Care Coordination Program Research Articles

P-1452. Exploration of Associations Between Social Determinants of Health and Treatment Failure in People with HIV

Abstract Background Addressing Social Determinants of Health (SDOH) and health disparities is at the core of “Ending the HIV Epidemic.” To address SDOH, there is a funded HIV Care Coordination Program (CCP) at Henry Ford Health (HFH), with support to surmount SDOH in people with HIV (PWH). In this pilot study, we explore associations between SDOH and treatment failure (TF) in this program. Methods A retrospective study was conducted on PWH in our CCP at HFH from 2022 to 2023. Variables were extracted from data monitoring. CCP enrollment required referral by HIV providers. PWH were surveyed on SDOH related to ART challenges, and these SDOH were assessed throughout the course of one year. HIV genotypes were obtained upon enrollment, and HIV-1 viral load (VL) was collected every 3 months for one year. Significant differences between PWH with or without TF (defined as VL > 200 copies/mL at 1 year) were determined using Chi-Square test for categorical variables and Kruskal-Wallis for continuous variables. Multivariable logistic regression was used to find associations between independent variables and TF. Results A total of 144 PWH were included in this study and divided into with (n=26) and without (n=118) TF (Table 1). There were no statistically significant differences in age, gender, risk factors and mean years living with HIV between the two groups. TF PWH had significantly lower incidence of insurance issues and need for financial assistance. Using linear regression analysis while adjusting for age, race, gender, genotype and other SDOH factors, there was no significant association between insurance issues or financial assistance. Although drug resistant mutations (DRMs) were not linked to specific demographics or SDOH, TF PWH had a significantly higher number of DRMs at baseline (p< 0.0176, OR 3.45, 95% CI 1.24-9.60) and a trend towards increased low frequency (< 10%) DRMs. Conclusion TF occurred in 18% of PWH with adverse SDOH at enrollment into CCP. While we were unable to identify an association of specific SDOH with TF, the TF rate was elevated in these PWH. Overcoming SDOH is essential to achieve viral suppression. DRMs at CCP entry were significantly associated with TF, and were present in all those with TF. Our study is ongoing, and with larger numbers, we aim to assess the impact of SDOH in TF PWH in future studies. Disclosures Indira Brar, MD, Gilead: Advisor/Consultant|Gilead: Grant/Research Support|Gilead: Honoraria|Merck: Grant/Research Support|ViiV Healthcare: Grant/Research Support|ViiV Healthcare: Honoraria

Preventing Infant Mortality Through Medicaid-Administered Prenatal Care Coordination: Evidence From Wisconsin.

To estimate associations between Wisconsin Medicaid's Prenatal Care Coordination (PNCC) program and infant mortality. We analyzed birth records, Medicaid claims, and infant death records for all resident and in-state Medicaid-paid live deliveries during 2010-2018. We measured PNCC exposure during pregnancy dichotomously (none; any) and categorically (none; assessment/care plan only; service receipt). Our outcome was infant mortality (death at age < 365 days). Adjusted binary logit regressions and propensity score weighted regressions tested associations between PNCC receipt and infant mortality, and we estimated probabilities and average marginal effects of infant mortality. We also executed regressions with interactions on maternal race/ethnicity to determine if associations varied across Black non-Hispanic (NH), Hispanic, and White NH births. Our sample consisted of 231,540 Medicaid-paid births during 2010-2018. PNCC is only available to pregnant Medicaid beneficiaries. Infant mortality was lower among PNCC assessment/care plan only births (5.0 deaths/1000 births) and PNCC service receipt births (6.1 deaths/1000 births) relative to non-PNCC births (6.8 deaths/1000 births). This pattern was consistent in Black NH and Hispanic subgroups, but infant mortality did not vary by PNCC among White NH deliveries. Overall, adjusted binary logit regressions indicated that the probabilities of infant mortality were 0.70% for no PNCC and 0.53% for any PNCC, yielding an average marginal effect of -0.17 percentage points (95% confidence interval -0.22 percentage points, -0.11 percentage points). This association did not vary by PNCC exposure level. PNCC-infant mortality associations were significantly stronger for Black NH births relative to White NH births. Results were consistent in propensity score weighted regressions. PNCC during pregnancy is associated with a lower probability of infant mortality, particularly in Black NH families. The benefit of PNCC on infant mortality may not depend on receiving services beyond care planning.

