Addressing nonmedical needs-such as the need for housing-is critical to advancing population health, improving the quality of care, and lowering the costs of care. Accountable care organizations ...(ACOs) are well positioned to address these needs. We used qualitative interviews with ACO leaders and site visits to examine how these organizations addressed the nonmedical needs of their patients, and the extent to which they did so. We developed a typology of medical and social services integration among ACOs that disentangles service and organizational integration. We found that the nonmedical needs most commonly addressed by ACOs were the need for transportation and housing and food insecurity. ACOs identified nonmedical needs through processes that were part of the primary care visit or care transformation programs. Approaches to meeting patients' nonmedical needs were either individualized solutions (developed patient by patient) or targeted approaches (programs developed to address specific needs). As policy makers continue to provide incentives for health care organizations to meet a broader spectrum of patients' needs, these findings offer insights into how health care organizations such as ACOs integrate themselves with nonmedical organizations.
Despite interest in addressing social determinants of health to improve patient outcomes, little progress has been made in integrating social services with medical care. We aimed to understand how ...health care providers with strong motivation (for example, operating under new payment models) and commitment (for example, early adopters) fared at addressing patients' social needs. We collected qualitative data from twenty-two accountable care organizations (ACOs). These ACOs were early adopters and were working on initiatives to address social needs, including such common needs as transportation, housing, and food. However, even these ACOs faced significant difficulties in integrating social services with medical care. First, the ACOs were frequently "flying blind," lacking data on both their patients' social needs and the capabilities of potential community partners. Additionally, partnerships between ACOs and community-based organizations were critical but were only in the early stages of development. Innovation was constrained by ACOs' difficulties in determining how best to approach return on investment, given shorter funding cycles and longer time horizons to see returns on social determinants investments. Policies that could facilitate the integration of social determinants include providing sustainable funding, implementing local and regional networking initiatives to facilitate partnership development, and developing standardized data on community-based organizations' services and quality to aid providers that seek partners.
Background
The novel coronavirus disease 2019 (COVID-19) infected over 5 million United States (US) residents resulting in more than 180,000 deaths by August 2020. To mitigate transmission, most ...states ordered shelter-in-place orders in March and reopening strategies varied.
Objective
To estimate excess COVID-19 cases and deaths after reopening compared with trends prior to reopening for two groups of states: (1) states with an evidence-based reopening strategy, defined as reopening indoor dining after implementing a statewide mask mandate, and (2) states reopening indoor dining rooms before implementing a statewide mask mandate.
Design
Interrupted time series quasi-experimental study design applied to publicly available secondary data.
Participants
Fifty United States and the District of Columbia.
Interventions
Reopening indoor dining rooms before or after implementing a statewide mask mandate.
Main Measures
Outcomes included daily cumulative COVID-19 cases and deaths for each state.
Key Results
On average, the number of excess cases per 100,000 residents in states reopening without masks is ten times the number in states reopening with masks after 8 weeks (643.1 cases; 95% confidence interval (CI) = 406.9, 879.2 and 62.9 cases; CI = 12.6, 113.1, respectively). Excess cases after 6 weeks could have been reduced by 90% from 576,371 to 63,062 and excess deaths reduced by 80% from 22,851 to 4858 had states implemented mask mandates prior to reopening. Over 50,000 excess deaths were prevented within 6 weeks in 13 states that implemented mask mandates prior to reopening.
Conclusions
Additional mitigation measures such as mask use counteract the potential growth in COVID-19 cases and deaths due to reopening businesses. This study contributes to the growing evidence that mask usage is essential for mitigating community transmission of COVID-19. States should delay further reopening until mask mandates are fully implemented, and enforcement by local businesses will be critical for preventing potential future closures.
Relationships between physicians and hospitals have changed considerably over the past decade, as hospitals and physician groups have integrated and new public and private payment policies have ...created financial interdependence. The extent to which accountable care organizations (ACOs) involve hospitals in their operations may prove to be vitally important, because managing hospital care is a key part of improving health care quality and lowering cost growth. Using primary data on ACO composition and capabilities paired with hospital characteristics, we found that 20 percent of US hospitals were part of an ACO in 2014. Hospitals that were in urban areas, were nonprofit, or had a smaller share of Medicare patients were more likely to participate in ACOs, compared to hospitals that were in more rural areas, were for-profit or government owned, or had a larger share of Medicare patients, respectively. Qualitative data identified the following advantages of including a hospital in an ACO: the availability of start-up capital, advanced data sharing, and engagement of providers across the care continuum. Although the 63 percent of ACOs that included hospitals offered more comprehensive services compared to ACOs without hospitals, we found no differences between the two groups in their ability to manage hospital-related aspects of patient care.
