Showing papers by "Marshall H. Chin published in 2023"

Improving Diabetes Care Through Population Health Innovations and Payments: Lessons from Western Maryland

Abstract: Global budgets might incentivize healthcare systems to develop population health programs to prevent costly hospitalizations. In response to Maryland's all-payer global budget financing system, University of Pittsburgh Medical Center (UPMC) Western Maryland developed an outpatient care management center called the Center for Clinical Resources (CCR) to support high-risk patients with chronic disease.Evaluate the impact of the CCR on patient-reported, clinical, and resource utilization outcomes for high-risk rural patients with diabetes.Observational cohort study.One hundred forty-one adult patients with uncontrolled diabetes (HbA1c > 7%) and one or more social needs who were enrolled between 2018 and 2021.Team-based interventions that provided interdisciplinary care coordination (e.g., diabetes care coordinators), social needs support (e.g., food delivery, benefits assistance), and patient education (e.g., nutritional counseling, peer support).Patient-reported (e.g., quality of life, self-efficacy), clinical (e.g., HbA1c), and utilization outcomes (e.g., emergency department visits, hospitalizations).Patient-reported outcomes improved significantly at 12 months, including confidence in self-management, quality of life, and patient experience (56% response rate). No significant demographic differences were detected between patients with or without the 12-month survey response. Baseline mean HbA1c was 10.0% and decreased on average by 1.2 percentage points at 6 months, 1.4 points at 12 months, 1.5 points at 18 months, and 0.9 points at 24 and 30 months (P<0.001 at all timepoints). No significant changes were observed in blood pressure, low-density lipoprotein cholesterol, or weight. The annual all-cause hospitalization rate decreased by 11 percentage points (34 to 23%, P=0.01) and diabetes-related emergency department visits also decreased by 11 percentage points (14 to 3%, P=0.002) at 12 months.CCR participation was associated with improved patient-reported outcomes, glycemic control, and hospital utilization for high-risk patients with diabetes. Payment arrangements like global budgets can support the development and sustainability of innovative diabetes care models.

New Frontiers in Diabetes Care: Quality Improvement Study of a Population Health Team in Rural Critical Access Hospitals

Abstract: Rural populations are older, have higher diabetes prevalence, and have less improvement in diabetes-related mortality rates compared to urban counterparts. Rural communities have limited access to diabetes education and social support services. Determine if an innovative population health program that integrates medical and social care models improves clinical outcomes for patients with type 2 diabetes in a resource-constrained, frontier area. Quality improvement cohort study of 1764 patients with diabetes (September 2017–December 2021) at St. Mary’s Health and Clearwater Valley Health (SMHCVH), an integrated health care delivery system in frontier Idaho. The United States Department of Agriculture’s Office of Rural Health defines frontier as sparsely populated areas that are geographically isolated from population centers and services. SMHCVH integrated medical and social care through a population health team (PHT), where staff assess medical, behavioral, and social needs with annual health risk assessments and provide core interventions including diabetes self-management education, chronic care management, integrated behavioral health, medical nutritional therapy, and community health worker navigation. We categorized patients with diabetes into three groups: patients with two or more PHT encounters during the study (PHT intervention), one PHT encounter (minimal PHT), and no PHT encounters (no PHT). HbA1c, blood pressure, and LDL over time for each study group. Of the 1764 patients with diabetes, mean age was 68.3 years, 57% were male, 98% were white, 33% had three or more chronic conditions, and 9% had at least one unmet social need. PHT intervention patients had more chronic conditions and higher medical complexity. Mean HbA1c of PHT intervention patients significantly decreased from baseline to 12 months (7.9 to 7.6%, p < 0.01) and sustained reductions at 18 months, 24 months, 30 months, and 36 months. Minimal PHT patients decreased HbA1c from baseline to 12 months (7.7 to 7.3%, p < 0.05). The SMHCVH PHT model was associated with improved hemoglobin A1c among less well-controlled patients with diabetes.

