Health Care Savings with the Patient-Centered Medical Home: Community Care of North Carolina's Experience

This study evaluated the financial impact of integrating a systemic care management intervention program (Community Care of North Carolina) with person-centered medical homes throughout North Carolina for non-elderly Medicaid recipients with disabilities during almost 5 years of program history. It examined Medicaid claims for 169,676 non-elderly Medicaid recipients with disabilities from January 2007 through third quarter 2011. Two models were used to estimate the program's impact on cost, within each year. The first employed a mixed model comparing member experiences in enrolled versus unenrolled months, accounting for regional differences as fixed effects and within physician group experience as random effects. The second was a pre-post, intervention/comparison group, difference-in-differences mixed model, which directly matched cohort samples of enrolled and unenrolled members on strata of preenrollment pharmacy use, race, age, year, months in pre-post periods, health status, and behavioral health history. The study team found significant cost avoidance associated with program enrollment for the non-elderly disabled population after the first years, savings that increased with length of time in the program. The impact of the program was greater in persons with multiple chronic disease conditions. By providing targeted care management interventions, aligned with person-centered medical homes, the Community Care of North Carolina program achieved significant savings for a high-risk population in the North Carolina Medicaid program. (Population Health Management 2013;17:141–148

Do primary care medical homes facilitate care transitions after psychiatric discharge for patients with multiple chronic conditions?

Primary-care-based medical homes may facilitate care transitions for persons with multiple chronic conditions (MCC) including serious mental illness. The purpose of this manuscript is to assess outpatient follow-up rates with primary care and mental health providers following psychiatric discharge by medical home enrollment and medical complexity

Do Medical Homes Offer Improved Diabetes Care for Medicaid Enrollees with Co-occurring Schizophrenia?

To determine whether Medicaid recipients with co-occurring diabetes and schizophrenia that are medical-home-enrolled are more likely to receive guideline-concordant diabetes care than those who are not medical-home-enrolled, controlling for confounders

Advancing heart health in North Carolina primary care: the Heart Health NOW study protocol

Abstract Background The objective of Heart Health NOW (HHN) is to determine if primary care practice support—a comprehensive evidence-based quality improvement strategy involving practice facilitation, academic detailing, technology support, and regional learning collaboratives—accelerates widespread dissemination and implementation of evidence-based guidelines for cardiovascular disease (CVD) prevention in small- to medium-sized primary care practices and, additionally, increases practices’ capacity to incorporate other evidence-based clinical guidelines in the future. Methods/design HHN is a stepped wedge, stratified, cluster randomized trial to evaluate the effect of primary care practice support on evidence-based CVD prevention, organizational change process measures, and patient outcomes. Each practice will start the trial as a control, receive the intervention at a randomized time point, and then enter a maintenance period 12 months after the start of the intervention. The intervention will be randomized to practices in one of four strata defined by region of the state (east or west) and degree of practice readiness for change. Seventy-five practices in each region with a high degree of readiness will be randomized 1:1:1 in blocks of 3 sometime prior to month 8 to receive the intervention at month 9, 11, or 12. An additional 75 practices within each region that have a low degree of readiness or are recruited later will be randomized 1:1 in blocks of 2 prior to month 13 to receive the intervention at month 14 or 16. The sites will be ordered within each strata based on time of enrollment with the blocking based on this ordering. Evaluation will examine the effect of primary care practice support on (1) practice-level delivery of evidence-based CVD prevention, (2) patient-level health outcomes, (3) practice-level implementation of clinical and organizational changes that support delivery of evidence-based CVD prevention, and (4) practice-level capacity to implement future evidence-based clinical guidelines. Discussion Results will indicate whether primary care practice support is an effective strategy for widespread dissemination and implementation of evidence-based clinical guidelines in primary care practices. Discernible reductions in cardiovascular risk in 300 practices covering over an estimated 900,000 adult patients would likely lead to prevention of thousands of cardiovascular events within 10 years. Trial registration ClinicalTrials.gov NCT0258555

