Home-Based Primary Care and the Risk of Ambulatory Care–Sensitive Condition Hospitalization Among Older Veterans With Diabetes Mellitus

Edwards, Samuel T.; Prentice, Julia C.; Simon, Steven R.; Pizer, Steven D.

doi:10.1001/jamainternmed.2014.4327

Cited by 60 publications

(71 citation statements)

References 33 publications

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“…Taking into account available resources, adults with a risk score at the top 10% from the risk algorithm were considered high-risk adults for targeting the home-based primary care delivered by a multidisciplinary team (nurse practitioner, social worker, dietitian, and community health worker) over a period of up to 2 years. The home-based care was designed to improve diabetes care, especially for low-income patients with multi-comorbidities (De Jonge et al, 2014; Edwards et al, 2014; Yaggy et al, 2006). …”

Section: Methodsmentioning

confidence: 99%

Substance use disorders and medical comorbidities among high-need, high-risk patients with diabetes

Ghitza

Zhu

et al. 2018

Drug and Alcohol Dependence

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Background The majority of the U.S. healthcare resources are utilized by a small population characterized as high-risk, high-need persons with complex care needs (e.g., adults with multiple chronic conditions). Substance use disorders (SUDs) and mental health disorders (MHDs) are a driver of poor health and additional healthcare costs, but they are understudied among high-need patients. Objective We examine the prevalence and correlates of SUDs and MHDs among adults with high-risk diabetes, who are patients at the top 10% risk score for developing poor outcomes (hospital admission or death). Methods A risk algorithm developed from Duke University Health System electronic health records (EHRs) data was used to identify patients with high-risk diabetes for targeting home-based primary care. The EHR data of the 263 patients with high-risk diabetes were analyzed to understand patterns of SUDs and MHDs to inform care-coordinating efforts. Results Both SUDs (any SUD 48.3%, alcohol 12.5%, tobacco 38.8%, drug 23.2%) and MHDs (any MHD 74.9%, mood 53.2%, sleep 37.3%, anxiety 32.7%, schizophrenia/psychotics/delusional 14.8%, dementia/delirium/amnestic/cognitive 14.4%, adjustment 9.1%) were prevalent. Overall, 81.7% of the sample had SUD or MHD. Elevated odds of SUD were noted among men (tobacco, alcohol) and those who were never-married (alcohol, cannabis). African-American race (vs. other race/ethnicity) was associated with lower odds of anxiety disorders. Conclusion While data are limited to one large academic health system, they provide clinical evidence revealing that 82% of patients with high-risk diabetes had SUD and/or MHD recorded in their EHRs, highlighting a need for developing service models to optimize high-risk care.

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Section: Methodsmentioning

confidence: 99%

Substance use disorders and medical comorbidities among high-need, high-risk patients with diabetes

Ghitza

Zhu

et al. 2018

Drug and Alcohol Dependence

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“…Effectively managed home care improves the QOL of both patients and their caregivers, and it is also associated with good prognoses and the preservation of cognitive and physical function (8)(9)(10)(11). In a 2014 study, older adults who had their home care needs met reported higher levels of life satisfaction and lower levels of loneliness and perceived life stress compared to patients with unmet needs (12).…”

Section: Introductionmentioning

confidence: 99%

Risk factors for the discontinuation of home medical care among low-functioning older patients

Umegaki

Asai²,

Kanda³

et al. 2016

The Journal of nutrition, health and aging

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“…Home-based primary care is considered in these high-risk patients, since this care model combines traditional clinical care for medical needs with team-based care management, self-care education, and care coordination. Home-based primary care may reduce unnecessary hospitalizations and enhance coordination of social support services and referrals to specialty clinics [38,39]. Consequently, the SBIRT intervention is conducted in the participants' home.…”

Section: Methodsmentioning

confidence: 99%

Using electronic health record data for substance use Screening, Brief Intervention, and Referral to Treatment among adults with type 2 diabetes: Design of a National Drug Abuse Treatment Clinical Trials Network study

Brady

Spratt

et al. 2016

Contemporary Clinical Trials

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Background The Affordable Care Act encourages healthcare systems to integrate behavioral and medical healthcare, as well as to employ electronic health records (EHRs) for health information exchange and quality improvement. Pragmatic research paradigms that employ EHRs in research are needed to produce clinical evidence in real-world medical settings for informing learning healthcare systems. Adults with comorbid diabetes and substance use disorders (SUDs) tend to use costly inpatient treatments; however, there is a lack of empirical data on implementing behavioral healthcare to reduce health risk in adults with high-risk diabetes. Given the complexity of high-risk patients' medical problems and the cost of conducting randomized trials, a feasibility project is warranted to guide practical study designs. Methods We describe the study design, which explores the feasibility of implementing substance use Screening, Brief Intervention, and Referral to Treatment (SBIRT) among adults with high-risk type 2 diabetes mellitus (T2DM) within a home-based primary care setting. Our study includes the development of an integrated EHR datamart to identify eligible patients and collect diabetes healthcare data, and the use of a geographic health information system to understand the social context in patients' communities. Analysis will examine recruitment, proportion of patients receiving brief intervention and/or referrals, substance use, SUD treatment use, diabetes outcomes, and retention. Discussion By capitalizing on an existing T2DM project that uses home-based primary care, our study results will provide timely clinical information to inform the designs and implementation of future SBIRT studies among adults with multiple medical conditions.

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Home-Based Primary Care and the Risk of Ambulatory Care–Sensitive Condition Hospitalization Among Older Veterans With Diabetes Mellitus

Cited by 60 publications

References 33 publications

Substance use disorders and medical comorbidities among high-need, high-risk patients with diabetes

Substance use disorders and medical comorbidities among high-need, high-risk patients with diabetes

Risk factors for the discontinuation of home medical care among low-functioning older patients

Using electronic health record data for substance use Screening, Brief Intervention, and Referral to Treatment among adults with type 2 diabetes: Design of a National Drug Abuse Treatment Clinical Trials Network study

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