Anne Elizabeth Glassgow

An innovative health-care delivery model for children with medical complexity

Children with medical complexity (CMC) account for a disproportionate share of pediatric health-care utilization and cost that is largely attributable to long hospitalizations, frequent hospital readmissions, and high use of emergency departments. In response, the Centers for Medicare and Medicaid Services Health Care Innovation Center supports the development and testing of innovative health-care payment and service delivery models. The purpose of this article is to describe the CMS-funded coordinated health care for complex kids (CHECK) program, an innovative system of health-care delivery that provides improved, comprehensive, and well-coordinated services to CMC. The CHECK program uses a combination of high-tech and low-tech interventions to connect patients, stakeholders, and providers. It is anticipated that the investment in additional support services to CMC will result in improved quality of care that leads to a reduction in unnecessary inpatient hospitalizations, readmissions, and emergency department visits and a total cost savings. The CHECK program has the potential to inform future cost-effective health-care models aimed at improving the quality of life and care for CMC and their families.

Patient Navigation Improves Subsequent Breast Cancer Screening After a Noncancerous Result: Evidence from the Patient Navigation in Medically Underserved Areas Study

BACKGROUND Past efforts to assess patient navigation on cancer screening utilization have focused on one-time uptake, which may not be sufficient in the long term. This is partially due to limited resources for in-person, longitudinal patient navigation. We examine the effectiveness of a low-intensity phone- and mail-based navigation on multiple screening episodes with a focus on screening uptake after receiving noncancerous results during a previous screening episode. METHODS The is a secondary analysis of patients who participated in a randomized controlled patient navigation trial in Chicago. Participants include women referred for a screening mammogram, aged 50-74 years, and with a history of benign/normal screening results. Navigation services focused on identification of barriers and intervention via shared decision-making processes. A multivariable logistic regression intent-to-treat model was used to examine differences in odds of obtaining a screening mammogram within 2 years of the initial mammogram (yes/no) between navigated and non-navigated women. Sensitivity analyses were conducted to explore patterns across subsets of participants (e.g., navigated women successfully contacted before the initial appointment; women receiving care at Hospital C). RESULTS The final sample included 2,536 women (741 navigated, 1,795 non-navigated). Navigated women exhibited greater odds of obtaining subsequent screenings relative to women in the standard care group in adjusted models and analyses including women who received navigation before the initial appointment. CONCLUSIONS Our findings suggest that low-intensity navigation services can improve follow-up screening among women who receive a noncancerous result. Further investigation is needed to confirm navigations impacts on longitudinal screening.

The effect of father's absence, parental adverse events, and neighborhood disadvantage on children’s aggression and delinquency: A multi-analytic approach

ABSTRACT We applied multiple statistical approaches to address the covarying nature of neighborhood, household context, and children’s behavioral problems. The focal relationship under investigation was the effect of fathers presence on child’s aggression. We take advantage of hybrid models to examine within-group fixed effects of time-varying variables, while paying attention to household stable characteristics. Findings demonstrate that the level of childs aggression was influenced more by household and neighborhood-level stable characteristics. Living in a disadvantaged neighborhood had direct and indirect effects on child s aggression, controlling for other variables. Fixed effects model showed no significant relationship between having a father in the household and childs aggression. However, hybrid models with between- and within-group differences in fathers absence indicated that the between-individual difference was significantly associated with childs aggression. The findings suggest that contextual forces that precede the relationship between fathers absence and childs aggression might determine who may be likely to live in households with characteristics that affect both fathers absence and childs aggression. When there are systematic selection biases, statistical methods suited for determining causal inference, such as fixed effects models, cannot fully tease out larger contextual and systemic forces that sort individuals into certain types of households and neighborhoods.

A Real-World Community Health Worker Care Coordination Model for High-Risk Children:

Health care systems across the United States are considering community health worker (CHW) services for high-risk patients, despite limited data on how to build and sustain effective CHW programs. We describe the process of providing CHW services to 5,289 at-risk patients within a state-run health system. The program includes 30 CHWs, six care coordinators, the Director of Care Coordination, the Medical Director, a registered nurse, mental health specialists, and legal specialists. CHWs are organized into geographic and specialized teams. All CHWs receive basic training that includes oral and mental health; some receive additional disease-specific training. CHWs develop individualized care coordination plans with patients. The implementation of these plans involves delivery of a wide range of social service and coordination support. The number of CHW contacts is determined by patient risk. CHWs spend about 60% of their time in an office setting. To deliver the program optimally, we had to develop multiple CHW job categories that allow for CHW specialization. We created new technology systems to manage operations. Field issues resulted in program changes to improve service delivery and ensure safety. Our experience serves as a model for how to integrate CHWs into clinical and community systems.

