Eric Kessell

Engaging Individuals Recently Released From Prison Into Primary Care: A Randomized Trial

OBJECTIVES Individuals released from prison have high rates of chronic conditions but minimal engagement in primary care. We compared 2 interventions designed to improve primary care engagement and reduce acute care utilization: Transitions Clinic, a primary care-based care management program with a community health worker, versus expedited primary care. METHODS We performed a randomized controlled trial from 2007 to 2009 among 200 recently released prisoners who had a chronic medical condition or were older than 50 years. We abstracted 12-month outcomes from an electronic repository available from the safety-net health care system. Main outcomes were (1) primary care utilization (2 or more visits to the assigned primary care clinic) and (2) emergency department (ED) utilization (the proportion of participants making any ED visit). RESULTS Both groups had similar rates of primary care utilization (37.7% vs 47.1%; P = .18). Transitions Clinic participants had lower rates of ED utilization (25.5% vs 39.2%; P = .04). CONCLUSIONS Chronically ill patients leaving prison will engage in primary care if provided early access. The addition of a primary care-based care management program tailored for returning prisoners reduces ED utilization over expedited primary care.

Public Health Care Utilization in a Cohort of Homeless Adult Applicants to a Supportive Housing Program

Supportive housing is subsidized housing with on-site or closely linked services for chronically homeless persons. Most literature describing the effects of supportive housing on health service utilization does not describe use across multiple domains of services. We conducted a retrospective cohort study of 249 applicants to a supportive housing program; 114 (45.7%) were housed in the program. We describe the pattern of service use across multiple domains (housing, physical health care, mental health care, substance abuse treatment). We examine whether enrollment in supportive housing was associated with decreased use of acute health services (emergency department (ED) and inpatient medical hospitalizations) and increased use of ambulatory services (ambulatory medical and generalist care, mental health, and substance abuse treatment) as compared to those eligible but not enrolled. Participants in both groups exhibited high rates of service utilization. We did not find a difference in change in utilization patterns between the two groups [those that received housing (intervention) and those that applied, were eligible, but did not establish residency (usual care group)] comparing the two years prior to the intervention to the two years after. The finding of high rates of maintenance of housing is, in itself, noteworthy. The consistently high use of services across multiple domains and across multiple years speaks to the level of infirmity of this population and the costs of caring for its members.

“Missing Pieces”—Functional, Social, and Environmental Barriers to Recovery for Vulnerable Older Adults Transitioning from Hospital to Home

To describe barriers to recovery at home for vulnerable older adults after leaving the hospital.

Support From Hospital to Home for Elders: A Randomized Trial

BACKGROUND Hospitals are implementing discharge support programs to reduce readmissions, and these programs have had mixed success. OBJECTIVE To examine whether a peridischarge, nurse-led intervention decreased emergency department (ED) visits or readmissions among ethnically and linguistically diverse older patients admitted to a safety-net hospital. DESIGN Randomized, controlled trial using computer-generated randomization with 1:1 allocation, stratified by language. (Clinical Trials.gov: NCT01221532). SETTING Publicly funded urban hospital in Northern California. PATIENTS Hospitalized adults aged 55 years or older with anticipated discharge to the community who spoke English, Spanish, or Chinese (Mandarin or Cantonese). INTERVENTION Usual care versus in-hospital, one-on-one, self-management education given by a dedicated language-concordant registered nurse combined with a telephone follow-up after discharge from a nurse practitioner. MEASUREMENTS Staff blinded to the study groups determined ED visits or readmissions to any facility at 30, 90, and 180 days after initial hospital discharge using administrative data from several hospitals. RESULTS There were 700 low-income, ethnically and linguistically diverse patients with a mean age of 66.2 years (SD, 9.0). The primary outcome of ED visits or readmissions did not differ between the intervention and usual care groups (hazard ratio, 1.26 [95% CI, 0.89 to 1.78] at 30 days, 1.21 [CI, 0.91 to 1.62] at 90 days, and 1.11 [CI, 0.86 to 1.43] at 180 days). LIMITATIONS This study was done at a single acute-care hospital. There were fewer outcomes than expected, which may have caused the study to be underpowered. CONCLUSION A nurse-led, in-hospital discharge support intervention did not show a reduction in readmissions or ED visits among diverse, low-income older adults at a safety-net hospital. Although wide CIs preclude firm conclusions, the intervention may have increased ED visits. Alternative readmission prevention strategies should be tested in this population. PRIMARY FUNDING SOURCE Gordon and Betty Moore Foundation.

