Managed Care Delivery Research Articles

Evaluation of a Multidisciplinary Care Coordination Program for Frequent Users of the Emergency Department.

The purpose of this study was to evaluate the impact of a quality improvement multidisciplinary care coordination program designed to reduce frequent emergency department (ED) utilization and hospital admissions. The single hospital ED is part of a large, integrated, managed care delivery system in Northern California serving the city of Oakland, California. A retrospective cohort study design was used to analyze a multidisciplinary care coordination program on 58 patients during January 2015 and August 2018. Patients were identified from a high-utilization report when they had 10 or more ED visits in a 6-month period, were 18 years of age or older, and members of the integrated delivery system's health plan. Data were collected at initiation and 6 months postintervention. The pre-/postanalysis consisted of descriptive statistics, Wilcoxon signed ranks test, and binary logistic regression. There was a statistically significant pre-/postdifference of 7.7 ED visits (95% confidence interval [CI] = 4.44-10.97, p < .001). The program did not result in statistically significant reduced hospital admissions (95% CI =-1.24 to 1.45, p = .875). Prior frequent use, number of pre-ED visits, age, sex, complex medical history, and mental health disorder had a significant effect on frequent ED use (χ[6] =17.62, p = .007, McFadden R = .32]. Sex (odds ratio [OR] = 5.13, p = .070), prior frequent use (OR = 2.87, p = .252), and complex medical history (OR = 2.52, p = .412) had the greatest odds of ongoing frequent ED use. We demonstrated reductions in ED use among frequent users with a low-cost care management intervention. Our multidisciplinary care coordination program confirms the positive impact case management has on utilization and health outcomes. We established that a care coordination program can optimize the overall quality of care and control hospital costs incurred by this vulnerable population. The effectiveness of this program contributes to the advancement of case management efforts in undertaking the challenging health care issue of reducing repeated visits by frequent users, a practice that strains emergency medical services.

Population Health: The Diabetes Educator's Evolving Role.

The US health care system's focus on high-quality, efficient, and cost-effective care has led payers and provider groups to identify new models with a shift toward value-based care. This perspective on clinical practice describes the population health movement and the opportunities for diabetes educators beyond diabetes self-management education, as well as steps to engage in and drive new care models to demonstrate individual, organizational, and payer value. Diabetes educators have an opportunity to position themselves as diabetes specialists for diabetes management, education, and population health care delivery. With expertise that extends beyond diabetes self-management education and with a wide variety of skills, diabetes educators recognize that there is a range of personal, social, economic, and environmental factors that influence diabetes health outcomes. Diabetes educators should align with organizational strategic plans and support the population-level performance measures and quality initiatives, thus enhancing the value that diabetes educators bring to health care organizations.

705-P: Health Extension: A Better Way to Manage Diabetes?

Background: Given the increasing number of individuals with diabetes who live in settings with limited access to care, new models of care delivery for management of diabetes are critical. Health Extension for Diabetes (HED), a community-based non-clinical diabetes education program delivered by a Health Extension Agent, is based on the AADE7 Self-Care Behaviors for Managing Diabetes. Methods: This intervention is a mixed-methods research study with a primary outcome to reduce/prevent complications associated with diabetes. Goal assessment metrics were selected by clinical, non-clinical and evaluation staff, and resulted in 3 categories: health behaviors, health outcomes, and healthcare utilization. Pre/post analysis of graduates in HED cohorts 1-3 focuses on health behaviors and health outcomes with emphasis on 2 crucial measures, diet and exercise. Pre/post data were compared using Stata 15. Results: Table 1 shows client demographics and the pre/post analysis of several variables collected during evaluation process. Conclusion: Overall, this novel educational diabetes self-management support intervention was found to be effective shown through the short-term outcome measures. This new method increased client physical activity and confidence (self-efficacy) in regard to diabetes management while lowering consumption of sugary beverages. Disclosure C.J. Dietz: None. P. Tilkemeier: None. W.W. Sherrill: None. D.E. McFall: None. M.D. Stancil: None. M.A. Parisi: None. C. Beauchamp: None. H.N. White: None. Funding Greenville Health Authority

Arizona providers plagued with unpaid claims, layoffs after BH transition

Faced with millions in unpaid claims, credentialing issues, service reductions and staff layoffs, Arizona community mental health providers are struggling to stay afloat amid a major transformation of its Medicaid system to a managed care delivery integrated care system. Some are on the brink of closure, say observers.