A Comparison of Different Intensities of Patient Navigation After Abnormal Mammography

Background. Patient navigation is a practice strategy to address barriers to timely diagnosis and treatment of cancer. The aim of this study was to examine the effectiveness of varying intensities of patient navigation and timely diagnostic resolution after abnormal mammography. Method. This is a secondary analysis of a subset of women with an abnormal screening or diagnostic mammogram who participated in the “patient navigation in medically underserved areas” 5-year randomized trial. We compared timely diagnostic resolution in women assigned to different intensities of patient navigation including, full navigation intervention, no contact with navigators, or limited contact with navigators. Results. The sample included 1,725 women with abnormal mammogram results. Women who interacted with patient navigators had significantly fewer days to diagnostic resolution after abnormal mammography compared with women who did not interact with patient navigators. Discussion. Results from our study suggest that even limited contact with navigators encourages women to seek more timely diagnostic resolution after an abnormal mammogram, which may offer a low-cost practice strategy to improve timely diagnosis for disadvantaged and underserved women.

Substance-exposed newborn infants and public health law: Differences in addressing the legal mandate to report

Prenatal exposure to illicit substances is a finding that typically requires reporting to a child protective services agency. We examine whether there is differential reporting to two public agencies, and whether it varies by race/ethnicity and region. We also study predictors of indicating a maltreatment report as credible. Data on positive neonatal toxicology reports were obtained from the Illinois Department of Public Health (IDPH) and the Illinois Department of Children and Family Services (DCFS). Variation in reporting rates by race/ethnicity and region were compared with Pearson chi-square analysis. Multivariate logistic regression examined factors related to the likelihood of DCFS indicating a report as credible for maltreatment. IDPH recorded 1838 reports of substance-exposed newborn infants while DCFS only recorded 459 reports. There was a greater percentage of whites than blacks reported to DCFS as compared to those reported to IDPH (p < 0.001). There was a greater percentage of whites than blacks found to be indicated by DCFS as compared to those reported to IDPH (p < 0.001). Infants reported in rural areas were indicated less often (OR:0.34, 95% CI:0.17-0.67, p = 0.002) than those from urban areas. In conclusion, there was variation in reporting patterns between the two agencies. To optimize health outcomes for substance-exposed newborn infants (SEIs), the law should be clarified to provide clear standards for reporting and managing SEIs. Clinicians should ensure they are acting within the confines of existing law, and should engage in an interprofessional process with a broad array of stakeholders to develop statewide drug testing and reporting protocols.

Gendered and Racialized Social Expectations, Barriers, and Delayed Breast Cancer Diagnosis: Barriers to Diagnostic Mammography

Black women are more likely to be diagnosed at a later stage of breast cancer in part due to barriers to timely screening mammography, resulting in poorer mortality and survival outcomes. Patient navigation that helps to overcome barriers to the early detection of breast cancer is an effective intervention for reducing breast cancer disparity. However, the ability to recognize and seek help to overcome barriers may be affected by gendered and racialized social expectations of women.

Behavioral Health Disparities Among Children and Youth with Special Health Care Needs

The burden of mental health morbidity, disability, and mortality in children is not equally distributed across populations in the United States. The consequence is widespread differences in health status between certain groups of children that result in systematic behavioral health disparities. In the US, an estimated 12.8% of children (9.4 million) have a special health care need. Mental, emotional, and behavioral problems and disorders are widespread among children and youth with special health care needs (CYSHCN), but are often undetected and untreated despite the adverse consequences to children throughout the life course. CYSHCN experience behavioral health disparities in the prevalence of behavioral health problems and conditions, and in the access to needed services. Further investigation is required to fully identify behavioral health needs, the mechanisms contributing to the disparities, and effective strategies to prevent and provide interventions for CYSHCN. Investing in research and interventions is vital to reducing behavioral health disparities. [Pediatr Ann. 2017;46(10):e382-e386.].