Rhode Island's investment in primary care transformation: A case study.

INTRODUCTION: Rhode Island has received national recognition as a leader in statewide, multipayer, multistakeholder initiatives that focus on investments in primary care as a strategy to build a strong delivery system foundation that delivers high-quality, affordable health care. METHOD: For this case study we summarize key structural, process and outcomes factors and lessons learned from internal and external evaluations and project based and stakeholder-engaged quality improvement efforts that helped Rhode Island become the most improved U.S. health system over the past 5 years. RESULTS: Rhode Island's Office of the Insurance Commissioner through a collaborative process contractually established per-member, per-month payments to practices that engaged in the statewide transformation program to the patient-centered medical home model of care and paid incentives for achieving quality, patient experience, and hospital utilization targets. DISCUSSION: Critical lessons learned include the importance of engaging stakeholders in systems change, measuring and monitoring primary care spending, and continuous learning and best-practice sharing. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Care Transformation Collaborative of Rhode Island: Building a Strong Foundation for Comprehensive, High-Quality Affordable Care.

As the Patient Centered Medical Home (PCMH) model has evolved nationally and in Rhode Island, there has been increased recognition that PCMH has not been sufficient to achieve desired cost and quality goals. In this article, we describe the evolving concept of "comprehensive primary care" in Rhode Island, which includes addressing the behavioral health and social determinants of health (SDOH) needs of patients. These needs are identified through systematic screening and dedicated care management and care coordination for patients who present with complex needs.

Trait anxiety and nicotine dependence in adolescents: a report from the DANDY study.

The Revised Children's Manifest Anxiety Scale (RCMAS) and the Hooked on Nicotine Checklist (HONC) were used to measure trait anxiety and tobacco dependence in a population of 581 adolescents. Smokers demonstrated higher mean RCMAS scores (9.3, S.D.=6.5) than nonsmokers did (7.4, S.D.=6.2, t=-3.7, P<.001). Participants with symptoms of tobacco dependence had higher RCMAS scores (mean=11.6, S.D.=6.0, n=115) than did the participants without symptoms (mean=7.8, S.D.=6.0, n=177, t=-5.3, P<.001). Scores on the RCMAS and the HONC correlated positively (n=292, r=.32, P<.001). Participants who had felt relaxed in response to their first exposure to nicotine were also more likely to develop dependence and to report that stress caused cravings or a need to smoke. Trait anxiety and relaxation in response to the first dose of nicotine were unrelated and appear to be independent risk factors for the development of nicotine dependence and a reliance on tobacco to cope with stress.

Recollections and repercussions of the first inhaled cigarette.

CONTEXT: It has not been determined if a youth's reaction to the first smoking experience is predictive of future nicotine dependence, or whether the impact of the first cigarette can be altered by manipulating levels of tar, nicotine and menthol. OBJECTIVE: To determine if the recalled response to the first cigarette is predictive of the development of symptoms of nicotine dependence and whether it is influenced by the type of cigarette smoked. DESIGN AND SETTING: A retrospective/prospective longitudinal study of the natural history of nicotine dependence employing individual interviews conducted three times annually in two urban school systems over 3 years. Subjects were asked to recall their first smoking experience. PARTICIPANTS: A cohort of 237 subjects who had inhaled on a cigarette. MAIN OUTCOME MEASURES: Symptoms associated with smoking; the Hooked on Nicotine Checklist of 10 symptoms of dependence. RESULTS: Reactions to the initial smoking experience were unrelated to gender or cigarette brand, strength or mentholation. Relaxation in response to the first inhalation was the strongest predictor of symptoms of nicotine dependence. Dizziness and nausea were also independent predictors of dependence symptoms. CONCLUSIONS: The data suggest that increased sensitivity to nicotine as manifested by relaxation, dizziness, or nausea in response to the first exposure to nicotine represents a risk factor for the development of nicotine dependence.

Measuring the loss of autonomy over nicotine use in adolescents: the DANDY (Development and Assessment of Nicotine Dependence in Youths) study.

CONTEXT: There is no validated, theory-based tool for assessing the onset of nicotine dependence. However, the use of all addictive substances can result in a loss of autonomy. We propose that nicotine dependence begins when autonomy is lost, ie, when the sequelae of tobacco use, either physical or psychological, present a barrier to quitting. OBJECTIVES: To test the autonomy theory of nicotine dependence, and to evaluate the Hooked on Nicotine Checklist (HONC) as a measure of the loss of autonomy over tobacco use. DESIGN: The psychometric performance and concept validity of the HONC were evaluated in a 30-month prospective longitudinal study of the natural history of tobacco use in a cohort of 679 seventh-grade students. RESULTS: As hypothesized, endorsement of a single item on the HONC was associated with a failed attempt at smoking cessation (odds ratio [OR], 29; 95% confidence interval [CI], 13-65), continued smoking until the end of follow-up (OR, 44; 95% CI, 17-114), and daily smoking (OR, 58; 95% CI, 24-142). Scores on the HONC correlated with the maximum amount smoked (r = 0.65; P<.001) and the maximum frequency of smoking (r = 0.79; P<.001). Internal reliability was 0.94. A 1-factor solution explained 66% of the total variance. CONCLUSIONS: The data support the autonomy theory that dependence begins with the loss of autonomy. The autonomy theory represents a potentially useful alternative to current concepts of nicotine dependence for adolescents, and the HONC appears to measure lost autonomy in adolescents. Construct validity was demonstrated by its utility in predicting failed cessation and the progression of tobacco use. In addition, the psychometric properties were excellent.