Care Coordination Program Research Articles

The logistical landscape of lay dementia care

AbstractBackgroundIn 2018, more than 16 million unpaid caregivers (CG) provided care for people with dementia (PWD), care that is associated with increased caregiver depression, poor health and caregiver burden (Alzheimer’s Association, 2019). This observational, cross‐sectional study examined CGs’ relationships to PWDs, how CGs allot their caregiving time, how caregiving affects their work, and CGs’ mental health. We hypothesized that CGs would be primarily spouses or children of the PWD, that they would provide the majority of unpaid care without an extensive support system and with a significant amount of time spent on caregiving, that would disrupt their employment, and be accompanied by relatively high levels of mental health symptoms.MethodAt the initiation of a dementia care coordination program, CGs (N = 96) were surveyed regarding their personal characteristics, the PWDs they care for (N = 96), and CG perceptions of caregiving. Descriptive information about the landscape of their caregiving at baseline is presented (Table 1).ResultMost CGs were women, whereas PWD gender was more evenly split. Most CGs were spouses or children of PWDs, and over 70% lived with the PWD. Only about half were the PWD’s power of attorney. The majority of CGs provided over 80% of care to the PWD, often unpaid and without other help. On average, CGs spent the equivalent of a full‐time job supervising and assisting with complex activities of daily living (ADLs) and the equivalent of a part‐time job assisting with basic ADLs. Of employed CGs (<50%), over 85% were not paid for caregiving, and caregiving disrupted their work. CGs on average had a clinical degree of depression, minimal anxiety, and mild to moderate caregiver burden.ConclusionThis sample of CGs is generally consistent with our expectations and national U.S. statistics on CGs (e.g., Alzheimer’s Association, 2019). Importantly, CGs spend large amounts of time providing unpaid caregiving with significant financial consequences and little support from others. CGs are a vulnerable group in terms relatively high levels of depression and CG burden. Innovations in provision of caregiver support are needed to help this vulnerable but growing population.

Protective factors associated with mental health symptoms in caregivers of persons with dementia

AbstractBackgroundCaregivers (CGs) of persons with dementia (PWDs) have relatively high levels of caregiver burden, depression, and anxiety. This observational, cross‐sectional study examined the extent to which preparedness for caregiving and knowledge about dementia might be associated with lower levels of these mental health symptoms.MethodAt the entry into a dementia care coordination program, CGs (N = 74) were surveyed about personal characteristics, characteristics of the PWD they care for (N = 74), mental health symptoms, and their perceptions about caregiving. Three univariate linear regressions were conducted to assess associations between protective factors (i.e., preparedness for caregiving, dementia knowledge) and CGs’ levels of depression, anxiety, and caregiver burden, controlling for CG age, CG education, and PWD level of functional independence in activities of daily living (ADLs).Result(Table 1). Neither preparedness for caregiving or dementia knowledge were significantly associated with CG depression or anxiety. However, younger CGs reported higher levels of depression (B = ‐.007, t = ‐3.33, p = 0.001) and anxiety (B = ‐.12, t = ‐2.91, p = 0.005). CGs with higher preparedness for caregiving reported lower CG burden (B = ‐.67, t = ‐2.51, p = 0.015), and CGs of PWDs with lower functional independence reported higher CG burden (B = ‐2.19, t = ‐2.96, p = 0.004).ConclusionResults of this cross‐sectional, observational study indicate that CGs’ preparedness for caregiving is associated with CG burden and that younger GGs had higher levels of depression and anxiety. These findings suggest that CG age may impact CG mental health and provide opportunities for intervention including targeting mood in younger CGs and increasing CG preparedness to potentially decrease CG burden. Additionally, emotional preparation for providing care to PWDs may be more important for reducing CGs’ burden than teaching specific knowledge about what to expect in dementia, and CGs of PWDs with lower functional abilities may benefit from targeted supports to reduce burden.

