Effect of Continuity of Care on Hospital Utilization for Seniors With Multiple Medical Conditions in an Integrated Health Care System

PURPOSE

Lower continuity of care has been associated with higher rates of adverse outcomes for persons with multiple chronic medical conditions. It is unclear, however, whether this relationship also exists within integrated systems that offer high levels of informational continuity through shared electronic health records.

METHODS

We conducted a retrospective cohort study of 12,200 seniors with 3 or more chronic conditions within an integrated delivery system. Continuity of care was calculated using the Continuity of Care Index, which reflects visit concentration with individual clinicians. Using Cox proportional hazards regression permitting continuity to vary monthly until the outcome or censoring event, we separately assessed inpatient admissions and emergency department visits as a function of primary care continuity and specialty care continuity.

RESULTS

After adjusting for covariates (demographics; baseline, primary, and specialty care visits; baseline outcomes; and morbidity burden), greater primary care continuity and greater specialty care continuity were each associated with a lower risk of inpatient admission (respective hazard ratios (95% CIs) = 0.97 (0.96, 0.99) and 0.95 (0.93, 0.98)) and a lower risk of emergency department visits (respective hazard ratios = 0.97 (0.96, 0.98) and 0.98 (0.96, 1.00)). For the subgroup with 3 or more primary care and 3 or more specialty care visits, specialty care continuity (but not primary care continuity) was independently associated with a decreased risk of inpatient admissions (hazard ratio = 0.94 (0.92, 0.97)), and primary care continuity (but not specialty care continuity) was associated with a decreased risk of emergency department visits (hazard ratio = 0.98 (0.96, 1.00)).

CONCLUSIONS

In an integrated delivery system with high informational continuity, greater continuity of care is independently associated with lower hospital utilization for seniors with multiple chronic medical conditions. Different subgroups of patients will benefit from continuity with primary and specialty care clinicians depending on their care needs.     

CSHCN in Texas: Meeting the Need for Specialist Care

Objective: Assuring the sufficiency and suitability of systems of care and services for children with special health care needs (CSHCN) presents a challenge to Texas providers, agencies, and state Title V programs. To meet the need for specialist care, referrals from primary care doctors are often necessary. The objective of this study was to describe the factors associated with the need for specialist care and problems associated with obtaining referrals in Texas. Methods: Bivariate and multivariate analyses were performed using the National Survey of Children with Special Health Care Needs (NS-CSHCN) weighted sample for Texas (n = 719,014) to identify variables associated with the need for specialist care and problems obtaining referrals for specialist care. Results: Medical need of the CSHCN and sensitivity to family values/customs was associated with greater need for specialist care, and Hispanic ethnicity and lower maternal education were associated with less need. Medical need, amount of time spent with doctors and sensitivity to values/customs, living in a large metropolitan statistical area, and lack of medical information were associated with problems obtaining a specialist care referral. Conclusions: Findings revealed some similarities and differences with meeting the need for specialist care when comparing Texas results to other studies. In Texas, aspects of customer satisfaction variables, especially doctors’ sensitivity to family values/customs and parents’ not receiving enough information on medical problems, were significantly associated with problems obtaining specialist referrals. Findings indicate a need to further research relationships and communication among doctors, CSHCN, and their families.     

Utilization of Preventive Care by Haitian Immigrants in Miami, Florida

In order to evaluate the health needs and consequences of barriers to health care access for the Haitian immigrant community of Miami-Dade County, Florida, we collected in 2001 demographic and health needs and access data from a probability sample of county residents of Haitian origin. We computed frequencies and prevalence ratios, and employed chi-square and logistic regression methods for data analysis. Hypertension and diabetes were among the most prevalent health conditions mentioned. Up to 39% of participants failed to have an annual physical and 10% failed to receive care for their serious health conditions. On bivariate analysis, insurance coverage, a usual place of care, educational attainment, household income, citizenship status, and duration of residency were associated with services utilization. Citizenship status was the strongest independent predictor of services utilization. The findings suggest that this community faces distinct health needs and daunting challenges to meet those needs.     