Numerical instability of the Akhmediev breather and a finite-gap model of it

In this paper we study the numerical instabilities of the NLS Akhmediev breather, the simplest space periodic, one-mode perturbation of the unstable background, limiting our considerations to the simplest case of one unstable mode. In agreement with recent theoretical findings of the authors, in the situation in which the round-off errors are negligible with respect to the perturbations due to the discrete scheme used in the numerical experiments, the split-step Fourier method (SSFM), the numerical output is well-described by a suitable genus 2 finite-gap solution of NLS. This solution can be written in terms of different elementary functions in different time regions and, ultimately, it shows an exact recurrence of rogue waves described, at each appearance, by the Akhmediev breather. We discover a remarkable empirical formula connecting the recurrence time with the number of time steps used in the SSFM and, via our recent theoretical findings, we establish that the SSFM opens up a vertical unstable gap whose length can be computed with high accuracy, and is proportional to the inverse of the square of the number of time steps used in the SSFM. This neat picture essentially changes when the round-off error is sufficiently large. Indeed experiments in standard double precision show serious instabilities in both the periods and phases of the recurrence. In contrast with it, as predicted by the theory, replacing the exact Akhmediev Cauchy datum by its first harmonic approximation, we only slightly modify the numerical output. Let us also remark, that the first rogue wave appearance is completely stable in all experiments and is in perfect agreement with the Akhmediev formula and with the theoretical prediction in terms of the Cauchy data.Comment: 27 pages, 8 figures, Formula (30) at page 11 was corrected, arXiv admin note: text overlap with arXiv:1707.0565

Reach, Usage, and Effectiveness of a Medicaid Patient Navigator Intervention to Increase Colorectal Cancer Screening, Cape Fear, North Carolina, 2011

IntroductionScreening for colorectal cancer can reduce incidence and death, but screening is underused, especially among vulnerable groups such as Medicaid patients. Effective interventions are needed to increase screening frequency. Our study consisted of a controlled trial of an intervention designed to improve colorectal cancer screening among Medicaid patients in North Carolina.MethodsThe intervention included a mailed screening reminder letter and decision aid followed by telephone support from an offsite, Medicaid-based, patient navigator. The study included 12 clinical practices, 6 as intervention practices and 6 as matched controls. Eligible patients were aged 50 years or older, covered by Medicaid, and identified from Medicaid claims data as not current with colorectal cancer screening recommendations. We reviewed Medicaid claims data at 6 months and conducted multivariate logistic regression to compare participant screening in intervention practices with participants in control practices. We controlled for sociodemographic characteristics.ResultsMost of the sample was black (53.1%) and female (57.2%); the average age was 56.5 years. On the basis of Medicaid claims, 9.2% of intervention participants (n = 22/240) had had a colorectal cancer screening at the 6-month review, compared with 7.5% of control patients (n = 13/174). The adjusted odds ratio when controlling for age, comorbidities, race, sex, and continuous Medicaid eligibility was 1.44 (95% confidence interval, 0.68–3.06). The patient navigator reached 44 participants (27.6%).ConclusionThe intervention had limited reach and little effect after 6 months on the number of participants screened. Higher-intensity interventions, such as use of practice-based navigators, may be needed to reach and improve screening rates in vulnerable populations