The West Philadelphia asthma care implementation study (NHLBI# U01HL138687)

Asthma is the most common chronic condition among children, with low-income families living in urban areas experiencing significantly higher rates. Evidence based interventions for asthma are routinely implemented in either the home, school, or primary care setting. However, even when caregivers of poor children are engaged in asthma interventions in one setting, they often have to navigate challenges in another setting, such as an under-resourced home, non-supportive school, or disengaged health care provider. The West Philadelphia Asthma Care Implementation Plan aims to compare the effectiveness of a primary care-based intervention, school-based intervention, and combined primary care and school intervention to usual care for improving asthma control in school-age children to explore if the synergistic effect of Community Health Worker (CHW) support in the home, school, and health care environments will result in improved asthma control. Children ages 5–13 with uncontrolled asthma from four West Philadelphia recruitment sites will be eligible for enrollment. The families of school age children interested in participating will be randomized to receive a primary care CHW or usual care. Those identified as attending a participating school will have a CHW-led school intervention or usual care in school. If proven effective, this care coordination program will assist caregivers in assessing resources, improving self-management skills, and ultimately reducing asthma-related ED visits and hospitalizations as well as provide additional information for healthcare systems and policy makers to inform their decisions about how and where to focus additional resources and investments in childhood asthma care to improve health outcomes.

Older Adults and Serious Mental Illness: What We Know and What We Imagine

Older Adults and Serious Mental Illness: What We Know and What We Imagine

Access-to-care: evidence from home-based postnatal coordinated care after hospital discharge

BackgroundHome-based postnatal care after hospital discharge has become an integral part of postnatal care. This study aimed to determine the factors relating either to individuals or the healthcare system that affect enrollment and full participation (adherence) in the French home-based postnatal coordinated care program (PRADO).MethodsAll admitted women for delivery in a French district over one year and eligible for this home-based midwifery support after hospital discharge were included (N = 4189). Both a simple probit model and a probit Heckman selection model were used. The control variables were the characteristics of the women, the municipalities, and the hospitals.ResultsApproximately 68% of the eligible women chose to enroll in the PRADO program, of who nearly 60% fully participated in this program. Enrollment in the program was influenced mostly by the family context, such as the woman’s age at the time of her pregnancy and the number of children in the household, the woman’s level of prenatal education and information about postnatal care, as well as some hospital variables such as the characteristics and organization of the maternity units. Full participation in the program was influenced by the accessibility to health professionals, particularly midwives. Furthermore, the women’s level of prenatal education and information about postnatal care, as well as their accessibility to health professionals, correlated with the socioeconomic environment.ConclusionWhile individual factors impacted enrollment in the PRADO program, only healthcare system-related factors influenced full participation in the program. A public health policy promoting home-based postnatal care could increase the women’s participation by improving their level of prenatal education and information about postnatal care. In addition, reducing regional inequality is likely to have a positive impact, as the availability of health professionals is a key factor for participation in home-based postnatal coordinated care.

HIV Care Coordination promotes care re-engagement and viral suppression among people who have been out of HIV medical care: an observational effectiveness study using a surveillance-based contemporaneous comparison group

BackgroundMedical care re-engagement is critical to suppressing viral load and preventing HIV transmission, morbidity and mortality, yet few rigorous intervention studies address this outcome. We assessed the effectiveness of a Ryan White Part A-funded HIV Care Coordination Program relative to ‘usual care,’ for short-term care re-engagement and viral suppression among people without recent HIV medical care.MethodsThe Care Coordination Program was launched in 2009 at 28 hospitals, health centers, and community-based organizations in New York City. Designed for people with HIV (PWH) experiencing or at risk for poor HIV outcomes, the Care Coordination Program provides long-term, comprehensive medical case management utilizing interdisciplinary teams, structured health education and patient navigation. The intervention was implemented as a safety-net services program, without a designated comparison group. To evaluate it retrospectively, we created an observational, matched cohort of clients and controls. Using the HIV surveillance registry, we identified individuals meeting program eligibility criteria from December 1, 2009 to March 31, 2013 and excluded those dying prior to 12 months of follow-up. We then matched clients to controls on baseline status (lacking evidence of viral suppression, consistently suppressed, inconsistently suppressed, or newly diagnosed in the past 12 months), start of follow-up and propensity score. For this analysis, we limited to those out of care at baseline (defined as having no viral load test in the 12 months pre-enrollment) and still residing within jurisdiction (defined as having a viral load or CD4 test reported to local surveillance and dated within the 12-month follow-up period). Using a GEE model with binary error distribution and logit link, we compared odds of care re-engagement (defined as having ≥ 2 laboratory events ≥ 90 days apart) and viral suppression (defined as having HIV RNA ≤ 200 copies/mL on the most recent viral load test) at 12-month follow-up.ResultsAmong 326 individuals out of care at baseline, 87.2% of clients and 48.2% of controls achieved care re-engagement (Odds Ratio: 4.53; 95%CI 2.66, 7.71); 58.3% of clients and 49.3% of controls achieved viral suppression (Odds Ratio: 2.05; 95%CI 1.30, 3.23).ConclusionsHIV Care Coordination shows evidence of effectiveness for care and treatment re-engagement.