Trust Dynamics of Community Health Workers in Frontier Food Banks and Pantries: a Qualitative Study

Abstract: Medical mistrust has had devastating consequences during the COVID-19 pandemic, particularly in rural communities. Community Health Workers (CHWs) have been shown to build trust, but there is little research on trust-building by CHWs in rural communities.This study aims to understand the strategies that CHWs use to build trust with participants of health screenings in frontier Idaho.This is a qualitative study based on in-person, semi-structured interviews.We interviewed CHWs (N=6) and coordinators of food distribution sites (FDSs; e.g., food banks and pantries) where CHWs hosted a health screening (N=15).Interviews were conducted with CHWs and FDS coordinators during FDS-based health screenings. Interview guides were initially designed to assess facilitators and barriers to health screenings. Trust and mistrust emerged as dominant themes that determined nearly every aspect of the FDS-CHW collaboration, and thus became the focus of interviews.CHWs encountered high levels of interpersonal trust, but low institutional and generalized trust, among the coordinators and clients of rural FDSs. When working to reach FDS clients, CHWs anticipated confronting mistrust due to their association with the healthcare system and government, especially if CHWs were perceived as "outsiders." Hosting health screenings at FDSs, which were trusted community organizations, was important for CHWs to begin building trust with FDS clients. CHWs also volunteered at FDS locations to build interpersonal trust before hosting health screenings. Interviewees agreed that trust building was a time- and resource-intensive process.CHWs build interpersonal trust with high-risk rural residents, and should be integral parts of trust building initiatives in rural areas. FDSs are vital partners in reaching low-trust populations, and may provide an especially promising environment to reach some rural community members. It is unclear whether trust in individual CHWs also extends to the broader healthcare system.

What Should Antiracist Payment Reform Look Like?

Abstract: Racism reduces eligibility for health insurance and access to high-quality care for people of color in the United States, and current payment structures exacerbate the resultant de facto racial segregation. Payers and health plans do not adequately support and incentivize clinicians and health care delivery organizations to meet the health needs of minoritized communities. This article describes foundational work needed to create an antiracist culture of equity; the Roadmap to Advance Health Equity; and specific, actionable antiracist payment reform strategies, including increasing access to and the scope of health insurance coverage, antiracism accountability in managed-care contracts, support for the safety-net system, strengthened nonprofit hospital tax status requirements, and payment incentives to advance health equity. Antiracist payment reforms have great potential to desegregate health care systems and to ensure that everyone has a fair opportunity to receive good health services and optimize their health.

Integrated Interventions to Bridge Medical and Social Care for People Living with Diabetes

Abstract: Social drivers of health impact health outcomes for patients with diabetes, and are areas of interest to health systems, researchers, and policymakers. To improve population health and health outcomes, organizations are integrating medical and social care, collaborating with community partners, and seeking sustainable financing with payors. We summarize promising examples of integrated medical and social care from the Merck Foundation Bridging the Gap: Reducing Disparities in Diabetes Care initiative. The initiative funded eight organizations to implement and evaluate integrated medical and social care models, aiming to build a value case for services that are traditionally not eligible for reimbursement (e.g., community health workers, food prescriptions, patient navigation). This article summarizes promising examples and future opportunities for integrated medical and social care across three themes: (1) primary care transformation (e.g., social risk stratification) and workforce capacity (e.g., lay health worker interventions), (2) addressing individual social needs and structural changes, and (3) payment reform. Integrated medical and social care that advances health equity requires a significant paradigm shift in healthcare financing and delivery.

Opportunities for psychologists to advance health equity: Using liberation psychology to identify key lessons from 17 years of praxis.

Abstract: Health and health care inequities persist because the efforts to eliminate them have ignored structural racism, typically using a power neutral approach to diagnose and solve the problem. Critical theory can address many of the conceptual weaknesses of current approaches, help identify how racism operates in health care, and open the door for more effective individual employee and organizational actions to advance health equity. We apply Martín-Baró's (1996) liberation psychology to lessons we learned through implementing a transdisciplinary national health and health care equity program. The program, which began in 2005, conducts equity-focused health services interventions and research, using the best available evidence to assist health and health care policymakers, payers, community-based organizations, care delivery organizations, and patients to transform and align their activities in order to advance health equity. It serves as a rare model to explore how misconceptions resulting from racist structures can hinder progress, even when everyone involved is highly motivated to address health and health care inequities. Liberation psychology guides our interpretation of the lessons learned and recommendations for the field of psychology. Psychologists advancing equity in health and health care should integrate liberation psychology and other critical theories into their own work. In addition, partnerships with other disciplines and communities outside of academia and professional health services are key to success. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Exploring the Value of Improvisational Theater in Medical Education for Advancing the Doctor–Patient Relationship and Health Equity

