Care Management Program Research Articles

Predicting Pain Response to a Remote Musculoskeletal Care Program for Low Back Pain Management: Development of a Prediction Tool.

Low back pain (LBP) presents with diverse manifestations, necessitating personalized treatment approaches that recognize various phenotypes within the same diagnosis, which could be achieved through precision medicine. Although prediction strategies have been explored, including those employing artificial intelligence (AI), they still lack scalability and real-time capabilities. Digital care programs (DCPs) facilitate seamless data collection through the Internet of Things and cloud storage, creating an ideal environment for developing and implementing an AI predictive tool to assist clinicians in dynamically optimizing treatment. This study aims to develop an AI tool that continuously assists physical therapists in predicting an individual's potential for achieving clinically significant pain relief by the end of the program. A secondary aim was to identify predictors of pain nonresponse to guide treatment adjustments. Data collected actively (eg, demographic and clinical information) and passively in real-time (eg, range of motion, exercise performance, and socioeconomic data from public data sources) from 6125 patients enrolled in a remote digital musculoskeletal intervention program were stored in the cloud. Two machine learning techniques, recurrent neural networks (RNNs) and light gradient boosting machine (LightGBM), continuously analyzed session updates up to session 7 to predict the likelihood of achieving significant pain relief at the program end. Model performance was assessed using the area under the receiver operating characteristic curve (ROC-AUC), precision-recall curves, specificity, and sensitivity. Model explainability was assessed using SHapley Additive exPlanations values. At each session, the model provided a prediction about the potential of being a pain responder, with performance improving over time (P<.001). By session 7, the RNN achieved an ROC-AUC of 0.70 (95% CI 0.65-0.71), and the LightGBM achieved an ROC-AUC of 0.71 (95% CI 0.67-0.72). Both models demonstrated high specificity in scenarios prioritizing high precision. The key predictive features were pain-associated domains, exercise performance, motivation, and compliance, informing continuous treatment adjustments to maximize response rates. This study underscores the potential of an AI predictive tool within a DCP to enhance the management of LBP, supporting physical therapists in redirecting care pathways early and throughout the treatment course. This approach is particularly important for addressing the heterogeneous phenotypes observed in LBP. ClinicalTrials.gov NCT04092946; https://clinicaltrials.gov/ct2/show/NCT04092946 and NCT05417685; https://clinicaltrials.gov/ct2/show/NCT05417685.

The impact of a payer-provider joint venture on healthcare value.

To examine how a novel payer-provider joint venture (JV) between one payer and multiple competitive delivery systems in New Hampshire (NH), which included value-based payment, care management, and non-financial supports, impacted healthcare value and payer and provider group experiences. We conducted a mixed-methods study. We used a quasi-experimental longitudinal difference-in-differences design to examine the impact of the JV (which started in January 2016 and ended in December 2020) on healthcare utilization, quality, and spending, using members in Maine (ME) as a control group. We also analyzed patient uptake of the JV's care management program using routinely collected administrative data and assessed payer and provider group leaders' perspectives about the JV via semi-structured interviews. We used administrative and claims data from 2013 to 2019 in a commercially insured population under 65 years in NH and ME. We also used administrative data on care management eligibility and uptake and conducted semi-structured interviews with payer and provider group leaders affiliated with the JV. The JV was associated with no sustained change in medical utilization, quality, and spending throughout the study period. In the first year of the JV, there was a $142 (95% confidence interval: $41, $243) increase in pharmaceutical spending per member and a 13% (4.4%, 25%) relative increase in days covered for diabetes medications. Only 15% of eligible members engaged in care management, which was a key component of the JV's multi-pronged approach. In a disconnect from the empirical findings, payer and provider group leaders believed that the JV reduced healthcare costs and improved quality. Our findings provide evidence for future payer-provider JVs and demonstrate the importance of having a valid control group when evaluating JVs and value-based payment arrangements.

Consumer Preferences for Health Services Offered by Health Insurance Companies in Germany

Abstract German health insurance companies increasingly strive to position themselves as health partners to their customers to improve customers’ health and contain costs. However, there is uncertainty about customers’ preferences for health services offered by health insurance companies. Therefore, this paper studies consumer preferences for health services that are or could be provided by health insurance companies in Germany. An online survey was conducted using two stated preference techniques to collect and analyze the data (namely, rating and ranking of health services considered by insurance companies). A sample of 880 German health insurance customers between 18 and 65 years old filled out the online questionnaire, of which 860 submitted complete responses. Ordinal logistic regression analysis was used for the rating and ranking. Preliminary examinations, care management, and health programs were the three health services most important to the respondents. The results suggest that people want their health insurance to support them with preventive health services that offer direct therapeutic value and not just informational, economic, access-related, or convenience-related benefits. These preferences for health services are homogeneous for most subgroups of the population, implying that health insurance companies could consider an overall strategy to address these preferences for all clients by focusing on the important health services. Key messages • People value health services provided by health insurers that offer direct therapeutic value over those that offer only informational, economic, access or convenience benefits. • As preferences are homogeneous across the population, insurers could consider an overall strategy by focusing on the important health services.

