Showing papers in "Population Health Management in 2019"

Recent Patterns of Multimorbidity Among Older Adults in High-Income Countries.

Abstract: Population aging along with the rising burden of chronic medical conditions (CMCs) is challenging the sustainability of health care systems globally. The authors sought to characterize contemporary patterns of multimorbidity among older adults (aged ≥65 years) in high-income countries (HICs). Medline, EMBASE, CINAHL, PsycINFO, and Web of Science were searched in January 2018 for English-language articles that reported the prevalence of multimorbidity (defined as co-occurrence of ≥2 CMCs in an individual without defining an index disease) among older adults in HICs, or the proportions with ≥3 or ≥5 CMCs. Only studies that utilized data collected during January 2007-December 2017 were included. A total of 52 articles (45 studies) that reported data among >60 million older adults in 30 HICs were included. The overall prevalence of multimorbidity was 66.1% (interquartile range [IQR] 54.4-76.6). The multimorbidity prevalence increased with age as well as with the number of CMCs included in the assessment. The prevalence of ≥3 or ≥5 CMCs was 44.2% (IQR 34.0-70.3) and 12.3% (IQR 8.7-19.1), respectively. The multimorbidity prevalence was also higher among females as well as among studies using care-based data rather than self-reported data. The prevalence of hypertension, dyslipidemia, diabetes, pain disorders, depression, heart failure, cancer, and dementia among the older adults was 60.6%, 51.2%, 25.2%, 34.0%, 12.0%, 14.0%, 8.6%, and 8.4%, respectively. The available data suggest a high prevalence of multimorbidity among older adults. There is a need for increased research into understanding the causal mechanisms that underlie multimorbidity toward supporting the development of cost-effective interventions. In addition, the study results reiterate the need for preventive health care to move beyond targeting single diseases in favor of directing efforts toward reducing overall morbidity among this population.

Transforming Diabetes Care Through Artificial Intelligence: The Future Is Here.

Abstract: An estimated 425 million people globally have diabetes, accounting for 12% of the world's health expenditures, and yet 1 in 2 persons remain undiagnosed and untreated. Applications of artificial intelligence (AI) and cognitive computing offer promise in diabetes care. The purpose of this article is to better understand what AI advances may be relevant today to persons with diabetes (PWDs), their clinicians, family, and caregivers. The authors conducted a predefined, online PubMed search of publicly available sources of information from 2009 onward using the search terms "diabetes" and "artificial intelligence." The study included clinically-relevant, high-impact articles, and excluded articles whose purpose was technical in nature. A total of 450 published diabetes and AI articles met the inclusion criteria. The studies represent a diverse and complex set of innovative approaches that aim to transform diabetes care in 4 main areas: automated retinal screening, clinical decision support, predictive population risk stratification, and patient self-management tools. Many of these new AI-powered retinal imaging systems, predictive modeling programs, glucose sensors, insulin pumps, smartphone applications, and other decision-support aids are on the market today with more on the way. AI applications have the potential to transform diabetes care and help millions of PWDs to achieve better blood glucose control, reduce hypoglycemic episodes, and reduce diabetes comorbidities and complications. AI applications offer greater accuracy, efficiency, ease of use, and satisfaction for PWDs, their clinicians, family, and caregivers.

Systematic Review of Community Paramedicine and EMS Mobile Integrated Health Care Interventions in the United States

Abstract: Emergency medical services (EMS) in the United States are frequently used for nonurgent medical needs. Use of 911 and the emergency department (ED) for primary care-treatable conditions is expensive, inefficient, and undesirable for patients and providers. The objective is to describe the outcomes from community paramedicine (CP) and mobile integrated health care (MIH) interventions related to the Quadruple Aim. Three electronic databases were searched for peer-review literature on CP-MIH interventions in the United States. Eight articles reporting data from 7 interventions were included. Four studies reported high levels of patient satisfaction, and only 3 measured health outcomes. No study reported provider satisfaction measures. Reducing ED and inpatient utilization were the most common study outcomes, and programs generally were successful at reducing utilization. With reduced utilization, costs should be reduced; however, most studies did not quantify savings. Future studies should conduct economic analyses that not only compare the intervention to traditional EMS services, but also measure potential cost savings to the EMS agencies running the intervention. Most cost savings from reduced utilization will be to insurance companies and patients, but more efficient use of EMS agencies' resources could lead to cost savings that could offset intervention implementation costs. The other 3 aims (health, patient satisfaction, and provider satisfaction) were reported inconsistently in these studies and need to be addressed further. Given the small number of heterogeneous studies reviewed, the potential for CP-MIH interventions to comprehensively address the Quadruple Aim is still unclear, and more research on these programs is needed.

