improving population and clinical health with integrated...
TRANSCRIPT
![Page 1: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/1.jpg)
Strategies to Achieve Alignment, Collaboration, and Synergy across Delivery and Financing Systems
ImprovingPopulationandClinicalHealthwithIntegratedServicesandDecisionSupport
Research-in-Progress WebinarWednesday, January 9, 2019
12:00-1:00 pm ET/ 9:00 am-10:00 am PT
Funded by the Robert Wood Johnson Foundation
![Page 2: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/2.jpg)
AgendaWelcome: ShanaMoore,PhD,MPA
DirectorofDisseminationandResearchDevelopmentRWJFSystemsforAction NationalCoordinatingCenterUniversityofKentuckyCollegeofPublicHealth
Presenter: JoshuaVest,PhD,MPHDirector,CenterforHealthPolicyAssociateProfessor,HealthPolicy&ManagementIndianaUniversityRichardMFairbanksSchoolofPublicHealth- IndianapolisAffiliatedScientist,RegenstriefInstitute
Commentary: GlenMays,PhDDirectorRWJFSystemsforAction NationalCoordinatingCenterUniversityofKentuckyCollegeofPublicHealth
Q&A: ModeratedbyShanaMoore,PhD,MPA
![Page 3: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/3.jpg)
Presenter
JoshuaVest,PhD,MPHDirector,CenterforHealthPolicyAssociateProfessor,HealthPolicy&ManagementIndianaUniversityRichardMFairbanksSchoolofPublicHealth- IndianapolisAffiliatedScientist,RegenstriefInstitute
![Page 4: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/4.jpg)
Commentary Speaker
GlenP.Mays,PhD,MPHDirectorRWJFSystemsforAction NationalCoordinatingCenterUniversityofKentuckyCollegeofPublicHealth
![Page 5: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/5.jpg)
ImprovingPopulationandClinicalHealthwithIntegratedServicesandDecisionSupport
JoshuaRVest,PhD,MPHDirector,CenterforHealthPolicy
AssociateProfessor,HealthPolicy&ManagementIndianaUniversityRichardMFairbanksSchoolofPublicHealthatIUPUI
Investigator,RegenstriefInstitute,Inc.
ThisworkwassupportedbytheRobertWoodJohnsonFoundationthroughtheSystemsforActionNationalCoordinatingCenter,ID73485.@JoshuaRVest
![Page 6: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/6.jpg)
Acknowledgements
IndianaUniversity• PaulKHalverson(Co-PI)• NirMenachemi• ShaunGrannis• SurangaKasthuriranthne• …many,many,others
VestJR,HarrisLE,HautDP,HalversonPK,MenachemiN.IndianapolisProvider’sUseOfWraparoundServicesAssociatedWithReducedHospitalizationsAndEmergencyDepartmentVisits.HealthAff (Millwood).2018;37(10):1555-1561.
VestJR,MenachemiN,GrannisS,FerrellJ,KasthurirathneS,*ZhangY,TongY,HalversonP.Impactofriskstratificationonreferralsanduptakeofwraparoundservicestoaddresssocialdeterminants:asteppedwedgedtrial.AmericanJournalofPreventativeMedicine. Inpress.
![Page 7: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/7.jpg)
USpolicyismovingtomakeprovidersaccountableforpatienthealth.
Upstream.com
Upstreamthinking
Focusonprevention
Addressingsocialdeterminants
![Page 8: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/8.jpg)
Fitday.com
Moreandmorehealthcareorganizationsareofferingnon-medicalor“wraparound”servicestoimprovepatienthealth.
http://cchci.org/_services/behavioral-health/
www.chelseajew
ish.org/celebrating-social-w
ork-month-senior-care/
Pplay.google.com
guide.berkeley.edu/undergraduatedmkelite.com
usf.edu
![Page 9: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/9.jpg)
Whatrolesdoestheseservicesfulfill?
• Theseservicesmostdirectlyaddress:healthbehaviors,socialcontexts,andenvironments– Thesesocialdeterminantsofhealtharelargerdriversofhealththanmedicalcare
– Thesesocialdeterminantscaninhibitcaredelivery• Lackoftransportation,poorsocialnetworks,loweducationallcomplicate(orprevent)care
• Clinicianstraditionallynottrained(andhealthcaresystemwerenotorganized)toaddresstheseissues– Requiresspecializedprofessionals
![Page 10: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/10.jpg)
Researchquestion:
Doesreceiptofwraparoundservicesreducepatients’healthcareutilization?
Approach:
Measuretheassociationbetweenreceiptofwraparoundservicesandutilizationoutcomesinan11-yearpanelofadultpatients.