Impact of a clinician-to-clinician electronic consultation program in heart failure patients with previous hospitalization. Implications for heart failure multidisciplinary management

Abstract Background A clinician-to-clinician electronic consultation (e-consultation) programme may not only improve the accessibility to care but may also impact patient outcomes, particularly in heart failure (HF) patients with a previous episode of hospitalization (HFH), group of patients associated with a worse outcome. Purpose To evaluate the impact of an outpatient care management programme that includes a clinician-to-clinician e-consultation on delay time in care, hospital admissions, and mortality in a high-risk group of patients with heart failure (HF) and previous episodes of HF hospitalization (HFH). Materials and methods We selected 6444 HF patients who visited the cardiology service at least once between 2010 and 2021. Of these, 4146 were attended in e-consultation, and 2230 had previous HFH (Fig 1a). Using an interrupted time series regression model, we analysed the impact of incorporating e-consultation into the healthcare model in the group of patients with HFH and evaluated the elapsed time to cardiology care, HF, cardiovascular (CV), and all-cause hospital admissions and mortality, calculating the incidence relative risk (iRR). We performed a multivariate logistic regression for each of these outcomes in both groups. Results Patients with HFH had a higher prevalence of men (P &amp;lt; 0.001) but had a similar age (P = 0.267) compared to patients without HFH. Patients with HFH had a higher prevalence of diabetes (P &amp;lt; 0.001), ischaemic heart disease (P = 0.036), and peripheral arterial disease (P = 0.008) (Fig 1b). In the group of patients with HFH, the introduction of e-consult substantially decreased waiting times to cardiology care (8.6 [8.7] vs. 55.4 [79.9] days, P &amp;lt; 0.001) (Fig 2a). In that group of patients, after e-consult implantation, hospital admissions for HF were reduced (iRR [95%CI]: 0.837 [0.840–0.833]), 0.900 [0.862–0.949] for CV and 0.699 [0.678–0.726] for all-cause hospitalizations (Fig 2b). There was also lower mortality (iRR [95%CI]: 0.715 [0.657–0.798] due to HF, 0.737 [0.764–0.706] for CV and 0.687 [0.652–0.718] for all-cause) (Fig 2c). The improved outcomes after e-consultation implementation were significantly higher in the group of patients with previous HFH. The multivariate analyses showed a higher risk of hospitalizations in men, patients with HFH, and those who required more emergency department assistance (Fig 2d). Conclusions In patients with HFH, an outpatient care programme that includes an e-consultation significantly reduced waiting times to cardiology care and was safe, with a lower rate of hospital admissions and mortality in the first year. Our results may have implications for optimize the heart failure care organization.Figure 1Figure 2

Reducing rehospitalization in cardiac patients: a randomized, controlled trial of a cardiac care management program (“Cardiolotse”) in Germany

BackgroundWe conducted a prospective, randomized, controlled, two-group parallel trial investigating the effectiveness of a care management program employing cardiac care navigators providing post-discharge support to patients compared to standard care.MethodsThe intervention commenced in 2019/2020 for 2862 patients hospitalized with heart failure, coronary heart disease, or cardiac arrhythmias in departments of cardiology across eight participating sites of a hospital group in Berlin, Germany. We analyzed the results using an intention-to-treat approach. The primary outcome was the all-cause rehospitalization rate after 12 months. Secondary outcomes included rehospitalizations due to one of the qualifying cardiac diagnoses, duration of rehospitalization, mortality, health-related quality of life, and several process indicators.Trial data were collected from a combination of face-to-face and phone interviews conducted by hospital staff throughout the 12-month follow-up period using standardized questionnaires. Administrative claims data were provided by a large statutory health insurer. Outcomes for the intervention and control groups were compared using logistic regression, generalized linear models (GLMs) with a negative binomial distribution, ordinary least squares, and Cox proportional hazards regression.ResultsCompared to the control group (N = 1294), the intervention group (N = 1256) had a lower rate of all-cause rehospitalizations (62.6% vs. 66.4%, p = 0.05) and shorter lengths of stay (14.49 vs. 16.89 days, p = 0.02) during the 12-month follow-up period. These differences were also present for rehospitalizations due to the cardiac diseases qualifying for study recruitment, with rehospitalization rates for the intervention and control groups being 58.0% vs. 61.4% (p = 0.08) and particularly pronounced for lengths of rehospitalization stay of 12.97 vs. 15.40 days (p = 0.01), respectively. Subgroup analyses indicated positive effects of the intervention for patients 70 years and older (p = 0.05), females (p = 0.06), and those with little or no German language proficiency (p = 0.03). Furthermore, we found positive effects on patients’ adherence to health-related behavioral recommendations (81.91% vs. 73.95%, p = 0.000).ConclusionsThis study adds to the body of evidence indicating that care management interventions supporting patients as they transition from the inpatient to the outpatient sector can lower rehospitalizations, decrease length of rehospitalization stays, and improve adherence to post-discharge recommendations.Trial registrationGerman Clinical Trial Register, DRKS00020424. Registered 2020-06-18. (retrospectively registered).