Heterogeneity of provider preferences for HIV Care Coordination Program features: latent class analysis of a discrete choice experiment

The PROMISE study assessed revisions designed to facilitate implementation of an HIV care coordination program (CCP) addressing gaps in care and treatment engagement among people living with HIV in New York City (NYC). Through latent class analysis (LCA) of a discrete choice experiment (DCE), we explored heterogeneity of provider preferences regarding CCP features. From January-March 2020, 152 NYC CCP providers completed a DCE with 3–4 levels on each of 4 program attributes: 1) Help with Adherence to Antiretroviral Therapy (ART), 2) Help with Primary Care Appointments, 3) Help with Issues Other than Primary Care, and 4) Where Program Visits Happen. We used LCA to assess patterns of preference, and choice simulation to estimate providers’ endorsement of hypothetical CCPs. LCA identified three subgroups. The two larger subgroups (n = 133) endorsed more intensive individual program features, including directly observed therapy, home visits, and appointment reminders with accompaniment of clients to their appointments. The smallest subgroup (n = 19) endorsed medication reminders only, appointment reminders without accompaniment, and meeting at the program location rather than clients’ homes. Choice simulation analysis affirmed the highest degree of endorsement (62%) for hypothetical programs combining the intensive features described above. Results indicated providers’ preference for intensive program features and also reinforced the need for flexible service delivery options. Provider perspectives on service delivery approaches can inform program adjustments for successful long-term implementation, which in turn can improve patient outcomes.

EXPERIENCES EMBEDDING MIND AT HOME DEMENTIA CARE COORDINATION PROGRAM IN PRIMARY CARE

Abstract The prevalence of people living with dementia (PLWD) is growing and dementia is one of the highest burden, and highest cost chronic conditions in the US. Care management support within primary care practices is one solution to provide patient- and care partner (CP)-centered care, improve patient care outcomes, e.g., hospitalizations, ED visits, polypharmacy, high care partner strain, and reduce healthcare costs. This session describes a collaborative adaptation and implementation of the MIND at Home Dementia Care Coordination Program into two large primary care clinics in two states (e.g., Iowa and North Carolina). The program pilot expanded the skills of existing primary care staff members to the level of Memory Care Coordinators (MCCs), who worked with larger primary care teams on combining the benefits of clinic-based with home-based services that support PLWD, their families, and CPs. 106 primary care patients and their CPs were recruited for a 3-month intervention period and process measures, including identified and addressed needs of the PLWD and CP, were ascertained. This session will discuss the feasibility of program implementation in a racially, economically, and geographically diverse population of PLWD and provide qualitative and quantitative outcomes on patient, provider and MCC program acceptability, program impact, and barriers and facilitators to implementation from the primary care practice perspective. The presentation will reflect on specific issues important to consider in primary care including underdiagnosis of dementia, patient recruitment and outreach, incorporation of home visits, interdisciplinary collaboration and consultation, and outcomes ascertainment.

Estimating Cost Savings of Care Coordination for Older Adults: Evidence from the Iowa Return to Community Program.

In response to rising costs associated with providing health care services to Americans over 65 years old, policymakers have called for the expansion of care coordination programs to reduce total spending while improving patient outcomes and provider efficiency. This study uses a Markov Chain model to estimate financial impacts associated with the implementation of a care coordination program across the state of Iowa. Estimates revealed an association between the implementation of the Iowa Return to Community (IRTC) and a reduction in health care service use, which yielded per capita cost savings of $7,920.24 over a 5-year span. Subgroup analysis showed that inclusion of informal care partners enhances these savings, as they contributed to reduced inpatient hospital use and deferred nursing home admissions. The continued expansion of the IRTC appears as a viable strategy to curtail aggregate health care spending while supporting older adults stay at home.

A Prescription Produce Program integrating lifestyle behavior counseling and health education: A program description and evaluation.

