2011-2013 Connecting Consumer with Care: Grant Area Evaluation

The Blue Cross Blue Shield of Massachusetts Foundation has funded the Connecting Consumers with Care grant program consistently since 2001. The program supports community health centers and community-based organizations in helping consumers enroll in and maintain publicly subsidized health insurance coverage. The program also encourages collaborative problem solving to minimize system-level barriers and enhanced education and empowerment of consumers so that they may navigate systems of health coverage and care with decreasing dependence on grantee organizations. During the October 2011 -- September 2013 grant cycle, the Foundation funded 13 organizations across Massachusetts. While this funding period preceded the first Affordable Care Act (ACA) open enrollment period, lessons from the outreach, enrollment, and post-enrollment work of these grantees remain invaluable to efforts to connect consumers with health coverage and care both in Massachusetts and across the country.This report describes findings from the evaluation of the 2011 -- 2013 grant cycle. The aims of the evaluation were to 1) assess progress made across the grantee sites on select outreach and enrollment measures; 2) describe the practices grantees adopted to reach out to and enroll consumers in insurance, increase consumer self-sufficiency, and collaborate with other agencies to minimize barriers to care; and 3) characterize barriers experienced by grantees as they worked to meet the goals of the program

Evaluation of a Patient Communication Program and Patient Appointment Reminder Calls in a Community Health Center Setting

Community health centers across the country struggle with patients who frequently miss appointments. Missed and unused appointment slots represent lost revenue for health centers and disruption in care continuity. The medical home model recognizes these challenges and establishes patient access as a core element, key components of which include more efficient scheduling functions and capacity for same-day appointments. Identifying effective and feasible strategies to reduce the no-show rate is a critical component of these efforts. The Massachusetts League of Community Health Centers, the University of Massachusetts Medical School, and the Edward M. Kennedy Community Health Center came together to launch a patient communications pilot program that involved outsourcing and centralizing patient communication functions. With grant funding, the collaborators were able to evaluate the effectiveness of the pilot program and the performance of the appointment reminder system. Secondary data sources - call reminder disposition data merged with data on patients and other characteristics - were analyzed to assess the performance of the call reminder system and the factors associated with a patient showing up for an appointment. The collaborators will present their innovative partnership approach and findings on patient demographics and other factors that can result in missed appointments

Barriers and Facilitators to Implementation of Value-Based Care Models in New Medicaid Accountable Care Organizations in Massachusetts: A Study Protocol

Introduction: Massachusetts established 17 new Medicaid accountable care organizations (ACOs) and 24 affiliated Community Partners (CPs) in 2018 as part of a large-scale healthcare reform effort to improve care value. The new ACOs will receive $1.8 billion dollars in state and federal funding over 5 years through the Delivery System Reform Incentive Program (DSRIP). The multi-faceted study described in this protocol aims to address gaps in knowledge about Medicaid ACOs\u27 impact on healthcare value by identifying barriers and facilitators to implementation and sustainment of the DSRIP-funded programs. Methods and analysis: The study\u27s four components are: (1) Document Review to characterize the ACOs and CPs; (2) Semi-structured Key Informant Interviews (KII) with ACO and CP leadership, state-level Medicaid administrators, and patients; (3) Site visits with selected ACOs and CPs; and (4) Surveys of ACO clinical teams and CP staff. The Consolidated Framework for Implementation Research\u27s (CFIR) serves as the study\u27s conceptual framework; its versatile menu of constructs, arranged across five domains (Intervention Characteristics, Inner Setting, Outer Setting, Characteristics of Individuals, and Processes) guides identification of barriers and facilitators across multiple organizational contexts. For example, KII interview guides focus on understanding how Inner and Outer Setting factors may impact implementation. Document Review analysis includes extraction and synthesis of ACO-specific DSRIP-funded programs (i.e., Intervention Characteristics); KIIs and site visit data will be qualitatively analyzed using thematic analytic techniques; surveys will be analyzed using descriptive statistics (e.g., counts, frequencies, means, and standard deviations). Discussion: Understanding barriers and facilitators to implementing and sustaining Medicaid ACOs with varied organizational structures will provide critical context for understanding the overall impact of the Medicaid ACO experiment in Massachusetts. It will also provide important insights for other states considering the ACO model for their Medicaid programs. Ethics and dissemination: IRB determinations were that the overall study did not constitute human subjects research and that each phase of primary data collection should be submitted for IRB review and approval. Study results will be disseminated through traditional channels such as peer reviewed journals, through publicly available reports on the mass.gov website; and directly to key stakeholders in ACO and CP leadership

Uptake of Direct Acting Antivirals for Hepatitis C Virus in a New England Medicaid Population, 2014-2017

