ImportanceIntensive primary care interventions have been promoted to reduce hospitalization rates and improve health outcomes for medically complex patients, but evidence of their efficacy is limited.ObjectiveTo assess the efficacy of a multidisciplinary ambulatory intensive care unit (A-ICU) intervention on health care utilization and patient-reported outcomes.Design, Setting, and ParticipantsThe Streamlined Unified Meaningfully Managed Interdisciplinary Team (SUMMIT) randomized clinical trial used a wait-list control design and was conducted at a health care clinic for patients experiencing homelessness in Portland, Oregon. The first patient was enrolled in August 2016, and the last patient was enrolled in November 2019. Included patients had 1 or more hospitalizations in the prior 6 months and 2 or more chronic medical conditions, substance use disorder, or mental illness. Data analysis was performed between March and May 2021.InterventionThe A-ICU included a team manager, a pharmacist, a nurse, care coordinators, social workers, and physicians. Activities included comprehensive 90-minute intake, transitional care coordination, and flexible appointments, with reduced panel size. Enhanced usual care (EUC), consisting of team-based primary care with access to community health workers and mental health, addiction treatment, and pharmacy services, served as the comparator. Participants who received EUC joined the A-ICU intervention after 6 months.Main Outcomes and MeasuresThe main outcome was the difference in rates of hospitalization (primary outcome), emergency department (ED) visits, and primary care physician (PCP) visits per person over 6 months (vs the prior 6 months). Patient-reported outcomes included changes in patient activation, experience, health-related quality of life, and self-rated health at 6 months (vs baseline). We performed an intention-to-treat analysis using a linear mixed-effects model with a random intercept for each patient to examine the association between study group and outcomes.ResultsThis study randomized 159 participants (mean [SD] age, 54.9 [9.8] years) to the A-ICU SUMMIT intervention (n = 80) or to EUC (n = 79). The majority of participants were men (102 [65.8%]) and most were White (121 [76.1%]). A total of 64 participants (41.0%) reported having unstable housing at baseline. Six-month hospitalizations decreased in both the A-ICU and EUC groups, with no difference between them (mean [SE], −0.6 [0.5] vs −0.9 [0.5]; difference, 0.3 [95% CI, −1.0 to 1.5]). Emergency department use did not differ between groups (mean [SE], −2.0 [1.0] vs 0.9 [1.0] visits per person; difference, −1.1 [95% CI, −3.7 to 1.6]). Primary care physician visits increased in the A-ICU group (mean [SE], 4.2 [1.6] vs −2.0 [1.6] per person; difference, 6.1 [95% CI, 1.8 to 10.4]). Patients in the A-ICU group reported improved social functioning (mean [SE], 4.7 [2.0] vs −1.1 [2.0]; difference, 5.8 [95% CI, 0.3 to 11.2]) and self-rated health (mean [SE], 0.7 [0.3] vs −0.2 [0.3]; difference, 1.0 [95% CI, 0.1 to 1.8]) compared with patients in the EUC group. No differences in patient activation or experience were observed.Conclusions and RelevanceThe A-ICU intervention did not change hospital or ED utilization at 6 months but increased PCP visits and improved patient well-being. Longer-term studies are needed to evaluate whether these observed improvements lead to eventual changes in acute care utilization.Trial RegistrationClinicalTrials.gov Identifier: NCT03224858

Introduction : Federally qualified health centers (FQHC) provide care to over 28 million people in the United States, primarily serving people with low incomes who are underinsured or not insured. FQHC patients have different patterns of illness than non-FQHC populations, which may require tailored interventions to support at the population level. Model based segmentation methods can identify patterns of need but may generate spurious results without clinical context. Here, we used stakeholder feedback combined with machine learning methods to identify subgroups of patients seen by a large FQHC in an urban setting. Methods : We used electronic health record and administrative hospital utilization data to identify subgroups of patients seen at the FQHC in 2017 using latent class analysis (LCA). We designed an activity to gather feedback from physicians, social service staff, and administrators during model design. We trained a final model using a feed-forward neural network. Results : Using data from 5,985 primary care patients, we identified four candidate LCA models—with 26, 27, 28, and 29 classes—and integrated inter-professional feedback to develop a final model with 19 clinically meaningful classes. Three classes had greater medical complexity and older age, 15 classes were separated primarily by behavioral health diagnoses, and a final class had low complexity. Conclusions : Populations served by FQHCs are clinically heterogenous with varying levels of complexity. Use of LCA can provide insights into patterns among FQHC patients, which can be used to inform the development of interventions tailored to the needs of specific classes.

PURPOSE High-need high-cost (HNHC) patients consume a large proportion of health resources but often receive suboptimal care in traditional primary care. Intensive ambulatory care interventions attempt to better meet these patients' needs, but we know little about how teams delivering these interventions in clinics serving socially complex patient populations perceive their work. METHODS We performed a qualitative study of multidisciplinary staff experiences at a Federally Qualified Health Center (FQHC) caring for predominantly homeless HNHC patients in the context of an ongoing implementation of an ambulatory intensive care unit (A-ICU) intervention. We conducted semistructured interviews with 9 ambulatory intensive care team members and 6 "usual care" members. We conducted a thematic analysis, using an inductive approach, at a semantic level. RESULTS Staff viewed complexity as a combination of social, behavioral, and medical challenges that lead to patient-health care system mismatch. Staff perceive the following as key ingredients in caring for HNHC patients: addressing both psychosocial and clinical needs together; persistence in staying connected to patients through chaotic periods; shared commitment and cohesion among interdisciplinary team members; and flexibility to tailor care to patients' individual situations. Participants' definitions of success focused more on improving patient engagement than reducing utilization or cost. CONCLUSION FQHC staff working with HNHC patients perceive mismatch between the health care system and patients' clinical and social needs as the key driver of poor outcomes for these patients. Intensive ambulatory care teams may bridge mismatch through provision of psychosocial supports, flexible care delivery, and fostering team cohesion to support patient engagement.

