Changes In Care Management Research Articles

Changes in Care Associated With Integrating Medicare and Medicaid for Dual-Eligible Individuals

There is growing interest in expanding integrated models, in which 1 insurer manages Medicare and Medicaid spending for dually eligible individuals. Fully integrated dual-eligible special needs plans (FIDE-SNPs) are one of the largest integrated models, but evidence about their performance is limited. To evaluate changes in care associated with integrating Medicare and Medicaid coverage in a FIDE-SNP in Pennsylvania. This cohort study using a difference-in-differences analysis compared changes in care between 2 cohorts of dual-eligible individuals: (1) an integration cohort composed of Medicare Dual Eligible Special Needs Plan enrollees who joined a companion Medicaid plan following a 2018 state reform mandating Medicaid managed care (leading to integration), and (2) a comparison cohort with nonintegrated coverage before and after the start of Medicaid managed care. Analyses were conducted between February 2022 and June 2023. Analyses examined outcomes in 4 domains: use of home- and community-based services (HCBS), care management and coordination, hospital stays and postacute care, and long-term nursing home stays. The study included 7967 individuals in the integration cohort and 3832 individuals in the comparison cohort. In the integration cohort, the mean (SD) age at baseline was 63.3 (14.7) years, and 5268 individuals (66.1%) were female and 2699 (33.9%) were male. In the comparison cohort, the mean (SD) age at baseline was 64.8 (18.6) years, and 2341 individuals (61.1%) were female and 1491 (38.9%) were male. At baseline, integration cohort members received a mean (SD) of 2.83 (8.70) days of HCBS per month and 3.34 (3.56) medications for chronic conditions per month, and the proportion with a follow-up outpatient visit after a hospital stay was 0.47. From baseline through 3 years after integration, HCBS use increased differentially in the integration vs comparison cohorts by 0.61 days/person-month (95% CI, 0.28-0.94; P < .001). However, integration was not associated with changes in care management and coordination, including medication use for chronic conditions (-0.02 fills/person-month; 95% CI, -0.10 to 0.06; P = .65) or follow-up outpatient care after a hospital stay (-0.01 visits/hospital stay; 95% CI, -0.04 to 0.03; P = .61). Hospital stays did not change differentially between the cohorts. Unmeasured factors contributing to differential mortality limited the ability to identify changes in long-term nursing home stays associated with integration. In this cohort study with a difference-in-differences analysis of 2 cohorts of individuals dually eligible for Medicare and Medicaid, integration was associated with greater HCBS use but not with other changes in care patterns. The findings highlight opportunities to strengthen how integrated programs manage care and a need to further evaluate their performance.

Care management trajectories of infants with life-limiting conditions who died before 12 months of age; a retrospective patient health record review

PurposeTo characterise the care management trajectories of infants with life-limiting conditions, who died before 12 months, including clinical decision-making processes, identification of triggers that led to changes in care management from cure-orientated to palliative care and specialist palliative care team involvement. Design and methodsRetrospective patient health record review of infants with life-limiting conditions who died before 12 months of age and received care at three hospitals in Western Australia. Two data analysis methods; directed content analysis and process mapping. ResultsA total of 45 patient health records were reviewed. Process mapping led to typology of care management encompassing four trajectories; early de-escalation due to catastrophic event; treatment with curative intent throughout; treatment with curative intent until a significant point; and early treatment limits. Standardised advance care planning processes were used for just over 10% of infants. There was specialist palliative care team involvement for 25% of infants. ConclusionOnly a proportion of infants received early integration of palliative care principles and practices. Infants and their families may benefit from earlier integration of palliative care, and standardised processes for advance care planning that are done in parallel to treatment. Practice implicationsThere is opportunity to further enhance the delivery of palliative care to infants with life-limiting conditions and optimise the experience for families through education for health professionals, implementation of advance care planning and standardisation through policies and clinical practice guidelines.

Impact of the COVID-19 pandemic and a national lockdown on hospitalizations for stroke and related 30-day mortality in France: A nationwide observational study.

