Community Health Workers Bring Cost Savings to Patient-Centered Medical Homes.

The Patient-Centered Medical Home (PCMH) model demonstrated that processes of care can be improved while unnecessary care, such as preventable emergency department utilization, can be reduced through better care coordination. A complementary model, the Integrated Primary Care and Community Support (I-PaCS) model, which integrates community health workers (CHWs) into primary care settings, functions beyond improved coordination of primary medical care to include management of the social determinants of health. However, the PCMH model puts downward pressure on the panel sizes of primary care providers, increasing the average fixed costs of care at the practice level. While the I-PaCS model layers an additional cost of the CHWs into the primary care cost structure, that additional costs is relatively small. The purpose of this study is to simulate the effects of the PCMH and I-PaCS models over a 3-year period to account for program initiation to maturity. The costs and cost offsets of the model were estimated at the clinic practice level. The studies which find the largest cost savings are for high-risk, paneled patients and therefore do not represent the effects of the PCMH model on moderate-utilizing patients or practice-level effects. We modeled a 12.6% decrease in the inpatient hospital, outpatient hospital and emergency department costs of high and moderate risk patients. The PCMH is expected to realize a 1.7% annual savings by year three while the I-PaCS program is expected to a 7.1% savings in the third year. The two models are complementary, the I-PaCS program enhancing the cost reduction capability of the PCMH.

The Evolution of an Innovative Community-Engaged Health Navigator Program to Address Social Determinants of Health.

BACKGROUND: Health navigators and other types of community health workers (CHWs) have become recognized as essential components of quality care, and key for addressing health disparities owing to the complex health care services landscape presents almost insurmountable challenges for vulnerable individuals. Bernalillo County, New Mexico, has high rates of uninsurance, poverty, and food insecurity. OBJECTIVES: The design of the Pathways to a Healthy Bernalillo County Program (BP) has evolved innovations that are unique in terms of program stability and security, expansive reach, and community capacity across six domains: sustainable public mechanism for program funding, involvement of community organizations in designing the program, expanded focus to address the broader social determinants of health with targeted outreach, an integrated, community-based implementation structure, an outcomes-based payment structure, and using an adaptive program design that actively incorporates navigators in the process. METHODS: In 2008, the Pathways to a Healthy Bernalillo County Program (BP), located in the Albuquerque metropolitan area in central New Mexico, was established to provide navigation and support for the most vulnerable county residents. BP is funded through a 1% carve out of county mill levy funds. RESULTS: The pathways model is an outcome-based approach for health and social services coordination that uses culturally competent CHW as "navigators" trained to connect at-risk individuals to needed health and social services. CONCLUSIONS: One of the important innovations of the pathways approach is a shift in focus from merely providing discrete services to confirming healthy outcomes for the individual patient.

Process evaluation of a promotora de salud intervention for improving hypertension outcomes for Latinos living in a rural U.S.-Mexico border region.

Hypertension is a growing public health problem for U.S.-Mexico border Latinos, who commonly experience low levels of awareness, treatment, and control. We report on a process evaluation that assessed the delivery of Corazón por la Vida, a 9-week promotora de salud-led curriculum to help Latinos manage and reduce hypertension risks in two rural/frontier counties in the New Mexico border region. Ninety-six adults participated in the program, delivered in three waves and in three communities. We assessed program delivery and quality, adherence, exposure, and participant responsiveness. Participant outcome measures included self-reported eating and physical activities and assessment of community resources. Findings suggest that the program was fully delivered (99%) and that most participants (81.7%) were very satisfied with the educational sessions. The average participant attendance for educational sessions was 77.47%. We found significant differences in self-reported behavioral changes depending on the number of sessions completed: The higher the dose of sessions, the better the self-reported outcomes. These findings suggest that a promotora-led curriculum may be useful for promoting self-management of chronic disease in rural/frontier border Latino populations. Future evaluation should focus on training and implementation adaptations within evidence-based chronic disease programs for diverse Latino communities.

