Population Health Management最新文献

{"title":"Enhanced Primary Care for Severe Mental Illness Reduces Inpatient Admission and Emergency Room Utilization Rates.","authors":"Joy J Choi, Daniel D Maeng, Marsha N Wittink, Telva E Olivares, Kevin Brazill, Hochang B Lee","doi":"10.1089/pop.2024.0109","DOIUrl":"10.1089/pop.2024.0109","url":null,"abstract":"<p><p>Cardiovascular disease (CVD) is a leading cause of premature mortality among patients with severe mental illness (SMI). Effective care delivery models are needed to address this mortality gap. This study examines the impact of an enhanced primary care (PC) program that specializes in the treatment of patients with SMI, called Medicine in Psychiatry Service-Primary Care (MIPS-PC). Using multipayer claims data in Western New York from January 1, 2016 to December 31, 2021, patients with SMI and CVD were identified using International Classification of Diseases, Tenth Revision codes. National Provider Identification numbers of MIPS-PC providers were then used to identify those patients who were treated by MIPS-PC during the period. These MIPS-PC-treated patients were compared against a cohort of one-to-one propensity score matched contemporaneous comparison group (ie, patients receiving PC from providers unaffiliated with MIPS-PC). A difference-in-difference approach was used to identify the treatment effects of MIPS-PC on all-cause emergency department (ED) visits and hospitalization rates. The MIPS-PC group was associated with a downtrend in the acute care utilization rates over a 3-year period following the index date (ie, date of first MIPS-PC or other PC provider encounter), specifically a lower hospitalization rate in the first year since the index date (25%; <i>P</i> < 0.001). ED visit rate reduction was significant in the third-year period (18%; <i>P</i> = 0.021). In summary, MIPS-PC treatment is associated with a decreasing trend in acute care utilization. Prospective studies are needed to validate this effect of enhanced PC in patients with SMI and CVD.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"382-389"},"PeriodicalIF":1.8,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142361933","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Optimizing Hierarchical Condition Category-Risk Adjustment Factor Management in Population Health Using Rapid Process Improvement Methods.","authors":"Karri L Benjamin, Brett C Meyer, Jeff Pan, Susie R Guidi, Shivon Carreño, Khai Nguyen, Heather Hofflich, Nathan C Timmerman, Constance Eckenrodt, Usha Kollipara, Leann Lopez, Michelle G Albright, Matthew P Satre, Eileen M Haley, Parag Agnihotri","doi":"10.1089/pop.2024.0147","DOIUrl":"10.1089/pop.2024.0147","url":null,"abstract":"<p><p>Centers for Medicare & Medicaid Services provides reimbursement through Hierarchical Condition Category (HCC) coding. Medical systems strive toward risk adjustment optimization, often implementing costly chart review processes. Previously, our organization implementing countermeasures through workflows was complex and performed in silos. Our goal was to put in place HCC-Risk Adjustment Factor (RAF) improvement tools to optimize HCC-RAF management in Population Health using rapid process improvement methods. In this quality improvement analysis (IRB#806198), we used Lean methodology to develop tools and implement streamlined processes for providers to manage, document, and code high-risk HCC conditions. Rather than applying costly countermeasures, Transformational Healthcare conducted a Rapid Process Improvement Workshop (RPIW), with workgroups implementing proposed changes, to improve processes. Each of these tools was embedded in standard work, for teams to use in practice. Tools included the development of RPIW-inspired work groups, a Provider Education website, tip sheets, clinical champions, trainings, audits, practice alerts, smart phrases, schedule view tools, severity scores, reports, dashboards, on-screen decision-support tools, coding expertise, and HCC standard work. Quantitatively, Year 1 showed enterprise HCC-RAF scores improved by 4.1%. We were able to develop tools for providers and team members to allow for more optimized pathways. Although quantitatively we realized an improvement in enterprise HCC-RAF score, our overall aim was to improve process flow and limit waste. Leveraging Lean improvement methods for the collective design of tools has supported culture change. In the end, we found that providers are indeed willing to adopt these newly built tools. These tools have optimized operations, allowing providers to work smarter, not harder.