Contingent engagement: What we learn from patients with complex health problems and low socioeconomic status

Komaromy, Miriam; Madden, Erin Fanning; Zurawski, Andrea; Kalishman, Summers; Barker, Kristin K.; O’Sullivan, Patricia; Jurado, Martin; Arora, Sanjeev

doi:10.1016/j.pec.2017.08.019

Cited by 15 publications

(18 citation statements)

References 32 publications

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“…Previous research has shown that patients often defer responsibility for decision making to their doctor and take a passive role in their health care [50]. This is particularly true for individuals of lower SES, who are more likely to have low levels of health literacy [51–54], lower levels of engagement [55], greater trust in physician expertise [50, 56], and less involvement in decision-making [55]. Our study does not allow us to make any broad conclusions regarding family physicians’ knowledge and attitudes towards midwifery care; however, previous research has found a lack of understanding and trust in the education and scope of practice of midwives [57–59].…”

Section: Discussionmentioning

confidence: 99%

Access to midwifery care for people of low socio-economic status: a qualitative descriptive study

Darling

Grenier

Nussey

et al. 2019

BMC Pregnancy Childbirth

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BackgroundDespite public funding of midwifery care, people of low-socioeconomic status are less likely to access midwifery care in Ontario, Canada, but little is known about barriers that they experience in accessing midwifery care. The purpose of this study was to examine the barriers and facilitators to accessing midwifery care experienced by people of low-socioeconomic status.MethodsA qualitative descriptive study design was used. Semi-structured interviews were conducted with 30 pregnant and post-partum people of low-socioeconomic status in Hamilton, Ontario from January to May 2018. Transcribed interviews were coded using open coding techniques and thematically analyzed.ResultsWe interviewed 13 midwifery care recipients and 17 participants who had never received care from midwives. Four themes arose from the interviews: “I had no idea…”, “Babies are born in hospitals”, “Physicians as gateways into prenatal care”, and “Why change a good thing?”. Participants who had not experienced midwifery care had minimal knowledge of midwifery and often had misconceptions about midwives’ scope of practice and education. Prevailing beliefs about pregnancy and birth, particularly concerns about safety, drove participants to seek care from a physician. Physicians are the entry point into the health care system for many, yet few participants received information about midwifery care from physicians. Participants who had experienced midwifery care found it to be an appropriate match for the needs of people of low socioeconomic status. Word of mouth was a primary source of information about midwifery and the most common reason for people unfamiliar with midwifery to seek midwifery care.ConclusionsAccess to midwifery care is constrained for people of low-socioeconomic status because lack of awareness about midwifery limits the approachability of these services, and because information about midwifery care is often not provided by physicians when pregnant people first contact the health care system. For people of low-socioeconomic status, inequitable access to midwifery care may be exacerbated by lack of knowledge about midwifery within social networks and a tendency to move passively through the health care system which traditionally favours physician care. Targeted efforts to address this issue are necessary to reduce disparities in access to midwifery care.

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Section: Discussionmentioning

confidence: 99%

Access to midwifery care for people of low socio-economic status: a qualitative descriptive study

Darling

Grenier

Nussey

et al. 2019

BMC Pregnancy Childbirth

View full text Add to dashboard Cite

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“…The predominance of applications originating from Medicaid members has historically been attributed to the socioeconomic barriers faced by many who are eligible for government assistance. Challenges that include limited access to healthy food, a negative environment, and detrimental behavior are more prevalent among population that is eligible for Medicaid . Surprisingly, we observed that the proportions of applications for bariatric surgery are similar between Medicaid members and members enrolled in commercial insurance.…”

Section: Discussionmentioning

confidence: 59%

“…Challenges that include limited access to healthy food, a negative environment, and detrimental behavior are more prevalent among population that is eligible for Medicaid. 4,5 Surprisingly, we observed that the proportions of applications for bariatric surgery are similar between Medicaid members and members enrolled in commercial insurance. We plan to delve further into this finding by examining approval rates among the populations and overall health status of applicants at the time of application.…”