Racial/Ethnic and Socioeconomic Disparities in Total Knee Arthroplasty 30- and 90-Day Readmissions: A Multi-Payer and Multistate Analysis, 2007-2014.

Abstract: Previous studies have addressed racial/ethnic and socioeconomic disparities in total knee arthroplasty (TKA) within the Medicare population. However, there is limited research examining these disparities across racial/ethnic and socioeconomic groups in the general population. This study used administrative data from the State Inpatient Databases from the Healthcare Cost and Utilization Project for the years 2007-2014 from California (2007-2011 only), Florida, New York, and Maryland (2012-2014 only). In all, 739,857 TKA readmission-eligible patients aged ≥8 years were included in the analysis. Black patients and patients with Medicaid had a higher likelihood of 30- and 90-day readmissions compared to white patients and patients with private insurance, respectively. Patients living in higher median income areas and patients treated at higher volume hospitals had lower likelihoods of 30- and 90-day readmissions compared to patients in the lowest median income quartile and patients treated at the lowest volume hospitals, respectively. These results confirmed racial/ethnic and socioeconomic disparities in TKA readmissions across 4 geographically diverse states, identified public insurance status as the salient factor across subpopulations, and raise awareness of the existence of these disparities outside of the Medicare population.

The Case for Patient Navigation in Lung Cancer Screening in Vulnerable Populations: A Systematic Review

Abstract: Patient navigation has been proposed to combat cancer disparities in vulnerable populations. Vulnerable populations often have poorer cancer outcomes and lower levels of screening, adheren...

Trends in Publications on Medical Cannabis from the Year 2000.

Abstract: Widespread use of cannabis as a drug and passage of legislation on its use should lead to an increase in the number of scientific publications on cannabis. The aim of this study was to compare trends in scientific publication for papers on medical cannabis, papers on cannabis in general, and all papers between the years 2000 and 2017. A search of PubMed and Web of Science was conducted. The overall number of scientific publications in PubMed increased 2.5-fold. In contrast, the number of publications on cannabis increased 4.5-fold and the number of publications on medical cannabis increased almost 9-fold. The number of publications on medical cannabis in Web of science increased even more (10-fold). The most significant number of publications was in the field of psychiatry. In the fields of neurology and cancer treatment there was a significant increase in the years 2011-2013. There was a rise in the number of publications on children and the elderly after 2013. The specific indications with the largest number of publications were HIV (261), chronic pain (179), multiple sclerosis (118), nausea and vomiting (102), and epilepsy (88). More than half of the publications on medical cannabis originated from the United States, followed by Canada. More than 66% of the publications were original studies. The spike in the number of scientific publications on medical cannabis since 2013 is encouraging. In light of this trend the authors expect an even greater increase in the number of publications in this area in coming years.

Developmental Disorders and Medical Complications Among Infants with Subclinical Intrauterine Opioid Exposures.

Abstract: The objective was to compare diagnosis rates representing developmental outcomes and medical complications between infants with intrauterine opioid exposures who did not receive pharmacolo...

Complexities of Addressing Food Insecurity in an Urban Population.

Abstract: There is an association between food insecurity, poor health outcomes, and increased health care spending. The Temple Food Insecurity Program was initiated to screen patients for food inse...

Integration of Buprenorphine Treatment with Primary Care: Comparative Effectiveness on Retention, Utilization, and Cost.

Abstract: Opioid use disorder (OUD) is a national crisis. Health care must achieve greater success than it has to date in helping opioid users achieve recovery. Integration of comprehensive primary ...

Engaging Primary Care Providers to Reduce Unwanted Clinical Variation and Support ACO Cost and Quality Goals: A Unique Provider-Payer Collaboration.

