Transforming Care: Reporting on Health System Improvement

Transforming Care, The Commonwealth Fund’s newest publication, focuses on new models of care, payment approaches, and patient engagement strategies that have the potential to reshape our delivery system to better meet the needs of the nation’s sickest and most vulnerable patients. Published quarterly, the newsletter is a source of innovative ideas for health system leaders, clinicians, and policymakers.

  • December 22, 2016 Issue
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Publications of Note

Depression Care Through Home Health Reduces Hospitalization Risk
A study of an intervention that integrated depression care with home health services found it significantly reduced the risk of hospitalization and rehospitalization for Medicare beneficiaries. The Depression Care for Patients at Home model guides nurses in managing depression during routine home visits. Services include weekly symptom assessment, medication management, care coordination, patient education, and goal setting. Researchers found the program reduced the risk of hospitalization by 35 percent within 30 days of starting home health care and by 28 percent within 60 days. Among participants referred to home health directly from the hospital, the relative risk of being rehospitalized was approximately 55 percent lower. M. L. Bruce, M.C. Lohman, R. L. Greenberg et al., “Integrating Depression Care Management into Medicare Home Health Reduces Risk of 30- and 60-Day Hospitalization: The Depression Care for Patients at Home Cluster-Randomized Trial,” Journal of the American Geriatrics Society, Nov. 2016 64(11):2196–203. 

Medicare’s New Bundled Payment Program May Penalize Hospitals That Treat Medically Complex Patients
A study of the Comprehensive Care for Joint Replacement bundled payment program found it may unintentionally penalize hospitals that care for patients with complex medical needs because it lacks a mechanism to account for such complexity. The researchers modeled bonuses and penalties using payment methodologies similar to those outlined by the Centers for Medicare and Medicaid Services to determine the net difference in payments with and without risk adjustment. They found that payments would be reduced by $827 per episode for each standard-deviation increase in a hospital’s patient complexity. They also found risk adjustment could increase reconciliation payments to some hospitals by as much as $114,184 annually. C. Ellimoottil, A. M. Ryan, H. Hou et al., “Medicare’s New Bundled Payment for Joint Replacement May Penalize Hospitals That Treat Medically Complex Patients,” Health Affairs, Sept. 2016 35(9):1651–7.

Preventable Death Rates Fell in Communities That Expanded Population Health Activities
An analysis of data from 306 metropolitan communities in the U.S. found lower death rates due to cardiovascular disease, diabetes, and influenza in communities with multisector networks pursuing population health activities. The study assessed the scope of population health improvement activities implemented in each community—including periodic needs assessments and allocating resources to improve health—and the range of sectors engaged (e.g., public health agencies, hospitals, primary care providers, employers, and schools.) The communities were then categorized based on the degree of collaboration—with stronger networks described as having more “population health system capital.” These communities were more likely than their counterparts to have adopted smoking bans and achieved lower rates of smoking, obesity, and physical inactivity among low-income residents, researchers found. They were also better resourced, suggesting incentives and infrastructure may be needed to support activities in lower resourced areas. G. P. Mays, C. B. Mamaril, and L. R. Timsina, “Preventable Death Rates Fell Where Communities Expanded Population Health Activities Through Multisector Networks,” Health Affairs, Nov. 2016 35(11):2005–13.

Deprivation Index May Help U.S. Reduce Health Disparities
The authors of this article describe how the United Kingdom and New Zealand have collated data from their censuses or administrative data sets to construct indices that capture material and social deprivation and use them to measure socioeconomic variation across communities, assess community needs, inform research, adjust clinical funding, allocate community resources, and determine policy impact. They recommend the U.S. develop a similar index, and suggest models. R. L. Phillips, W. Liaw, P. Crampton et al., “How Other Countries Use Deprivation Indices—and Why the United States Desperately Needs One,” Health Affairs, Nov. 2016 35(11):1991–8. 

Economic Policy Is Linked to Population Health
Using two decades of data from 50 states, researchers found better health outcomes in states that enacted higher tax credits for the poor or higher minimum wages, as well as in states without a right-to-work law that limits union power. Larger tax credits for the poor were associated with better outcomes for six of seven health measures. States with higher-than-average minimum wages had better values on three measures of health: a composite measure of poor health and rates of smoking and obesity, compared with states with an average minimum wage. And the absence of right-to-work laws was associated with better performance of five of seven measures of health, including smoking rates. By contrast, they found three economic policies—tax burden on the rich, corporate tax rate, and sales tax rates—were associated with only one of the seven health measures studied. They conclude economic policies that direct resources to working–class families may improve population health more than policies that target the rich or the population overall. E. Rigby and M. E. Hatch, “Incorporating Economic Policy Into a ‘Health-In-All-Policies’ Agenda,” Health Affairs, Nov. 2016 35(11):2044–52. 

Well-Being Measures Linked to Life Expectancy at the County Level
Researchers seeking to explain geographic disparities in life expectancy not fully explained by differences in race and socioeconomic status investigated whether population well-being—a comprehensive measure of physical, mental, and social health that takes into account factors like stress and access to safe housing and nutritious food—might account for some of the variation. They found at the county level, for every one standard deviation increase in the well-being score, life expectancy was 1.9 years higher for females and 2.6 years higher for males. They remained positively associated even after controlling for race, poverty, and education. A. Arora, E. Spatz, J. Herrin et al., “Population Well-Being Measures Help Explain Geographic Disparities in Life Expectancy at the County Level,” Health Affairs, Nov. 2016 35(11):2075–82. 