Mortality among clients in the New York city HIV Care Coordination Program (CCP): incidence and associated clinical factors

We examined psychosocial factors (housing, drug use, incarceration history or mental health) and care factors (comorbidities and acute care) associated with all-cause and HIV-related mortality while enrolled in the New York City Ryan White HIV Care Coordination Program (CCP), an intensive case management program for people with barriers to HIV care and treatment. We used hazards regression (HR) to understand factors associated with mortality. 8,135 people (13,479.4 person years [PY]) enrolled in the CCP from March 2011 to December 2016. The all-cause mortality rate while enrolled was 28.8 per 1000 PY (N = 388), with 43% of deaths (N = 167) related to HIV (12.4 per 1000 PY). Controlling for demographics and clinical status, the variables associated with increased hazards of all-cause mortality included hospitalizations or emergency-department visits prior to enrollment (aHRHospitalizations: 2.54; 95% Confidence Interval 2.07-3.11 and aHRED: 1.54; 1.24-1.92) or a diabetes or Hepatitis C diagnosis at enrollment (aHRDiabetes: 1.80; 1.36-2.37 and aHRHCV: 1.78; 1.37-2.30). These factors also increased the hazards of HIV-related mortality. CCP and similar case management programs should systematically screen enrolling clients for a history of acute care and comorbidities, as they may be important markers of need for more intensive engagement and follow-up to prevent death.

Evaluating specialty referral, research involvement, and PROs in a CNS-involved metastatic breast cancer care coordination program.

47 Background: Central nervous system (CNS) metastases are associated with decreased survival and quality of life for patients with metastatic breast cancer (MBC). Multi-disciplinary care can optimize outcomes. This project aims to improve access to coordinated care for patients with MBC and CNS metastases while assessing patient-reported outcomes (PROs) in the context of the multidisciplinary care experience. Methods: Patients with MBC and CNS metastases are referred and offered to enroll in our care coordination program. A team of specialists (breast medical oncology, breast cancer genetics, radiation oncology, neurosurgery, neuro-oncology, physical medicine and rehabilitation (PM&R), neuropsychology, and palliative care) supports a dedicated program coordinator who provides navigation, education, specialty referral, and clinical trial screening. A unique intake form developed for the program creates personalized, coordinated, and expedited referrals. PROs and caregiver assessments are collected on a voluntary basis using the following validated questionnaires: PROMIS Cancer Function Brief 3D Profile, MD Anderson Symptom Inventory Brain Tumor (MDASI), and Short Form Zarit Burden Interview (ZBI-12), a screening tool for caregiver burden. Results: Since May 2020, 43 patients were referred and a total of 40 patients (93%) were enrolled – 2 (5%) declined due to perceived burden of participation and 1 (2%) died before enrollment. The majority of patients were White (n = 34, 85%). Median time to program intake was 1 day (range: 0-8 days). Of the 43 patients referred, 17 (40%) consented to research studies in the metastatic setting. 11 were for an interventional trial (65%), while 9 consents were for non-interventional studies (53%). In addition to the initially referred specialty, 56 referrals were made across 7 sub-specialties; 37 patients (66%) were subsequently seen by a sub-specialist, most commonly radiation oncology (n = 9), PM&R (n = 9), neuro-oncology (n = 8), and neuropsychology (n = 8). Of the nine patients seen by PM&R, 5 completed the PROMIS Profile (55%). Similar completion rates were seen for the MDASI (13 of 23 surveys given, 56.5%) and ZBI-12 (13 of 26 surveys given, 50%) questionnaires. Conclusions: Implementation of a care coordination program for patients with MBC and CNS metastases allows for improved access to care across sub-specialties and supports participation in clinical research for a group of cancer patients historically underrepresented in research studies. Though completion of questionnaires is optional in this program, the rate of completion raises the question of whether this patient population faces unique challenges that make it difficult to complete questionnaires that are often required in research studies. Funding source: National Comprehensive Cancer Network Oncology Research Program from financial support from Pfizer.

