Community Care Of North Carolina Research Articles

Collaborative Care Model Gaining Traction in North Carolina

Collaborative Care Model Gaining Traction in North Carolina

Hydroxyurea Prescription Fills and Adherence, Among Pediatric and Adult Medicaid Eligible Patients with Sickle Cell Disease in North Carolina

Introduction: Sickle cell disease (SCD) is a complex disease for which pain is the hallmark. Hydroxyurea (HU) is the standard of care for treatment for most patients with SCD and reduces the frequency of pain episodes, acute chest syndrome, need for red blood cell transfusions, hospitalizations and has been shown to improve mortality. Despite National Heart Lung and Blood Institute (NHLBI) recommendations for the use of HU beginning at 9 months of age, adherence has been historically low. We aimed to: 1) describe HU prescription fills and adherence for persons with SCD enrolled in Medicaid during a 12-month period in North Carolina (NC); and 2) determine factors that may predict good adherence. Methods: Medicaid claims were examined from data obtained from Community Care of North Carolina (CCNC) for patients with a diagnosis of SCD (ICD 9 CM codes: 282.6x, ICD 10 CM codes: D57.0x, D57.1, D57.2x, D57.4x, D57.8x) between March 1, 2016 and February 28, 2017. HU claims were identified using the drug name. Only those enrolled in Medicaid for 12 months were included in this analysis. The number of HU prescriptions filled per enrollee by age group was determined by summing the number of filled HU prescriptions over the study period for each eligible enrollee. The number of HU days supplied is the sum of the days of supply on the prescription (e.g. 30-day supply) in a 12-month period per person. The duration of HU treatment days was measured as the number of days between the date of the first HU prescription filled and the last day of the study period. The number of days between breaks in treatment is the sum of days with no HU supplied, divided by the number of gaps (missing next HU prescription fill) per person. HU adherence was categorized into one of the followings: 1) Good - if number of days supplied is ≥80% of duration of HU treatment; 2) Fair or Moderate - if number of days supplied is 60-79% of duration of HU treatment; 3) Poor - if number of days supplied is < 60% of duration of HU treatment. Logistic regression was used to evaluate HU treatment adherence (good versus fair or poor). The model was conditioned on age, gender, participant residence (metro, non-metro adjacent to metro and non-metro non-adjacent to metro), co-management (at least one PCP and one hematologist visit/patient during the study period) and months enrolled in CCNC. Results: A total of 2,790 patients with Medicaid claims data were reviewed, with 649 patients meeting inclusion criteria (at least one HU prescription and 12 months enrollment in Medicaid). The participants in the sample were majority female (51.77%), lived in metropolitan areas (78.12%) and had a mean age of 16.49 years old (SD=11.49) A third of the sample (32.20%) had at least 1 HU prescription during the study period (Table 1). Those who were 1-9 years old had the highest median number of days supplied (221; range 21-750), the least median days between breaks in HU treatment (14.20; range 0-318), and the longest duration of HU treatment days (median 340; range 0-364). Those who were 18-30 years old had the lowest number of median days supplied (110; range 4-366) and the most median days between treatment (49.3; range 0-337). The 1-9 year olds also had the highest number of patients classified as good HU adherence (47.50%) and conversely the lowest classified as poor HU adherence (37.50%). In contrast, the 18-30 year old age group had the lowest good HU adherence (18.03%) and the highest poor HU adherence (69.40%) in the sample. The 31-45 year old age groups had the next lowest good HU adherence (20.93%) and next highest poor HU adherence (60.47%). Good HU adherence was most influenced by participant age. Prediction by co-management was minimal (Figure 1). Gender, residency and number of months enrolled in CCNC had little influence on HU adherence. Conclusions: Although recommended for most patients, HU was prescribed for less than one third of all patients with Medicaid in NC. Pediatric patients had the highest rate of HU prescription (40-46%) and patients over the age of 30 had the lowest (11-12%). In addition, of those prescribed HU, most patients were not classified as having good adherence. Importantly, poor HU adherence was most prevalent in the transition age group (18-30 year old), supporting the need for increased focus during the move from pediatric to adult care. Efforts should continue to explore methods that improve adherence including provider education and innovative patient strategies such as mHealth. Disclosures Shah: Alexion: Speakers Bureau; GBT: Research Funding; Novartis: Consultancy, Research Funding, Speakers Bureau. Tanabe:NIH: Research Funding; AHRQ: Research Funding.