Effects of an Integrated Care System on Quality of Care and Satisfaction for Children with Special Health Care Needs

To assess the effects of an Integrated Care System (ICS) on parent-reported quality of care and satisfaction for Children with Special Health Care Needs (CSHCN). In 2006 Florida reformed its Medicaid program in Broward and Duval counties. Children’s Medical Services Network (CMSN) chose to participate in the reform and developed an ICS for CSHCN. The ICS ushered in several changes such as more prior approval requirements and closing of the provider network. Telephone surveys were conducted with CMSN parents whose children reside in the reform counties and parents whose children reside outside of the reform counties in 2006 and 2007 (n = 1,727). Results from multivariate quasi-experimental models show that one component of parent-report quality of care, customer service, increased. Following implementation of the ICS, customer service increased by 0.22 points. After implementation of the ICS, parent-reported quality and satisfaction were generally unaffected. Although significant increases were not seen in the majority of the quality and satisfaction domains, it is nonetheless encouraging that parents did not report negative experiences with the ICS. It is important to present these interim findings so that progress can be monitored and decision-makers can begin to consider if the program should be expanded statewide.     

State Medicaid Eligibility Criteria and Unmet Preventive Dental Care Need for CSHCN

Maternal and Child Health Journal - Objective To determine if Medicaid eligibility is associated with unmet preventive dental care need for Medicaid-enrolled CSHCN. Methods We analyzed the...     

Consultative Care Coordination Through the Medical Home for CSHCN: A Randomized Controlled Trial

The purpose of this study was to examine the impact of a care coordination intervention aimed at improving the medical home for children with special health care needs (CSHCN). 100 CSHCN referred by a Medicaid managed care plan were randomly assigned to a care coordination intervention or to a wait list comparison group that received standard care. For the intervention group, a care coordinator supported the medical home by consulting with primary care providers at multiple practices to develop an integrated, individualized plan to meet child and family needs. During the second phase of the study, the wait list comparison group received the 6-month intervention. At the end of 12 months, the two groups were combined to examine within subject differences (n = 61). Compared to the control group, participants in the initial intervention group reported a decreased need for information and improved satisfaction with mental health services and specialized therapies. This effect was replicated when the wait list control group received the intervention. Additional benefits were observed in the within subject analysis, including a decline in unmet needs, improved satisfaction with specialty care and care coordination, and improved ratings of child health and family functioning. This intervention improved outcomes for CSHCN and their families by supporting the efforts of primary care physicians to provide comprehensive and coordinated care through the medical home. The consulting care coordinator may provide an efficient and cost effective approach to enhancing the quality of care for CSHCN.     

Changes in Insurance Status and Access to Care in an Integrated Safety Net Healthcare System

This paper focuses on a cohort of uninsured patients that have accessed outpatient healthcare services in an urban safety net, evaluating the degree to which they switch insurance status and the impact this switching has on access to care. The results indicate that in an integrated safety net system, there is a high frequency of insurance status switching by the uninsured. Uninsured patients who switch to insured status were found to be more likely to visit specialty points of care and less likely to visit urgent points of care than the continuously uninsured. It is well documented that insurance coverage and continuity of care influence health status. Continuity of insurance coverage also has an impact on access to care for those receiving services within a safety net healthcare system.     

A Data Driven Process in Washington State to Improve Systems of Care for Children With Special Health Care Needs: The National Survey of CSHCN

Objectives: The purpose of this article is to present strategies used in one state to engage public health stakeholders in the use of National Survey of Children With Special Health Care Needs (NS-CSHCN) results to improve systems of care for children with special health care needs (CSHCN). This is not a research report. Methods: Seven “CSHCN Road Shows” were conducted with 39 local health departments, five state agencies, five parent leaders, three managed health care plans, and 12 school nurses. These “CSHCN Road Shows” were used to present and validate Washington State findings from the NS-CSHCN, obtain input on additional topics for analysis and elicit ways of incorporating NS-CSHCN results into the state’s MCH Five Year Needs Assessment. Results: Overall, a majority of stakeholders reported a high level of interest in using state-level data from the NS-CSHCN for local community efforts. Uses included program planning, presenting data to local boards of health and other community agencies, and utilizing results as talking points with other partners on the needs and unmet needs of the population. The state Title V office used feedback from “CSHCN Road Show” participants to prioritize program-planning activities, initiate policy discussions, and incorporate feedback into the MCH Five Year Needs Assessment. Conclusions: State-level data from the NS-CSHCN are a rich source of information for driving improvements in systems of care, facilitating state and local program planning efforts, writing grants, and completing MCH Five Year Needs Assessment activities.     

Effect of the Medicaid Primary Care Rate Increase on Prenatal Care Utilization Among Medicaid-Insured Women

Maternal and Child Health Journal - To evaluate the effect of the 2013–2014 ACA Medicaid Primary Care Rate Increase on Medicaid-insured women’s prenatal care utilization, overall and by...     