Background and purposeThe aim of this nationwide study was to assess the impact of the COVID‐19 pandemic on stroke hospitalization rates, patient characteristics and 30‐day case fatality rates.MethodsAll hospitalizations for stroke from January to June of each year from 2017 to 2020 were selected using International Classification of Diseases, 10th revision, codes I60 to I64 in the national hospital discharge database. Patient characteristics and management were described according to three time periods: pre‐lockdown, lockdown, and post‐lockdown. Weekly incidence rate ratios (IRRs) were computed to compare time trends in the rates of patients hospitalized for stroke as well as in‐hospital and 30‐day case fatality rates between the years 2017–2019 and 2020.ResultsIn 2020, between weeks 1 and 24, 55,308 patients were hospitalized for stroke in France. IRRs decreased by up to 30% for all age groups, sex, and stroke types during the lockdown compared to the period 2017–2019. Patients hospitalized during the second and third weeks of the lockdown had higher in‐hospital case fatality rates compared to 2017–2019. In‐hospital case fatality rates increased by almost 60% in patients aged under 65 years. Out‐of‐hospital 30‐day case fatality rates increased between weeks 11 and 15 among patients who returned home after their hospitalization. Important changes in care management were found, including fewer stroke patients admitted to resuscitation units, more admitted to stroke care units, and a shorter mean length of hospitalization.ConclusionsDuring the first weeks of the lockdown, rates of patients hospitalized for stroke fell by 30% and there were substantial increases of both in‐hospital and out‐of‐hospital 30‐day case fatality rates.

Strategy to reduce adverse health outcomes in subjects highly vulnerable to COVID-19: results from a population-based study in Northern Italy

ObjectivesThis study describes a new strategy to reduce the impact of COVID-19 on the elderly and other clinically vulnerable subjects, where general practitioners (GPs) play an active role in managing...

1730P Electronic medical record (EMR)-assisted phone follow-up (PFU) for breast cancer survivors (CS) during COVID-19 pandemic: An Italian single institution experience

The COVID-19 outbreak became a public health emergency, leading to radical changes in care management. Telemedicine was adopted to minimize hospitals exposure for CS. In our region all patients (pts) data are available through an EMR: thus, the clinicians are able to access at any time CS medical history. From the start of COVID-19 pandemic we adopted EMR-assisted PFU instead of usual follow-up (FU) visit. This study aims to prospectively assess how breast CS perceived PFU.

‘Two-eyed seeing’: the integration of spiritual care in Aboriginal residential aged care in South Australia

ABSTRACTIt is argued that spirituality acts as a powerful determinant of health and influences the general care experiences of older people living in residential aged care. This impact is significant, especially for Aboriginal residents, whose cultural and spiritual well-being is shown to be strongly connected with divine beliefs, land and community. This study, a qualitative exploration from conversational interviews with 7 Aboriginal residents and 19 carers, aimed to investigate how the Aboriginal residents’ spiritual well-being related to living in residential aged care in South Australia. Participants shared what spirituality meant to them and how spiritual needs are met in aged care centres for Aboriginal residents. Three major themes emerged from the views of the residents and carers: a lack of understanding of spiritual well-being; challenges around aged care plan; and practice and inadequate resources and funding. The main themes and sub-themes contributed to carers’ unawareness around the spiritual care needs of Aboriginal residents. This study concluded there was a requirement for changes in care management and staff approach, and management structure in order to integrate spiritual care into general care for Aboriginal residents in aged care.

Feasibility of identifying important changes in care management resulting from cardiovascular magnetic resonance (CMR) using hospital episode data in patients who activate the primary percutaneous coronary intervention (PPCI) pathway

BackgroundWe determined whether it is feasible to identify important changes in care management resulting from cardiovascular magnetic resonance (CMR) in patients who activate the primary percutaneous coronary intervention (PPCI) pathway from hospital episode data, in order to construct a composite primary outcome (hypothesised to reduce the risk of major adverse cardiac-related events, MACE) to compare patients exposed to CMR or not.MethodsWe used Hospital Episode Statistics (HES) and Patient Episode Database for Wales (PEDW) to identify clinical events that reflected important changes in management in the year following the index admission in five subgroups of patients who activated the PPCI pathway recruited as part of a feasibility cohort study (n = 1655 with HES/PEDW data). For all subgroups, we identified frequency of events and time to the first event for each change in management.ResultsWe identified all clinical events (new diagnoses, additional diagnostic tests and procedures) except for medication prescriptions. Diagnostic tests were underestimated because most are carried out in outpatient clinics and outpatient datasets had missing procedure codes for 74% of patients (some tests done in hospital may also not be recorded). We successfully tabulated frequencies of events and distributions of times to first event for most changes in management by CMR status and in CMR / non CMR centres.ConclusionsIt is feasible to identify changes in care management between patients who have / do not have CMR within relevant patient subgroups. Further work to derive a weighting algorithm is required before attempting to combine the events in a composite endpoint.

