142nd APHA Annual Meeting and Exposition

Home Events & Meetings Annual Meeting Schedule & Program

Online Program

Annual Meeting Recordings are now available for purchase

309841
Transforming primary care delivery: A focus on patients with complex conditions in rural and urban settings

142nd APHA Annual Meeting and Exposition (November 15 - November 19, 2014): http://www.apha.org/events-and-meetings/annual
Tuesday, November 18, 2014

Irina V. Haller, PhD, MS , Division of Research, Essentia Institute of Rural Health, Duluth, MN
Pat Conway, PhD , Essentia Institute of Rural Health, Duluth, MN
Joseph Bianco, MD , Essentia Health Ely Clinic, Essentia Health, Ely, MN
Paul Hitz , Research Informatics, Essentia Institute of Rural Health, Duluth, MN
Sharon Quinlan, RN, MS, MBA , Primary Care Essentia Medical Group, Essentia Health, Duluth, MN
Daniel M. Saman, DrPH, MPH, CPH , Division of Research, Essentia Institute of Rural Health, Duluth, MN
Michael Van Scoy, MD , Population Care Management, Essentia Health, Duluth, MN
Catherine VonRueden , Population Care Management, Essentia Health, Duluth, MN
Background. As the prevalence of older adults, especially those with multiple and chronic conditions, continues to grow, health care providers need to effectively identify patients who will benefit most from care coordination to ensure appropriate and timely care and reduction of avoidable services and costs. This study focused on identifying patients for nurse-lead care coordination part of the primary care delivery transformation occurring within an integrated health care system the Upper Midwest.

Methods. The purpose of this retrospective study was to describe the primary care patient population 50 years old and older in respect to demographics, rurality, comorbidity and intensive care utilization (≥3 ED visits or hospitalization in 12 months); and to evaluate an EHR-based, 24-marker risk scoring model for identifying patients with complex needs. Logistic regression was used to assess the impact of baseline risk status, demographics and rurality on intensive utilization during the next 12 months.

Results. At baseline, the average age was 65.4 years (n=123,622). Scoring model stratified patients to no risk (0), 31%, low to moderate risk (1-6), 68%, and high risk (≥7), 2%. Average risk scores increased with age (p<.001), and were higher in urban settings (p<.001) compared to rural. Baseline high risk score, older age and urban residence increased the likelihood of intensive care utilization during follow-up (p<.001).

Conclusions. Findings indicate that the risk score is a good predictor of future intensive utilization. Further work is needed to assess the contribution of individual risk markers to the overall score and future intensive care utilization.

Learning Areas:

Conduct evaluation related to programs, research, and other areas of practice

Learning Objectives:
Describe an approach to identify patients who benefit from care coordination

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I have been the principal investigator or co-investigator of multiple grants focusing on health and chronic diseases among older adults from rural settings. Currently, I am a co-principal investigator for primary care redesign evaluation at Essentia Health, an integrated health care delivery system.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.

Back to: 4002.0: Roundtable: Translating Aging Research into Practice