Literature Collection

The authors aimed to investigate potential differences between health care use and related payments for patients with complex needs and high costs in Health Resources and Services Administration-funded health centers (HCs) and with other safety net primary care providers. The authors used data from the California Health Homes Program that was designed to improve health outcomes and reduce expenditures of such Medicaid managed care beneficiaries. The authors used 2018 data prior to program implementation and conducted propensity score-matched regressions. The authors then estimated predicted rates of use across seven service categories and payment values for each category and for overall payments. The authors found that 29% of the sample were HC patients and had lower estimated average total payment values ($21,220) than group provider patients ($23,180). HC patients also had lower values for hospitalizations and long-term facility stays and higher values for primary and mental health services than all other providers. Payment differences were generally consistent with differences in predicted rates of use. These findings suggest that HC approaches to managing patient care access and integrated mental health services may explain these differences in use and payment patterns.

Autonomous mobile clinics (AMCs) have the potential to revolutionize healthcare delivery by bringing healthcare services to patients at the order of patient's fingertips. Particularly, AMCs can act as an essential touch point of integrated care, which is a worldwide response to the fragmented delivery of health by focusing on more coordinated and integrated forms of care provision. However, the impact of AMCs on the health satisfaction outcome effectiveness still remains unknown. In this article, in collaboration with United Family Healthcare (UFH), we study the potential effectiveness improvement of integrated care delivery through AMCs.

Governance has been highlighted as an important building block underpinning the process of mental health integration into primary healthcare. This qualitative systematic review aims to identify the governance issues faced by countries in the Sub-Saharan Africa and South Asia Region in the implementation of integrated primary mental healthcare. PRISMA guideline was used to conduct a systematic search of relevant studies from 4 online databases that were filtered according to inclusion and exclusion criteria. Using the Critical Appraisal Skills Program (CASP) Qualitative Checklist, a quality appraisal of the selected articles was performed. By drawing upon institutional theory, data was extracted based on a pre-constructed matrix. The CERQual approach synthesized evidence and rank confidence level as low, moderate or high for 5 key findings. From 567 references identified, a total of 8 studies were included. Respondents were policymakers or implementers involved in integrated primary mental healthcare from the national, state, and district level. Overall, the main governance issues identified were a lack of leadership and mental health prioritization; inadequate financing and human resource capacity; and negative mental health perceptions/attitudes. The implication of the findings is that such issues must be addressed for long-term health system performance. This can also improve policymaking for better integration of primary mental health services into the health systems of countries in the Sub-Saharan and South Asia region.

Medical-legal partnerships (MLPs) address social determinants of health by integrating legal services into health care settings. This study examines associations between health-harming legal needs (HHLNs) and mental health quality among family medicine clinic patients screened for MLP referral. A retrospective cohort of 475 patients completed an HHLN screening instrument, including a measure of mentally unhealthy days (MUDs). Zero-inflated negative binomial models assessed associations between HHLNs and MUDs, adjusting for demographics. Patients with any HHLN had 65% lower odds of reporting zero MUDs. Worrying about housing instability was the strongest independent predictor of increased MUDs, associated with a 56% increase. Black race was associated with greater odds of reporting zero MUDs. Housing concerns are a key driver of mental health quality, highlighting the need for targeted legal interventions. Integrating MLP screening into primary care may help identify and address legal issues impacting patient mental health.

BACKGROUND: Opioid dependence carries the highest disease burden of all illicit drugs. Opioid agonist therapy (OAT) is an evidence-based medical intervention that reduces morbidity and mortality. There is limited knowledge on the health-related quality of life (HRQoL) of long-term patients in OAT. This study measures HRQoL and self-perceived health of long-term patients on OAT, compares the scores to a Norwegian reference population, and assesses changes in these scores at 1-year follow up. METHODS: We conducted a nested prospective cohort study among nine OAT outpatient clinics in Norway. 609 OAT patients were included, 245 (40%) followed-up one year later. Data on patient characteristics, HRQoL, and self-perceived health was collected. HRQoL was assessed with the EQ-5D-5L, which measures five dimensions (mobility, self-care, usual activities, pain/discomfort and anxiety/depression) on a five-point Likert scale (from "no problems" to "extreme problems"). An UK value set was applied to calculate index values (from 0 to 1) for the EQ-5D-5L and compare them to a Norwegian reference population. Self-perceived health was measured with EQ-VAS (from 0 to 100). RESULTS: Mean (standard deviation (SD)) EQ-5D-5L index value at baseline was 0.699 (0.250) and EQ-VAS 57 (22) compared to 0.848 (0.200) and 80(19) for the Norwegian reference population. There were large variations in EQ-5D-5L index values, where 43% had > 0.8 and 5% had < 0.2 at baseline. The lowest EQ-5D-5L index values were observed for female patients, age groups older than 40 years and for methadone users. At follow-up, improvements in HRQoL were observed across almost all dimensions and found significant for mobility and pain/discomfort. Mean (SD) overall index value and EQ-VAS at follow up were 0.729 (0.237) and 59 (22) respectively. CONCLUSION: The average HRQoL and self-perceived health of OAT patients is significantly lower than that of the general population, and lower than what has been found among other severe somatic and psychiatric conditions. Around 34% had very good HRQoL, higher than average Norwegian values, and around 5% had extremely poor HRQoL.

