital visits and telephone outreach from PNs for 30 days after every qualifying discharge. DATA COLLECTION/EXTRACTION METHODS We used administrative and electronic encounter data, and a survey of nurses; costs were imputed from the Medicare fee schedule. PRINCIPAL FINDINGS Total costs per patient over the 180 days postindex discharge for those aged ≥60 years were significantly lower for PN patients compared to controls ($5,676 vs. $7,640, p = .03); differences for patients aged <60 ($9,942 vs. $9,046, p = .58) or for the entire cohort ($7,092 vs. $7,953, p = .27) were not significant. CONCLUSIONS Patient navigator interventions may be useful strategies for specific groups of patients in safety-net systems to improve transitional care while containing costs.
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Affiliation(s)
- Alison A. Galbraith
- Center for Healthcare Research in PediatricsHarvard Medical School and Harvard Pilgrim Health Care InstituteBostonMA
- Department of Population MedicineHarvard Medical School and Harvard Pilgrim Health Care InstituteBostonMA
- Division of General PediatricsBoston Children's HospitalBostonMA
| | - David J. Meyers
- Department of Health Services, Policy, and PracticeBrown University School of Public HealthProvidenceRI
- Department of Health Policy and ManagementHarvard T.H. Chan School of Public HealthBostonMA
| | - Dennis Ross‐Degnan
- Department of Population MedicineHarvard Medical School and Harvard Pilgrim Health Care InstituteBostonMA
| | - Marguerite E. Burns
- Department of Population Health SciencesUniversity of Wisconsin School of Medicine and Public HealthMadisonWI
| | | | | | | | - Fang Zhang
- Department of Population MedicineHarvard Medical School and Harvard Pilgrim Health Care InstituteBostonMA
| | - Meredith Rosenthal
- Department of Health Services, Policy, and PracticeBrown University School of Public HealthProvidenceRI
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Affiliation(s)
| | | | - David Chin
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Schmidt S, Higgins S, George M, Stone A, Bussey-Jones J, Dillard R. An Experiential Resident Module for Understanding Social Determinants of Health at an Academic Safety-Net Hospital. MedEdPORTAL 2017; 13:10647. [PMID: 30800848 PMCID: PMC6338147 DOI: 10.15766/mep_2374-8265.10647] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Accepted: 09/28/2017] [Indexed: 05/14/2023]
Abstract
Introduction Half of the U.S. population has chronic illness. Many disparities exist in health care for management of chronic disease among poorer individuals, including decreased access to healthy foods, homelessness, and difficulty navigating large hospital systems due to low health literacy. A survey of resident physicians found significant gaps in preparedness to provide cross-cultural care. Education is needed to promote consideration of patients' social and cultural barriers in managing disease and navigating the health care system. This module was created as an introduction to social determinants of health, and highlights disparities in access to healthy food, water, shelter, and medical care in a sample of the residents' own continuity clinic patient panel. Methods We designed this experiential module to help internal medicine residents at an urban institution better understand how social constructs might hinder patient health. Activities were chosen by learners from a list of options, and carried out in small groups during a half day of protected time. We used reflective writing exercises to elicit resident thoughts about the module. Results Thirty-nine second-year residents participated in the module. Following the course, 41% of residents submitted reflective statements about their experience. Reflective responses suggest an enhanced appreciation for social determinants of health, a sense of empowerment to advocate for better patient resources, and an appreciation for systems-level factors that play a role in social determinants of health. Discussion Our results demonstrate that a short, experience-based module can impact resident attitudes about social determinants and improve advocacy around identifying community resources.