Abstract: This project was undertaken to reduce unneeded variation among practicing primary care clinicians participating in an accountable care organization (ACO) and to raise quality and reduce costs. This real-world, quasi-controlled experiment compared ACO target improvements between 3 participating geographic regions and members within the ProHealth ACO against nonparticipating regions and members. The authors used a novel care standardization initiative to engage participating providers. This was a 2-year longitudinal study with 6 rounds of serially measured provider care decisions and customized individual and group improvement feedback. Participating providers cared for online patient simulations as they would actual patients, and their care decisions were scored against evidence-based guidelines. This approach generated significant increases in evidence-based quality scores (+27%) and reductions in unneeded testing (-55%) in the patient simulations. Improvements in the online simulated patients correlated with improvements in patient-level ACO quality measures, which showed gains above and beyond the quasi-control group. Reductions calculated for spending on unneeded tests and specialist referrals exceeded $4.8 million. This study found that supporting practicing physicians in ACOs with evidence-based feedback significantly improved care and cost-efficiency.

Association of Resilience and Social Networks with Pain Outcomes Among Older Adults.

Abstract: Depression, stress, and poor sleep have been associated with increased pain among older adults; positive resources, such as resilience and social networks, may help to buffer the impacts o...

Association Between Community Social Capital and Hospital Readmission Rates.

Abstract: Hospital readmissions remain frequent, and are partly attributable to patients' social needs. The authors sought to examine whether local community levels of social capital are associated with hospital readmission rates. Social capital refers to the connections among members of a society that foster norms of reciprocity and trust, which may influence the availability of support for postdischarge recovery after hospitalization. Associations between hospital-wide, risk-stratified readmission rates for hospitals in the United States (n = 4298) and levels of social capital in the hospitals' service areas were examined. Social capital was measured by an index of participation in associational activities and civic affairs. A multivariate linear regression model was used to adjust for hospital and community factors such as hospital financial performance, race, income, and availability of heath care services. Results showed that higher social capital was significantly associated with lower readmission ra...

Mechanisms Associated with Clinical Improvement in Interventions That Address Health-Related Social Needs: A Mixed-Methods Analysis.

Abstract: Linking individuals to community resources in order to help meet health-related social needs, such as food, medications, or transportation, may improve clinical outcomes. However, little i...

Nursing Home Compare Star rankings and the variation in potentially preventable emergency department visits and hospital admissions.

Abstract: Measurement of the quality of US health care increasingly emphasizes clinical outcomes over clinical processes. Nursing Home Compare Star Ratings are provided by Medicare to help select better nursing home care. The authors determined the rates and types of 2 important clinical outcomes-potentially preventable hospital admissions and potentially preventable emergency department (ED) visits-for a subset of 439,011 long-term nursing homes residents residing in 12,883 nursing homes throughout the United States over a 2-year period (2010-2011) and compared them with the Star Rating system. This study found that (1) the likelihood of potentially preventable events increases with increasing burden of chronic illness, (2) the principle reasons for hospital admissions and ED visits (eg, septicemia, pneumonia, confusion, gastroenteritis) are not part of existing nursing home quality measures, (3) the rate of potentially preventable admissions and ED visits for nursing homes residents varies greatly both across and within states, with 5 states having in excess of 20% more than the national average for both, and (4) the Nursing Home Compare Stars measure has limited correlation with rates of these potentially preventable events. Nursing Home Compare Star rankings could benefit by incorporating outcomes measures such as preventable hospitalizations and ED visits, and by comparing nursing home performance on results drawn from across states rather than within them. Such reform could better help users find nursing homes of higher quality and stimulate homes to improve quality in ways that benefit residents.

Framework for Evaluating Workplace Health Promotion in a Health Care Delivery Setting.

Abstract: This case study describes a multistage approach applied to evaluation of an employee wellness program at Northwell Health. The paper describes a framework that other large employers may adopt in their wellness program evaluations. Evaluators worked with Northwell to develop, tailor, and apply a structure-process-outcome framework aligned with the organization's specific goals. Analyses of structural, process, and outcome variables will provide Northwell with valuable information about strengths and weaknesses of its wellness program. The measurement and evaluation framework can serve as a model for businesses aspiring to improve their workplace programs. This framework provides businesses with the opportunity to analyze key elements that need to be addressed collectively to gain a complete picture of program implementation processes and subsequent health and business outcomes.

Unmet Need for Care Coordination Among Children with Special Health Care Needs.

Abstract: Socioeconomic disparities in access to care coordination have been noted among children with special health care needs (CSHCN). Following recent policy developments and technological innov...

Evaluating the Impact of Year-Long, Augmented Diabetes Self-Management Support.