![Page 11: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/11.jpg)
Setting,sample,&measuresSetting:• EskenaziHealthFQHCs• Expandedwraparoundservicesonco-locatedbasisin2011
Sample:• Adults(≥18)withprimarycarevisitsfrom2006-2016
– Hadtohave≥1visitbefore2011&≥1visitafter2011Determinantofinterest:receiptofwraparoundservices(Vest,Grannis,etalIJMI2017)
• Anysocialwork,behavioralhealth,nutritioncounseling,respiratorytherapy,financialplanning,medical-legalpartnership,patientnavigation,orpharmacistconsultation– Allpatientsinthestudysamplereceivedatleastonewraparoundserviceduringthestudyperiod
Outcome:• Outcomes:annualhospitalizations;annualEDvisits
Measures:• Annualriskscores,utilizationhistory,(binary)receiptofwraparoundservices(time-varying)• Chronicconditionsanddemographicfactors(timeinvariant)
![Page 12: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/12.jpg)
Patient-levelfixed-effectsPoissonregressionmodelsdescribedtheassociationbetweenwraparoundservicesandoutcomes.
• Patient-fixedeffectscontrolledfortime-invariantfactors(e.g.race/ethnicity)• Time-varyingmeasuresincludedinmodel(e.g.annualriskscores)• Yeardummiesincludedtoadjustfortrends• Robuststandarderrorstoadjustforclustering• Wraparoundservicesenteredasalaggedbinary-indicator
– Associationwithsubsequent yearutilization
Robustnesschecks:• repeatedusingfixed-effectsnegativebinomialregression• propensity-scorematchedcomparisongroupofpatientswhodidnotreceiveany
wraparoundserviceswithrandom-interceptPoissonmodels
![Page 13: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/13.jpg)
Highdiseaseburdenreflectiveofasafety-netpopulation%
DemographicsAge 49.7(mean)Female 71.9Race/ethnicityHispanic 18.7AfricanAmerican 41.4White,non-Hispanic 26.7Other/unknown 13.4
PatientseverityResourceutilizationband 2.54(mean)
DiagnosesHypertension 65.2Asthma 17.8Depression 42.3Diabetes 43.8
Substanceabusehistory 20.7Tobaccousehistory 33.8AnnualutilizationhistoryOutpatientvisitcount 3.42(mean)Specialistvisitcount 2.86(mean)Emergencydepartmentvisitcount 0.81(mean)Hospitalizationcount 0.20(mean)
![Page 14: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/14.jpg)
Dietitiansfollowedbysocialworkersarethemostcommonlyaccessedwraparoundservices.
49.2
29.4
9.7
3.4
1.0
7.2
0
5
10
15
20
25
30
35
40
45
50
Dietitian Socialwork Behavioralhealth Respiratorytherapy Patientnavigation Multiple
percent
![Page 15: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/15.jpg)
Receiptofanywraparoundservicewasassociatedwithalowercountofhospitalizationsinthesubsequentyear.
Hospitalizations
β(95%CI) pReceiptofanywraparoundserviceintheprioryear -0.07(-0.12,-0.02) 0.006Severityscore 0.66(0.63,0.69) <0.001AnnualnumberofencountersHospitalizations --EDvisits 0.01(0.00,0.02) 0.008
Outpatientvisits 0.01(0.01,0.02) <0.001
Specialtycarevisits 0.03(0.03,0.03) <0.001
Patientfixedeffectsregressionmodelswithyeardummiesomittedforreadability.
![Page 16: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/16.jpg)
ReceiptofanywraparoundservicewasassociatedwithalowercountofEDvisitsinthesubsequentyear.
Hospitalizations Emergencydepartmentvisits
β(95%CI) p β(95%CI) pReceiptofanywraparoundserviceintheprioryear -0.07(-0.12,-0.02) 0.006 -0.05(-0.09,-0.02) 0.003Severityscore 0.66(0.63,0.69) <0.001 0.52(0.51,0.54) <0.001AnnualnumberofencountersHospitalizations -- 0.03(0.01,0.04) <0.001EDvisits 0.01(0.00,0.02) 0.008 --Outpatientvisits 0.01(0.01,0.02) <0.001 0.01(0.00,0.01) <0.001Specialtycarevisits 0.03(0.03,0.03) <0.001 0.01(0.00,0.01) 0.016
Patientfixedeffectsregressionmodelswithyeardummiesomittedforreadability.
![Page 17: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/17.jpg)
Limitations
• Generalizability– Single,safety-netinstitution– Wraparoundservicesofferedonaco-locatedbasis(maynotapplytoorganizationsrelyingonreferrals)
• Reductionsmaybeattributabletootherqualityimprovementactivitiesoccurringatthesametime
• Resultsdonotprovideinsightsastotherelativevalueofeachservice
![Page 18: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/18.jpg)
Receiptofanywraparoundservicewasassociatedwitha7%lowercountofhospitalizations&a5%lowercountofEDvisitsinthesubsequentyear.
• Aportfolioofwraparoundservicesmaybeaneffectivestrategyfororganizationsservingacomplexpatientpopulations.
• Wraparoundservicecouldcomplementhealthinformationexchange,riskstratification,orcross-sectoralcollaborations.
![Page 19: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/19.jpg)
Sohowcanwebettersupportefficientandeffectiveuseofwraparoundservices?