Arizona moves to managed care delivery integrated care system

Nearly a month and a half into its new integrated care delivery system for Medicaid beneficiaries, Arizona officials say the transition, in the works for two years, is moving forward smoothly.

North Carolina to shift Medicaid program to managed care delivery system

North Carolina officials are transforming the state's Medicaid program following recent federal approval to shift the program from fee‐for‐service (FFS) to a managed care delivery system. The move is intended to push the state's health care system toward further integration and coordination, said officials.

Responsabilidad Social en la educación de Enfermería. Un Estudio piloto en Chile

Summary: Background: Service learning has been demonstrated as a suitable methodology in education. Nursing education should support ethics, values and stimulate social responsibility within the curriculum .Aim: To evaluate a Service learning experience in clinical practice in nursing undergraduate students, contributing social responsibility in education and health organisations. Method: A pilot study was carried out using quantitative and qualitative measures. Students worked in groups under the supervision of nursing instructors. The goal of the experience was to develop a service learning project which may respond to the needs of patients, relatives and communities inside of paediatric centres. Conclusion: Students learned strategies such as problem-solving, making-decision process, leadership abilities, improving management process and care delivery. The experience strengthens both critical and reflective thinking. This methodology could play a remarkable role in nursing education.

Geographical differences exist in high-value care delivery for inpatient management of cirrhosis: Cost conscious care in cirrhosis.

Background and AimsThe United States spends more money per person on health care than any other country in the world. Patients with cirrhosis are at an increased risk of health‐care utilization. The aim of this study is to evaluate differences in health‐care utilization based on the region of treatment during the inpatient management of patients with cirrhosis.MethodA retrospective database analysis using the Nationwide Inpatient Sample was performed, including adult patients with a primary diagnosis of cirrhosis determined by ICD‐9 codes. Univariate and multivariate analyses were performed to analyze liver decompensation, mortality, length of stay, and total charges in different regions across the United States.ResultsA total of 75 280 patients with cirrhosis who received treatment in nine different regions across the United States were included. Rates of liver decompensation were significantly decreased in the Pacific region compared to the New England region (OR: 0.69, 95% CI: 0.51–0.94). Length of stay was significantly different between regions; however, the means only varied by half a day and were of minimal clinical significance. Inpatient mortality rates were not significantly different between regions. Total charges for inpatient management between regions were significantly different, with the Pacific region having the highest total hospital charges with a mean of $82 731.ConclusionsHealth‐care utilization during the inpatient management of cirrhosis varies based on the region. The charges for treatment were the highest in the West despite no impact on mortality, minimal improvement in length of stay, and fewer features of decompensation on admission.

Interprofessional Healthcare Teams in the Military: A Scoping Literature Review.

Research into healthcare delivered via interprofessional healthcare teams (IHTs) has uncovered that IHTs can improve patient satisfaction, enhance collaborative behaviors, reduce clinical error rates, and streamline management of care delivery. Importantly, these achievements are attained by IHTs that have been trained via interprofessional education (IPE). Research indicates that IHT training must be contextualized to suit the demands of each care context. However, research into the unique demands required of military IHTs has yet to be explored. For any form of IPE to be successfully implemented in the military, we need a clear understanding of how IHT competencies must be tailored to suit military care contexts. Specifically, we must know: (1) What evidence is currently available regarding IHTs in the military?; and (2) What gaps in the evidence need to be addressed for IPE to be customized to meet the needs of military healthcare delivery? A scoping review of the literature was conducted to identify the breadth of knowledge currently available regarding military interprofessional healthcare teams (MIHTs). A search of PubMed, EMBASE, PsycInfo, ERIC, DTIC.mil, and NYAM Gray Literature databases was conducted without date restrictions. The search terms were: (interprofessional* OR inter-professional*) AND (military OR Army OR Navy OR Naval OR Marines OR “Air Force” OR “Public Health Service”) AND (health OR medicine). Of the 675 articles identified via the initial search, only 21 articles met inclusion criteria (i.e., involved military personnel, included teams that were medically focused, comprised at least two professional disciplines, and had at least two people). The manuscripts included: seven original research studies, six commentaries, five reviews, one letter, one annual report, and one innovation report. Analyses identified three themes (i.e., effective communication, supportive team environments, shared role understanding, and equity among team members) related to successful MIHT collaborations and five related to unsuccessful MIHT collaborations (i.e., inability to develop team cohesion, lack of trust, ineffective communication and communication breakdowns, unaddressed or unresolved conflicts, and rank conflicts). These manuscripts highlighted contextual factors that shape MIHTs. For example, MIHTs often work and live together for extended periods of time when deployed. Also, military rank can facilitate collaboration by establishing clear lines of reporting but can problematize collaboration when inexperienced care providers (e.g., early career physicians) outrank other team members (e.g., medics) who have more experience providing care in deployment contexts. Given that the experiences of military personnel can be perilous and unpredictable, the military has an obligation to study the unique contexts of care where MIHTs are employed. In doing so, educational interventions can be tailored to better aid our service men and women, as well as their families.

