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Background: This study assessed the impact of Affordable Care Act (ACA) Medicaid expansion on health insurance rates and receipt of cardiovascular‐related preventive screenings (body mass index, glycated hemoglobin [HbA1c], low‐density lipoproteins, and blood pressure) for cancer survivors seen in community health centers (CHCs). Methods: This study identified cancer survivors aged 19 to 64 years with at least 3 CHC visits in 13 states from the Accelerating Data Value Across a National Community Health Center Network (ADVANCE). Via inverse probability of treatment weighting multilevel multinomial modeling, insurance rates before and after the ACA were estimated by whether a patient lived in a state that expanded Medicaid, and changes between a pre‐ACA time period and 2 post‐ACA time periods were assessed. Results: The weighted estimated sample size included 409 cancer survivors in nonexpansion states and 2650 in expansion states. In expansion states, the proportion of uninsured cancer survivors decreased significantly from 20.3% in 2012‐2013 to 4.5%in 2016‐2017, and the proportion of those with Medicaid coverage increased significantly from 38.8% to 55.6%. In nonexpansion states, there was a small decrease in uninsurance rates (from 33.6% in 2012‐2013 to 22.5% in 2016‐2017). Cardiovascular‐related preventive screening rates increased over time in both expansion and nonexpansion states: HbA1c rates nearly doubled from the pre‐ACA period (2012‐2013) to the post‐ACA period (2016‐2017) in expansion states (from 7.2% to 12.8%) and nonexpansion states (from 9.3% to 16.8%). Conclusions: This study found a substantial decline in uninsured visits among cancer survivors in Medicaid expansion states. Yet, 1 in 5 cancer survivors living in a state that did not expand Medicaid remained uninsured. Several ACA provisions likely worked together to increase cardiovascular‐related preventive screening rates for cancer survivors seen in CHCs. The Affordable Care Act (ACA) provides coverage options for cancer survivors seen in community health centers, especially in states that have expanded Medicaid; unfortunately, 1 in 5 cancer survivors living in a state that has not expanded Medicaid coverage eligibility remains uninsured. The ACA Medicaid expansion provision change, likely in tandem with other ACA changes, has also contributed to modest improvements in rates of cardiovascular‐related screenings for cancer survivors. [ABSTRACT FROM AUTHOR]

Introduction: Community health centers (CHCs) care for vulnerable patients who use tobacco at higher than national rates. States that expanded Medicaid eligibility under the Affordable Care Act (ACA) provided insurance coverage to tobacco users not previously Medicaid-eligible, thereby potentially increasing their odds of receiving cessation assistance. We examined if tobacco users in Medicaid expansion states had increased quit rates, cessation medications ordered, and greater health care utilization compared to patients in non-expansion states.Methods: Using electronic health record (EHR) data from 219 CHCs in 10 states that expanded Medicaid as of January 1, 2014, we identified patients aged 19-64 with tobacco use status documented in the EHR within 6 months prior to ACA Medicaid expansion and ≥1 visit with tobacco use status assessed within 24 months post-expansion (January 1, 2014 to December 31, 2015). We propensity score matched these patients to tobacco users from 108 CHCs in six non-expansion states (n = 27 670 matched pairs; 55 340 patients). Using a retrospective observational cohort study design, we compared odds of having a quit status, cessation medication ordered, and ≥6 visits within the post-expansion period among patients in expansion versus non-expansion states.Results: Patients in expansion states had increased adjusted odds of quitting (adjusted odds ratio [aOR] = 1.35, 95% confidence interval [CI]: 1.28-1.43), having a medication ordered (aOR = 1.53, 95% CI: 1.44-1.62), and having ≥6 follow-up visits (aOR = 1.34, 95% CI: 1.28-1.41) compared to patients from non-expansion states.Conclusions: Increased access to insurance via the ACA Medicaid expansion likely led to increased quit rates within this vulnerable population.Implications: CHCs care for vulnerable patients at higher risk of tobacco use than the general population. Medicaid expansion via the ACA provided insurance coverage to a large number of tobacco users not previously Medicaid-eligible. We found that expanded insurance coverage was associated with increased cessation assistance and higher odds of tobacco cessation. Continued provision of insurance coverage could lead to increased quit rates among high-risk populations, resulting in improvements in population health outcomes and reduced total health care costs. [ABSTRACT FROM AUTHOR]

