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Publications of Note: October—December 2018

Timely Follow-Up Not Associated With Reduced Hospitalizations for Homeless Patients with Mental Illnesses

A study examining whether timely outpatient follow-up after hospital discharge reduced the risk of subsequent hospitalization among homeless patients with mental illnesses found neither outpatient medical services nor laboratory services within seven days of discharge were associated with reduced likelihood of rehospitalization within two, six, or 12 months. More than half of the participants studied were rehospitalized within a year of the index discharge. The authors recommend addressing housing as a component of discharge planning, alongside outpatient care. Lauren B. Currie et al., “Continuity of Care Among People Experiencing Homelessness and Mental Illness: Does Community Followup Reduce Hospitalization?Health Services Research 53, no. 5 (Oct. 2018): 3400–15.


Maryland Health Enterprise Zone Lowers Hospitalization Rates, Total Costs

A study of Maryland’s Health Enterprise Zone, which was designed to enhance access to primary care in underserved communities and promote healthy behaviors, found the initiative was associated with a reduction of 18,562 hospital stays and an increase of 40,488 emergency department visits between 2013 and 2016 (the latter may be due to incentives encouraging use of observation visits). The net cost savings from reduced inpatient stays far outweighed the initiative’s cost to the state. As part of the effort, which provided behavioral health care, dental services, health education, and school-based health services, community health workers were deployed to underserved communities. Darrell J. Gaskin et al., “The Maryland Health Enterprise Zone Initiative Reduced Hospital Cost and Utilization in Underserved Communities,” Health Affairs 37, no. 10 (Oct. 2018): 1546–54.


Neighborhood Factors Associated with Readmission Risk at Urban Teaching Hospital

A study that sought to determine whether neighborhood characteristics, measured by the Area Deprivation Index, influenced patients’ readmission risk found patients residing in more disadvantaged neighborhoods had significantly higher 30-day readmission risks compared with those living in less disadvantaged neighborhoods. Those who lived in the most socioeconomically challenged neighborhoods were 70 percent more likely to be readmitted than those in less disadvantaged neighborhoods. Jianhui Hu, Amy J.H. Kind, and David Nerenz, “Area Deprivation Index Predicts Readmission Risk at Urban Teaching Hospital,American Journal of Medical Quality 33, no. 5 (Sept./Oct. 2018): 493–501.


Spending on High-Cost Dual Eligible Beneficiaries Tied to Long-Term Care Not Preventable Hospitalizations

A study that sought to determine what proportion of patients eligible for both Medicare and Medicaid (“dual eligibles”) had persistently high costs found more than half of high-cost beneficiaries remained so over a three-year period. These patients were younger than transiently high-cost beneficiaries, with fewer medical comorbidities and greater intellectual impairment. Persistently high-cost patients spent $161,224 per year compared with $86,333 per year for transiently high-cost patients and $22,352 per year dual eligibles who were not high cost. Most of the spending among persistently high-cost patients (68.8%) was related to long-term care, and very little (<1%) was related to potentially preventable hospitalizations for ambulatory care–sensitive conditions. Jose F. Figueroa et al., “Persistence and Drivers of High-Cost Status Among Dual-Eligible and Medicaid Beneficiaries: An Observational Study,” Annals of Internal Medicine 169, no. 8 (Oct. 2018): 528–34.


Wraparound Services Associated with Reduced Hospitalizations and Emergency Department Visits

The use of wraparound services, including behavioral health, social work, dietetics, patient navigation, and other services that address patients’ social and behavioral needs, reduced subsequent hospitalizations and emergency department visits among primary care patients at federally qualified health centers associated with Eskenazi Health, an Indianapolis, Ind.–based safety-net provider. Receipt of wraparound services produced estimated cost savings of $1.4 million annually. The authors note under value-based payment, wraparound services may be part of a portfolio of strategies to improve health and lower costs. Joshua R. Vest et al., “Indianapolis Provider’s Use of Wraparound Services Associated with Reduced Hospitalizations and Emergency Department Visits,” Health Affairs 37, no. 10 (Oct. 2018): 1555–61.


Supportive Housing Leads to Reduced Hospital Use for Elderly Medicare Beneficiaries

A study of a nonprofit, community-based program in Queens, New York, that supplied affordable housing with supportive social services to elderly Medicare beneficiaries found the program reduced hospital use, including admissions for ambulatory care–sensitive conditions. The evaluators found among residents of the buildings, hospitalization  rates were 32 percent lower, hospital lengths-of-stay one day shorter, and admissions for ambulatory care–sensitive conditions 30 percent lower than for their Medicare counterparts living in the same neighborhood but in different buildings. Michael K. Gusmano, Victor G. Rodwin, and Daniel Weisz, “Medicare Beneficiaries Living in Housing with Supportive Services Experienced Lower Hospital Use Than Others,” Health Affairs 37, no. 10 (Oct. 2018): 1562–9.


