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Strategies to Achieve Alignment, Collaboration, and Synergy across Delivery and Financing Systems
ImprovingPopulationandClinicalHealthwithIntegratedServicesandDecisionSupport
Research-in-Progress WebinarWednesday, January 9, 2019
12:00-1:00 pm ET/ 9:00 am-10:00 am PT
Funded by the Robert Wood Johnson Foundation
AgendaWelcome: ShanaMoore,PhD,MPA
DirectorofDisseminationandResearchDevelopmentRWJFSystemsforAction NationalCoordinatingCenterUniversityofKentuckyCollegeofPublicHealth
Presenter: JoshuaVest,PhD,MPHDirector,CenterforHealthPolicyAssociateProfessor,HealthPolicy&ManagementIndianaUniversityRichardMFairbanksSchoolofPublicHealth- IndianapolisAffiliatedScientist,RegenstriefInstitute
Commentary: GlenMays,PhDDirectorRWJFSystemsforAction NationalCoordinatingCenterUniversityofKentuckyCollegeofPublicHealth
Q&A: ModeratedbyShanaMoore,PhD,MPA
Presenter
JoshuaVest,PhD,MPHDirector,CenterforHealthPolicyAssociateProfessor,HealthPolicy&ManagementIndianaUniversityRichardMFairbanksSchoolofPublicHealth- IndianapolisAffiliatedScientist,RegenstriefInstitute
Commentary Speaker
GlenP.Mays,PhD,MPHDirectorRWJFSystemsforAction NationalCoordinatingCenterUniversityofKentuckyCollegeofPublicHealth
ImprovingPopulationandClinicalHealthwithIntegratedServicesandDecisionSupport
JoshuaRVest,PhD,MPHDirector,CenterforHealthPolicy
AssociateProfessor,HealthPolicy&ManagementIndianaUniversityRichardMFairbanksSchoolofPublicHealthatIUPUI
Investigator,RegenstriefInstitute,Inc.
ThisworkwassupportedbytheRobertWoodJohnsonFoundationthroughtheSystemsforActionNationalCoordinatingCenter,ID73485.@JoshuaRVest
Acknowledgements
IndianaUniversity• PaulKHalverson(Co-PI)• NirMenachemi• ShaunGrannis• SurangaKasthuriranthne• …many,many,others
VestJR,HarrisLE,HautDP,HalversonPK,MenachemiN.IndianapolisProvider’sUseOfWraparoundServicesAssociatedWithReducedHospitalizationsAndEmergencyDepartmentVisits.HealthAff (Millwood).2018;37(10):1555-1561.
VestJR,MenachemiN,GrannisS,FerrellJ,KasthurirathneS,*ZhangY,TongY,HalversonP.Impactofriskstratificationonreferralsanduptakeofwraparoundservicestoaddresssocialdeterminants:asteppedwedgedtrial.AmericanJournalofPreventativeMedicine. Inpress.
USpolicyismovingtomakeprovidersaccountableforpatienthealth.
Upstream.com
Upstreamthinking
Focusonprevention
Addressingsocialdeterminants
Fitday.com
Moreandmorehealthcareorganizationsareofferingnon-medicalor“wraparound”servicestoimprovepatienthealth.
http://cchci.org/_services/behavioral-health/
www.chelseajew
ish.org/celebrating-social-w
ork-month-senior-care/
Pplay.google.com
guide.berkeley.edu/undergraduatedmkelite.com
usf.edu
Whatrolesdoestheseservicesfulfill?
• Theseservicesmostdirectlyaddress:healthbehaviors,socialcontexts,andenvironments– Thesesocialdeterminantsofhealtharelargerdriversofhealththanmedicalcare
– Thesesocialdeterminantscaninhibitcaredelivery• Lackoftransportation,poorsocialnetworks,loweducationallcomplicate(orprevent)care
• Clinicianstraditionallynottrained(andhealthcaresystemwerenotorganized)toaddresstheseissues– Requiresspecializedprofessionals
Researchquestion:
Doesreceiptofwraparoundservicesreducepatients’healthcareutilization?
Approach:
Measuretheassociationbetweenreceiptofwraparoundservicesandutilizationoutcomesinan11-yearpanelofadultpatients.