Background Despite expansions in public health insurance, many children remain uninsured or experience gaps in coverage. Community health centers (CHCs) provide primary care to many children at risk for uninsurance and are well-positioned to help families obtain and retain children's coverage. Recent advances in health information technology (HIT) capabilities provide the means to create tools that could enhance CHCs' insurance outreach efforts. Objective To present the study design, baseline patient characteristics, variables, and statistical methods for the Innovative Methods for Parents And Clinics to Create Tools for Kids' Care (IMPACCT Kids' Care) study. Methods/design In this mixed methods study, we will design, test and refine health insurance outreach HIT tools through a user-centered process. We will then implement the tools in four CHCs and evaluate their effectiveness and barriers and facilitators to their implementation. To measure effectiveness, we will quantitatively assess health insurance coverage continuity and utilization of healthcare services for pediatric patients in intervention CHCs compared to matched control sites using electronic health record (EHR) and Oregon Medicaid administrative data over 18 months pre- and 18 months post-implementation (n = 34,867 children). We will also qualitatively assess the implementation process to understand how the tools fit into the clinics' workflows and the CHC staff experiences with the tools. Conclusions This study creates, implements, and evaluates health insurance outreach HIT tools. The use of such tools will likely improve care delivery and health outcomes, reduce healthcare disparities for vulnerable populations, and enhance overall healthcare system performance. ClinicalTrials.gov Identifier: NCT02298361 . [ABSTRACT FROM AUTHOR]

PURPOSE There is debate about whether community health centers (CHCs) will experience increased demand from patients gaining coverage through Affordable Care Act Medicaid expansions. To better understand the effect of new Medicaid coverage on CHC use over time, we studied Oregon's 2008 randomized Medicaid expansion (the "Oregon Experiment"). METHODS We probabilistically matched demographic data from adults (aged 19-64 years) participating in the Oregon Experiment to electronic health record data from 108 Oregon CHCs within the OCHIN community health information network (originally the Oregon Community Health Information Network) (N = 34,849). We performed intent-to-treat analyses using zero-inflated Poisson regression models to compare 36-month (2008-2011) usage rates among those selected to apply for Medicaid vs not selected, and instrumental variable analyses to estimate the effect of gaining Medicaid coverage on use. Use outcomes included primary care visits, behavioral/mental health visits, laboratory tests, referrals, immunizations, and imaging. RESULTS The intent-to-treat analyses revealed statistically significant differences in rates of behavioral/mental health visits, referrals, and imaging between patients randomly selected to apply for Medicaid vs those not selected. In instrumental variable analyses, gaining Medicaid coverage significantly increased the rate of primary care visits, laboratory tests, referrals, and imaging; rate ratios ranged from 1.27 (95% CI, 1.05-1.55) for laboratory tests to 1.58 (95% CI, 1.10-2.28) for referrals. CONCLUSIONS Our results suggest that use of many different types of CHC services will increase as patients gain Medicaid through Affordable Care Act expansions. To maximize access to critical health services, it will be important to ensure that the health care system can support increasing demands by providing more resources to CHCs and other primary care settings. [ABSTRACT FROM AUTHOR]

Objective: This study compared the preventive service utilization of uninsured patients receiving care at Oregon community health centers (CHCs) in 2008 through 2011 with that of continuously insured patients at the same CHCs in the same period, using electronic health record (EHR) data.Methods: We performed a retrospective cohort analysis, using logistic mixed effects regression modeling to calculate odds ratios and rates of preventive service utilization for patients without insurance, or with continuous insurance.Results: CHCs provided many preventive services to uninsured patients. Uninsured patients were less likely than continuously insured patients to receive 5 of 11 preventive services, ranging from OR 0.52 (95% CI: 0.35-0.77) for mammogram orders to 0.75 (95% CI: 0.66-0.86) for lipid panels. This disparity persisted even in patients who visited the clinic regularly.Conclusion: Lack of insurance is a barrier to preventive service utilization, even in patients who can access care at a CHC. Policymakers in the United States should continue to address this significant prevention disparity. [ABSTRACT FROM AUTHOR]