Quality improvement scorecards driving innovation and best practice in a large community oncology practice.

417 Background: Lean Six Sigma Visual Management dashboards, or scorecards, are visual tools designed to drive and improve quality patient care, operationalize best practices, and promote a culture of operational excellence. Practice scorecards create a disciplined problem-solving culture where root causes are identified, and systemic process-based improvements are implemented. Scorecards are created to show full practice data transparency, allowing all employees and sites to see each other’s data. Scorecards are designed so that providers can efficiently review the maximum amount of data, following a Green, Yellow, Red visual cue to signify goal adherence. Methods: Phase 1 (2018 – 2019): Clinical scorecards were created and introduced to all staff on a weekly basis focusing on a few key patient metrics (ex: pain scale, pain care plan, ACP, PHQ-9, teaching/consents, patient portal access). Phase 2 (2020 – 2022): Clinical scorecards were expanded with additional patient care initiatives. New nurse navigator scorecards created (ex: patient teaching and survivorship visits). New physician and APP scorecards created with practice-specific provider metrics. Phase 3 (2023 – 2024): Scorecards updated yearly to match practice quality initiatives. New dashboards for non-clinical employees initiated. Physician and APP compensation changed to include quality metric performance tied to financial incentive. Results: Over the course of 5 years, OHC quality scorecard metrics improved from below national averages (red) to exceeding top-tier threshold goals (green). Scorecard utilization increased across all areas of the business, expanding from one scorecard in 2018 to eight in 2024. Scorecards increased overall practice data transparency leading to increase practice quality metric performance. OHC staff utilize scorecards on a weekly, monthly, and quarterly basis to drive quality improvement adherence. Improved outcomes through full data transparency increased staff participation and ownership in quality metrics and led to achieved shared savings in managed care programs. Example of metrics and results: Patient NCCN Staging 36% (2588/7263) to 96% (10299/10749), Teaching/Consents 37% (423/1147) to 97% (3067/3160), and Oral regimen NCCN entry 69% (586/845) to 98% (1037/1055). Conclusions: Visual Management dashboards or practice scorecards are instrumental in driving and supporting practice change. Scorecards allowed OHC staff to efficiently visualize practice-wide actionable data with eye-catching colors to promote optimal clinical performance. As increased data procurement is on the rise, practices can empower their staff to drive change through data utilization. OHC’s scorecards have proven to bridge the gap to goal, facilitate transparent data sharing, and empower providers and staff toward collaboration and embracing operational excellence.

Effect of an oncology care management program on ED visits in a rural Medicaid population.

175 Background: Optum’s Cancer Support Program (CSP) provides care management to members with cancer diagnoses facing healthcare barriers. CSP nurses educate members on symptom management, palliative care and advance care planning, address psychosocial needs and close gaps in care. Improving health equity and outcomes is a program priority. In 2023, Optum analyzed outpatient claims for 24,221 Medicaid members with cancer and found that rural members visit emergency departments (ED) 31% more than urban members. As part of a CSP quality and outcomes assessment, we aimed to understand CSP’s impact on ED utilization within a high-risk rural Medicaid population. Methods: Beginning 1/1/23, Medicaid members in rural zip codes with an active cancer diagnosis were stratified as high- or low-risk based on diagnosis and clinical factors. High-risk members were invited to participate in CSP and receive individualized telephonic care management. 2023 outpatient medical claims were evaluated, and rural ED visit rates were compared for high-risk CSP participants and non-participants for approximately 4 months (average CSP engagement) after CSP enrollment or identification (non-participants). Population demographics were tested via a Mood's median test; ED visits per thousand members per year (PTMPY)—engaged, non-engaged, and difference in means—was tested via a 10,000-iteration bootstrap. Results: The study population included 421 members stratified as high-risk. Of those, 38% (161) enrolled in CSP. Reasons for non-enrollment included inability to reach the member (61%) and member refused (39%). There were no statistically significant differences between the groups’ demographic composition (all variables had p ≥ 0.05). Under a 10,000-iteration bootstrap, there were 2,696 ED visits PTMPY, 80% CI [2,258, 3,150] in the participant group and 3,427 ED visits PTMPY, 80% CI [2,904, 3,974] in the non-participant group. The difference in means between the groups was 730 ED visits PTMPY, 80% CI [52, 1,421]. Conclusions: Rural Medicaid members enrolled in CSP experienced lower ED visit rates, suggesting that care management may be effective at reducing ED utilization within rural populations that lack access to wraparound oncology services. Limitations of this study include small sample size and potential enrollment bias. Further analysis is underway to increase the study sample size and identify other factors that may be impacted by care management, thereby improving healthcare equity.

