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ABSTRACTJustice-impacted persons may inconsistently access HIV testing. This cross-sectional secondary analysis investigates lifetime HIV testing prevalence among adults with prior histories of incarceration in Southern California, United States, participating in health-focused programming (n = 3 studies). Self-reported demographic and lifetime HIV testing data were collected between 2017-2023; descriptive analyses were conducted. Across the three samples, at least 74% of participants were male; Latino and African American individuals accounted for nearly two-thirds of participants. Lifetime HIV testing ranged from 72.8% to 84.2%. Males were significantly more likely than females to report never being tested in two samples and accounted for >95% of those never tested. No statistically significant differences in testing were observed by race/ethnicity. Single young adults (ages 18-26) were less likely than their partnered peers to report testing. HIV testing is critical for ensuring that individuals access prevention and treatment. HIV testing among justice-impacted adults in this study was higher than in the general population, potentially due to opt-out testing in correctional settings. Nevertheless, these findings underscore the importance of implementing targeted interventions to reduce structural (e.g., health insurance, access to self-testing kits) and social barriers (e.g., HIV stigma) to increase HIV testing among justice-impacted males and single young adults.

Trauma-informed communities establish cross-sector coalitions that advocate for the use of trauma-informed practices. Whether and how communication occurs within newly established trauma-informed communities is unclear. We collected qualitative data and social network data from six trauma-informed community partnerships that received funding to build community capacity to address trauma across a range of special populations in Los Angeles county. We identified three communication network sub-types and highlight contributions of network leadership in setting the tone for cross-partnership communication. While partnership leaders shared the goal of strengthening cross-organizational communication, social network results illustrated a need to develop strategies that target these goals.

BACKGROUND: The effect of years of education on the maintenance of healthy cognitive functioning may differ by race and ethnicity given historical and ongoing inequities in educational quality. METHODS: We examined 20,311 Black, Latinx, and White adults aged 51-100 from the Health and Retirement Study (2008-2016). Telephone Interview for Cognitive Status-27 data was used to measure cognitive functioning. Generalized additive mixed models were stratified by race and ethnicity and educational attainment (≥12 vs.

BackgroundBy 2034, the number of US individuals with diabetes is predicted to increase from 23.7 to 44.1 million, and annual diabetes-related spending is expected to grow from $113 to $336 billion. Up to 55% of US Hispanics born in the year 2000 are expected to develop diabetes during their lifetime. Poor healthcare access and cultural barriers prevent optimal care, adherence, and clinical benefit, placing Hispanics at disproportionate risk for costly diabetes complications. Mobile technology is increasingly prevalent in all populations and can circumvent such barriers. Our group developed Dulce Digital, an educational text messaging program that improved glycemic control relative to usual care. Dulce Digital-Me (DD-Me) has been tailored to a participant's individual needs with a greater focus on health behavior change.MethodsThis is a three-arm, parallel group, randomized trial with equal allocation ratio enrolling Hispanic adults with low income and poorly managed type 2 diabetes (N = 414) from a San Diego County Federally Qualified Health Center. Participants are randomized to receive Dulce Digital, Dulce Digital-Me-Automated, or Dulce Digital-Me-Telephonic. The DD-Me groups include Dulce Digital components plus personalized goal-setting and feedback delivered via algorithm-driven automated text messaging (DD-Me-Automated) or by the care team health coach (DD-Me-Telephonic) over a 12-month follow-up period. The study will examine the comparative effectiveness of the three groups in improving diabetes clinical control [HbA1c, primary outcome; low-density lipoprotein cholesterol (LDL-C), and systolic blood pressure (SBP)] and patient-provider communication and patient adherence (i.e., medication, self-management tasks) over 12 months and will examine cost-effectiveness of the three interventions.DiscussionOur comparative evaluation of three mHealth approaches will elucidate how technology can be integrated most effectively and efficiently within primary care-based chronic care model approaches to reduce diabetes disparities in Hispanics and will assess two modes of personalized messaging delivery (i.e., automated messaging vs. telephonic by health coach) to inform cost and acceptability.Trial registrationNCT03130699-All items from the WHO Trial Registration data set are available in https://clinicaltrials.gov/ct2/show/study/NCT03130699 .