Background: This study assessed the impact of Affordable Care Act (ACA) Medicaid expansion on health insurance rates and receipt of cardiovascular-related preventive screenings (body mass index, glycated hemoglobin [HbA1c], low-density lipoproteins, and blood pressure) for cancer survivors seen in community health centers (CHCs).Methods: This study identified cancer survivors aged 19 to 64 years with at least 3 CHC visits in 13 states from the Accelerating Data Value Across a National Community Health Center Network (ADVANCE). Via inverse probability of treatment weighting multilevel multinomial modeling, insurance rates before and after the ACA were estimated by whether a patient lived in a state that expanded Medicaid, and changes between a pre-ACA time period and 2 post-ACA time periods were assessed.Results: The weighted estimated sample size included 409 cancer survivors in nonexpansion states and 2650 in expansion states. In expansion states, the proportion of uninsured cancer survivors decreased significantly from 20.3% in 2012-2013 to 4.5%in 2016-2017, and the proportion of those with Medicaid coverage increased significantly from 38.8% to 55.6%. In nonexpansion states, there was a small decrease in uninsurance rates (from 33.6% in 2012-2013 to 22.5% in 2016-2017). Cardiovascular-related preventive screening rates increased over time in both expansion and nonexpansion states: HbA1c rates nearly doubled from the pre-ACA period (2012-2013) to the post-ACA period (2016-2017) in expansion states (from 7.2% to 12.8%) and nonexpansion states (from 9.3% to 16.8%).Conclusions: This study found a substantial decline in uninsured visits among cancer survivors in Medicaid expansion states. Yet, 1 in 5 cancer survivors living in a state that did not expand Medicaid remained uninsured. Several ACA provisions likely worked together to increase cardiovascular-related preventive screening rates for cancer survivors seen in CHCs. [ABSTRACT FROM AUTHOR]

Medication maintenance is critical in the management of asthma. We investigated the differences in electronic health record (EHR) documentation of medication refills for Spanish- and English-speaking Latino children and non-Hispanic white children by examining rates of albuterol rescue inhaler refills from 2005 to 2017, and and inhaled corticosteroid refills from 2015 to 2017 in a multi-state network of community health centers (CHCs). We used data from the ADVANCE network of CHCs. Our sample consisted of children aged 3–17, with a diagnosis of asthma and either albuterol or inhaled corticosteroid prescriptions (n = 39,162; n = 4,738 children, respectively). Negative binomial regression was used to calculate rates of refills per prescription adjusted for relevant patient-level covariates. Analyses stratified by asthma severity were also conducted. English-speaking Latino children had lower rates of albuterol refills compared with non-Hispanic white children (rate ratio [RR] = 0.88, 95% confidence interval [CI]: 0.80–0.98), a trend that persisted among children with moderate/severe persistent asthma severity (RR = 0.85, 95% CI: 0.76–0.95). Spanish-speaking Latino and non-Hispanic white children had similar albuterol refills. Inhaled corticosteroid refill rates were comparable between all groups. In a multi-state network, these findings suggest that CHCs deliver equitable asthma care related to prescription refills between their Latino and white patients, but there is still opportunity for providers to ensure that their English-speaking Latino patients have access to necessary emergency asthma medication. [ABSTRACT FROM AUTHOR]

