Addressing Health-Related Social Needs Via Community Resources: Lessons From Accountable Health Communities.

The Center for Medicare and Medicaid Innovation launched the Accountable Health Communities (AHC) Model in 2017 to assess whether identifying and addressing Medicare and Medicaid beneficiaries' health-related social needs reduced health care use and spending. We surveyed a subset of AHC Model beneficiaries with one or more health-related social needs and two or more emergency department visits in the prior twelve months to assess their use of community services and whether their needs were resolved. Survey findings indicated that navigation-connecting eligible patients with community services-did not significantly increase the rate of community service provider connections or the rate of needs resolution, relative to a randomized control group. Findings from interviews with AHC Model staff, community service providers, and beneficiaries identified challenges connecting beneficiaries to community services. When connections were made, resources often were insufficient to resolve beneficiaries' needs. For navigation to be successful, investments in additional resources to assist beneficiaries in their communities may be required.

Health Care Impacts Of Resource Navigation For Health-Related Social Needs In The Accountable Health Communities Model.

Social determinants of health can adversely affect health and therefore lead to poor health care outcomes. When it launched in 2017, the Accountable Health Communities (AHC) Model was at the forefront of US health policy initiatives seeking to address social determinants of health. The AHC Model, sponsored by the Centers for Medicare and Medicaid Services, screened Medicare and Medicaid beneficiaries for health-related social needs and offered eligible beneficiaries assistance in connecting with community services. This study used data from the period 2015-21 to test whether the model had impacts on health care spending and use. Findings show statistically significant reductions in emergency department visits for both Medicaid and fee-for-service Medicare beneficiaries. Impacts on other outcomes were not statistically significant, but low statistical power may have limited our ability to detect model effects. Interviews with AHC Model participants who were offered navigation services to help them find community-based resources suggested that navigation services could have directly affected the way in which beneficiaries engage with the health care system, leading them to be more proactive in seeking appropriate care. Collectively, findings provide mixed evidence that engaging with beneficiaries who have health-related social needs can affect health care outcomes.

Intentional and unintentional nonadherence to hydroxyurea among people with sickle cell disease: a qualitative study.

Hydroxyurea is an efficacious treatment for sickle cell disease (SCD), but adoption is low among individuals with SCD. The objective of this study was to examine barriers to patients' adherence to hydroxyurea use regimens by using the intentional and unintentional medication nonadherence framework. We interviewed individuals with SCD age 15 to 49.9 years who were participants in the Sickle Cell Disease Implementation Consortium (SCDIC) Needs Assessment. The intentional and unintentional medication nonadherence framework explains barriers to using hydroxyurea and adds granularity to the understanding of medication adherence barriers unique to the SCD population. In total, 90 semi-structured interviews were completed across 5 of the 8 SCDIC sites. Among interviewed participants, 57.8% (n = 52) were currently taking hydroxyurea, 28.9% (n = 26) were former hydroxyurea users at the time of the interview, and 13.3% (n = 12) had never used hydroxyurea but were familiar with the medication. Using a constructivist grounded theory approach, we discovered important themes that contributed to nonadherence to hydroxyurea, which were categorized under unintentional (eg, Forgetfulness, External Influencers) and intentional (Negative Perceptions of Hydroxyurea, Aversion to Taking Any Medications) nonadherence types. Participants more frequently endorsed adherence barriers that fell into the unintentional nonadherence type (70%) vs intentional nonadherence type (30%). Results from this study will help SCD health care providers understand patient choices and decisions as being either unintentional or intentional, guide tailored clinical discussions regarding hydroxyurea therapy, and develop specific, more nuanced interventions to address nonadherence factors.

A qualitative framework-based evaluation of radiology clinical decision support initiatives: eliciting key factors to physician adoption in implementation.

OBJECTIVES: To illustrate key contextual factors that may have effects on clinical decision support (CDS) adoption and, ultimately, success. MATERIALS AND METHODS: We conducted a qualitative evaluation of 2 similar radiology CDS innovations for near-term endpoints affecting adoption and present the findings using an evaluation framework. We identified key contextual factors between these 2 innovations and determined important adoption differences between them. RESULTS: Degree of electronic health record integration, approach to education and training, key drivers of adoption, and tailoring of the CDS to the clinical context were handled differently between the 2 innovations, contributing to variation in their relative degrees of adoption and use. Attention to these factors had impacts on both near and later-term measures of success (eg, patient outcomes). DISCUSSION: CDS adoption is a well-studied early-term measure of CDS success that directly impacts outcomes. Adoption requires attention throughout the design phases of an intervention especially to key factors directly affecting it, including how implementation across multiple sites and systems complicates adoption, which prior experience with CDS matters, and that practice guidelines invariably require tailoring to the clinical context. CONCLUSION: With better planning for the capture of early-term measures of successful CDS implementation, especially adoption, critical adjustments may be made to ensure that the CDS is effectively implemented to be successful.

Framework for Research on Implementation of Process Redesigns.