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Affiliation(s)
- Stacie Schmidt
- Assistant Professor, Department of General Medicine and Geriatrics, Emory University
| | - Stacy Higgins
- Associate Professor, Department of General Medicine and Geriatrics, Emory University
| | - Maura George
- Assistant Professor, Department of General Medicine and Geriatrics, Emory University
| | - Alanna Stone
- Assistant Professor, Department of General Medicine and Geriatrics, Emory University
| | - Jada Bussey-Jones
- Section Chief at Grady, Department of General Medicine and Geriatrics, Emory University
| | - Rebecca Dillard
- Assistant Program Director, Emory Center for Health in Aging, Emory University
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Gerber DE, Hamann HA, Santini NO, Abbara S, Chiu H, McGuire M, Quirk L, Zhu H, Lee SJC. Patient navigation for lung cancer screening in an urban safety-net system: Protocol for a pragmatic randomized clinical trial. Contemp Clin Trials 2017; 60:78-85. [PMID: 28689056 PMCID: PMC7066861 DOI: 10.1016/j.cct.2017.07.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [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] [Received: 02/20/2017] [Revised: 06/26/2017] [Accepted: 07/03/2017] [Indexed: 01/22/2023]
Abstract
The National Lung Screening Trial demonstrated improved lung cancer mortality with annual low-dose computed tomography (CT) screening, leading to lung cancer screening endorsement by the United States Preventive Services Task Force and coverage by the Centers for Medicare and Medicaid. Adherence to annual CT screens in that trial was 95%, which may not be representative of real-world, particularly medically underserved populations. This pragmatic trial will determine the effect of patient-focused, telephone-based patient navigation on adherence to CT-based lung cancer screening in an urban safety-net population. 340 adults who meet standard eligibility for lung cancer screening (age 55-77years, smoking history≥30 pack-years, quit within 15years if former smoker) are referred through an electronic medical record-based order by physicians in community- and hospital-based primary care settings within the Parkland Health and Hospital System in Dallas County, Texas. Eligible patients are randomized to usual care or patient navigation, which addresses adherence, patient-reported barriers, smoking cessation, and psycho-social concerns related to screening completion. Patients complete surveys and semi-structured interviews at baseline, 6-month, and 18-month follow-ups to assess attitudes toward screening. The primary endpoint of this pragmatic trial is adherence to three sequential, prospectively defined steps in the screening protocol. Secondary endpoints include self-reported tobacco use and other patient-reported outcomes. Results will provide real-world insight into the impact of patient navigation on adherence to CT-based lung cancer screening in a medically underserved population. This study was registered with the NIH ClinicalTrials.gov database (NCT02758054) on April 26, 2016.
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Affiliation(s)
- David E Gerber
- Division of Hematology-Oncology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA; Medical Oncology Clinic, Parkland Health and Hospital System, Dallas, TX, USA; Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA; Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA.
| | - Heidi A Hamann
- Departments of Psychology and Family and Community Medicine, University of Arizona, Tucson, AZ, USA; Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA.
| | - Noel O Santini
- Ambulatory Services, Parkland Health and Hospital System, Dallas, TX, USA.
| | - Suhny Abbara
- Departments of Radiology, UT Southwestern Medical Center, Parkland Health and Hospital System, Dallas, TX, USA.
| | - Hsienchang Chiu
- Division of Pulmonary Medicine, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA; Lung Diagnostics Clinic, Parkland Health and Hospital System, Dallas, TX, USA.
| | - Molly McGuire
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA.
| | - Lisa Quirk
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA.
| | - Hong Zhu
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA; Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA.
| | - Simon J Craddock Lee
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA; Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA.
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Rosenman MB, Decker B, Levy KD, Holmes AM, Pratt VM, Eadon MT. Lessons Learned When Introducing Pharmacogenomic Panel Testing into Clinical Practice. Value Health 2017; 20:54-59. [PMID: 28212969 PMCID: PMC7543044 DOI: 10.1016/j.jval.2016.08.727] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 08/14/2016] [Indexed: 05/21/2023]
Abstract
OBJECTIVES Implementing new programs to support precision medicine in clinical settings is a complex endeavor. We describe challenges and potential solutions based on the Indiana GENomics Implementation: an Opportunity for the Underserved (INGenious) program at Eskenazi Health-one of six sites supported by the Implementing GeNomics In pracTicE network grant of the National Institutes of Health/National Human Genome Research Institute. INGenious is an implementation of a panel of genomic tests. METHODS We conducted a descriptive case study of the implementation of this pharmacogenomics program, which has a wide scope (14 genes, 27 medications) and a diverse population (patients who often have multiple chronic illnesses, in a large urban safety-net hospital and its outpatient clinics). CHALLENGES We placed the clinical pharmacogenomics implementation challenges into six categories: patient education and engagement in care decision making; clinician education and changes in standards of care; integration of technology into electronic health record systems; translational and implementation sciences in real-world clinical environments; regulatory and reimbursement considerations, and challenges in measuring outcomes. A cross-cutting theme was the need for careful attention to workflow. Our clinical setting, a safety-net health care system, presented some distinctive challenges. Patients often had multiple chronic illnesses and sometimes were taking more than one pharmacogenomics-relevant medication. Reaching patients for recruitment or follow-up was another challenge. CONCLUSIONS New, large-scale endeavors in health care are challenging. A description of the challenges that we encountered and the approaches that we adopted to address them may provide insights for those who implement and study innovations in other health care systems.