In the US, nearly 11% of adults were living with diagnosed diabetes in 2017, and significant type 2 diabetes (T2D) disparities are experienced by socioeconomically disadvantaged, racial/ethnic minority populations, including Hispanics. The standard 15-min primary care visit does not allow for the ongoing self-management support that is needed to meet the complex needs of individuals with diabetes. "Team-based" chronic care delivery is an alternative approach that supplements physician care with contact from allied health personnel in the primary care setting (e.g., medical assistants; MAs) who are specially trained to provide ongoing self-management support or "health coaching." While rigorous trials have shown MA health coaching to improve diabetes outcomes, less is known about if and how such a model can be integrated within real world, primary care clinic workflows. Medical Assistant Health Coaching for Type 2 Diabetes in Diverse Primary Care Settings - A Pragmatic, Cluster-Randomized Controlled Trial will address this gap. Specifically, this study compares MA health coaching versus usual care in improving diabetes clinical control among N = 600 at-risk adults with T2D, and is being conducted at four primary care clinics that are part of two health systems that serve large, ethnically/racially, and socioeconomically diverse populations in Southern California. Electronic medical records are used to identify eligible patients at both health systems, and to examine change in clinical control over one year in the overall sample. Changes in behavioral and psychosocial outcomes are being evaluated by telephone assessment in a subset (n = 300) of participants, and rigorous process and cost evaluations will assess potential for sustainability and scalability.

BackgroundThere is limited information regarding the impact of dose and gestational timing of oral corticosteroid (OCS) use on preterm birth (PTB), especially among women with asthma.ObjectivesTo evaluate OCS dose and timing on PTB for asthma and, as a comparison, systemic lupus erythematosus (SLE).MethodsWe used health care data from California Medicaid enrollees linked to birth certificates (2007-2013), identifying women with asthma (n = 22,084) and SLE (n = 1174). We estimated risk ratios (RR) for OCS cumulative dose trajectories and other disease-related medications before gestational day 140 and hazard ratios (HR) for time-varying exposures after day 139.ResultsFor asthma, PTB risk was 14.0% for no OCS exposure and 14.3%, 16.8%, 20.5%, and 32.7% in low, medium, medium-high, and high cumulative dose trajectory groups, respectively, during the first 139 days. The high-dose group remained associated with PTB after adjustment (adjusted RR [aRR]: 1.46; 95% confidence interval [CI]: 1.00, 2.15). OCS dose after day 139 was not clearly associated with PTB, nor were controller medications. For SLE, PTB risk for no OCS exposure was 24.9%, and it was 39.1% in low- and 61.2% in high-dose trajectory groups. aRR were 1.80 (95% CI: 1.34, 2.40) for high and 1.24 (95% CI: 0.97, 1.58) for low groups. Only prednisone equivalent dose >20 mg/day after day 139 was associated with increased PTB (adjusted HR: 2.54; 95% CI: 1.60, 4.03).ConclusionsFor asthma, higher OCS doses early in pregnancy, but not later, were associated with increased PTB. For SLE, higher doses early and later in pregnancy were associated with PTB.

OBJECTIVE: To evaluate racial and ethnic disparities in utilization of total knee arthroplasty (TKA) in relation to demographic, health, and socioeconomic status variables. DESIGN: Prospective study of 102,767 Womens Health Initiative postmenopausal women initially aged 50-79, examining utilization rates of primary TKA between non-Hispanic Black/African American, non-Hispanic White, and Hispanic/Latina women (hereafter referred to as Black, White, and Hispanic). A total of 8,942 Black, 3,405 Hispanic, and 90,420 White women with linked Medicare claims data were followed until time of TKA, death, or transition from fee-for-service coverage. Absolute disparities were determined using utilization rates by racial/ethnic group and relative disparities quantified using multivariable hazards models in adjusting for age, arthritis, joint pain, mobility disability, body mass index, number of comorbidities, income, education, neighborhood socioeconomic status (SES), and geographic region. RESULTS: TKA utilization was higher among White women (10.7/1,000 person-years) compared to Black (8.5/1,000 person-years) and Hispanic women (7.6/1,000 person-years). Among women with health indicators for TKA including diagnosis of arthritis, moderate to severe joint pain, and mobility disability, Black and Hispanic women were significantly less likely to undergo TKA after adjusting for age [Black: HR (95% confidence interval) = 0.70 (0.63-0.79); Hispanic: HR = 0.58 (0.44-0.77)]. Adjustment for SES modestly attenuated the measured disparity, but significant differences remained [Black: HR = 0.75 (0.67-0.89); Hispanic: HR = 0.65 (0.47-0.89)]. CONCLUSIONS: Compared to White women, Black and Hispanic women were significantly less likely to undergo TKA after considering need and appropriateness for TKA and SES. Further investigation into personal-level and provider-level factors that may explain these disparities is warranted.

