Sharon Hewner

Frequent Emergency Department Utilization and Behavioral Health Diagnoses

BackgroundThere are 12 million emergency department (ED) visits each year related to behavioral health diagnoses. Frequent ED utilization among subpopulations, such as those with behavioral health diagnoses, flags the need for more accessible and effective healthcare delivery systems. Reducing frequent ED use is essential to controlling healthcare cost and poor outcomes of ED overcrowding. ObjectivesThe purpose of this study is to stratify individuals by overall health complexity and examine the relationship of behavioral health diagnoses (psychiatric and substance abuse) as well as frequent treat-and-release ED utilization in a cohort of Medicaid recipients. MethodsThis study was a retrospective analysis of 2009 Medicaid claims from two Western New York State counties. The claims represented 56,491 individuals (18–64 years old). Individuals were stratified into four separate cohorts for analysis based on underlying disease complexity. Data were analyzed using logistic regression models. ResultsThe following factors significantly increased the odds of frequent treat-and-release ED use in all the four complexity cohorts: psychiatric diagnosis (ORs = 1.4–2.3), substance abuse (ORs = 2.4–3.8), and smoking (ORs = 1.7–4.0). Medicaid patients with behavioral health diagnoses show high risk of frequent treat-and-release ED use. DiscussionThe results of this study show that psychiatric diagnosis, substance abuse, and smoking are associated with increased odds of frequent treat-and-release ED utilization for Medicaid recipients in all categories of underlying disease complexity. Our findings support associations reported in the literature.

Worker motivation and productivity in chinese (beijing) tricycle haulers: Integrating social and biological variables

Ethnographic assessment of worker lifestyle and motivation was paired with measurement of health, maximum oxygen uptake, anthropometry, and cold response to predict productivity in order to determine how well behavioral ratings and biological rankings of worker capacity predict actual productivity. The subjects were Chinese laborers hauling heavy loads on a cycle by human power during a Beijing winter. Worker productivity was measured as pay for unit of work done. This paper reports the ethnographic methods and results. Worker health was assessed through a physical examination including vital signs, echocardiogram (ECG), nutrition, hemoglobin, and hematocrit. Worker motivation was assessed during 10 weeks of participant observation, extensive interview, and a visit to the workers household. Motivation was rated using a rank‐order comparison of all 50 workers from lowest to highest. Other observational ratings (household assets, demands on worker, and health of household members) were completed at the time of the home visit using five‐point scales.

Aligning population-based care management with chronic disease complexity

BACKGROUND Risk-stratified care management requires knowledge of the complexity of chronic disease and comorbidity, information that is often not readily available in the primary care setting. The purpose of this article was to describe a population-based approach to risk-stratified care management that could be applied in primary care. METHODS Three populations (Medicaid, Medicare, and privately insured) at a regional health plan were divided into risk-stratified cohorts based on chronic disease and complexity, and utilization was compared before and after the implementation of population-specific care management teams of nurses. RESULTS Risk-stratified care management was associated with reductions in hospitalization rates in all three populations, but the opportunities to avoid admissions were different. CONCLUSIONS Knowledge of population complexity is critical to the development of risk-stratified care management in primary care, and a complexity matrix can help nurses identify gaps in care and align interventions to cohort and population needs.

The Roles of Chronic Disease Complexity, Health System Integration, and Care Management in Post-Discharge Healthcare Utilization in a Low-Income Population

Economically disadvantaged individuals with chronic disease have high rates of in-patient (IP) readmission and emergency department (ED) utilization following initial hospitalization. The purpose of this study was to explore the relationships between chronic disease complexity, health system integration (admission to accountable care organization [ACO] hospital), availability of care management interventions (membership in managed care organization [MCO]), and 90-day post-discharge healthcare utilization. We used de-identified Medicaid claims data from two counties in western New York. The study population was 114,295 individuals who met inclusion criteria, of whom 7,179 had index hospital admissions in the first 9 months of 2013. Individuals were assigned to three disease complexity segments based on presence of 12 prevalent conditions. The 30-day inpatient (IP) readmission rates ranged from 6% in the non-chronic segment to 12% in the chronic disease complexity segment and 21% in the organ system failure complexity segment. Rehospitalization rates (both inpatient and emergency department [ED]) were lower for patients in MCOs and ACOs than for those in fee-for-service care. Complexity of chronic disease, initial hospitalization in a facility that was part of an ACO, MCO membership, female gender, and longer length of stay were associated with a significantly longer time to readmission in the first 90 days, that is, fewer readmissions. Our results add to evidence that high-value post-discharge utilization (fewer IP or ED rehospitalizations and early outpatient follow-up) require population-based transitional care strategies that improve continuity between settings and take into account the illness complexity of the Medicaid population.

Integrating social context into comprehensive shared care plans: A scoping review

Background Failure to address social determinants of health (SDH) may contribute to the problem of readmissions in high-risk individuals. Comprehensive shared care plans (CSCP) may improve care continuity and health outcomes by communicating SDH risk factors across settings. Purpose The purpose of this study to evaluate the state of knowledge for integrating SDH into a CSCP. Our scoping review of the literature considered 13,886 articles, of which seven met inclusion criteria. Results Identified themes were: integrate health and social sectors; interoperability; standardizing ontologies and interventions; process implementation; professional tribalism; and patient centeredness. Discussion There is an emerging interest in bridging the gap between health and social service sectors. Standardized ontologies and theoretical definitions need to be developed to facilitate communication, indexing, and data retrieval. Conclusions We identified a gap in the literature that indicates that foundational work will be required to guide the development of a CSCP that includes SDH that can be shared across settings. The lack of studies published in the United States suggests that this is a critical area for future research and funding.

