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Promoting learning health systems using learning science 利用学习科学促进学习型卫生系统
IF 2.5 4区 医学 Q3 HEALTH POLICY & SERVICES Pub Date : 2023-06-01 DOI: 10.1016/j.hjdsi.2023.100693
Joshua M. Liao
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引用次数: 0
Achieving greater value for veterans through full cost transparency in primary care 通过初级保健的完全成本透明,为退伍军人创造更大的价值
IF 2.5 4区 医学 Q3 HEALTH POLICY & SERVICES Pub Date : 2023-06-01 DOI: 10.1016/j.hjdsi.2023.100687
Victor C. Agbafe , Nora Metzger , Brittani R. Garlick , Tanner Caverly , Sameer Saini , Eve Kerr , Sana Matloub , Jeffrey T. Kullgren

The COVID-19 pandemic has led to increased use of telephone and video encounters in the Veterans Health Administration and many other healthcare systems. One important difference between these virtual modalities and traditional face-to-face encounters is the different cost-sharing, travel costs, and time costs that patients face. Making the full costs of different visit modalities transparent to patients and their clinicians can help patients obtain greater value from their primary care encounters. From April 6, 2020 to September 30, 2021 the VA waived all copayments for Veterans receiving care from the VA, but since this policy was temporary it is important that Veterans receive personalized information about their expected costs so they can obtain the most value from their primary care encounters.

To test the feasibility, acceptability, and preliminary effectiveness of this approach, our team conducted a 12 week pilot project at the VA Ann Arbor Healthcare System from June–August 2021 in which we made personalized estimates of out-of-pocket, travel, and time costs available and transparent to patients and clinicians in advance of scheduled encounters and at the point of care. We found that it was feasible to generate and deliver personalized cost estimates in advance of visits, that this information was acceptable to patients, and that patients who used cost estimates during a visit with a clinician found this information helpful and would want to receive it again in the future. To achieve greater value in healthcare, systems must continue to pursue new ways to provide transparent information and needed support to patients and clinicians. This means ensuring clinical visits provide the highest levels of access, convenience, and return on patients’ healthcare-associated spending while minimizing financial toxicity.

新冠肺炎大流行导致退伍军人卫生管理局和许多其他医疗系统越来越多地使用电话和视频。这些虚拟方式与传统的面对面交流之间的一个重要区别是患者面临的不同的成本分担、差旅成本和时间成本。让不同就诊方式的全部费用对患者及其临床医生透明,可以帮助患者从初级保健中获得更大的价值。从2020年4月6日到2021年9月30日,退伍军人事务部免除了接受退伍军人事务部护理的退伍军人的所有自付费用,但由于这项政策是临时性的,因此退伍军人获得有关其预期费用的个性化信息很重要,这样他们就可以从初级护理中获得最大价值。为了测试这种方法的可行性、可接受性和初步有效性,我们的团队于2021年6月至8月在弗吉尼亚州安娜堡医疗保健系统进行了一个为期12周的试点项目,在该项目中,我们对自费、差旅和时间成本进行了个性化估计,并在预定就诊前和护理时向患者和临床医生透明。我们发现,在就诊前生成并提供个性化的成本估算是可行的,这些信息对患者来说是可以接受的,在临床医生就诊期间使用成本估算的患者发现这些信息很有帮助,并希望在未来再次收到。为了在医疗保健中实现更大的价值,系统必须继续寻求新的方式,为患者和临床医生提供透明的信息和所需的支持。这意味着确保临床就诊为患者的医疗保健相关支出提供最高水平的访问、便利和回报,同时最大限度地减少经济毒性。
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引用次数: 0
Perspectives of acute, post-acute, physician and community support providers on community collaborative efforts to improve transitions of care 急性、急性后、医生和社区支持提供者对社区合作努力改善护理转变的看法
IF 2.5 4区 医学 Q3 HEALTH POLICY & SERVICES Pub Date : 2023-03-01 DOI: 10.1016/j.hjdsi.2022.100673
Brianna Gass , Lacey McFall , Jane Brock , Jing Li , Christine LaRocca , Mark V. Williams

Background

Transitional care (TC) involves multiple organizations as patients transition from hospitals. Collaboration to reduce readmissions has been encouraged by government initiatives. As part of Project ACHIEVE, a comparative TC study, we sought provider perspectives on TC improvement efforts.