Stroke awareness and knowledge in an Urban New Zealand population

© 2015 National Stroke Association. Background Stroke is the third most common cause of death and a major cause of chronic disability in New Zealand. Linked to risk factors that develop across the life-course, stroke is considered to be largely preventable. This study assessed the awareness of stroke risk, symptoMS detection, and prevention behaviors in an urban New Zealand population. Methods Demographics, stroke risk factors awareness, symptoMS responsiveness, and prevention behaviors were evaluated using a structured oral questionnaire. Binomial logistic regression analyses were used to identify predictors of stroke literacy. Results Although personal experience of stroke increased awareness of symptoms and their likeliness to indicate the need for urgent medical attention, only 42.7% of the respondents (n = 850) identified stroke as involving both blood and the brain. Educational attainment at or above a trade certificate, apprenticeship, or diploma increased the awareness of stroke symptoms compared with those with no formal educational attainment. Pacific Island respondents were less likely than New Zealand Europeans to identify a number of stroke risk factors. Ma¯ori, Pacific Island, and Asian respondents were less likely to identify symptoms of stroke and indicate the need for urgent medical attention. Conclusions The variability in stroke awareness and knowledge may suggest the need to enhance stroke-related health literacy that facilitates understanding of risk and of factors that reduce morbidity and mortality after stroke in people of Ma¯ori and Pacific Island descent and in those with lower educational attainment or socioeconomic status. It is therefore important that stroke awareness campaigns include tailored components for target audiences

Determinants of health care utilization by immigrants in Portugal

<p>Abstract</p> <p>Background</p> <p>The increasing diversity of population in European Countries poses new challenges to national health systems. There is a lack of data on accessibility and use of health care services by migrants, appropriateness of the care provided, client satisfaction and problems experienced when confronting the health care system. This limits knowledge about the multiple determinants of the utilization of health services. The aim of this study was to describe the access of migrants to health care and its determinants in Portugal.</p> <p>Methods</p> <p>The study sample included 1513 immigrants (53% men), interviewed at the National Immigrant Support Centre, in Lisbon. Data were collected using questionnaires. The magnitude of associations between use of National Health Service and socio-demographic variables was estimated by means of odds ratios (OR) at 95% confidence intervals, calculated using logistic regression.</p> <p>Results</p> <p>Among participants, 3.6% stated not knowing where to go if facing a health problem. Approximately 20% of the respondents reported that they had never used the National Health Service, men more than women. Among National Health Service users, 35.6% attended Health Centres, 12% used Hospital services, and 54.4% used both. Among the participants that ever used the health services, 22.4% reported to be unsatisfied or very unsatisfied. After adjusting for all variables, utilization of health services, among immigrant men, remained significantly associated with length of stay, legal status, and country of origin. Among immigrant women, the use of health services was significantly associated with length of stay and country of origin.</p> <p>Conclusion</p> <p>There is a clear need to better understand how to ensure access to health care services and to deliver appropriate care to immigrants, and that special consideration must be given to recent and undocumented migrants. To increase health services use, and the uptake of prevention programs, barriers must be identified and approaches to remove them developed, through coherent and comprehensive strategies.</p

Health care access dimensions and cervical cancer screening in South Africa: analysis of the world health survey.

Background Cervical cancer is the most commonly diagnosed cancer and the leading cause of cancer mortality among women in sub-Saharan Africa. Recent recommendations for cervical cancer primary prevention highlight HPV vaccination, and secondary prevention through screening. However, few studies have examined the different dimensions of health care access, and how these may influence screening behavior, especially in the context of clinical preventive services. Methods Using the 2003 South Africa World Health Survey, we determined the prevalence of cervical cancer screening with pelvic examinations and/or pap smears among women ages 18 years and older. We also examined the association between multiple dimensions of health care access and screening focusing on the affordability, availability, accessibility, accommodation and acceptability components. Results About 1 in 4 (25.3%, n = 65) of the women who attended a health care facility in the past year got screened for cervical cancer. Screened women had a significantly higher number of health care providers available compared with unscreened women (mean 125 vs.12, p-value Conclusions Our findings suggest that cost issues (affordability component) and other patient level factors (captured in the acceptability, accessibility and accommodation components) were less important predictors of screening compared with availability of physicians in this population. Meeting cervical cancer screening and HPV vaccination goals will require significant investments in the health care workforce, improving health care worker density in poor and rural areas, and improved training of the existing workforce