A prior randomized trial assessed three care management (CM) interventions that were designed for adults at high risk of negative health outcomes following a hospital admission and implemented by a large health plan. These CM interventions positively and equivalently impacted several patient-centered outcomes over time. Use the prior randomized trial as the basis for testing post-hospitalization utilization and cost impacts (1) across three CM models (primary analysis) and (2) for each CM model (secondary analysis). Post hoc comparison of three randomly assigned integrated CM interventions (IC) and a randomly selected, contemporaneous usual care control group (UC). Recently discharged high-risk Medicaid or dual-eligible Medicaid/Medicare members with multiple chronic conditions. Three CM interventions: high-tech (4–12 months of remote patient monitoring with video visits/condition-specific texts and telephonic visits; n = 365); high-touch (4–12 months of telephonic visits; n = 335); optimal discharge planning (ODP; 2–4 weeks of telephonic visits; n = 149). All three included an initial in-person visit. Ninety-day readmission and emergency department (ED) visit rates; 12-month member care costs (total, medical, pharmacy). UC had access to, but rarely used, traditional health plan CM. Compared to UC members (N = 886), IC members (N = 886) had similar total cost of care (p = 0.58). IC pharmacy costs trended 93.6

Introduction:To accelerate transformation toward value-based, equitable care, health systems need a viable approach for engaging and aligning multiple stakeholders to promote innovation. Building and sustaining learning communities offers one possible solution. Methods:We describe how one learning community has leveraged the collective strengths, assets, and expertise of multiple stakeholders to improve care value for subpopulations who experience low-quality, high-cost, and/or inequitable health outcomes. Results:By providing critical infrastructure and support, UPMC's Learning Community was able to (1) accelerate adoption of risk-based payment models that promote shared accountability among providers, payers, and families/caregivers for the total costs of care of children and adolescents with medically complex conditions, (2) drive widespread practice change for improving physical and mental wellness for individuals with serious mental illness, and (3) increase access to evidence-based treatment and improve outcomes for individuals with opioid and substance use disorders. Conclusions:Learning communities can serve as important catalyzers for the payment, practice, and service delivery innovation necessary to achieve a high-value, equitable health system.

Tobacco use among individuals with behavioral health conditions is higher than in the general population and a leading cause for morbidity and early mortality. This study examines a value-based payment (VBP) model to incentivize provision of tobacco cessation counseling (TCC) and pharmacological treatment with varenicline among 38 behavioral health homes (a person-centered approach to coordinating comprehensive healthcare in behavioral health service settings for individuals with chronic behavioral and physical health conditions) within a non-profit Medicaid behavioral health managed care network utilizing the Behavioral Health Home Plus (BHHP) model. Pre-post comparisons indicate that rates of filled varenicline prescriptions increased in the BHHP population from 10.01 per 1,000 service users to 19.01 per 1,000 service users following implementation of the VBP (p < .0001). Comparisons with other in-network behavioral health service users without BHHP or VBP indicate higher receipt of TCC (p < .0001) and varenicline (p < .0001) among the BHHP VBP group. This study provides some evidence that value-based purchasing may be used to incentivize provider agencies with behavioral health homes to increase access to tobacco cessation treatment for individuals with behavioral health conditions.