Implementation of an Emergency Department Screening and Care Management Referral Process for Patients With Sickle Cell Disease.

The purpose of the project was to describe the implementation and evaluation of a care management referral program from emergency departments (EDs) to care management services for patients with sickle cell disease (SCD). Patients were referred to Community Care of North Carolina (CCNC), which is a private-public collaboration providing care management services and served as a referral hub for the program. Patients received follow-up from either CCNC or the North Carolina Sickle Cell Syndrome Program. A multidisciplinary, multiorganizational group streamlined the referral process for patients with SCD who have ongoing care needs by linking patients from the ED to care management services. The article presents a review of program implementation and evaluation over a 3½-year period. The target population were patients who had a diagnosis of SCD and presented to the ED for treatment. Emergency department staff used a modified version of the Emergency Department Sickle Cell Needs Assessment of Needs and Strengths tool to screen for social behavioral health needs in areas such as emotional, financial, pain management, and resources. All forms were faxed to a central number at CCNC for follow-up care management services. Community Care of North Carolina then linked the patient with the appropriate agency and staff for follow-up. More than 900 referrals were received in 3½ years. Pain was the most common reason for referral. An increase in care management intensity was observed over time. All levels of care management intensity saw an increase in the number of patients. Care management occurred across organizations after careful planning among stakeholders. The interagency cooperation permitted the development of a streamlined process. In particular, the creation of a single point for referral was an important component to allow for population-level monitoring and ease of making referrals. Patients with ongoing care needs were identified and there was an increase in the intensity of outpatient care management services delivered.

Antipsychotic adherence and emergency department utilization among patients with schizophrenia

This retrospective cohort study evaluated the relationship between antipsychotic medication adherence and emergency department (ED) utilization for 7851 Medicaid patients with schizophrenia enrolled in Community Care of North Carolina (CCNC). Claims and pharmacy data from January to December 2015 were collected. Medication adherence was approximated using the medication possession ratio (MPR). Negative binomial regressions estimated the effect of antipsychotic adherence on rates of medical and psychiatric ED visits. The results demonstrated a statistically significant negative relationship between antipsychotic adherence and medical ED utilization. Non- and partially adherent patients (MPR < 0.80) had 1.61 times the rate of medical ED visits as fully adherent patients (MPR ≥ 0.80) (95% CI: 1.50–1.74, p-value < 0.001). The relationship between adherence and psychiatric utilization was small and not statistically significant. The most common diagnostic categories of ED visits were injuries and poisonings (16%), ill-defined symptoms (14%), and musculoskeletal conditions (12%). This study demonstrates a clear association between antipsychotic adherence and medical ED utilization, suggesting an important link between psychiatric management and medical utilization in patients with schizophrenia.

Attitudes of Primary Care Physicians Toward Sickle Cell Disease Care, Guidelines, and Comanaging Hydroxyurea With a Specialist.

Sickle cell disease (SCD) is a complex chronic disease requiring multidisciplinary care that involves primary care physicians (PCPs) working with a hematologist or SCD specialists. However, PCPs often lack access to SCD specialists and are unaware of SCD guidelines or efficacious treatment. We partnered with Community Care of North Carolina (CCNC) to identify assigned PCPs for SCD patients with Medicaid across North Carolina. CCNC network administrators distributed a web-based questionnaire for completion. The questionnaire involved 12 self-reported items on a yes-no or a 1 to 5 Likert-type scale that assessed PCP attitudes toward SCD care, awareness of recent guidelines, and comanaging hydroxyurea. Of the 53 PCPs who completed the electronic survey, 73% felt they were comfortable with the number of SCD patients in their practice. Most PCPs reported having infrequent communications with an SCD specialist (67%) and most were also not aware of the 2014 SCD guidelines (66%). Many reported that they would frequently use the new SCD guidelines if provided to them (76%). Furthermore, 51% of PCPs expressed comfort with using mobile apps to access SCD guidelines and provided email contact to receive further information. The majority also reported being comfortable comanaging hydroxyurea with an SCD specialist (65%). Few PCPs in North Carolina were aware of the new SCD guidelines or had regular communication with an SCD specialist. The majority of PCPs, however, demonstrated a favorable attitude toward receiving the SCD guidelines and comanaging hydroxyurea with a specialist. In response to this gap in care, we have developed a mobile-based SCD toolbox specifically for PCPs to provide guidelines, algorithms, and a method to communicate with local SCD specialists. With the interest in receiving these guidelines, we are confident the toolbox will provide an easy to use platform to assist PCPs to utilize the SCD guidelines.

