Faced with increasing costs and inappropriate utilization of healthcare resources the Prince George’s County Maryland Health Department (PGCHD) designated zip code 20743 as a Health Enterprise Zone (HEZ). PGCHD focused its efforts on increasing access by deploying specially trained Community Health Workers (CHWs) to increase care coordination and patient engagement. For example, a successful intervention (pathway) might involve helping a patient prepare to access primary care instead of going to the emergency room by promoting health literacy, and coaching on effective communication and engagement with providers. Those who are challenged by social determinants of health, or lacked social support might be connected to social services or other community resources. Patient activation was encouraged and methods for disease management were provided in concert with Primary Care Physician (PCP) practices. The patients had individual needs assessment and plans to address those needs.

During the study period a group of patients (N=143) successfully and appropriately accessed services. Patients were stratified into groups including: (1) those who engaged with the CHWs and completed (graduated) or (2) those in the process of completing their plans (ongoing) or (3) those working independently to access needed resources (self-guided).

To evaluate program activities and outcomes, from 2015 to 2016 PGCHD worked with community hospitals and Maryland’s Quality Improvement Organization to gather data assessing the impact of the CHW intervention on improved patient utilization and costs. The results show consistent reductions in utilization and cost. Medicare patients were studied from March 2015 through May 2018 and results showed similar reductions. However, additional analysis of the Medicare data showed that over time the effect began to disappear. Further study is needed to determine if it is necessary to maintain CHW contact and support to sustain improvements, and what level of contact is needed.

PGCHD was able to demonstrate that CHW’s are effective in reducing hospital utilization, and the overall cost of care per patient. The recommendations for practice are to maintain and expand the CHW programs, and to continue researching frequent utilizers of healthcare who benefit from care coordination.

The Florida Coordinated Intake and Referral (CI&R) Learning Collaborative was established by Healthy Start Coalitions to streamline service delivery, resources utilization, and collectively track participation and referrals using universal prenatal-newborn risk screens. CI&R systems improvements can help to improve access to community-wide services and supports tailored to the needs of pregnant women and families with newborns.

A multi-year CI&R implementation evaluation identified relationships between Consolidated Framework for Implementation Research (CFIR) domains at baseline and will establish how CFIR domains influence CI&R processes and outcomes over time.

Evaluation activities included focus groups, implementation surveys, and a social network analysis (PARTNER). Transcripts from focus groups and social network data were analyzed to enrich and add context to quantitative survey results. Coincidence Analysis (CNA) of survey data categorized the 23 coalitions across CFIR domains and identified potential relationships between CFIR domains.

Baseline focus group comments confirmed that coalition members believe CI&R is important and will improve family services, and revealed positive attitudes and commitment to CI&R across most sites. Concerns were contractual obligations, external pressure, and uncertainty/unpreparedness for implementation. Three categories of sites were identified: high in all CFIR domains; mixed low-high; and mostly low domains with high-to-medium individual characteristics. CNA found that strong networks and cooperation between agencies consistently contributed to consideration of client and community needs, which together with highly committed, capable, knowledgeable and positive individuals resulted in higher functioning CI&R teams (inner setting). Alternatively, without competition across agencies for resources or referrals, then the presence of strong individuals leading consideration of client and community needs also contributed to high functioning CI&R teams (regardless of networks/cooperation). PARTNER illustrated a range of network size and density, but this did not correspond with CFIR domains.

This is among the first studies to identify relationships between CFIR domains. Results suggest that there may be two routes whereby features of the outer setting and characteristics of individuals lead to high functioning CI&R inner settings, which may be used to guide future capacity-building efforts. Next steps involve analyzing CI&R data to identify site characteristics and CFIR domains associated with success, and process strengths, gaps and bottlenecks.

introduction to problem or issue being addressed

Medicaid beneficiaries with behavioral health conditions have higher rates of potentially preventable readmissions compared to hospitalized beneficiaries with no mental health or substance use. Additionally, beneficiaries with mental health and/or substance use conditions experience multiple potentially preventable readmissions more often than beneficiaries without these conditions.

description of evidence and theory used to inform program development/ implementation

Evidence demonstrates that peer support lowers overall healthcare costs by reducing clients’ re-hospitalization rates and days spent in inpatient services. Equipped with personal experience, peers are uniquely able to improve clients’ quality of life, strengthen their relationships with providers and social supports, and help them navigate the healthcare system.

description of program activities and outcomes, or plan to evaluate outcomes

Through the New York State Delivery System Reform Incentive Payment program, the Maimonides Medical Center (MMC) Department of Population Health has heavily invested in peer supports throughout Brooklyn. The department contracted with two community organizations to place mental health and substance use peer advocates at Brooklyn hospitals, including Interfaith Medical Center (IMC), which has comprehensive mental health and substance abuse services in place already. Peers have seamlessly integrated into existing care teams at IMC, working one-on-one with clients and assisting in groups.

To evaluate the impact that peer-led interventions may have on clients’ health care utilization, the MMC Department of Population Health is evaluating clients’ emergency department and inpatient utilization across all New York State hospitals pre- and post- intervention using aggregate claims data from Salient Interactive Miner.

conclusion(s)

Peers help providers and clients navigate the healthcare system and share their lived experience with the clients they serve.

recommendations for practice

In order to ensure a successful peer intervention, it is imperative that peers work to build relationships with clients prior to hospital discharge. All staff involved in the care of these clients should be able to connect to a client to peer services and understand the benefits of peer services. Collaborating with outside agencies ensures that peers continue to function as such, rather than being co-opted or redeployed, and leverages the agencies’ connections with community-based organizations.

HIV infection among people in the incarcerated in the U.S. is 5-7 times greater than the general population and PR has a high incarceration rate (442 per 100,000). To address the intersection of HIV and justice-involved individuals, we used a Practice Transformation Model (PTM) to expand the workforce capacity of a community-based housing and employment agency to include Transitional Care Coordination for people living with HIV (PLWH), incarcerated in Puerto Rico (PR), and returning to the community after incarceration. The PTM included training housing and employment specialists to provide non-medical case management services. The PTM leveraging access to justice-impacted PLWH and an existing provider network to create an efficient and sustainable HIV service delivery system that improves quality outcomes for vulnerable populations. As a result, 79 PLWH received the intervention; 93 percent of clients released from a correctional facility with a transitional care plan were linked to primary HIV care and other services after incarceration. In addition, HIV education/risk reduction information was provided to 360 people in correctional facilities.

Addressing implementation challenges addressed access to care and the need for health equity by expanding the workforce capacity to facilitate linkages to care for PLWH who are incarcerated and returning to the community after incarceration. The PTM improved coordination and collaboration among health care and social service organizations resulting in the development of a coordinated network of care across the islands of PR.