For Super-Utilizers, Integrated Care Offers A New Path

Factors associated with persistent multiyear frequent emergency department use

BACKGROUND

Although frequent emergency department (ED) users have been widely studied in cross-sectional settings, there is some evidence suggesting that most frequent ED users do not remain frequent users over multiple consecutive years. The objective of this study was to explore the association between persistent multiyear frequent ED use and individuals' characteristics.

METHODS

A retrospective analysis using the Healthcare Cost and Utilization Project State Emergency Department Databases (2012-2017) for individuals aged 18-59 who visited any ED in Florida, Massachusetts and New York was conducted. Multivariable regression models were used to estimate the association between persistent frequent ED use over time (≥4 ED visits in each data year) and individuals' characteristics and clinical factors compared with non-persistent frequent users (≥4 ED visits only in the baseline year).

RESULTS

The databases for the three states included 3.3 million patients, who accounted for 4.5 million ED visits in the baseline year (2012). Of those, 3.2% of patients were frequent ED users (≥4 visits) accounting for 13.2% of all ED visits in the baseline year. Longitudinal follow-up revealed that 14.9% (15 617) of frequent users in 2012 remained persistently frequent ED users for 2-3 consecutive years and 3.6% (3774) for 4-6 consecutive years. Persistent frequent ED users differed significantly from non-persistent frequent ED users; they had more ED visits in the index year, were more likely to have no health insurance or public health insurance coverage, and had a higher prevalence of chronic conditions and comorbidities, and more ED visits for less medically urgent conditions.

CONCLUSION

Differences exist between persistent and non-persistent frequent ED users that should be considered when implementing interventions designed to improve health outcomes and curtail healthcare expenditures generated by the broad population of frequent ED users.

"Addressing the bigger picture": A qualitative study of internal medicine patients' perspectives on social needs data collection and use

BACKGROUND

There is increasing interest in collecting sociodemographic and social needs data in hospital settings to inform patient care and health equity. However, few studies have examined inpatients' views on this data collection and what should be done to address social needs. This study describes internal medicine inpatients' perspectives on the collection and use of sociodemographic and social needs information.

METHODS

A qualitative interpretive description methodology was used. Semi-structured interviews were conducted with 18 patients admitted to a large academic hospital in Toronto, Canada. Participants were recruited using maximum variation sampling for diverse genders, races, and those with and without social needs. Interviews were coded using a predominantly inductive approach and a thematic analysis was conducted.

RESULTS

Patients expressed that sociodemographic and social needs data collection is important to offer actionable solutions to address their needs. Patients described a gap between their ideal care which would attend to social needs, versus the reality that hospital-based teams are faced with competing priorities and pressures that make it unfeasible to provide such care. They also believed that this data collection could facilitate more holistic, integrated care. Patients conveyed a need to have a trusting and transparent relationship with their provider to alleviate concerns surrounding bias, discrimination, and confidentiality. Lastly, they indicated that sociodemographic and social needs data could be useful to inform care, support research to inspire social change, and assist them with navigating community resources or creating in-hospital programs to address unmet social needs.

CONCLUSIONS

While the collection of sociodemographic and social needs information in hospital settings is generally acceptable, there were varied views on whether hospital staff should intervene, as their priority is medical care. The results can inform the implementation of social data collection and interventions in hospital settings.

The Patient Centered Assessment Method (PCAM) for Action-Based Biopsychosocial Evaluation of Patient Needs: Validation and Perceived Value of the Dutch Translation

The Patient Centered Assessment Method (PCAM) is an action-based tool that supports professionals to engage in a biopsychosocial assessment with patients and measure their needs. It is a promising tool for person-centered care. As the Netherlands lacks such a tool, a Dutch version was developed. Furthermore, we aimed to contribute to the relatively limited insights into the psychometric properties and value of the tool when used as part of a needs assessment in primary care. Confirmatory factor analysis was used to study construct validity and Cronbach’s alpha was computed to assess reliability. Furthermore, we interviewed 15 primary care professionals who used the PCAM. It was confirmed that each PCAM domain measures a separate construct, informed by the biopsychosocial model. The tool showed adequate reliability (Cronbach’s alpha = 0.83). Despite face validity concerns, the tool was mainly valued for measurement of patient needs and to facilitate action planning. Criticism of the PCAM pertained to a limited focus on the patient perspective, which is one of the crucial aspects of person-centered care. These rich, mixed-method insights can help to improve the value of the PCAM, as one of the few multifunctional tools to support professionals in holistic assessments.

The Effect of the Medicaid Expansion on Frequent Emergency Department Use in New York

BACKGROUND

There is limited evidence on the effect of the Affordable Care Act (ACA) on frequent emergency department (ED) use.

OBJECTIVES

To estimate the effect of the ACA Medicaid expansion on frequent ED use in New York.