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"365-373"},"PeriodicalIF":1.8,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142584007","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Identifying Patients with Heart Failure Eligible for Guideline-Directed Medical Therapy.","authors":"Samantha Subramaniam, Shahzad Hassan, Ozan Unlu, Sanjay Kumar, David Zelle, John W Ostrominski, Hunter Nichols, Jacqueline Chasse, Marian McPartlin, Megan Twining, Emma Collins, Echo Fridley, Christian Figueroa, Ryan Ruggiero, Matthew Varugheese, Michael Oates, Christopher P Cannon, Akshay S Desai, Samuel Aronson, Alexander J Blood, Benjamin Scirica, Kavishwar B Wagholikar","doi":"10.1089/pop.2024.0132","DOIUrl":"10.1089/pop.2024.0132","url":null,"abstract":"<p><p>A majority of patients with heart failure (HF) do not receive adequate medical therapy as recommended by clinical guidelines. One major obstacle encountered by population health management (PHM) programs to improve medication usage is the substantial burden placed on clinical staff who must manually sift through electronic health records (EHRs) to ascertain patients' eligibility for the guidelines. As a potential solution, the study team developed a rule-based system (RBS) that automatically parses the EHR for identifying patients with HF who may be eligible for guideline-directed therapy. The RBS was deployed to streamline a PHM program at Brigham and Women's Hospital wherein the RBS was executed every other month to identify potentially eligible patients for further screening by the program staff. The study team evaluated the performance of the system and performed an error analysis to identify areas for improving the system. Of approximately 161,000 patients who have an echocardiogram in the health system, each execution of the RBS typically identified around 4200 patients. A total 5460 patients were manually screened, of which 1754 were found to be truly eligible with an accuracy of 32.1%. An analysis of the false-positive cases showed that over 38% of the false positives were due to incorrect determination of symptomatic HF and medication history of the patients. The system's performance can be potentially improved by integrating information from clinical notes. The RBS provided a systematic way to narrow down the patient population to a subset that is enriched for eligible patients. However, there is a need to further optimize the system by integrating processing of clinical notes. This study highlights the practical challenges of implementing automated tools to facilitate guideline-directed care.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"374-381"},"PeriodicalIF":1.8,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142780958","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"In the \"Drivers'\" Seat: How to Improve Drivers of Health, from Vision to Impact.","authors":"Ann Somers Hogg, Alexandra Schweitzer","doi":"10.1089/pop.2024.0148","DOIUrl":"10.1089/pop.2024.0148","url":null,"abstract":"<p><p>Despite focusing on drivers of health, or social determinants of health, for more than a decade, health care organizations have made minimal progress in improving these factors and associated health outcomes. This data- and theory-driven analysis looks at (1) why that is the case and (2) how organizational leaders and operators can go about correcting it. The authors' research finds that lack of progress is often due to ill-fit, entrenched business models that were optimized for a fee-for-service environment and cannot easily pivot to focus on drivers of health. Additionally, leaders are often unclear about what to change and overwhelmed by how to do it. The authors propose a 5-step strategy and execution process to address these challenges, laying out an end-to-end road map that enables health care leaders to meaningfully improve drivers of health and associated health outcomes for their patients and communities.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"408-414"},"PeriodicalIF":1.8,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142667767","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Social Risk ACTIONS Framework: Characterizing Responses to Social Risks by Health Care Delivery Organizations.","authors":"Mayuree Rao, Matthew L Maciejewski, Karin Nelson, Alicia J Cohen, Hill L Wolfe, Leah Marcotte, Donna M Zulman","doi":"10.1089/pop.2024.0162","DOIUrl":"10.1089/pop.2024.0162","url":null,"abstract":"<p><p>Social risks refer to individuals' social and economic conditions shaped by underlying social determinants of health. Health care delivery organizations increasingly screen patients for social risks given their potential impact on health outcomes. However, it can be challenging to meaningfully address patients' needs. Existing frameworks do not comprehensively describe and classify ways in which health care delivery organizations can address social risks after screening. Addressing this gap, the authors developed the Social Risk ACTIONS framework (Actionability Characteristics To Inform Organizations' Next steps after Screening) describing 4 dimensions of actionability: Level of action, Actor, Purpose of action, and Action. First, social risk actions can occur at 3 organizational levels (ie, patient encounter, clinical practice/institution, community). Second, social risk actions are initiated by different staff members, referred to as \"actors\" (ie, clinical care professionals with direct patient contact, clinical/institutional leaders, and researchers). Third, social risk actions can serve one or more purposes: strengthening relationships with patients, tailoring care, modifying the social risk itself, or facilitating population health, research, or advocacy. Finally, specific actions on social risks vary by level, actor, and purpose. This article presents the Social Risk ACTIONS framework, applies its concepts to 2 social risks (food insecurity and homelessness), and discusses its broader applications and implications. The framework offers an approach for leaders of health care delivery organizations to assess current efforts and identify additional opportunities to address social risks. Future work should validate this framework with patients, clinicians, and health care leaders, and incorporate implementation challenges to social risk action.