Background: Community health center (CHC) patients have high rates of smoking. Insurance coverage for smoking cessation assistance, such as that mandated by the Affordable Care Act, may aid in smoking cessation in this vulnerable population.Objective: We aimed to determine if uninsured CHC patients who gain Medicaid coverage experience greater primary care utilization, receive more cessation medication orders, and achieve higher quit rates, compared to continuously uninsured smokers.Design: Longitudinal observational cohort study using electronic health record data from a network of Oregon CHCs linked to Oregon Medicaid enrollment data.Patients: Cohort of patients who smoke and who gained Medicaid coverage in 2008-2011 after ≥ 6 months of being uninsured and with ≥ 1 smoking assessment in the 24-month follow-up period from the baseline smoking status date. This group was propensity score matched to a cohort of continuously uninsured CHC patients who smoke (n = 4140 matched pairs; 8280 patients).Intervention: Gaining Medicaid after being uninsured for ≥ 6 months.Main Measures: 'Quit' smoking status (baseline smoking status was 'current every day' or 'some day' and status change to 'former smoker' at a subsequent visit), smoking cessation medication order, and ≥ 6 documented visits (yes/no variables) at ≥ 1 smoking status assessment within the 24-month follow-up period.Key Results: The newly insured had 40 % increased odds of quitting smoking (aOR = 1.40, 95 % CI:1.24, 1.58), nearly triple the odds of having a medication ordered (aOR = 2.94, 95 % CI:2.61, 3.32), and over twice the odds of having ≥ 6 follow-up visits (aOR = 2.12, 95 % CI:1.94, 2.32) compared to their uninsured counterparts.Conclusions: Newly insured patients had increased odds of quit smoking status over 24 months of follow-up than those who remained uninsured. Providing insurance coverage to vulnerable populations may have a significant impact on smoking cessation. [ABSTRACT FROM AUTHOR]

Background : Multimorbidity (≥ 2 chronic diseases) is associated with greater disability and higher treatment burden, as well as difficulty coordinating self-management tasks for adults with complex multimorbidity patterns. Comparatively little work has focused on assessing multimorbidity patterns among patients seeking care in community health centers (CHCs). Objective: To identify and characterize prevalent multimorbidity patterns in a multi-state network of CHCs over a 5-year period. Design: A cohort study of the 2014–2019 ADVANCE multi-state CHC clinical data network. We identified the most prevalent multimorbidity combination patterns and assessed the frequency of patterns throughout a 5-year period as well as the demographic characteristics of patient panels by prevalent patterns. Participants: The study included data from 838,642 patients aged ≥ 45 years who were seen in 337 CHCs across 22 states between 2014 and 2019. Main measures: Prevalent multimorbidity patterns of somatic, mental health, and mental-somatic combinations of 22 chronic diseases based on the U.S. Department of Health and Human Services Multiple Chronic Conditions framework: anxiety, arthritis, asthma, autism, cancer, cardiac arrhythmia, chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), congestive heart failure, coronary artery disease, dementia, depression, diabetes, hepatitis, human immunodeficiency virus (HIV), hyperlipidemia, hypertension, osteoporosis, post-traumatic stress disorder (PTSD), schizophrenia, substance use disorder, and stroke. Key results: Multimorbidity is common among middle-aged and older patients seen in CHCs: 40% have somatic, 6% have mental health, and 24% have mental-somatic multimorbidity patterns. The most frequently occurring pattern across all years is hyperlipidemia-hypertension. The three most frequent patterns are various iterations of hyperlipidemia, hypertension, and diabetes and are consistent in rank of occurrence across all years. CKD-hyperlipidemia-hypertension and anxiety-depression are both more frequent in later study years. Conclusions: CHCs are increasingly seeing more complex multimorbidity patterns over time; these most often involve mental health morbidity and advanced cardiometabolic-renal morbidity. [ABSTRACT FROM AUTHOR]