Supportive Housing Placement Reduces Preventable Health Care Visits Among Homeless Families

A study that assessed the impact of a New York City supportive housing program found 87 percent of supportive housing tenants remained in housing after two years. Compared with unstably housed heads of families in a comparison group, those in the intervention group were 40 percent less likely to make preventable emergency department visits. Sungwoo Lim et al., “Impact of a New York City Supportive Housing Program on Housing Stability and Preventive Health Care Among Homeless Families,” Health Services Research 33, no. 5 (Oct. 2018): 3437–54.


Marginal Changes in Spending on End-of-Life Care Among ACOs

A study of accountable care organizations (ACOs) in the Medicare Shared Savings Program detected changes in the end-of-life care among both decedents and patients at high risk of death, however, most effects were small and inconsistent across cohorts of ACOs entering the program in different years. The authors concluded that ACOs have not substantially altered end-of-life care patterns and that additional incentives or time may be needed to curb wasteful end-of-life care. They say it is also possible that curbing such spending may not be a viable source of substantial savings under population-based payment models. Lauren G. Gilstrap et al., “Changes in End-of-Life Care in the Medicare Shared Savings Program,” Health Affairs 37, no. 10 (Oct. 2018): 1693–1700.


Behavioral Health Integration and Complex Care Initiative in Medi-Cal Lowered Inpatient Cost, Improved Clinical Indicators

A large Medi-Cal managed care plan that addressed access challenges for enrollees with multiple chronic conditions by increasing staffing for care management, care coordination, and behavioral health integration found participation in the program was associated with improved clinical indicators for common chronic conditions, reduced inpatient costs in some sites, and improved patient experience in all sites. Todd P. Gilmer et al., “Evaluation of the Behavioral Health Integration and Complex Care Initiative in Medi-Cal,” Health Affairs 37, no. 9 (Sept. 2018): 1442–49.


Public–Private Partnership Addresses Maternal Mortality and Morbidity in California

As part of the California Maternal Quality Care Collaborative, public and private organizations partnered to lead maternal quality improvement activities that included linking public health surveillance to actions, including developing a rapid-cycle “Maternal Data Center” to support and sustain quality improvement activities. By 2013, California’s maternal mortality rate had been cut in half to a three-year average of 7.0 maternal deaths per 100,000 live births — comparable to the average rate in Western Europe (7.2 per 100,000). In contrast, maternal mortality rates worsened in the U.S. in the 2010s. Elliott K. Main, Cathie Markow, and Jeff Gould, “Addressing Maternal Mortality and Morbidity in California Through Public-Private Partnerships,” Health Affairs 37, no. 9 (Sept. 2018): 1484–93.


Good Candidates for Complex Care Management Are Older, Take More Medications, and Have More Outpatient Visits

A study that asked care managers working in intensive care management programs to determine whether referred patients were good candidates for care management found less than two-thirds were considered good candidates. Eighteen percent were categorized as not needing care management and 19 percent were categorized as needing more than traditional care management could provide. Compared with the other two categories, good candidates were older, prescribed more medications, and had more outpatient visits in the prior year. For patients who were good candidates, the number of hospital and emergency department admissions were greater than among patients who did not need care management and less than for the group needing more. Their analysis found electronic medical record data identified patients who were good candidates for care management. Maria E. Garcia et al., “Which Complex Patients School Be Referred for Intensive Care Management? A Mixed-Methods Analysis,” Journal of General Internal Medicine 33, no. 9 (Sept. 2018): 1454–60.


Study Finds Equity‐Oriented Health Care Improves Health Outcomes

A study that sought to determine whether equity-oriented health care — that is, care that recognizes and strives to reduce the effects of income inequality and discrimination — leads to improvements in patients’ health outcomes found higher levels of equity-oriented health care predicted greater patient comfort and confidence in the care patients received. This led to greater confidence in preventing and managing their health problems, which, in turn, improved health outcomes. The researchers surveyed patients recruited from four primary care clinics in Canada to determine whether their perceptions of equity-oriented health care led to improvements in self-reported health outcomes including quality of life, chronic pain disability, and post-traumatic stress and depressive symptoms. The researchers also found financial strain and experiences of discrimination had significant negative effects on health outcomes. Marilyn Ford-Gilboe et al., “How Equity-Oriented Health Care Affects Health: Key Mechanisms and Implications for Primary Health Care Practice and Policy,” Milbank Quarterly 96, no. 4 (Oct. 2018): 1–37.

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