1
|
Zhao X, Varisco R, Borghouts J, Eikey EV, Safani D, Mukamel DB, Schueller SM, Sorkin DH. Facilitators of and barriers to County Behavioral Health System Transformation and Innovation: an interview study. BMC Health Serv Res 2024; 24:604. [PMID: 38720309 PMCID: PMC11080221 DOI: 10.1186/s12913-024-11041-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 04/24/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Inadequate and inequitable access to quality behavioral health services and high costs within the mental health systems are long-standing problems. System-level (e.g., fee-for-service payment model, lack of a universal payor) and individual factors (e.g., lack of knowledge of existing resources) contribute to difficulties in accessing resources and services. Patients are underserved in County behavioral health systems in the United States. Orange County's (California) Behavioral Health System Transformation project sought to improve access by addressing two parts of their system: developing a template for value-based contracts that promote payor-agnostic care (Part 1); developing a digital platform to support resource navigation (Part 2). Our aim was to evaluate facilitators of and barriers to each of these system changes. METHODS We collected interview data from County or health care agency leaders, contracted partners, and community stakeholders. Themes were informed by the Consolidated Framework for Implementation Research. RESULTS Five themes were identified related to behavioral health system transformation, including 1) aligning goals and values, 2) addressing fit, 3) fostering engagement and partnership, 4) being aware of implementation contexts, and 5) promoting communication. A lack of fit into incentive structures and changing state guidelines and priorities were barriers to contract development. Involving diverse communities to inform design and content facilitated the process of developing digital tools. CONCLUSIONS The study highlights the multifaceted factors that help facilitate or hinder behavioral health system transformation, such as the need for addressing systematic and process behaviors, leveraging the knowledge of leadership and community stakeholders, fostering collaboration, and adapting to implementation contexts.
Collapse
Affiliation(s)
- Xin Zhao
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, USA.
- Seattle Children's Research Institute, Seattle, USA.
| | - Rachel Varisco
- Department of Medicine, University of California, Irvine, USA
| | | | - Elizabeth V Eikey
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, USA
- The Design Lab, University of California San Diego, La Jolla, USA
| | - David Safani
- Department of Psychiatry and Human Behavior, University of California, Irvine, USA
| | - Dana B Mukamel
- Department of Medicine, University of California, Irvine, USA
| | | | - Dara H Sorkin
- Department of Medicine, University of California, Irvine, USA
| |
Collapse
|
2
|
Fritz E, Despins L, Vogelsmeier A. Nursing Professional Development in Ambulatory Care: A Phenomenological Study. J Nurses Prof Dev 2023; 39:299-305. [PMID: 37902632 DOI: 10.1097/nnd.0000000000000903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Nursing professional development (NPD) practitioners play an important role in ensuring the quality and safety of nursing care and in guiding nurses through practice transitions. Recently, increasing numbers of NPD practitioners have been employed in ambulatory care settings, yet little is known about how the ambulatory practice setting affects or is affected by NPD practice. The aim of this descriptive phenomenology was to describe how the NPD role is experienced in the ambulatory care setting.
Collapse
|
3
|
Lee S, Young J, Pearce S, Hansen BK, Custer B, Bradley CL. Specialty pharmacy: Incorporating workflow management and medication access into pharmacy lecture and laboratory courses. CURRENTS IN PHARMACY TEACHING & LEARNING 2023; 15:194-200. [PMID: 36898888 DOI: 10.1016/j.cptl.2023.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 09/30/2022] [Accepted: 02/24/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND AND PURPOSE The purpose of this study was to implement and evaluate a specialty pharmacy workshop across pharmacy management and skills lab courses. EDUCATIONAL ACTIVITY AND SETTING A specialty pharmacy workshop was developed and implemented. The lecture cohort (fall 2019) consisted of a 90-min lecture in pharmacy management. The lecture/lab cohort (fall 2020) consisted of the lecture plus a 30-min pre-lab video assignment and a two-hour laboratory activity. At the completion of lab, students presented findings virtually to specialty pharmacists. Pre-surveys and post-surveys assessed knowledge (10 items), self-confidence (9 items), and attitudes (11 items). FINDINGS Of the 123 students enrolled in the course, 88 students (71.5%) completed pre- and post-surveys. On a 10-point scale, knowledge improved from 5.6 (SD = 1.5) to 6.5 (SD = 2.0) points in the lecture cohort and from 6.0 (SD = 1.6) to 7.3 (SD = 2.0) points in the lecture/lab cohort with a significance difference favoring the lecture/lab cohort. Perceived confidence improved for five out of nine items in the lecture cohort but improved significantly for all nine items in the lecture/lab cohort. Attitudes toward learning about specialty pharmacy were generally positive for both cohorts. SUMMARY The specialty pharmacy workshop exposed students to workflow management and medication access processes. Students perceived the workshop to be a relevant and meaningful, allowing them to feel confident in developing knowledge and understanding of specialty pharmacy topics. The workshop can be replicated at a larger scale with schools of pharmacy utilizing the integration between didactic and laboratory courses.