Many interventions implemented for multi-visit patients (MVP) have been developed to address patient-centric needs of these individuals and reduce unplanned care for ambulatory-sensitive conditions. More rigorous research is needed to better understand the impact of these interventions on changes in care utilization including unplanned care. To evaluate the impact of the Enhanced Care Program (ECP), a payer-provider collaborative model, on unplanned care use and cost of care. Using propensity methods, a comparison group was constructed using insurer membership files. Comparisons were performed using a difference-in-differences analysis. Patients enrolled in ECP through December 2019 were considered eligible for the study (n = 357). All patients had five or more ED visits in the past year or two or more inpatient hospitalizations in the past year prior to enrollment. ECP is a high-intensity outpatient intervention intended to reduce avoidable unplanned care such as ED visits and inpatient hospital stays through home visits, chronic/acute disease management, and intensive care coordination. The primary outcomes of interest were events per 100 members per year of ED use with return to home, unplanned inpatient and observational status admissions, and unplanned behavioral health inpatient admission, and cost of care per member per month. Overall total unplanned care encounters were significantly reduced with a difference-in-difference of 320 unplanned care encounters per 100 members per year in the intervention group (p < 0.05). The ECP group showed statistically significant decreases in costs of unplanned ED, unplanned observation admission, and unplanned inpatient behavioral medicine costs, but statistically significant increases in overall pharmacy costs and lab costs. Changes in total costs of care for the ECP group were not statistically different than the control group (p = 0.55). ECP showed significant reduction of unplanned care for MVP patients.

OBJECTIVE:To characterize patterns of health care utilization before and after surgery and determine any association with preoperative frailty.BACKGROUND:Frail patients experience worse postoperative outcomes and increased costs during the surgical encounter. Evidence is comparatively lacking for the longer-term effects of frailty on postoperative health care utilization.METHODS:Retrospective, longitudinal cohort analysis of adult patients undergoing any elective surgical procedure after preoperative frailty assessment with the Risk Analysis Index from February 2016 to December 2020 at a large integrated health care delivery and financing system. Group-based trajectory modeling of claims data estimated distinct clusters of patients with discrete utilization trajectories. Multivariable regression predicted membership in trajectories of interest using preoperative characteristics, including frailty.RESULTS:Among 29,067 surgical encounters, 4 distinct utilization trajectories emerged in longitudinal data from the 12 months before and after surgery. All cases exhibited a surge in utilization during the surgical month, after which most patients returned to "low" [25,473 (87.6%)], "medium" [1403 (4.8%)], or "high" [528 (1.8%)] baseline utilization states established before surgery. The fourth trajectory identified 1663 (5.7%) cases where surgery occasioned a transition from "low" utilization before surgery to "high" utilization afterward. Risk Analysis Index score alone did not effectively predict membership in this transition group, but a multivariable model with other preoperative variables was effective ( c = 0.859, max rescaled R2 = 0.264).CONCLUSIONS:Surgery occasions the transition from low to high health care utilization for a substantial subgroup of surgical patients. Multivariable modeling may effectively discriminate this utilization trajectory, suggesting an opportunity to tailor care processes for these patients.

Introduction: Most people with Type 2 DM receive care directed by their PCP and do not access endocrinologists. TACos are proactive e-consults that provide therapeutic treatment recommendations. Diabetes TACos have been implemented at University of Pittsburgh Medical Center (UPMC) PCP practices by a collaborative team of the Division of Endocrinology, Clinical Analytics, UPMC PCPs, and UPMC Health Plan. Our previous analysis showed significant HbA1c reduction 6 months following TACos. A 12-month evaluation of a larger patient population demonstrates even more positive outcomes. Methods: The analysis included 574 individuals who received a TACos (intervention) matched to 1722 controls based on clinical and demographic criteria. The intervention and control groups were matched using 3:1 optimal propensity score matching. Twelve-month changes in HbA1c and health care costs per member per month (PMPM) were evaluated using an observational matched design and intention-to-treat (ITT) analysis. Results: Sixty-five percent of the TACos recommendations were implemented by PCPs. Percent change in HbA1c in 12 months after TACos was significantly higher in the intervention group (-13.9%, p=0.0003) vs the control group (-10%). Median total cost PMPM in 12 months after TACos was significantly lower in the intervention group (-24%, p<0.001) vs the control group. Inpatient hospital and observation utilization were significantly lower and SGLT2/GLP1 utilization was significantly higher in the intervention group. Conclusion: Members who received TACos had higher percent reduction in HbA1c; lower total cost; lower inpatient admission and 30-day readmissions; and higher SGLT2/GLP1 utilization compared to comparison group. TACos can improve diabetes control and decrease medical costs for people with Type 2 DM whose care is managed by their PCP. Disclosure E. Karslioglu-French: Research Support; Abbott, Pfizer Inc. J. Kanter: None. M.E. Winger: None. K.R. Williams: None. T. Grumski: None. J. Schuster: None. E. Beckjord: None.