Prescription Produce Programs (PPPs) are increasingly being used to address food insecurity and healthy diets. Yet, limited evidence exists on the effectiveness of integrating lifestyle counseling within a PPP to promote dietary and health behaviors. To describe the implementation of a 6- or 12-week PPP integrating lifestyle counseling to low-income adults. The PPP was implemented as part of a wellness and care coordination program and included: (i) a screening for social needs, (ii) PPP health education and lifestyle counseling visits, and (iii) distribution of produce. We conducted a pre- and post-descriptive analysis. We also reported a case study illustrating the PPP implementation and a Strengths/Weaknesses/Opportunities/Threats analysis. Fifty-three participants (85% Black American, 64% female, mean age: 66 years) completed the PPP. Food insecurity scores significantly decreased between pre- and post-enrollment in the PPP (P = .002). Compared with pre-enrollment, participants who completed the PPP reported an increase in the frequency of fruits and vegetables intake (χ2 = 12.6, P = .006). A majority of the participants (77%) reported setting and achieving at least one health-related goal by the end of the program. A strength of the PPP included the long-standing relationship with community partners. Weaknesses included the survey burden, the need for additional personnel, and the need for a sustained funding source. Integrating lifestyle counseling within a PPP can promote food security and a healthy diet. Future research is warranted using rigorous research methods, including randomization and a comparison group.

Patients with heart failure and reduced ejection fraction: A sub-analysis from the 3-year Coordinated Myocardial Infarction Care Program (KOS-MI) registry.

The Coordinated Care Program after Myocardial Infarction (KOS-MI) implemented in Poland has shown significant improvement in patient prognosis, ended in nationwide success, and got international attention. A similar program and methodology may be an attractive option for patients with heart failure (HF). This study aimed to analyze whether a similarly structured program would also be beneficial for HF patients after myocardial infarction. This is a multicenter retrospective study of 1972 patients hospitalized for MI. Almost half of patients (n = 963, 48.8%) participated in the KOS-MI program. In the total population, 467 patients presented with reduced ejection fraction HF (HFrEF ≤40%), and 237 (50.7%) participated in the program. Major adverse cardiovascular and cerebrovascular events were evaluated at a 3-year follow-up. Multivariate independent risk analysis was performed. We used propensity score matching for participants and non-participants in the KOS-MI program, resulting in 127 pairs. A 3-year follow-up (completed by 93% of patients), there was a 57% reduction in major adverse cardiovascular and cerebrovascular events (HR, 0.43; 95% CI, 0.31-0.6; P <0.001), 67% in mortality (HR, 0.33; 95% CI, 0.22-0.5; P <0.001), and 42% in hospital admissions for HF (HR, 0.58; 95% CI, 0.4-0.9; P <0.007) in the KOS-MI patients. There was no difference in the occurrence of MI (HR, 0.71; 95% CI, 0.37-1.34; P = 0.29), stroke (HR, 0.9; 95% CI, 0.18-4.45; P = 0.89), and repeated revascularization (HR, 0.6; 95% CI, 0.34-1.05; P = 0.07). Following propensity score matching 127, well-matched pairs between groups were created. Following adjustment, there was a statistically significant reduction in the risk of death (HR, 0.02; 95% CI, 0.29-0.89; P = 0.02) while other parameters were similar. The KOS-MI program significantly improved HFrEF patients' prognosis up to 3 years post-treatment, even after its cessation after one year. Thus, implementing a dedicated comprehensive care program for HF patients is warranted.