Standardising costs or standardising care? Qualitative evaluation of the implementation and impact of a hospital funding reform in Ontario, Canada

BackgroundSince 2011, the Government of Ontario, Canada, has phased in hospital funding reforms hoping to encourage standardised, evidence-based clinical care processes to both improve patient outcomes and reduce system costs. One aspect of the reform – quality-based procedures (QBPs) – replaced some of each hospital’s global budget with a pre-set price per episode of care for patients with specific diagnoses or procedures. The QBP initiative included publication and dissemination of a handbook for each of these diagnoses or procedures, developed by an expert technical group. Each handbook was intended to guide hospitals in reducing inappropriate variation in patient care and cost by specifying an evidence-based episode of care pathway. We explored whether, how and why hospitals implemented these episode of care pathways in response to this initiative.MethodsWe interviewed key informants at three levels in the healthcare system, namely individuals who conceived and designed the QBP policy, individuals and organisations supporting QBP adoption, and leaders in five case-study hospitals responsible for QBP implementation. Analysis involved an inductive approach, incorporating framework analysis to generate descriptive and explanatory themes from data.ResultsThe 46 key informants described variable implementation of best practice episode of care pathways across QBPs and across hospitals. Handbooks outlining evidence-based clinical pathways did not address specific barriers to change for different QBPs nor differences in hospitals’ capacity to manage change. Hospitals sometimes found it easier to focus on containing and standardising costs of care than on implementing standardised care processes that adhered to best clinical practices.ConclusionImplementation of QBPs in Ontario’s hospitals depended on the interplay between three factors, namely complexity of changes required, internal capacity for organisational change, and availability and appropriateness of targeted external facilitators and supports to manage change. Variation in these factors across QBPs and hospitals suggests the need for more tailored and flexible implementation supports designed to fit all elements of the policy, rather than one-size-fits-all handbooks alone. Without such supports, hospitals may enact quick fixes aimed mainly at preserving budgets, rather than pursue evidence- and value-based changes in care management. Overestimating hospitals’ change management capacity increases the risk of implementation failure.

Rationalization and sensemaking in care management: an experience of change in a hospital of the SUS (Unified Health System).

This study aimed to analyze organizational processes of change in the hospital care management by using qualitative evaluation developed in the case study. The study was developed at the Hospital Fornecedores de Cana de Piracicaba, in São Paulo State, Brazil, in September and October of 2012. There were 25 interviews with members of the senior board of directors of the hospital, managers and health professionals linked to healthcare of adults, in addition to the analysis of managerial documents and observations of some activities. In this article it is analyzed part of the results, dividing the organizational change in three axes: the planning process developed in the healthcare sectors; The protocol/creation of assisted routines in order to obtain better efficiency and safety for the patient; and the work of hospitalist physicians. The study highlights the complexity of the processes of change in the care management sphere in hospitals and the dynamism between a given management concept and its rational tools and the subjects and groups that seek, in the micropolitic and intersubjective processes, meanings to their practices.

Culturally-adapted Family Intervention (CaFI) for African-Caribbeans diagnosed with schizophrenia and their families: a feasibility study protocol of implementation and acceptability.