Development of a Prioritized Anesthesiology Residency Critical Care Content Outline.

Critical care education is an important, mandatory component of residency training in anesthesiology. Currently, there is no accepted national standardized curriculum, and a prioritized critical care content outline would be beneficial to the creation of a pragmatic standardized residency curriculum. The modified Delphi method is a recognized method for establishing consensus in medical education. We developed a prioritized critical care content outline using the modified Delphi method. Topics were selected from critical care topics included in the Program Requirements for Graduate Medical Education in Anesthesiology and the American Board of Anesthesiology Content Outline. Panel members rated critical care topics on a 9-point Likert scale (1 = not important, 9 = mandatory). Consensus was defined as ≥75% rating the topic as very important to mandatory for inclusion (Likert scale 7-9). Topics with >80% consensus were removed from subsequent surveys and included in the final list, and topics with <50% were removed. Members were asked to select the ideal timing of topic delivery during residency (Foundational-Early Residency, Intermediate-Mid Residency, Advanced-Late Residency). A total of 158 panel members who were contacted using national anesthesiology organization email lists completed the initial round, 119 (75%) completed the second iteration, and 116 (73%) completed the third. Response rate on the first survey was (22/55) 40% for anesthesiology critical care program directors, (18/132) 14% for core anesthesiology residency program directors, and (77/1150) 7% for the remaining respondents. Trainees (n = 41) were not included in response rate calculations. Most participants (103/158, 65%) had completed both core anesthesiology and subspecialty critical care medicine training and most (87/158, 55%) had formal roles in medical education. Forty-one (26%) responders were currently in training. All panelists worked in institutions with graduate medical education (GME) learners. Fifty-eight of 136 (43%) topics met consensus for inclusion. Most consensus topics (50/58, 86%) were recommended to be delivered early during residency with the other 8 topics to be delivered in the middle of residency. We developed a prioritized critical care content outline for anesthesiology residents that includes highly recommended critical care topics with ideal timing for inclusion in residency. This outline provides the first step in developing a pragmatic standardized curriculum to guide faculty and programs in critical care education.

The Management of Depression and Anxiety in Primary Care: Examining Predictors of Adherence to a Psychopharmacological Collaborative Care Management Program for Veterans.

Collaborative care management (CoCM) is an evidenced based approach to psychiatric treatment in primary care, yet literature examining factors associated with program adherence is lacking. This study analyzed predictors of adherence to a CoCM model of psychopharmacological treatment of depression and anxiety in primary care by conducting a retrospective cohort analysis on Veterans referred to a large VA Medical Center's CoCM program over an 18-month period. Baseline characteristics, symptomatic assessments, and covariates of interest were collected. For the primary outcome, the association between covariates and programmatic completion were analyzed. Secondary analyses assessed improvements in psychiatric symptoms. A total of 757 Veterans with depressive or anxiety disorders were included, and 256 completed the CoCM program. Baseline covariates associated with differences in completion rates included the following: age, contact with psychology prior to referral, baseline PHQ-9, baseline GAD-7, and a number of comorbid psychiatric/substance abuse covariates. After controlling for baseline differences, age remained a significant positive predictor of completion (OR 1.019, 95% CI 1.008‒1.030) and cannabis use a significant negative predictor (OR 0.507, 95% CI 0.275‒0.934). Both early improvement in PHQ-9 (OR 1.864, 95% CI 1.210‒2.872) and GAD-7 (OR 1.762, 95% CI 1.154‒2.691) scores were positive predictors. Secondary analyses showed that programmatic completion was associated with greater reductions in psychiatric symptoms. Results identified a number of modifiable parameters associated with differences in completion rates and greater symptomatic reduction for those who complete the program. Additional studies should be conducted examining interventions to optimize CoCM programs by supporting positive predictors while minimizing negative predictors.

Equity and Inclusion for LGBTQ+ Residents: Lessons Learned from the Initial Long-Term Care Equality Index (LEI)