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Affiliation(s)
- Marc B Rosenman
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA; Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| | - Brian Decker
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kenneth D Levy
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ann M Holmes
- Department of Health Policy and Management, Richard M. Fairbanks School of Public Health, IUPUI, Indianapolis, IN, USA
| | - Victoria M Pratt
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michael T Eadon
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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McFadden N, Daniel B, Hoyt R, Snider D. Development of a Web-Based Registry to Support Diabetes Care in Free Medical Clinics. Perspect Health Inf Manag 2017; 14:1a. [PMID: 28566990 PMCID: PMC5430109] [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] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The United States has more than 1,000 free medical clinics. Because these clinics do not bill Medicare or Medicaid, they are not eligible for federal reimbursement for electronic health record (EHR) adoption. As a result, most do not have EHRs or electronic disease registries. A web-based diabetes registry was created with all open-source components for use in an urban free clinic to manage patients with type 2 diabetes and comorbidities. The registry was modeled after the Chronic Disease Electronic Management System and recommendations of the American Diabetes Association. The software was enhanced to include multiple other features, such as progress notes, so that it can function as a simple EHR. The configuration permits other free clinics to join securely, and the software can be shared.
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Affiliation(s)
- Norman McFadden
- Our Lady of the Angel St. Joseph Medical Clinic in Pensacola, FL
| | | | - Robert Hoyt
- College of Health at the University of West Florida in Pensacola, FL
| | - Dallas Snider
- Hal Marcus College of Science and Engineering at the University of West Florida in Pensacola, FL
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Ellison J, Walley AY, Feldman JA, Bernstein E, Mitchell PM, Koppelman EA, Drainoni ML. Identifying Patients for Overdose Prevention With ICD-9 Classification in the Emergency Department, Massachusetts, 2013-2014. Public Health Rep 2016; 131:671-675. [PMID: 28123207 PMCID: PMC5230809 DOI: 10.1177/0033354916661981] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [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: 11/17/2022] Open
Abstract
The national rise in opioid overdose deaths signifies a need to integrate overdose prevention within healthcare delivery settings. The emergency department (ED) is an opportune location for such interventions. To effectively integrate prevention services, the target population must be clearly defined. We used ICD-9 discharge codes to establish and apply overdose risk categories to ED patients seen from January 1, 2013 to December 31, 2014 at an urban safety-net hospital in Massachusetts with the goal of informing ED-based naloxone rescue kit distribution programs. Of 96,419 patients, 4,468 (4.6%) were at increased risk of opioid overdose, defined by prior opioid overdose, misuse, or polysubstance misuse. A small proportion of those at risk were prescribed opioids on a separate occasion. Use of risk categories defined by ICD-9 codes identified a notable proportion of ED patients at risk for overdose, and provides a systematic means to prioritize and direct clinical overdose prevention efforts.
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Affiliation(s)
| | - Alexander Y. Walley
- Boston University School of Medicine, Boston, MA, USA
- Clinical Addiction Research and Education Unit, Boston Medical Center, Boston, MA, USA
| | - James A. Feldman
- Boston University School of Medicine, Boston, MA, USA
- Department of Emergency Medicine, Boston Medical Center, Boston, MA, USA
| | - Edward Bernstein
- Boston University School of Public Health, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
- Department of Emergency Medicine, Boston Medical Center, Boston, MA, USA
| | - Patricia M. Mitchell
- Boston University School of Medicine, Boston, MA, USA
- Department of Emergency Medicine, Boston Medical Center, Boston, MA, USA
| | | | - Mari-Lynn Drainoni
- Boston University School of Public Health, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
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Chu LH, Tu M, Lee YC, Sood N. The impact of patient-centered medical homes on safety net clinics. Am J Manag Care 2016; 22:532-538. [PMID: 27541701] [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] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To evaluate the impact of moving to a patient-centered medical home (PCMH) model in safety net clinics in a managed Medicaid plan. STUDY DESIGN Quasi-experimental, difference-in-differences design. METHODS The study examined whether the PCMH model reduced emergency department (ED) use and whether the growth in the seniors and people with disabilities (SPDs) population crowds out lower-cost populations. The study compared 7 PCMH safety net clinics (22,870 members) in late 2011 in the greater Los Angeles area with 110 general safety net clinics (143,530 members) between January 2011 and December 2013. During the time from 2011 to 2012, California began transitioning SPDs from fee-for-service Medicaid into managed care systems under a federal waiver. RESULTS Among clinics with less than 10% SPD membership, a PCMH model was associated with more office visits and less ED use. In particular, PCMH clinics-relative to non-PCMH clinics-reduced ED visits by an average of 70 visits per 1000 members per year (PTMPY) and reduced avoidable ED visits by 20 visits PTMPY. Neither the change in office visits nor ED visits was evident in clinics with SPD membership greater than 10%. CONCLUSIONS Adopting a PCMH model in safety net practices can effectively reduce ED use and increase the use of office visits among Medicaid patients. However, the beneficial effects of the PCMH model can be muted by a sudden influx of high-need users.