Collapse
Affiliation(s)
- Sun Lee
- High Point University Fred Wilson School of Pharmacy, One University Parkway, High Point, NC 27268, United States; Analysis Group, Inc, Boston, MA, United States.
| | - Jennifer Young
- Atrium Health Wake Forest Baptist, Winston-Salem, NC, United States.
| | - Sarah Pearce
- Atrium Health Wake Forest Baptist, Winston-Salem, NC, United States.
| | | | - Buzz Custer
- Atrium Health Wake Forest Baptist, Winston-Salem, NC, United States.
| | - Courtney L Bradley
- High Point University Fred Wilson School of Pharmacy, One University Parkway, High Point, NC 27268, United States.
| |
Collapse
|
4
|
Rodriguez HP, Fulton BD, Phillips AZ, Rubio K. Effect of State-Led Delivery System and Payment Reforms on Population-Level Detection and Management of Diabetes. Diabetes Care 2022; 45:2255-2263. [PMID: 35972261 PMCID: PMC9643138 DOI: 10.2337/dc21-2425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 06/01/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The Centers for Medicare and Medicaid Services State Innovation Models (SIM) initiative has invested more than $1 billion to test state-led delivery system and payment reforms that can affect diabetes care management. We examined whether SIM implementation between 2013 and 2017 was associated with diagnosed diabetes prevalence or with hospitalization or 30-day readmission rate among diagnosed adults. RESEARCH DESIGN AND METHODS The quasiexperimental design compared study outcomes before and after the SIM initiative in 12 SIM states versus five comparison states using difference-in-differences (DiD) regression models of 21,055,714 hospitalizations for adults age ≥18 years diagnosed with diabetes in 889 counties from 2010 to 2017 across the 17 states. For readmission analyses, comparative interrupted time series (CITS) models included 11,812,993 hospitalizations from a subset of nine states. RESULTS Diagnosed diabetes prevalence changes were not significantly different between SIM states and comparison states. Hospitalization rates were inconsistent across models, with DiD estimates ranging from -5.34 to -0.37 and from -13.16 to 0.92, respectively. CITS results indicate that SIM states had greater increases in odds of 30-day readmission during SIM implementation compared with comparison states (round 1: adjusted odds ratio [AOR] 1.07; 95% CI 1.04, 1.11; P < 0.001; round 2: AOR 1.06; 95% CI 1.03, 1.10; P = 0.001). CONCLUSIONS The SIM initiative was not sufficiently focused to have a population-level effect on diabetes detection or management. SIM states had greater increases in 30-day readmission for adults with diabetes than comparison states, highlighting potential unintended effects of engaging in the multipayer alignment efforts required of state-led delivery system and payment reforms.
Collapse
Affiliation(s)
- Hector P. Rodriguez
- Division of Health Policy and Management, School of Public Health, University of California Berkeley, Berkeley, CA
| | - Brent D. Fulton
- Division of Health Policy and Management, School of Public Health, University of California Berkeley, Berkeley, CA
| | - Aryn Z. Phillips
- Division of Health Policy and Management, School of Public Health, University of California Berkeley, Berkeley, CA
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Karl Rubio
- Division of Health Policy and Management, School of Public Health, University of California Berkeley, Berkeley, CA
| |
Collapse
|
5
|
Wildin RS, Giummo CA, Reiter AW, Peterson TC, Leonard DGB. Primary Care Implementation of Genomic Population Health Screening Using a Large Gene Sequencing Panel. Front Genet 2022; 13:867334. [PMID: 35547253 PMCID: PMC9081681 DOI: 10.3389/fgene.2022.867334] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/21/2022] [Indexed: 11/17/2022] Open
Abstract
To realize the promise of genomic medicine, harness the power of genomic technologies, and capitalize on the extraordinary pace of research linking genomic variation to disease risks, healthcare systems must embrace and integrate genomics into routine healthcare. We have implemented an innovative pilot program for genomic population health screening for any-health-status adults within the largest health system in Vermont, United States. This program draws on key research and technological advances to safely extract clinical value for genomics in routine health care. The program offers no-cost, non-research DNA sequencing to patients by their primary care providers as a preventive health tool. We partnered with a commercial clinical testing company for two next generation sequencing gene panels comprising 431 genes related to both high and low-penetrance common health risks and carrier status for recessive disorders. Only pathogenic or likely pathogenic variants are reported. Routine written clinical consultation is provided with a concise, clinical “action plan” that presents core messages for primary care provider and patient use and supports clinical management and health education beyond the testing laboratory’s reports. Access to genetic counseling is free in most cases. Predefined care pathways and access to genetics experts facilitates the appropriate use of results. This pilot tests the feasibility of routine, ethical, and scalable use of population genomic screening in healthcare despite generally imperfect genomic competency among both the public and health care providers. This article describes the program design, implementation process, guiding philosophies, and insights from 2 years of experience offering testing and returning results in primary care settings. To aid others planning similar programs, we review our barriers, solutions, and perceived gaps in the context of an implementation research framework.
