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Despite a growing focus on the healthcare system’s role in opioid use disorder (OUD) prevention through careful prescribing and increasing use of OUD treatments such as medications for OUD (MOUD), we know little about health system responses to the epidemic. Specifically, we do not know which types of healthcare organizations demonstrate success in treating OUD. We know that living in states that have more addiction therapy prescribers increases treatment access, but evidence on provider initiatives and their effectiveness is scarce. Other studies have shown living in states participating in payment reforms where providers are held accountable for the cost of OUD treatment (carve-in models) can increase access to outpatient treatment for OUD, but evidence on how individual providers are participating and implementing these payment reforms is limited. We propose to fill this evidence gap by using new surveys to describe whether and how healthcare organizations are addressing the opioid epidemic. Specifically, we will explore how participation in Accountable Care Organizations (ACOs, provider organizations held financially responsible for quality and cost of care) are influencing health systems’ approaches to treat OUD, and whether treatment for OUD under ACO contracts has changed over time. The overarching goals of ACO participation – optimizing coordination and population health, decreasing expenditure growth, and increasing use of evidence-based/cost-effective interventions and prescription drugs – align with both OUD prevention and treatment. At the same time, such population-based payment and delivery models raise concerns that providers may have reasons to avoid (or simply fail to target) patients expected to have high costs or for whom meeting quality benchmarks is likely to be challenging. People with substance use treatment needs often have substantially higher expected costs and difficulty in the management of physical health conditions. We will use two consecutive waves of the National Survey of ACOs (NSACO), fielded in 2017-2018 (Wave 4) and 2021-2022 (Wave 5), to estimate how approaches to OUD treatment have changed in provider organizations that participate in ACOs. The fielding of the 2021-2022 study is funded by a grant from the National Institute on Drug Abuse (NIDA R01DA049757, Principal Investigators: Meara, Lewinson), which seeks to use the 2021-2022 NSACO, in addition to other novel surveys and national Medicare and Medicaid claims to answer the following aims: Aim 1: To estimate changes in potentially hazardous prescribing, opioid use monitoring, and overdose associated with variations in organizational characteristics, including alternative payment model participation. Aim 2: To estimate changes in OUD treatment associated with variations in organizational characteristics, including alternative payment model participation. The proposed study included in this pre-registration is one of several that will use the 2021-2022 NSACO data.

This study examined whether and how organizations participating in accountable care organization (ACO) contracts integrate primary care and treatment for patients with serious mental illness.This study used responses to the 2017–2018 National Survey of ACOs (55% response rate) to measure ACO-reported use of three integrated care strategies: care manager to address physical health treatment coordination or nonmedical needs (e.g., job support and housing), patient registries to track physical health conditions, and primary care clinician colocated in a specialty mental health setting. Logistic regression was used to determine associations between ACO characteristics and strategy use.Of 399 respondents who answered questions on integration, 303 (76%) reported using at least one integrated care strategy in at least one location. Use of care managers (defined by the respondent) was most common (N=281, 70%), followed by use of a patient registry (N=146, 37%) and colocation of a primary care clinician in a specialty mental health setting (N=118, 30%). Respondents reporting that their largest Medicaid contract or largest commercial contract included quality measures specific to serious mental illness (e.g., antipsychotic adherence) were more likely to use each integrated care delivery strategy. Self-reported use of three collaborative care strategies (care management, patient registry, or mental health consulting clinician) for treatment of depression or anxiety was associated with use of integrated primary care and treatment for serious mental illness.In a national survey of ACOs, few respondents reported using either patient registries or primary care colocation to integrate primary care and treatment for serious mental illness.