In 35 states, certificate-of-need (CON) laws in health care restrict the supply of medical services. These regulations require providers hoping to open a new healthcare facility, expand an existing facility, or purchase certain medical equipment such as an MRI machine or a hospital bed to first prove to a regulatory body that their community needs the service in question. The approval process can be time consuming and expensive, and it offers incumbent providers an opportunity to oppose the entrance of new competitors. However, it was originally hoped that these laws would, among other things, reduce healthcare price inflation. In this brief, I review the basic economic theory of a supply restriction like CON, then summarize four decades of empirical research on the effect of CON on healthcare spending. There is no evidence that CON regulations limit healthcare price inflation and little evidence that they reduce healthcare spending. In fact, the balance of evidence suggests that CON laws are associated with higher per unit costs and higher total healthcare spending. JEL codes: D72, D78, H75, I1, L51

Background Medically complex urban patients experiencing homelessness comprise a disproportionate number of high-cost, high-need patients. There are few studies of interventions to improve care for these populations; their social complexity makes them difficult to study and requires clinical and research collaboration. We present a protocol for a trial of the streamlined unified meaningfully managed interdisciplinary team (SUMMIT) team, an ambulatory ICU (A-ICU) intervention to improve utilization and patient experience that uses control populations to address limitations of prior research. Methods/design Participants are patients at a Federally Qualified Health Center in Portland, Oregon that serves patients experiencing homelessness or who have substance use disorders. Participants meet at least one of the following criteria: > 1 hospitalization over past 6 months; at least one medical co-morbidity including uncontrolled diabetes, heart failure, chronic obstructive pulmonary disease, liver disease, soft-tissue infection; and 1 mental health diagnosis or substance use disorder. We exclude patients if they have < 6 months to live, have cognitive impairment preventing consent, or are non-English speaking. Following consent and baseline assessment, we randomize participants to immediate SUMMIT intervention or wait-list control group. Participants receiving the SUMMIT intervention transfer care to a clinic-based team of physician, complex care nurse, care coordinator, social worker, and pharmacist with reduced panel size and flexible scheduling with emphasis on motivational interviewing, patient goal setting and advanced care planning. Wait-listed participants continue usual care plus engagement with community health worker intervention for 6 months prior to joining SUMMIT. The primary outcome is hospital utilization at 6 months; secondary outcomes include emergency department utilization, patient activation, and patient experience measures. We follow participants for 12 months after intervention initiation. Discussion The SUMMIT A-ICU is an intensive primary care intervention for high-utilizers impacted by homelessness. Use of a wait-list control design balances community and staff stakeholder needs, who felt all participants should have access to the intervention, while addressing research needs to include control populations. Design limitations include prolonged follow-up period that increases risk for attrition, and conflict between practice and research; including partner stakeholders and embedded researchers familiar with the population in study planning can mitigate these barriers. Trial registration ClinicalTrials.gov NCT03224858, Registered 7/21/17 retrospectively registered https://clinicaltrials.gov/ct2/show/NCT03224858

Research demonstrates that homelessness is associated with frequent use of emergency department (ED) services, yet prior studies have not adequately examined the relationship between frequent ED use and utilization of non-ED health care services among those experiencing homelessness. There has also been little effort to assess heterogeneity among homeless individuals who make frequent use of ED services. To address these gaps, the present study used Medicaid claims data from 2010 to estimate the association between the number of ED visits and non-ED health care costs for a cohort of 6,338 Boston Health Care for the Homeless Program patients, and to identify distinct subgroups of persons in this cohort who made frequent use of ED services based on their clinical and demographic characteristics. A series of gamma regression models found more frequent ED use to be associated with higher non-ED costs, even after adjusting for demographic and clinical characteristics. Latent class analysis was used to examine heterogeneity among frequent ED users, and the results identified 6 characteristically distinct subgroups among these persons. The subgroup of persons with trimorbid illness had non-ED costs that far exceeded members of all 5 other subgroups. Study findings reinforce the connection between frequent ED use and high health care costs among homeless individuals and suggest that different groups of homeless frequent ED users may benefit from interventions that vary in terms of their composition and intensity.

Click to increase image sizeClick to decrease image size Matthew S. Mitchell is a recent graduate of Harvard Divinity School with a concentration in Religion, Ethics, and Politics. Notes 1. The imaginary woman, Sarah, is a character that Perry employs to demonstrate his point about Christian love in "The Morality of Human Rights: A Nonreligious Ground?" (2005) and notes that the love that Sarah exemplifies "is, obviously, an ideal. Moreover, it is, for most human beings, an extremely demanding idea; for many persons, it is also an implausible ideal" (CitationPerry 2007: 10). 2. See Johannes Morsink, The Universal Declaration of Human Rights: Origins, Drafting, and Intent (2000). 3. See Donnelly's substantially revised second edition of Universal Human Rights in Theory and Practice (2003).