Methods

We aimed to identify perceived problems that drove improvement efforts, influences on interventions implemented, facilitators or barriers to desired outcomes, and sustainability. Investigators interviewed 63 representatives from collaborative improvement efforts across 13 states in 2015. Directed content analysis was performed, with inductive coding as insights emerged. Data was also analyzed for differences in participant perceptions, such as the organization represented, geographic characteristics, and source of funding for interventions.

Results

Participants in semi-structured interviews included physicians, nurses, care navigators, and administrators from hospitals, nursing facilities, community-based organizations, and medical practices. Participants reported that changing reimbursement practices and readmissions penalties drove TC efforts, and common problems they sought to address included insufficient inter-provider communication, medication management, and challenges related to chronic condition management. Solutions implemented were often adapted according to community and setting characteristics and population factors. Findings also suggest differences in the types of interventions implemented according to funding sources, which also impacted the ability to sustain these interventions.

Conclusions

Cross-site collaboration, communication, and partnership among stakeholders is essential to effective transitional care. Collaboration led to shared understanding among stakeholders of health care and support services available in the community. Coalition-based work also facilitated trust among partners which led to expansion and sustainment of TC efforts. Unmet social needs of patients are a barrier.

Implications

Opportunities exist for increased and improved collaboration among clinical providers with community-based and social services organizations. Increased involvement of primary care providers in such collaborations would improve communication with both the patient and involved providers. Communities with external funding were more likely to implement evidence-based interventions, while those relying on institutional support addressed identified problems with more targeted interventions.

背景过渡期护理(TC)涉及多个组织,患者从医院过渡。政府举措鼓励开展合作,减少再次入院人数。作为TC比较研究“成就项目”的一部分,我们寻求供应商对TC改进工作的看法。方法我们旨在确定推动改进努力的感知问题、对实施干预措施的影响、实现预期结果的推动者或障碍以及可持续性。2015年,调查人员采访了来自13个州合作改进工作的63名代表。进行了定向内容分析,随着见解的出现,进行了归纳编码。还分析了参与者认知的差异,如所代表的组织、地理特征和干预措施的资金来源。结果半结构化访谈的参与者包括来自医院、护理机构、社区组织和医疗机构的医生、护士、护理导航员和管理人员。参与者报告说,不断变化的报销做法和再次入院处罚推动了TC的努力,他们寻求解决的常见问题包括提供者之间沟通不足、药物管理以及与慢性病管理相关的挑战。实施的解决方案往往根据社区和环境特点以及人口因素进行调整。调查结果还表明,根据资金来源实施的干预措施类型存在差异,这也影响了维持这些干预措施的能力。结论利益相关者之间的跨站点协作、沟通和伙伴关系对于有效的过渡期护理至关重要。通过合作,利益相关者对社区提供的医疗保健和支持服务有了共同的理解。以联盟为基础的工作也促进了合作伙伴之间的信任,从而扩大和维持了技术合作的努力。患者未得到满足的社会需求是一个障碍。关联存在增加和改善临床提供者与社区和社会服务组织之间合作的机会。初级保健提供者更多地参与此类合作将改善与患者和相关提供者的沟通。有外部资金的社区更有可能实施循证干预措施,而那些依赖机构支持的社区则通过更有针对性的干预措施来解决已发现的问题。
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引用次数: 1
A matter of trust: Commitment to act for health equity 信任问题:承诺为卫生公平采取行动
IF 2.5 4区 医学 Q3 HEALTH POLICY & SERVICES Pub Date : 2023-03-01 DOI: 10.1016/j.hjdsi.2023.100675
Ron Wyatt , Leslie Tucker , Kedar Mate , Fred Cerise , Alicia Fernandez , Sachin Jain , Ignatius Bau , Daniel Wolfson
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引用次数: 1
Changes in spending and quality after ACO contract participation for dually eligible beneficiaries with mental illness 精神疾病双重合格受益人参与ACO合同后支出和质量的变化
IF 2.5 4区 医学 Q3 HEALTH POLICY & SERVICES Pub Date : 2023-03-01 DOI: 10.1016/j.hjdsi.2022.100664
Carrie H. Colla , Valerie A. Lewis , Chiang-Hua Chang , Maia Crawford , Kristen A. Peck , Ellen Meara

Background

Fragmented care and misaligned payment across Medicare and Medicaid lower care quality for dually eligible beneficiaries with mental illness. Accountable care organizations aim to improve the quality and value of care.