Collapse
Affiliation(s)
- Robert S Wildin
- Department of Pathology & Laboratory Medicine, University of Vermont Health Network and Robert Larner M.D. College of Medicine at the University of Vermont, Burlington, VT, United States.,Department of Pediatrics, University of Vermont Health Network and Robert Larner M.D. College of Medicine at the University of Vermont, Burlington, VT, United States
| | - Christine A Giummo
- Department of Pathology & Laboratory Medicine, University of Vermont Health Network and Robert Larner M.D. College of Medicine at the University of Vermont, Burlington, VT, United States.,Department of Pediatrics, University of Vermont Health Network and Robert Larner M.D. College of Medicine at the University of Vermont, Burlington, VT, United States
| | - Aaron W Reiter
- Department of Family Medicine, University of Vermont Health Network and Robert Larner M.D. College of Medicine at the University of Vermont, Burlington, VT, United States
| | - Thomas C Peterson
- Department of Family Medicine, University of Vermont Health Network and Robert Larner M.D. College of Medicine at the University of Vermont, Burlington, VT, United States
| | - Debra G B Leonard
- Department of Pathology & Laboratory Medicine, University of Vermont Health Network and Robert Larner M.D. College of Medicine at the University of Vermont, Burlington, VT, United States
| |
Collapse
|
6
|
Boxall AM. What Does the State Innovation Model Experiment Tell Us About States' Capacity to Implement Complex Health Reforms? Milbank Q 2022; 100:525-561. [PMID: 35348251 DOI: 10.1111/1468-0009.12559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Policy Points To make progress implementing payment and delivery system reforms, state governments need to make genuine stakeholder engagement routine business, develop reforms that build on past successes, and ensure health reform is a top priority for bureaucrats and political leaders. To support state-led reform initiatives, the federal government needs to provide financial support directly to state governments; build bureaucratic capability in supporting state officials with policy design and implementation; develop more flexible, outcome-focused funding programs; reform its own programs, particularly Medicare; and commit to a long-term strategy for progressing payment and delivery system reforms. CONTEXT For decades, Americans have debated whether the states need federal government support to reform health care. The Affordable Care Act has allowed the federal government to trial innovative ways of accelerating state-led reform initiatives through the State Innovation Model (SIM), which was run by the Centers for Medicare and Medicaid Services Innovation Center between 2013 and 2019. This study assesses states' progress implementing health reforms under SIM and examines how well the federal government supported them. METHODS Detailed case studies were conducted in six states: Arkansas, Connecticut, Oregon, New York, Tennessee, and Washington. Data was collected from SIM evaluation and annual reports and through semistructured interviews with 39 expert informants, mostly state or federal officials involved in SIM. Preliminary findings were tested and refined through an online forum with health policy experts, facilitated by the Milbank Memorial Fund. FINDINGS States that made the most progress implementing reforms had a strong track record and managed to sustain stakeholder, bureaucratic, and political support for their reform agenda. There was a clear correlation between past reform success and success under SIM, which raises questions about the value of federal government support beyond providing funding. State officials said the federal government could better support states, particularly those with less reform experience, by providing tailored advice that helped state officials overcome problems designing and implementing reforms. State officials also said the federal government could better support them by reforming their own programs, particularly Medicare, and committing to a long-term strategy for health system reform. CONCLUSIONS States can make some progress reforming health care on their own, but real progress requires long-term cooperation between state and federal governments. Federal initiatives like SIM that foster cooperation between governments should be continued but refined so they provide better support to states.
