Strategies to Achieve Alignment, Collaboration, and Synergy across Delivery and Financing Systems

ImprovingPopulationandClinicalHealthwithIntegratedServicesandDecisionSupport

Research-in-Progress WebinarWednesday, January 9, 2019

12:00-1:00 pm ET/ 9:00 am-10:00 am PT

Funded by the Robert Wood Johnson Foundation

AgendaWelcome: ShanaMoore,PhD,MPA

DirectorofDisseminationandResearchDevelopmentRWJFSystemsforAction NationalCoordinatingCenterUniversityofKentuckyCollegeofPublicHealth

Presenter: JoshuaVest,PhD,MPHDirector,CenterforHealthPolicyAssociateProfessor,HealthPolicy&ManagementIndianaUniversityRichardMFairbanksSchoolofPublicHealth- IndianapolisAffiliatedScientist,RegenstriefInstitute

Commentary: GlenMays,PhDDirectorRWJFSystemsforAction NationalCoordinatingCenterUniversityofKentuckyCollegeofPublicHealth

Q&A: ModeratedbyShanaMoore,PhD,MPA

Presenter

JoshuaVest,PhD,MPHDirector,CenterforHealthPolicyAssociateProfessor,HealthPolicy&ManagementIndianaUniversityRichardMFairbanksSchoolofPublicHealth- IndianapolisAffiliatedScientist,RegenstriefInstitute

Commentary Speaker

GlenP.Mays,PhD,MPHDirectorRWJFSystemsforAction NationalCoordinatingCenterUniversityofKentuckyCollegeofPublicHealth

ImprovingPopulationandClinicalHealthwithIntegratedServicesandDecisionSupport

JoshuaRVest,PhD,MPHDirector,CenterforHealthPolicy

AssociateProfessor,HealthPolicy&ManagementIndianaUniversityRichardMFairbanksSchoolofPublicHealthatIUPUI

Investigator,RegenstriefInstitute,Inc.

ThisworkwassupportedbytheRobertWoodJohnsonFoundationthroughtheSystemsforActionNationalCoordinatingCenter,ID73485.@JoshuaRVest

Acknowledgements

IndianaUniversity• PaulKHalverson(Co-PI)• NirMenachemi• ShaunGrannis• SurangaKasthuriranthne• …many,many,others

VestJR,HarrisLE,HautDP,HalversonPK,MenachemiN.IndianapolisProvider’sUseOfWraparoundServicesAssociatedWithReducedHospitalizationsAndEmergencyDepartmentVisits.HealthAff (Millwood).2018;37(10):1555-1561.

VestJR,MenachemiN,GrannisS,FerrellJ,KasthurirathneS,*ZhangY,TongY,HalversonP.Impactofriskstratificationonreferralsanduptakeofwraparoundservicestoaddresssocialdeterminants:asteppedwedgedtrial.AmericanJournalofPreventativeMedicine. Inpress.

USpolicyismovingtomakeprovidersaccountableforpatienthealth.

Upstream.com

Upstreamthinking

Focusonprevention

Addressingsocialdeterminants

Fitday.com

Moreandmorehealthcareorganizationsareofferingnon-medicalor“wraparound”servicestoimprovepatienthealth.

http://cchci.org/_services/behavioral-health/

www.chelseajew

ish.org/celebrating-social-w

ork-month-senior-care/

Pplay.google.com

guide.berkeley.edu/undergraduatedmkelite.com

usf.edu

Whatrolesdoestheseservicesfulfill?

• Theseservicesmostdirectlyaddress:healthbehaviors,socialcontexts,andenvironments– Thesesocialdeterminantsofhealtharelargerdriversofhealththanmedicalcare

– Thesesocialdeterminantscaninhibitcaredelivery• Lackoftransportation,poorsocialnetworks,loweducationallcomplicate(orprevent)care

• Clinicianstraditionallynottrained(andhealthcaresystemwerenotorganized)toaddresstheseissues– Requiresspecializedprofessionals

Researchquestion:

Doesreceiptofwraparoundservicesreducepatients’healthcareutilization?

Approach:

Measuretheassociationbetweenreceiptofwraparoundservicesandutilizationoutcomesinan11-yearpanelofadultpatients.