In the United States, many individuals with diabetes mellitus (DM) do not achieve treatment goals despite the availability of effective interventions. Provider clinical inertia is one cause of these unfavorable outcomes. Targeted automatic eConsults (TACos) are an emerging technology-based intervention with potential to address clinical inertia in primary care (PC). TACos prospectively identify at-risk patients and use unsolicited specialist recommendations to prompt treatment intensification. Through a payer-provider collaboration, a TACos intervention was piloted for adults with uncontrolled DM (HbA1c >8%) to understand impact on DM clinical inertia and outcomes. Clinical inertia was assessed by measuring whether a PC provider implemented recommended therapeutic changes. Six-month changes in HbA1c and health care costs per member per month were evaluated using an observational matched design and intention-to-treat (ITT) analysis. The analysis included 196 individuals who received a TACos between February 2021 and August 2021 (ITT group) matched to 392 controls based on clinical and demographic criteria. TACos recommendations were implemented 65% of the time. Median percent change in HbA1c was significantly greater for the ITT group versus controls (-10.9% vs. -10.2%; P = 0.0359). Median total costs were 7.9% lower in the ITT group (P = 0.0900). A per protocol analysis was done to examine effects between ITT group individuals with an implemented TACos recommendation (n = 126) and controls. Median percent change in HbA1c was significantly greater (-19.5% vs. -10.2%; P < 0.0001), but there was no difference in total costs (-7.9%; P = 0.1753). TACos may feasibly address clinical inertia in PC and improve HbA1c for uncontrolled DM.

A comprehensive, whole-person approach to individuals' health care can be achieved by aligning, integrating, and coordinating health services with other human services. HealthChoices, Pennsylvania's managed Medicaid program, delegates responsibility for Medicaid-funded behavioral health service management to individual counties or multicounty collaboratives. County administrators' programmatic and fiscal oversight of Medicaid-funded services allows them to create synergies between behavioral health and other human service delivery systems and to set priorities on the basis of local needs. This model supports access to community-based care, integration of general medical and behavioral health services, and programs that address social determinants of health.

The association between housing insecurity and reduced access to healthcare, diminished mental and physical health, and increased mortality is well-known. This association, along with structural racism, social inequities, and lack of economic opportunities, continues to widen the gap in health outcomes and other disparities between those in higher and lower socio-economic strata in the United States and throughout the advanced economies of the world. System-wide infrastructure failures at municipal, state, and federal government levels have inadequately addressed the difficulty with housing affordability and stability and its associated impact on health outcomes and inequities. Healthcare systems are uniquely poised to help fill this gap and engage with proposed solutions. Strategies that incorporate multiple investment pathways and emphasize community-based partnerships and innovation have the potential for broad public health impacts. In this manuscript, we describe a novel framework, "Give, Partner, Invest," which was created and utilized by the University of Pittsburgh Medical Center (UPMC) Insurance Services Division (ISD) as part of the Integrated Delivery and Finance System to demonstrate the financial, policy, partnership, and workforce levers that could make substantive investments in affordable housing and community-based interventions to improve the health and well-being of our communities. Further, we address housing policy limitations and infrastructure challenges and offer potential solutions.