Collapse
Affiliation(s)
- Anne-Marie Boxall
- Commonwealth Fund Australian Harkness Fellow, 2019-2020; University of Sydney, Australia
| |
Collapse
|
7
|
Weiss L, Griffin K, Wu M, DeGarmo E, Jasani F, Pagán JA. Transforming Primary Care in New York Through Patient-Centered Medical Homes: Findings From Qualitative Research. J Prim Care Community Health 2022; 13:21501319221112588. [PMID: 35847997 PMCID: PMC9290170 DOI: 10.1177/21501319221112588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background: The patient-centered medical home (PCMH) model, an important component of healthcare transformation in the United States, is an approach to primary care delivery with the goal of improving population health and the patient care experience while reducing costs. PCMH research most often focuses on system level indicators including healthcare use and cost; descriptions of patient and provider experience with PCMH are relatively sparse and commonly limited in scope. This study, part of a mixed-methods evaluation of a multi-year New York State initiative to refine and expand the PCMH model, describes patient and provider experience with New York State PCMH and its key components. Methods: The qualitative component of the evaluation included focus groups with patients of PCMH practices in 5 New York State counties (n = 9 groups and 67 participants) and interviews with providers and practice administrators at New York State PCMH practices (n = 9 interviews with 10 participants). Through these focus groups and interviews, we elicited first-person descriptions of experiences with, as well as perspectives on, key components of the New York State PCMH model, including accessibility, expanded use of electronic health records, integration of behavioral health care, and care coordination. Results: There was evident progress and some satisfaction with the PCMH model, particularly regarding integrated behavioral health and, to some extent, expanded use of electronic health records. There was less evident progress with respect to improved access and reasonable wait times, which caused patients to continue to use urgent care or the emergency department as substitutes for primary care. Conclusions: It is critical to understand the strengths and limitations of the PCMH model, so as to continue to improve upon and promote it. Strengths of the model were evident to participants in this study; however, challenges were also described. It is important to note that these challenges are difficult to separate from wider healthcare system issues, including inadequate incentives for value-based care, and carry implications for PCMH and other models of healthcare delivery.
Collapse
Affiliation(s)
- Linda Weiss
- The New York Academy of Medicine, New York, NY, USA
| | | | - Meng Wu
- New York State Department of Health, Albany, NY, USA
| | | | - Foram Jasani
- The New York Academy of Medicine, New York, NY, USA
| | - José A Pagán
- NYU School of Global Public Health, New York, NY, USA
| |
Collapse
|
8
|
Deb P, Gangaram A, Khajavi HN. The impact of the State Innovation Models Initiative on population health. ECONOMICS AND HUMAN BIOLOGY 2021; 42:101013. [PMID: 33989870 DOI: 10.1016/j.ehb.2021.101013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 04/12/2021] [Accepted: 04/25/2021] [Indexed: 06/12/2023]
Abstract
In this paper, we examine the effects of the State Innovation Models Initiative (SIM) on population-level health status. SIM provided $250 million to six states in 2013 for broad delivery system reforms. We use data from the Behavioral Risk Factor Surveillance System for the years 2010-2016. Our sample is restricted to individuals ages 45 and older residing in 6 SIM and 15 control states. Treatment effects in a difference-in-difference design are estimated using a latent factor model for multiple indicators of health status. In addition to estimates for the primary sample, we obtain estimates for six subsamples based on strata of age, education, income, race and urban/rural status. We find that individuals in states that implemented SIM show significant improvements in health status. The effects of SIM are greater among older, Medicare eligible individuals, including those living in rural areas. The State Innovation Models Initiative, which provided financial incentives for states to implement health care delivery system reforms, led to population-level improvements in health status.
Collapse
Affiliation(s)
- Partha Deb
- Hunter College and NBER, Department of Economics, 695 Park Avenue, New York, NY 10065, United States.