Background: Cancer survivors face increased risk for chronic diseases resulting from cancer, preexisting conditions, and cancer treatment. Having an established primary care clinic or health insurance may influence patients' receipt of recommended preventive care necessary to manage, treat, or diagnose new conditions. This study sought to understand receipt of healthcare in community health centers (CHCs) before and after cancer diagnosis among cancer survivors. We also examined the type of care received and assessed whether being established with a CHC or the type of health insurance affected the use of services. Methods: Using electronic health record data and linked cancer registries from 5,649 CHC patients in three states from 2012 through 2018, we obtained monthly rates of primary care and mental health/behavioral health (MHBH) visits and the probability of receipt of care before and after a cancer diagnosis. Results: Seventy‐five percent of CHC patients diagnosed with cancer returned to their primary CHC for care within 2‐years of their diagnosis. Among those who returned, there was a sharp increase in primary and MHBH care shortly before their diagnosis. Significantly more primary care (pre: 19.6%, post: 21.9%, p < 0.001) and MHBH care (pre: 1.2%, post: 1.6%, p < 0.001) was received after diagnosis than before. However, uninsured patients had fewer visits after their diagnosis than before. Conclusion: Use of preventive care for cancer survivors is particularly important. Having an established primary care clinic may help to ensure survivors receive recommended screening and care. [ABSTRACT FROM AUTHOR]

Background: Smoking among cancer survivors can increase the risk of cancer reoccurrence, reduce treatment effectiveness and decrease quality of life. Cancer survivors without health insurance have higher rates of smoking and decreased probability of quitting smoking than cancer survivors with health insurance. This study examines the associations of the Affordable Care Act (ACA) Medicaid insurance expansion with smoking cessation assistance and quitting smoking among cancer survivors seen in community health centers (CHCs).Methods: Using electronic health record data from 337 primary care community health centers in 12 states that expanded Medicaid eligibility and 273 CHCs in 8 states that did not expand, we identified adult cancer survivors with a smoking status indicating current smoking within 6 months prior to ACA expansion in 2014 and ≥ 1 visit with smoking status assessed within 24-months post-expansion. Using an observational cohort propensity score weighted approach and logistic generalized estimating equation regression, we compared odds of quitting smoking, having a cessation medication ordered, and having ≥6 visits within the post-expansion period among cancer survivors in Medicaid expansion versus non-expansion states.Results: Cancer survivors in expansion states had higher odds of having a smoking cessation medication order (adjusted odds ratio [aOR] = 2.54, 95%CI = 1.61-4.03) and higher odds of having ≥6 office visits than those in non-expansion states (aOR = 1.82, 95%CI = 1.22-2.73). Odds of quitting smoking did not differ significantly between patients in Medicaid expansion versus non-expansion states.Conclusions: The increased odds of having a smoking cessation medication order among cancer survivors seen in Medicaid expansion states compared with those seen in non-expansion states provides evidence of the importance of health insurance coverage in accessing evidence-based tobacco treatment within CHCs. Continued research is needed to understand why, despite increased odds of having a cessation medication prescribed, odds of quitting smoking were not significantly higher among cancer survivors in Medicaid expansion states compared to non-expansion states. [ABSTRACT FROM AUTHOR]

Background: In addition to delivering vital health care to millions of patients in the United States, community health centers (CHCs) provide needed health insurance outreach and enrollment support to their communities. We developed a health insurance enrollment tracking tool integrated within the electronic health record (EHR) and conducted a hybrid implementation-effectiveness trial in a CHC-based research network to assess tool adoption using two implementation strategies.Methods: CHCs were recruited from the OCHIN practice-based research network. Seven health center systems (23 CHC clinic sites) were recruited and randomized to receive basic educational materials alone (Arm 1), or these materials plus facilitation (Arm 2) during the 18-month study period, September 2016-April 2018. Facilitation consisted of monthly contacts with clinic staff and utilized audit and feedback and guided improvement cycles. We measured total and monthly tool utilization from the EHR. We conducted structured interviews of CHC staff to assess factors associated with tool utilization. Qualitative data were analyzed using an immersion-crystallization approach with barriers and facilitators identified using the Consolidated Framework for Implementation Research.Results: The majority of CHCs in both study arms adopted the enrollment tool. The rate of tool utilization was, on average, higher in Arm 2 compared to Arm 1 (20.0% versus 4.7%, p < 0.01). However, by the end of the study period, the rate of tool utilization was similar in both arms; and observed between-arm differences in tool utilization were largely driven by a single, large health center in Arm 2. Perceived relative advantage of the tool was the key factor identified by clinic staff as driving tool utilization. Implementation climate and leadership engagement were also associated with tool utilization.Conclusions: Using basic education materials and low-intensity facilitation, CHCs quickly adopted an EHR-based tool to support critical outreach and enrollment activities aimed at improving access to health insurance in their communities. Though facilitation carried some benefit, a CHC's perceived relative advantage of the tool was the primary driver of decisions to implement the tool.Trial Registration: ClinicalTrials.gov: NCT02355262, Posted February 4, 2015. [ABSTRACT FROM AUTHOR]