Determinants of nonmedical use, abuse or dependence on prescription drugs, and use of substance abuse treatment.

BACKGROUND: Previous studies have found a negative association between health insurance and nonmedical use of prescription drugs (NMUPD), and abuse or dependence on prescription drugs (ADPD); and mixed associations between health insurance and use of substance abuse treatment (SAT). However, effect of health insurance in the specific subgroups of population is largely unknown. OBJECTIVE: To estimate the relationship between health insurance and (1) NMUPD, (2) ADPD, and (3) use of SAT services among 12-64 years old, noninstitutionalized individuals and to see if these relationships are different in different subgroups of population. METHODS: This study used cross-sectional survey data from 2007 National Survey on Drug Use and Health. Bivariate and multiple logistic regression analyses were conducted. RESULTS: In 2007, self-reported prevalence of NMUPD was approximately 10% (N=15,509,703). In multivariate analysis, NMUPD was negatively associated with health insurance, age, race other than non-Hispanic White, education, marital status, and income ($40,000-$74,999). Past year use of tobacco and alcohol were positively associated with NMUPD. Among those with private health insurance, Hispanics and individuals with family income less than $20,000 and $40,000-$74,999 were more likely prone to NMUPD than others. High school graduates with public health insurance were less likely prone to NMUPD. Approximately, 13% of nonmedical users reported ADPD (N=2,011,229). Health insurance and age were negatively associated with ADPD. However, people who were unmarried, reported fair/poor health, and used tobacco were more likely to report ADPD. Lastly, the use of substance abuse treatment programs was approximately 73% and 76% between NMUPD and ADPD population, respectively. Health insurance was not associated with use of substance abuse treatment. Individuals with high school education were 2.6 times more likely to use substance abuse treatment than the college graduates. Additionally, no significant interaction effects were found between health insurance, and sociodemographic factors on ADPD and the use of substance abuse treatment. CONCLUSIONS: Health insurance had a differential impact on NMUPD only. Among privately insured, Hispanics and individuals reporting family income less than $20,000 were more likely to engage in NMUPD. There is a need to better understand and monitor the use of prescription drugs among these groups. This knowledge can help in developing public health programs and policies that discourage NMUPD among these individuals.

A system-based intervention to improve colorectal cancer screening uptake.

OBJECTIVE: To determine whether mailing guaiac-based fecal occult blood tests (gFOBTs) directly to patients who are due for colorectal cancer screening would achieve higher screening uptake than using visit-based screening. STUDY DESIGN: Comparative effectiveness analysis. METHODS: We used an electronic medical record to identify 7053 New Mexico Veterans Affairs Health Care System patients aged 50 to 80 years who were due for screening in 2008. We invited 3869 randomly selected patients to participate in a randomized controlled trial comparing adherence with different fecal blood tests; 202 intervention patients were assigned to receive mailed gFOBTs. We identified the following 3 control groups who could receive only visit-based colorectal cancer screening: 3184 individuals who were not invited for the randomized controlled trial (control group 1), 2525 individuals who did not respond to invitations to participate in the randomized controlled trial (control group 2), and 255 individuals who could not be contacted (control group 3). We measured gFOBT screening within 3 months after enrollment in the intervention group, as well as gFOBT or colonoscopy screening within 6 months of identification as a control subject. We compared screening across groups using multivariate logistic regression analysis to adjust for sex, race/ethnicity, clinic site, previous gFOBT, and comorbidities. RESULTS: Colorectal screening occurred less often in each of the control groups (in 18.6% of control group 1, in 14.3% of control group 2, and in 18.8% of control group 3) than among patients mailed a gFOBT (48.5%). Adjusted odds ratios for screening among the control groups were all less than in the intervention group (adjusted odds ratios, 0.25, 0.19, and 0.23, respectively; all, P <.001). CONCLUSION: Using an electronic medical record to identify screening-eligible patients and mailing them gFOBT cards achieved higher colorectal screening uptake than performing visit-based screening.