Setting,sample,&measuresSetting:• EskenaziHealthFQHCs• Expandedwraparoundservicesonco-locatedbasisin2011
Sample:• Adults(≥18)withprimarycarevisitsfrom2006-2016
– Hadtohave≥1visitbefore2011&≥1visitafter2011Determinantofinterest:receiptofwraparoundservices(Vest,Grannis,etalIJMI2017)
• Anysocialwork,behavioralhealth,nutritioncounseling,respiratorytherapy,financialplanning,medical-legalpartnership,patientnavigation,orpharmacistconsultation– Allpatientsinthestudysamplereceivedatleastonewraparoundserviceduringthestudyperiod
Outcome:• Outcomes:annualhospitalizations;annualEDvisits
Measures:• Annualriskscores,utilizationhistory,(binary)receiptofwraparoundservices(time-varying)• Chronicconditionsanddemographicfactors(timeinvariant)
Patient-levelfixed-effectsPoissonregressionmodelsdescribedtheassociationbetweenwraparoundservicesandoutcomes.
• Patient-fixedeffectscontrolledfortime-invariantfactors(e.g.race/ethnicity)• Time-varyingmeasuresincludedinmodel(e.g.annualriskscores)• Yeardummiesincludedtoadjustfortrends• Robuststandarderrorstoadjustforclustering• Wraparoundservicesenteredasalaggedbinary-indicator
– Associationwithsubsequent yearutilization
Robustnesschecks:• repeatedusingfixed-effectsnegativebinomialregression• propensity-scorematchedcomparisongroupofpatientswhodidnotreceiveany
wraparoundserviceswithrandom-interceptPoissonmodels
Highdiseaseburdenreflectiveofasafety-netpopulation%
DemographicsAge 49.7(mean)Female 71.9Race/ethnicityHispanic 18.7AfricanAmerican 41.4White,non-Hispanic 26.7Other/unknown 13.4
PatientseverityResourceutilizationband 2.54(mean)
DiagnosesHypertension 65.2Asthma 17.8Depression 42.3Diabetes 43.8
Substanceabusehistory 20.7Tobaccousehistory 33.8AnnualutilizationhistoryOutpatientvisitcount 3.42(mean)Specialistvisitcount 2.86(mean)Emergencydepartmentvisitcount 0.81(mean)Hospitalizationcount 0.20(mean)
Dietitiansfollowedbysocialworkersarethemostcommonlyaccessedwraparoundservices.
49.2
29.4
9.7
3.4
1.0
7.2
0
5
10
15
20
25
30
35
40
45
50
Dietitian Socialwork Behavioralhealth Respiratorytherapy Patientnavigation Multiple
percent
Receiptofanywraparoundservicewasassociatedwithalowercountofhospitalizationsinthesubsequentyear.
Hospitalizations
β(95%CI) pReceiptofanywraparoundserviceintheprioryear -0.07(-0.12,-0.02) 0.006Severityscore 0.66(0.63,0.69) <0.001AnnualnumberofencountersHospitalizations --EDvisits 0.01(0.00,0.02) 0.008
Outpatientvisits 0.01(0.01,0.02) <0.001
Specialtycarevisits 0.03(0.03,0.03) <0.001
Patientfixedeffectsregressionmodelswithyeardummiesomittedforreadability.
ReceiptofanywraparoundservicewasassociatedwithalowercountofEDvisitsinthesubsequentyear.
Hospitalizations Emergencydepartmentvisits
β(95%CI) p β(95%CI) pReceiptofanywraparoundserviceintheprioryear -0.07(-0.12,-0.02) 0.006 -0.05(-0.09,-0.02) 0.003Severityscore 0.66(0.63,0.69) <0.001 0.52(0.51,0.54) <0.001AnnualnumberofencountersHospitalizations -- 0.03(0.01,0.04) <0.001EDvisits 0.01(0.00,0.02) 0.008 --Outpatientvisits 0.01(0.01,0.02) <0.001 0.01(0.00,0.01) <0.001Specialtycarevisits 0.03(0.03,0.03) <0.001 0.01(0.00,0.01) 0.016
Patientfixedeffectsregressionmodelswithyeardummiesomittedforreadability.
Limitations
• Generalizability– Single,safety-netinstitution– Wraparoundservicesofferedonaco-locatedbasis(maynotapplytoorganizationsrelyingonreferrals)
• Reductionsmaybeattributabletootherqualityimprovementactivitiesoccurringatthesametime
• Resultsdonotprovideinsightsastotherelativevalueofeachservice
Receiptofanywraparoundservicewasassociatedwitha7%lowercountofhospitalizations&a5%lowercountofEDvisitsinthesubsequentyear.
• Aportfolioofwraparoundservicesmaybeaneffectivestrategyfororganizationsservingacomplexpatientpopulations.