Introduction Introduction of the direct acting antiviral (DAA) sofosbuvir (SOV) in 2013 offered significant improvement over previous options for hepatitis C virus (HCV) treatment. Initial uptake was low in Medicaid and other populations, perhaps in part due to high drug cost and prior authorization (PA) restrictions related to fibrosis stage, prescribing provider specialty, and sobriety. Both the subsequent introduction of ledipasvir/sofosbuvir (LDV/SOV), an all-oral regimen for most genotypes, and lifting of PA restrictions were expected to increase overall uptake, but little is known about recent prescribing patterns. We examined trends in DAA uptake in a Medicaid population and identified the effect of these two events on treatment initiation. Study Design An interrupted time series (ITS) design utilized enrollment, medical, and pharmacy claims from Medicaid enrollees in three New England states, 12/2013-12/2017. Trends in treatment uptake, defined as 1+ pharmacy claim for a DAA, were examined overall, by demographic characteristics, and prior to and after two time points: 10/2014 (LDV/SOV approval date) and 7/2016 (date PA restrictions affecting two-thirds of members were lifted). Chi-square evaluated demographic differences, segmented regression models examined trends. Study Population The population included members ages 18-64 years with HCV (2+ claims with ICD-9/10 code for HCV or 1+ claim for chronic HCV). Eligible individuals remained in the sample until treatment initiation or Medicaid disenrollment. Findings The analytic sample averaged 30,433 members with HCV per month, mean age 42.9 years, 60% male. In 2014 3.3% of eligible members initiated treatment, increasing to 7.7% in 2017 (p = Conclusion While initial uptake of DAAs was low in this multi-state Medicaid population, treatment initiation among eligible members increased through 2017. Introduction of new medications and lifting of PA restrictions led to an immediate increase in uptake followed by relatively flat monthly utilization. Policy implications Sharp increases in uptake after LDV/SOV introduction may indicate warehousing of members in anticipation of LDV/SOV approval; increases after PA restrictions were lifted indicates demand for treatment among those affected by restrictions. As a large percentage of the Medicaid HCV population remains untreated, planned provider interviews will help to understand barriers and facilitators of treatment for HCV

Integrating Measures of Social Determinants of Health Into Health Care Encounters: Opportunities and Challenges

There are a number of potential benefits for identifying and documenting social determinants of health in health care delivery settings

Methodological challenges of measuring primary care delivery to pediatric medicaid beneficiaries who use community health centers

Efforts to measure quality of care have focused on ambulatory care providers. We examined the performance of community health centers serving children on Medicaid in 3 states. Descriptive analysis showed considerable patient population heterogeneity, and regression analysis demonstrated that variation explained by the assigned provider was small (mean R(2) = 4.3%) compared with the variation explained by patient demographic variables (mean R(2) = 29.9%). The results reinforce the need for caution when one is attributing quality differences to provider performance

On-site provision of substance abuse treatment services at community health centers

We examined on-site and off-site referral-based provision of substance abuse (SA) treatment services among a sample of community health centers (CHCs). Analyses used survey data collected from CHCs in three states merged with administrative claims to both characterize CHC care delivery models and examine the association between models and care quality. Care quality was based on the Washington Circle measures of initiation and engagement. Approximately half the sample provided at least some SA treatment services on site. The provision of intensive outpatient treatment services on site was associated with significantly higher engagement rates. It was also associated with higher (but not significantly) initiation rates. At the same time, on-site provision of screening and counseling services was negatively associated with both initiation and engagement rates. Given limited resources, investing in more intensive services on site may yield better outcomes for CHC patients than lower level services, but further study is recommended

2013-2015 Connecting Consumers with Care Grant Area Evaluation

This report includes findings from the evaluation of the 2013-2015 Connecting Consumers with Care grant program. The goals of the evaluation were to 1) assess progress made on select outreach and enrollment measures, 2) describe the practices grantees adopted to reach and enroll consumers in health insurance, and 3) characterize efforts and challenges in defining, promoting, and evaluating consumer self-sufficiency

Achieving excellence in community health centers: implications for health reform

BACKGROUND: Existing studies tell us little about care quality variation within the community health center (CHC) delivery system. They also tell us little about the organizational conditions associated with CHCs that deliver especially high quality care. The purpose of this study was to examine the operational practices associated with a sample of high performing CHCs. METHODS: Qualitative case studies of eight CHCs identified as delivering high-quality care relative to other CHCs were used to examine operational practices, including systems to facilitate care access, manage patient care, and monitor performance. RESULTS: Four common themes emerged that may contribute to high performance. At the same time, important differences across health centers were observed, reflecting differences in local environments and CHC capacity. CONCLUSIONS: In the development of effective, community-based models of care, adapting care standards to meet the needs of local conditions may be important

Coordinating Care for Patients with Alcohol or Drug Use Disorders: Effective Practices and Common Barriers in Three Centers

This report describes the process of providing integrated care for patients with substance use disorders at three sites in central Massachusetts: Edward M. Kennedy Community Health Center, Family Health Center of Worcester, and Community Healthlink. It identifies common practices that improve care coordination and presents key findings