Depression and anxiety in ambulatory patients with heart failure.

BACKGROUND: Depression and anxiety are common in heart failure, but the prevalence, incidence, and relationship of these conditions to health service use and mortality remains uncertain. OBJECTIVE: The authors sought to delineate these parameters and identify patient factors predicting hospitalizations for heart failure and mortality 12 months after their initial diagnosis of heart failure. METHOD: The authors utilized a retrospective database cohort of 12,028 ambulatory patients with newly diagnosed heart failure to examine diagnosed depression and anxiety and the relationship of these conditions to health service use and all-cause mortality. RESULTS: Patients with diagnosed depression and/or anxiety (18% of the cohort) were frequently identified by providers within the first 30 days after a heart failure diagnosis. They subsequently utilized twice as many health services, but they did not show increased mortality risk. DISCUSSION: Although mental health intervention data for heart failure patients are limited, the prevalence and impact of depression and anxiety in these patients suggest that assessment and intervention efforts appear warranted early in the heart failure process.

Strategic opportunities in the oversight of the U.S. hospital accreditation system.

Hospital accreditation and state certification are the means that the Centers for Medicare & Medicaid Services (CMS) employs to meet quality of care requirements for medical care reimbursement. Hospitals can choose to use either a national accrediting agency or a state certification inspection in order to receive Medicare payments. Approximately, 80% of hospitals choose the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The purpose of this paper is to analyze and discuss improvements on the structure of the accreditation process in a Principal-Agent-Supervisor framework with a special emphasis on the oversight by the principal (CMS) of the supervisor (JCAHO).

Prevalence of dementia among Veterans Affairs medical care system users.

OBJECTIVES: In an aging population, the number of veterans diagnosed with dementia is likely to increase. Knowledge of existing dementia prevalence will be beneficial in planning for future patient care needs. Our objectives were to assess the prevalence of the dementia diagnosis among those treated at Veterans Affairs (VA) medical centers and determine how it varies across race and Veterans Integrated Service Network (VISN). MATERIALS AND METHODS: Data were collected on all veterans seen within the VA medical system from 1997 through the first half of 2001. Only veterans aged 65 and over were included in the study. Veterans were included if they had one of the following dementia ICD-9 codes: 290.XX, 291.2, 294.XX, 331.XX, 046.1, or 046.3. RESULTS: The overall prevalence of dementia was 7.3%. The prevalence of dementia was similar among white patients and patients of other races, except African-American patients, in whom it was 50% higher. Across VISNs, the prevalence of dementia ranged from 5.8 to 9.4%. Alzheimer's disease was the most frequently diagnosed type of dementia within the VA, and inpatient service utilization and outpatient psychiatry visits by individuals with dementia were high relative to other VA patients. DISCUSSION: The overall prevalence identified is consistent with that reported in the literature, as is the elevated prevalence in African-Americans versus whites. The data on prevalence by VISN may identify regional variation in either the types of dementia present or the diagnostic criteria used. The dementia diagnosis is clearly associated with substantial service use.

Prospect theory in the valuation of health.

Prospect theory is the prominent nonexpected utility theory in the estimation of health state preference scores for quality-adjusted life year calculation. Until recently, the theory was not considered to be developed to the point of implementation in economic analysis. This review focuses on the research and evidence that tests the implementation of prospect theory into health state valuation. The typical application of expected utility theory assumes that a decision maker has stable preferences under conditions of risk and uncertainty. Under prospect theory, preferences are dependent on whether the decision maker regards the outcome of a choice as a gain or loss, relative to a reference point. The conceptual preference for standard gamble utilities in the valuation of health states has led to the development of elicitation techniques. Empirical evidence using these techniques indicates that when individual preferences are elicited, a prospect theory consistent framework appears to be necessary for adequate representation of individual health utilities. The relevance of prospect theory to policy making and resource allocation remains to be established. Societal preferences may not need the same attitudes towards risks as individual preferences, and may remain largely risk neutral.