Methods

Using Medicare fee-for-service Part A and B claims data from 2009 to 2017 and a difference-in-differences design, we compared the spending and utilization of dually eligible beneficiaries with mental illness that were and were not attributed to Medicare ACO providers before and after ACO contract entry.

Results

Dually eligible beneficiaries with mental illness (N = 5,157,533, 70% depression, 22% bipolar, 27% schizophrenia and other psychotic disorders) had average annual Medicare spending of $17,899. ACO contract participation was generally not associated with spending or utilization changes. However, ACO contract participation was associated with higher rates of follow-up visits after mental health hospitalization: 1.17 and 1.30 percentage points within 7 and 30 days of discharge, respectively (p < 0.001). ACO-attributed beneficiaries with schizophrenia, bipolar, or other psychotic disorders received more ambulatory visits (393.9 per 1000 person-years, p = 0.002), while ACO-attributed beneficiaries with depression experienced fewer emergency department visits (−29.5 per 1000 person-years, p = 0.003) after ACO participation.

Conclusions

Dually eligible beneficiaries served by Medicare ACOs did not have lower spending, hospitalizations, or readmissions compared with other beneficiaries. However, ACO participation was associated with timely follow-up after mental health hospitalization, as well as more ambulatory care and fewer ED visits for certain diagnostic groups.

Implications

ACOs that include dually eligible beneficiaries with mental illness should tailor their designs to address the distinct needs of this population.

背景:医疗保险和医疗补助之间的支离破碎的护理和不一致的支付降低了双重资格的精神疾病受益人的护理质量。负责任的护理组织旨在提高护理的质量和价值。方法利用2009年至2017年医疗保险按服务收费的A部分和B部分索赔数据,采用双差法设计,比较在签订医疗保险非辅助医疗服务合同前后,属于和不属于医疗保险非辅助医疗服务提供者的精神疾病双重资格受益人的支出和利用情况。结果双重符合条件的精神疾病受益人(N = 5,157,533, 70%抑郁症,22%双相情感障碍,27%精神分裂症和其他精神障碍)的平均年医疗保险支出为17,899美元。ACO合同的参与通常与支出或利用变化无关。然而,参与ACO合同与精神健康住院后更高的随访率相关:出院后7天和30天内分别为1.17和1.30个百分点(p <0.001)。患有精神分裂症、双相情感障碍或其他精神障碍的ACO归因受益人在参加ACO后获得了更多的门诊就诊(每1000人年393.9次,p = 0.002),而患有抑郁症的ACO归因受益人在参加ACO后急诊科就诊较少(每1000人年- 29.5次,p = 0.003)。结论:与其他受益人相比,医疗保险ACOs服务的符合条件的受益人没有较低的支出、住院或再入院率。然而,参与ACO与精神健康住院后及时随访,以及某些诊断组更多的门诊护理和更少的急诊科就诊有关。包括双重符合资格的精神疾病受益人的aco应量身定制其设计,以满足这一人群的独特需求。
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引用次数: 0
Building bi-directional referral and communication pathways across the community-clinic divide: Experiences from a systems-informed innovation project in Los Angeles 在社区和诊所之间建立双向转诊和沟通途径:来自洛杉矶系统知情创新项目的经验
IF 2.5 4区 医学 Q3 HEALTH POLICY & SERVICES Pub Date : 2023-03-01 DOI: 10.1016/j.hjdsi.2022.100671
Amelia R. DeFosset , Noel C. Barragan , Gabrielle Green , Janina L. Morrison , Tony Kuo

Bi-directional communication and referral pathways (BCRPs) between clinics and community-based organizations could promote well-being among vulnerable populations with complex and overlapping health and social needs. While BCRPs are promising, establishing them is complex, involving system and process changes across diverse organizational settings. To date, few models have been implemented or empirically tested.

