For Super-Utilizers, Integrated Care Offers A New Path

Vaida, Bara

doi:10.1377/hlthaff.2017.0112

Cited by 15 publications

(12 citation statements)

References 1 publication

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“…Moreover, the concrete operationalization of these strategies is still missing in many settings. For example, it is often unclear how to expand the scope of integrated care beyond traditional health services and how to address the social determinants of health in the processes of care [24]. Some integrated healthcare organizations such as Kaiser Permanente in the U.S [25].…”

Section: Introductionmentioning

confidence: 99%

Combining Integration of Care and a Population Health Approach: A Scoping Review of Redesign Strategies and Interventions, and their Impact

Farmanova¹,

Baker²,

Cohen

2019

International Journal of Integrated Care

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Background and aim: Many health systems attempt to develop integrated and population health-oriented systems of care, but knowledge of strategies and interventions to support this effort is lacking. We aimed to identify specific redesign strategies and interventions, and to present evidence of their effectiveness. Method: A modified scoping review process was carried out. Fifteen relevant examples of integrated care organizations that incorporated a broad population health approach in countries of the Organization for Economic Cooperation and Development described in 57 articles and reports were included in analysis. Results: Seven key redesign strategies and multiple redesign interventions have been identified and are described. Most commonly used redesign strategies included focusing on health and wellness, embracing intersectoral action and partnerships, addressing health in vulnerable groups, and addressing a wide range of determinants of health, including making improvements in health services. Redesign interventions included creative and innovative ways of addressing clinical and non-clinical issues such as establishing housing surgeries in primary care, establlishing vast social and provider networks to support patients with complex needs and also broadening of the scope of services, workforce redesign and other. Potential reductions in the utilization of care and costs could be derived by the wider adoption of these strategies and interventions. Conclusion: Development of integrated and population health-oriented systems of care requires the redesign of how services are organized and delivered, and how organizations and care systems operate. Combining integration of care with the population health approach can be supported by a set of cohesive strategies and interventions aimed at preventing disease, addressing social determinants of health and improving health equity at both population- and individual-level.

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Section: Introductionmentioning

confidence: 99%

Combining Integration of Care and a Population Health Approach: A Scoping Review of Redesign Strategies and Interventions, and their Impact

Farmanova¹,

Baker²,

Cohen

2019

International Journal of Integrated Care

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“…get the care they need most. 3,[7][8][9] Care transitions have been identified as a critical time for intervention, since health care costs particularly escalate surrounding hospitalizations related to chronic disease exacerbations. [7][8][9][10][11][12] Furthermore, research demonstrates that patients with complex chronic conditions are among those with the highest needs and highest cost.…”

mentioning

confidence: 99%

“…3,[7][8][9] Care transitions have been identified as a critical time for intervention, since health care costs particularly escalate surrounding hospitalizations related to chronic disease exacerbations. [7][8][9][10][11][12] Furthermore, research demonstrates that patients with complex chronic conditions are among those with the highest needs and highest cost. 13,14 But thus far, there is insufficient evidence regarding the essential components of care transition programs needed to achieve triple aim goals of improved quality and outcomes and reduced costs for high-need, high-cost patients with complex chronic conditions.…”

mentioning

confidence: 99%

Effect of Intensive Interdisciplinary Transitional Care for High-Need, High-Cost Patients on Quality, Outcomes, and Costs: a Quasi-Experimental Study

et al. 2019

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BACKGROUND: Many health systems have implemented team-based programs to improve transitions from hospital to home for high-need, high-cost patients. While preliminary outcomes are promising, there is limited evidence regarding the most effective strategies. OBJECTIVE: To determine the effect of an intensive interdisciplinary transitional care program emphasizing medication adherence and rapid primary care follow-up for high-need, high-cost Medicaid and Medicare patients on quality, outcomes, and costs. DESIGN: Quasi-experimental study. PATIENTS: Among 2235 high-need, high-cost Medicare and Medicaid patients identified during an index inpatient hospitalization in a non-profit health care system in a medically underserved area with complete administrative claims data, 285 participants were enrolled in the SafeMed care transition intervention, and 1950 served as concurrent controls. INTERVENTIONS:The SafeMed team conducted hospitalbased real-time screening, patient engagement, enrollment, enhanced discharge care coordination, and intensive home visits and telephone follow-up for at least 45 days. MAIN MEASURES: Primary difference-in-differences analyses examined changes in quality (primary care visits, and medication adherence), outcomes (preventable emergency visits and hospitalizations, overall emergency visits, hospitalizations, 30-day readmissions, and hospital days), and medical expenditures. KEY RESULTS: Adjusted difference-in-differences analyses demonstrated that SafeMed participation was associated with 7% fewer hospitalizations (− 0.40; 95% confidence interval (CI), − 0.73 to − 0.06), 31% fewer 30-day readmissions

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“…In one systematic review of international healthcare systems (including those in the USA, UK, Switzerland, Ireland, the Netherlands, Sweden, Canada, and Taiwan), frequent ED users were more likely to be older, female, and have a mental health diagnosis 11. Efforts to understand and support patients with high healthcare utilisation, coined ‘superutilizers’, have also been extensive, including focus on social determinants of health to enhance disease prevention and control the amount of healthcare required 12. An article in T he New Yorker entitled ‘The Hot Spotters’13 highlighted one of the most well-known of these approaches, the Camden Core Model, the subject of the currently reviewed randomised trial.…”

Section: Health Care Hotspotting: a Randomized Controlled Trialmentioning

confidence: 99%

Quality & safety in the literature: May 2020

2020

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For Super-Utilizers, Integrated Care Offers A New Path

Abstract: Many health systems continue to experiment with the best way to care for those patients who end up in the hospital most frequently.

Cited by 15 publications

References 1 publication

Combining Integration of Care and a Population Health Approach: A Scoping Review of Redesign Strategies and Interventions, and their Impact

Combining Integration of Care and a Population Health Approach: A Scoping Review of Redesign Strategies and Interventions, and their Impact

Effect of Intensive Interdisciplinary Transitional Care for High-Need, High-Cost Patients on Quality, Outcomes, and Costs: a Quasi-Experimental Study

Quality & safety in the literature: May 2020

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