Social needs, including food, housing, utilities, transportation, and experience with interpersonal violence, are linked to health outcomes. Identifying patients with unmet social needs is a ...necessary first step to addressing these needs, yet little is known about the prevalence of screening.
To characterize screening for social needs by physician practices and hospitals.
Cross-sectional survey analyses of responses by physician practices and hospitals to the 2017-2018 National Survey of Healthcare Organizations and Systems. Responses were collected from survey participants from June 16, 2017, to August 17, 2018.
Organizational characteristics, including participation in delivery and payment reform.
Self-report of screening patients for food insecurity, housing instability, utility needs, transportation needs, and experience with interpersonal violence.
Among 4976 physician practices, 2333 responded, a response rate of 46.9%. Among hospitals, 757 of 1628 (46.5%) responded. After eliminating responses because of ineligibility, 2190 physician practices and 739 hospitals remained. Screening for all 5 social needs was reported by 24.4% (95% CI, 20.0%-28.7%) of hospitals and 15.6% (95% CI, 13.4%-17.9%) of practices, whereas 33.3% (95% CI, 30.5%-36.2%) of practices and 8.0% (95% CI, 5.8%-11.0%) of hospitals reported no screening. Screening for interpersonal violence was most common (practices: 56.4%; 95% CI, 53.3%-2 59.4%; hospitals: 75.0%; 95% CI, 70.1%-79.3%), and screening for utility needs was least common (practices: 23.1%; 95% CI, 20.6%-26.0%; hospitals: 35.5%; 95% CI, 30.0%-41.0%) among both hospitals and practices. Among practices, federally qualified health centers (yes: 29.7%; 95% CI, 21.5%-37.8% vs no: 9.4%; 95% CI, 7.2%-11.6%; P < .001), bundled payment participants (yes: 21.4%; 95% CI, 17.1%-25.8% vs no: 10.7%; 95% CI, 7.9%-13.4%; P < .001), primary care improvement models (yes: 19.6%; 95% CI, 16.5%-22.6% vs no: 9.6%; 95% CI, 6.0%-13.1%; P < .001), and Medicaid accountable care organizations (yes: 21.8%; 95% CI, 17.4%-26.2% vs no: 11.2%; 95% CI, 8.6%-13.7%; P < .001) had higher rates of screening for all needs. Practices in Medicaid expansion states (yes: 17.7%; 95% CI, 14.8%-20.7% vs no: 11.4%; 95% CI, 8.1%-14.6%; P = .007) and those with more Medicaid revenue (highest tertile: 17.1%; 95% CI, 11.4%-22.7% vs lowest tertile: 9.0%; 95% CI, 6.1%-11.8%; P = .02) were more likely to screen. Academic medical centers were more likely than other hospitals to screen (49.5%; 95% CI, 34.6%-64.4% vs 23.0%; 95% CI, 18.5%-27.5%; P < .001).
This study's findings suggest that few US physician practices and hospitals screen patients for all 5 key social needs associated with health outcomes. Practices that serve disadvantaged patients report higher screening rates. The role of physicians and hospitals in meeting patients' social needs is likely to increase as more take on accountability for cost under payment reform. Physicians and hospitals may need additional resources to screen for or address patients' social needs.
► We examine the relationship between religiosity and civic engagement using Portraits of American Life Study national survey data. ► Religiosity positively related to multiple civic outcomes. ► ...Relationship between religiosity and civic engagement is often explained by religious social networks, not beliefs or affiliation. ► Religious networks have stronger impact on civic engagement than general social networks. ► Having social networks from a religious congregation is associated with increased civic participation, though the specific mechanism at work is unknown.
A substantial literature has found that religiosity is positively related to individuals’ civic engagement and informal helping behavior. Concurrently, social networks as sources of information and encouragement have been suggested as the mechanism underlying phenomena including successful job searches, improved health and greater subjective well-being. In this paper we use data from the Portraits of American Life Study (PALS) to examine whether religiously based social networks explain the well-established relationship between religion and civic engagement. We test potential mechanisms including beliefs, affiliation, and social networks, and we find that having a strong network of religious friends explains the effect of church attendance for several civic and neighborly outcomes. We suggest this phenomenon may exist in other, non-religious, spheres that also produce strong friendship networks.