58 Using Machine Learning to Predict Hospital Disposition With Geriatric Emergency Department Innovations Intervention

The geriatric emergency department innovations (GEDI) program is a nurse-based geriatric assessment and care coordination program that reduces preventable admissions for older adults and decreases Medicare expenditures. All adults age 65+ in the ED are currently eligible, but only 5% of older adults receive GEDI care due to resource limitations. Currently available geriatric screenings to identify older adults likely to benefit from programs like GEDI perform poorly in the ED. The objective of this study was to predict likelihood of hospitalization accurately and consistently with and without GEDI care using machine learning models to better target the GEDI program. We performed a cross sectional observational study of ED records from (1/2010 to 3/2018). Using propensity score matching, GEDI patients were matched to non-GEDI patients. Logistic regression, random forest, support vector machine, gradient boosting, and neural network techniques were used to predict hospital admission using demographic data, medical history, ED visit chief complaint, vitals, and geographic data. Hospital admission was then predicted with and without GEDI assessment during the ED visit. Visits were classified into one group with a predicted change in hospital disposition with the GEDI assessment and another group with no predicted change in disposition with GEDI assessment. In this second analysis feature importance was performed on the tree-based models. Final model performance was reported as the area under the curve (AUC) using receiver operating characteristic models for the test data. We included 55,056 patients age 65+ who accounted for 134, 361 ED visits. Of these, 3, 860 visits were included in the training set and 10, 142 in the testing set to predict hospital admission. 5, 071 visits were used in the training and testing sets to predict change in disposition with GEDI. The random forest model had the best performance with an AUC of 0.81 (95% CI 0.79-0.83). In the random forest model, 9, 756 (96.2%) ED visits were predicted to have no change in disposition with GEDI assessment, and 386 (3.8%) ED visits were predicted to have a change in disposition with GEDI assessment (Table 1). Of those with a predicted change in disposition from admitted to discharged with GEDI assessment the top 5 most influential variables out of 86 variables with their relative importance are in Table 2. The higher relative importance the more it influenced the model’s outcome, however ranking does not imply the direction of influence. All importance values add up to a total of 1. Our machine learning models were able to predict who is likely to be discharged with GEDI assessment with good accuracy and thus select a cohort appropriate for GEDI care. Future implementation of this machine learning model into the electronic health record may assist in the identification of older adults who should be prioritized for GEDI care.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Schizophrenia population health management: perspectives of and lessons learned from population health decision makers.