ObjectivesMost older adults with lesbian, gay, bisexual, queer, questioning, transgender, and related identities (LGBTQ+) are concerned about receiving lower-quality care and/or being mistreated in nursing homes. Older LGBTQ+ veterans may have additional reservations about care in Department of Veterans Affairs (VA) nursing homes (Community Living Centers [CLCs]) because of experience with past discriminatory military policies (eg, bans on participating in military service, Don't Ask Don't Tell). This article describes one of the first VA CLCs to participate in the Human Rights Campaign–developed Long-Term Care Equality Index (LEI). DesignA single-site formative evaluation was completed to support quality improvement and identify opportunities for growth using the LEI. The LEI is a facility benchmarking tool to support more inclusive environments for LGBTQ+ residents and employees. The LEI offers 4 evaluation criteria: (1) Non-Discrimination and Staff Training; (2) LGBTQ+ Resident Services and Support; (3) Employee Benefits and Policies; and (4) Resident and Community Engagement. Facilities receive ratings based on the number of requirements achieved in each category. Participants and Methods: Older LGBTQ+ veterans, current CLC residents, interdisciplinary CLC providers and leadership, and national Geriatrics and Extended Care program managers collaborated to pilot the LEI and develop tools and materials to support other VA facilities' participation in the LEI. ResultsQualitative interviews with veterans and CLC residents supported inclusion of gender identity and sexual orientation in resident handbooks, discussions about person-centered care, and opportunities for additional staff training and community engagement (eg, observing Pride Month in June). Resources to support VA long-term care facilities' participation in the LEI were developed. Conclusions and ImplicationsThe LEI offers a structured approach to identifying areas for improvement in providing high-quality and equitable care in long-term care settings. Practical suggestions for CLCs and other nursing home settings considering the LEI for the first time are discussed.

Effectiveness of Implementing an Integrated Care Management Program for Rabies Vaccination Patients

Objective: To analyze the effect of implementing a comprehensive nursing management program for rabies vaccination patients. Methods: 100 cases of rabies vaccination patients were selected as observation objects from January 2022 to December 2023, and after enrollment, they were grouped according to the different nursing management programs, with 50 cases in each group. The control group was only given routine nursing management, and the observation group was combined with comprehensive nursing management on the basis of routine nursing management. The completion rate of vaccination, the rate of adverse reactions, and the satisfaction rate were assessed, comparing the clinical effects of different nursing management programs. Results: The completion rate of the 5th shot of rabies vaccination in the observation group was 82.00% higher than 64.00% in the control group (χ2 = 4.1096, P &lt; 0.05); the rate of adverse reaction of vaccination in the observation group was 4.00% lower than 18.00% in the control group (χ2 = 5.0051, P &lt; 0.05); the vaccination satisfaction in the observation group was 98.00% higher than 86.00% in the control group (χ2 = 4.8913, P &lt; 0.05). Conclusion: The application of comprehensive nursing management program can help rabies vaccination patients to improve the completion rate of vaccination and reduce the incidence of adverse reactions to vaccination, with clear effects.

Supportive care improves self-care management and knowledge of patients with heart failure and diabetes mellitus

Abstract Introduction Heart failure (HF) and diabetes mellitus (DM) most of the times occur together, aggravating patients’ outcomes and the interaction of the two conditions, which is complex, make the application of effective management programs necessary, in order to improve patients’ outcomes. Purpose The aim of the current study was to evaluate the effectiveness of an individualized supportive care management program in patients with HF and DM, in order to improve patients’ self-management compared to the ‘usual’ care. Methods The current study is a sub-analysis of the randomized clinical trial named ‘SupportHeart’ using pragmatic methodology. It was consisted by the intervention group (IG) and the control group (CG). The study investigated the patients for a period of one year at 5 time points (in baseline, 1 month, 3 months, 6 months and 1 year). Self –care management was measured with the Greek versions of two tools: the ‘Self-care of Heart Failure Index’ (Gr-SCHFI) and the ‘European Heart Failure Self-Care Behavior Scale’ (Gr9EHFScBS). Linear Mixed Models Effects (LMME) were also used. Results The sample consisted of 121 patients with HF and DM and 66% were male patients. The Linear Mixed Model results have shown that there was a statistically significant effect of the intervention at all the time points after the intervention p &amp;lt; 0.001 in all the dimensions of the SCHFI; in the dimension of maintenance [1 month=2.6 (0.81, 4.4) p= 0.005, 3 months = 5.2 (3.4, 7.1) p &amp;lt; 0.001, 6 months = 8.1 (6.2, 10) p &amp;lt; 0.001, 1 year = 7.5 (5.7, 9.4) p &amp;lt; 0.001], on the management [1 month = 4.1(2.8, 5.4) p &amp;lt; 0.001, 3 months = 5.1 (3.8, 6.4) p &amp;lt; 0.001, 6 months = 7.5 (6.1, 8.9) p &amp;lt; 0.001, 1 year = 10 (8.7, 11) p &amp;lt; 0.001 and on the self-confidence [1 month =4.9 (3.4, 6.5) p &amp;lt; 0.001, 3 months = 7.8 (6.2, 9.4) p &amp;lt; 0.001, 6 months = 8.5 (6.9, 10) p &amp;lt; 0.001 and in 1 year = 9.1 (7.5, 11) p &amp;lt; 0.001]. The Linear Mixed Model results showed also a statistically significant effect of the intervention at all the time points after the intervention p &amp;lt; 0.001 in all the dimensions of the GR9EHFScBS: in the dimension of adhering to recommendations [1 month=1.5 (0.71, 2.3) p &amp;lt; 0.001, 3 months = 1.4 (0.59, 2.3) p &amp;lt; 0.001, 6 months=1.6 (0.69, 2.4) p &amp;lt; 0.001, in 1 year = 4.3 (3.5, 5.1) p &amp;lt; 0.001], on the fluid and sodium management [1 month = 2.3 (1.3, 3.2) p &amp;lt; 0.001, 3 months = 3.6 (2.6, 4.6) ) p &amp;lt; 0.001, 6 months = 4.5 (3.5, 5.5) p &amp;lt; 0.001, in 1 year = 6.4 (5.4, 7.4) ) p &amp;lt; 0.001 and on the physical activity and recognition of deteriorating symptoms [1 month = 2.6 (1.7, 3.6) p &amp;lt; 0.001, 3 months = 3.4 (2.4, 4.3) p &amp;lt; 0.001, 6 months = 3.9 (2.9, 4.9) p &amp;lt; 0.001, 1 year = 5.8 (4.8, 6.7) p &amp;lt; 0.001]. Conclusion Supportive care seems to be a promising concept for HF-DM management programs. The pragmatic methodology that was used in the research study has an intensive intervention which started rapidly and in early stages, on a person-centred basis.