BACKGROUND: Long-acting beta2-agonists (LABAs), with or without inhaled corticosteroids (ICSs), delivered by handheld inhalers or nebulizers are recommended as maintenance therapy in chronic obstructive pulmonary disease (COPD). This study evaluated exacerbations, health resource utilization (HRU), and costs among Medicare beneficiaries with COPD on handheld ICS+LABA who switched to nebulized arformoterol (ARF) or continued ICS+LABA following a respiratory event. METHODS: Using Medicare claims, we identified beneficiaries with COPD (international classification of disease, 9th revision, clinical modification [ICD-9-CM] 490-492.xx, 494.xx, 496.xx) between 2010-2014 who had ≥ 1 year of continuous enrollment in Parts A, B, and D; ≥ 2 COPD-related outpatient visits ≥ 30 days apart or ≥ 1 hospitalization(s); ICS+LABA use 90-days before ARF initiation; and a respiratory event (COPD-related hospitalization or emergency department [ED] visit < 30 days before ARF initiation). Using propensity scores, 423 beneficiaries who switched to ARF were matched to 423 beneficiaries who continued on handheld ICS+LABA (controls). Difference-in-difference regression models examined outcomes at 180-days follow-up. RESULTS: Beneficiaries who switched to ARF had 1.5 fewer exacerbations (p=0.015) but no difference in hospitalizations and ED visits compared to controls. Durable medical equipment (DME) costs were higher among ARF users than controls ($1590), yet total health care costs were similar due to cost offsets by ARF in pharmacy (-$794), inpatient (-$524), and outpatient care (-$65). ARF accounted for 55% ($886.63) of DME costs, with the remaining costs attributed to oxygen therapy ($428.10) and nebulized corticosteroids ($590.85). CONCLUSIONS: Switching from handheld ICS+LABA to nebulized ARF resulted in fewer COPD exacerbations among Medicare beneficiaries. Nebulized LABAs may improve outcomes in selected patients with COPD.

OBJECTIVE: To examine the cost-effectiveness of a community-based Diabetes Prevention Program (DPP) for Medicaid beneficiaries from the perspective of the health care sector. DATA SOURCES/STUDY SETTING: A total of 847 Medicaid enrollees at high risk for type 2 diabetes participating in a community-based DPP. STUDY DESIGN: Pre- and post clinical outcome and cost data were used as inputs into a validated diabetes simulation model. The model was used to evaluate quality-adjusted life years (QALYs) and health care costs over a 40-year time horizon from the perspective of the health care sector. DATA COLLECTION/EXTRACTION METHODS: Clinical outcome and cost data were derived from a study examining the effect of financial incentives on weight loss. PRINCIPAL FINDINGS: Study participants lost an average of 4.2 lb (p

People with serious mental illness, such as schizophrenia and bipolar disorder, experience premature mortality, often from cardiovascular disease (CVD). Unfortunately, people with serious mental illness typically are not screened or treated for CVD risk factors despite national guideline recommendations. Access to primary preventive care in community mental health settings has the potential to reduce early mortality rates in this population. The authors review best practices for developing an integrated care model for people with serious mental illness by considering economic feasibility and sustainability from the perspective of a community mental health clinic (CMHC). A process-mapping approach was used to gather information on clinic costs (staff roles, responsibilities, time, and salary) of serving 544 patients at one CMHC. The estimated annual cost of the model was measurable and modest, at $74 per person, suggesting that this model may be financially feasible.