Longitudinal cluster-randomized designs have been popular tools for comparative effective research in clinical trials. The methodologies for the three-level hierarchical design with longitudinal outcomes need to be better understood under more pragmatic settings; that is, with a small number of clusters, heterogeneous cluster sizes, and missing outcomes. Generalized estimating equations (GEEs) have been frequently used when the distribution of data and the correlation model are unknown. Standard GEEs lead to bias and an inflated type I error rate due to the small number of available clinics and non-completely random missing data in longitudinal outcomes. We evaluate the performance of inverse probability weighted (IPW) estimating equations, with and without augmentation, for two types of missing data in continuous outcomes and individual-level treatment allocation mechanisms combined with two bias-corrected variance estimators. Our intensive simulation results suggest that the proposed augmented IPW method with bias-corrected variance estimation successfully prevents the inflation of false positive findings and improves efficiency when the number of clinics is small, with moderate to severe missing outcomes. Our findings are expected to aid researchers in choosing appropriate analysis methods for three-level longitudinal cluster-randomized designs. The proposed approaches were applied to analyze data from a longitudinal cluster-randomized clinical trial involving adults with serious mental illnesses.

The present project utilized a Learning Collaborative (LC) to disseminate the Behavioral Health Home Plus (BHHP) physical-behavioral health integration model to providers serving two behavioral health populations at risk for adverse health conditions: youth psychiatric residential treatment facilities (five sites) and adult opioid treatment providers (seven sites). Following the positive results of a randomized controlled trial utilizing an LC to implement two behavioral health home models in community mental health provider organizations serving adults with serious mental illness, Community Care Behavioral Health Organization facilitated integration of the models to scale health and wellness supports to additional behavioral health care delivery settings. This paper presents provider results focused on BHHP implementation training, LC implementation, physical health and wellness promotion within sites, and BHHP model sustainment plans. Provider self-reported data indicate that the LC approach is a successful tool for integrating and sustaining BHHP model components in routine care.

Research ObjectiveBehavioral Health Home Plus (BHHP) is an evidence‐based model to enhance physical health and wellness for individuals with serious mental illness (SMI) and chronic medical conditions. To better understand model effectiveness and best practices for dissemination, we implemented BHHP in 7 adult Opioid Treatment Programs (OTP) and 5 youth Residential Treatment Facilities (RTF).Study DesignWe utilized a hybrid study design to examine dissemination and support of BHHP through a 12‐month Learning Collaborative (LC) and outcomes via propensity‐score matched analyses. Mixed methods included semi‐structured staff interviews and confidence surveys to assess feasibility. Data were collected on involvement/confidence in managing physical health (survey) and utilization of primary/specialty care and unplanned healthcare (claims) over 18‐months.Population StudiedIn Pennsylvania's Medicaid HealthChoices program, behavioral health agencies serve as health homes with support and training in wellness by a behavioral health managed care organization, Community Care Behavioral Health of the UPMC Insurance Services Division. Enrollment into BHHP for OTP included adults (n = 689), average age 39.19 ± 9.99 years, 60% female and youth (n = 354) for RTF, average age 14.04 ± 2.52 years, 31% female. Propensity score matching was successful for OTP (n = 688) and RTF (n = 312) members.Principal FindingsProviders reported barriers (training time, staff turnover, workflow integration, family engagement) and facilitators (model resources, education on population‐specific health topics, learning from other sites implementation experiences) to implementation. At 18‐month follow up, over 70% of staff reported being highly confident in working with individuals on physical health and wellness; over 60% of service‐users reported being highly involved in working with their behavioral health provider on physical health and wellness, and 67% of OTP and 43% of RTF service‐users reported being highly confident in their ability to manage their physical health and wellness.Service utilization outcomes showed large decreases over 18 months in medically emergent care for OTP members while rates remained steady for the matched comparison group (p = 0.0055); a similar pattern was found for medications for physical health chronic conditions (p < 0.0001). For OTP, more individuals remained connected to ambulatory substance use disorder services in the comparison group at 18 months. For RTF both intervention and comparison groups showed decreased behavioral health hospitalizations; however, a greater proportion of the intervention group remained connected to ambulatory psychiatric service at 18 months (62% v. 48%). The comparison group showed larger decreases in medically emergent care over time (p = 0.0186).ConclusionsSites have fully integrated the BHHP model into workflows and promote physical health and wellness amongst their complex and medically vulnerable populations. BHHP is associated with positive changes in service utilization outcomes but was comparable to matched comparison groups.Implications for Policy or PracticeHealth homes offer an opportunity for improved health outcomes for vulnerable populations with chronic conditions. The LC approach, which allows for full virtual implementation, is an effective and scalable approach to wide‐spread implementation and successful uptake of care models.Primary Funding SourcePatient‐Centered Outcomes Research Institute.

