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BackgroundOlder adults with serious mental illness (SMI) often have multiple comorbidities and complex medication schedules. Shortages of behavioral health specialists (BHSs), especially in rural areas, frequently make primary care providers (PCPs) the only clinician managing this complex population. The aim of this study was to describe rural/urban psychiatric medication prescribing in older adults with SMI by PCPs and BHSs, and by clinician type.MethodsThis retrospective descriptive analysis used 2018 Medicare data to identify individuals with a bipolar, major depression, schizophrenia, or psychosis diagnosis and examined medication claims for antianxiety, antidepressants, antipsychotics, hypnotics, and anticonvulsants. Descriptive statistics summarized percentage of medications provided by PCPs and BHSs stratified by rural and urban areas and by drug class. Additional analyses compared psychiatric prescribing patterns by physicians, advanced practice registered nurses (APRNs), and physician assistants (PAs).ResultsIn urban areas, PCPs prescribed at least 50% of each psychiatric medication class, except antipsychotics, which was 45.2%. BHSs prescribed 40.7% of antipsychotics and less than 25% of all other classes. In rural areas, percentages of psychiatric medications from PCPs were over 70% for each medication class, except antipsychotics, which was 60.1%. Primary care physicians provided most psychiatric medications, between 36%-57% in urban areas and 47%-65% in rural areas. Primary care APRNs provided up to 13% of prescriptions in rural areas, which was more than the amount prescribed by BHS physicians, expect for antipsychotics. Psychiatric mental health APRNs provided up to 7.5% of antipsychotics in rural areas, but their prescribing contribution among other classes ranged between 1.1%-3.6%. PAs provided 2.5%-3.4% of medications in urban areas and this increased to 3.9%-5.1% in rural areas.ConclusionsResults highlight the extensive roles of PCPs, including APRNs, in managing psychiatric medications for older adults with SMI.

Background Methods Results Conclusions As the US population ages, there is an increasing demand for home‐based primary care (HBPC) by those with Alzheimer's/dementia, multiple chronic conditions, severe physical limitations, or those facing end‐of life. Nurse practitioners (NPs) are increasingly providing HBPC, yet little is known about their quality of care in this unique setting.This observational study uses Medicare claims data from 2018 to assess the quality of care for high‐intensity HBPC users (5 or more visits/year) based on provider type (NP‐only, physician (MD)‐only, or both NP and MDs). We employ 12 quality measures from 3 care domains: access and prevention, acute care utilization, and end‐of‐life. Analysis includes bivariate comparisons and logistic regression models that adjust for demographic, clinical, and geographic characteristics.Among the 574,567 beneficiaries with 5 or more HBPC visits, 37% saw an NP, 37% saw a MD, and 27% saw both NPs and MDs. In multivariate models, those receiving HBPC from an NP or both NP‐MD are significantly more likely to receive a flu shot than the MD‐only group, but less likely to access preventive care. NP‐only care is associated with more acute care hospitalizations, avoidable ED visits, and fall‐related injuries, but significantly fewer avoidable admissions. For end‐of‐life care, those with NP‐only or both NP‐MD care are significantly more likely to have an advanced directive, be in hospice in the last 3 days of life, and more likely to die in hospice. The NP group is also more likely to die in the next year.HBPC patients are complex, with both palliative and curative needs. NPs provide almost half of HBPC in the Medicare program, to patients who are possibly sicker than those treated by physicians, with similar quality to MDs. [ABSTRACT FROM AUTHOR]

Objectives: Currently, the Medicare Shared Savings Program (MSSP) requires beneficiaries to have 1 or more visits with a qualifying physician to be attributed to an accountable care organization (ACO). Allowing primary care nurse practitioners (NPs) to serve as qualifying providers for the sake of attribution could be an effective way to expand access to the program but could potentially draw in sicker beneficiaries and increase an ACO's benchmarks. Study Design: This observational study assesses the potential impact of changing the MSSP attribution rules to include NPs and other advanced practice clinicians. Methods: For this analysis, we ran MSSP attribution for the entire United States with and without including NPs as attribution-eligible providers. We then compared the change in attributed population with the change in CMS hierarchical condition category (HCC) risk scores. Results: For the majority of ACOs, allowing NPs to serve as an attribution-eligible provider had little impact on the number of attributed beneficiaries or the mean HCC score. For a small number of ACOs (n = 18), the change increased attribution by more than 10%. The mean change in HCC score was 0. Conclusions: Allowing NPs to serve as attribution-eligible clinicians would result in more attribution to MSSP ACOs without increasing the level of patient complexity, a positive impact for those interested in growing ACOs. [ABSTRACT FROM AUTHOR]