OBJECTIVE This cluster (clinic-level) randomized controlled trial (RCT) compared medical assistant (MA) health coaching (MAC) with usual care (UC) among at-risk adults with type 2 diabetes in two diverse real-world primary care environments: a federally qualified health center (FQHC; Neighborhood Healthcare) and a large nonprofit private insurance--based health system (Scripps Health). RESEARCH DESIGN AND METHODS A total of 600 adults with type 2 diabetes who met one or more of the following criteria in the last 90 days were enrolled: HbA1c ≥8% and/or LDL cholesterol ≥100 mg/dL and/or systolic blood pressure (SBP) ≥140 mmHg. Participants at MAC clinics received in-person and telephone self-management support from a specially trained MA health coach for 12 months. Electronic medical records were used to examine clinical outcomes in the overall sample. Behavioral and psychosocial outcomes were evaluated in a subsample (n = 300). RESULTS All clinical outcomes improved significantly over 1 year in the overall sample (P < 0.001). The reduction in HbA1c was significantly greater in the MAC versus UC group (unstandardized Binteraction = -0.06; P = 0.002). A significant time by group by site interaction also showed that MAC resulted in greater improvements in LDL cholesterol than UC at Neighborhood Healthcare relative to Scripps Health (Binteraction = -1.78 vs. 1.49; P < 0.05). No other statistically significant effects were observed. CONCLUSIONS This was the first large-scale pragmatic RCT supporting the real-world effectiveness of MAC for type 2 diabetes in U.S. primary care settings. Findings suggest that this team-based approach may be particularly effective in improving diabetes outcomes in FQHC settings. [ABSTRACT FROM AUTHOR]

BackgroundThe Centers for Medicare & Medicaid Services (CMS) Medicare Health Plan Quality and Performance Ratings program, or Star Ratings program, includes 3 medication adherence outcome measures (Medication Adherence for Diabetes Medications, Medication Adherence for Hypertension, and Medication Adherence for Cholesterol), which contribute to approximately 31% of a Medicare Advantage prescription drug (MA-PD) plan's Part D summary rating and 12% of its overall star rating (a weighted summary of a plan's Part C and Part D ratings). MA-PD plans have been increasing their adherence intervention efforts as an approach to improving beneficiaries' medication adherence and the plan's quality performance ratings. However, few evaluations have examined the effects of these interventions on medication adherence and performance ratings.ObjectiveTo assess the impact of a quasi-experimental multichannel adherence intervention on beneficiaries' medication adherence and health plan quality performance measures for 2 MA-PD plans. The intervention included a daily prescriber-directed 90-day retail refill component and a weekly member-directed refill reminder component.MethodsMembers filling 1 or more medications assessed by the 3 CMS star ratings adherence measures (oral antidiabetics [DM], antihypertensives [HTN], and statins [CHOL]) were identified for a 2-component intervention starting in April 2013. The retail-based 90-day refill component sent populated 90-day prescription letters via fax to prescribers of members who had filled a 30-day prescription. One fax per member-medication instance was sent and included the option to fax approval of a new 90-day prescription. For prescribers who approved, members were notified that a 90-day refill was available at their retail pharmacies. The refill reminder component used weekly scans of pharmacy claims to identify members' refill patterns. Reminder letters were sent to members 7 days late to refill. An intent-to-treat approach was used to assess intervention effectiveness. Pharmacy claims and health plan enrollment data were used to calculate adherence among members enrolled 1 year pre- and postintervention start (April 2013) for the intervention group and a comparator group that consisted of 4 MA-PD plans not implementing an adherence intervention. Adherence was estimated by the proportion of days covered (PDC) and generalized linear models were fit to calculate difference-in-difference (DID) estimators to control for demographics, comorbidity, and changes in adherence over the study period. To estimate the impact of the intervention on health plan quality performance, 2013 and 2014 CMS star ratings for the respective 2012 and 2013 measurement years were compared by group.ResultsDuring the first year of the intervention, 1,344 prescribers representing 6,701 members were faxed 15,284 populated prescription letters. Prescriber response rate was 53.7% and approval rate (approved letters of total sent) was 47.3%. An average of 539 refill reminder letters were sent per week. DID estimators showed positive influence of the intervention on adherence to HTN and CHOL. For the intervention group, adherence increased 2.0 percentage points (P < 0.001) for HTN and 1.8 percentage points (P < 0.001) for CHOL, relative to the control group. The odds of achieving adherence (PDC ≥ 80%) were greater in the intervention group compared with control for HTN (ratio of odds ratio [ROR] = 1.334; 95% CI = 1.203-1.479) and for CHOL (ROR = 1.247; 95% CI = 1.132-1.374). For the 2 plans implementing the intervention, CMS-published adherence rates for DM, HTN, and CHOL increased from 2012 to 2013 by an average 5.5, 6.0, and 7.0 percentage points, respectively, compared with the control group (3.5, 2.0, and 1.8 percentage points, respectively).ConclusionsThis study found increases in adherence to HTN and CHOL in 2 MA-PD plans implementing a combined prescriber and patient-directed intervention. MA-PD plans can use broad multichannel interventions to address common adherence barriers and as an approach to improving members' adherence to maintenance medications and CMS quality performance ratings.DisclosuresNo funding was received in return for conducting this research. Leslie is an employee of MedImpact Healthcare Systems. The authors report no conflicts of interest. Study concept was developed primarily by Leslie, along with Gilmer. Leslie took the lead in data collection, while data interpretation was performed by Leslie, Natarajan, and Gilmer. The manuscript was written primarily by Leslie, along with Gilmer and assisted by Hovell. Leslie, Gilmer, and Hovell revised the manuscript, with assistance from Natarajan.