5144 Lessons Learned: Evaluation of a Fracture Liaison Service Quality Improvement Efforts

Abstract Disclosure: M.S. Rothman: None. D.R. Fixen: None. L.M. Schilling: None. A.M. Elsheikh: None. A.M. Marcus: None. S.J. Billups: None. Background: The Fracture Liaison Service (FLS) care model, a care coordination program for patients experiencing a fragility fracture, is proven to improve management of patients with an osteoporotic fracture, but treatment initiation gaps persist. We describe the evolution of a centralized FLS within a university-based healthcare system, including impact of adding clinical pharmacist consultation and describe circumstances surrounding continued care gaps. Design: Cohort analysis of osteoporosis medication initiation before FLS, after initial implementation, and after addition of pharmacist consultation. Patients: Individuals aged 65 and older experiencing any fragility fracture between 7/1/16 - 3/31/22. Intervention: A centralized team outreached eligible patients, ordered dual x-ray absorptiometry and laboratory tests as needed, and scheduled an osteoporosis-focused primary care appointment. Three years after FLS implementation, clinical pharmacist consultative review was added prior to the primary care visit. Main Measures: Initiation of osteoporosis pharmacologic therapy, completion of DXA, primary care follow-up rate, and description of circumstances where therapy was not initiated. Key Results: Of 1204 new fractures between 7/1/16-3/31/22, 315 patients were enrolled in one of two FLS phases, and 89 eligible historical controls were identified. Medication initiation rates went from 22/89 (25%) pre-FLS to 201/428 (47%) after-FLS phase 1 [POST1], (p&amp;lt;0.001) and to 106/187 (57%) after FLS phase 2 (POST2), when clinical pharmacist consultation was added (p=0.03 versus POST1). DXA was completed in 56/89 (67%) of pre-FLS patients, 364/428 (85%) POST1 patients (p&amp;lt;0.001 versus pre), and 163/187 (87%) POST2 (p&amp;lt; 0.001 versus PRE, p=0.59 versus POST1). Of 375 patients who did not initiate osteoporosis medication, more in the combined post-FLS cohorts attended a follow-up primary care appointment (233/308, 76% attended, versus pre-FLS 41/67, 61% , p=0.016). Conclusion: An FLS including centralized outreach and care coordination significantly improved patient follow-up, DXA, and medication initiation. Addition of de-centralized pharmacist consultation further improved medication initiation rates. Presentation: 6/3/2024

A Proactive Telephonic Outreach Program to Address Unmet Social Needs of Children in Immigrant and Refugee Families at a Federally Qualified Health Center.

We developed a telephonic outreach and care coordination program for children in immigrant and refugee families (CIRF) at a federally qualified health center (FQHC) in North Carolina to address unmet health-related social needs (HRSN). Participants were recruited between December 2020 and October 2021. Eligible children were ages 0-5, non-English speaking, and were seen at the FQHC in the 2years prior. A bicultural/bilingual case manager completed telephonic outreach to caregivers of participants with HRSN screening. Bilingual patient navigators made follow-up calls to assess connection to resources and to develop strategies for addressing unmet needs. Three hundred forty-two families received outreach; 212 (62.0%) completed the baseline questionnaire. The majority (N = 160, 75.5%) completed at least one follow-up. The majority (N = 186, 88.1%) were Spanish-speaking, and over two-thirds (N = 149, 70.3%) were uninsured. Most participants had between 3-5 HRSNs identified (N = 121, 57.1%); "employment" (n = 158, 74.5%) and "food" (n = 138, 65.1%) were the most common. Despite repeated assistance, the majority of participants struggled to link to a community resource for their highest priority need (N = 123, 78.3%). Proactive phone-based HRSN screening may be a feasible and effective intervention to facilitate the identification of social needs for CIRF. The delivery of the intervention in languages other than English may have further contributed to program acceptability. Despite program feasibility and acceptability, community-level barriers to the resolution of HRSNs persist. While similar care coordination models can be considered to identify the high burden of unmet HRSN among CIRF, addressing the limited capacity of community-based resources for this population will be a critical component to ensuring the sustainability of such programs.

Engaging Interprofessional Health Students in a Prescription Produce Plan.

Nursing students participated in an interprofessional student-led prescription produce program (PPP) serving low-income older adults attending a community-based wellness and care coordination program. Students engaged in an online training module covering nutrition education and health promotion, integral components of a PPP. Ninety-five percent of students self-rated themselves as somewhat confident/very confident to participate in the PPP after completing an online learning module. Further investigation is needed on integrating students from diverse health professions to address the multifaceted factors related to nutrition and other social determinants of health affecting the management of chronic diseases.