Incremental Benefit of a Home Visit Following Discharge for Patients with Multiple Chronic Conditions Receiving Transitional Care.

Transitional care management is effective at reducing hospital readmissions among patients with multiple chronic conditions, but evidence is lacking on the relative benefit of the home visit as a component of transitional care. The sample included non-dual Medicaid recipients with multiple chronic conditions enrolled in Community Care of North Carolina (CCNC), with a hospital discharge between July 2010 and December 2012. Using claims data and care management records, this study retrospectively examined whether home visits reduced the odds of 30-day readmission compared to less intensive transitional care support, using multivariate logistic regression to control for demographic and clinical characteristics. Additionally, the researchers examined group differences within clinical risk strata on inpatient admissions and total cost of care in the 6 months following hospital discharge. Of 35,174 discharges receiving transitional care from a CCNC care manager, 21% (N = 7468) included a home visit. In multivariate analysis, home visits significantly reduced the odds of readmission within 30 days (odds ratio = 0.52, 95% confidence interval 0.48–0.57). At the 6-month follow-up, home visits were associated with fewer inpatient admissions within 4 of 6 clinical risk strata, and lower total costs of care for highest risk patients (average per member per month cost difference $970; P < 0.01). For complex chronic patients, home visits reduced the likelihood of a 30-day readmission by almost half compared to less intensive forms of nurse-led transitional care support. Higher risk patients experienced the greatest benefit in terms of number of inpatient admissions and total cost of care in the 6 months following discharge. (Population Health Management 2016;19:163–170)

Translating Medical Guidelines Into Practice.

“Dr. Willson! I tried what you told me to do, but my 7-year-old son is still constipated and messing his pants at school. I want to see a specialist.” This is certainly a reasonable request that I am willing to facilitate; however, the question is how soon the pediatric gastroenterologist will be able to see her son. My nurse confirms my fear, saying, “Dr. Willson, the next available appointment with the pediatric gastroenterologist will be in 10 weeks.” My nurse then hands me a copy of the consensus guidelines on diagnosing and managing constipation developed by Community Care of North Carolina (CCNC). I base my management on these recommendations and hand the parent education notes to the mother. I tell her that the pediatric gastroenterologist wants me to start her son on this treatment while he is awaiting his appointment. The consensus guidelines on constipation created by CCNC provide an immediate “consultation” with the gastroenterologist. Often, by following the guidelines, the constipation resolves and the specialist referral may be cancelled, allowing the specialist to see other referrals sooner. If the child does not improve, then I can call the specialist and request a more urgent visit. Unnecessary laboratory and imaging studies are avoided, leading to decreased costs. Also, by knowing the guideline was followed, the specialist may be ready to look for more unusual diagnoses that require more expensive tests. The American Academy of Pediatrics has documented what most of us in general pediatrics have known for years: there is a shortage of pediatric subspecialists in the United States [1]. To address this problem, CCNC, a statewide, physician-led network of primary care practices, brought together pediatric subspecialists from across the state to draft consensus guidelines for primary care physicians to use when treating conditions commonly referred to specialists. The goal was 2-fold. First, guidelines can educate the doctors “in the trenches” about the latest work-up and management of commonly referred conditions and, second, they can decrease unnecessary referrals to subspecialists. Besides guidelines on constipation, there are also guidelines on gastroesophageal reflux, chronic abdominal pain, sickle cell disease, and headaches. Is this cookbook medicine? I do not think so. These guidelines are merely starting places for managing some of the most perplexing conditions of childhood. Over time, the management may be modified by the primary care physician to meet the specific needs of the patient. A referral to the specialist may still be needed, but the specialist will know better where to start in her evaluation. At the Brody School of Medicine, we have introduced these CCNC guidelines at our annual CME day and have used the guidelines as teaching tools for our residents in our continuity clinics. We encourage our physicians to access them through the CCNC website. Over time, we hope that our subspecialists will be able to document fewer unnecessary referrals and shorter waiting times for referrals, and we hope our primary care physicians will document improved parent satisfaction and outcomes. Clinical guidelines, created by credible experts, are a powerful tool to help reach our nation’s goal of improved access to care, higher quality care, and decreased cost.