ObjectiveTo characterize the health risk of enrollees in California's state-based insurance marketplace (Covered California) by metal tier, region, month of enrollment, and plan.Data source/study setting2014 Open-enrollment data from Covered California linked with 2012 hospitalization and emergency department (ED) visit records from statewide all-payer administrative databases.Data collection/extraction methodsChronic Illness and Disability Payment System (CDPS) health risk scores derived from an individual's age and sex from the enrollment file and the diagnoses captured in the hospitalization and ED records. CDPS scores were standardized by setting the average to 1.00.Principal findingsAmong the 1,286,089 enrollees, 120,573 (9.4 percent) had at least one ED visit and/or a hospitalization in 2012. Higher risk enrollees chose plans with greater actuarial value. The standardized CDPS health risk score was 11 percent higher in the first month of enrollment (1.08; 99 percent CI: 1.07-1.09) than the last month (0.97; 99 percent CI: 0.97-0.97). Four of the 12 plans enrolled 91 percent of individuals; their average health risk scores were each within 3 percent of the marketplace's statewide average.ConclusionsProviding health plans with a means to assess the health risk of their year 1 enrollees allowed them to anticipate whether they would receive or contribute payments to a risk-adjustment pool. After receiving these findings as a part of their negotiations with Covered California, health plans covering the majority of enrollees decreased their initially proposed 2015 rates, saving consumers tens of millions of dollars in potential premiums.

Introduction: Patient engagement in research can improve a health system's responsiveness to patient need, but patient experience with integrated care is not well understood. This qualitative study explores patient experience and provider perceptions of patient experience with the Behavioral Health Integration and Complex Care Initiative (BHICCI), which is a large-scale system redesign that delivers integrated care to persons with complex needs. Methods: We conducted 8 patient focus groups (n = 54 patients) and n = 32 interviews with BHICCI providers at five community health settings participating in the BHICCI during which patients and providers described how patient experience with care had changed under the initiative. Results: Patient experience and provider perception of patient experience aligned under 2 themes: (a) care coordination is essential for positive patient experience; and (b) the BHICCI strengthened patient provider relationships. Perspectives diverged under theme (c) patient experience with programmatic 'growing pains.' Discussion: This study highlights the importance of seeking outpatient feedback and incorporating these experiences into the redesign of integrated care systems. Formal mechanisms, such as patient advisory boards, are needed to ensure that health care quality improvement initiatives are patient centered. Keywords: patient experience, integrated care, qualitative methods, Persons living with mental illness are at elevated risk for a range chronic care conditions and experience 25 years of life lost compared with the general population (Colton & Manderscheid, [...]