BackgroundAfrican-Caribbeans in the UK have the highest schizophrenia incidence and greatest inequity in access to mental health services of all ethnic groups. The National Institute for Health and Care Excellence (NICE) highlights this crisis in care and urgent need to improve evidence-based mental healthcare, experiences of services and outcomes for this group. Family intervention (FI) is clinically and cost-effective for the management of schizophrenia but it is rarely offered. Evidence for FI with minority ethnic groups generally, and African-Caribbeans in particular, is lacking. This study aims to test the feasibility and acceptability of delivering Culturally-adapted Family Intervention (CaFI) to African-Caribbean service users diagnosed with schizophrenia.Methods/DesignThis is a feasibility cohort design study. Over a 12-month intervention period, 30 service users and their families, recruited from hospital and community settings, will receive ten one-hourly sessions of CaFI. Where biological families are absent, access to the intervention will be optimised through ‘family support members’; trusted individuals nominated by service users or study volunteers.We shall collect data on eligibility, uptake, retention and attrition and assess the utility and feasibility of collecting various outcome measures including readmission, service engagement, working alliance, clinical symptoms and functioning, perceived criticism, psychosis knowledge, familial stress and economic costs. Measures will be collected at baseline, post-intervention and at 3-month follow-up using validated questionnaires and standardised interviews. Admission rates and change in care management will be rated by independent case note examination. Variability in the measures will inform sample size estimates for a future trial. Independent raters will assess fidelity to the intervention in 10 % of sessions. Feedback at the end of each session along with thematically-analysed qualitative interviews will examine CaFI’s acceptability to service users, families and healthcare professionals.DiscussionThis innovative response to inequalities in mental healthcare experienced by African-Caribbeans diagnosed with schizophrenia might improve engagement in services, access to evidence-based interventions and clinical outcomes. Successful implementation of CaFI in this group could pave the way for better engagement and provision across marginalised groups and therefore has potentially important implications for commissioning and service delivery in ethnically diverse populations. This study will demonstrate whether the approach is feasible and acceptable and can be implemented with fidelity in different settings.

Care home staff can detect the difference between delirium, dementia and depression

Prevention of delirium is an important part of looking after care home residents, however, it can be difficult to detect, especially in those who have dementia. This article explores the perceptions and experiences of care home staff integrating delirium prevention activity in their everyday work. As part of the Stop delirium! feasibility study interviews were carried out and when they were analysed five themes were identified: triggers and knowledge; detection and observation; effect of closest contact; changes in management of care; and communication and teamwork to overcome difficulties. Together these provide insight into how carers identified a potential episode of delirium and indicated the steps that might be taken to manage residents' care. Communication and teamwork were identified as important in delirium prevention and appropriate management.

Health Care as If Health Mattered

THERE IS CONSENSUS ABOUT THE NEED FOR FUNDAMENtal change in the US health care system and there has beenattentiontotheimportantproblemsofinadequate access and increasing costs. But the most serious shortcoming—that the nation’s health system is not designed to maximize health—has been overshadowed. Individuals in theUnitedStatesreceiveonlyabouthalftherecommendedmedical services. Only 43% of individuals with diagnosed diabetes, 37% with hypertension, and 25% with hypercholesterolemia have adequate control of their disease; furthermore, less than20%ofsmokerswhotrytoquitreceiveassistancefrom theirphysicians,andonly2%areprescribedpharmacotherapy. Lack of effective primary health care is a public health problem that results in avoidable blindness, amputations, strokes, heart attacks, and premature death. Nearly 9 of 10 Americans with uncontrolled diabetes, hypertension, and hypercholesterolemia already have private or public health insurance. If reforming US health care results only in expanded access to care, costs will increase faster but with limited health benefits. If only cost controls are instituted, even more individuals will be denied access to needed care. Health care must be restructured to make maximizing health the organizing principle. To do this, 3 synergistic changes are needed: (1) payment that offers substantial rewards for disease prevention and effective management of chronic disease; (2) an information system oriented toward prevention; and (3) changes in care management and practice workflows. Efforts to implement each of these changes separately have failed to substantially improve care because they lacked sufficient focus on prevention and because these 3 interventions are needed jointly. Pay-for-performance initiatives have been hamperedby lackof reliable informationonqualityofcareand outcomes. Electronic health records (EHRs) have had limited or no effect because most have not been designed to facilitate, encourage, and trackpreventive services for entirepatientpopulations.Andwithoutfinancial incentivesorthepower of EHRs to track individual patients and patient panels, clinicians are not able to achieve scale or sustain improvements in preventive services or care for those with chronic conditions. Inmostof thecurrentUShealthcare system, treating illness is more profitable than promoting health. Preventive services are usually poorly reimbursed or not reimbursed at all. A patient who has sustained a myocardial infarction may require cardiac surgery that costs $100 000 or more. But a physician who counsels patients to adopt a healthy lifestyle, prescribes the right medications, and follows up regularly to help reduce the patient’s infarction risk can lose money. As a result, health care information systems and practice workflows do not prioritizepreventionor facilitatemanagementofchronicdisease. If a substantialproportionofphysicians’ reimbursementswere based on the proportion of patients who complete all vaccinations and core cancer screenings, have good management of bloodpressureandcholesterol levels, andeitherdonot smoke or have documented assisted attempts at quitting, many more patients would receive these lifesaving preventive services. Todate,pay-for-performancesystemshavegeneratedscant evidence of measurable quality improvements and may offernoadvantageoverfee-for-service inimprovingcareandcontainingcosts. Pay-for-performancesystemsdonotfundamentallyalter thesubstantial financialadvantagesof intensivetreatmentofadvanced illnessoverdiseaseprevention.Currentpayfor-performanceprogramsofferonlysmallperformancebonuses, are often not integrated with quality-improvement initiatives, and often focus on what is easy to measure rather than what willmost improve thehealthofpatients andcommunities. Of thehundredsofambulatorycaremeasuresapprovedbynational quality organizations, none address screening the generalpopulationforhumanimmunodeficiencyvirus,hypercholesterolemia, or depression. Furthermore, these measures often are based on processes performed, such as whether physiciansmeasure lipid levels, rather thanonoutcomes, such as how well lipid levels are controlled. But processes and outcomes may not be correlated. Pay-for-performance might be much more effective at improving health, and would encourage innovation in doing so, if it rewarded outcomes or reliable predictors of outcomes such as control of blood pressure and cholesterol levels and if the rewards were prioritized based on their potential to increase patients’ years of healthy life. Well-designedandeffectively implementedEHRsareanecessary,butnotsufficient,component tochangepaymentstructure and improve health care system performance. EHRs have thepotential toenablevalidclinicalqualitymeasurement,highqualitypreventivecare,andbettermanagementofchronicconditions such as hypertension and hypercholesterolemia. The US Department of Veterans Affairs (VA), which has a financial incentive to improve prevention, implemented an effective EHR system in the mid-1990s and now outperforms the private sector on almost every measure of quality. Patients at VA facilities receive 67% of the recommended level of health care vs 51% received by non-VA patients. A systematic review found that in a small number of institutions, EHRs have