The effectiveness of supportive management programs in caregivers of patients with heart failure: a systemartic review

Abstract Introduction Supportive management programs involving caregivers of heart failure (HF) patients may be beneficial not only for the patient, but also for the caregiver. This study aims to investigate the effectiveness of supportive management programs for caregivers in terms of quality of life (QoL), depressive and/or anxiety symptoms and caregivers’ burden. Methods A systematic review was conducted in order to identify interventional studies delivering supportive management programs to dyads and evaluating the effectiveness for caregivers in terms of their QoL, depressive symptoms and burden. A systematic search in PubMed, CINAHL, and the Cochrane Library was performed. Inclusion and exclusion criteria and the Preferred Reporting Items (PRISMA) statement checklist were used. Fourteen randomized (RCT’s) and interventional studies were included. Results Fourteen articles were included in the review from a pool of thirty-five papers. A large heterogeneity was observed among the studies regarding several aspects; the intervention as such (e.g psychological support, cognitive behavioral therapy), the duration of the follow- up period and the method that the intervention was delivered (e.g telephone conducts, home visits). Another striking feature was the variety of outcomes that were studied. The most common outcomes were: anxiety and depressive symptoms, burden and impaired quality of life. Conclusions Supportive care management programs are beneficial for both, the patients and the caregivers. It provides the supporting environment for the best possible results and outcomes and most importantly quality of life of the patients and the caregivers.

Non-emergency department (ED) interventions to reduce ED utilization: a scoping review

BackgroundEmergency department (ED) crowding is a global burden. Interventions to reduce ED utilization have been widely discussed in the literature, but previous reviews have mainly focused on specific interventions or patient groups within the EDs. The purpose of this scoping review was to identify, summarize, and categorize the various types of non-ED-based interventions designed to reduce unnecessary visits to EDs.MethodsThis scoping review followed the JBI Manual for Evidence Synthesis and the PRISMA-SCR checklist. A comprehensive structured literature search was performed in the databases MEDLINE and Embase from 2008 to March 2024. The inclusion criteria covered studies reporting on interventions outside the ED that aimed to reduce ED visits. Two reviewers independently screened the records and categorized the included articles by intervention type, location, and population.ResultsAmong the 15,324 screened records, we included 210 studies, comprising 183 intervention studies and 27 systematic reviews. In the primary studies, care coordination/case management or other care programs were the most commonly examined out of 15 different intervention categories. The majority of interventions took place in clinics or medical centers, in patients’ homes, followed by hospitals and primary care settings - and targeted patients with specific medical conditions.ConclusionA large number of studies have been published investigating interventions to mitigate the influx of patients to EDs. Many of these targeted patients with specific medical conditions, frequent users and high-risk patients. Further research is needed to address other high prevalent groups in the ED - including older adults and mental health patients (who are ill but may not need the ED). There is also room for further research on new interventions to reduce ED utilization in low-acuity patients and in the general patient population.

Effects of Medicaid managed care on early detection of cancer: Evidence from mandatory Medicaid managed care program in Pennsylvania.