| | - Anjelica Gangaram
- University of Michigan, School of Public Health, Department of Health Management and Policy, 1415 Washington Heights, Ann Arbor, MI 48109, United States
| | - Hoda Nouri Khajavi
- Visiting Nurse Service of New York, 220 East 42 Street, Floor 7, New York, NY 10017, United States
| |
Collapse
|
9
|
Wadhera RK, Secemsky EA, Wang Y, Yeh RW, Goldhaber SZ. Association of Socioeconomic Disadvantage With Mortality and Readmissions Among Older Adults Hospitalized for Pulmonary Embolism in the United States. J Am Heart Assoc 2021; 10:e021117. [PMID: 34210156 PMCID: PMC8403328 DOI: 10.1161/jaha.121.021117] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background In the United States, hospitalizations for pulmonary embolism (PE) are increasing among older adults insured by Medicare. Although efforts to reduce health disparities have intensified, it remains unclear whether clinical outcomes differ between socioeconomically disadvantaged and nondisadvantaged Medicare beneficiaries hospitalized with PE. Methods and Results In this study, there were 53 386 Medicare fee-for-service beneficiaries age ≥65 years hospitalized for PE between October 2015 and January 2017. Of these, 5494 (10.3%) were socioeconomically disadvantaged and 47 892 (89.7%) were nondisadvantaged. Socioeconomically disadvantaged adults were of similar age as nondisadvantaged adults (77.1 versus 77.0), more likely to be female (68.5% versus 54.2%), and less likely to receive advanced therapies (11.0% versus 12.1%). After adjustment for demographics, 90-day all-cause mortality rates were similar between disadvantaged and nondisadvantaged adults. In contrast, 1-year mortality rates were higher among socioeconomically disadvantaged adults (hazard ratio [HR], 1.16; 95% CI, 1.10-1.22), although these differences were partially attenuated after additional adjustments for comorbidities and PE severity (HR, 1.09; 95% CI, 1.02-1.16). Risk-adjusted 30-day and 90-day all-cause readmission rates were substantially higher among socioeconomically disadvantaged patients (30-day HR, 1.14 [95% CI, 1.06-1.22]; 90-day HR, 1.18 [95% CI, 1.12-1.25]). In addition, 90-day readmissions attributed to PE, deep vein thrombosis, and/or bleeding were higher among socioeconomically disadvantaged patients (HR, 1.16; 95% CI, 1.02-1.32). Conclusions Socioeconomically disadvantaged older adults hospitalized with PE have higher 1-year mortality rates compared with their nondisadvantaged counterparts. Nearly 1 in 3 socioeconomically disadvantaged older adults was readmitted within 90 days of a hospitalization for PE. Targeted strategies are needed to improve transitional and ambulatory care for this vulnerable population.
Collapse
Affiliation(s)
- Rishi K Wadhera
- Richard and Susan Smith Center for Outcomes Research in Cardiology Division of Cardiology Beth Israel Deaconess Medical and Harvard Medical School Boston MA
| | - Eric A Secemsky
- Richard and Susan Smith Center for Outcomes Research in Cardiology Division of Cardiology Beth Israel Deaconess Medical and Harvard Medical School Boston MA
| | - Yun Wang
- Richard and Susan Smith Center for Outcomes Research in Cardiology Division of Cardiology Beth Israel Deaconess Medical and Harvard Medical School Boston MA
| | - Robert W Yeh
- Richard and Susan Smith Center for Outcomes Research in Cardiology Division of Cardiology Beth Israel Deaconess Medical and Harvard Medical School Boston MA
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine Brigham and Women's Hospital Harvard Medical School Boston MA
| |
Collapse
|
10
|
Wei S, McConnell ES, Corazzini KN, Moody J, Pan W, Granger B. Relational processes in heart failure care transitions: A data-driven case report. Heart Lung 2021; 50:622-626. [PMID: 34091107 DOI: 10.1016/j.hrtlng.2021.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 04/18/2021] [Accepted: 04/20/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Effective patient care transitions require consideration of social and clinical context, yet how these factors and relational processes in care coordination relate remains poorly described. This case report aims to describe provider networks and the clinical care and social context involved during longitudinal care transitions across settings. CASE We examined the utilization and provider networks of an oldest old woman with heart failure (HF) before and after her first hospitalization for HF. She used primary care for care management and had insurance, strong caregiver support, and comprehensive discharge planning; however, after the hospitalization, Mrs. A's ambulatory provider networks were more diverse yet sparser and less strongly connected. CONCLUSIONS Turbulence in care transition can result from sources other than transitioning between settings. The data-driven case report approach using electronic health records uncovered relational processes important for care coordination and may inform patient-centered approaches to improve care for patients with HF.
Collapse
Affiliation(s)
- Sijia Wei
- Duke University School of Nursing, Durham, NC, USA.
