Deborah Gurewich

Suicide and Suicidal Attempts in the United States: Costs and Policy Implications.

The national cost of suicides and suicide attempts in the United States in 2013 was

System-level factors and use of cardiac rehabilitation.

58.4 billion based on reported numbers alone. Lost productivity (termed indirect costs) represents most (97.1%) of this cost. Adjustment for under‐reporting increased the total cost to

On-site provision of substance abuse treatment services at community health centers

93.5 billion or

Managing Care for Patients With Substance Abuse Disorders at Community Health Centers

298 per capita, 2.1–2.8 times that of previous studies. Previous research suggests that improved continuity of care would likely reduce the number of subsequent suicidal attempts following a previous nonfatal attempt. We estimate a highly favorable benefit–cost ratio of 6 to 1 for investments in additional medical, counseling, and linkage services for such patients.

Comparative performance of community health centers and other usual sources of primary care

PURPOSE Despite well-established benefits, only 10% to 20% of eligible candidates in the United States currently use formal cardiac rehabilitation (CR) services. Existing studies identify both patient- and provider-level barriers to physician referral and patient uptake. This study, which was driven by new evidence indicating that utilization rates vary enormously from state to state, within states, and from hospital to hospital, explores the relationship between system-level factors and CR use. METHODS Using a qualitative design with semistructured questions, we telephone-interviewed both directors of CR facility programs and presidents of CR state associations operating in states with high and low rates of CR use. We explored the political and cultural environment in which CR facilities operate and the technical capacity to secure referrals and convert referrals to enrollment. RESULTS We identified 4 system-level factors that may help explain regional variation in CR use. These included the degree of automation and assertiveness around securing CR referrals, level of integration of CR within the hospital setting and physician community, relationship to other CR facilities, and capacity constraints. CONCLUSIONS As some of the identified system-level factors can be altered by public and hospital-level policy, study results suggest opportunities for interventions and directions for future research that could increase the use of CR.

Achieving excellence in community health centers: implications for health reform

We examined on-site and off-site referral-based provision of substance abuse (SA) treatment services among a sample of community health centers (CHCs). Analyses used survey data collected from CHCs in three states merged with administrative claims to both characterize CHC care delivery models and examine the association between models and care quality. Care quality was based on the Washington Circle measures of initiation and engagement. Approximately half the sample provided at least some SA treatment services on site. The provision of intensive outpatient treatment services on site was associated with significantly higher engagement rates. It was also associated with higher (but not significantly) initiation rates. At the same time, on-site provision of screening and counseling services was negatively associated with both initiation and engagement rates. Given limited resources, investing in more intensive services on site may yield better outcomes for CHC patients than lower level services, but further study is recommended.

Methodological Challenges of Measuring Primary Care Delivery to Pediatric Medicaid Beneficiaries Who Use Community Health Centers

Coordinating medical and substance use disorder (SUD) services is associated with good health and treatment outcomes but it is not widely practiced. This may be due to a lack of real-world models for coordinating care. This study examined the operational practices associated with a sample of community health centers (CHCs) identified as effectively coordinating SUD services relative to other CHCs. Case studies were used to describe the process of identifying patient need and linking patients with SA treatment services, and to generate propositions about operational approaches for effectively coordinating care. Integrating behavioral health staff within the primary care team was identified as especially critical for facilitating key care transitions. Additional operational approaches that aim to improve care transitions within and across care settings were identified. Future study will be needed to understand the significance of these approaches in terms of health and treatment outcomes. On-going coordination activities among primary care and SUD provided for shared patients remained a challenge for all sites.

Patient-Centered Medical Home Adoption: Lessons Learned and Implications for Health Care System Reform.

Objective:To determine how Community Health Centers (CHCs) perform relative to other primary care providers. Research Design:A retrospective cohort study of Medicaid claims comparing provider groups on the basis of avoidable hospitalizations and costs. Results:Avoidable hospitalization rates did not differ significantly across care settings. Hospital outpatient departments and CHCs had comparable total costs, whereas physicians had slightly but significantly lower total costs. Conclusions:Understanding determinants of care cost differences could inform future performance improvement initiatives. Care quality variance within provider groups may be more significant than care quality performance across care settings.

Medical Debt and Consumer Credit Counseling Services

Background. Existing studies tell us little about care quality variation within the community health center (CHC) delivery system. They also tell us little about the organizational conditions associated with CHCs that deliver especially high quality care. The purpose of this study was to examine the operational practices associated with a sample of high performing CHCs. Methods. Qualitative case studies of eight CHCs identified as delivering high-quality care relative to other CHCs were used to examine operational practices, including systems to facilitate care access, manage patient care, and monitor performance. Results Four common themes emerged that may contribute to high performance. At the same time, important differences across health centers were observed, reflecting differences in local environments and CHC capacity. Conclusions. In the development of effective, community-based models of care, adapting care standards to meet the needs of local conditions may be important.

The Effect of Hospital Ownership Conversions on Nonacute Care Providers

Efforts to measure quality of care have focused on ambulatory care providers. We examined the performance of community health centers serving children on Medicaid in 3 states. Descriptive analysis showed considerable patient population heterogeneity, and regression analysis demonstrated that variation explained by the assigned provider was small (mean R(2) = 4.3%) compared with the variation explained by patient demographic variables (mean R(2) = 29.9%). The results reinforce the need for caution when one is attributing quality differences to provider performance.