BACKGROUND: Despite therapeutic advances for patients with schizophrenia, improving patient outcomes and reducing the cost of care continue to challenge formulary decision makers. OBJECTIVES: To (1) understand the perspectives of formulary decision makers on challenges to optimal schizophrenia population management and (2) identify best practices and recommendations for mitigating these challenges. METHODS: This mixed-methods study, conducted in a double-blind manner, comprised in-depth telephone interviews with formulary decision makers from February through May 2020, and a web-based follow-on survey that was sent to all participants in October 2020. US-based formulary decision makers were recruited if they were directly involved in schizophrenia drug formulary or coverage decision making for national or regional payers, health systems, or behavioral health centers. Formulary decision makers' perceptions of challenges, policies, and programs related to schizophrenia population health management were assessed generally and in the context of the COVID-19 pandemic. RESULTS: 19 formulary decision makers participated in the interviews and 18 (95%) completed the survey. Participants reported a spectrum of patient- and payer-driven challenges in schizophrenia population health management, including medication nonadherence, high pharmacy and medical costs, and frequent hospitalizations and emergency department visits. Participants noted that COVID-19 had worsened all identified challenges, although patient unemployment (mean score of 2.00 on a scale of 1 [made much worse] to 5 [made much better]) and reduced access to psychiatric care (mean score, 2.12) were most negatively affected. The most common strategies implemented in order to improve schizophrenia population health management included case management (89%), telemedicine (83%), care coordination programs (72%), strategies to mitigate barriers to accessing medication (61%), and providing nonmedical services to address social determinants of health (56%). Participants noted that, ideally, all treatments for schizophrenia would be available on their formularies without utilization management policies in place in order to increase accessibility to medication, but cost to the health plans made that difficult. Whereas 61% of respondents believed that long-acting injectable antipsychotics (LAIs) were currently underused in their organizations, only 28% represented organizations with open access policies for LAIs. Participants believed that among patients with schizophrenia, LAIs were most beneficial for those with a history of poor or uncertain adherence to oral medications (mean score of 4.50 on a scale of 1 [not at all beneficial] to 5 [extremely beneficial]) and those with recurring emergency department visits and inpatient stays (mean score, 3.94). Study participants reported slightly increased use of LAIs (mean score of 3.17 on a scale of 1 [negatively impacted] to 5 [positively impacted]) among their patients with schizophrenia in response to the COVID-19 pandemic; 29% of participants reported easing access restrictions for LAIs. CONCLUSIONS: Participants described persisting challenges and various approaches intended to improve schizophrenia population health management. They also recommended strategies to optimize future health management for this population, including expanding programs to address social determinants of health and mitigating barriers to accessing treatment. DISCLOSURES: This study was funded by Janssen Scientific Affairs, LLC. Roach, Graf, Pednekar, and Chou are employees of PRECISIONheor, which received financial support from Janssen Scientific Affairs, LLC, to conduct this study. Chou owns equity in Precision Medicine Group, the parent company of PRECISIONheor. Lin and Benson are employees of Janssen Scientific Affairs, LLC. Doshi has served as a consultant, advisory board member, or both, for Acadia, Allergan, Boehringer Ingelheim, Janssen, Merck, Otsuka, and Sage Therapeutics and has received research funding from AbbVie, Biogen, Humana, Janssen, Novartis, Merck, Pfizer, PhRMA, Regeneron, Sanofi, and Valeant.

Improving Outcomes for Families of Children With Medical Needs Known to Child Welfare: A Nurse Care Coordination Program.

Children known to child welfare are more likely to have poor health compared to the general population. Most children served by child welfare are served in their own homes. New Jersey implemented the Child and Family Nurse Program (CFNP) to provide nurse care coordination to address the health needs of children who remain in-home. Our study described: 1) families served by CFNP; 2) services provided to these families; and 3) family well-being outcomes. The study focused on the 304 families served by CFNP from 2016 to 2017. We used CFNP data to describe families served and services provided, and family baseline and follow-up surveys to assess change in family well-being over time. Families served by CFNP experienced improvements in family protective factors and health-related quality of life from baseline to follow-up. While more rigorous studies are needed to learn CFNP's impact, it is a promising approach that merits consideration by state child welfare leaders.

Outpatient Follow-up Care After Hospital Discharge of Children With Complex Chronic Conditions at a Rural Tertiary Care Hospital.

To determine factors associated with completion of recommended outpatient follow-up visits in children with complex chronic conditions (CCCs) following hospital discharge. We retrospectively identified children aged 1 to 17 years diagnosed with a CCC who were discharged from our rural tertiary care children's hospital between 2017 and 2018 with a diagnosis meeting published CCC criteria. Patients discharged from the neonatal intensive care unit and patients enrolled in a care coordination program for technology-dependent children were excluded. Of 113 eligible patients, 77 (68%) had outpatient follow-up consistent with discharge instructions. Intensive care unit (ICU) admission (P = .020) and prolonged length of stay (P = .004) were associated with decreased likelihood of completing recommended follow-up. Among children with CCCs who were not already enrolled in a care coordination program, ICU admission was associated with increased risk of not completing recommended outpatient follow-up. This population could be targeted for expanded care coordination efforts.