To examine changes in late- versus early-stage diagnosis of cancer associated with the introduction of mandatory Medicaid managed care (MMC) in Pennsylvania. We analyzed data from the Pennsylvania cancer registry (2010-2018) for adult Medicaid beneficiaries aged 21-64 newly diagnosed with a solid tumor. To ascertain Medicaid and managed care status around diagnosis, we linked the cancer registry to statewide hospital-based facility records collected by an independent state agency (Pennsylvania Health Care Cost Containment Council). We leveraged a natural experiment arising from county-level variation in mandatory MMC in Pennsylvania. Using a stacked difference-in-differences design, we compared changes in the probability of late-stage cancer diagnosis among those residing in counties that newly transitioned to mandatory managed care to contemporaneous changes among those in counties with mature MMC programs. N/A. Mandatory MMC was associated with a reduced probability of late-stage cancer diagnosis (-3.9 percentage points; 95% CI: -7.2, -0.5; p = 0.02), particularly for screening-amenable cancers (-5.5 percentage points; 95% CI: -10.4, -0.6; p = 0.03). We found no significant changes in late-stage diagnosis among non-screening amenable cancers. In Pennsylvania, the implementation of mandatory MMC for adult Medicaid beneficiaries was associated with earlier stage of diagnosis among newly diagnosed cancer patients with Medicaid, especially those diagnosed with screening-amenable cancers. Considering that over half of the sample was diagnosed with late-stage cancer even after the transition to mandatory MMC, Medicaid programs and managed care organizations should continue to carefully monitor receipt of cancer screening and design strategies to reduce barriers to guideline-concordant screening or diagnostic procedures.

COVID-19 and mental health treatment in primary care: Impact of a global pandemic on a psychopharmacological collaborative care management program.

The COVID-19 pandemic has had a profound impact on individuals with mental health (MH) disorders and on the delivery of MH services. Few studies have examined treatment models not requiring substantial changes to the delivery of services during pandemic restrictions, such as collaborative care management (CoCM) programs. Therefore, a longitudinal retrospective cohort analysis was conducted to examine the impact of the COVID-19 pandemic on a psychopharmacological CoCM program. Data were collected on all U.S. Veterans enrolled in a CoCM program at a large VA during the first 10 months of the COVID-19 pandemic and compared to a matched control group one-year prior to that date. Treatment in the program pre-COVID vs. treatment during the pandemic was compared in relation to baseline symptomatology, improvements in MH symptoms, and program adherence. A total of 462 Veterans were referred during the control period, compared to 351 during the same time period during the pandemic. Veterans enrolled during the first four months of each study arm, to allow for a minimum of 6 months of follow up data, had no differences in baseline symptoms of depression or anxiety between groups. Veterans receiving care during the pandemic had higher rates of program completion than pre-pandemic controls. COVID-era Veterans also had higher rates of depression response compared to controls, but no differences were observed between groups on depression remission, anxiety response, or anxiety remission. Psychopharmacological CoCM treatment models can successfully manage depression and anxiety with no observed decrease in the effectiveness of this intervention even during periods of unprecedented disruptions to MH services.

Multiple Goals Theory and Communication Quality Analysis for Fellows Communication Training.

End-of-life communication skills are vital to high-quality critical care. Patients and families often report deficiencies in end-of-life communication by providers. However, formalized training is difficult to implement and study on a large scale. Furthermore, curricula are often designed with early-stage clinical trainees in mind and are not tailored to advanced clinician learners. The goal of this pilot study was to explore educational and practical implications of using Multiple Goals Theory (MGT), Communication Quality Analysis (CQA), and communication logs as a three-pronged, reflective communication curriculum for advanced trainees. We describe design and qualitative evaluation of a novel, pilot, longitudinal curricular intervention for pulmonary and critical care fellows and program directors at a tertiary academic medical center. The 2-year longitudinal communication curriculum incorporates 1) a theoretical framework from communication science (MGT), with 2) a novel training modality of analyzing audio-recorded intensive care unit family meetings (CQA), and 3) written communication logs after an intensive care unit family meeting. The sample included 13 pulmonary and critical care medicine fellows and two program directors. Qualitative thematic analysis was conducted on seven fellow interviews and on 23 communication logs completed. Four themes emerged from interviews: 1) fellows incorporated the skills into real-life practice and found the curriculum useful and valuable; 2) a key takeaway from MGT was the deemphasis of task goals; 3) CQA was an engaging opportunity for self-reflection and learning; and 4) written communication logs were perceived as helpful in theory but too burdensome in practice. Findings from analyses of the communication logs included that most fellows' writing was brief and without substantial reflection. Many scholars have argued that communication theory can impact practice, but few have recognized the potential of theory and methods, such as MGT and CQA, as educational tools. Our findings demonstrate that MGT is a feasible and useful theoretical framework for improving communication skills among advanced trainees, and CQA fosters meaningful self-reflection about practice. Communication logs were not feasible or useful training tools in this context, but CQA workshops helped fulfill the goals of narrative reflection. Next steps are to implement this curriculum in more programs and measure changes in behavior acquisition and clinical care.

Informal Caregivers of People with Dementia in Germany: Psychosocial Characteristics and Unmet Needs.