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BACKGROUND: Cardiac rehabilitation (CR) is highly effective as secondary prevention for cardiovascular diseases (CVDs). Uptake of CR remains suboptimal (30% of eligible patients), and long-term adherence to a physically active lifestyle is even lower. Innovative strategies are needed to counteract this phenomenon. OBJECTIVE: The Physical Activity Toward Health (PATHway) system was developed to provide a comprehensive, remotely monitored, home-based CR program for CVD patients. The PATHway-I study aimed to investigate its feasibility and clinical efficacy during phase III CR. METHODS: Participants were randomized on a 1:1 basis to the PATHway (PW) intervention group or usual care (UC) control group in a single-blind, multicenter, randomized controlled pilot trial. Outcomes were assessed at completion of phase II CR and 6-month follow-up. The primary outcome was physical activity (PA; Actigraph GT9X link). Secondary outcomes included measures of physical fitness, modifiable cardiovascular risk factors, endothelial function, intima-media thickness of the common carotid artery, and quality of life. System usability and patients' experiences were evaluated only in PW. A mixed-model analysis of variance with Bonferroni adjustment was used to analyze between-group effects over time. Missing values were handled by means of an intention-to-treat analysis. Statistical significance was set at a 2-sided alpha level of .05. Data are reported as mean (SD). RESULTS: A convenience sample of 120 CVD patients (mean 61.4 years, SD 13.5 years; 22 women) was included. The PATHway system was deployed in the homes of 60 participants. System use decreased over time and system usability was average with a score of 65.7 (SD 19.7; range 5-100). Moderate-to-vigorous intensity PA increased in PW (PW: 127 [SD 58] min to 141 [SD 69] min, UC: 146 [SD 66] min to 143 [SD 71] min; Pinteraction=.04; effect size of 0.42), while diastolic blood pressure (PW: 79 [SD 11] mmHg to 79 [SD 10] mmHg, UC: 78 [SD 9] mmHg to 83 [SD 10] mmHg; Pinteraction=.004; effect size of -0.49) and cardiovascular risk score (PW: 15.9% [SD 10.4%] to 15.5% [SD 10.5%], UC: 14.5 [SD 9.7%] to 15.7% [SD 10.9%]; Pinteraction=.004; effect size of -0.36) remained constant, but deteriorated in UC. CONCLUSIONS: This pilot study demonstrated the feasibility and acceptability of a technology-enabled, remotely monitored, home-based CR program. Although clinical effectiveness was demonstrated, several challenges were identified that could influence the adoption of PATHway. TRIAL REGISTRATION: ClinicalTrials.gov NCT02717806; https://clinicaltrials.gov/ct2/show/NCT02717806. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1136/bmjopen-2017-016781. ispartof: JOURNAL OF MEDICAL INTERNET RESEARCH vol:22 issue:2 ispartof: location:Canada status: published

Issue: With an incentive to provide high-quality care while controlling costs, accountable care organizations (ACOs) may focus on patients who require the most resources and are most at risk for encountering serious problems with their care. Understanding how ACOs approach care for complex patients requires examination of their organizational strategies, contracting details, and leadership structures. Goals: Describe the specific strategies employed by ACOs that have comprehensive care management programs and processes for complex patients. Methods: Cross-sectional descriptive analysis of the fourth wave of the National Survey of ACOs. Key Findings: Most ACOs report having comprehensive chronic care management processes or programs in place to manage people with complex needs. More labor-intensive interventions, however, are rare. Few ACOs report having advanced programs for engaging patients, in-home visits after hospital discharge, or evidence-based services for patients needing mental health or addiction treatment. Conclusion: While ACOs have increased their efforts to target populations with complex care needs, there is a need for more varied approaches to improving care delivery.

Purpose: Cardiovascular disease (CVD) is the leading cause of premature death and disability in Europe. Effective exercise-based cardiac rehabilitation (CR) can improve mortality and morbidity rates, yet uptake of community-based CR is low (1). PATHway (Physical Activity Towards Health) is a technology-enabled lifestyle behaviour change intervention designed to enhance patient self-management of CVD through adherence to physical activity and other health behaviours. This paper explains the co-design and user validation process that is being employed for the development of the PATHway platform. Methods: CVD patients from a) hospital-based CR and b) community-based CR across two sites (Dublin, Ireland; Leuven, Belgium) are invited to participate in the study. To facilitate an iterative process, three separate rounds of semi-structured interviews, a total of twelve focus groups (4 groups x 3 rounds) are planned between February and April 2016. In round one interviews, participants were exposed to the PATHway intervention and system designed by the research team, and feedback was elicited. Interviews were audio-recorded, transcribedand content analysed. Key recommendations regarding technical and intervention content were identified and are currently being used by the research team to improve the PATHway system. Completion of the interviews is due for April 2016 Results: Round one data indicated that i) tailoring intervention content for exercise prescription and health behaviour change was important; ii) further health information and monitoring through the system was valuable, and iii) the potential for patients to be connected with their healthcare professionals was appealing. Technical recommendations included amending the avatar display to reflect an average BMI and be ‘more human-like’. Additional behaviour change recommendations included stressing the importance of positive reinforcement even when a participant is not meeting set goals. Conclusions: An iterative co-design and user validation process can be a vital component of the development of complex behavioural interventions for CVD patients. This project has received funding from the European Union’s Horizon 2020 Framework Programme for Research and Innovation Action under Grant Agreement no. 643491. PATHway: Technology enabled behavioural change as a pathway towards better self-management of CVD (www.pathway2health.eu)