Abstract: This was a randomized controlled study to test a scalable intervention model addressing the need for ongoing diabetes support. The study included individuals receiving care in a Federally Qualified Health Center (FQHC) with HbA1c >8. The aim of this project was to determine whether augmenting diabetes self-management education (DSME) with support for an economically vulnerable population might better meet patient needs and reduce morbidity and premature mortality. The intervention utilized pre and post comparisons and was designed to test the efficacy of a telephonic diabetes support intervention to increase patient engagement in self-care and with the health care system as a means to improve clinical outcomes. There were significant improvements in HbA1c, body mass index, low-density lipoprotein cholesterol, triglycerides, and depression screening scores in the year following DSME. However, there was no statistically significant difference between the 2 groups. This randomized controlled study demonstrated that comprehensive face-to-face care with consistent assessment and documentation over time in FQHCs produce clinically significant and predictable improvement for people with diabetes. The addition of structured provision of telephonic support overlapping in time with the comprehensive face-to-face process of care in this environment did not produce statistically significant clinical or behavioral care improvement.

Underutilization of Statin Therapy for Secondary Prevention of Cardiovascular Disease Among Older Adults.

Abstract: Secondary cardiovascular disease (CVD) clinical trials have demonstrated that higher intensity levels of statin therapy are more effective than lower levels in reducing mortality rates. De...

Prioritizing Population Approaches in Cancer Prevention and Control: Results of a Case Study Evaluation of Policy, Systems, and Environmental Change.

Abstract: Development and implementation of policy, systems, and environmental (PSE) change is a commonly used public health approach to reduce disease burden. The Centers for Disease Control and Prevention's National Comprehensive Cancer Control Program conducted a demonstration with 13 programs to determine whether and to what extent dedicated resources would enhance the adoption of PSE strategies. This paper describes results of the qualitative portion of a longitudinal, mixed-methods evaluation of this demonstration. Case studies were conducted with a diverse subset of the 13 programs, and 106 in-depth interviews were completed with state/tribal program staff, community partners, and decision makers. Interviews addressed PSE change planning and capacity building, partnerships, local context, and how programs achieved PSE change. Dedicated PSE resources, including a policy analyst, helped increase PSE change capacity, intensify focus on PSE change overall, and accomplish specific PSE changes within individual jurisdictions. Stakeholders described PSE change as a gradual process requiring preparation and prioritization, strategic collaboration, and navigation of local context. Findings suggest that the demonstration program, including PSE-dedicated funds and a policy analyst, was successful in both increasing PSE change capacity and achieving PSE change itself. These results may be useful to other state, tribal, territorial, and public health organizations planning or implementing PSE change strategies.

Health Care System Factors Associated with Transition Preparation in Youth with Special Health Care Needs.

Abstract: The aim of this study was to assess: (1) the proportion of youth with special health care needs (YSHCN) with adequate transition preparation, (2) whether transition preparation differs by individual, condition-related and health care system-related factors, and (3) whether specific components of the medical home are associated with adequate transition preparation. The authors conducted a cross-sectional analysis of the 2009-2010 National Survey of Children with Special Health Care Needs, which surveyed a nationally representative sample of 17,114 parents of YSHCN ages 12 to 18 years. Adequate transition preparation was based on positive responses to questions about transition to an adult provider, changing health care needs, maintaining insurance coverage, and if providers encouraged YSHCN to take responsibility for health care needs. Weighted descriptive, bivariate and multivariate analyses were conducted to determine the association between patient and health care system factors and adequate transition preparation. Overall, 32.1% of YSHCN had adequate transition preparation. Older age, female sex, income ≤400% of the poverty level, lack of medical complexity, and having shared decision making, family-centered care, and effective care coordination were associated with increased odds of transition preparation. The majority of YSHCN do not receive adequate transition preparation and younger, male adolescents with medical complexity were less likely to receive transition preparation. Different patterns of disparities were identified for each subcomponent measure of transition preparation, which may help target at-risk populations for specific services. Efforts to improve transition preparation should leverage specific components of the medical home including care coordination, shared decision making, and family-centered care.

The Importance of Rural Hospitals: Transfers and 30-day Readmissions Among Rural Residents and Patients Presenting at Rural Hospitals.