| | - Eleanor S McConnell
- Duke University School of Nursing, Durham, NC, USA; Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, NC, USA; Duke University Center for the Study of Aging and Human Development, Durham, NC, USA
| | - Kirsten N Corazzini
- Duke University School of Nursing, Durham, NC, USA; University of Maryland School of Nursing, Baltimore, MD, USA
| | - James Moody
- Duke University Department of Sociology, Durham, NC, USA; Duke Network Analysis Center, Duke University, Durham, NC, USA
| | - Wei Pan
- Duke University School of Nursing, Durham, NC, USA; Duke University School of Medicine, Durham, NC, USA
| | - Bradi Granger
- Duke University School of Nursing, Durham, NC, USA; Heart Center Nursing Research Program, Duke University Health System and School of Nursing, Durham, NC, USA
| |
Collapse
|
11
|
Phillips AZ, Brewster AL, Kyalwazi MJ, Rodriguez HP. The Centers for Medicaid and Medicare Services State Innovation Models Initiative and Social Risk Factors: Improved Diagnosis Among Hospitalized Adults With Diabetes. Am J Prev Med 2020; 59:e161-e166. [PMID: 32800676 PMCID: PMC7508756 DOI: 10.1016/j.amepre.2020.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 04/01/2020] [Accepted: 04/16/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Unaddressed social risks among hospitalized patients with chronic conditions contribute to costly complications and preventable hospitalizations. This study examines whether the Centers for Medicaid and Medicare Services State Innovation Models initiative, through payment and delivery system reforms, accelerates the diagnosis of social risk factors among hospitalized adults with diabetes. METHODS Encounter-level data were from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project State Inpatient Databases (2010-2015, N=5,040,456). Difference-in-difference logistic regression estimated the extent to which hospitalized adults with diabetes in 4 State Innovation Models states (Arkansas, Massachusetts, Oregon, and Vermont) had increased odds of having a social risk factor diagnosed with an ICD-9 V code compared with hospitalized adults with diabetes in 4 comparison states (Arizona, Georgia, New Jersey, and New Mexico) 2 years after implementation. Data were analyzed between June and December 2019. RESULTS Adults with diabetes who were hospitalized in State Innovation Models states had a 30% greater increase in the odds of having a V code documented after implementation than adults with diabetes who were hospitalized in comparison states (AOR=1.29, 95% CI=1.07, 1.56). However, V code use remained infrequent, with only 2.05% of encounters, on average, having any V codes on record in State Innovation Models states after implementation. CONCLUSIONS The State Innovation Models initiative slightly but significantly improved the diagnosis of social risks among hospitalized adults with diabetes. State-led delivery system and payment reform may help support movement of hospitals toward better recognition and management of social determinants of health.
Collapse
Affiliation(s)
- Aryn Z Phillips
- Center for Healthcare Organizational and Innovation Research, School of Public Health, University of California, Berkeley, Berkeley, California.
| | - Amanda L Brewster
- Center for Healthcare Organizational and Innovation Research, School of Public Health, University of California, Berkeley, Berkeley, California
| | - Martin J Kyalwazi
- Center for Healthcare Organizational and Innovation Research, School of Public Health, University of California, Berkeley, Berkeley, California
| | - Hector P Rodriguez
- Center for Healthcare Organizational and Innovation Research, School of Public Health, University of California, Berkeley, Berkeley, California
| |
Collapse
|
12
|
Sandbach JF, Bachelor J, Larson K, Jordan D, Mullins J, Davis D, Sheff G. Hospitalization Rates Related to Coordinated Home Health Care Services With a Community Oncology Practice. JCO Oncol Pract 2020; 16:e1045-e1049. [DOI: 10.1200/jop.19.00755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE: Oncology care reimbursement has been shifting from a traditional fee-for-service model to either 1- or 2-sided risk models during the past 5 years. A major expense associated with the total cost of care is hospitalization cost. The study set out to investigate whether the creation of an Advanced Community Care Model (ACCM) of home health care would affect 60-day hospitalization and 30-rehospitalization rates in a community oncology setting. METHODS: In conjunction with a single home health care organization, an ACCM was modified for oncology care to include intervention protocols to address antiemetic issues, pain control, dehydration, shortness of breath, diarrhea, and fever. Weekly and monthly joint management meetings began. Quality metrics were defined. RESULTS: Overall, 457 unique home health care admissions were evaluated. Hospitalization associated with intervention protocols was evaluated. Sixty-day hospitalization rates decreased from 14% to 8%. Thirty-day rehospitalization rates decreased from 25% to 10%. CONCLUSION: An oncology ACCM, as created in this study, appears to have reduced both 60-day hospitalization and 30-day rehospitalization rates.
Collapse
|
13
|
Abstract
Policy Points Strategically purchasing health care has been and continues to be a popular policy idea around the world. Key asymmetries in information, market power, political power, and financial power hinder the effective implementation of strategic purchasing. Strategic purchasing has consistently failed to live up to its promises for these reasons. Future strategies based on strategic purchasing should tailor their expectations to its real effectiveness. CONTEXT Strategic purchasing of health care has been a popular policy idea around the world for decades, with advocates claiming that it can lead to improved quality, patient satisfaction, efficiency, accountability, and even population health. In this article, we report the results of an inquiry into the implementation and effects of strategic purchasing. METHODS We conducted three in-depth case studies of England, the Netherlands, and the United States. We reviewed definitions of purchasing, including its slow acquisition of adjectives such as strategic, and settled on a definition of purchasing that distinguishes it from the mere use of contracts to regulate stable interorganizational relationships. The case studies review the career of strategic purchasing in three different systems where its installation and use have been a policy priority for years. FINDINGS No existing health care system has effective strategic purchasing because of four key asymmetries: market power asymmetry, information asymmetry, financial asymmetry, and political power asymmetry. CONCLUSIONS Further investment in policies that are premised on the effectiveness of strategic purchasing, or efforts to promote it, may not be worthwhile. Instead, policymakers may need to focus on the real sources of power in a health care system. Policy for systems with existing purchasing relationships should take into account the asymmetries, ways to work with them, and the constraints that they create.