Setting,sample,&measuresSetting:• EskenaziHealthFQHCs• Expandedwraparoundservicesonco-locatedbasisin2011

Sample:• Adults(≥18)withprimarycarevisitsfrom2006-2016

– Hadtohave≥1visitbefore2011&≥1visitafter2011Determinantofinterest:receiptofwraparoundservices(Vest,Grannis,etalIJMI2017)

• Anysocialwork,behavioralhealth,nutritioncounseling,respiratorytherapy,financialplanning,medical-legalpartnership,patientnavigation,orpharmacistconsultation– Allpatientsinthestudysamplereceivedatleastonewraparoundserviceduringthestudyperiod

Outcome:• Outcomes:annualhospitalizations;annualEDvisits

Measures:• Annualriskscores,utilizationhistory,(binary)receiptofwraparoundservices(time-varying)• Chronicconditionsanddemographicfactors(timeinvariant)

Patient-levelfixed-effectsPoissonregressionmodelsdescribedtheassociationbetweenwraparoundservicesandoutcomes.

• Patient-fixedeffectscontrolledfortime-invariantfactors(e.g.race/ethnicity)• Time-varyingmeasuresincludedinmodel(e.g.annualriskscores)• Yeardummiesincludedtoadjustfortrends• Robuststandarderrorstoadjustforclustering• Wraparoundservicesenteredasalaggedbinary-indicator

– Associationwithsubsequent yearutilization

Robustnesschecks:• repeatedusingfixed-effectsnegativebinomialregression• propensity-scorematchedcomparisongroupofpatientswhodidnotreceiveany

wraparoundserviceswithrandom-interceptPoissonmodels

Highdiseaseburdenreflectiveofasafety-netpopulation%

DemographicsAge 49.7(mean)Female 71.9Race/ethnicityHispanic 18.7AfricanAmerican 41.4White,non-Hispanic 26.7Other/unknown 13.4

PatientseverityResourceutilizationband 2.54(mean)

DiagnosesHypertension 65.2Asthma 17.8Depression 42.3Diabetes 43.8

Substanceabusehistory 20.7Tobaccousehistory 33.8AnnualutilizationhistoryOutpatientvisitcount 3.42(mean)Specialistvisitcount 2.86(mean)Emergencydepartmentvisitcount 0.81(mean)Hospitalizationcount 0.20(mean)

Dietitiansfollowedbysocialworkersarethemostcommonlyaccessedwraparoundservices.

49.2

29.4

9.7

3.4

1.0

7.2

0

5

10

15

20

25

30

35

40

45

50

Dietitian Socialwork Behavioralhealth Respiratorytherapy Patientnavigation Multiple

percent

Receiptofanywraparoundservicewasassociatedwithalowercountofhospitalizationsinthesubsequentyear.

Hospitalizations

β(95%CI) pReceiptofanywraparoundserviceintheprioryear -0.07(-0.12,-0.02) 0.006Severityscore 0.66(0.63,0.69) <0.001AnnualnumberofencountersHospitalizations --EDvisits 0.01(0.00,0.02) 0.008

Outpatientvisits 0.01(0.01,0.02) <0.001

Specialtycarevisits 0.03(0.03,0.03) <0.001

Patientfixedeffectsregressionmodelswithyeardummiesomittedforreadability.

ReceiptofanywraparoundservicewasassociatedwithalowercountofEDvisitsinthesubsequentyear.

Hospitalizations Emergencydepartmentvisits

β(95%CI) p β(95%CI) pReceiptofanywraparoundserviceintheprioryear -0.07(-0.12,-0.02) 0.006 -0.05(-0.09,-0.02) 0.003Severityscore 0.66(0.63,0.69) <0.001 0.52(0.51,0.54) <0.001AnnualnumberofencountersHospitalizations -- 0.03(0.01,0.04) <0.001EDvisits 0.01(0.00,0.02) 0.008 --Outpatientvisits 0.01(0.01,0.02) <0.001 0.01(0.00,0.01) <0.001Specialtycarevisits 0.03(0.03,0.03) <0.001 0.01(0.00,0.01) 0.016

Patientfixedeffectsregressionmodelswithyeardummiesomittedforreadability.