Community Care of North Carolina – A statewide initiative for innovative pharmacy practice with a behavioral health focus

Community Care of North Carolina (CCNC) is a state-wide public/private partnership, primarily serving North Carolina (NC) Medicaid recipients, which focuses on the Primary Care Medical Home model of care. The CCNC Behavioral Health Pharmacy Coordinator has a leadership role for the direction and management of Behavioral Health Initiative (BHI) pharmacy projects, while other CCNC clinical pharmacists work in a variety of settings and help to implement and support those BHI projects. CCNC clinical pharmacists also perform medication management in all settings, help to implement the NC Medicaid Preferred Drug List (PDL), support the care managers, and are involved with the transitional care (TC) process. Transitional care medication management focuses on the identification of medication list discrepancies after discharge from an acute care facility. Patients receiving TC were 20% less likely to return to the hospital in the coming year. We observed the same trend even when looking specifically at those patients who were discharged from a psychiatric unit (Wilcoxon-Gehan statistic = 21.22, p&amp;lt;.0001). It is the goal of the CCNC behavioral health team to provide practicing pharmacists (those directly supported by CCNC and those collaborating with CCNC) with the tools to continue serving populations with behavioral health issues.

Comanagement of medically complex children by subspecialists, generalists, and care coordinators.

* Abbreviations: C5 — : Center for Children with Complex and Chronic Conditions CCNC — : Community Care of North Carolina CHACC — : Child Health Accountable Care Collaboration In North Carolina, ∼5% or 57 000 children enrolled in Medicaid have complex medical conditions and account for >50% of the Medicaid dollars spent each year on the medical care of children. In 2012, Community Care of North Carolina (CCNC) received a Center for Medicare and Medicaid Innovations grant to establish the North Carolina Child Health Accountable Care Collaborative (CHACC) to address the health care needs of these children. Care coordination is an integral part of health reform activities, including many Medicare programs. CHACC appears to use a unique approach of targeting higher-cost pediatric Medicaid patients and placing specialty care managers in tertiary children’s services.1,2 CCNC serves North Carolina Medicaid beneficiaries through a statewide, community-based public–private partnership, providing care through medical homes using population management approaches to improve care and contain costs.3 CHACC encourages medical and other health professionals to improve quality and cost-effectiveness of care for children on Medicaid with complex medical conditions. A primary goal of CHACC is to ensure that every child with a complex illness has a medical home in the community where he or she lives and receives coordinated primary and subspecialty care to reduce care fragmentation and cost. One target is reduction of unnecessary emergency department visits and hospitalizations. Although hospital revenues will be affected, hospitals will be better positioned to compete in the value-based care environment.4 CHACC patients are all North Carolina Medicaid beneficiaries enrolled in CCNC for care, allowing seamless identification and clinical information exchange by CHACC staff who are CCNC employees. Historically, CCNC has focused on primary care; however, CHACC bridges subspecialty and hospital-based care at 13 North Carolina hospitals with tertiary children’s services with embedded care coordinators. The care coordinators are nurses or social workers with pediatric clinical experience. Their … Address correspondence to Steven Wegner, MD, JD, AccessCare, 3000 Aerial Center Parkway, Suite 101, Morrisville, NC 27560-9131. E-mail: stevewegner{at}ncaccesscare.org

Health care utilization from chemotherapy-related adverse events among low-income breast cancer patients: effect of enrollment in a medical home program.