ObjectivePermanent supportive housing (PSH) programs are being implemented throughout the United States. This study examined the relationship between fidelity to the Housing First model and health service use among clients in PSH programs in California.MethodsData from a survey of PSH program practices were merged with administrative data on service utilization to examine the association between fidelity to a benchmark program, the Housing First model, and health service use among 5,067 clients in 77 PSH programs. Regression analyses were used to compare inpatient, crisis and residential, and outpatient mental health service use between high-, mid-, and low-fidelity programs in a pre-post design.ResultsDuring the preenrollment period, clients in mid- and high-fidelity PSH programs, compared with low-fidelity programs, used inpatient and crisis and residential services more but used outpatient mental health services less. Postenrollment, patients in high-fidelity programs showed the largest increase in the number of outpatient visits, followed by clients in mid- and low-fidelity programs: 71.6 versus 48.2 and 29.0, respectively.ConclusionsClients in housing programs with higher fidelity to the Housing First model had greater increases in outpatient visits. Compared with lower-fidelity programs, higher-fidelity programs also enrolled clients who used fewer mental health outpatient services in the year before enrollment. Higher-fidelity programs may be more effective than lower-fidelity programs in increasing outpatient service utilization and in their outreach to and engagement of clients who are not appropriately served by the public mental health system.

BackgroundPhysical inactivity is high in Latinas, as are chronic health conditions. There is a need for physical activity (PA) interventions that are not only effective but have potential for cost-effective widespread dissemination. The purpose of this paper was to assess the costs and cost effectiveness of a Spanish-language print-based mail-delivered PA intervention that was linguistically and culturally adapted for Latinas.MethodsAdult Latinas (N = 266) were randomly assigned to receive mail-delivered individually tailored intervention materials or wellness information mailed on the same schedule (control). PA was assessed at baseline, six months (post-intervention) and 12 months (maintenance phase) using the 7-Day Physical Activity Recall Interview. Costs were calculated from a payer perspective, and included personnel time (wage, fringe, and overhead), materials, equipment, software, and postage costs.ResultsAt six months, the PA intervention cost $29/person/month, compared to $15/person/month for wellness control. These costs fell to $17 and $9 at 12 months, respectively. Intervention participants increased their PA by an average of 72 min/week at six months and 94 min/week at 12 months, while wellness control participants increased their PA by an average of 30 min/week and 40 min/week, respectively. At six months, each minute increase in PA cost $0.18 in the intervention group compared to $0.23 in wellness control, which fell to $0.07 and $0.08 at 12 months, respectively. The incremental cost per increase in physical activity associated with the intervention was $0.15 at 6 months and $0.05 at 12 months.ConclusionsWhile the intervention was more costly than the wellness control, costs per minute of increase in PA were lower in the intervention. The print-based mail-delivered format has potential for broad, cost-effective dissemination, which could help address disparities in this at-risk population.Trial registrationNCT01583140; Date of Registration: 03/06/2012; Funding Source of Trial: National Institute of Nursing Research (NINR); Name of Institutional Review Board: Brown University IRB; Date of Approval: 05/19/2009.