Visits to Primary Care and Emergency Department Reliance for Foster Youth: Impact of Medicaid Managed Care

ObjectiveTo examine the rate of access to primary and preventive care and emergency department (ED) reliance for foster youth as well as the impact of a transition from fee-for-service (FFS) Medicaid to managed care (MC) on this access. MethodsSecondary administrative data were obtained from Medicaid programs in one state that transitioned foster youth from an FFS to an MC (Texas) and another state, comparable in population size and racial/ethnic diversity, which continuously enrolled foster youth in an FFS system (Florida). Eligible participants were foster youth (aged 0–18 years) enrolled in these states between 2006 and 2010 (n = 126,714). A Puhani approach to difference-in-difference was used to identify the effect of transition after adjusting for race/ethnicity, gender, and health status. Data were used to calculate access to primary and preventive care as well as ED reliance. ED reliance was operationalized as the number of ED visits relative to the number of total ambulatory visits; high ED reliance was defined as ≥33%. ResultsThe transition to MC was associated with a 6% to 13% increase in access to primary care. Preventive care visits were 10% to 13% higher among foster youth in MC compared to those in FFS. ED reliance declined for the intervention group but to a lesser extent than did the control group, yielding a positive mean percentage change. ConclusionsFoster youth access to care may benefit from a Medicaid MC delivery system, particularly as the plans used are designed with the unique needs of this vulnerable population.

An Efficient, Clinically-Natural Electronic Medical Record System that Produces Computable Data.

Current commercially-available electronic medical record systems produce mainly text-based information focused on financial and regulatory performance. We combined an existing method for organizing complex computer systems—which we label activity-based design—with a proven approach for integrating clinical decision support into front-line care delivery—Care Process Models. The clinical decision support approach increased the structure of textual clinical documentation, to the point where established methods for converting text into computable data (natural language processing) worked efficiently. In a simple trial involving radiology reports for examinations performed to rule out pneumonia, more than 98 percent of all documentation generated was captured as computable data. Use cases across a broad range of other physician, nursing, and physical therapy clinical applications subjectively show similar effects. The resulting system is clinically natural, puts clinicians in direct, rapid control of clinical content without information technology intermediaries, and can generate complete clinical documentation. It supports embedded secondary functions such as the generation of granular activity-based costing data, and embedded generation of clinical coding (e.g., CPT, ICD-10 or SNOMED). Most important, widely-available computable data has the potential to greatly improve care delivery management and outcomes.

The Impact of Obstetrician/Gynecologist Hospitalists on Maternal Quality of Care in Yogyakarta Indonsia: A Cohort Study

Background: The hospitalist is defined by 24-hour a day/7 day a week physician who assists or is employed by the hospital to manage patients, triage and emergencies. The hospitalist model in obstetric care that was introduced over the last decades now has an important role in care delivery management with the potential positive impact on maternal outcomes. Unfortunately, in Indonesia there were limited data available related to the implementation of hospitalist model and the impact on maternal quality of care. Objective: To determine the impact of obstetrician/gynecologist hospitalist on maternal quality care. Method: This research design was a retrospective cohort. Participants included were the patients in the time before and after implementation of obstetrician/gynecologist hospitalist policy during October 2013 until September 2014. Univariate and multivariate analysis were conducted to evaluate and determine the factors, which significantly contribute to maternal outcomes. Result and Discussion: We included a total of 71 patients (30 in the on-call group and 41 in the full time hospitalist group). Univariate analysis indicated mean response time was significantly different in the hospitalist group compared to the on-call group (65.3 ± 25.89 vs 84 ± 22.29 mins; p = 0.002). Implementation of full-time hospitalists did not impact the ICU admission and transfusion incidence. Conclusions: Implementation of the full-time hospitalist model was associated with a significant improvement of response time in emergency obstetric care without affecting maternal outcomes. Keywords: Maternal mortality, obstetrician/gynecologist hospitalist, labor and delivery, maternal care, ICU response time

Status Update on Translation of Integrated Primary Dental-Medical Care Delivery for Management of Diabetic Patients.