Chemotherapy-related health care utilization by breast cancer patients can be expensive for payers and patients. This study evaluated the patient-centered medical home program Community Care of North Carolina (CCNC) in terms of its potential to reduce health care utilization associated with chemotherapy-related adverse events (AEs). Early-stage breast cancer cases diagnosed during the 5-year period 2003-2007 were identified in the North Carolina Central Cancer Registry; these cases were then linked to North Carolina Medicaid claims data. We measured health care utilization associated with chemotherapy-related AEs by setting (inpatient, outpatient, or emergency department) during a 15-month postdiagnosis follow-up period. Descriptive and multivariate analyses were performed to examine associations between CCNC enrollment and health care utilization associated with chemotherapy-related AEs. A large proportion of breast cancer patients had at least 1 health care visit associated with a chemotherapy-related AE (n = 412 [72.3%]). The mean numbers of AE-related visits occurring in inpatient, outpatient, and emergency department settings were 0.30 (standard deviation [SD] = 0.83), 6.92 (SD = 10.94), and 0.46 (SD = 1.26), respectively. CCNC enrollment was associated with significantly fewer inpatient admissions (marginal effect, -0.1421; 95% confidence interval, -0.280 to -0.004). In this observational study, we were unable to draw conclusions about the causality of these associations. Patients enrolled in CCNC had fewer inpatient health care visits associated with chemotherapy-related AEs. Future research should continue to explore the extent to which patient-centered medical homes can monitor and help manage the effects of cancer treatments.

Multidisciplinary team puts the ‘home’ in hospital-to-home

Kim Thrasher, PharmD, BCPS, CPP, recently received a call from a care manager at Community Care of the Lower Cape Fear (CCLCF) about a medically fragile 2-year-old patient. The child had had numerous hospitalizations and was on multiple chronic medications. Most recently, the child had been discharged from the hospital after being on a ventilator and receiving narcotics for several weeks. She was discharged with a 36-hour supply of compounded methadone solution to combat withdrawal symptoms.

Community Care of North Carolina’s Approach to Asthma Management

Community Care of North Carolina (CCNC) takes a comprehensive approach to asthma management. Support from CCNC helps providers follow evidence-based practice guidelines; data guide continuous quality improvement initiatives and inform the care of individual patients and populations; and care managers work with high-risk patients.

Is Medical Home Enrollment Associated With Receipt of Guideline-Concordant Follow-up Care Among Low-Income Breast Cancer Survivors?

Community Care of North Carolina (CCNC) initiated an innovative medical home program in the 1990 s to improve primary care in Medicaid-insured populations. CCNC has been successful in improving asthma, diabetes, and cardiovascular outcomes but has not been evaluated in the context of cancer care. We explored whether CCNC enrollment was associated with guideline-concordant follow-up care among breast cancer survivors. Using state cancer registry records matched to Medicaid claims, we identified women 18 to 64 years old who were diagnosed with stage 0, I, II, or unstaged breast cancer from 2003 to 2007 and tracked their monthly CCNC enrollment. Using published American Society for Clinical Oncology guidelines to define our outcomes, we employed multivariate logistic regressions to examine, as a function of CCNC enrollment, receipt of mammogram and at least 2 physical examinations/history-taking visits within observational windows consistent with the guidelines. Of the 840 women, approximately half were enrolled into the CCNC for some time during the study period. Between 40% and 85% received follow-up mammogram in accordance with guidelines, with significant variation by CCNC status, and 95% of women received at least 2 physical examinations/history-taking visits. In multivariate models, increasing months of CCNC enrollment was significantly positively associated with receipt of follow-up mammogram but not with physical examinations/history-taking visits. Results suggest that CCNC enrollment is associated with guideline-concordant follow-up care for Medicaid-insured survivors. Given the growing population of cancer survivors and increased emphasis on primary care medical homes, future studies should explore what factors are associated with medical home participation and whether similar findings are observed with extended follow-up.

