News and Notes

RAND final report on SAMHSA’s grant program for integrated care: In 2009, the Substance Abuse and Mental Health Services Administration (SAMHSA) created the Primary and Behavioral Health Care Integration (PBHCI) grant program to address excess morbidity and mortality among people with serious mental illness. The program supports an array of coordinated primary care services in community behavioral health settings. Currently, 100 community agencies have received PBHCI grants. The RAND Corporation has just released a final report of its evaluation of PBHCI processes, outcomes, and model features. Overall, the evaluation found wide variation in the service infrastructures and packages that grantees implemented for consumers enrolled in the program. A comparative effectiveness study found that PBHCI consumers improved on some but not all health indicators. Compared with consumers at control clinics, PBHCI consumers showed improvements in diastolic blood pressure, total cholesterol, LDL cholesterol, and fasting plasma glucose; however, there were no differences in self-reported smoking, body mass index, systolic blood pressure, HDL cholesterol, hemoglobin A1c, and triglycerides. Several program features had an impact on access to integrated care, such as the number of days per week that a primary care clinic was open and whether the integrated care staff met regularly. However, access was not clearly associated with health outcomes. The 139-page report, which is available on the SAMHSA Web site at www.integration.samhsa.gov, concludes with suggestions for improving systems of integrated care for this population and for designing future evaluations.

USICH updates the Federal Strategic Plan to Prevent and End Homelessness: The U.S. Interagency Council on Homelessness (USICH) has released an update to the Federal Strategic Plan to Prevent and End Homelessness, a comprehensive initiative announced by the Obama Administration in June 2010. The 35-page update, Opening Doors, highlights the momentum generated over the past three years by the 19 federal agencies that constitute USICH. The U.S. Department of Housing and Urban Development’s Point-in-Time count, compiled on a single night in January 2013, indicated that homelessness overall declined by 6% since 2010, and for the first time, reductions were noted across all subpopulations. Between 2010 and 2013, homelessness among people in family households declined by more than 8%, and chronic homelessness fell by nearly 16%. Notably, homelessness has decreased among veterans by 24%. The report describes USICH agencies’ key activities in five areas that have led to positive outcomes. The report highlights a growing body of evidence for the effectiveness of rapid rehousing, an approach in which families receive assistance quickly and are able to regain both a place to live and control of their lives in a short time. Several federal agencies have joined forces to promote expansion of rapid rehousing as a part of communities’ crisis response systems. The report is available on the USICH Web site at www.usich.gov.

Kaiser Commission analysis of new data on Medicaid enrollment under the ACA: Data recently released by the Centers for Medicare and Medicaid Services (CMS) provide new insight into how the Affordable Care Act (ACA) is affecting Medicaid enrollment. As of March 2014, enrollment grew by more than 4.8 million people, compared with average monthly enrollment in the three months before the health insurance marketplaces opened in October 2013. An issue brief from the Kaiser Commission on Medicaid and the Uninsured takes a closer look at data not previously available to policy makers that CMS began to publish monthly in April 2014. The new data address a broad set of performance indicators for Medicaid and for the Children’s Health Insurance Program that are designed to improve management and oversight of these programs. Enrollment growth in states that have expanded Medicaid coverage outpaced the national average and was significantly higher than growth in states deciding not to expand (12.9% versus 2.6%). However, data needed for the key measure of ACA’s success—the change in the number of uninsured—will not be available for many months. To address the absence of data in the near term, the Kaiser Foundation has released a 16-page data note describing interim sources of data—largely, private and federal surveys—that policy analysts can use to examine changes in insurance coverage. Both documents are available on the Kaiser Foundation site at www.kff.org.

Components of disease management programs for integrated care: A new technical assistance brief from CMS’s Integrated Care Resource Center (ICRC) highlights best practices in disease management and care management programs and describes ways that states can incorporate these practices and principles into integrated care models, such as CMS’s financial alignment models for dually eligible Medicaid and Medicare beneficiaries and other state initiatives for high-cost, high-need Medicaid beneficiaries. Since the first disease management program was introduced nearly 30 years ago, research has shown that instead of targeting a single diagnosis, such programs must address multiple comorbid diseases and must manage the needs of a person across a range of health and social service settings. The six-page CMS issue brief highlights nine key components of disease management programs. For example, effective programs target their efforts to those most likely to benefit; ensure in-person contact between beneficiaries and care managers, rather than relying on telephone contacts; require that the composition of care management teams meets the needs of enrollees; promote self-care; and foster interactions between care managers and providers. The technical assistance brief is available on the ICRC Web site at www.integratedcareresourcecenter.net/icmprogramdesign.aspx.

