Incremental Benefit of a Home Visit Following Discharge for Patients with Multiple Chronic Conditions Receiving Transitional Care

Transitional care management is effective at reducing hospital readmissions among patients with multiple chronic conditions, but evidence is lacking on the relative benefit of the home visit as a component of transitional care. The sample included non-dual Medicaid recipients with multiple chronic conditions enrolled in Community Care of North Carolina (CCNC), with a hospital discharge between July 2010 and December 2012. Using claims data and care management records, this study retrospectively examined whether home visits reduced the odds of 30-day readmission compared to less intensive transitional care support, using multivariate logistic regression to control for demographic and clinical characteristics. Additionally, the researchers examined group differences within clinical risk strata on inpatient admissions and total cost of care in the 6 months following hospital discharge. Of 35,174 discharges receiving transitional care from a CCNC care manager, 21% (N = 7468) included a home visit. In multivariate analysis, home visits significantly reduced the odds of readmission within 30 days (odds ratio = 0.52, 95% confidence interval 0.48–0.57). At the 6-month follow-up, home visits were associated with fewer inpatient admissions within 4 of 6 clinical risk strata, and lower total costs of care for highest risk patients (average per member per month cost difference $970; P < 0.01). For complex chronic patients, home visits reduced the likelihood of a 30-day readmission by almost half compared to less intensive forms of nurse-led transitional care support. Higher risk patients experienced the greatest benefit in terms of number of inpatient admissions and total cost of care in the 6 months following discharge. (Population Health Management 2016;19:163–170

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

Racial Disparities in Blood Pressure Control and Treatment Differences in a Medicaid Population, North Carolina, 2005-2006

Introduction: Racial disparities in prevalence and control of high blood pressure are well-documented. We studied blood pressure control and interventions received during the course of a year in a sample of black and white Medicaid recipients with high blood pressure and examined patient, provider, and treatment characteristics as potential explanatory factors for racial disparities in blood pressure control. Methods: We retrospectively reviewed the charts of 2,078 black and 1,436 white North Carolina Medicaid recipients who had high blood pressure managed in primary care practices from July 2005 through June 2006. Documented provider responses to high blood pressure during office visits during the prior year were reviewed. Results: Blacks were less likely than whites to have blood pressure at goal (43.6% compared with 50.9%, P = .001). Blacks above goal were more likely than whites above goal to have been prescribed 4 or more antihypertensive drug classes (24.7% compared with 13.4%, P < .001); to have had medication adjusted during the prior year (46.7% compared with 40.4%, P = .02); and to have a documented provider response to high blood pressure during office visits (35.7% compared with 30.0% of visits, P = .02). Many blacks (28.0%) and whites (34.3%) with blood pressure above goal had fewer than 2 antihypertensive drug classes prescribed. Conclusion: In this population with Medicaid coverage and access to primary care, blacks were less likely than whites to have their blood pressure controlled. Blacks received more frequent intervention and had greater use of combination antihypertensive therapy. Care patterns observed in the usual management of high blood pressure were not sufficient to achieve treatment goals or eliminate disparities

Level of blood pressure above goal and clinical inertia in a Medicaid population

Failure to adjust hypertension therapy despite elevated blood pressure (BP) levels is an important contributor to lack of BP control. One possible explanation is that small elevations above goal BP are not concerning to clinicians. BP levels farther above goal, however, should be more likely to prompt clinical action. We reviewed one year’s worth of primary care records of 3,742 North Carolina Medicaid recipients 21 years and older with hypertension (a total of 15,516 office visits) to examine variations in hypertension management stratified by level of BP above goal and the association of BP level above goal with documented anti-hypertensive medication change. Among the 53% of patients not at goal BP, 42% were within 10/5 mm Hg of goal; 11% had a BP ≥40/20 mm Hg above goal. Higher level of BP above goal was independently associated with anti-hypertensive medication change. Compared to visits at which BP was <10/5 mm Hg above goal, the adjusted odds of medication change were 7.9 (95% CI 6.2-10.2) times greater at visits when patients’ BP was ≥ 40/20 mm Hg above goal. However, even when BP was above goal at this level, treatment change occurred only 46% (95% CI 40.2-51.8) of the time

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

Prevention and Treatment of Childhood Obesity: Care Received by a State Medicaid Population

Based on chart review for a representative cluster sample of North Carolina Medicaid enrollees aged 3 to 5 years (n = 1951) and 13 to 16 years (n = 1922) years, this study describes prevalence, practice patterns, and comorbidities related to overweight/obese immediately prior to 2007 Expert Recommendations. In total, 16% of children in both age groups were overweight, and 20% (ages 3–5 years) and 25% (ages 13–16 years) were obese. For 3- to 5-year-olds, body mass index percentile was infrequently recorded (22%) or plotted on growth charts (24%), and weight status category was rarely documented (10%). Results were similar for adolescents (21%, 20%, and 12%, respectively). In both groups, documentation of counseling in nutrition or physical activity was rare (16% for ages 3–5 years; 7% for ages 13–16 years). In adolescents, approximately 20% received recommended laboratory screening and overweight/obesity was significantly associated with chart-documented asthma, back pain, prediabetes, gastroesophageal reflux disease, hypertension, and sleep apnea. Whether improvements in documentation of care followed these new guidelines deserves further research

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

Shaping the Future of Academic Health Centers: The Potential Contributions of Departments of Family Medicine

Academic health centers (AHCs) must change dramatically to meet the changing needs of patients and society, but how to do this remains unclear. The purpose of this supplement is to describe ways in which departments of family medicine can play leadership roles in helping AHCs evolve. This overview provides background for case studies and commentaries about the contribution of departments of family medicine in 5 areas: (1) ambulatory and primary care, (2) indigent care, (3) education in community and international settings, (4) workforce policy and practice, and (5) translational research. The common theme is a revitalization of the relationship between AHCs and the communities they serve across all missions. Family medicine leadership can provide dramatic organizational improvement in primary and ambulatory care networks and foster opportunities for leadership by AHCs in improving the health of the population. Departments of family medicine can also play a leading role in developing new partnerships with community-based organizations, managing the care of the indigent, and developing new curricula in community and international settings. Finally, family medicine departments and their faculty have a central role in helping AHCs respond to workforce needs and in developing translational research that emphasizes the health of the population and effectiveness of care. AHCs are a public good that must now evolve substantially to meet the needs of patients and society. By pushing for substantial change, by helping to reinvigorate the relationship between AHCs and the communities they serve, and by emphasizing fundamental innovation in clinical care, teaching, and research, family medicine can help lead the renewal of the AHC