Abstract: The purpose was to examine factors associated with transfers and readmissions among Medicare patients initially presenting at rural facilities. Data from the 2013 Medicare Claims file were used to identify fee-for-service patients with a hospital admission (n = 298,783) or an emergency department visit immediately followed by a hospital admission (117,416), for a total of 416,199. Transfers were defined as hospitalization at a different facility within 1 day of a discharge from a prior inpatient or emergency department encounter. For analysis of 30-day readmission, beneficiaries who died before discharge were excluded, for a total of 416,198 observations. Overall, 4.8% of index encounters resulted in a transfer. The transfer rate was higher for patients living in rural areas (9.8%, P < 0.0001), with the highest among residents of small rural areas (10.1%). The transfer rate was higher among those initial encounters in an urban facility (5.3%) than those admitted to a rural facility (2.7%, P < 0.0001). In adjusted analysis, beneficiaries with index encounters in rural or critical access facilities had higher odds of being transferred than those seen at urban facilities. The 30-day readmission rate was lower among patients presenting initially at rural versus urban hospitals (12.1% versus 19.2%). Although transfer status slightly increased the odds of rehospitalization in adjusted analysis, initial presentation at a rural facility was associated with reduced odds. The relatively high rate of transfers from rural hospitals to urban institutions suggests that systems must ensure that their patients' follow-up care meets their needs.

Effect of Patient Care Coordination on Hospital Encounters and Related Costs

Abstract: Given high costs of hospital encounters, providers have increasingly turned to patient-centered health care programs to improve cost-effectiveness and population health for patients with high needs. Yet, evidence is mixed about program effectiveness. This pre-post comparative analysis assessed whether the number of hospital encounters and related costs decreased for patients who received care coordination services funded through Texas's 1115(a) Medicaid waiver incentive-based payment model, under which providers created new programs to improve care quality, population health, and cost-effectiveness. This study compared hospital records for patients who were frequent emergency department users at 4 urban safety net hospitals in Texas and state data for hospital encounters for the calendar years 2013 through 2015. The study included 9061 patients who frequently used emergency departments: 4117 patients who received waiver-funded care coordination services at 2 hospitals and 4944 patients who received usual care at 2 comparison hospitals. Regression models compared changes in patients' hospital use and length of stay for the 2 groups. Patients receiving waiver-funded care coordination had a 19% lower probability of hospitalization after receiving care coordination relative to patients who received usual care, for a mean savings of approximately $1500 per year per patient. Receiving care coordination was not associated with a change in length of stay. Care coordination developed by hospitals to meet the needs of their most vulnerable patients can reduce their use of hospital resources through better preventive care. These findings bolster the business case for care coordination, which may help ensure service continuation.

Integrating social and behavioral determinants of health into population health analytics: A conceptual framework and suggested road map

Abstract: There is growing recognition that social and behavioral risk factors impact population health outcomes. Interventions that target these risk factors can improve health outcomes. This study presents a review of existing literature and proposes a conceptual framework for the integration of social and behavioral data into population health analytics platforms. The authors describe several use cases for these platforms at the patient, health system, and community levels, and align these use cases with the different types of prevention identified by the Centers for Disease Control and Prevention. They then detail the potential benefits of these use cases for different health system stakeholders and explore currently available and potential future sources of social and behavioral domains data. Also noted are several potential roadblocks for these analytic platforms, including limited data interoperability, expense of data acquisition, and a lack of standardized technical terminology for socio-behavioral factors.

Health Care Access Barriers Bring Children to Emergency Rooms More Frequently: A Representative Survey

Abstract: Children may visit the emergency department (ED) regularly in part because they and their caregivers may be experiencing barriers to appropriate and timely pediatric care. However, assessi...

Risk Reduction Research Initiative: A National Community–Academic Framework to Improve Health and Social Outcomes

Abstract: The American health care system is costly and underperforms compared to health care systems in other developed countries. In our view, one reason for this poor performance is that our health system does not identify and address the full range of risks affecting health and socioeconomic outcomes. As our health care system is transitioning from a fee-for-service to a value-based payment approach, there are opportunities to improve effectiveness and reduce costs. To achieve better health outcomes, our health system should comprehensively address medical, social, and behavioral factors of risk. If this is done, policy makers and practitioners will be able to prioritize investments and interventions more effectively to address the most important risks contributing to health and other important socioeconomic outcomes. In this commentary, we present a research initiative framework to inform beneficial transformations in the American health and social service systems. It is predicated on the idea that there is a need for a more comprehensive approach to identify and address important individually modifiable factors of risk – particularly for at-risk individuals. The framework seeks to guide research to improve our understanding of risk factors, their interrelationships, and their relative impact on a range of specific outcomes, including medical outcomes such as disease control and hospitalization, as well as other critical socioeconomic outcomes such as school performance and employment. Building knowledge in these areas, we argue, is needed to increase the ability of policy makers and health professionals to improve health and other outcomes through more effective and efficient interventions, investments, and payment models. The Problem

Physician Characteristics and Decisions Regarding Cancer Screening: A Systematic Review.