Overcoming barriers to integrating care in rural areas: States seeking to promote better coordination of care, either within Medicaid or through participation in multipayer initiatives, will run into long-standing challenges to delivering care and promoting health in rural areas, where there are often notable disparities in access, health status, and infrastructure, compared with more urban settings. An issue brief from the National Academy for State Health Policy (NASHP) presents a set of action steps that states can use to design coordinated care programs based on initiatives in six states: Alabama, Colorado, Montana, New Mexico, North Carolina, and Vermont. For example, a first step is to survey the existing infrastructure in the state’s rural areas to identify key resources: qualified providers, trained care coordinators to help patients navigate systems of care, and health information technology tools that facilitate information sharing. In this way, some states have been able to create successful rural programs by pulling together a “hodge-podge” of organizations and relying on incremental implementation, particularly to allow time for recruitment of qualified personnel. Officials in all six states described in the issue brief affirmed that even though greater local autonomy will come at the expense of standardization of care coordination approaches, it is critical to grant local entities the flexibility to develop tailored coordination strategies. The nine-page brief, Realizing Rural Care Coordination: Considerations and Action Steps for State Policy-Makers, is available on the NASHP Web site at www.nashp.org.

AHRQ guide to development of registries to evaluate patient outcomes: The Agency for Healthcare Research and Quality (AHRQ) has issued the third edition of Registries for Evaluating Patient Outcomes: A User's Guide. The guide is intended to support the design, implementation, analysis, interpretation, and quality evaluation of registries created to increase understanding of patient outcomes. It defines a patient registry as an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure and that serves one or more predetermined scientific, clinical, or policy purposes. Registries are classified according to how their populations are defined. For example, health services registries compile data for patients who have had a common procedure, clinical encounter, or hospitalization. Disease or condition registries are defined by patients who have the same diagnosis. The book is divided into two volumes. Volume 1 (342 pages) includes the first three sections: Creating Registries; Legal and Ethical Considerations for Registries; and Operating Registries. Volume 2 (295 pages) includes Technical, Legal, and Analytic Considerations for Combining Registry Data With Other Data Sources; Special Applications in Registries; and Evaluating Registries. Real-world contemporary case examples are provided to illustrate key principles of registry design, operation, and evaluation and to demonstrate various strategies and perspectives to address common challenges. Both volumes are available on the AHRQ site at www.effectivehealthcare.ahrq.gov.

New ranking of 30 largest ACOs: The marketing contacts firm SK&A has released a new ranking of the nation's 30 largest accountable care organizations (ACOs), based on the total number of affiliated physicians. Topping the list are Partners Healthcare, based in Boston; Valley Preferred Aetna, Allentown, Pennsylvania; and Hill Phys/Dignity Health/UCSF Health Net, San Ramon, California. As described in the SK&A report, an ACO is defined as a joint venture between physicians, medical groups, clinics, health systems, hospitals, and, in many cases, insurance companies. ACOs provide coordinated care to a population of patients with the goal of creating efficiencies, reducing costs, and decreasing errors. SK&A identified 537 ACOs in the United States, with a total of 289,000 health care providers and business personnel. The ranking list provides information on the ACO’s location, the total number of facilities and physicians involved, and the type of ACO. SK&A classifies ACOs into five categories: Medicare shared savings (MSS) programs coordinate care for Medicare fee-for-service beneficiaries; commercial ACOs are distinct from Medicare ACOs in that a commercial payer, rather than Medicare, is the entity providing financial incentives; “look-alike” ACOs contract with commercial plans in a model similar to other ACOs but do not contract with Medicare; Medicaid ACOs employ a fee-for-service arrangement through Medicaid; and pioneer ACOs are for early adopters of coordinated care that take on more risk than the MSS model. The SK&A report is available at www.skainfo.com/health_care_market_reports/ACO_Top30.pdf.

AHRQ brief on adult hospital readmissions by payer: Among adult Medicaid patients, the three conditions with the largest number of hospital readmissions in 2011 were mood disorders, schizophrenia, and diabetes. These conditions resulted in about $839 million in hospital costs. Among the privately insured, the top three conditions were maintenance chemotherapy, mood disorders, and complications of surgical or medical care, resulting in about $785 million in costs. These data are from a recent analysis of readmissions data from AHRQ’s Healthcare Cost and Utilization Project that identified conditions with the largest number of 30-day all-cause readmissions among U.S. hospitals in 2011. Overall, there were approximately 3.3 million such readmissions in 2011, and they were associated with about $41.3 billion in hospital costs. The brief is available on the AHRQ Web site at www.hcup-us.ahrq.gov.