China productivity project: General description and analysis of productivity

The amount of work that people do is a focal point of human life, an outcome with extraordinarily complex roots. The physical task itself, the natural setting, biological work capacity, and behavioral patterns presumably condition productivity. This paper presents a model by which work output of Chinese cycle haulers was investigated, and outlines investigative techniques including work physiology, health assessment, cold response, and ethnography of the workplace and home. The objective is to explain variation in work done on a daily, monthly, and seasonal basis. This paper also quantifies work output, or productivity, using long‐term pay records as measures of productivity. While pay records, which show statistically normal distributions, serve as the primary dependent variable in the analysis, field observations and experiments offer supplementary data on the behaviors that produce work output. In a sample of 48 men, various measures of biological capacity and behaviors, such as motivation, predict overall productivity regardless of season. Since mean daily pay and monthly pay have different predictors, there is much individual choice in how many days per month one works.

Integrating Social Determinants of Health into Primary Care Clinical and Informational Workflow during Care Transitions

Context: Care continuity during transitions between the hospital and home requires reliable communication between providers and settings and an understanding of social determinants that influence recovery. Case Description: The coordinating transitions intervention uses real time alerts, delivered directly to the primary care practice for complex chronically ill patients discharged from an acute care setting, to facilitate nurse care coordinator led telephone outreach. The intervention incorporates claims-based risk stratification to prioritize patients for follow-up and an assessment of social determinants of health using the Patient-centered Assessment Method (PCAM). Results from transitional care are stored and transmitted to qualified healthcare providers across the continuum. Findings: Reliance on tools that incorporated interoperability standards facilitated exchange of health information between the hospital and primary care. The PCAM was incorporated into both the clinical and informational workflow through the collaboration of clinical, industry, and academic partners. Health outcomes improved at the study practice over their baseline and in comparison with control practices and the regional Medicaid population. Major Themes: Current research supports the potential impact of systems approaches to care coordination in improving utilization value after discharge. The project demonstrated that flexibility in developing the informational and clinical workflow was critical in developing a solution that improved continuity during transitions. There is additional work needed in developing managerial continuity across settings such as shared comprehensive care plans. Conclusions: New clinical and informational workflows which incorporate social determinant of health data into standard practice transformed clinical practice and improved outcomes for patients.

Comparative Effectiveness of Risk-Stratified Care Management in Reducing Readmissions in Medicaid Adults With Chronic Disease.

Hospitalized adult Medicaid recipients with chronic disease are at risk for rehospitalization within 90 days of discharge, but most research has focused on the Medicare population. The purpose of this study is to examine the impact of population-based care management intensity on inpatient readmissions in Medicaid adults with pre-existing chronic disease. Retrospective analyses of 2,868 index hospital admissions from 2012 New York State Medicaid Data Warehouse claims compared 90-day post-discharge utilization in populations with and without transitional care management interventions. High intensity managed care organization interventions were associated with higher outpatient and lower emergency department post-discharge utilization than low intensity fee-for-service management. However, readmission rates were higher for the managed care cases. Shorter time to readmission was associated with managed care, diagnoses that include heart and kidney failure, shorter length of stay for index hospitalization, and male sex; with no relationship to age. This unexpected result flags the need to re-evaluate readmission as a quality indicator in the complex Medicaid population. Quality improvement efforts should focus on care continuity during transitions and consider population-specific factors that influence readmission. Optimum post-discharge utilization in the Medicaid population requires a balance between outpatient, emergency and inpatient services to improve access and continuity.

Reducing Emergency Room Visits and In‐Hospitalizations by Implementing Best Practice for Transitional Care Using Innovative Technology and Big Data

BACKGROUND Efforts to improve care transitions require coordination across the healthcare continuum and interventions that enhance communication between acute and community settings. AIMS To improve post-discharge utilization value using technology to identify high-risk individuals who might benefit from rapid nurse outreach to assess social and behavioral determinants of health with the goal of reducing inpatient and emergency department visits. METHODS The project employed a before and after comparison of the intervention site with similar primary care practice sites using population-level Medicaid claims data. The intervention targeted discharged persons with preexisting chronic disease and delivered a care transition alert to a nurse care coordinator for immediate telephonic outreach. The nurse assessed social determinants of health and incorporated problems into the EHR to share across settings. The project evaluated health outcomes and the value of nursing care on existing electronic claims data to compare utilization in the years before and during the intervention using negative binomial regression to account for rare events such as inpatient visits. RESULTS Avoiding readmissions and emergency visits, and increasing timely outpatient visits improved the individuals experience of care and the work life of healthcare providers, while reducing per capita costs (Quadruple Aim). In the intervention practice, the nurse care coordinator demonstrated the value of nursing care by reducing inpatient (25%) and emergency (35%) visits, and increasing outpatient visits (27%). The estimated value of avoided encounters over the secular Medicaid trend was

Exploring Medicaid claims data to understand predictors of healthcare utilization and mortality for Medicaid individuals with or without a diagnosis of lung cancer: a feasibility study

664 per adult with chronic disease, generating