This article describes an innovation and planning project to build a BCRP, linking patients in safety net primary care clinics to a comprehensive suite of community-based health and wellness supports in Los Angeles. During a year-long process, a multi-sector team iteratively engaged data to facilitate learning and improvement. The project proceeded through three distinct, but overlapping, phases: (1) Discovery, (2) Systems Mapping, and (3) BCRP Re-design and Testing, which were coordinated through frequent collaborative meetings. By using a stepwise systems-informed approach to collect and examine data, the team was able to generate new change ideas, dispel assumptions, and make transparent and informed decisions.

It was critical to have engagement from both internal partners with knowledge of “on-the-ground” practice realities, and external stakeholders with the fresh perspective needed to identify opportunities and define an improvement agenda. These efforts represent first steps towards implementing sustainable BCRPs and realizing their full potential to dynamically bridge the community-clinic divide and improve population health. Other jurisdictions can learn from and adapt the practical data-driven approach used in Los Angeles to build BCRPs that will be thoroughly operationalized, consistently implemented, and optimized within their own unique contexts.

诊所和社区组织之间的双向沟通和转诊途径可以促进有复杂和重叠健康和社会需求的弱势群体的福祉。虽然BCRP很有前景,但建立它们是复杂的,涉及不同组织环境中的系统和流程变化。迄今为止,很少有模型得到实施或实证检验。本文描述了一个建立BCRP的创新和规划项目,将安全网初级保健诊所的患者与洛杉矶的一套全面的社区健康支持联系起来。在长达一年的过程中,一个多部门团队反复使用数据,以促进学习和改进。该项目经历了三个不同但重叠的阶段:(1)发现、(2)系统映射和(3)BCRP重新设计和测试,这些阶段通过频繁的协作会议进行协调。通过使用逐步系统知情的方法来收集和检查数据,团队能够产生新的变革想法,消除假设,并做出透明和知情的决策。至关重要的是,既要让了解“实地”实践现实的内部合作伙伴参与,也要让外部利益攸关方从新的角度参与,以确定机会并确定改进议程。这些努力是实施可持续BCRP的第一步,也是实现其动态弥合社区诊所鸿沟和改善人口健康的全部潜力的第一步。其他司法管辖区可以学习和调整洛杉矶使用的实用数据驱动方法,以建立将在其独特背景下彻底实施、持续实施和优化的BCRP。
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引用次数: 1
Succeeding in Medicare’s newest bundled payment program: Results from teaching hospitals 医疗保险最新捆绑支付计划的成功:教学医院的结果
IF 2.5 4区 医学 Q3 HEALTH POLICY & SERVICES Pub Date : 2023-03-01 DOI: 10.1016/j.hjdsi.2022.100672
Matthew C. Baker, Erin N. Hahn, Theresa R.F. Dreyer, Keith A. Horvath

Background

In 2018, Medicare implemented a successor to its Bundled Payments for Care Improvement (BPCI) program, BPCI Advanced, with stricter participation rules and new financial incentives to reduce spending.

Methods

Using claims-based episode data from thirteen participants, we compared spending and utilization in the first fifteen months of the new program (October 2018 to December 2019) to hospital- and episode-specific target prices, with a deep dive into clinical correlates for the most commonly-selected clinical episodes, sepsis and congestive heart failure.

Results

Twelve out of thirteen participants in a collaborative of teaching hospitals achieved shared savings for both Medicare and their own institution. Aggregate hospital shared savings were 5.8% of benchmark prices across 6,131 patients in 16 clinical episodes (p<0.001), appreciably higher than the reference savings rates reported after the first period of Medicare’s predecessor BPCI program. Differences in shared savings across hospitals for sepsis and congestive heart failure correlated with reductions in patients’ use of post-acute care, including reductions in skilled nursing facility, readmission, and home health rates. Evidence is presented showing reductions in patient utilization for cost-intensive post-acute settings accompanied increases in the proportion of patients exclusively utilizing non-institutional care after discharge from an anchor stay or procedure.