The SOFIA pilot trial: a cluster-randomized trial of coordinated, co-produced care to reduce mortality and improve quality of life in people with severe mental illness in the general practice setting

BackgroundPeople with severe mental illness (SMI) have an increased risk of premature mortality, predominantly due to somatic health conditions. Evidence indicates that primary and tertiary prevention and improved treatment of somatic conditions in patients with SMI could reduce this excess mortality. This paper reports a protocol designed to evaluate the feasibility of a coordinated co-produced care program (SOFIA model, a Danish acronym for Severe Mental Illness and Physical Health in General Practice) in the general practice setting to reduce mortality and improve quality of life in patients with severe mental illness.MethodsThe SOFIA pilot trial is designed as a cluster randomized controlled trial targeting general practices in two regions in Denmark. We aim to include 12 practices, each of which is instructed to recruit up to 15 community-dwelling patients aged 18 and older with SMI. Practices will be randomized by a computer in a ratio of 2:1 to deliver a coordinated care program or usual care during a 6-month study period. A randomized algorithm is used to perform randomization. The coordinated care program includes educational training of general practitioners and their clinical staff educational training of general practitioners and their clinical staff, which covers clinical and diagnostic management and focus on patient-centered care of this patient group, after which general practitioners will provide a prolonged consultation focusing on individual needs and preferences of the patient with SMI and a follow-up plan if indicated. The outcomes will be parameters of the feasibility of the intervention and trial methods and will be assessed quantitatively and qualitatively. Assessments of the outcome parameters will be administered at baseline, throughout, and at end of the study period.DiscussionIf necessary the intervention will be revised based on results from this study. If delivery of the intervention, either in its current form or after revision, is considered feasible, a future, definitive trial to determine the effectiveness of the intervention in reducing mortality and improving quality of life in patients with SMI can take place. Successful implementation of the intervention would imply preliminary promise for addressing health inequities in patients with SMI.Trial registrationThe trial was registered in Clinical Trials as of November 5, 2020, with registration number NCT04618250.Protocol version: January 22, 2021; original version

Pediatric Complexity Tool Best Practice Alert: Early Identification of Care Coordination for Children with Special Health Care Needs.

Care coordination programs continue to be developed for children with special health care needs (CSHCN). The goals for these programs are to improve access, increase communication, and decrease the overall length of stay for CSHCN. Care coordination optimizes resources to support children's health and well-being early in their hospitalization and facilitates a smooth discharge process and transition to home. Providing care coordination for CSHCN requires collaboration from many disciplines. To achieve high-quality care coordination, early identification of medically complex pediatric patients on admission is optimal. For more efficient and timelier enrollment into our care coordination program, we created a best practice alert within our electronic medical record to help overcome the challenges in timely identification of CSHCN. The best practice alert has helped us to provide care coordination benefits to our patients earlier in their hospital course. The purpose of this paper is to describe a quality improvement initiative to improve the early identification of CSHCN on hospital admission through the development of a best practice alert.

A Care Coordination Intervention Improves Symptoms But Not Charges in High-Risk Patients With Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is associated with substantial symptom burden, variability in clinical outcomes, and high direct costs. We sought to determine if a care coordination-based strategy was effective at improving patient symptom burden and reducing healthcare costs for patients with IBD in the top quintile of predicted healthcare utilization and costs. We performed a randomized controlled trial to evaluate the efficacy of a patient-tailored multicomponent care coordination intervention composed of proactive symptom monitoring and care coordinator-triggered algorithms. Enrolled patients with IBD were randomized to usual care or to our care coordination intervention over a 9-month period (April 2019 to January 2020). Primary outcomes included change in patient symptom scores throughout the intervention and IBD-related charges at 12 months. Eligible IBD patients in the top quintile for predicted healthcare utilization and expenditures were identified. A total of 205 patients were enrolled and randomized to our intervention (n= 100) or to usual care (n= 105). Patients in the care coordinator arm demonstrated an improvement in symptoms scores compared with usual care (coefficient, -0.68, 95% confidence interval, -1.18 to -0.18; P= .008) without a significant difference in median annual IBD-related healthcare charges ($10,094 vs $9080; P= .322). In this first randomized controlled trial of a patient-tailored care coordination intervention, composed of proactive symptom monitoring and care coordinator-triggered algorithms, we observed an improvement in patient symptom scores but not in healthcare charges. Care coordination programs may represent an effective value-based approach to improve symptoms scores without added direct costs in a subgroup of high-risk patients with IBD. (ClinicalTrials.gov, Number: NCT04796571).