BACKGROUND: Complex system interventions benefit from close attention to factors affecting implementation and resultant outcomes. This article describes a framework for examining these factors in process redesign (PR) and for assessing PR outcomes. METHODS: Using literature scans and expert comment on draft frameworks based on the Consolidated Framework for Implementation Research, a team of researchers developed the PR framework for the Agency for Healthcare Research and Quality. As a case study, an independent team of researchers in a large care system subsequently applied the PR framework to implementation of Lean-based primary care redesigns. RESULTS: The PR framework adds 2 domains to the Consolidated Framework for Implementation Research, focused on relevant measures of implementation and outcomes, as well as some new constructs to the Consolidated Framework for Implementation Research. Using the PR framework to guide a study of primary care PR, researchers found that the health care reform environment encouraged staff recognition of need for redesign, but physicians worried about key redesign issues, including colocation with care team partners and the competencies of the individuals assigned to manage new workflows. Team member acceptance of the redesign was also influenced by other features of the implementation process and contextual features, including the decision style of the local clinic. CONCLUSIONS: The PR framework helped guide the qualitative study and aided researchers in informing their leadership about critical issues affecting PR implementation.

Impact Of The YMCA Of The USA Diabetes Prevention Program On Medicare Spending And Utilization.

The YMCA of the USA received a Health Care Innovation Award from the Centers for Medicare and Medicaid Services to provide a diabetes prevention program to Medicare beneficiaries with prediabetes in seventeen regional networks of participating YMCAs nationwide. The goal of the program is to help participants lose weight and increase physical activity. We tested whether the program reduced medical spending and utilization in the Medicare population. Using claims data to compute total medical costs for fee-for-service Medicare participants and a matched comparison group of nonparticipants, we found that the overall weighted average savings per member per quarter during the first three years of the intervention period was $278. Total decreases in inpatient admissions and emergency department (ED) visits were significant, with nine fewer inpatient stays and nine fewer ED visits per 1,000 participants per quarter. These results justify continued support of the model.

A framework to guide implementation research for care transitions interventions.

Evaluating implementation of complex interventions to improve care transitions and comparison across studies is challenging due to issues such as variation in methods and lack of reporting key evaluation elements. This article describes a framework for evaluating implementation of hospital to ambulatory care transitions interventions and application to a case study. We searched published and gray literature for relevant frameworks. We adapted the general Consolidated Framework for Implementation Research, adding elements relevant to other complex interventions. We refined these adaptations through structured expert input and application to case studies. Key adaptations included conceptualization around organizations, not just settings, and around patient- and caregiver-centeredness. Although these interventions are often oriented toward institutional outcomes such as readmissions, tailoring interventions to specific patient needs strengthens effectiveness. Coordination and communication are important between organizations and providers and with patients and caregivers. Roles of those involved in the intervention--providers, administrators, and facilitators from different organizations--are also key constructs. Finally, as these interventions often are tailored to specific settings and adapt over time, assessing intervention design--which components are implemented as part of the bundle, how they are actually implemented, and their differential impact on effectiveness--is critical.

Biosurveillance in outbreak investigations.

Following the terrorist attacks of September 11 and the anthrax attacks in 2001, public health entities implemented automated surveillance systems based on disease syndromes for early detection of bioterror events and to increase timeliness of responses. Despite widespread adoption, syndromic surveillance systems' ability to provide early notification of outbreaks is unproven, and there is little documentation on their role in outbreak response. We hypothesized that biosurveillance is used in practice to augment classical outbreak investigations, and we used case studies conducted in 2007-08 to determine (1) which steps in outbreak investigations were best served by biosurveillance, and (2) which steps presented the greatest opportunities for improvement. The systems used in the case studies varied in how they functioned, and there were examples in which syndromic systems had identified outbreaks before other methods. Biosurveillance was used successfully for all steps of outbreak investigations. Key advantages of syndromic systems were sensitivity, timeliness, and flexibility and as a source of data for situational awareness. Limitations of biosurveillance were a lack of specificity, reliance on chief complaint data, and a lack of formal training for users. Linking syndromic data to triage notes and medical chart data would substantially increase the value of biosurveillance in the conduct of outbreak investigations and reduce the burden on health department staff.

Impact of the CDC's Section 317 Immunization Grants Program funding on childhood vaccination coverage.

The Centers for Disease Control and Prevention's Section 317 Grants Program is the main source of funding for state and jurisdictional immunization programs, yet no study has evaluated its direct impact on vaccination coverage rates. Therefore, we used a fixed-effects model and data collected from 56 US jurisdictions to estimate the impact of Section 317 financial assistance immunization grants on childhood vaccination coverage rates from 1997 to 2003. Our results showed that increases in Section 317 funding were significantly and meaningfully associated with higher rates of vaccination coverage; a 10 dollars increase in per capita funding corresponded with a 1.6-percentage-point increase in vaccination coverage. Policymakers charged with funding public health programs should consider this study's findings, which indicate that money allocated to vaccine activities translates directly into higher vaccine coverage rates.

An instrument for assessing public health system performance: validity in rural settings.

PURPOSE: This study evaluated the validity and utility of the Local Public Health System Assessment Instrument (Local Instrument) of the National Public Health Performance Standards Program in rural settings. METHODS: The study compared the Local Instrument scores of 6 rural local public health systems to external assessments of those public health systems. The 6 public health systems represented 3 states in which 1 of the 2 local jurisdictions had scored well below and the other well above the state median in a pilot test of the Local Instrument. The study design featured a case study approach consisting of an iterative and integrated combination of semistructured individual and focus group interviews along with the collection of archival materials provided by the 6 public health systems. FINDINGS: Despite differences in Local Instrument scores, the representative public health systems in each state provided roughly the same levels of public health services. Sites varied tremendously in the percentage of survey items rated highly or less relevant. CONCLUSIONS: The National Public Health Performance Standards Program Local Instrument can provide a useful structure and process for assessing public health system performance at the local level. Key informants provided several recommendations to improve the Local Instrument, including clarification of difficult terminology and acronyms, and development of multiple instruments structured around subsets of survey items.