Caregivers of people with dementia living at home (CPwDh) are likely to be affected by a range of health problems. However, CPwDh are often regarded as accompanying persons and receive less attention in research and care. Little is known about this population and their needs in Germany. However, better knowledge of CPwDH is needed to design effective interventions. The objective of this report is to describe the situation of CPwDh and highlight differences based on sex and living situation. This was a cross-sectional analysis of the psychosocial characteristics of participants in the GAIN trial, a cluster-randomized, controlled intervention trial investigating the effectiveness of a care management program. A total of n = 192 CPwDh were recruited in GP offices, memory clinics or through public campaigns in the German federal state of Mecklenburg-Western Pomerania. The inclusion criteria were an age of 18 years or above, being a CPwDh, written informed consent. In a comprehensive digital assessment, psychosocial variables, burden, and care needs were assessed. Partners, women, and people living in the same household represented the majority of caregivers, and their mean number of needs was 8.7. Overall, participants indicated a mild to moderate burden. There are differences in burden based on sex and living situation, with caregivers living with people with dementia showing less burden and different psychosocial demographics. There is a need for interventions to reduce caregivers' unmet needs in the CPwDh. Such interventions should consider differences in sex and living situation to better address individual caregiver needs.

Medicaid Managed Care and Pediatric Dental Emergency Department Visits

Millions of economically disadvantaged children depend on Medicaid for dental care, with states differing in whether they deliver these benefits using fee-for-service or capitated managed care payment models. However, there is limited research examining the association between managed care and the accessibility of dental services. To estimate the association between the adoption of managed care for dental services in Florida's Medicaid program and nontraumatic dental emergency department visits and associated charges. This cohort study used an event-study difference-in-differences design, leveraging Florida Medicaid's staggered adoption of managed care to examine its association with pediatric nontraumatic dental emergency department visits and associated charges. This study included all Florida emergency department visits from 2010 to 2014 in which the patient was 17 years or younger, the patient was a Florida resident, Medicaid paid for the visit, and a primary or secondary International Classification of Diseases, Ninth Revision, code was used to classify a nontraumatic dental condition. Analyses were conducted between May 2023 and April 2024. The county of residence transitioning Medicaid dental services from fee-for-service to a fully capitated managed care program managed by a dental plan. The rate of nontraumatic dental emergency department visits per 100 000 pediatric Medicaid enrollees and the associated mean charges per visit. Nontraumatic dental emergency department visits are a well-documented proxy for access to dental care. Data on emergency department visit counts came from the Florida Agency for Health Care Administration. Medicaid population denominators were derived from the American Community Survey's 5-year estimates. Among the 34 414 pediatric nontraumatic dental emergency department visits that met inclusion criteria across Florida's 67 counties, the mean (SD) age of patients was 8.11 (5.28) years, and 50.8% of patients were male. Of these, 10 087 visits occurred in control counties and 24 327 in treatment counties. Control counties generally had lower rates of NTDC ED visits per 100 000 enrollees compared with treatment counties (123.5 vs 132.7). Over the first 2.5 years of implementation, the adoption of managed care was associated with an 11.3% (95% CI, 4.0%-18.4%; P = .002) increase in nontraumatic dental emergency department visits compared with pre-implementation levels. There was no evidence that the average charge per visit changed. In this cohort study, Florida Medicaid's adoption of managed care for pediatric dental services was associated with increased emergency department visits for children, which could be associated with decreased access to dental care.

A Pilot Trial of CRESCENT in a Large Academic Healthcare System: A CaReEcoSystem Primary Care Embedded DemeNtia Treatment

ObjectiveThe prevalence of Alzheimer's Disease (AD) and related dementias is escalating, with substantial societal and economic impact. Existing dementia care is often inadequate due to underdiagnosis, delayed diagnosis, and insufficient resources, especially for caregivers. Behavioral symptoms of dementia further complicate care, contributing to negative outcomes. Collaborative care programs show promise, yet resource-intensive models can be challenging to scale. This study aimed to assess the feasibility of CRESCENT (CaReEcoSystem primary Care Embedded dementia Treatment), an adaptation of the CareEcosystem intervention, providing dementia care training to nurse care managers in a primary care setting. DesignEmbedded pilot cluster randomized controlled study. ParticipantsThe thirty nurse care managers enrolled in the trial had 393 patients with an ICD-10 diagnosis code consistent with dementia on their panels, 206 patients corresponding to the 15 intervention nurses and 187 patients corresponding to the 15 control nurses. MeasurementsPrimary outcome: Feasibility of capturing ED utilization using Medicare claims data and of implementing the intervention in a care management program. Secondary outcomes: ED use and change in caregiver distress (via survey) between baseline and 6-month follow-up using the Neuropsychiatric Inventory Questionnaire (NPI-Q) Distress scale. ResultsWe demonstrated the feasibility of collecting ED visit data through Medicare claims and of implementing the intervention in a busy care management program. In the 6-month follow-up, there were no changes in ED visits postintervention. A nonsignificant 2.7-point greater reduction in caregiver distress among caregivers of PWD in the intervention cohort was observed. ConclusionA dementia care coordination program can be integrated into a care management program. Future trials will explore the effectiveness of CRESCENT in a fully powered clinical trial, aiming to address the rising dementia epidemic and improve dementia-informed care in healthcare systems.