Background: National leaders recommend documenting social determinants of health and actions taken to address social determinants of health in electronic health records, and a growing body of evidence suggests the health benefits of doing so. However, little evidence exists to guide implementation of social determinants of health documentation/action.Methods: This paper describes a 5-year, mixed-methods, stepped-wedge trial with realist evaluation, designed to test the impact of providing 30 community health centers with step-by-step guidance on implementing electronic health record-based social determinants of health documentation. This guidance will entail 6 months of tailored support from an interdisciplinary team, including training and technical assistance. We will report on tailored support provided at each of five implementation steps; impact of tailored implementation support; a method for tracking such tailoring; and context-specific pathways through which these tailored strategies effect change. We will track the competencies and resources needed to support the study clinics' implementation efforts.Discussion: Results will inform how to tailor implementation strategies to meet local needs in real-world practice settings. Secondary analyses will assess impacts of social determinants of health documentation and referral-making on diabetes outcomes. By learning whether and how scalable, tailored implementation strategies help community health centers adopt social determinants of health documentation and action, this study will yield timely guidance to primary care providers. We are not aware of previous studies exploring implementation strategies that support adoption of social determinants of action using electronic health and interventions, despite the pressing need for such guidance.Trial Registration: clinicaltrials.gov, NCT03607617 , registration date: 7/31/2018-retrospectively registered. [ABSTRACT FROM AUTHOR]

Background: Children with health insurance have increased access to healthcare and receive higher quality care. However, despite recent initiatives expanding children's coverage, many remain uninsured. New technologies present opportunities for helping clinics provide enrollment support for patients. We developed and tested electronic health record (EHR)-based tools to help clinics provide children's insurance assistance.Methods: We used mixed methods to understand tool adoption, and to assess impact of tool use on insurance coverage, healthcare utilization, and receipt of recommended care. We conducted intent-to-treat (ITT) analyses comparing pediatric patients in 4 intervention clinics (n = 15,024) to those at 4 matched control clinics (n = 12,227). We conducted effect-of-treatment-on-the-treated (ETOT) analyses comparing intervention clinic patients with tool use (n = 2240) to intervention clinic patients without tool use (n = 12,784).Results: Tools were used for only 15% of eligible patients. Qualitative data indicated that tool adoption was limited by: (1) concurrent initiatives that duplicated the work associated with the tools, and (2) inability to obtain accurate insurance coverage data and end dates. The ITT analyses showed that intervention clinic patients had higher odds of gaining insurance coverage (adjusted odds ratio [aOR] = 1.32, 95% confidence interval [95%CI] 1.14-1.51) and lower odds of losing coverage (aOR = 0.77, 95%CI 0.68-0.88), compared to control clinic patients. Similarly, ETOT findings showed that intervention clinic patients with tool use had higher odds of gaining insurance (aOR = 1.83, 95%CI 1.64-2.04) and lower odds of losing coverage (aOR = 0.70, 95%CI 0.53-0.91), compared to patients without tool use. The ETOT analyses also showed higher rates of receipt of return visits, well-child visits, and several immunizations among patients for whom the tools were used.Conclusions: This pragmatic trial, the first to evaluate EHR-based insurance assistance tools, suggests that it is feasible to create and implement tools that help clinics provide insurance enrollment support to pediatric patients. While ITT findings were limited by low rates of tool use, ITT and ETOT findings suggest tool use was associated with better odds of gaining and keeping coverage. Further, ETOT findings suggest that use of such tools may positively impact healthcare utilization and quality of pediatric care.Trial Registration: ClinicalTrials.gov, NCT02298361 ; retrospectively registered on November 5, 2014. [ABSTRACT FROM AUTHOR]