![Page 20: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/20.jpg)
Anywraparoundreferralrisk
scoreBehavioralhealth
referralriskscore
Dietitianreferralrisk
scoreSocialworkreferralrisk
score
Claims&EHR
Diagnoses&Utilization
Machinelearningalgorithmstoidentifythoseinneedofwraparoundservices.
ArearesourcesLivingconditionsSocialcontextSafetyTransport
nationswell.com
www.citygalleryindy.org
NeighborhoodriskbehaviorsChronicdiseases
AdditionalhealthbehaviorsUtilizationatotherproviders
![Page 21: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/21.jpg)
![Page 22: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/22.jpg)
Automatedprocesstoprovideriskstratificationinformation.
5:00AM
Beforeclinicsopen
![Page 23: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/23.jpg)
Researchquestion:
Doesriskstratifyingpatientsaccordingtowraparoundserviceneeds:1. Increasereferrals2. Increasekeptappointment(i.e.betteruptake)
Approach:
Pragmatictrialusingastepped-wedgedesign
![Page 24: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/24.jpg)
Riskstratificationwasrolledout3clinicsatatimefromJulytoNovember2017.
August September October November December JanuaryJulyJune
3cliniclocationsliveBaseline
3cliniclocationsliveBaseline
3cliniclocationsliveBaseline
![Page 25: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/25.jpg)
Measures&analyses
• Exposure:– Riskstratificationcategoryforeachservice
![Page 26: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/26.jpg)
80%ofthepopulationhasaprobability<0.19
95%ofthepopulationhasaprobability<0.27
RisingRisk
HighRiskLowRisk
![Page 27: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/27.jpg)
Measures&analyses
• Exposure:– Riskstratificationcategoryforeachservice
• High• Rising• Low• Samedayappointments• Controlsite(referencegroup)
![Page 28: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/28.jpg)
Measures&analyses
• Exposure:– Riskstratificationcategory(high,rising,low,sameday,none)
• Covariates– Demographics(e.g.gender,age,race/ethnicity)– Location– Comorbidityscores
• Analysis– GeneralizedEstimatingEquation(GEE)logisticregressionmodelsforeach
wraparoundservice(accountsforrepeatedpatientobservation)– Keptappointmentsonlyforpatientswithreferrals– NonequivalentDV(HealthyMe)
![Page 29: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/29.jpg)
Interventionwasnotassociatedwithincreasedreferralsforanyservice.
Interventionwasassociatedwithincreasedreferralstosocialworkers
Suggestsnobroadchangestogeneralreferralpracticesintheclinics.
Forsaydayappointments(whennoscoreavailable)referralsarelesslikely• Workflowissue?• Samedaymorelikelytobeacutecondition?
![Page 30: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/30.jpg)
Generalincreaseinkeptappointmentsoncepatientswerereferredtoservices.• Evenwithsomeindicationsofdose
response(notoversellingpilot!)
![Page 31: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/31.jpg)
AutomatedriskstratificationscoressuccessfullydeliveredtoEskenaziHealthprimarycareclinics.
• Interventionassociatedwithincreasedreferralsforsocialworkers.
• Interventionassociatedwithincreasedratesofkeptappointmentsformultiplesocialdeterminantsofhealthservices.
• Nextstep:putitintoEPIC
JoshuaRVest,PhD,[email protected]@JoshuaRVest
![Page 32: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/32.jpg)
Upcoming Webinars
Archives http://systemsforaction.org/research-progress-webinars
UpcomingJanuary23,2019,12p.m., ETSystemsforActionIndividualResearchProjectImplementingaCultureofHealthamongDelaware'sProbationPopulationDanielJ.O'Connell,PhD,DepartmentofCriminalJustice,UniversityofDelaware
February13,2019,12p.m.,ETSystemsforActionIntramuralResearchProjectTBAGlenP.Mays,PhD,MPH,andCBMamaril,PhD,SystemsforActionNationalProgramOffice,UniversityofKentuckyCollegeofPublicHealth
February27,2019,12p.m., ETSystemsforActionIndividualResearchProjectHousingforHealth:Cross-SectorImpactsofSupportiveHousingforHomelessHighUsersofHealthCareRicardoBasurtoDavila,PhD,MS,ChiefExecutiveOfficer,PolicyAnalysisUnit,LosAngelesCo.DepartmentofPublicHealthandCorrinBuchanan,MPP,ProgramManager,HousingforHealth,LosAngelesCo.DepartmentofPublicServices
![Page 33: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/33.jpg)
Questions?
www.systemsforaction.org
![Page 34: Improving Population and Clinical Health with Integrated ...systemsforaction.org/sites/...IU_Vest_FinalSlides... · Indiana University Richard M Fairbanks School of Public Health](https://reader035.vdocument.in/reader035/viewer/2022062403/6057186b77e1a020b301b6ea/html5/thumbnails/34.jpg)
Acknowledgements
Systems for Action is a National Program Office of the Robert WoodJohnson Foundation and a collaborative effort of the Center for Public HealthSystems and Services Research in the College of Public Health, and theCenter for Poverty Research in the Gatton College of Business and Economics,administered by the University of Kentucky, Lexington, Ky.
and