Needs of children with neurodevelopmental disorders and medical complexity: Caregiver perspectives

BackgroundCaregivers of children with neurodevelopmental disorders and medical complexities (NDD-MC) coordinate care across complex multisectoral systems. Often NDD-MC children have complex behaviors, however there is limited information on coordination needs for families. Aim: The objective of this mixed methods study was to understand the needs of families with NDD-MC children. Methods and Procedures: This sequential exploratory study obtained the perspectives of 67 caregivers of NDD-MC children using semi-structured interviews and validated questionnaires to measure family quality of life, care integration, and resource use. An adapted model using Maslow’s hierarchy of needs was integrated, to understand the impacts of caregiving on quality of life. Outcomes and Results: Lack of support in caring for NDD-MC children negatively impacted family quality of life, resulting in various unmet needs, including caregiver burden, behavioural challenges, financial losses, and mental health issues. Caregivers dealt with a fragmented healthcare system that offered limited support to address coordination challenges. Conclusions and Implications: The implementation of a needs-based care coordination program is recommended to consider the health, educational, and social needs of NDD-MC children and their families. Effective care for children with complex needs should tailor support for families using Maslow’s hierarchy to enhance quality of life.

Primary Care Quality Improvement Through Patient-Centered Medical Homes and the Impact on Emergency Department Utilization for Children With Autism and Mental Health Disorders.

To address health care spending growth, coordinated care, and patient-centered primary care, most states in the United States have adopted value-based care coordination programs such as patient-centered medical homes (PCMHs). The objective of this study was to understand the relationship between having access to PCMHs and emergency department (ED) utilization for high cost/need children with autism and children with mental health disorders (MHDs). This cross-sectional study included 87 723 children between ages 3 and 17 years in the 2016-2018 National Survey for Children's Health. Multivariate-adjusted logistic regression analyses were used to assess the association between ED and PCMH utilization for children with autism, with MHDs without autism, and others without autism or MHDs. Marginal predictions were used to examine whether PCMH utilization was moderated by health conditions. The results showed that children with a PCMH had a 16% reduction in the odds to visit the ED (adjusted odds ratio [aOR] = 0.84; confidence interval [CI], 0.77-0.92; P < .001). When compared with the reference group of children without autism and without MHDs, children with MHDs but without autism had 93% higher odds to visit the ED (aOR = 1.93; CI, 1.75-2.13; P < .001) and children with autism had 35% higher odds to visit the ED (aOR = 1.35; CI, 1.04-1.75; P = .023). Marginal effects results suggested that PCMHs reduced the odds of ED visits the most for children with MHDs without autism and reduced the predicted ED visits from 30.1% to 23.7% (P < .001). Primary care quality improvement through access to a PCMH reduced ED visits for children, but the effect varied by autism and MHD conditions. Future PCMH efforts should continue to support children with autism and address unmet needs for children with MHDs with a focus on needed care coordination, family-centered care, and referrals.

Care Navigation and Coordination Program on Reducing Hospital Use for Adults with Complex Health and Psychosocial Needs in South West Sydney, Australia.

Complex and siloed health and social service systems can be difficult for people to navigate. The fragmented and poorly linked services leads to ineffective communication between care teams, delayed access to services, concerns regarding quality and safety of patient care, as well as patient frustration and disengagement. Planned Care for Better Health (PCBH) is a community-based care navigation and coordination program for people with complex health and psychosocial needs who are at risk of future hospitalisation. It focuses on early identification and holistic care to remove barriers and improve access to healthcare. By including a persons', family and carers in planning, listening to their needs, supporting the person to achieve their goals, and empowering them to make decisions on their own health, PCBH aims to enhance clients' healthcare experience and reduce preventable hospital utilisation. Building trusting and collaborative relationships with clients, families, carers, and health service providers requires commitment. Acknowledging and addressing psychosocial needs is critical for enhancing health outcomes. Equipping patients with self-management skills and knowledge to navigate and engage support services may generate lasting effects, even post-program enrolment. PCBH is associated with a notable reduction in unplanned hospitalisations and total bed days. However, reduction in ED presentations is similar between the intervention and comparison cohorts. Future initiatives should focus on a shared vision of integrated care, robust leadership, and participative co-creation with service-level stakeholders. Sustained program establishment, a multidisciplinary care coordinator team, and an early creation of robust evaluation strategy must be considered.

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.

High Reliability in a Safety Net Hospital Leading to Operational Excellence.

