Roles and Responsibilities of Community Health Workers in Louisiana Medicaid Managed Care Organizations

We explored the roles of community health workers (CHWs) working in Medicaid Managed Care Organizations in Louisiana by conducting 10 interviews with CHWs, supervisors, and administrators. We identified 6 themes: CHWs' backgrounds and training; roles as they related to nationally recognized competencies; team integration; who CHWs serve and how members are identified; metrics for success; and the effects of COVID. CHWs are hired for their community connections. CHWs generally do not receive core competency training, and they focus primarily on improving individual-level health outcomes. Administrators and supervisors may need training and support on CHW competencies, supervision, and using common evaluation indicators.

Community health worker team integration in Medicaid managed care: Insights from a national study

Introduction

Community health workers (CHWs) have historically worked in community-based settings. Medicaid managed care organizations (MCOs) are integrating CHWs into their teams, largely to support social determinants of health. Little is known about how teams are structured in these environments or how CHWs and their supervisors perceive CHW roles in MCOs.

Methods

In 2021, two CHW professional associations and a university partnered to conduct a national cross-sectional survey of CHWs working with MCOs.

Results

A total of 146 CHWs representing 29 states and 55 supervisors working in 34 states completed the survey. Although two-thirds of supervisors said only a high school diploma or equivalent was required for hiring, over half of CHWs reported having a bachelors or graduate degree. The majority of CHWs (72.6%) and employers (80%) said CHWs receive training in core competencies. Under half of CHWs reported working with a registered nurse (RN) (45.8%) or social worker (43.8%), and about a third work with a behavioral health (36.3%) or primary care provider (33.6%). Among supervisors, 70.9% identified social workers as CHWs' team members and over half indicated CHW work with RNs (56.4%), behavioral health (54.5%) and primary care providers (52.7%). Over half of CHWs (52.1%) and roughly two thirds (63.6%) of supervisors indicated that CHWs use electronic health records. Roughly 85% of CHWs make referrals and roughly three quarters conduct social screenings. Around half of CHWs said they assist with care planning (54.1%), conduct health screenings (52.1%) or participate in case reviews (49.3%). About three quarters of CHWs (75.3%) and over two thirds of supervisors (67.3%) believed that CHWs are utilized to their full potential. Under three quarters of CHWs (72.6%) and over half of supervisors (54.4%) believe CHWs are equitably compensated for their work.

Discussion

Overall, CHWs roles in MCOs appear to focus on supporting clinical care and making referrals for social issues, rather than addressing community-level concerns. Health plans should ensure that CHWs have the professional freedom to develop community-based solutions to common social needs. MCOs should also ensure that CHWs receive equitable compensation and ensure that CHWs have opportunities for promotion.

What Are the Roles of Community Health Workers in Medicaid Managed Care? Results from a National Study

Managed care organizations (MCOs) are increasingly engaging community health workers (CHWs) to support service delivery for their members, particularly in the realm of social determinants of health. Some states now require MCOs to offer CHW services. Although the roles and activities of CHWs working in other contexts (eg, clinics, hospitals, community-based organizations) are well established, there is sparse knowledge about how MCOs are operationalizing CHW roles and whether CHW activities differ based on whether CHWs are employed directly by MCOs or contracted through other organizations. In 2021, 2 CHW professional associations and a university partnered to conduct a national cross-sectional survey of CHWs working with MCOs. Respondents (n = 146) represented 29 states. CHWs employed by MCOs reported receiving significantly more training and benefits from their employers than CHWs who were contracted through other organizations. MCO-based CHWs were more likely to support members with high-cost conditions and high service use, whereas contracted CHWs were more likely to engage in population-focused interventions, which may produce less immediately visible financial returns. Health plans would do well to ensure the CHWs they support, whether through contract or direct hiring, receive appropriate compensation and training, and have the freedom to engage in the full range of CHW roles, including community-level interventions.

What are the health consequences associated with differences in medical malpractice liability laws? An instrumental variable analysis of surgery effects on health outcomes for proximal humeral facture across states with different liability rules

BACKGROUND

States enacted tort reforms to lower medical malpractice liability, which are associated with higher surgery rates among Medicare patients with shoulder conditions. Surgery in this group often entails tradeoffs between improved health and increased risk of morbidity and mortality. We assessed whether differences in surgery rates across states with different liability rules are associated with surgical outcomes among Medicare patients with proximal humeral fracture.