BACKGROUND: While research on health-related social needs (HRSNs) has expanded, important gaps remain in understanding associations between HRSN and healthcare cost, especially across general populations of patients with broad-ranging medical and social needs. OBJECTIVE: To examine the association between HRSN and healthcare cost in a large, diverse, insured population. DESIGN: In this cross-sectional study, we evaluated cost differences between patients with different HRSN levels using survey-weighted multivariable generalized linear models. We examined three alternate model specifications: one that included controls for basic demographics; another adding insurance type, race/ethnicity, and social isolation; and a third adding a diagnosis-based medical risk index called DxCG. Variables added in the latter models were assessed separately due to concern for over-correlations with HRSN. PARTICIPANTS: 10,226 adult survey respondents (23% response rate) from eight states and Washington, D.C. MAIN MEASURES: The primary exposure was patient-reported HRSN, based on survey questions asking about financial strain, food insecurity, housing instability, and transportation difficulties. HRSN was constructed as a three-level variable. The primary outcome was total direct healthcare cost. KEY RESULTS: "Moderate HRSN" was not significantly associated with cost in any model. In the model controlling for patient demographics, costs for patients with "Severe HRSN" were 1.27 (95%CI: 1.00-1.60) times those of patients with "No HRSN." In a model that adjusted for medical risk (DxCG), the relationship between HRSN and cost was not statistically significant. CONCLUSIONS: Relationships between HRSN and healthcare cost may vary by HRSN level. Our mixed findings highlight the complex relationship between medical and social risks, which often have bi-directional causal relationships. If measures of medical risk incidentally capture variation in social risk, then models controlling for medical risk may mask relationships between HRSN and cost. Further studies should investigate the extent to which HRSN may be related to cost, even when controlling for specific patient diagnoses.

IMPORTANCE: Health-related social needs (HRSN) influence health outcomes and health care utilization. Clinicians face challenges addressing HRSN due to limited skills, expertise, and time. Further insight is needed on how patients and clinicians navigate HRSN in clinical encounters. OBJECTIVE: This study examines outpatient primary care encounters predating widespread HRSN screening to identify how discussions on HRSN are initiated and addressed. DESIGN, SETTING, AND PARTICIPANTS: This qualitative analysis was conducted on transcripts of 97 audiotaped English-speaking patient encounters from 3 clinics in New York City within a municipal health care system from January 2011 through April 2015. Patients were eligible if they were older than 18 years, self-identified as Black or White, had a diagnosis of hypertension, and had at least one prior encounter with the participating clinician. Codes were developed from social needs domains addressed by the Accountable Health Communities HRSN Screening Tool. Codes were added for further social needs identified, whether a patient or clinician initiated the HRSN discussion, and how a social need was addressed, if at all. Encounters were analyzed between June 2023 and February 2024. MAIN OUTCOMES AND MEASURES: Characterization of the content and nature of HRSN discussions during clinical encounters within safety-net clinics. RESULTS: A total of 97 patients (55 [56.7%] women, 58 [59.8%] Black, mean [SD] age, 59.7 [10.6] years) had audiotaped encounters with 27 clinicians (18 [66.7%] women, 15 [55.6%] White, mean [SD] age, 36 [5.8] years). Physical activity (36% of encounters), financial strain (35%), mental health (34%), and substance use (28%) were the most discussed HRSN domains across the 97 encounters. Patients introduced financial strain most often (70% of the time), while clinicians led substance use (75%), physical activity (51%) and mental health (51%) discussions. Patients initiated conversations on employment (77%), food insecurity (62%), and housing instability (52%). Interventions included prescriptions, forms, counseling, and referrals. Domains frequently intervened on included health care navigation needs (85% of discussions), substance use (33%), and mental health (27%). CONCLUSIONS AND RELEVANCE: In this qualitative study of HRSN discussions in primary care encounters, clinicians were more likely to initiate discussions on substance use, physical activity, and mental health, behaviors routinely assessed in primary care, but different from topics introduced by patients. Findings underscore the need for standardized screening to improve identification of domains less frequently addressed by clinicians. Additional interventions are also needed, including clinician training for how to address HRSN in resource-constrained settings and integration of other health care team members, to enhance HRSN identification and intervention.