Limitations

• Generalizability– Single,safety-netinstitution– Wraparoundservicesofferedonaco-locatedbasis(maynotapplytoorganizationsrelyingonreferrals)

• Reductionsmaybeattributabletootherqualityimprovementactivitiesoccurringatthesametime

• Resultsdonotprovideinsightsastotherelativevalueofeachservice

Receiptofanywraparoundservicewasassociatedwitha7%lowercountofhospitalizations&a5%lowercountofEDvisitsinthesubsequentyear.

• Aportfolioofwraparoundservicesmaybeaneffectivestrategyfororganizationsservingacomplexpatientpopulations.

• Wraparoundservicecouldcomplementhealthinformationexchange,riskstratification,orcross-sectoralcollaborations.

Sohowcanwebettersupportefficientandeffectiveuseofwraparoundservices?

Anywraparoundreferralrisk

scoreBehavioralhealth

referralriskscore

Dietitianreferralrisk

scoreSocialworkreferralrisk

score

Claims&EHR

Diagnoses&Utilization

Machinelearningalgorithmstoidentifythoseinneedofwraparoundservices.

ArearesourcesLivingconditionsSocialcontextSafetyTransport

nationswell.com

www.citygalleryindy.org

NeighborhoodriskbehaviorsChronicdiseases

AdditionalhealthbehaviorsUtilizationatotherproviders

Automatedprocesstoprovideriskstratificationinformation.

5:00AM

Beforeclinicsopen

Researchquestion:

Doesriskstratifyingpatientsaccordingtowraparoundserviceneeds:1. Increasereferrals2. Increasekeptappointment(i.e.betteruptake)

Approach:

Pragmatictrialusingastepped-wedgedesign

Riskstratificationwasrolledout3clinicsatatimefromJulytoNovember2017.

August September October November December JanuaryJulyJune

3cliniclocationsliveBaseline

3cliniclocationsliveBaseline

3cliniclocationsliveBaseline

Measures&analyses

• Exposure:– Riskstratificationcategoryforeachservice

80%ofthepopulationhasaprobability<0.19

95%ofthepopulationhasaprobability<0.27

RisingRisk

HighRiskLowRisk

Measures&analyses

• Exposure:– Riskstratificationcategoryforeachservice

• High• Rising• Low• Samedayappointments• Controlsite(referencegroup)

Measures&analyses

• Exposure:– Riskstratificationcategory(high,rising,low,sameday,none)

• Covariates– Demographics(e.g.gender,age,race/ethnicity)– Location– Comorbidityscores

• Analysis– GeneralizedEstimatingEquation(GEE)logisticregressionmodelsforeach

wraparoundservice(accountsforrepeatedpatientobservation)– Keptappointmentsonlyforpatientswithreferrals– NonequivalentDV(HealthyMe)

Interventionwasnotassociatedwithincreasedreferralsforanyservice.

Interventionwasassociatedwithincreasedreferralstosocialworkers

Suggestsnobroadchangestogeneralreferralpracticesintheclinics.

Forsaydayappointments(whennoscoreavailable)referralsarelesslikely• Workflowissue?• Samedaymorelikelytobeacutecondition?

Generalincreaseinkeptappointmentsoncepatientswerereferredtoservices.• Evenwithsomeindicationsofdose

response(notoversellingpilot!)

AutomatedriskstratificationscoressuccessfullydeliveredtoEskenaziHealthprimarycareclinics.

• Interventionassociatedwithincreasedreferralsforsocialworkers.

• Interventionassociatedwithincreasedratesofkeptappointmentsformultiplesocialdeterminantsofhealthservices.

• Nextstep:putitintoEPIC

JoshuaRVest,PhD,MPHjoshvest@iu.edu@JoshuaRVest

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Acknowledgements

Systems for Action is a National Program Office of the Robert WoodJohnson Foundation and a collaborative effort of the Center for Public HealthSystems and Services Research in the College of Public Health, and theCenter for Poverty Research in the Gatton College of Business and Economics,administered by the University of Kentucky, Lexington, Ky.

and