OTHR-13. IMPACT the brain: improving metastatic breast cancer patient access to coordinated treatment

Central nervous system (CNS) metastases are associated with decreased survival and quality of life for patients with metastatic breast cancer (MBC). Multi-disciplinary care can optimize outcomes. This project aims to improve access to coordinated care for patients with MBC and CNS metastases.Patients with MBC and CNS metastases are referred and offered to enroll in our care coordination program. A team consisting of specialists (breast medical oncology, breast cancer genetics, radiation oncology, neurosurgery, neuro-oncology, physical medicine and rehabilitation (PM&R), neuropsychology, and palliative care) supports a dedicated program coordinator who provides navigation, education, specialty referral, and clinical trial screening. A unique intake form developed for the program creates personalized, coordinated, and expedited referrals. Patient-reported outcomes and caregiver burden assessments are collected.Since May 2020, 43 patients were referred and a total of 40 patients (93%) were enrolled – 2 (5%) declined due to perceived burden of participation and 1 (2%) died before enrollment. 85% of patients were Caucasian (n = 34) and 15% were non-Caucasian (n=6). Median time to program intake was 1 day (range: 0–8 days). Of the 43 patients referred, 17 (40%) consented to research studies in the metastatic setting. 11 were for an interventional trial (65%), while 9 consents were for non-interventional studies (53%). In addition to the initially referred specialty, 56 referrals were made across 7 sub-specialties; 37 patients (66%) were subsequently seen by a sub-specialist, most commonly radiation oncology (n = 9), neuro-oncology (n=8), PM&R (n=8), and neuropsychology (n=8).Implementation of a care coordination program for patients with MBC and CNS metastases is feasible. Further, it allows for improved access to care across sub-specialties and supports participation in clinical research for a group of cancer patients historically underrepresented in research studies.Funding: National Comprehensive Cancer Network Oncology Research Program from financial support provided by Pfizer.

Stratifying for Value: An Updated Population Health Risk Stratification Approach.

Most risk stratification approaches attempt to predict clinical outcomes rather than value. For a provider organization or health system to have financial success in value-based contracting, future risk models must analyze costs as well as disease burden. The purpose of this study was to create a customized risk stratification algorithm that considered a patient's medical spend alongside disease burden while delivering a scoring system that improves the efficiency of a care coordination program. The authors focused on University Hospitals (UH) Health System's Accountable Care Organization population of 554,805 because this patient cohort is engaged with UH's primary care network and has the most robust data. The 5-category risk algorithm was found to be meaningful and impactful after integrating the foundation of the Minnesota Tiering system with an expanded comorbidity list and weighting the result by the previous 12 months of medical spend. This new technique can identify patients in need of intensive care coordination. The complex risk tier of the stratification system reduces the number of patients from 551,045 to 27,552, or 5% of the patient population, and accounts for 67.9% ($1,107,822,887) of total annual medical spend. Expanding care coordination efforts to patients in the top 2 tiers would account for 15% of the patients and 83.2% ($1,357,545,872) of annual medical spend. The novelty of the new approach allows clinical teams to focus intense resources on a smaller sample of the patient population and to identify chronic conditions contributing to costs, and feel confident that they have greater explanatory power regarding value.

Healthcare Utilization of Complex Chronically Ill Children Managed by a Telehealth-Based Team.

