A Multi-Level Fit-Based Quality Improvement Initiative to Improve Colorectal Cancer Screening in a Managed Care Population.

IntroductionColorectal cancer (CRC) is a common but largely preventable disease with suboptimal screening rates despite national guidelines to screen individuals age 50-75. Single-component interventions aimed to improve screening uptake only modestly improve rates; data suggest that multi-modal approaches may be more effective.MethodsWe designed, implemented, and evaluated the impact of a multi-modal intervention on CRC screening uptake among unscreened patients in a large managed care population. Patient-level components included a mailed letter with education about screening options and pre-colonoscopy telephone counseling. For providers, we facilitated communication of screening test results and work-flow for abnormal results. System-level modifications included establishment of a patient navigator, expedited work-up for abnormal results, and stream-lined colonoscopy scheduling. We measured the rate of screening uptake overall, screening uptake by modality, change in the proportion of the population screened, and positive fecal immunochemical test (FIT) follow-up rates in the 1-year study period.ResultsThere were 5093 patients in the intervention cohort. Of these, 33.2% participated in FIT or colonoscopy screening within 1 year of the mailing. A total of 1078 (21.2%) participants completed a FIT and 611 (12.0%) completed a screening colonoscopy. The screening rate in the managed care population increased from 65.1 to 76.6%. Fifty-nine patients (5.5%) had a positive FIT, of which 30 (50.8%) completed a diagnostic colonoscopy.ConclusionMulti-modal interventions can result in substantial improvement in CRC screening uptake in large and diverse managed care populations.Translational impactHealth systems should shift their focus from single-level to multi-level interventions when addressing barriers to CRC screening

Patient Experience with In-Person and Telehealth Visits Before and During the COVID-19 Pandemic at a Large Integrated Health System in the United States

BackgroundInformation about telehealth versus in-office visits and how patient experience before compared to during the COVID-19 pandemic is important for healthcare planning.ObjectiveTo compare patient experience by visit type and before and during the pandemic.DesignSurvey of patients assessing ambulatory care before and during the pandemic.ParticipantsA total of 58,500 adult patients (13,928 primary care and 44,581 specialty physician visits) at a large integrated health system with 197 clinics on the west coast of the United States. The majority were female (59%), 55 or older (65%), and non-Hispanic White (55%), and had an in-office visit (87%) while 10% had a tele-video and 3% a phone visit.Main measuresConsumer Assessment of Healthcare Providers and Systems (CAHPS®) Survey 3.0 doctor communication, care coordination, access, and office staff composites; an overall rating of the doctor; and whether the patient would recommend the doctor to family and friends.Key resultsPatient experience with telehealth visits was as positive as or more positive than that with traditional office-based visits. Doctor communication on tele-video visits was viewed as slightly more positive than that of in-office or phone visits. Tele-video visits were also slightly more positive than in-office visits for care coordination, overall rating of the doctor, and willingness to recommend to family and friends. Office staff were viewed less positively on the phone than tele-video or in-office visits. Patient experience was similar before and during the COVID-19 pandemic (e.g., on a 0-100 possible range with a higher score being better, doctor communication was 94.4 before and 94.9 during).ConclusionsThe positive experiences with telehealth, especially tele-video, may be due to patient appreciation of efforts made to maintain access, the focused nature of telehealth visits, and help by staff for navigation technical issues. Lessons learned about delivering responsive telehealth care can be used to ensure high-quality care after the pandemic

Delivering On Accountable Care: Lessons From A Behavioral Health Program To Improve Access And Outcomes.

Patients with behavioral health disorders often have worse health outcomes and have higher health care utilization than patients with medical diseases alone. As such, people with behavioral health conditions are important populations for accountable care organizations (ACOs) seeking to improve the efficiency of their delivery systems. However, ACOs have historically faced numerous barriers in implementing behavioral health population-based programs, including acquiring reimbursement, recruiting providers, and integrating new services. We developed an evidence-based, all-payer collaborative care program called Behavioral Health Associates (BHA), operated as part of UCLA Health, an integrated academic medical center. Building BHA required several innovations, which included using our enterprise electronic medical record for behavioral health referrals and documentation; registering BHA providers with insurance plans' mental health carve-out products; and embedding BHA providers in primary care practices throughout the UCLA Health system. Since 2012 BHA has more than tripled the number of patients receiving behavioral health services through UCLA Health. After receiving BHA treatment, patients had a 13 percent reduction in emergency department use. Our efforts can serve as a model for other ACOs seeking to integrate behavioral health care into routine practice

The Population Health Value Framework: Creating Value by Reducing Costs of Care for Patient Subpopulations With Chronic Conditions.

PROBLEM:With the growth in risk-based and accountable care organization contracts, creating value by redesigning care to reduce costs and improve outcomes and the patient experience has become an urgent priority for health care systems. APPROACH:In 2016, UCLA (University of California, Los Angeles) Health implemented a system-wide population health approach to identify patient populations with high expenses and promote proactive value-based care. The authors created the Patient Health Value framework to guide value creation: (1) identify patient populations with high expenses and reasons for spending; (2) create design teams to understand the patient story; (3) create custom analytics and spending-based risk stratification; and (4) develop targeted care pathways based on spending risk tiers. Primary care patients with three chronic conditions-dementia, chronic kidney disease (CKD), and cancer-were identified as high-cost subpopulations. OUTCOMES:For each patient subpopulation, a multispecialty, multidisciplinary design team identified reasons for spending and created care pathways to meet patient needs according to levels of spending risk. Larger, lower-risk cohorts received necessary but less intensive interventions while smaller, higher-risk cohorts received more intensive interventions. Preliminary analyses showed a 1% monthly decrease in inpatient bed day utilization among dementia patients (incident rate ratio [IRR] 0.99, P < .03) and a 2% monthly decrease in hospitalizations (IRR 0.98, P < .001) among CKD patients. NEXT STEPS:Use of the PHV framework is expanding across other high-cost subpopulations with chronic conditions. UCLA Health is using the framework to organize care across specialties, build capacity, and grow a culture for value

Delivering On Accountable Care: Lessons From A Behavioral Health Program To Improve Access And Outcomes.

Patients with behavioral health disorders often have worse health outcomes and have higher health care utilization than patients with medical diseases alone. As such, people with behavioral health conditions are important populations for accountable care organizations (ACOs) seeking to improve the efficiency of their delivery systems. However, ACOs have historically faced numerous barriers in implementing behavioral health population-based programs, including acquiring reimbursement, recruiting providers, and integrating new services. We developed an evidence-based, all-payer collaborative care program called Behavioral Health Associates (BHA), operated as part of UCLA Health, an integrated academic medical center. Building BHA required several innovations, which included using our enterprise electronic medical record for behavioral health referrals and documentation; registering BHA providers with insurance plans' mental health carve-out products; and embedding BHA providers in primary care practices throughout the UCLA Health system. Since 2012 BHA has more than tripled the number of patients receiving behavioral health services through UCLA Health. After receiving BHA treatment, patients had a 13 percent reduction in emergency department use. Our efforts can serve as a model for other ACOs seeking to integrate behavioral health care into routine practice