OBJECTIVESTo compare patterns of psychiatric hospitalization and readmission within 30 days for Medicaid expansion (expansion) vs previously insured (legacy) samples.STUDY DESIGNRetrospective analysis using Medicaid behavioral health service claims.METHODSWe identified 24,044 individuals with hospitalizations in calendar years 2017 and 2018 within the network of a behavioral health managed care organization in Pennsylvania. Logistic regression was used to examine factors associated with readmission.RESULTSIndividuals covered under expansion (n = 7747) vs legacy (n = 16,297) were older and more likely to be male and European American, with higher rates of cooccurring mental health (MH) and substance use disorder (SUD) diagnoses, as well as lower rates of MH and SUD services in the 30 days prior and any prior MH hospitalization. A higher proportion of individuals with expansion vs legacy status were readmitted (11.3% vs 9.0%; P < .0001). Controlling for factors associated with readmission, regression showed an increased likelihood of readmission for expansion vs legacy status (adjusted odds ratio [AOR], 1.23; 95% CI, 1.12-1.35; P < .0001). Increased risk for readmission was also found across populations for male patients (AOR, 1.12; 95% CI, 1.02-1.22; P = .0124), those with prior MH hospitalizations (AOR, 1.65; 95% CI, 1.51-1.81; P < .0001) or other behavioral health services (AOR, 1.14; 95% CI, 1.03-1.26; P = .0142), those with longer hospitalization episodes (AOR, 1.01; 95% CI, 1.00-1.01; P < .0001), and those with cooccurring SUD (AOR, 1.58; 95% CI, 1.44-1.74; P < .0001).CONCLUSIONSIndividuals with coverage through Medicaid expansion compared with legacy coverage have an increased risk of psychiatric readmission and may warrant targeted interventions that also address service utilization and cooccurring SUD.

Objectives Buprenorphine/naloxone is an effective medication for the treatment of opioid use disorder. Unlike methadone, which can only be dispensed in federally waived clinics and which must be combined with specific psychosocial treatment, buprenorphine can be dispensed by individual prescribers who have completed an 8-hour training program, with no requirement that patients receive concomitant psychotherapy. The objective of this study is to quantify the association of counseling and psychotherapy on retention in treatment. We also examine the effect of buprenorphine dosage on retention. Methods We examined a cohort of 4987 members of a not-for-profit managed care organization serving Medicaid members in 41 counties in Pennsylvania. This cohort was selected from all members who had a full year without any medication for opioid use disorder followed by initiation of treatment with buprenorphine/naloxone in 2016 to 2017 and who remained Medicaid eligible for at least 80% of the following 2 years. Outcomes were estimated using inverse probability weighted propensity scores. Results The addition of counseling and psychotherapy within the first 8 weeks of treatment was associated with greater total retention in treatment and there was a dose-response relationship. A 16 mg/d or greater dose of buprenorphine was also associated with greater retention. Conclusions These results provide support for an integrated approach to treating people with an opioid use disorder, through a combination of buprenorphine pharmacotherapy and targeted counseling and psychotherapy within the first 2 months of treatment.