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"397-404"},"PeriodicalIF":1.8,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142716931","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Design and Framework of a Technology-Based Closed-Loop Referral Project for Care Coordination of Social Determinants of Health.","authors":"Shreela V Sharma, Heidi McPherson, Micaela Sandoval, David Goodman, Carol Paret, Kallol Mahata, Junaid Husain, James Gallagher, Eric Boerwinkle","doi":"10.1089/pop.2024.0129","DOIUrl":"10.1089/pop.2024.0129","url":null,"abstract":"<p><p>Screening for social determinants of health (SDOH) has been mandated by health systems nationwide. However, a gap exists in closed-loop referral for care coordination between health care and social services. This article presents the framework of a technology-based project to facilitate closed-loop referral between health care and social service agencies in Greater Houston by leveraging and connecting the existing care coordination technology infrastructure. Ten health care and social service organizations in Greater Houston participated in the demonstration project initiated in January 2023. The authors leveraged and linked regional health information exchange (HIE) technology with a master patient index of >18 million, and sector-specific care coordination platforms to build closed-loop referral capacity between HIE-participating health care organizations and social service organizations to meet patient SDOH needs. Evaluation efforts will assess the reach, adoption, implementation, and the effectiveness of the closed-loop framework in improving social and health outcomes. The framework comprised the following 4 components: (1) establishment of collaborative governance for shared decision-making processes, fostering trust, alignment, and transparency among organizations; (2) development of technology linkages between existing platforms to facilitate seamless referrals between organizations and ensure visibility of referral outcomes; (3) integration of regional resource directories into technology infrastructure to ensure resource accessibility/quality; and (4) evaluation of the system's impact on health equity, efficiency, and cost reduction. This project aimed to close the loop for care coordination between health care and social service agencies, enable data evaluation to determine care coordination effectiveness, and lay the foundation for SDOH-related research/practice equitably.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"390-396"},"PeriodicalIF":1.8,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142740261","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Rosalind Franklin Society Proudly Announces the 2023 Award Recipient for <i>Population Health Management</i>.","authors":"Marik Moen","doi":"10.1089/pop.2024.12337.rfs2023","DOIUrl":"https://doi.org/10.1089/pop.2024.12337.rfs2023","url":null,"abstract":"","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":"27 5","pages":"299"},"PeriodicalIF":1.8,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142506493","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Association of Timely Outpatient Follow-Up and Readmission Risk in a Mobile Integrated Health Program.","authors":"Nicholas Brady, Yuanyuan Liang, Kristin L Seidl, David Marcozzi, Benoit Stryckman, Daniel B Gingold","doi":"10.1089/pop.2024.0020","DOIUrl":"10.1089/pop.2024.0020","url":null,"abstract":"<p><p>The objective was to identify medical conditions associated with 30-day readmission, determine patient characteristics for which outpatient follow-up is most associated with reduced readmission, and evaluate how readmission risk changes with time to outpatient follow-up within a mobile integrated health-community paramedicine (MIH-CP) program. This retrospective observational study used data from 1,118 adult patient enrollments in a MIH-CP program operating in Baltimore, Maryland, from May 14, 2018, to December 21, 2021. Bivariate analysis identified chronic disease exacerbations associated with higher 30-day readmission risk. Kaplan-Meier curves and Cox proportional hazard regressions were used to measure how hazard of readmission changes with outpatient follow-up and how that association may vary with other factors. Receiver operating characteristic analysis was used to evaluate how well time to follow-up could predict 30-day readmission. Timely outpatient follow-up was associated with a significant reduction in hazard of readmission for patients aged 50 and younger and for patients with fewer than 5 social determinants of health needs identified. No significant association between readmission and specific chronic disease exacerbations was observed. An optimal follow-up time frame to reduce readmissions could not be identified. Timely outpatient follow-up may be effective for reducing readmissions in younger patients and patients who are less socially complex. Programs and policies aiming to reduce 30-day readmissions may have more success by expanding efforts to include these patients.