Integrating Health And Human Services In California’s Whole Person Care Medicaid 1115 Waiver Demonstration

Chuang, Emmeline; Pourat, Nadereh; Haley, Leigh Ann; O’Masta, Brenna; Albertson, Elaine Michelle; Lu, Connie

doi:10.1377/hlthaff.2019.01617

Cited by 25 publications

(15 citation statements)

References 8 publications

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“…[21,23,26,[35][36][37][38] Furthermore, this work is underscored by new reimbursement approaches prioritizing value and incentivizing health plans and systems to more holistically address social and medical needs, reduce healthcare disparities, and build infrastructural and organizational capacity for structural change. [24,25,27] Limitations. study population was comprised of patients from only one healthcare system in San…”

Section: Discussionmentioning

confidence: 99%

“…[21][22][23] Financial incentive structures and value-based payment models have emphasized population and public health. [24,25] Often, this focus on SDOH has increased the screening and referral for social resources for patient populations, and documenting these actions within electronic health records (EHRs). [23,26,27] However, most health systems have not effectively leveraged EHRs to understand the impact of place, speci cally patient residence, on patient health outcomes.…”

Section: Introductionmentioning

confidence: 99%

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Integrating geo-linked electronic health records with neighborhood data to identify place-based barriers for diabetes management in a public healthcare system

Desai

Nguyen

Inamdar

et al. 2021

Preprint

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Background Despite the body of research on place-based disparities in diabetes, there is room for advancing methods in this space by leveraging multiple datasets, including population census and clinical datasets. Specifically, healthcare systems can leverage geo-linked electronic health records (EHRs) to investigate geospatial clustering and identify social determinants of health. Methods We examined geographic clustering of poor diabetes control and corresponding structural and social determinants of health within San Francisco’s safety-net healthcare system. Specifically, we used EHR data to identify individual patient-level addresses and clinical outcomes for diabetes, using hot spot analysis to determine significant hot and cold clusters of diabetes control throughout San Francisco. In addition, by linking patient addresses to public datasets, we described the neighborhood-level conditions associated with hot spots. Results Our hot spot analysis showed 18.8% of patients with poor glycemic control (n = 2,126) clustered in hot spots, and 12.8% of patients with controlled diabetes clustered in cold spots. Neighborhoods of patients in hot spots had more Black, Latinx, Native American, and Native Hawaiian or Pacific Islander residents and more residents receiving SNAP benefits, experiencing unemployment, food insecurity, greater rent burden, and low grocery store access. Conclusions We present methodological advantages of hotspot analyses utilizing EHR data, as well as the value of combining these approaches with additional public population census data about neighborhood conditions. Moving forward, healthcare systems must partner with public health agencies to utilize EHR data as a means to evaluate structural interventions and eventually target investment in place-based health-enabling resources.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Integrating geo-linked electronic health records with neighborhood data to identify place-based barriers for diabetes management in a public healthcare system

Desai

Nguyen

Inamdar

et al. 2021

Preprint

View full text Add to dashboard Cite

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“…Integration of medical, behavioral and social health are becoming increasingly needed in order to coordinate care, particularly among high risk populations. 32 Linking MPCs with health care providers offers an opportunity for MPCs to refer their older adult client population to local health care providers who may play a critical role in improving their health. Though older adults interviewed indicated they already had primary care providers and were reluctant to make a change, 10.9% of those surveyed indicated receiving the care they needed, but without a regular provider.…”

Section: Discussionmentioning

confidence: 99%

Evaluation of Recruitment of Older Adults of Color into a Community-Based Chronic Disease Self-Management Wellness Pathway Program in Los Angeles County

Marshall¹,

Carrillo

Reyes

et al. 2020

Ethn Dis

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Background: Established relationships between researchers, stakeholders and potential participants are integral for recruitment of potential older adult participants and Evidence-Based Programs (EBPs) for chronic disease management have empirically been shown to help improve health and maintain healthy and active lives. To accelerate recruitment in EBPs and potential future research, we propose a Wellness Pathway allowing for delivery within multipurpose senior centers (MPCs) linked with medical facilities among lower-income urban older adults. The study aims were to: 1) assess the effectiveness of three MPC-delivered EBPs on disease management skills, health outcomes, and self-efficacy; and 2) assess the feasibility of the proposed Wellness Pathway for lower-income urban-dwelling older adults of color.Methods: We administered surveys and conducted a pre-post analysis among participants enrolled in any 1 of 3 MPC-based EBPs (n=53). To assess feasibility of the pathway, we analyzed survey data and interviews (EBP participants, MPC staff, physicians, n=10).Results: EBP participation was associated with greater disease management skills (increased time spent stretching and aerobic activity) but not improvements in self-efficacy or other health outcomes. Interviews revealed: 1) older adults valued EBPs and felt the Wellness Pathway feasible; 2) staff felt it feasible given adequate growth management; 3) physicians felt it feasible provided adequate medical facility integration.Conclusion: MPC-based EBPs were associated with improvements in disease management skills among older adults; a proposed Wellness Pathway shows early evidence of feasibility and warrants further investigation. Future efforts to implement this model of recruiting older adults of color into EBPs should address barriers for implementation and sustainability. Ethn Dis. 2020;30(Suppl 2):735-744; doi:10.18865/ed.30.S2.735

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“…[22][23][24][25] However, other clinically significant results, including a decrease in unnecessary care utilization or improvement in chronic care conditions, are inconsistent or have not been consistently obtained. 22,23,26,27 True patient-centered outcomes, the primary objective of care integration, are less often assessed. If we accept patient-centered care to mean "the experience (to the extent the informed, individual patient desires it) of transparency, individualization, recognition, respect, dignity, and choice in all matters, without exception, related to one's person, circumstances, and relationships in health care," 28 then patients must be viewed as active participants in their own care, and outcomes must be obtained from the patients themselves.…”

Section: Integrated Carementioning

confidence: 99%

“…For example, both California and Missouri developed Medicaid-sponsored WPC programs to meet the needs of their high-risk, high-utilizing populations. 24,26 Regrettably, despite their monikers, neither states' program reaches the SAMHSA ideal of fully integrated care.…”

Section: Integrated Carementioning

confidence: 99%

Disrupting the System: An Innovative Model of Comprehensive Care

Conley¹,

Judge-Ellis²

2021

The Journal for Nurse Practitioners

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Despite health care reform, our nation continues to struggle containing health care costs while meeting the needs of persons with behavioral health disorders and comorbid chronic care conditions. The purpose of this article is to propose that dually certified primary care and psychiatric mental health nurse practitioners may be the disruptive innovation that becomes the solution for improving the coordination and care for high-need patients while containing costs. The concepts of disruptive innovation, integrated care, and whole person care are discussed followed by an introduction to the innovative primary care and psychiatric mental health nurse practitioner's role and its potential for health care system disruption. Finally, a call to nursing is proffered to seize current opportunities to meet the Triple Aim challenge by providing whole person care that is highquality, cost-effective, and satisfactory to patients because it is truly patient centered and meets their needs.

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Integrating Health And Human Services In California’s Whole Person Care Medicaid 1115 Waiver Demonstration

Cited by 25 publications

References 8 publications

Integrating geo-linked electronic health records with neighborhood data to identify place-based barriers for diabetes management in a public healthcare system

Integrating geo-linked electronic health records with neighborhood data to identify place-based barriers for diabetes management in a public healthcare system

Evaluation of Recruitment of Older Adults of Color into a Community-Based Chronic Disease Self-Management Wellness Pathway Program in Los Angeles County

Disrupting the System: An Innovative Model of Comprehensive Care

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