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Purpose: Results of a study to determine whether routine use of a multifaceted medication-focused intervention at a safety-net hospital was feasible and could reduce hospital readmissions in a Medicare fee-for-service population are reported., Methods: A quality-improvement cohort study of 1,059 admissions of 667 patients at an inner-city hospital was conducted. Patients in the intervention groups received some or all components of the multifaceted "Medication REACH" intervention, with direct pharmacist involvement from admission through postdischarge aftercare. A pharmacist reconciled medications, provided patient-centered education, collaborated with healthcare providers to optimize therapy, ensured access to medications, and followed up with patients at home as needed. Rates of unplanned readmissions within 30 days of discharge in the full- and partial-intervention groups and in patients who received standard discharge care were compared., Results: Among patients who received the full Medication REACH intervention, 30 of 305 admissions (9.8%) resulted in unplanned readmissions within 30 days, as compared with a readmission rate of 20.4% (110 of 538 patients) among patients who received standard discharge care ( p < 0.001). Linear regression modeling, with adjustments for patient age, sex, ethnicity, and case-mix index, indicated an adjusted risk difference favoring the full-intervention group of 9.4 percentage points (95% confidence interval, 4.3-14.6 percentage points; p < 0.001)., Conclusion: Rates of 30-day readmission were substantially lower with pharmacist involvement and collaboration with other healthcare team members during patient transitions from the hospital to the home setting., (Copyright © 2018 by the American Society of Health-System Pharmacists, Inc. All rights reserved.)

Care management (CM) is a promising team-based, patient-centered approach "designed to assist patients and their support systems in managing medical conditions more effectively." As little is known about its implementation, this article describes CM implementation and associated lessons from 12 Agency for Healthcare Research and Quality-sponsored projects. Two rounds of data collection resulted in project-specific narratives that were analyzed using an iterative approach analogous to framework analysis. Informants also participated as coauthors. Variation emerged across practices and over time regarding CM services provided, personnel delivering these services, target populations, and setting(s). Successful implementation was characterized by resource availability (both monetary and nonmonetary), identifying as well as training employees with the right technical expertise and interpersonal skills, and embedding CM within practices. Our findings facilitate future context-specific implementation of CM within medical homes. They also inform the development of medical home recognition programs that anticipate and allow for contextual variation.

Medical records, which are increasingly directly accessible to patients, contain highly technical terms unfamiliar to many patients. A federally qualified health center (FQHC) sought to help patients interpret their records by embedding context-specific hyperlinks to plain-language patient education materials in its portal. We assessed the impact of this innovation through a 3-year retrospective cohort study. A total of 12,877 (10% of all patients) in this safety net population had used the MPC links. Black patients, Latino patients comfortable using English, and patients covered by Medicaid were more likely to use the informational hyperlinks than other patients. The positive association with black race and Latino ethnicity remained statistically significant in multivariable models that controlled for insurance type. We conclude that many of the sociodemographic factors associated with the digital divide do not present barriers to accessing context-specific patient education information once in the portal. In fact, this type of highly convenient plain-language patient education may provide particular value to patients in traditionally disadvantaged groups.

The Affordable Care Act made admirable strides toward the "triple aim" of reducing health care costs, increasing health care quality, and improving the health of the community at large. A key element of reform is the accountable care organization (ACO), which restructures health care delivery such that networks of providers are held responsible for a group of patients they serve. The recently announced Medicare ACO program lays the foundation for 2 of its 3 major goals by allowing ACOs to share in any cost savings, provided they meet quality criteria. Yet it seems that the public health goals of accountable care-arguably the most important of the 3-have been left behind. To better address public health goals, we propose a novel method for quality reporting within ACOs: introducing an "expanded denominator" that attributes patients to a health system if they have ever been seen within the system. An expanded denominator would ensure that ACOs are held accountable not only for patients already engaged in primary care but also for patients with fragmented care and high-risk community members not receiving adequate care. Ultimately, payment reform in Medicare, and potentially Medicaid, must support this new approach to quality measurement for it to have lasting ramifications.