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"249-256"},"PeriodicalIF":1.8,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140866167","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Long-Term HIV Pre-Exposure Prophylaxis Persistence and Reinitiation in Connecticut from 2012 to 2018.","authors":"Jun Tao, Mofan Gu, Omar Galarraga, Jhanavi Kapadia, Harrison Martin, Hannah Parent, Philip A Chan","doi":"10.1089/pop.2024.0012","DOIUrl":"10.1089/pop.2024.0012","url":null,"abstract":"<p><p>HIV pre-exposure prophylaxis (PrEP) is a highly effective biomedical prevention for HIV infections. PrEP persistence is critical to achieving optimal protection against HIV infection. However, little is known about PrEP persistence in the United States. This study utilized the Connecticut All-Payer Claims Database (APCD) to identify PrEP persistence among patients who filled their PrEP prescriptions in the state. The authors identified 1,576 PrEP patients who picked up PrEP prescriptions and extracted medical and pharmacy claims to evaluate a longitudinal cohort during 2012-2018 based on the Connecticut APCD. Patients who did not pick up medication for one consecutive month (ie, 30 days) were defined as discontinuing PrEP. Kaplan-Meier Survival Curve and proportional hazard regression were used to describe PrEP persistence. Of the 1,576 patients who picked up PrEP prescriptions, the median age was 32.0 (interquartile range [IQR]: 22.0-44.0). The majority were male individuals (93%). Of 1,040 patients who discontinued PrEP, 702 (67.5%) restarted PrEP at least once. The median time of PrEP persistence was 3 months (IQR: 1-6 months) for initial PrEP use. The median time on PrEP was also around 3 months in the following episodes of PrEP use. Being female, being on parent's insurance, and having high co-pays were associated with shorter periods of PrEP persistence. PrEP persistence was low among patients who picked up PrEP prescriptions. Although many patients restarted PrEP, persistence remained low during follow-up PrEP use and possibly led to periods of increased HIV risk. Effective interventions are needed to improve PrEP persistence and reduce HIV incidence.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"267-274"},"PeriodicalIF":1.8,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11698670/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141564147","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Knowledge, Attitudes, and Practices Regarding Herpes Zoster Vaccination Among Specialists.","authors":"David Singer, Carolyn Sweeney, Nikita Stempniewicz, Maria Reynolds, Diana Garbinsky, Sara Poston","doi":"10.1089/pop.2023.0284","DOIUrl":"10.1089/pop.2023.0284","url":null,"abstract":"<p><p>Recombinant zoster vaccine has been recommended by the US Advisory Committee on Immunization Practices (ACIP) for the prevention of herpes zoster (HZ) in immunocompetent adults aged at least 50 years since 2018. In January 2022, this was extended to immunodeficient/immunosuppressed adults aged at least 19 years. Key study objectives were to assess specialists' knowledge of the ACIP HZ vaccination recommendations, their attitudes toward HZ vaccination, and HZ vaccination practices/barriers. This cross-sectional, web-based survey (conducted in March 2022) included US dermatologists, gastroenterologists, infectious disease specialists, oncologists, and rheumatologists who treat patients with psoriasis, inflammatory bowel disease, human immunodeficiency syndrome, solid tumors/hematological malignancies, and rheumatoid arthritis, respectively. Although most of the 613 specialists correctly identified the ACIP HZ vaccination recommendations for adults aged at least 50 years (84%) and immunodeficient/immunosuppressed adults aged at least 19 years (67%), only 29% knew that recombinant zoster vaccine is recommended for individuals who have previously received zoster vaccine live, and only 18% knew all current ACIP recommendations. For patients with the diseases listed, 84% of specialists thought that HZ is a serious risk, 75% that HZ vaccination is extremely/very important, and 69% were extremely/very likely to recommend HZ vaccination. Only 36% administer vaccines themselves, mainly because patients receive vaccinations from others. Barriers to vaccination included more urgent/acute issues, insufficient time, and lack of patient motivation/willingness. Full knowledge of the ACIP HZ vaccination recommendations among the surveyed specialists was low. There may be a need to educate specialists to improve adherence to these recommendations. [Figure: see text].</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"231-240"},"PeriodicalIF":1.8,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141262669","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}