Section: Discussionmentioning

confidence: 77%

Enhancing knowledge of authorization requests through registry development

Kuntz-Melcavage

Gahagan

Fracasso

et al. 2017

Learning Health Systems

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Understanding the member population to which medical coverage policies apply is important for ensuring the relevance of a health insurer's policies. The medical policy unit of our company developed a registry and workflow to enhance our knowledge about the members who seek authorization for bariatric surgery. Data captured in the registry have allowed us to construct a descriptive profile of the entire population that seeks bariatric surgery (both members who are approved and members who are denied). In addition, we have examined characteristics associated with denied authorization requests, determined the proportion of requests originating from specific insurance products, and studied the relationship between results on a specific laboratory test and authorization decisions. Given the growing importance of data in the realm of health care management, this article is an important demonstration of how data can be used to understand populations of members who are affected by medical policies. and medical policies, with each insurer developing its own companyspecific policies. It is essential that medical coverage policies be written in a manner that promotes the best health for insured members while aligning with the mission of a company. Sometimes, there is insufficient evidence on a new procedure or drug to know for sure which patients will benefit from it most and which may not benefit at all.As part of an academic health system, our organization strives to maximize the knowledge obtained from data we collect. Current research in the industry relies heavily on administrative claims 1,2 that are useful for providing data about use and costs. However, there are other sources of information that can be informative to medical policy decisions that remain largely untapped. Claims data do not contain information that is submitted as part of pre-authorization requests (such as clinical measurements and laboratory values). Additionally, data from claims do not contain information about members who were denied authorization for a procedure. A source of data beyond claims can be helpful for providing a more complete profile of a member population seeking services. We are currently working to expand knowledge at the juncture between the medical-policy setting and the subset of members who are affected by coverage decisions. The mechanism we have chosen to increase our knowledge in this area is the development of registries.The need for a registry to record member-level information surrounding certain procedures first became apparent, as the medical policy unit at our company planned a revision to the coverage policy for bariatric surgery. Anecdotal stories and opinions about bariatric surgery were prevalent, but no one was able to provide information derived from an aggregate collection of authorization requests.To address the uncertainty about details contained in requests for bariatric surgery, we developed a registry of bariatric surgery requests containing data to inform future policy decisions. The registry r...

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“…These findings are complemented by a qualitative analysis of patient experiences with ECHO Care, in which enrollment correlated with improved trust in their healthcare providers and improvements in patient health behaviors. 13 Several factors should be considered when replicating ECHO Care. To maximize cost-effectiveness, ECHO Care teams should either begin small-with one NP/PA and one CHW-and grow as the patient panel grows or ensure that a full patient panel is enrolled at launch.…”

Section: Discussionmentioning

confidence: 99%

“…Teams' ability to provide home-based care was strengthened by the CHWs, who spent extended time with patients to address their social needs as a foundation for further engagement in care. 13 In addition to an intensive, in-person training, OITs were supported using the ECHO model, which connected them to a multidisciplinary team of specialists in weekly videoconferenced teleECHO™ sessions. The Complex Care teleECHO provided OITs with expert advice on complex topics using case-based mentoring.…”

Section: The Echo Care Interventionmentioning

confidence: 99%

A Novel Intervention for High-Need, High-Cost Medicaid Patients: a Study of ECHO Care

et al. 2019

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BACKGROUND: A small number of high-need patients account for a disproportionate amount of Medicaid spending, yet typically engage little in outpatient care and have poor outcomes. OBJECTIVE: To address this issue, we developed ECHO (Extension for Community Health Outcomes) Care™, a complex care intervention in which outpatient intensivist teams (OITs) provided care to high-need high-cost (HNHC) Medicaid patients. Teams were supported using the ECHO model™, a continuing medical education approach that connects specialists with primary care providers for casebased mentoring to treat complex diseases. DESIGN: Using an interrupted time series analysis of Medicaid claims data, we measured healthcare utilization and expenditures before and after ECHO Care. PARTICIPANTS: ECHO Care served 770 patients in New Mexico between September 2013 and June 2016. Nearly all had a chronic mental illness, and over three-quarters had a chronic substance use disorder. INTERVENTION: ECHO Care patients received care from an OIT, which typically included a nurse practitioner or physician assistant, a registered nurse, a licensed mental health provider, and at least one community health worker. Teams focused on addressing patients' physical, behavioral, and social issues. MAIN MEASURES: We assessed the effect of ECHO Care on Medicaid costs and utilization (inpatient admissions, emergency department (ED) visits, other outpatient visits, and dispensed prescriptions. KEY RESULTS: ECHO Care was associated with significant changes in patients' use of the healthcare system. At 12 months post-enrollment, the odds of a patient having an inpatient admission and an ED visit were each reduced by approximately 50%, while outpatient visits and prescriptions increased by 23% and 8%, respectively. We found no significant change in overall Medicaid costs associated with ECHO Care. CONCLUSIONS: ECHO Care shifts healthcare utilization from inpatient to outpatient settings, which suggests decreased patient suffering and greater access to care, including more effective prevention and early intervention for chronic conditions.

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Contingent engagement: What we learn from patients with complex health problems and low socioeconomic status

Cited by 15 publications

References 32 publications

Access to midwifery care for people of low socio-economic status: a qualitative descriptive study

Access to midwifery care for people of low socio-economic status: a qualitative descriptive study

Enhancing knowledge of authorization requests through registry development

A Novel Intervention for High-Need, High-Cost Medicaid Patients: a Study of ECHO Care

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