METHODS

We obtained data for 67,966 Medicare beneficiaries with a diagnosis of proximal humeral fracture in 2011. Outcome measures included adverse events, mortality, and treatment success rates, defined as surviving the treatment period with < $300 in shoulder-related expenditures. We used existing state-level tort reform rules as instruments for surgical treatment and separately as predictors to answer our research question, both for the full cohort and for stratified subgroups based on age and general health status measured by Charlson Comorbidity Index and Function-Related Indicators.

RESULTS

We found a 0.32 percentage-point increase (p < 0.05) in treatment success and a 0.21 percentage-point increase (p < 0.01) in mortality for every 1 percentage-point increase in surgery rates among patients in states with lower liability risk. In subgroup analyses, mortality increased among more vulnerable patients, by 0.29 percentage-point (p < 0.01) for patients with Charlson Comorbidity Index >  = 2 and by 0.45 percentage-point (p < 0.01) among those patients with Function-Related Indicator scores >  = 2. On the other hand, treatment success increased in patients with lower Function-Related Index scores (< 2) by 0.54 percentage-point (p < 0.001). However, younger Medicare patients (< 80 years) experienced an increase in both mortality (0.28 percentage-point, p < 0.01) and treatment success (0.89 percentage-point, p < 0.01). The reduced-form estimates are consistent with our instrumental variable results.

CONCLUSIONS

A tradeoff exists between increased mortality risk and increased treatment success across states with different malpractice risk levels. These results varied across patient subgroups, with more vulnerable patients generally bearing the brunt of the increased mortality and less vulnerable patients enjoying increased success rates. These findings highlight the important risk-reward scenario associated with different liability environments, especially among patients with different health status.

Effect of care coordination on patients with Alzheimer disease and their caregivers

OBJECTIVES

To assess whether a care coordination and caregiver support intervention reduced use of acute medical services for both patients with Alzheimer disease (AD) and their caregivers.

STUDY DESIGN

Data were collected from patients with AD (n = 101) and their caregivers (n = 63) at Greenville Health System (now Prisma Health) in late 2012. Their data were linked to secondary all-payer claims data in South Carolina between 2011 and 2014.

METHODS

We conducted both a difference-in-differences regression and segmented regression analysis on the patients' health care utilization patterns pre- and post intervention. Propensity score matching identified a control group composed of nonintervention patients with AD in South Carolina (n = 928). We examined caregiver differences via t tests of differences in means.

RESULTS

Overall, the Memory Program did not reduce acute medical services. However, program participants experienced increases in total charges ($5243; 95% CI, $977-$9510) and in inpatient admissions with AD as a diagnosis (0.15; 95% CI, 0.029-0.272) but no increase in total all-cause charges. Intervention patients also had fewer emergency department (ED) visits (-0.0538; 95% CI, -0.102 to -0.0052) in some analyses. Finally, results suggest that post intervention, caregivers had half as many acute visits with depression as a diagnosis (from 0.22 to 0.11, difference of 0.11; 95% CI, -0.242 to 0.0198).

CONCLUSIONS

Although care coordination did not decrease overall acute health services use, coordination improved clinical documentation of patients' memory impairment. ED visits may have begun to decrease among patients. Finally, stress levels may have fallen among caregivers.

Associations Between Physician Supply Levels and Amenable Mortality Rates: An Analysis of Taiwan Over Nearly 4 Decades

Access to health care is an important determinant of health, but it remains unclear whether having more physicians reduces mortality. In this study, we used Taiwan’s population-level National Death Certification Registry data to investigate whether a greater supply of physicians is associated with lower rates of amenable mortality, defined as deaths that can be delayed with appropriate and timely medical treatment. Our baseline regression analysis adjusting only for age and sex shows that an increase in the number of physicians per 1000 is associated with a reduction of 1.7 (P < .01) and 0.97 (P < .01) age-standardized deaths per 100 000 for men and women, respectively. However, in our full analyses that control for socioeconomic factors and Taiwan’s health insurance expansion, we find that physician supply is no longer statistically associated with amenable mortality rates. Nevertheless, we found that greater physician supply levels are associated with a reduction in deaths from ischemic heart disease (−0.13 (P < .05) for men, and −0.066 (P < .05) for women). These findings suggest that overall, physician supply is not associated with amenable mortality rates after controlling for socioeconomic factors but may help reduce amenable mortality rates in specific causes of death.

Unusual presentations of pouch colon

Pouch colon associated with high anorectal malformation is a rare anomaly. Two unique anatomic variants of congenital pouch colon, never reported before, are presented.