The objective of this work was to establish sustainable systems for quality improvement in an Academic Medical Center and Safety Net Hospital. High reliability principles of leadership engagement, a culture of safety, and sustainable performance improvement were used. Target areas for improvement were clinical outcomes for patients, public reputation scores, and lower cost of care. The system was based on annual focused goals with specific targets, improvement teams, transparent scorecards, and data driven work. Program visibility was championed by leaders. Consistent education on quality, safety, efficiency, and effectiveness for all employees created buy-in. Data review and accountability tracked progress, helped resource allocation, and defined next steps. In the first 5 years, all patient quality and safety metrics improved between 10% and 60%. This improvement resulted in higher CMS Star Ranking and Leapfrog patient safety grade. The next phase included maximizing value by expanding into hospital operations and finance with a focus on improved clinical documentation and reduced length of stay and cost of care. Clinical documentation improvement led to a 15% increase in comorbidity capture. This positively impacted reported outcomes and hospital payment by appropriate risk adjustment. Length of stay was addressed with a new care coordination program and physician-driven utilization review. High reliability principles are applicable in a resource limited healthcare system. Improved clinical and operational results were achieved through goal setting, improvement teams, and data driven projects leading to creation of an office of operational excellence.

#2628 A haemodialysis patient-centred model of care with a multidisciplinary programme: what is its clinical and health efficiency impact?

Abstract Background and Aims Chronic kidney disease (CKD) constitutes a public health concern due to its notable morbidity &amp; mortality and associated costs. The Patient Care Coordination program (PCC) provides comprehensive and personalized care to haemodialysis (HD) patients. This study evaluated the cost-effectiveness of PCC compared to standard of care (SoC). Method The study included patients in 9 HD clinics (5 PCC, 4 SoC) in Catalonia, Spain, in 2020-2021. A comparative effectiveness evaluation was conducted to compare change in Individual Patient Performance Score (IPPS, score 0-100, evaluates parameters such as vascular access, adequacy of HD, anaemia, mineral bone disease, arterial hypertension, nutrition/hydration status) and number of hospitalisations of PCC patients vs SoC during the first year in the program. Instrumental variables (IV) regression analysis was performed to address potential confounding; number of interactions with program specialists was a valid IV to estimate degree of PCC use. An incremental cost-effectiveness analysis (iCEA) through microsimulation was performed using the effectiveness data from the previous step, population data from the renal patient registry of Catalonia, and the cost of hospitalisations obtained from the Public Health System. Results 127 patients in PCC and 363 patients in SoC were included. The degree of PCC use had a positive impact on IPPS variation during the first year of the program (p = 0.012). In the iCEA the PCC program resulted in a mean gain of 3.4 additional IPPS points, a reduction of 0.2 hospitalisations per patient, and reduced mean costs of €1,265 per patient in the first year compared to SoC, resulting to be a dominant alternative (Fig. 1). Conclusion The holistic and interdisciplinary approach to the patient has further highlighted the relevance of programme use and not only belonging to the programme in achieving clinical goals. The PCC program represents thus a dominant alternative, with greater effectiveness and total cost savings that could sum up to €5.5 million per year in the region due to reduced hospitalizations. This approach may be an alternative to address the challenges of CKD and optimise the allocation of healthcare resources.

Overcoming challenges in real-world evidence generation: An example from an Adult Medical Care Coordination program.

The Adult Medical Care Coordination program ("the program") was implemented at Mayo Clinic to promote patient self-management and improve 30-day unplanned readmission for patients with high risk for readmission after hospital discharge. This study aimed to evaluate the impact of the program compared to usual care using a pragmatic, stepped wedge cluster randomized trial ("stepped wedge trial"). However, several challenges arose including large differences between the study arms. Our goal is to describe the challenges and present lessons learned on how to overcome such challenges and generate evidence to support practice decisions. We describe the challenges encountered during the trial, the approach to addressing these challenges, and lessons learned for other learning health system researchers facing similar challenges. The trial experienced several challenges in implementation including several clinics dropping from the study and care disruptions due to COVID-19. Additionally, there were large differences in the patient population between the program and usual care arms. For example, the mean age was 76.8 for the program and 68.1 for usual care. Due to these differences, we adapted the methods using the propensity score matching approach that is traditionally applied to observational designs and adjusted for differences in observable characteristics. When conducting pragmatic research, researchers will encounter factors beyond their control that may introduce bias. The lessons learned include the need to weigh the tradeoffs of pragmatic design elements and the potential value of adaptive designs for pragmatic trials. Applying these lessons would promote the successful generation of evidence that informs practice decisions.