ObjectiveTo characterize the 20 most common prescription medications and the 10 most common prescription medications classified in the former U.S. Food and Drug Administration categories D or X dispensed to pregnant women enrolled in the U.S. Medicaid program.MethodsWe conducted a cohort study of 1,106,757 pregnant women with live births using 2000-2007 Medicaid Analytic eXtract data. We used outpatient pharmacy records to identify medication dispensings and reported the proportion of pregnancies that were dispensed at least one prescription medication. Maternal age and race and ethnicity-stratified estimates were compared using prevalence ratios and 95% confidence intervals (CIs).ResultsDuring pregnancy, 82.5% of the cohort had a dispensing for one or more prescription medication. The most commonly dispensed medications during pregnancy included nitrofurantoin (21.6%), metronidazole (19.4%), amoxicillin (18.0%), azithromycin (16.9%), and promethazine (13.5%). Proportions were highest among younger women for several medications; eg, nitrofurantoin (23.9% compared with 15.4%; prevalence ratio 1.55, CI 1.52-1.58), metronidazole (20.7% compared with 12.0%; prevalence ratio 1.73, CI 1.69-1.77), and azithromycin (21.1% compared with 11.0%; prevalence ratio 1.93, CI 1.89-1.97) were more common among women younger than 20 years than among women aged 35 years or older. Proportions were highest among white women with some exceptions; eg, compared with white women, metronidazole was more common among black women (29.8% compared with 14.4%; prevalence ratio 2.07, CI 2.05-2.09). Excluding fertility treatments, 42.0% had at least one dispensing for a D or X medication during pregnancy. Codeine (11.9%) and hydrocodone (10.2%) were the most common D medications.ConclusionMedications used to treat infections were the most commonly dispensed prescription medications. Dispensing of commonly used prescription medications during pregnancy varied by maternal age and race-ethnicity.Level of evidenceII.

ObjectiveThis study examined whether receipt of outpatient psychiatric services after hospital discharge was associated with reduced risk of readmission.MethodsTreatment records from patients admitted to San Diego County psychiatric hospitals over a one-year period were obtained from the San Diego County Behavioral Health Services electronic health record system. A discrete-time proportional hazards model was used to examine the association of receipt of outpatient psychiatric services with readmission within 30 days of discharge from the index hospitalization.ResultsOf the 4,663 patients, 16% were readmitted within 30 days. In an adjusted model, receipt of outpatient therapy after discharge was associated with a greater likelihood of being readmitted (hazard ratio=1.36, 95% confidence interval=1.14-1.67), whereas receipt of case management or medication management was not associated with readmission.ConclusionsThe differential risk of readmission by service type suggests a need for studies that explore reasons for an increased risk of readmission with certain types of services.

ObjectiveCalifornia's full-service partnerships (FSPs) provide a combination of subsidized permanent housing and multidisciplinary team-based services with a focus on rehabilitation and recovery. The goal of the study was to examine whether participation in FSPs is associated with changes in health service use and costs compared with usual care.MethodsA quasi-experimental, pre-post, intent-to-treat design with a propensity score-matched contemporaneous control group was used to compare health service use and costs among 10,231 FSP clients and 10,231 matched clients with serious mental illness who were receiving public mental health services in California from January 1, 2004, through June 30, 2010.ResultsAmong FSP participants, the mean annual number of mental health outpatient visits increased by 55.5, and annual mental health costs increased by $11,725 relative to the matched control group. Total service costs increased by $12,056.ConclusionsParticipation in an FSP was associated with increases in outpatient visits and their associated costs. As supportive housing programs are implemented nationally and on a large scale, these programs will likely need to be more effectively designed and targeted in order to achieve reductions in costly inpatient services.

OBJECTIVES: Despite the significant prevalence of elevated blood pressure (BP) and body mass index (BMI) in children, few studies have assessed their combined impact on healthcare costs. This study estimates healthcare costs related to BP and BMI in children and adolescents. STUDY DESIGN: Prospective dynamic cohort study of 71,617 children aged 3 to 17 years with 208,800 child years of enrollment in integrated health systems in Colorado or Minnesota between January 1, 2007, and December 31, 2011. METHODS: Generalized linear models were used to calculate standardized annual estimates of total, inpatient, outpatient, and pharmacy costs, outpatient utilization, and receipt of diagnostic and evaluation tests associated with BP status and BMI status. Results: Total annual costs were significantly lower in children with normal BP ($736, SE = $15) and prehypertension ($945, SE = $10) than children with hypertension ($1972, SE = $74) (P

Adjustments for the underlying differences in risks among patients in payment approaches has been widely used and accepted; yet current risk adjustment approaches are limited because they do not account for the various social determinants of health (SDH) that can also influence health outcomes. This can have implications for providers serving disadvantaged populations. This article discusses why the inclusion of SDH in the formulas for risk adjustment is important for federally qualified health centers (FQHCs) under the Patient Protection and Affordable Care Act (ACA) and recommends ways in which FQHCs can be leaders in informing payment reform policies.