Surveillance in a time of changing health care practices: estimating ectopic pregnancy incidence in the United States.

Ectopic pregnancy is a common condition with significant health consequences; complications are a major cause of maternal mortality in the United States. Accurate ascertainment of the number of ectopic pregnancies occurring in the United States has been dramatically affected by changing medical practices, causing estimates based on hospital data to be falsely low. This study was performed to identify nationally representative data on ectopic pregnancies and determine overlap of these data, to calculate the annual weighted number of ectopic pregnancies and confidence intervals for these estimates, and to determine barriers to estimation of ectopic pregnancy incidence. To assess whether a national estimate of the incidence of ectopic pregnancy could be calculated, we analyzed 1992-99 data from the six nationally representative data sets that include information on ectopic pregnancy. We examined relevant data in each data set and assessed whether any combination of data sets could be used to estimate ectopic pregnancy incidence. We calculated weighted estimates and 95% confidence intervals for hospitalizations, outpatient surgeries, outpatient medical procedures, and physician visits for and self-reports of ectopic pregnancy. Small sample sizes severely limited calculation of estimates of ectopic pregnancy. Data needed for assessing multiple counting was not available consistently. The likelihood of multiple counting of cases was substantial when data set counts were combined. A reliable incidence rate for ectopic pregnancy in the United States could not be estimated from existing nationally representative data sources. Major advances in diagnosis and treatment of ectopic pregnancy have affected surveillance in two ways: inpatient hospital treatment of ectopic pregnancy has decreased, and multiple health care visits for a single ectopic pregnancy have increased. Alternate means of surveillance are needed to improve understanding of risk factors and trends for ectopic pregnancy, and we recommend examination of the databases of public and private insurance systems and managed care systems. Similar alternate means of surveillance may be needed for other health conditions with comparable changes in management of care.

Changes in long-term mental health nursing.

This article tells the story of a group of people with severe and persistent mental disorder and the team who cared for them. A long-term research project into their needs and potential for changes in their care was conducted over 12 years (1, 2). Its findings and innovations present examples of fundamental changes in care management that can be replicated elsewhere.

A decade of nurse-midwifery practice in a tertiary University-affiliated Hospital

This report is a ten-year review (1973–1982) of nurse-midwifery practice at Grady Memorial Hospital, Atlanta, Georgia. In this tertiary-level university-affiliated hospital for the indigent, two models of care were established: comprehensive and episodic. Selected patient characteristics, different aspects of management of care, and several outcome measures are described for both models of care. Changes in management of care document the adaptation by nurse-midwives to advanced technology and pressures for non-intervention in obstetric care.