Abstract: Purpose Health care inequities persist, and it is difficult to teach health professions students effectively about implicit bias, structural inequities, and caring for patients from underrepresented or minoritized backgrounds. Improvisational theater (improv), where performers create everything in a spontaneous and unplanned manner, may help teach health professions trainees about advancing health equity. Core improv skills, discussion, and self-reflection can help improve communication; build trustworthy relationships with patients; and address bias, racism, oppressive systems, and structural inequities. Method Authors integrated a 90-minute virtual improv workshop using basic exercises into a required course for first-year medical students at University of Chicago in 2020. Sixty randomly chosen students took the workshop and 37 (62%) responded to Likert-scale and open-ended questions about strengths, impact, and areas for improvement. Eleven students participated in structured interviews about their experience. Results Twenty-eight (76%) of 37 students rated the workshop as very good or excellent, and 31 (84%) would recommend it to others. Over 80% of students perceived their listening and observation skills improved, and that the workshop would help them take better care of patients with experiences different than their own. Six (16%) students experienced stress during the workshop but 36 (97%) felt safe. Eleven (30%) students agreed there were meaningful discussions about systemic inequities. Qualitative interview analysis showed that students thought the workshop helped develop interpersonal skills (communication, relationship building, empathy); helped personal growth (insights into perception of self and others, ability to adapt to unexpected situations); and felt safe. Students noted the workshop helped them to be in the moment with patients and respond to the unexpected in ways more traditional communication curricula have not. The authors developed a conceptual model relating improv skills and equity teaching methods to advancing health equity. Conclusions Improv theater exercises can complement traditional communication curricula to advance health equity.

Advancing health equity through partnerships of state Medicaid agencies, Medicaid managed care organizations, and health care delivery organizations

Abstract: Background Reducing health inequities in marginalized populations, including people with Medicaid insurance, requires care transformation to address medical and social needs that is supported and incentivized by tailored payment methods. Collaboration across health care stakeholders is essential to overcome health system fragmentation and implement sustainable reform in the United States (U.S.). This paper explores how multi-stakeholder teams operationalized the Roadmap to Advance Health Equity model during early stages of their journey to (a) build cultures of equity and (b) integrate health equity into care transformation and payment reform initiatives. Methods Advancing Health Equity: Leading Care, Payment, and Systems Transformation is a national program in the U.S. funded by the Robert Wood Johnson Foundation that brings together multi-stakeholder teams to design and implement initiatives to advance health equity. Each team consisted of representatives from state Medicaid agencies, Medicaid managed care organizations, and health care delivery organizations in seven U.S. states. Between June and September 2021, semi-structured interviews were conducted with representatives (n = 23) from all seven teams about experiences implementing the Roadmap to Advance Health Equity model with technical assistance from Advancing Health Equity. Results Facilitators of building cultures of equity included (1) build upon preexisting intra-organizational cultures of equity, (2) recruit and promote diverse staff and build an inclusive culture, and (3) train staff on health equity and anti-racism. Teams faced challenges building inter-organizational cultures of equity. Facilitators of identifying a health equity focus area and its root causes included (1) use data to identify a health equity focus and (2) overcome stakeholder assumptions about inequities. Facilitators of implementing care transformation and payment reform included (1) partner with Medicaid members and individual providers and (2) support and incentivize equitable care and outcomes with payment. Facilitators of sustainability planning included (1) identify evidence of improved health equity focus and (2) maintain relationships among stakeholders. Teams faced challenges determining the role of the state Medicaid agency. Conclusions Multi-stakeholder teams shared practical strategies for implementing the Roadmap to Advance Health Equity that can inform future efforts to build intra- and inter-organizational cultures of equity and integrate health equity into care delivery and payment systems.