Background: The enumeration of the primary care workforce relies on potentially inaccurate specialty designations sourced from licensure registries and clinician surveys. Objective: To use an activity-based measure of primary care to estimate the number of physicians, nurse practitioners (NPs), and physician assistants (PAs) providing primary care to Medicare beneficiaries. Design: Observational study using Medicare fee-for-service (FFS) claims data. Subjects: All clinicians in the US billing Medicare in 2019 and their fee-for-service Medicare patients. Main Measures: We construct three measures that together distinguish primary care from specialty clinicians: (1) presence of evaluation and management (E&M) services in a setting consistent with primary care, (2) the dispersion of clinical care across International Classification of Diseases-10 (ICD-10) chapters, and (3) the extent of provided services that are atypical of primary care (e.g., surgical procedure). We apply parameters to the measures to identify the clinicians likely providing primary care and compare the resulting classifications across provider type. Key Results: Of physicians with at least 50 Medicare beneficiaries, 19–22% provide primary care. Of medical generalists (i.e., family medicine, internal medicine) with at least 50 beneficiaries, 61–68% provide primary care. We estimate that 40–45% of NPs and 27–30% of PAs meeting the panel size threshold are primary care providers in FFS Medicare. Conclusions: Our findings suggest that based on a primary care practice style, the number of primary care physicians in FFS Medicare is likely smaller than conventional estimates. However, compared to prior estimates, the number of primary care NPs is larger and the number of PAs is similar. [ABSTRACT FROM AUTHOR]

Physician supervision of nurse practitioners (NPs) was temporarily waived in Massachusetts in response to a state of emergency due to the COVID-19 pandemic. The authors examined the impact of the scope-of-practice changes and pandemic-related demands on psychiatric mental health NPs (PMHNPs) during the state's first COVID-19 surge. A mixed-methods Web-based survey was conducted in May and June of 2020. Fisher's exact test was used to compare associations across certification types, and inductive content analysis was applied to open-ended responses. The survey response rate was 41% (N=389 of 958), consisting of 26 PMHNPs and 363 other NPs. Compared with other NPs, PMHNPs were significantly more likely to work in a telehealth setting (42% vs. 11%, p<0.001), to spend more time working during the initial surge (50% vs. 26%, p<0.05), and to believe that the waiver improved clinical work (52% vs. 25%, p<0.01). Content analysis of PMHNPs' open-ended responses identified four themes: the supervision waiver reduced burden on PMHNPs, collaboration and mentorship models persisted, the pandemic exacerbated the already high demand for psychiatric care, and telehealth helped meet the high demand for such care. PMHNPs may be more sensitive to the scope-of-practice changes and telehealth expansion than other NPs because of the constraints of the psychiatrist shortage and high relative uptake of telehealth in psychiatric care. The interactions of workforce supply, telehealth expansion, and scope-of-practice laws are important to consider in the development of policies to improve access to mental health care. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To describe the use of home-based services in accountable care organizations (ACOs). STUDY DESIGN: Cross-sectional analysis of 2019 ACO survey. METHODS: We analyzed surveys completed by 151 ACOs describing the characteristics of home-based care programs serving high-need, high-cost patients. We linked survey results to publicly available information about ACO characteristics, governance, and risk model participation. RESULTS: Twenty-five percent of respondent ACOs had formal home-based care programs, 25% offered occasional home visits, and 17% were actively developing new programs. Home-based primary care was the most common program type. Half of programs were established within the past 3 years. The programs utilized multidisciplinary care teams, but two-thirds had fewer than 500 visits annually. Funding sources included direct billing for services, health system subsidies, and ACO shared savings. A majority of respondents expressed interest in expanding services but were concerned about their ability to demonstrate a return on investment (ROI), which was reported as a major or moderate challenge by three-quarters of respondents. CONCLUSIONS: ACOs deliver a diverse array of home-visit services including primary care, acute medical care, palliative care, care transitions, and interventions to address social determinants of health. Many services provided are not billable, and therefore ACO leaders are hesitant to fund expansions without strong evidence of ROI. Expanding Medicare ACO home-visit waivers to all risk-bearing ACOs and covering integrated telehealth services would improve the financial viability of these programs. [ABSTRACT FROM AUTHOR]

Data from the Worcester Family Research Project were analyzed to determine whether social support processes are altered by poverty and whether kin and nonkin support are differentially related to mental health in low-income mothers. The authors found that conflict with family and friends predicted adverse mental health and more strongly predicted these outcomes than emotional and instrumental support. Moreover, sibling conflict was a stronger predictor of mental health than parent conflict. Finally, only instrumental support from professionals predicted mental health.