Guideline-concordant surveillance and follow-up care among low-income patients with breast cancer: The role of primary care medical homes.

171 Background: Community Care of North Carolina (CCNC) initiated an innovative medical home (MH) program in the 1990s to improve primary care in Medicaid-insured populations. CCNC has been successful in improving asthma, diabetes, and cardiovascular outcomes, but has not been evaluated in the context of cancer care. We sought to determine whether MH enrollment was associated with guideline-concordant surveillance and follow-up care among breast cancer survivors. Methods: Using state cancer registry records matched to Medicaid claims, we identified women ages 18-64 diagnosed with stage 0, I, or II breast cancer from 2003-2007 and tracked their CCNC enrollment. Using published American Society for Clinical Oncology breast cancer survivorship guidelines to define our outcomes, we employed multivariate logistic regressions to examine correlates of receipt of surveillance mammogram and at least two physical exams within 15 months post-diagnosis. Results: In total, 840 women were included in our sample. Approximately half were enrolled in a CCNC MH during the study period, 38% were enrolled for more than 7 months post-diagnosis. Enrollment in a MH for at least 7 months post-diagnosis was strongly associated with receiving guideline-recommended surveillance mammogram (p&lt;0.01) and at least 2 physical exams (p&lt;0.01) within 15 months post-diagnosis. Conclusions: Results suggest that MH enrollment is associated with higher quality breast cancer survivorship care among women insured by Medicaid. Given the growing population of cancer survivors and increased emphasis on primary care MH, more research is needed to explore how medical homes can enhance and ensure the provision of guideline-recommended care during cancer survivorship.

Patient-centered medical homes may improve breast cancer surveillance among survivors.

6029 Background: Community Care of North Carolina (CCNC) initiated a medical home (MH) program in the early 1990s focused on improving care in Medicaid-insured populations. CCNC has been successful in improving asthma, diabetes, and cardiovascular disease outcomes, but has not been examined in the context of cancer care. We sought to determine whether CCNC enrollment was associated with improved cancer surveillance among breast cancer survivors. Methods: Using state cancer registry records linked to Medicaid claims, we identified women ages 18-64 diagnosed with stage 0, I, or II breast cancer from 2003-2007. We included only cases insured by Medicaid for at least 12 of 15 months following the index cancer diagnosis. Reflecting ASCO guidelines for breast cancer surveillance for survivors (2006), we defined outcomes as time to first surveillance mammogram post-diagnosis and overall receipt of mammogram by 15-months post-diagnosis. Our primary independent variable was enrollment in CCNC, categorized as never enrolled, enrolled up to 6 months, and enrolled 7 months or more. We used multivariate Cox proportional hazards stratified by receipt of radiation therapy (RT) and logistic regressions. Results: 840 women were included in our sample. Approximately half were enrolled in CCNC for at least some time during the study period, 38% for more than 7 months post-diagnosis. Among women who received RT, being in a MH for at least 7 months corresponded to earlier follow-up mammogram (Hazard Ratio: 1.34; p=0.028), controlling for all other factors. Enrollment in a MH for at least 7 months post-diagnosis also was associated with overall receipt of mammogram by 15 months (p&lt;0.01). Interaction terms indicated that women enrolled in MHs and living in a rural area had a statistically significant higher likelihood of receiving mammography. Conclusions: Results suggest that MH enrollment is associated with improved cancer surveillance among breast cancer survivors insured by Medicaid. Given the growing population of cancer survivors and increased emphasis on MHs in the Affordable Care Act, more research is needed to explore how patient-centered medical homes can be enhanced to improve the transition from cancer patient to cancer survivor.

An Update on Community Care of North Carolina’s Medicare Demonstrations

To enhance the impact of Community Care of North Carolina (CCNC)'s population health initiatives, CCNC partnered with the US Centers for Medicare and Medicaid Services to bring persons who are dually eligible for both Medicaid and Medicare, as well as Medicare beneficiaries, into CCNC's system of medical homes and community-based care management supports.