METHODS

We used data from the Healthcare Cost and Utilization Project State Emergency Department Databases and State Inpatient Databases from 2011 to 2016. A consistent and unique patient identifier enabled us to identify ED visits by the same patient across different facilities within the state for each calendar year. Multivariate logistic regressions were used to quantify the policy's effect on frequent ED use (≥ 4 ED visits/year). We included in-state residents 18 to 64 years of age who were covered by Medicaid, private insurance, or were uninsured. Sensitivity analyses were conducted using alternative definitions of frequent use. To validate the findings, a falsification analysis was also conducted using only the 3 pre-expansion years.

RESULTS

Our study included 14.3 million ED patients with 23.8 million ED visits from 2011 to 2016. Frequent users (7.2%) accounted for 26.6% of all ED visits. The likelihood of frequent ED use declined by 4% among Medicaid beneficiaries (adjusted odds ratio [AOR] 0.96, 95% confidence intervals (CI) 0.95-0.97) and by 12% for the uninsured (AOR 0.88, 95% CI 0.86-0.89) in the post-expansion period, compared with the pre-expansion period. Private insurance enrollees were 9% more likely to exhibit frequent use in the post-expansion period (AOR 1.09, 95% CI 1.08-1.11). The sensitivity analyses yielded results similar to those of the main model. The falsification analyses revealed small and insignificant year-to-year changes in the 3 pre-expansion years.

CONCLUSION

The likelihood of frequent ED use decreased 3 years after New York implemented the ACA Medicaid expansion, particularly for Medicaid beneficiaries and the uninsured, highlighting the importance of expanding health insurance and provisions tailored at high-need populations.

Social media language of healthcare super-utilizers

An understanding of healthcare super-utilizers' online behaviors could better identify experiences to inform interventions. In this retrospective case-control study, we analyzed patients' social media posts to better understand their day-to-day behaviors and emotions expressed online. Patients included those receiving care in an urban academic emergency department who consented to share access to their historical Facebook posts and electronic health records. Super-utilizers were defined as patients with more than six visits to the Emergency Department (ED) in a year. We compared posts by super-utilizers with a matched group using propensity scoring based on age, gender and Charlson comorbidity index. Super-utilizers were more likely to post about confusion and negativity (D = .65, 95% CI-[.38, .95]), self-reflection (D = .63 [.35, .91]), avoidance (D = .62 [.34, .90]), swearing (D = .52 [.24, .79]), sleep (D = .60 [.32, .88]), seeking help and attention (D = .61 [.33, .89]), psychosomatic symptoms, (D = .49 [.22, .77]), self-agency (D = .56 [.29, .85]), anger (D = .51, [.24, .79]), stress (D = .46, [.19, .73]), and lonely expressions (D = .44, [.17, .71]). Insights from this study can potentially supplement offline community care services with online social support interventions considering the high engagement of super-utilizers on social media.

Development and Implementation of a Complex Health System Intervention Targeting Transitions of Care from Hospital to Post-acute Care

BACKGROUND

Failure of effective transitions of care following hospitalization can lead to excess days in the hospital, readmissions, and adverse events. Evidence identifies both patient and system factors that influence poor care transitions, yet health systems struggle to translate evidence into complex interventions that have a meaningful impact on care transitions.

OBJECTIVE

We report on our experience developing, pilot testing, and evaluating a complex intervention (Addressing Complex Transitions program, or ACT program) that aims to improve care transitions for complex patients.

DESIGN

Following the Medical Research Council (MRC) framework, we engaged in iterative, stakeholder-driven work to develop a complex care intervention, assess feasibility and pilot methods, evaluate the intervention in practice, and facilitate ongoing implementation monitoring and dissemination.

PARTICIPANTS

Patients receiving care from UW Medicine's health system including 4 hospitals and 20-site Post-Acute Care network.

INTERVENTION

Literature review and prospective data collection activities informed ACT program design. ACT program components include a tailored risk calculator that provides real-time scoring of transitions of care risk factors, a multidisciplinary team with the capacity to address complex barriers to safe transitions, and enhanced discharge workflows to improve care transitions for complex patients.

KEY MEASURES

Program evaluation metrics included estimated hospital days saved and program acceptance by care team members.

KEY RESULTS

During the 6-month pilot, 565 patients were screened and 97 enrolled in the ACT program. An estimated 664 hospital days were saved for the index admission of ACT program participants. Analysis of pre/post-hospital utilization for ACT program participants showed an estimated 3227 fewer hospital days after ACT program enrollment.

CONCLUSIONS

Health systems need to address increasingly difficult challenges in care delivery. The use of evidence-based frameworks, such as the MRC framework, can guide systems to design complex interventions that respond to their local context and stakeholder needs.

Health Care Hotspotting - A Randomized, Controlled Trial

BACKGROUND

There is widespread interest in programs aiming to reduce spending and improve health care quality among "superutilizers," patients with very high use of health care services. The "hotspotting" program created by the Camden Coalition of Healthcare Providers (hereafter, the Coalition) has received national attention as a promising superutilizer intervention and has been expanded to cities around the country. In the months after hospital discharge, a team of nurses, social workers, and community health workers visits enrolled patients to coordinate outpatient care and link them with social services.