社区流动人口孕产妇全覆盖管理模式的实施效果分析

目的分析外来孕产妇全覆盖管理模式在社区的实施效果。方法选取上海市浦东新区3个街道为干预社区,3个街道为对照社区,在干预社区实施孕产妇全覆盖管理干预模式,提供孕产保健服务;在对照社区按常规提供孕产保健服务。结果随访2年后,干预社区流动人口孕产妇产前检查超过5次的占93.02%,超过对照组的88.16%(P<0.001);经多因素非条件Logistic分析,干预后两组孕检次数有统计学意义,而在足月分娩及流产或存活等方面两组无显著性差异。结论全覆盖管理模式可以改善流动人口孕产妇管理现状,扩大孕产期保健的覆盖面,但进一步发挥作用需要制度保障。     

费用补偿方式对医疗服务需求和利用的影响

文章采用按服务项目付费和按人头付费2种补偿方式,比较2种方式样本人群的门诊医疗服务需求和利用的情况,探讨不同费用补偿方式对医疗服务需求和利用的影响程度.结果显示2种费用补偿方式在服务需求利用及医疗费用方面存在显著差异(P＜0.01).在医疗服务的费用补偿中引入供方风险分担机制,这是控制医疗费用快速增长的一个重要举措:同时应积极探索多种费用补偿方式的联合使用,相对客观地反映医疗服务的真实成本,对协调医疗费用和服务质量的平衡意义重大.     

Racial and Ethnic Disparities in Diabetes Care Quality among Women of Reproductive Age in an Integrated Delivery System

BackgroundDiabetes is increasingly prevalent among women of reproductive age, yet little is known about quality of diabetes care for this population at increased risk of diabetes complications and poor maternal and infant health outcomes. Previous studies have identified racial/ethnic disparities in diabetes care, but patterns among women of reproductive age have not been examined.MethodsThis retrospective cohort study analyzed 2016 data from Kaiser Permanente Northern California, a large integrated delivery system. Outcomes were quality of diabetes care measures—glycemic testing, glycemic control, and medication adherence—among women ages 18 to 44 with type 1 or type 2 diabetes (N = 9,923). Poisson regression was used to estimate the association between patient race/ethnicity and each outcome, adjusting for other patient characteristics and health care use.ResultsIn this cohort, 83% of participants had type 2 diabetes; 31% and 36% of women with type 2 and type 1 diabetes, respectively, had poor glycemic control (hemoglobin A1c of ≥9%), and approximately one-third of women with type 2 diabetes exhibited nonadherence to diabetes medications. Compared with non-Hispanic White women with type 2 diabetes, non-Hispanic Black women (adjusted risk ratio, 1.2; 95% confidence interval, 1.1–1.3) and Hispanic women (adjusted risk ratio, 1.2; 95% confidence interval, 1.1–1.3) were more likely to have poor control. Findings among women with type 1 diabetes were similar.ConclusionsOur findings indicate opportunities to decrease disparities and improve quality of diabetes care for reproductive-aged women. Elucidating the contributing factors to poor glycemic control and medication adherence in this population, particularly among Black, Hispanic, and Asian women, should be a high research and practice priority.     

An Evaluation of an Integrated Health Care Program for Children With Special Needs

This study was designed to evaluate a program integrating physical and mental health services for children with special health care needs. Clinical outcomes were assessed by comparing families in integrated clinics (N = 80) with families in traditional clinics (N = 36). Parents and children ages 8 to 16 completed a series of questionnaires to assess differences in child behavior and coping, parents' perceptions of child vulnerability, and parent well-being and coping. Demographic variables and child's health status were also assessed with questionnaires and controlled for in subsequent analyses. There were no differences between groups on demographic variables or health status, though children in the integrated clinics had been diagnosed at an earlier age. Parents in the integrated program reported significantly fewer behavioral symptoms than parents in the nonintegrated clinics. Significantly fewer children from integrated clinics were in the clinical range for poor school functioning compared to children in nonintegrated clinics. No differences emerged in coping or parent well-being. Results provide preliminary support for integrating health and mental health care services for children with special needs. Suggestions for improving future evaluation efforts and clinical practice are discussed.     

An Evaluation of an Integrated Health Care Program for Children With Special Needs

This study was designed to evaluate a program integrating physical and mental health services for children with special health care needs. Clinical outcomes were assessed by comparing families in integrated clinics (N = 80) with families in traditional clinics (N = 36). Parents and children ages 8 to 16 completed a series of questionnaires to assess differences in child behavior and coping, parents' perceptions of child vulnerability, and parent well-being and coping. Demographic variables and child's health status were also assessed with questionnaires and controlled for in subsequent analyses. There were no differences between groups on demographic variables or health status, though children in the integrated clinics had been diagnosed at an earlier age. Parents in the integrated program reported significantly fewer behavioral symptoms than parents in the nonintegrated clinics. Significantly fewer children from integrated clinics were in the clinical range for poor school functioning compared to children in nonintegrated clinics. No differences emerged in coping or parent well-being. Results provide preliminary support for integrating health and mental health care services for children with special needs. Suggestions for improving future evaluation efforts and clinical practice are discussed.     