Background: The United States is steadily shifting away from volume-based payments toward value-based payment for health care. The nursing model's emphasis on high-value care, such as disease prevention and health maintenance, ideally positions nurse practitioner (NP) practice owners to contribute to the goals of value-based care. However, little is known about NP participation in value-based care. Purpose: To better understand NP-owned practice participation in value-based care. Methodology: Using convenience sampling, we developed a registry of NP owned practices, which we used to conduct a web-based survey from November 2019 to February 2020. Results: Of the 47 NP-owner respondents, 40 practice in primary or specialty care. Practices are relatively small with a mean clinical staff of 4 full-time equivalent (FTE; range: 1-17), mean total staff of 7 FTE (1-28.5), and with a mean of 325 patient visits annually. A third participate in value-based payment arrangements, whereas a half are considering and three quarters are knowledgeable about value-based payment arrangements. Over 70% of practice owners report lack of knowledge, lack of financial protections, and lack of payer partnership as barriers to participation in value-based payment models. Conclusions: NP practice owners face many challenges to taking on risk, including insufficient patient volume. Implications: Joining together may allow small NP practices to participate in and thrive under value-based payment. Reducing the barriers and regulation of all NPs will enable the health care system to capitalize on the nursing model to meet the goals of value-based care. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To assess the ability of accountable care organizations (ACOs) to use electronic health record (EHR) data for quality. STUDY DESIGN: Cross-sectional study of ACOs participating in the Medicare Shared Savings Program (MSSP). METHODS: A national survey of MSSP ACOs included questions on the number of EHR systems used across all providers in the ACO and barriers to reporting EHR-based quality measures. RESULTS: Just 9% of ACOs use a single EHR system, whereas 77% use 6 or more EHR systems. The more EHR systems an ACO uses, the less likely it is to report having the infrastructure to aggregate EHR data and the more concerned it is about the short-term viability and accuracy of EHR-based quality measures. CONCLUSIONS: ACOs have diverse structures that often result in the usage of multiple EHR systems. This has the potential to cause serious delays when CMS begins requiring ACOs to report their quality measures through their EHRs in 2022. [ABSTRACT FROM AUTHOR]

Homeless children are more likely to have poor health and to use more medical services than low-income housed children. Researchers analyzed resource use in 293 homeless and 334 low-income housed children. Homeless children were more likely to have poor health and had more outpatient and emergency department visits than the other children. They were more likely to have fever, ear infections, diarrhea and asthma than the other children. This was true even after adjusting for other factors that might explain this association., Objective. Previous studies of homeless children have described more health problems and service use than in housed children, but failed to control for potential confounding factors that may differ between these children. This observational study examines the relationship of homelessness and other determinants to health status and service use patterns in 627 homeless and low-income housed children. Methods. Case-control study of 293 homeless and 334 low-income housed children aged 3 months to 17 years and their mothers conducted in Worcester, Massachusetts. Information was collected about mothers&apos; housing history, income, education, emotional distress, and victimization history. Standardized instruments were administered to assess children&apos;s health. Health service use questions were adapted from national surveys. Main outcome measures included health status, acute illness morbidity, emergency department and outpatient medical visits. Multivariable regression analyses were used to examine the association of family and environmental determinants, including homelessness, with health status and service use outcomes. Results. Mothers of homeless children were more likely to report their children as being in fair or poor health compared with their housed counterparts. Homeless children were reported to experience a higher number of acute illness symptoms, including fever, ear infection, diarrhea, and asthma. Emergency department and outpatient medical visits were higher among the homeless group. After controlling for potential explanatory factors, homeless children remained more likely to experience fair or poor health status (adjusted odds ratio [OR] = 2.83; 95% confidence interval [CI], 1.16, 4.87), and a higher frequency of outpatient (OR = 1.71; 95% CI, 1.18, 2.48) and emergency department visits (OR = 1.21; 95% CI, 0.83, 1.74). Mothers&apos; emotional distress was independently associated with acute illness symptoms and frequent use of outpatient and emergency department settings. Conclusions. Homelessness is an independent predictor of poor health status and high service use among children. The present findings highlight the importance of preventive interventions and efforts to increase access to primary care among homeless children. Pediatrics 1998;102:554-562; homelessness, health, health services, children., Homelessness, with its associated adverse health consequences, continues to be an important national problem.[1] Families with children now comprise more than one third of the overall homeless population, with estimates [...]