Factors affecting psychiatric inpatient hospitalization from a psychiatric emergency service

OBJECTIVE As a gateway to the mental health system, psychiatric emergency services (PES) are charged with assessing a heterogeneous array of short-term and long-term psychiatric crises. However, few studies have examined factors associated with inpatient psychiatric hospitalization following PES in a racially diverse sample. We examine the demographic, service use and clinical factors associated with inpatient hospitalization and differences in predisposing factors by race and ethnicity. METHOD Three months of consecutive admissions to San Franciscos only 24-h PES (N = 1,305) were reviewed. Logistic regression was used to estimate the associations between demographic, service use, and clinical factors and inpatient psychiatric hospitalization. We then estimated separate models for Asians, Blacks, Latinos and Whites. RESULTS Clinical severity was a consistent predictor of hospitalization. However, age, gender, race/ethnicity, homelessness and employment status were all significant related to hospitalization. Alcohol and drug use were associated with lower probability of inpatient admission, however specific substances appear particularly salient for different racial/ethnic groups. DISCUSSION While clinical characteristics played an essential role in disposition decisions, these results point to the importance of factors external to PES. Individual and community factors that affect use of psychiatric emergency services merit additional focused attention.

Review of Medicare, Medicaid, and Commercial Quality of Care Measures: Considerations for Assessing Accountable Care Organizations

Accountable care organizations (ACOs) have proliferated under the Affordable Care Act (ACA). If ACOs are to improve health care quality and lower costs, quality measures will be increasingly important in determining if provider consolidations associated with the development of ACOs are achieving their intended purpose. This article assesses quality measurement across public and private sectors. We reviewed available quality measures for a subset of programs in six organizations and assessed the number and domain of measures (structure, process, outcomes, and patient experience). Two-thirds of all quality measures were categorized as process measures. Outcome measures made up nearly 20 percent of measures. Patient experience and structure measures made up approximately 8 percent and 7 percent, respectively. We propose further improvements to quality measurement initiatives. For example, programs that reward providers should consider reward size and distribution within the organization. Quality improvement initiatives should consider what encourages provider buy-in and participation and the effects on populations with disproportionate health care needs. As the focus of quality initiatives may change from year to year, measures should be periodically revisited to ensure continued improvement and sustainability. Finally, we suggest quality measures that regulators could use prior to ACO formation or in the year or two following formation.

Comment: Housing Policy and Health

We summarize and comment on the policy sections of the articles in this issue concerned with the health effects of residential environments. We review the implications in the context of public policies implemented over at least the last century to improve the least, as well as most, expensive housing. We make the argument that public policy can reduce but not eliminate the contribution of housing to the differences in health between the wealthy and poor. We conclude that the applied value of work such as that presented in this issue arises from its contribution to sustaining the improvements in health enjoyed over the last century, not from whether it helps eliminate the gap in health between the poor and wealthy.

Functional disability in late-middle-aged and older adults admitted to a safety-net hospital

To determine the prevalence of preadmission functional disability in late‐middle‐aged and older safety‐net inpatients and to identify characteristics associated with functional disability by age.

Covered California: The Impact of Provider and Health Plan Market Power on Premiums

We explain the establishment of Covered California, Californias health insurance marketplace. The marketplace uses an active purchaser model, which means that Covered California can selectively contract with some health plans and exclude others. During the 2014 open-enrollment period, it enrolled 1.3 million people, who are covered by eleven health plans. We describe the market shares of health plans in California and in each of the nineteen rating regions. We examine the empirical relationship between measures of provider market concentration--spanning health plans, hospitals, and medical groups--and rating region premiums. To do this, we analyze premiums for silver and bronze plans for specific age groups. We find both medical group concentration and hospital concentration to be positively associated with premiums, while health plan concentration is not statistically significant. We simulate the impact of reducing hospital concentration to levels that would exist in moderately competitive markets. This produces a predicted overall premium reduction of more than 2 percent. However, in three of the nineteen rating regions, the predicted premium reduction was more than 10 percent. These results suggest the importance of provider market concentration on premiums.

Wang et al. Respond

We would like to thank Schafhalter-Zoppoth et al. for highlighting the growing numbers of Latinos in prison, who have an increased vulnerability to poor health outcomes upon release. We agree that by excluding Spanish-speaking Latinos, we are unable to generalize our results to this population. But we disagree that their exclusion would bias our study to null results. Schafhalter-Zoppoth et al. are assuming that our intervention would have the same effect among Spanish speakers and are arguing that because they have higher emergency department use, the same effect would make a bigger difference, such that our not including them would bias our study toward the null. However, we have no data to support or refute that. The intervention could work better, the same, or worse. We were unable to find the number of Spanish-speaking prisoners that are released to California, nor any data regarding their health care utilization patterns following release. It is plausible that many are being deported to their original country of origin upon completion of their sentence. Certainly more studies are warranted. We agree with Schafhalter-Zoppoth et al. that the absolute reduction of emergency department utilization between Transitions Clinic and Expedited Primary Care is 13.7%.