Sidebar: Challenges to Providing Services to North Carolina Veterans Who Have Traumatic Brain Injury

ncmedicaljournal.com NCMJ vol. 72, no. 1 ncmedicaljournal.com 51 CareLine and with the North Carolina National Guard. The goal of promoting the behavioral and physical health of military families will be addressed with programs and evidence-based practices that support the families’ resilience and emotional health. The DMHDDSAS Practice Improvement Collaborative, managed by the Governor’s Institute on Alcohol and Drug Abuse, reviews and catalogues evidence-based practices designed to address the health care needs of this special group. The historic collaboration between LMEs and state hospitals has been expanded to include the VA, the University of North Carolina system, Area Health Education Centers and Community Care of North Carolina (CCNC), and the Center of Excellence for Integrated Care (CEIC). The DMHDDSAS will continue to work with SAMHSA’s national technical-assistance center to improve the quality of service delivered in North Carolina. CCNC provides managed primary care for Medicaideligible patients, under the guidance of the North Carolina Division of Medical Assistance. According to Michael Lancaster, director of behavioral health at CCNC, care managers help coordinate health care for military members, veterans, or family members who have Medicaid coverage. The CCNC case manager works cooperatively with the LME care coordinator to ensure that appropriate services are secured. North Carolina has worked to improve care for all of its citizens, including those who served the nation as a member of the military. One avenue of improvement is being investigated by the CEIC, whose work addresses the disconnection between mental health and physical health, a by-product of the US health-care system’s payment system. This disconnection has made access to timely mental health services and coordinated care difficult for residents in North Carolina and the United States and has exacerbated the stigma many patients may feel about seeking mental health services. While the VA has led the way in integrating mental health care and physical health care at VA facilities, the public and private health systems have lagged in efforts to help patients who have mental and physical conditions. In 2006, professional organizations, state agencies, consumer groups, and others joined together to create the training program, clinical tools, and practice-based demonstration projects to enable primary care practices to integrate a mental health or substance abuse provider into the practice. This integration could be as minimal as an agreement to share patient care between a primary care practice and a mental health or substance abuse provider in the same region, or it could be as complex as the full integration of the behavioral health or primary care provider into the practice’s teams of Challenges to Providing Services to North Carolina Veterans Who Have Traumatic Brain Injury

Health Care Reform and Care at the Behavioral Health--Primary Care Interface

Health Care Reform and Care at the Behavioral Health--Primary Care Interface

Cost to primary care practices of responding to payer requests for quality and performance data.

We wanted to determine how much it costs primary care practices to participate in programs that require them to gather and report data on care quality indicators. Using mixed quantitative-qualitative methods, we gathered data from 8 practices in North Carolina that were selected purposively to be diverse by size, ownership, type, location, and medical records. Formal practice visits occurred between January 2008 and May 2008. Four quality-reporting programs were studied: Medicare's Physician Quality Reporting Initiative (PQRI), Community Care of North Carolina (CCNC), Bridges to Excellence (BTE), and Improving Performance in Practice (IPIP). We estimated direct costs to the practice and on-site costs to the quality organization for implementation and maintenance phases of program participation. Major expenses included personnel time for planning, training, registry maintenance, visit coding, data gathering and entry, and modification of electronic systems. Costs per full-time equivalent clinician ranged from less than $1,000 to $11,100 during program implementation phases and ranged from less than $100 to $4,300 annually during maintenance phases. Main sources of variation included program characteristics, amount of on-site assistance provided, experience and expertise of practice personnel, and the extent of data system problems encountered. The costs of a quality-reporting program vary greatly by program and are important to anticipate and understand when undertaking quality improvement work. Incentives that would likely improve practice participation include financial payment, quality improvement skills training, and technical assistance with electronic system troubleshooting.

In This Issue: Community Care, Healing, and Excellence in Research

This issue of the Annals features a special report[1][1] describing how Community Care of North Carolina (CCNC) has improved quality and reduced total costs for care of Medicaid patients during the last decade. CCNC is a system of community health networks led by local primary care physicians that