Medical Care Research and Review最新文献

Public health care policymakers and payers are increasingly investing in efforts to address patients' health-related social needs (HRSNs) as a strategy for improving health while controlling or reducing costs. However, evidence regarding the implementation and impact of HRSN interventions remains limited. California's Whole Person Care Pilot program (WPC) was a Medicaid Section 1115 waiver demonstration program focused on the provision of care coordination and other services to address eligible beneficiaries' HRSN. In this study, we examine pilot-level variation in impact on acute care utilization and identify factors associated with differential outcomes. The majority of pilots reduced emergency department (ED) visits for enrollees relative to matched controls; however, only four pilots reduced both ED visits and hospitalizations. Coincidence analysis results highlight the importance of cross-sector partnerships, field-based outreach and engagement, and adequate program investment in differentiating pilots that reduced acute care utilization from those that did not.

The supply of personal care aides (PCAs), who assist people receiving home care, is a growing concern. PCA shortages result, in part, from the low wages earned by these workers. State policies have had some effect on wages. Self-direction (SD) may be associated with wages because SD allows home care recipients to hire and manage workers, including setting wages in most states. We used wage data from the Bureau of Labor Statistics to examine the association between SD and the wages of PCAs. We found implementation of SD did not have a consistent association with PCA wages, with wages improving in some states and worsening in others. We also found little difference in PCA wages between states that allow participants to set worker wages and those that do not. SD does not seem to improve PCA wages in states, so other policy strategies will be needed.

Behavioral health needs continue rise in the United States and constitute a key driver of health care utilization, costs, and outcomes. Social workers provide a wide range of services across health, behavioral health, and community settings, and while this heterogeneity in practice benefits care delivery, it complicates health workforce analyses. This analysis compares five commonly used national data sources and details similarities and differences in their estimates of the number, type, and practice characteristics of social workers. The analysis suggests that estimates vary significantly between data sets ranging from 282,425 to 1,022,859 social workers; as well as yield different findings of types of social workers in the United States, depending on the data set used. These differences have the potential to shape how researchers and policy makers assess the adequacy of the social work workforce and identify solutions to address the nation's behavioral health and social care needs.

Primary care practitioners (PCPs) are the first point of contact for most patients with suspected dementia and have identified a need for more training and support around dementia diagnosis and care. This qualitative study examined the Alzheimer's Disease-Extension for Community Healthcare Outcomes (AD-ECHO) program. AD-ECHO was designed to strengthen PCP capacity in dementia through bimonthly virtual meetings with a team of dementia experts. We conducted 24 hr of direct observations at AD-ECHO sessions and interviewed 14 participants about their experiences participating. Using thematic analysis, we found that participants valued the supportive learning environment and resources; knowledge gained empowered them to take more action around dementia; they identified ways of disseminating knowledge gained into their practice settings, and many desired ongoing AD-ECHO engagement. However, most identified time as a barrier to participation. AD-ECHO has the potential to strengthen the primary care workforce's knowledge and confidence around dementia care.

To foster bottom-up innovations, health care organizations are leveraging interdisciplinary frontline innovation teams. These teams include workers across hierarchical levels and professional backgrounds, pooling diverse knowledge sources to develop innovations that improve patient and worker experiences and care quality, equity, and costs. Yet, these frontline innovation teams experience barriers, such as time constraints, being new to innovation, and team-based role hierarchies. We investigated the practices that such teams in federally qualified health centers (FQHCs) used to overcome these barriers. Our 20-month study of two FQHC innovation teams provides one of the first accounts of how practices that sustained worker engagement in innovation and supported their ideas to implementation evolve over time. We also show the varied quantity of engagement practices used at different stages of the innovation process. At a time when FQHCs face pressure to innovate amid staff shortages, our study provides recommendations to support their work.

Many Veterans receive Department of Veterans Affairs (VA)-purchased care from non-VA facilities but little is known about factors that Veterans consider for this choice. Between May 2020 and August 2021, we surveyed VA-purchased care-eligible VA patients about barriers and facilitators to choosing where to receive care. We examined the association between travel time to their VA facility and their choice of VA-purchased care (VA-paid health care received in non-VA settings) versus VA facility and whether this association was modified by distrust. We received 1,662 responses and 692 (42%) chose a VA facility. Eighty percent reported quality care was in their top three factors that influenced their decision. Respondents with the highest distrust and who lived >1 hr from the nearest VA facility had the lowest predicted probability (PP) of choosing VA (PP 15%; 95% confidence interval: 10%-20%). Veterans value quality of care. VA and other health care systems should consider patient-centered ways to improve and publicize quality and reduce distrust.

Evidence suggests that perinatal doula care can support maternal health and reduce racial inequities among low-income pregnant and postpartum people, prompting growing interest by state Medicaid agencies to reimburse for doula services. Emerging peer-reviewed and gray literature document factors facilitating or impeding that reimbursement. We conducted a scoping review of that literature (2012-2022) to distill key policy considerations for policymakers and advocates in the inclusion of doula care as a Medicaid-covered benefit. Fifty-three reports met the inclusion criteria. Most (53%) were published in 2021 or 2022. Their stated objectives were advocating for expanded access to doula care (17%), describing barriers to policy implementation, and/or offering recommendations to overcome the barriers (17%). A primary policy consideration among states was prioritizing partnership with doulas and doula advocates to inform robust and equitable policymaking to sustain the doula profession.

Census data are vital to health care research but must also protect respondents' confidentiality. The 2020 decennial Census employs a new Differential Privacy framework; this study examines its effect on the accuracy of an important tool for measuring health disparities, the Bayesian Improved Surname and Geocoding (BISG) algorithm, which uses Census Block Group data to estimate race and ethnicity when self-reported data are unavailable. Using self-reported race and ethnicity data as our standard, we compared the accuracy of BISG estimates calculated using the original 2010 Census counts to the accuracy of estimates calculated using 2010 data but with 2020 Differential Privacy in place. The Differential Privacy methodology slightly decreases BISG accuracy for American Indian and Alaska Native people but has little effect for other groups, suggesting that the methodology will not impede health disparities research that employs BISG and similar methods.

Many older adults are experiencing unmet needs for assistance with the activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Such unmet needs might threaten their physical and psychosocial well-being. We conducted a systematic review to provide a comprehensive picture of the health consequences of unmet ADL/IADL needs among older adults. Twenty-eight published articles were included for qualitative synthesis. We found that unmet ADL/IADL needs were consistently associated with higher health care utilization (e.g., hospitalization, medical spending) and adverse psychosocial consequences (e.g., anxiety, depression), while the findings of falls and mortality remain inconsistent. More studies are needed to draw firm conclusions and to allow for quantitative synthesis. This review advocates for more coordinated and comprehensive long-term care services for older adults. Future studies should explore how the adverse health outcomes identified in this review can be prevented or improved by adequately meeting older adults' needs for assistance.

Healthcare provider shortages are associated with adverse health outcomes, presumably stemming from the lack of access to primary care. This study examines the impact of Health Professional Shortage Areas (HPSAs) on healthcare utilization and spending across different types of care. Using the Medical Expenditure Panel Survey from 2002 to 2019, this study estimates the difference in healthcare utilization in HPSAs compared with non-HPSAs using a generalized random forest, which allows for more complex modeling of the outcome and a principled examination of heterogenous treatment effects. The results indicate HPSAs are associated with a 5% reduction in medical office visits, but no reduction in hospital-based care. These effects are concentrated in older persons living in urban areas, Black persons, and Medicaid beneficiaries. No statistically significant effects on annual spending were observed. These results offer insight into potential areas for further policy efforts aimed at reducing provider shortages.