Collapse
Affiliation(s)
| | | | - EWOUT VAN GINNEKEN
- European Observatory on Health Systems and PoliciesBerlin University of Technology
| |
Collapse
|
14
|
The Early Impact of the Centers for Medicare & Medicaid Services State Innovation Models Initiative on 30-Day Hospital Readmissions Among Adults With Diabetes. Med Care 2020; 58 Suppl 6 Suppl 1:S22-S30. [PMID: 32412950 DOI: 10.1097/mlr.0000000000001276] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND The Centers for Medicare & Medicaid Services (CMS) State Innovation Models (SIM) Initiative funds states to accelerate delivery system and payment reforms. All SIM states focus on improving diabetes care, but SIM's effect on 30-day readmissions among adults with diabetes remains unclear. METHODS A quasi-experimental research design estimated the impact of SIM on 30-day hospital readmissions among adults with diabetes in 3 round 1 SIM states (N=671,996) and 3 comparison states (N=2,719,603) from 2010 to 2015. Difference-in-differences multivariable logistic regression models that incorporated 4-group propensity score weighting were estimated. Heterogeneity of SIM effects by grantee state and for CMS populations were assessed. RESULTS In adjusted difference-in-difference analyses, SIM was associated with an increase in odds of 30-day hospital readmission among patients in SIM states in the post-SIM versus pre-SIM period relative to the ratio in odds of readmission among patients in the comparison states post-SIM versus pre-SIM (ratio of adjusted odds ratio=1.057, P=0.01). Restricting the analyses to CMS populations (Medicare and Medicaid beneficiaries), resulted in consistent findings (ratio of adjusted odds ratio=1.057, P=0.034). SIM did not have different effects on 30-day readmissions by state. CONCLUSIONS We found no evidence that SIM reduced 30-day readmission rates among adults with diabetes during the first 2 years of round 1 implementation, even among CMS beneficiaries. It may be difficult to reduce readmissions statewide without greater investment in health information exchange and more intensive use of payment models that promote interorganizational coordination.
Collapse
|
15
|
Crabtree BF, Howard J, Miller WL, Cromp D, Hsu C, Coleman K, Austin B, Flinter M, Tuzzio L, Wagner EH. Leading Innovative Practice: Leadership Attributes in LEAP Practices. Milbank Q 2020; 98:399-445. [PMID: 32401386 DOI: 10.1111/1468-0009.12456] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Policy Points An onslaught of policies from the federal government, states, the insurance industry, and professional organizations continually requires primary care practices to make substantial changes; however, ineffective leadership at the practice level can impede the dissemination and scale-up of these policies. The inability of primary care practice leadership to respond to ongoing policy demands has resulted in moral distress and clinician burnout. Investments are needed to develop interventions and educational opportunities that target a broad array of leadership attributes. CONTEXT Over the past several decades, health care in the United States has undergone substantial and rapid change. At the heart of this change is an assumption that a more robust primary care infrastructure helps achieve the quadruple aim of improved care, better patient experience, reduced cost, and improved work life of health care providers. Practice-level leadership is essential to succeed in this rapidly changing environment. Complex adaptive systems theory offers a lens for understanding important leadership attributes. METHODS A review of the literature on leadership from a complex adaptive system perspective identified nine leadership attributes hypothesized to support practice change: motivating others to engage in change, managing abuse of power and social influence, assuring psychological safety, enhancing communication and information sharing, generating a learning organization, instilling a collective mind, cultivating teamwork, fostering emergent leaders, and encouraging boundary spanning. Through a secondary qualitative analysis, we applied these attributes to nine practices ranking high on both a practice learning and leadership scale from the Learning from Effective Ambulatory Practice (LEAP) project to see if and how these attributes manifest in high-performing innovative practices. FINDINGS We found all nine attributes identified from the literature were evident and seemed important during a time of change and innovation. We identified two additional attributes-anticipating the future and developing formal processes-that we found to be important. Complexity science suggests a hypothesized developmental model in which some attributes are foundational and necessary for the emergence of others. CONCLUSIONS Successful primary care practices exhibit a diversity of strong local leadership attributes. To meet the realities of a rapidly changing health care environment, training of current and future primary care leaders needs to be more comprehensive and move beyond motivating others and developing effective teams.