基本医疗卫生制度对居民基本医疗服务可及性和利用的影响:基于甘肃的个案研究

基本医疗卫生制度建立的目的是消除居民利用基本卫生服务的经济障碍,向全体居民提供适应经济发展阶段和政府及个人承受能力的,安全、有效、方便、价廉的基本医疗服务,促进卫生服务利用公平性的提高。将探索卫生服务可及性和利用的分析方法,并以甘肃省为个案,对基本医疗卫生制度建立前后居民基本医疗服务可及性和利用状况的变化进行测量,评价基本医疗卫生制度对其产生的影响。     

Effectiveness and Reach of the FLU-FIT Program in an Integrated Health Care System: A Multisite Randomized Trial

Objectives. We tested the effectiveness of offering home fecal immunochemical tests (FITs) during influenza vaccination clinics to increase colorectal cancer screening (CRCS).Methods. In a clinical trial at Kaiser Permanente Northern California influenza clinics in Redwood City, Richmond, South San Francisco, Union City, and Fresno, we randomly assigned influenza clinic dates to intervention (FIT offered) or control (FIT not offered) and compared subsequent CRCS activity.Results. Clinic staff provided FITs to 53.9% (1805/3351) of intervention patients aged 50 to 75 years. In the intent-to-treat analysis, 26.9% (900/3351) and 11.7% (336/2884) of intervention and control patients completed an FIT, respectively, within 90 days of vaccination (P ≤ .001). The adjusted odds ratio for completing FIT in the intervention versus the control arm was 2.75 (95% confidence interval = 2.40, 3.16). In the per protocol analysis, 35.4% (648/1830) of patients given FIT and 13.3% (588/4405) of patients not given FIT completed FIT within 90 days of vaccination (P ≤ .001).Conclusions. This intervention may increase CRCS among those not reached by other forms of CRCS outreach. Future research should include the extent to which these programs can be disseminated and implemented nationally.More than 143 000 new cases of colorectal cancer and more than 51 000 colorectal cancer deaths are expected in the US 2012 Census, making it the fourth leading cause of nonskin cancers diagnosed and the second leading cause of all cancer deaths among Americans.1 Colorectal cancer mortality can be reduced with screening.1,2 The US Preventive Services Task Force recommends colorectal cancer screening (CRCS) for average-risk adults aged 50 to 75 years using annual high-sensitivity fecal occult blood tests such as fecal immunochemical tests (FITs), flexible sigmoidoscopy every 5 years with interval fecal occult blood testing, or colonoscopy every 10 years.3 Only 58.6% of US adults aged 50 to 75 years were up to date with guideline-recommended screening in 2010.4Achieving high CRCS rates requires evidence-based approaches, such as removal of barriers to obtaining and completing recommended tests, 1-to-1 health care team member interventions, and organized patient reminders.5 At Kaiser Permanente Northern California (KPNC), a combination of traditional primary care strategies and an organized system of FIT kit mailings has led to a CRCS rate of more than 75.0% for patients aged 50 to 75 years, exceeding the Healthy People 2020 target of 70.5%.6–8 Nonetheless, even at KPNC, many age-eligible patients remain unscreened. A strategy that may add to these efforts is the FLU-FIT Program, which is designed to allow non–physician-led health care teams to offer FIT kits to eligible patients when they seek annual influenza vaccinations. The program has been tested in safety net settings9–11 and was pilot tested at KPNC’s Santa Clara facility in 2008.12 In this new study, we provided a comprehensive test of the effectiveness of the FLU-FIT Program for KPNC influenza vaccination clinic attendees not reached with or responding to other CRCS opportunities.     

Effect of Frequent SARS-CoV-2 Testing on Weekly Case Rates in Long-Term Care Facilities,Florida, USA

We analyzed 1,292,165 SARS-CoV-2 test results from residents and employees of 361 long-term care facilities in Florida, USA. A 1% increase in testing resulted in a 0.08% reduction in cases 3 weeks after testing began. Increasing SARS-CoV-2 testing frequency is a viable tool for reducing virus transmission in these facilities.