• Wraparoundservicecouldcomplementhealthinformationexchange,riskstratification,orcross-sectoralcollaborations.
Sohowcanwebettersupportefficientandeffectiveuseofwraparoundservices?
Anywraparoundreferralrisk
scoreBehavioralhealth
referralriskscore
Dietitianreferralrisk
scoreSocialworkreferralrisk
score
Claims&EHR
Diagnoses&Utilization
Machinelearningalgorithmstoidentifythoseinneedofwraparoundservices.
ArearesourcesLivingconditionsSocialcontextSafetyTransport
nationswell.com
www.citygalleryindy.org
NeighborhoodriskbehaviorsChronicdiseases
AdditionalhealthbehaviorsUtilizationatotherproviders
Automatedprocesstoprovideriskstratificationinformation.
5:00AM
Beforeclinicsopen
Researchquestion:
Doesriskstratifyingpatientsaccordingtowraparoundserviceneeds:1. Increasereferrals2. Increasekeptappointment(i.e.betteruptake)
Approach:
Pragmatictrialusingastepped-wedgedesign
Riskstratificationwasrolledout3clinicsatatimefromJulytoNovember2017.
August September October November December JanuaryJulyJune
3cliniclocationsliveBaseline
3cliniclocationsliveBaseline
3cliniclocationsliveBaseline
Measures&analyses
• Exposure:– Riskstratificationcategoryforeachservice
80%ofthepopulationhasaprobability<0.19
95%ofthepopulationhasaprobability<0.27
RisingRisk
HighRiskLowRisk
Measures&analyses
• Exposure:– Riskstratificationcategoryforeachservice
• High• Rising• Low• Samedayappointments• Controlsite(referencegroup)
Measures&analyses
• Exposure:– Riskstratificationcategory(high,rising,low,sameday,none)
• Covariates– Demographics(e.g.gender,age,race/ethnicity)– Location– Comorbidityscores
• Analysis– GeneralizedEstimatingEquation(GEE)logisticregressionmodelsforeach
wraparoundservice(accountsforrepeatedpatientobservation)– Keptappointmentsonlyforpatientswithreferrals– NonequivalentDV(HealthyMe)
Interventionwasnotassociatedwithincreasedreferralsforanyservice.
Interventionwasassociatedwithincreasedreferralstosocialworkers
Suggestsnobroadchangestogeneralreferralpracticesintheclinics.
Forsaydayappointments(whennoscoreavailable)referralsarelesslikely• Workflowissue?• Samedaymorelikelytobeacutecondition?
Generalincreaseinkeptappointmentsoncepatientswerereferredtoservices.• Evenwithsomeindicationsofdose
response(notoversellingpilot!)
AutomatedriskstratificationscoressuccessfullydeliveredtoEskenaziHealthprimarycareclinics.
• Interventionassociatedwithincreasedreferralsforsocialworkers.
• Interventionassociatedwithincreasedratesofkeptappointmentsformultiplesocialdeterminantsofhealthservices.
• Nextstep:putitintoEPIC
JoshuaRVest,PhD,[email protected]@JoshuaRVest
Upcoming Webinars
Archives http://systemsforaction.org/research-progress-webinars
UpcomingJanuary23,2019,12p.m., ETSystemsforActionIndividualResearchProjectImplementingaCultureofHealthamongDelaware'sProbationPopulationDanielJ.O'Connell,PhD,DepartmentofCriminalJustice,UniversityofDelaware
February13,2019,12p.m.,ETSystemsforActionIntramuralResearchProjectTBAGlenP.Mays,PhD,MPH,andCBMamaril,PhD,SystemsforActionNationalProgramOffice,UniversityofKentuckyCollegeofPublicHealth
February27,2019,12p.m., ETSystemsforActionIndividualResearchProjectHousingforHealth:Cross-SectorImpactsofSupportiveHousingforHomelessHighUsersofHealthCareRicardoBasurtoDavila,PhD,MS,ChiefExecutiveOfficer,PolicyAnalysisUnit,LosAngelesCo.DepartmentofPublicHealthandCorrinBuchanan,MPP,ProgramManager,HousingforHealth,LosAngelesCo.DepartmentofPublicServices
Questions?
www.systemsforaction.org
Acknowledgements
Systems for Action is a National Program Office of the Robert WoodJohnson Foundation and a collaborative effort of the Center for Public HealthSystems and Services Research in the College of Public Health, and theCenter for Poverty Research in the Gatton College of Business and Economics,administered by the University of Kentucky, Lexington, Ky.
and