Self-Directed Health Budgets a Possible Model for High-Need Patients in the U.S.
The authors of this commentary describe England’s use of self-directed health budgets for patients with complex needs, which allow patients with chronic conditions including diabetes, chronic obstructive pulmonary disease, Parkinson’s disease, and serious mental illness to set their own service priorities and allocate funds accordingly. In coordination with their health care providers and with approval from the National Health Services, patients can choose to spend the money on home-based support services or cover transportation, psychological therapies, and non-traditional services including housing in pursuit of a health goal. A study of the model found it was cost effective relative to traditional care and associated with improved quality of life. The greatest savings were observed among patients with budgets of $1,500 or more. Patients with personal health budgets used fewer acute-care services than their counterparts, and instead increased expenditures on help from support workers, information technology, mobility equipment, physical activity, and education and training, among other things. L. O’Shea and A. B. Bindman, “Personal Health Budgets for Patients with Complex Needs,” New England Journal of Medicine, Nov. 10, 2016 375(19):1815–7.

Increased Use of EDs by Newly Covered Medicaid Beneficiaries in Oregon Sustained Over Time
Researchers who had previously found newly insured Medicaid enrollees in Oregon made greater use of emergency departments than those who remained uninsured found the increase in utilization persisted over the two years—suggesting the cause may not be pent-up demand that dissipates over time. They also found that Medicaid coverage increased the probability of a person’s having both an ED visit and an office visit by 13.2 percentage points, suggesting that access to primary care does not curtail ED use, as had been expected. A. N. Finkelstein, S. L. Taubman, H. L. Allen et al., “Effect of Medicaid Coverage on ED Use—Further Evidence from Oregon’s Experiment,” New England Journal of Medicine, Oct. 20, 2016 375(16):1505–7. 

Increases in Government Spending Associated with Higher Performance on County Health Rankings
Researchers found significant positive associations between performance on the County Health Rankings and a community’s spending on some health and non-health expenses. The County Health Rankings score counties based on health outcomes—such as length and quality of life—and factors that assess the social determinants of health and other factors related to the physical and social environment within a county. Overall the researchers found jurisdictions with higher rankings devote larger proportions of their expenditures to community health care and public health, parks and recreation, sewerage, fire protection, and libraries, compared with jurisdictions with lower health outcome rankings. They also found evidence of an association between social services spending and subsequent population health outcomes, even after controlling for health factors. The authors observed decreasing returns on spending in some social service categories, suggesting investment above a certain threshold may yield fewer health benefits. J. M. McCullough and J. P. Leider, “Government Spending In Health and Nonhealth Sectors Associated with Improvement in County Health Rankings,” Health Affairs, Nov. 2016 35(11):2037–43. 

More Attention Needed to Integrating and Aggregating Medical and Social Data
To ensure that data captured in electronic health record (EHR) systems on the social determinants of health can be efficiently and effectively aggregated to inform population health activities, payment reform, and quality improvement initiatives, more attention is needed to the back-end processes for doing so, the authors of this article say. After outlining the potential benefits of pulling data from EHRs, including information available from medical coding tools like the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10), which includes “z-codes” that capture patients’ social characteristics, they describe the challenges of doing so. The authors call on medical documentation experts, researchers in health services social interventions, and organizations that have advanced social screening tools as well as other health leaders to reach consensus on best practices and standardization of methods for translating and aggregating data from surveys and EHRs. L. Gottlieb, R. Tobey, J. Cantor et al., “Integrating Social and Medical Data to Improve Population Health: Opportunities and Barriers,” Health Affairs, Nov. 2016 35(11):2116–23. 

Safety-Net Hospitals Reduce Readmissions But May Still Be at a Disadvantage with Penalties
Researchers studying the impact of the Medicare’s Hospital Readmissions Reduction Program on safety-net hospitals found these hospitals made considerable improvement, lessening the disparity between hospitals serving high and low shares of low-income patients, who are at greater risk of readmission. But they also found safety-net hospitals did not improve as much as hospitals that had similarly high initial readmission rates, which may reflect the difficulties safety-net hospitals face in addressing such issues as homelessness and lack of family support. They say their findings support an approach recommended by MedPAC, which includes evaluating safety-net hospitals against others like them. K. Carey and M. Lin, “Hospital Readmissions Reduction Program: Safety-Net Hospitals Show Improvement, Modifications to Penalty Formula Still Needed,” Health Affairs, Oct. 2016 35(10):1918–23. 

Home Repairs and At-Home Care Improve Physical Functioning of Older Dual Eligibles
The Community Aging in Place, Advancing Better Living for Elders (CAPABLE) program deploys teams of occupational therapists, registered nurses, and handymen to the homes of low-income elderly patients to address the challenges they face with activities of daily living (ADLs), such as getting out of bed, going to the toilet, and getting dressed. It also provides home repairs to eliminate safety hazards and improve mobility. A study of the program, funded through a Center for Medicare and Medicaid Innovation demonstration, found it improved patients’ capacity to perform ADLs and reduced symptoms of depression. Participants had difficulty with an average of 3.9 out of 8.0 ADLs at baseline, compared with 2.0 after five months. The ability to perform instrumental ADLs such as shopping and managing medications also improved. Researchers are studying the program’s impact on costs. S. L. Szanton, B. Leff, J. L. Wolff et al., “Home-Based Care Program Reduces Disability and Promotes Aging in Place,” Health Affairs, Sept. 2016 35(9):1558–63. 

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