June 2017 Research Round-Up

Impact of a Patient Navigator Program on Hospital-Based and Outpatient Utilization Over 180 Days in a Safety-Net Health System
R.B. Balaban, F. Zhang, C.E. Vialle-Valentin, et al.
Journal of General Internal Medicine

The authors of this paper evaluated a post-hospital discharge outreach program in which patient navigators provided coaching and help with medical needs, transportation to outpatient appointments, connections to services, and health insurance problems using an RCT. Among older high-risk patients, the outreach program decreased hospital-based utilization and increased outpatient visits in the first 30-days post-discharge, but in younger populations, the program resulted in higher hospital-based utilization and no significant change in outpatient utilization.

Clinic-to-Community Models to Address Food Insecurity
E. Barnidge, S. Stenmark, H. Seligman
JAMA Pediatrics

The authors of this commentary describe the challenges and innovative opportunities within two current models for screening and addressing food insecurity in clinical settings: a comprehensive model that includes dedicated expertise and support from clinical team members to evaluate social needs and ensure successful connections to community resources; and the narrower direct provision of food resources through on-site food pantries, community-based food pharmacies, and vouchers for food.

Health Care Merged with Senior Housing: Description and Evaluation of a Successful Program
T.T. Barry
Gerontology and Geriatric Medicine

The author of this case study describes a partnership between a large health care organization and housing for seniors which provides on-site, primary care visits by a physician and a nurse in addition to intensive social services to in an affordable senior housing building.

Mapping Neighborhood Health Geomarkers to Clinical Care Decisions to Promote Equity in Child Health
A.F. Beck, M.T. Sandel, P.H. Ryan, R.S. Kahn
Health Affairs

The authors of this article highlight how community-level data on social determinants of health from national and local sources could be incorporated into patient-centered care to improve care experiences and clinical outcomes while reducing disparities and costs. The authors also discuss how this information could stimulate cross-sector interventions that promote health equity and identify research questions on the role of geographical place at the bedside.

Integrating Social Services and Home-Based Primary Care for High-Risk Patients
J. Feinglass, G. Norman, R.L. Golden, N. Muramatsu, M. Gelder, T. Cornwell
Population Health Management

The authors of this review focus on the prospects for integrating social services with the health care delivery system for vulnerable patient populations. It examines the historical context for delivery system transformation and summarizes principles of home- and person-centered care based, the potential of coordination of social services with new models of integrated medical care, and how this new model might emerge in the coming decade.

Bending the Spending Curve by Altering Care Delivery Patterns: The Role of Care Management within a Pioneer ACO
J. Hsu, M. Price, C. Vogeli, et al.
Health Affairs

The results of this study demonstrate that participation in a care management program, which included assessing and addressing psychosocial needs, was associated with substantial reductions in rates for hospitalizations and ED visits, as well as Medicare spending.

Clinicians’ Perceptions of Screening for Food Insecurity in Suburban Pediatric Practice
D. Palakshappa, A. Vasan, S. Khan, L. Seifu, C. Feudtner, A.G. Fiks
Pediatrics

Providers successfully screened 4,371 (77.4%) of patients and identified 122 (2.8%) food insecure families; though only 1 family received new SNAP benefits. In focus groups, clinician’s reported that time and workflow were not barriers to screening, but concerns about embarrassing families and being unable to provide adequate resources were. Clinicians also reported that parents felt the screening showed caring, which reinforced clinicians’ continued screening. Finally, clinicians suggested implementing screening before the visit to reduce stigma and give clinicians time to prepare resources for those who screened positive.

Suburban Families’ Experience with Food Insecurity Screening in Primary Care Practices
D. Palakshappa, A. Vasan, S. Khan, L. Seifu, C. Feudtner, A.G. Fiks
Pediatrics

Parents’ perceptions of food insecurity screening during well-child visits in pediatric primary care were explored in this qualitative study. Three primary themes emerged: Parents expressed initial surprise at screening followed by comfort discussing their unmet food needs; parents experience shame, frustration, and helplessness regarding FI, but discussing FI with their clinician helped alleviate these feelings; parents suggested practices could help them more directly access food resources, which, depending on income, may not be available to them through government programs.

Innovative Home Visit Models Associated with Reductions in Costs, Hospitalizations, and Emergency Department Use
S. Ruiz, L.P. Snyder, C. Rotondo, C. Cross-Barnet, E. Murphy Colligan, K. Giuriceo
Health Affairs

The authors of this study evaluated the impact of five Health Care Innovation Awards of the Centers for Medicare and Medicaid Services funded home-based care models led by practice-extender teams (registered nurses or lay health workers). Components of care delivery identified in the models included care coordination; patient or caregiver education; referrals to home and community based services (e.g. transportation, food, housing assistance); disease management; advanced care planning; or environmental assessment. Two models achieved significant reductions in Medicare expenditures, and three models reduced utilization in the form of emergency department visits, hospitalizations, or both for beneficiaries relative to comparison groups.

Building Baltimore’s Accountable Health Community
S. Sarkar, D. O’Neill, L.S. Wen
New England Journal of Medicine Catalyst

The authors of this post describe the development of and principles behind Baltimore City’s city-wide Accountable Health Communities (AHC) model, one of the 32 sites funded by CMMI in its AHC model demonstration project.

Impact of Health Care Delivery System Innovations on Total Cost of Care
K.W. Smith, A. Bir, N.L. Freeman, B.C. Koethe, J. Cohen, T.J. Day
Health Affairs

The authors of this study analyzed results from 43 ambulatory care programs funded by the first round of the Center for Medicare and Medicaid Innovation’s Health Care Innovations Awards. While most innovations did not impact total costs of care within the first two years, meta-regression analysis on the effects of five common intervention components (health information technology, behavioral health, community health workers, medical home, and telemedicine) showed greater cost savings from health information technology and community health workers as well as innovations targeting clinically fragile complex patients at risk for disease progression. No meaningful effects of innovations targeting socially fragile patients at risk because of social circumstances were observed.

Universal v. Risk-Based Screening for Food Insecurity
J.F. Steiner, C. Zeng
Public Health Nutrition

In this letter to the editor, the authors discuss ethical and practical considerations of risk-based versus universal screening for food insecurity, highlighting the high false positive rates that would result from universal screening in low food insecurity populations.

Civil Legal Services and Medical-Legal Partnerships Needed by the Homeless Population: A National Survey
J. Tsai, D. Jenkins, E. Lawton
American Journal of Public Health

The authors of this study examined the prevalence of civil legal needs among patients of homeless service sites in 26 states, and the availability of screening for legal needs and medical-legal partnerships in these sites. It found that more than 90% of sites reported that their patients experienced at least one civil legal issue, however only half of the sites screened patients for legal needs and only 10% had a medical-legal partnership.

For Super-Utilizers, Integrated Care Offers a New Path
B. Vaida
Health Affairs

The author of this commentary describes trends and examples of how addressing social determinants of health as part of clinical care can improve outcomes for complex care patients, with highlights from the Camden Coalition in New Jersey, the Southcentral Foundation’s Nuka System in Alaska, CareOregon, and Wisconsin’s efforts with Medicaid beneficiaries in the Milwaukee area.