OBJECTIVE: This study examined variation in the implementation of Californias Full Service Partnerships (FSPs), which are supported housing programs that do whatever it takes to improve outcomes among persons with serious mental illness who are homeless or at risk of homelessness. DATA SOURCES/SETTING: Ninety-three FSPs in California. STUDY DESIGN: A mixed methods approach was selected to develop a better understanding of the complexity of the FSP programs. The design structure was a combined explanatory and exploratory sequential design (qual→QUAN→qual) where a qualitative focus group was used to develop a quantitative survey that was followed by qualitative site visits. The survey was used to describe the breadth of variation based on fidelity to the Housing First model, while the site visits were used to provide a depth of information on high- versus low-fidelity programs. PRINCIPAL FINDINGS: We found substantial variation in implementation among FSPs. Fidelity was particularly low along domains related with housing and service philosophy, indicating that many FSPs implemented a rich array of services but applied housing readiness requirements and did not adhere to consumer choice in housing. CONCLUSIONS: There remains room for improvement in the recovery-orientation of FSPs. Fortunately, we have identified several processes by which program managers and counties can increase the fidelity of their programs.

Social health is important to measure when assessing outcomes in community mental health. Our objective was to validate social health scales using items from two broader commonly used measures that assess mental health outcomes. Participants were 609 adults receiving psychological treatment services. Items were identified from the California Quality of Life (CA-QOL) and Mental Health Statistics Improvement Program (MHSIP) outcome measures by their conceptual correspondence with social health and compared to the Social Functioning Questionnaire (SFQ) using correlational analyses. Pearson correlations for the identified CA-QOL and MSHIP items with the SFQ ranged from .42 to .62, and the identified scale scores produced Pearson correlation coefficients of .56, .70, and, .70 with the SFQ. Concurrent validity with social health was supported for the identified scales. The current inclusion of these assessment tools allows community mental health programs to include social health in their assessments.

Background: The aging population has led to an increase in emergency department (ED) visits by older adults who have complex medical conditions and high social needs. The purpose of this study was to assess if comprehensive geriatric evaluation and management impacted service utilization and cost by older adults admitted to the ED. Methods: This is a retrospective matched case–control study at a level 1 geriatric ED (GED) from January 1, 2018–March 31, 2020. Geriatric nurse specialists (GENIEs) provided comprehensive evaluations and management for GED patients. Propensity score matching was used to match patients receiving GENIE consultations to ED patients who did not receive a GENIE consult. Regression was used to assess the impact of the GENIE services on inpatient admissions, ED revisits and cost of inpatient and ED care from the payor perspective. Results: GENIE consults were associated with a 13.0% reduction in absolute risk of admission through the ED at index (95% confidence interval [CI] −17.0%, −9.0%, p < 0.001) and a reduction in risk for total admissions at 30 and 90‐days post discharge (−11.3%, 95% CI −15.6%, −7.1%, p‐value < 0.001; and −10.0, 95% CI −13.8%, −6.0%; p < 0.001 respectively), both driven by reduced risk of admission at the index visit. GENIE consults were associated with a 4% increase in absolute risk of revisits to the ED within 30 days (95% CI 0.6%, 7.3%; p = 0.001). GENIE consults were associated with a decrease in cost of inpatient and ED care, with savings of $2344 within 30 days (95% CI $2247, $2441, p < 0.001) and savings of $2004 USD within 90 days (95% CI $1895, $2114, p < 0.001), driven by reduced costs at the index visit. Conclusions: GENIE consults were associated with decreased inpatient admissions through the ED, modestly increased ED revisits, and decreased cost of inpatient and ED care. The results of this study can be useful for EDs considering approaches to better serve older adults. They can also be of interest to payers as an area of potential cost savings. See related Editorial by Southerland et al. in this issue. [ABSTRACT FROM AUTHOR]