Abstract: The guidelines provided by experts regarding various cancer screening tests are not universally accepted by physicians or patients. This systematic review describes the literature regarding the associations of physician characteristics with the implementation of and referral of patients for selected cancer screening tests. In October 2016, the authors conducted a thorough search of articles found in 4 databases, using keywords describing physician characteristics and cancer screening. English-language articles reporting on patient surveys or records of patients' screening history, and surveys of physicians' practices or opinions, in the United States were included. The physician characteristics most commonly analyzed were specialty and sex. The screening tests most commonly analyzed were those for cervical and colorectal cancers. Female and white physicians were found to screen more patients than male and nonwhite physicians. Obstetrician-gynecologists screened more for breast and cervical cancer than internists, who screened more than family or general practitioners. Physician sex, race, and specialty were consistently associated with cancer screening practices and should be the focus of efforts to harmonize practices with recommendations.

The Impact of the Patient-Centered Medical Home on Health Care Disparities: Exploring Stakeholder Perspectives on Current Standards and Future Directions.

Abstract: Over the past decade, the Patient-Centered Medical Home (PCMH) has become a preeminent model for primary care delivery. Simultaneously, health care disparities have gained increasing attention. There has been limited research on whether and how the PCMH can or should affect health care disparities. The authors conducted qualitative interviews with key stakeholders and experts on the PCMH model and health care disparities, including grant and policy makers, accreditors, researchers, patient advocates, primary care practices, practice transformation organizations, and payers, to assess perspectives on the role of the PCMH in addressing health care disparities. The application of grounded theory and thematic analysis elucidated best practice recommendations for the PCMH model's role in addressing health care disparities. Although the majority of stakeholders support greater integration of efforts to reduce health care disparities into the PCMH model, most stakeholders view the current PCMH model as having minimal or indirect influence on health care disparities. The majority supported greater integration of efforts to reduce health care disparities into the PCMH model. As the PCMH model continues to be refined, and as the health care system strives toward improving population health, there must be reflection on the policies and delivery systems that impact health care disparities.

Extent of Health Care Fragmentation in Different Payer Populations: Evidence from the Hudson Valley of New York.

Abstract: Health care fragmentation occurs when patients see multiple ambulatory providers, but no single provider accounts for a substantial proportion of visits. Most previous studies have measure...

Utilizing Community Health Needs Assessments (CHNAs) in Nonprofit Hospitals to Guide Population-Centered Outcomes Research for Pediatric Patients: New Recommendations for CHNA Reporting.

Abstract: Currently, Community Health Needs Assessment (CHNA) reports lack a standard structure, making it difficult to derive meaningful information. However, they have the potential to be a useful tool for analyzing pediatric outcomes, guiding resource allocation, and linking to Patient-Centered Outcomes Research Institute priorities. The objective was to evaluate the utility of CHNA for informing future pediatric, patient-centered outcomes research. The authors analyzed CHNA documents, published before July 1, 2016 by 61 nonprofit hospitals, focusing on 4 metropolitan areas in Florida: Miami, Orlando, Tampa, and Jacksonville. Out of 18 health priorities identified, access to care and obesity were universally recognized as the most urgent pediatric health needs across all hospital types and metropolitan regions. This analysis also yielded insights into key regional differences. The authors advocate that a major change in the CHNA format be implemented using a common set of domains to produce meaningful, interpretable, and comparable results that inform and guide patient-centered health outcomes research.

Impact of Health Care and Socioeconomic Needs on Health Care Utilization and Disease Management: The University of New Mexico Hospital Care One Program.

Abstract: Understanding how unmet basic needs impact health care in patients with complex conditions is vital to improve health outcomes and reduce health care costs. The purpose of this observation...