Conclusions

These findings provide an example of the fulfillment of a core promise of bundled payments to uncover new opportunities for reduced spending.

Level of evidence

Non-random cohort of hospitals.

背景2018年,联邦医疗保险实施了其捆绑支付护理改善(BPCI)计划的后续计划BPCI Advanced,该计划有更严格的参与规则和新的财政激励措施来减少支出。方法使用来自13名参与者的基于索赔的发作数据,我们将新计划前15个月(2018年10月至2019年12月)的支出和使用情况与医院和发作的具体目标价格进行了比较,并深入研究了最常见的临床发作、败血症和充血性心力衰竭的临床相关性。结果在一个教学医院合作项目中,13名参与者中有12人实现了医疗保险和自己机构的共同储蓄。在16次临床发作中,6131名患者的医院共享储蓄总额为基准价格的5.8%(p<0.001),明显高于医疗保险前身BPCI计划第一期后报告的参考储蓄率。不同医院在败血症和充血性心力衰竭方面的共同储蓄差异与患者使用急性后护理的减少相关,包括熟练护理设施、再次入院和家庭健康率的减少。有证据表明,在费用密集型急性后环境中,患者利用率降低,同时在出院后专门利用非机构护理的患者比例增加。结论这些发现为实现捆绑支付的核心承诺提供了一个例子,以发现减少支出的新机会。证据水平医院的非随机队列。
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引用次数: 0
Innovation pathways to preserve: Rapid healthcare innovation and dissemination during the COVID-19 pandemic 创新之路:COVID-19大流行期间的快速医疗保健创新和传播
IF 2.5 4区 医学 Q3 HEALTH POLICY & SERVICES Pub Date : 2022-12-01 DOI: 10.1016/j.hjdsi.2022.100660
Danielle Voke , Amanda Perry , Shoshana H. Bardach , Nirav S. Kapadia , Amber E. Barnato

During the COVID-19 pandemic, healthcare systems rapidly responded to challenges in healthcare delivery with innovation. Innovations developed during the COVID-19 pandemic have filled needed gaps in medical care and many may be sustained long term. The unique conditions and processes that facilitated such rapid, successful, and collective innovation should be explored to support future change in healthcare. Decentralized decision making, crowdsourcing, and nontraditional information sharing may be valuable for ongoing innovation in healthcare delivery. Shared, collective purpose in solving challenges in healthcare appear critical to this work. Health care systems aiming to sustain rapid healthcare delivery innovation should consider these processes and focus on facilitating shared purpose to sustain ongoing innovation.

在2019冠状病毒病大流行期间,卫生保健系统通过创新迅速应对了卫生保健服务方面的挑战。在2019冠状病毒病大流行期间开发的创新填补了医疗保健方面的必要空白,其中许多可能会长期持续下去。应该探索促进这种快速、成功和集体创新的独特条件和过程,以支持医疗保健领域未来的变革。分散决策、众包和非传统信息共享可能对医疗保健服务的持续创新很有价值。解决医疗保健挑战的共同、集体目标似乎对这项工作至关重要。旨在维持快速医疗服务创新的卫生保健系统应该考虑这些过程,并将重点放在促进共同目标上,以维持持续的创新。
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引用次数: 1
书评
IF 2.5 4区 医学 Q3 HEALTH POLICY & SERVICES Pub Date : 2022-12-01 DOI: 10.1016/j.hjdsi.2022.100659
Rick Mathis
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引用次数: 0
Putting the design in health system redesign: Doing the jobs-to-be-done 将设计纳入卫生系统重新设计:做好该做的工作
IF 2.5 4区 医学 Q3 HEALTH POLICY & SERVICES Pub Date : 2022-12-01 DOI: 10.1016/j.hjdsi.2022.100652
Jubi Y.L. Lin , Joy S. Lee , Joshua M. Liao
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引用次数: 0
期刊
Healthcare-The Journal of Delivery Science and Innovation
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