Escalating prevalence of both diabetes and periodontal disease, two diseases associated with bi-directional exacerbation, has been reported. Periodontal disease represents a modifiable risk factor that may reduce diabetes onset or progression, and integrated models of cross-disciplinary care are needed to establish and manage glycemic control in affected patients. An ad-hoc environmental scan of current literature and media sought to characterize factors impacting status of integrated care models based on review of the existing evidence base in literature and media surrounding: (1) current cross-disciplinary practice patterns, (2) epidemiological updates, (3) status on risk assessment and screening for dysglycemia in the dental setting, (4) status on implementation of quality metrics for oral health, (5) care model pilots, and (6) public health perspectives. The survey revealed: escalating prevalence of diabetes and periodontitis globally; greater emphasis on oral health assessment for diabetic patients in recent medical clinical practice guidelines; high knowledgeability surrounding oral-systemic impacts on diabetes and growing receptivity to medical-dental integration among medical and dental providers; increasing numbers of programs/studies reporting on positive impact of emerging integrated dental-medical care models on diabetic patient healthcare access and health outcomes; a growing evidence base for clinically significant rates of undiagnosed dysglycemia among dental patients reported by point-of-care pilot studies; no current recommendation for population-based screening for dysglycemia in dental settings pending a stronger evidence base; improved definition of true periodontitis prevalence in (pre)/diabetics; emerging recognition of the need for oral health quality indicators and tracking; evidence of persistence in dental access disparity; updated status on barriers to integration. The potential benefit of creating clinically-applicable integrated care models to support holistic management of an escalating diabetic population by targeting modifiable risk factors including periodontitis is being recognized by the health industry. Cross-disciplinary efforts supported by high quality research are needed to mitigate previously- and newly-defined barriers of care integration and expedite development and implementation of integrated care models in various practice settings. Implementation of quality monitoring in the dental setting will support definition of the impact and efficacy of interventional clinical care models on patient outcomes.

North Carolina Medicaid Reform: Seizing Opportunities and Addressing Challenges.

North Carolina has made progress toward improving the health of its citizens, yet much more needs to be done. Now is the right time for the state to transform its Medicaid and North Carolina Health Choice programs into a managed care delivery system that gives providers more flexibility to deliver care that focuses on the whole person and benefits people's lives beyond the medical setting. The North Carolina Department of Health and Human Services is focused on maximizing opportunities and managing challenges, and the department understands that collaboration of health care professionals and other stakeholders is essential to achieve the right results for North Carolinians.

Impact of Obstetrician/Gynecologist Hospitalists on Response Time of Obstetric Emergency Operation in Sardjito Hospital Yogyakarta Indonesia: A Retrospective Cohort Study

Background: The hospitalist model in obstetric care which was introduced over the last decades now has an important role in care delivery management with the potential positive impact on maternal and neonatal outcomes.Objective: The aim of this study was to evaluate the effect of hospitalist model towards surgical emergency response time.Method: This research design was cohort a retrospective study. Participants included were the patient in the time before and after implementation of obstetrician/gynecologist full-hospitalist policy during October 2013 until September 2014. The outcome measured were mean response time and possible hospital factors which contribute to response time.Result and Discussion: We included a total of 71 patients (30 on-call obstetrician group and 41 full-time hospitalist group). Univariate analysis indicated mean response time was significantly differ in full-time hospitalist group when compared to the on-call obstetrician group (65.3 + 25.89 vs. 84 + 22.29 mins; p = 0.002). Multivariable analysis determined that hospital factors which contribute to response time are readiness of operating theatre.Conclusion: Implementation of full-time hospitalist model is associated with a significant improvement of response time in emergency obstetric care.Keywords: Maternal mortality, Obstetrician/Gynecology Hospitalist, C-section, Response Time

Out of hours workload management: Bayesian inference for decision support in secondary care.