Defragmentation of care in complex patients with ESKD improves clinical outcomes.

Given the problematic fragmentation of care for patients with end-stage kidney disease (ESKD), a kidney care organization and an integrated health system within a large accountable care organization partnered to best utilize their individual capabilities to collaborate around their shared patients in a coordinated care approach. Ultimately, the goal of the program is to allow care teams to achieve the triple aim of improving the patient experience, improving clinical outcomes, and reducing the total cost of health care. This is a retrospective examination of the first year of the Shared Patient Care Coordination (SPCC)program. The analysis consisted of 2 parts. First, rates of hospitalizations and emergency department visits were compared between the SPCC patients and other patients of the integrated health system who had ESKD but did not participate in SPCC. Second, rates of clinical indicators-central venous catheter (CVC) use, home dialysis, advance care planning, and missed dialysis treatments-were benchmarked vs normative data taken by bootstrap sampling of the kidney care organization's patient population. Overall, dialysis patients participating in the SPCC program had a 15% lower rate of hospital admissions than those not participating ( P = .02). Additionally, the bootstrap analysis showed that by the second year, dialysis patients in the program had favorable rates (above the 95th percentile) of CVC use, dialysis treatment absenteeism, and completion of advance care plans. Enhanced and structured communication between dialysis providers and patient care teams provides a unique opportunity to coordinate patient-centered care and improve patient outcomes.

Strategies to Improve Emergency Transitions From Long-Term Care Facilities: A Scoping Review.

Older adults residing in residential aged care facilities (RACFs) often experience substandard transitions to emergency departments (EDs) through rationed and delayed ED care. We aimed to identify research describing interventions to improve transitions from RACFs to EDs. In our scoping review, we included English language articles that (a) examined an intervention to improve transitions from RACF to EDs; and (b) focused on older adults (≥65 years). We employed content analysis. Dy et al.'s Care Transitions Framework was used to assess the contextualization of interventions and measurement of implementation success. Interventions in 28 studies included geriatric assessment or outreach services (n = 7), standardized documentation forms (n = 6), models of care to improve transitions from RACFs to EDs (n = 6), telehealth services (n = 3), nurse-led care coordination programs (n = 2), acute-care geriatric departments (n = 2), an extended paramedicine program (n = 1), and a web-based referral system (n = 1). Many studies (n = 17) did not define what "improvement" entailed and instead assessed documentation strategies and distal outcomes (e.g., hospital admission rates, length of stay). Few authors reported how they contextualized interventions to align with care environments and/or evaluated implementation success. Few studies included clinician perspectives and no study examined resident- or family/friend caregiver-reported outcomes. Mixed or nonsignificant results prevent us from recommending (or discouraging) any interventions. Given the complexity of these transitions and the need to create sustainable improvement strategies, future research should describe strategies used to embed innovations in care contexts and to measure both implementation and intervention success.

A care coordination program to support patients with hepatitis B virus at Kaiser Permanente Mid-Atlantic States

BackgroundEliminating hepatitis B virus (HBV) is a significant worldwide challenge requiring innovative approaches for vaccination, screening, disease management, and the prevention of related conditions. Programs that support patients in accessing needed clinical services can help optimize access to preventive services and treatment resources for hepatitis B.MethodsHere, we outline a coordinator-supported program (HBV Pathway) that connects patients infected with HBV to laboratory testing, imaging, and specialty care for treatment initiation and/or liver cancer surveillance (screening of high-risk patients for liver cancer). This study describes the HBV Pathway steps and reports sociodemographic factors of patients by initiation and completion.ResultsResults showed a 72.5% completion rate (defined as completing all Pathway steps including the final specialty visit) among patients who initiated the Pathway. Differences in completion were observed by age, race, ethnicity, and service area, with higher rates for younger ages, Asian race, non-Hispanic ethnicity, and lower rates for patients within one service area. Of those who completed the specialty visit, 59.5% were referred for hepatocellular carcinoma surveillance.ConclusionsThe HBV Pathway offers dual benefits– care coordination support for patients to promote Pathway completion and a standardized testing and referral program to reduce physician burden. This program provides an easy and reliable process for patients and physicians to obtain updated clinical information and initiate treatment and/or liver cancer screening if needed.