Homeless children experience many stresses and this could be reduced by providing more services to their families. A survey of the parents of 167 preschool children who were either homeless or came from a low-income family found that both groups of children exhibited behavioral problems related to stress. The mother's emotional health was the strongest predictor of behavioral problems in the child. Other influences were placement in a foster home, physical abuse and the death of a friend. Behavioral problems included anxiety, depression, and delinquent or aggressive behavior., Objectives. To describe the characteristics of homeless and low-income preschool-aged children, and to identify family and environmental determinants of their behavior. Methods. An unmatched case-control design was used to recruit a sample of sheltered homeless families and a comparison group of low-income housed families who were never homeless in Worcester, Massachusetts. Seventy-seven sheltered homeless and 90 low-income housed mothers with preschool-age children were assessed using a comprehensive interview protocol. Information about mothers&apos; housing, income, service use, parenting practices, and children&apos;s father was obtained. Data about children&apos;s background, health, and life events were included. Standardized instruments were administered to assess mothers&apos; mental health and their children&apos;s behavior. Comparisons of homeless and low-income housed families were used to describe the sample of 167 preschoolers. Multiple linear regression was used to examine the association of various stressors, such as homelessness, and family factors with their behavior. Results. Although homeless preschoolers were significantly more likely to have experienced stressful life events, undergone a care and protection investigation, and been placed in foster care when compared with low income preschoolers, differences in adverse behaviors were minimal. Although homeless children scored higher than housed children on the internalizing, externalizing, and total problem score on the Child Behavior Checklist (CBCL) (52.5 vs 49.9, 54.8 vs 51.2, and 54.4 vs 51.1, respectively), approximately equal numbers of children from both groups scored in the clinical range. With regard to determinants of behavior, mothers&apos; emotional status was one of the strongest independent predictors of negative behavioral outcomes on both subscales. Foster care placement and death of a child&apos;s friend were predictors of adverse internalizing behavioral outcomes on the CBCL. After controlling for housing status, parenting practices, child&apos;s age, child&apos;s history of physical abuse, and specific life stressors predicted adverse externalizing behavioral outcomes. For both subscales&apos; housing status and behavior were only marginally associated in the multivariate model. Conclusions. Both homeless and low-income children experienced significant adversity in their lives, with homeless preschool children facing more stress. However, differences in behavior as measured by the CBCL were minimal. Mothers&apos; emotional status, in addition to various stressors, strongly predict children&apos;s negative outcomes for both CBCL subscales. These findings emphasize the importance of preventive family-oriented interventions that address the needs of preschoolers and their mothers. Pediatrics 1997,100:92-100; homelessness, families, preschoolers., Almost 1 in 5 American children are growing up in poverty -- and the situation is worsening. Since 1973, the US economy has been growing at a slower rate on [...]

Objectives. To identify risk and protective factors for family homelessness, a case-control study of homeless and low-income, never-homeless families, all female-headed, was conducted. Methods. Homeless mothers (n = 220) were enrolled from family shelters in Worcester, Mass. Low-income housed mothers receiving welfare (n = 216) formed the comparison group. The women completed an interview covering socioeconomic, social support, victimization, mental health, substance use, and health domains. Results. Childhood predictors of family homelessness included foster care placement and respondent's mother's use of drugs. Independent risk factors in adulthood included minority status, recent move to Worcester, recent eviction, interpersonal conflict, frequent alcohol or heroin use, and recent hospitalization for a mental health problem. Protective factors included being a primary tenant, receiving cash assistance or a housing subsidy, graduating from high school, and having a larger social network. Conclusions. Factors that compromise an individual's economic and social resources are associated with greater risk of losing one's home. (Am J Public Health. 1997;87:241-248)