Objectives: Medical advances have improved survival of critically ill children, increasing the number that have substantial ongoing care needs. The first aim of this study was to compare healthcare utilization of children with complex chronic conditions across an extensive geographic area managed by a predominantly telehealth-based team (FamiLy InteGrated Healthcare Transitions—FLIGHT) compared to matched historical controls. The second aim was to identify risk factors for healthcare utilization within the FLIGHT population.Methods: We performed a retrospective cohort study of all patients enrolled in the care management team. First, we compared them to age- and technology-based matched historic controls across medical resource-utilization outcomes. Second, we used univariable and multivariable linear regression models to identify risk factors for resource utilization within the FLIGHT population.Results: Sixty-four FLIGHT patients were included, with 34 able to be matched with historic controls. FLIGHT patients had significantly fewer hospital days per year (13.6 vs. 30.3 days, p = 0.02) and shorter admissions (6.0 vs. 17.3 days, p = 0.02) compared to controls. Within the telehealth managed population, increased number of technologies was associated with more admissions per year (coefficient 0.90, CI 0.05 – 1.75) and hospital days per year (16.83, CI 1.76 – 31.90), although increased number of complex chronic conditions was not associated with an increase in utilization.Conclusion: A telehealth-based care coordination team was able to significantly decrease some metrics of healthcare utilization in a complex pediatric population. Future study is warranted into utilization of telemedicine for care coordination programs caring for children with medical complexity.

Behavioral Health Screening and Care Coordination for Rural Veterans in a Federally Qualified Health Center.

Many rural veterans receive care in community settings but could benefit from VA services for certain needs, presenting an opportunity for coordination across systems. This article details the Collaborative Systems of Care (CSC) program, a novel, nurse-led care coordination program identifying and connecting veterans presenting for care in a Federally Qualified Health Center to VA behavioral health and other services based upon the veteran’s preferences and eligibility. The CSC program systematically identifies veteran patients, screens for common behavioral health issues, explores VA eligibility for interested veterans, and facilitates coordination with VA to improve healthcare access. While the present program focuses on behavioral health, there is a unique emphasis on assisting veterans with the eligibility and enrollment process and coordinating additional care tailored to the patient. As VA expands its presence in community care, opportunities for VA-community care coordination will increase, making the development and implementation of such interventions important.

The timeliness of lung cancer care: A systematic review of systematic/scoping reviews on risk factors and interventions.

e18575 Background: Lung cancer is the leading cause of cancer death worldwide, and over half of lung cancer cases are diagnosed with advanced stage, indicating an urgent need to improve the timeliness of lung cancer services. In this systematic review of systematic and scoping reviews, we summarize the current evidence of risk factors and interventions on diagnostic and treatment intervals. Methods: Eligible articles were published systematic or scoping reviews and meta-analyses that used systematic searching to investigate risk factors for longer time intervals or interventions aimed to reduce time intervals in original studies on lung cancer, based on at least one interval involving the date of diagnosis as the start or end point. Articles were searched via PubMed, Embase, Web of Science, and the Cochrane Library; the date range of the search was from database inception to 6 August 2020 (PROSPERO identifier: CRD42020203530). Results: A total of 16 systematic/scoping reviews published in 2002-2020 were included (10 on risk factors and 9 on interventions). According to these reviews, we found that risk factors had intersected impacts on the increase of diagnostic and treatment intervals. However, these factors could be summarized based on tumor, patient, healthcare provider and healthcare system levels as: (tumor level) adenocarcinoma, small size; (patient level) living in a rural area, lower education level, lower-income level, longer travel distance, non-specific symptom, non-white race (in the USA), fear and lack of knowledge about lung cancer; (healthcare provider level) low index of suspicion, multiple consultations for diagnosis, missed diagnosis; (healthcare system level) long waiting time for hospitalization, health system’s incapacity to treat all patients, high cost, inaccessibility or lack of diagnostic tools/investigations, poor organization and management of health services. To reduce time intervals, these reviews indicated that effective interventions include multidisciplinary teams or clinics, lung-specific clinics, nurse navigation or other care coordination program. In these reviews, we found that the types of time intervals used in original studies were poorly reported. Conclusions: Therisk factors identified from the current reviews indicate disparities in timely access to lung cancer services, as well as potential for improvements to reduce waiting time at the patient, healthcare provider and healthcare system levels. To reduce waiting time, effective interventions suggested from the current reviews should be considered for implementation.