Collapse
Affiliation(s)
| | | | | | - DeANN Cromp
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | - Clarissa Hsu
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | - Katie Coleman
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | - Brian Austin
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | | | - Leah Tuzzio
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | - Edward H Wagner
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| |
Collapse
|
16
|
Kandel ZK, Rittenhouse DR, Bibi S, Fraze TK, Shortell SM, Rodríguez HP. The CMS State Innovation Models Initiative and Improved Health Information Technology and Care Management Capabilities of Physician Practices. Med Care Res Rev 2020; 78:350-360. [PMID: 31967494 DOI: 10.1177/1077558719901217] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Centers for Medicare and Medicaid Services' (CMS) State Innovation Models (SIMs) initiative funded 17 states to implement health care payment and delivery system reforms to improve health system performance. Whether SIM improved health information technology (HIT) and care management capabilities of physician practices, however, remains unclear. National surveys of physician practices (N = 2,722) from 2012 to 2013 and 2017 to 2018 were linked. Multivariable regression estimated differential adoption of 10 HIT functions and chronic care management processes (CMPs) based on SIM award status (SIM Round 1, SIM Round 2, or non-SIM). HIT and CMP capabilities improved equally for practices in SIM Round 1 (5.3 vs. 6.8 capabilities, p < .001), SIM Round 2 (4.7 vs. 7.0 capabilities, p < .001), and non-SIM (4.2 vs. 6.3 capabilities, p < .001) states. The CMS SIM Initiative did not accelerate the adoption of ten foundational physician practice capabilities beyond national trends.
Collapse
Affiliation(s)
| | - Diane R Rittenhouse
- University of California, Berkeley, CA, USA.,University of California, San Francisco, CA, USA
| | - Salma Bibi
- University of California, Berkeley, CA, USA
| | | | | | | |
Collapse
|
17
|
Rittenhouse DR, Phillips AZ, Bibi S, Rodriguez HP. Implementation Variation in Natural Experiments of State Health Policy Initiatives. AMERICAN JOURNAL OF ACCOUNTABLE CARE 2019; 7:12-17. [PMID: 31750412 PMCID: PMC6866654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES An increasing number of federal initiatives allow states flexibility in selecting the strategies used to achieve initiative-specific goals. Variation in the foci and intensity of implementation may explain why federal policy initiatives succeed in some states and fail in others. The CMS State Innovation Models (SIM) initiative is a complex policy intervention implemented with substantial variation across states and may have variable impacts. This paper presents a method to characterize and account for that variation in states' implementation foci and intensity in natural policy experiments. STUDY DESIGN A combination of quantitative and qualitative measures of SIM implementation was used to characterize the foci of payment and delivery system reforms across states. METHODS A modified Delphi expert panel process was used to prioritize the features of SIM implementation that would differentiate grantee states with respect to improved health outcomes. Three researchers then reviewed summaries of published evaluations and reports to characterize and score states on each implementation feature. Expert panelists guided the researchers on developing the criteria and weights applied to the focus areas when calculating SIM implementation intensity scores for states. RESULTS Over 3 years of an expert panel process, 4 dimensions of SIM implementation that would most affect health outcomes were prioritized: 1) extent and breadth of stakeholder engagement, (2) extent that SIM implementation was focused on improving behavioral health, (3) amount of SIM funding per capita, and (4) breadth and depth of value-based payment reforms. Scoring states based on the prioritized factors resulted in composite scores that differentiated states into 3 categories: high, moderate, and low implementation intensity. CONCLUSIONS We developed a stakeholder-driven method to measure and account for variation in implementation foci and intensity in a federal policy initiative that was implemented heterogeneously across grantee states. Our method for characterizing state implementation variation may be useful for natural policy experiments examining the variable impact of policy initiatives.
Collapse
Affiliation(s)
- Diane R Rittenhouse
- Department of Family and Community Medicine, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco (DRR), San Francisco, CA; Center for Healthcare Organizational and Innovation Research, School of Public Health, University of California, Berkeley (AZP, SB, HPR), Berkeley, CA
| | - Aryn Z Phillips
- Department of Family and Community Medicine, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco (DRR), San Francisco, CA; Center for Healthcare Organizational and Innovation Research, School of Public Health, University of California, Berkeley (AZP, SB, HPR), Berkeley, CA
| | - Salma Bibi
- Department of Family and Community Medicine, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco (DRR), San Francisco, CA; Center for Healthcare Organizational and Innovation Research, School of Public Health, University of California, Berkeley (AZP, SB, HPR), Berkeley, CA
| | - Hector P Rodriguez
- Department of Family and Community Medicine, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco (DRR), San Francisco, CA; Center for Healthcare Organizational and Innovation Research, School of Public Health, University of California, Berkeley (AZP, SB, HPR), Berkeley, CA
| |
Collapse
|