Background: Patient engagement strategies can equip patients with tools to navigate treatment decisions and improve patient-centered outcomes. Despite increased recognition about the importance of ...patient engagement, little is known about the extent of physician practice adoption of patient engagement strategies nationally. Methods: We analyzed data collected from the National Survey of Healthcare Organizations and Systems (NSHOS) on physician practice adoption of patient engagement strategies. Stratified-cluster sampling was used to select physician practices operating under different organizational structures. Multivariable linear regression models estimated the association of practice ownership, health information technology functionality, use of screening activities, patient responsiveness, chronic care management processes, and the adoption of patient engagement strategies, including shared decision-making, motivational interviewing, and shared medical appointments. All regression models controlled for participation in payment reforms, practice size, Medicaid revenue percentage, and geographic region. Results: We found modest and varied adoption of patient engagement strategies by practices of different ownership types, with health system-owned practices having the lowest adoption of ownership types. Practice capabilities, including chronic care management processes, routine screening of medical and social risks, and patient care dissemination strategies were associated with greater practice-level adoption of patient engagement strategies. Conclusions: This national study is the first to characterize the adoption of patient engagement strategies by US physician practices. We found modest adoption of shared decision-making and motivational interviewing, and low adoption of shared medical appointments. Risk-based payment reform has the potential to motivate greater practice-level patient engagement, but the extent to which it occurs may depend on internal practice capabilities.
This Viewpoint examines in-depth 5 features of health care systems that may influence quality of care: pooled resources, centralization, standardization, interprovider coordination, and ...cross-practice learning.
Background
Concerns exist about the ability of safety net health care organizations to participate in US health care reform. Primary care practices are key to several efforts, but little is known ...about how capabilities of primary care practices serving a high share of disadvantaged patients compare to other practices.
Objective
To assess capabilities around access to and quality of care among primary care practices serving a high share of Medicaid and uninsured patients compared to practices serving a low share of these patients.
Design
We analyzed data from the National Survey of Healthcare Organizations and Systems (response rate 46.8%), conducted 2017–2018.
Participants
A total of 2190 medical practices with at least three adult primary care physicians.
Main Measures
Our key exposures are payer mix and federally qualified health center (FQHC) designation. We classified practices as safety net if they reported a combined total of at least 25% of annual revenue from uninsured or Medicaid patients; we then further classified safety net practices into those that identified as an FQHC and those that did not.
Key Results
FQHCs were more likely than other safety net practices and non-safety net practices to offer early or late appointments (79%, 55%, 62%;
p
=0.001) and weekend appointments (56%, 39%, 42%;
p
=0.03). FQHCs more often provided medication-assisted treatment for opioid use disorders (43%, 27%, 25%;
p
=0.004) and behavioral health services (82%, 50%, 36%;
p
<0.001). FQHCs were more likely to screen patients for social and financial needs. However, FQHCs and other safety net providers had more limited electronic health record (EHR) capabilities (61%, 71%, 80%;
p
<0.001).
Conclusion
FQHCs were more likely than other types of primary care practices (both safety net practices and other practices) to possess capabilities related to access and quality. However, safety net practices were less likely than non-safety net practices to possess health information technology capabilities.
To measure rates of intimate partner violence (IPV) screening during the perinatal period among people experiencing physical violence in the United States.
We used 2016-2019 Pregnancy Risk Assessment ...Monitoring System data (n = 158 338) to describe the incidence of physical IPV before or during pregnancy. We then assessed the prevalence of IPV screening before, during, or after pregnancy and predictors of receiving screening among those reporting violence.
Among the 3.5% (n = 6259) of respondents experiencing violence, 58.7%, 26.9%, and 48.3% were not screened before, during, or after pregnancy, respectively. Those reporting Medicaid or no insurance at birth, American Indian/Alaska Native people, and Spanish-speaking Hispanic people faced increased risk of not having a health care visit during which screening might occur. Among those attending a health care visit, privately insured people, rural residents, and non-Hispanic White respondents faced increased risk of not being screened.
Among birthing people reporting physical IPV, nearly half were not screened for IPV before or after pregnancy. Public health efforts to improve maternal health must address both access to care and universal screening for IPV. (
. 2023;113(3):297-305. https://doi.org/10.2105/10.2105/AJPH.2022.307195).
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