Individuals living with a serious mental illness are disproportionately affected by preventable and/or manageable chronic conditions. Integrated care and support for behavioral and physical health within community mental health provider (CMHP) settings, also known as behavioral health homes (BHH), can lead to improvements in care and cost outcomes. This study explored staff perceptions of barriers and facilitators to BHH implementation. We conducted semi-structured interviews with CMHP staff at baseline, 1, and 2 years after the start of implementation. We analyzed interviews to identify major themes. We conducted 65 total interviews with 30 unique staff members. Common barriers included staff turnover, hesitation to change care processes, and acute service user needs. Facilitators included agency-wide culture change, intervention champions, and integration of intervention processes into daily workflows. Despite common barriers, CMHP staff identified several elements related to successful BHH implementation, including the CMHP-wide cultural shift to comprehensively address health/wellness that benefitted service users and staff alike.

OBJECTIVEThis study evaluated the impact of two behavioral health home (BHH) approaches, provider-supported care and self-directed care, on health care utilization and cost outcomes among adult Medicaid recipients with serious mental illness.METHODSEleven community mental health provider sites were randomly assigned to one of the BHH approaches, which each site implemented over a 2-year period. In both approaches, staff were trained in wellness coaching to support patients' progress toward general health and wellness goals. Provider-supported sites employed a full-time on-site registered nurse, who provided consultation to patients and wellness coaches. Each approach had a consistently enrolled treatment group (combined N=859) with a matched comparison cohort that was identified for analysis. Approaches were compared with each other and with baseline, and differences between each approach and its comparison cohort were examined by using analysis of covariance to determine impact on total health care cost, prescription costs, and use and cost of general medical and behavioral health services.RESULTSRelative to its comparison cohort, each approach achieved significant reductions in total cost (15% for provider-supported care and 26% for self-directed care) and increases in use of outpatient general medical services (43% for provider-supported care and 29% for self-directed care). Compared with self-directed care, provider-supported care resulted in approximately 28% lower use of general medical inpatient services and 26% lower related costs.CONCLUSIONSBHH approaches in community mental health settings can produce health care savings and decrease use of inpatient health care.

Nearly half of Americans live with chronic disease. Many have multiple chronic conditions that often present as a combination of physical and mental health conditions. Aligning stakeholder-driven, patient-centered outcomes research with population health strategies such as innovative ways to deliver care management can reduce the burden of multiple chronic conditions. In addition, successfully creating meaningful, inclusive research requires actively engaging stakeholders throughout the lifecycle of a study. This study integrates stakeholder engagement, using a large health plan in western Pennsylvania, to conduct a randomized controlled trial. Three care management strategies, High-Touch, High-Tech, and Usual Care, are compared for effectiveness among members with multiple chronic conditions. Care strategies are delivered via the Community Team, a multidisciplinary community-based team, offering in-person (High-Touch) and digital (High-Tech) care management in 14 counties across Pennsylvania. Participants are followed for 12months, with repeated measurements of self-reported health status and activation in care, while tracking administrative measurements of primary and specialty health service utilization. Quality of life, care satisfaction, engagement in care, and service utilization will be compared using generalized mixed models. Additionally, semi-structured interviews are conducted for both participants and care managers over the course of the study to evaluate feasibility. This manuscript presents implementation strategies, while noting that the implementation of patient-centered outcomes research in a real-world setting requires rapid evaluation, redesign of workflow, and tailored approaches for success.

This randomized trial investigates the impact of the Camden Coalition of Healthcare Providers' Care Management Program: Link2Care.The program targets "super-utilizers" of the health care system -specifically adults with 2 or more hospitalizations in the last six months and 2 or more chronic conditions -with intensive care-management services in the one to three months following hospital discharge.A team of nurses, social workers, community health workers and health coaches, supported by real-time data of healthcare utilization, perform home visits, accompany patients to doctor visits, and help patients enroll in social-service programs.This approach aims to improve the self-sufficiency of patients in navigating the healthcare and socialservice systems and has the potential to reduce healthcare costs and improve patient health.Through random assignment to the intervention, we plan to study the impact of the Link2Care program, particularly on subsequent hospital use.