The implementation lessons can inform state Medicaid Health Home models as well as accountable care organizations considering incorporation of behavioral health care. (PsycINFO Database Record
BACKGROUND: Longitudinal care management (LCM) for high-risk patients is a cornerstone of primary care models aiming to improve quality and reduce costs. OBJECTIVE: Describe the extent to which LCM was implemented in the second year of Comprehensive Primary Care Plus (CPC+), and barriers to and facilitators of implementation. DESIGN: Mixed-methods. PARTICIPANTS: Quantitative: 2715 practices participating in CPC+ in 2018. Qualitative: Interviews with practitioners and staff in 23 representative CPC+ practices. MAIN MEASURES: Across all CPC+ practices, we report median percentages of empaneled patients placed in the highest-risk tiers and, of those, the median percentage receiving LCM. Across 23 CPC+ practices, we report qualitative findings on LCM implementation. KEY RESULTS: While practices reported benefits of LCM, a small proportion of patients received LCM. Practices placed 2.4% (median) of patients in the highest-risk tier; of these, 30% (median) received LCM. Practices placed 10% (median) of patients in the second-highest-risk tier; of these, 7% (median) received LCM. Interviews revealed LCM uptake across tiers was low because of insufficient care manager staffing. Other challenges included lack of practitioner buy-in to using risk stratification to identify high-risk patients, patients' reluctance to engage in LCM or change behaviors, and limited health information technology functionality for developing, maintaining, and accessing high-risk patients' care plans. Facilitators included embedding care managers within practices and electronic health record functionalities that support LCM. CONCLUSIONS: Despite substantial financial and other supports, and practices' perceived benefits of LCM, insufficient care manager staffing and other barriers have limited its potential in CPC+ to date. To expand LCM's reach, practices need additional care managers, training to overcome barriers to patient engagement, better identification of patients who might benefit from LCM, improved information technology tools for risk stratification and care plans, and more practitioner buy-in to risk stratification.
is her own clinical trial with a cohort of 1. Tricia has been diagnosed with narcolepsy with severe cataplexy. This dual diagnosis is characterized by the inability to maintain voluntary wakefulness, abnormal REM, and sudden paralysis or weakness in muscle tone without loss of consciousness. If left uncontrolled, her symptoms make it nearly impossible for her to live normally. Her ability to live a higher quality of life is made possible by a cocktail of medications that were all developed for purposes other than narcolepsy. Patients and physicians facing uncommon or atypical disorders like Tricia's must consider a complicated series of decisions. Most therapeutic regimens and pharmaceutical developments are based on treating the underlying mechanism of a disease, a pattern that is growing more pronounced following tremendous advances in basic science and translational research. But what happens when that paradigm fails? How do things change for both patient and physician when determining an accurate diagnosis-let alone treatment-can take years? What happens when it is not possible to address the mechanism of a disease, when the clinical focus must be shifted to treating symptoms? The ethical and professional challenges to the treating physician are very real, but so too are the thoughts and reactions of the patient. In her own words, this is Tricia Higgins' story.When I was 34 years old my world started caving in. I was a mother of 3, wife to a wonderful man completing his third degree, homemaker, emergency room nurse, and good friend to anyone in need. I was a volunteer in my children's classrooms and a CCD teacher at our local Catholic Church. Yet suddenly I was the one in need, a role I hated from the beginning and still hate today.
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