METHODS

We randomly assigned 800 hospitalized patients with medically and socially complex conditions, all with at least one additional hospitalization in the preceding 6 months, to the Coalition's care-transition program or to usual care. The primary outcome was hospital readmission within 180 days after discharge.

RESULTS

The 180-day readmission rate was 62.3% in the intervention group and 61.7% in the control group. The adjusted between-group difference was not significant (0.82 percentage points; 95% confidence interval, -5.97 to 7.61). In contrast, a comparison of the intervention-group admissions during the 6 months before and after enrollment misleadingly suggested a 38-percentage-point decline in admissions related to the intervention because the comparison did not account for the similar decline in the control group.

CONCLUSIONS

In this randomized, controlled trial involving patients with very high use of health care services, readmission rates were not lower among patients randomly assigned to the Coalition's program than among those who received usual care. (Funded by the National Institute on Aging and others; ClinicalTrials.gov number, NCT02090426; American Economic Association registry number, AEARCTR-0000329.).

Effect of Intensive Interdisciplinary Transitional Care for High-Need, High-Cost Patients on Quality, Outcomes, and Costs: a Quasi-Experimental Study

BACKGROUND

Many health systems have implemented team-based programs to improve transitions from hospital to home for high-need, high-cost patients. While preliminary outcomes are promising, there is limited evidence regarding the most effective strategies.

OBJECTIVE

To determine the effect of an intensive interdisciplinary transitional care program emphasizing medication adherence and rapid primary care follow-up for high-need, high-cost Medicaid and Medicare patients on quality, outcomes, and costs.

DESIGN

Quasi-experimental study.

PATIENTS

Among 2235 high-need, high-cost Medicare and Medicaid patients identified during an index inpatient hospitalization in a non-profit health care system in a medically underserved area with complete administrative claims data, 285 participants were enrolled in the SafeMed care transition intervention, and 1950 served as concurrent controls.

INTERVENTIONS

The SafeMed team conducted hospital-based real-time screening, patient engagement, enrollment, enhanced discharge care coordination, and intensive home visits and telephone follow-up for at least 45 days.

MAIN MEASURES

Primary difference-in-differences analyses examined changes in quality (primary care visits, and medication adherence), outcomes (preventable emergency visits and hospitalizations, overall emergency visits, hospitalizations, 30-day readmissions, and hospital days), and medical expenditures.

KEY RESULTS

Adjusted difference-in-differences analyses demonstrated that SafeMed participation was associated with 7% fewer hospitalizations (- 0.40; 95% confidence interval (CI), - 0.73 to - 0.06), 31% fewer 30-day readmissions (- 0.34; 95% CI, - 0.61 to - 0.07), and reduced medical expenditures ($- 8690; 95% CI, $- 14,441 to $- 2939) over 6 months. Improvements were limited to Medicaid patients, who experienced large, statistically significant decreases of 39% in emergency department visits, 25% in hospitalizations, and 79% in 30-day readmissions. Medication adherence was unchanged (+ 2.6%; 95% CI, - 39.1% to 72.9%).

CONCLUSIONS

Care transition models emphasizing strong interdisciplinary patient engagement and rapid primary care follow-up can enable health systems to improve quality and outcomes while reducing costs among high-need, high-cost Medicaid patients.

Combining Integration of Care and a Population Health Approach: A Scoping Review of Redesign Strategies and Interventions, and their Impact

Background and aim:

Many health systems attempt to develop integrated and population health-oriented systems of care, but knowledge of strategies and interventions to support this effort is lacking. We aimed to identify specific redesign strategies and interventions, and to present evidence of their effectiveness.

Method:

A modified scoping review process was carried out. Fifteen relevant examples of integrated care organizations that incorporated a broad population health approach in countries of the Organization for Economic Cooperation and Development described in 57 articles and reports were included in analysis.

Results:

Seven key redesign strategies and multiple redesign interventions have been identified and are described. Most commonly used redesign strategies included focusing on health and wellness, embracing intersectoral action and partnerships, addressing health in vulnerable groups, and addressing a wide range of determinants of health, including making improvements in health services. Redesign interventions included creative and innovative ways of addressing clinical and non-clinical issues such as establishing housing surgeries in primary care, establlishing vast social and provider networks to support patients with complex needs and also broadening of the scope of services, workforce redesign and other. Potential reductions in the utilization of care and costs could be derived by the wider adoption of these strategies and interventions.

Conclusion:

Development of integrated and population health-oriented systems of care requires the redesign of how services are organized and delivered, and how organizations and care systems operate. Combining integration of care with the population health approach can be supported by a set of cohesive strategies and interventions aimed at preventing disease, addressing social determinants of health and improving health equity at both population- and individual-level.