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Affiliation(s)
- Li-Hao Chu
- LA Care Health Plan, 1055 West 7th St, 10th Fl, Los Angeles, CA 90017. E-mail:
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Lundeen S, Sorensen S, Bland M, George S, Snyder B. Nurses' Perspectives on the Process of Attaining Baby-Friendly Designation. Nurs Womens Health 2016; 20:277-287. [PMID: 27287354 DOI: 10.1016/j.nwh.2016.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [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] [Received: 11/08/2015] [Revised: 12/20/2015] [Indexed: 06/06/2023]
Abstract
The Baby-Friendly Hospital Initiative is a global initiative that aims to protect, promote, and support breastfeeding. This study explores and describes the process of attaining Baby-Friendly designation from nurses' perspectives. A purposive sampling design was used to recruit registered nurse participants in a large, safety-net, tertiary care facility. Data were collected via semistructured interviews and were analyzed using descriptive interpretative analysis. The following themes were revealed: Resistance, Culture, Investment in the Journey, Teamwork, and Source of Pride. Results indicate that comfortable yet antiquated practices led to fear of change and resistance. Initial culture shock was mediated by a successful education model, powerful experiences, and positive outcomes.
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Affiliation(s)
| | | | | | - Sybil George
- Harris Health System, Ben Taub Hospital, in Houston, TX
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The Dental Care System in California: An Analysis. J Calif Dent Assoc 2016; 44:330-2. [PMID: 27451542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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O'Connor M. Changing the face of a troubled community. Hosp Health Netw 2016; 90:24. [PMID: 27468453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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Abstract
Free clinics provide free or reduced fee health services to the un- or under-insured. Patient engagement is important to understand patients' needs and to improve healthcare systems. There are few studies that examined patient engagement and satisfaction among the underserved and how patients perceive the quality of healthcare services in a free clinic setting. This study examined free clinic patients' satisfaction in order to better understand how free clinic patients perceive quality of healthcare services. English or Spanish speaking patients (N = 351), aged 18 years or older completed a self-administered survey using standardized measures of patient satisfaction and health status. Additional questions of patient satisfaction and experience with healthcare which fit a free clinic setting were developed. While the satisfaction with interpreter services was overall high, there were potential issues of a family member as an interpreter and unmet needs for interpreter services. Participants reported different levels of patient satisfaction by three language categories: native English speakers, non-native English speakers, and Spanish speakers. Health status is an important indicator to determine patient satisfaction. To improve patient satisfaction and engagement among free clinic patients, factors such as: quality of a family interpreter, unmet needs for interpreter services, social support, and health education programs may need to be considered. The differences in these three language groups indicate that not all free clinic patients may be combined together into a general category of free clinic patients. It may be necessary to provide customized treatment for each of these groups.
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Affiliation(s)
- Akiko Kamimura
- Department of Sociology, University of Utah, 380 S 1530 E, Salt Lake City, UT, 84112, USA,
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Johnston BJ, Peppard L, Newton M. Staying Connected: Sustaining Collaborative Care Models with Limited Funding. J Psychosoc Nurs Ment Health Serv 2015; 53:36-44; quiz 46-7. [PMID: 26268480 DOI: 10.3928/02793695-20150720-06] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Accepted: 06/16/2015] [Indexed: 11/20/2022]
Abstract
Providing psychiatric services in the primary care setting is challenging. The multidisciplinary, coordinated approach of collaborative care models (CCMs) addresses these challenges. The purpose of the current article is to discuss the implementation of a CCM at a free medical clinic (FMC) where volunteer staff provide the majority of services. Essential components of CCMs include (a) comprehensive screening and assessment, (b) shared development and communication of care plans among providers and the patient, and (c) care coordination and management. Challenges to implementing and sustaining a CCM at a FMC in Virginia attempting to meet the medical and psychiatric needs of the underserved are addressed. Although the CCM produced favorable outcomes, sustaining the model long-term presented many challenges. Strategies for addressing these challenges are discussed.
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