In this paper, we aim to evaluate the use of electronic technologies in out of hours (OoH) task-management for assisting the design of effective support systems in health care; targeting local facilities, wards or specific working groups. In addition, we seek to draw and validate conclusions with relevance to a frequently revised service, subject to increasing pressures. We have analysed 4 years of digitised demand-data extracted from a recently deployed electronic task-management system, within the Hospital at Night setting in two jointly coordinated hospitals in the United Kingdom. The methodology employed relies on Bayesian inference methods and parameter-driven state-space models for multivariate series of count data. Main results support claims relating to (i) the importance of data-driven staffing alternatives and (ii) demand forecasts serving as a basis to intelligent scheduling within working groups. We have displayed a split in workload patterns across groups of medical and surgical specialities, and sustained assertions regarding staff behaviour and work-need changes according to shifts or days of the week. Also, we have provided evidence regarding the relevance of day-to-day planning and prioritisation. The work exhibits potential contributions of electronic tasking alternatives for the purpose of data-driven support systems design; for scheduling, prioritisation and management of care delivery. Electronic tasking technologies provide means to design intelligent systems specific to a ward, speciality or task-type; hence, the paper emphasizes the importance of replacing traditional pager-based approaches to management for modern alternatives.

The Impact of Obstetrician/Gynecologist Hospitalists on Neonatal Quality of Care in Sardjito General Hospital Yogyakarta, Indonesia: A Retrospective Cohort Study

ABSTRACT Background : The hospitalist model in obstetric care which was introduced over the last decades now has an important role in care delivery management with the potential positive impact on neonatal outcomes. Methods : This research design was retrospective cohort. Participants included is the patient in the time before and after implementation of obstetrician/gynecologist full-hospitalist policy during October 2013 until September 2014. The outcome measured were mean response time, APGAR score at 5 minutes, , NICU admission. Univariate and multivariable analyses was conducted to evaluate and determine the factor which significantly contribute to neonatal outcomes. Results and Discussion: We included total 71 patients (37 on-call obstetrician group and 34 full-time hospitalist group). Univariate analysis indicated mean response time was significantly differ in full-time hospitalist group when compared to the on-call obstetrician group (65,3 + 25,89 vs. 84 + 22,29 mins; p = 0,002). Implementation of full-time hospitalist did not impact the NICU admission and APGAR score at 5 minutes. Conclusion : Implementation of full-time hospitalist model is not affecting neonatal outcomes. Keywords : Infant and Maternal Mortality, Obtericians / Gynecologist Hospitalist, Labor and Delivery, Maternal and Neonatal Care, ICU Response Time.

Block Granting Medicaid: A Model for Twenty-First Century Health Reform?

Block Granting Medicaid: A Model for Twenty-First Century Health Reform?

Transaction cost analysis of in-clinic versus telehealth consultations for chronic pain: preliminary evidence for rapid and affordable access to interdisciplinary collaborative consultation.

With ever increasing mandates to reduce costs and increase the quality of pain management, health care institutions are faced with the challenge of adopting innovative technologies and shifting workflows to provide value-based care. Transaction cost economic analysis can provide comparative evaluation of the consequences of these changes in the delivery of care. The aim of this study was to establish proof-of-concept using transaction cost analysis to examine chronic pain management in-clinic and through telehealth. Participating health care providers were asked to identify and describe two comparable completed transactions for patients with chronic pain: one consultation between patient and specialist in-clinic and the other a telehealth presentation of a patient's case by the primary care provider to a team of pain medicine specialists. Each provider completed two on-site interviews. Focus was on the time, value of time, and labor costs per transaction. Number of steps, time, and costs for providers and patients were identified. Forty-six discrete steps were taken for the in-clinic transaction, and 27 steps were taken for the telehealth transaction. Although similar in costs per patient ($332.89 in-clinic vs. $376.48 telehealth), the costs accrued over 153 business days in-clinic and 4 business days for telehealth. Time elapsed between referral and completion of initial consultation was 72 days in-clinic, 4 days for telehealth. U.S. health care is moving toward the use of more technologies and practices, and the information provided by transaction cost analyses of care delivery for pain management will be important to determine actual cost savings and benefits.

Medicaid Managed Care Lifts Barriers to Home Care

Medicaid Managed Care Lifts Barriers to Home Care