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ImportanceHousing deposits and tenancy supports have become new Medicaid benefits in multiple states; however, evidence on impacts from these specific housing interventions is limited.ObjectiveTo evaluate the association of rental housing deposits and health care use among Medicaid beneficiaries receiving social needs case management as part of a Whole-Person Care (Medicaid 1115 waiver) pilot program in California.Design, setting, and participantsThis cohort study compared changes in health care use among a group of adults who received a housing deposit between October 2018 and December 2021 along with case management vs a matched comparison group who received case management only in Contra Costa County, California, a large county in the San Francisco Bay Area. All participants were enrolled in health and social needs case management based on elevated risk of acute care use. Data analysis took place from March 2023 to June 2024.ExposureRental housing deposit funds that covered 1-time moving transition costs. Funds averaged $1750 per recipient.Main outcomes and measuresChanges in hospitalizations, emergency department visits, primary care visits, specialty care visits, behavioral health visits, psychiatric emergency services, or detention intakes during the 6 months before vs 6 months after deposit receipt. Changes 12 months before and after deposit receipt were examined as a sensitivity analysis.ResultsOf 1690 case management participants, 845 received a housing deposit (362 [42.8%]

ObjectiveHealth systems are expanding efforts to address health and social risks, although the heterogeneity of early evidence indicates need for more nuanced exploration of how such programs work and how to holistically assess program success. This qualitative study aims to identify characteristics of success in a large-scale, health and social needs case management program from the perspective of interdisciplinary case managers.SettingCase management program for high-risk, complex patients run by an integrated, county-based public health system.Participants30 out of 70 case managers, purposively sampled to represent their interdisciplinary health and social work backgrounds. Interviews took place in March-November 2019.Primary and secondary outcome measuresThe analysis intended to identify characteristics of success working with patients.ResultsCase managers described three characteristics of success working with patients: (1) establishing trust; (2) observing change in patients' mindset or initiative and (3) promoting stability and independence. Cross-cutting these characteristics, case managers emphasised the importance of patients defining their own success, often demonstrated through individualised, incremental progress. Thus, moments of success commonly contrasted with external perceptions and operational or productivity metrics.ConclusionsThemes emphasise the importance of compassion for complexity in patients' lives, and success as a step-by-step process that is built over longitudinal relationships.

BackgroundHealth care systems can support dissemination of innovations, such as social risk screening in physician practices, but to date, no studies have examined the association of health system characteristics and practice-level adoption of social risk screening.PurposeThe aim of the study was to examine the association of multilevel organizational capabilities and adoption of social risk screening among system-owned physician practices.MethodologySecondary analyses of the 2018 National Survey of Healthcare Organizations and Systems were conducted. Multilevel linear regression models examined physician practice and system characteristics associated with practice adoption of screening for five social risks (food insecurity, housing instability, utility needs, interpersonal violence, and transportation needs), accounting for clustering of practices within systems using random effects.ResultsSystem-owned practices screened for an average of 1.7 of the five social risks assessed. The intraclass correlation indicated 16% of practice variation in social risk screening was attributable to differences between their health systems owners, with 84% attributable to differences between individual practices. Practices owned by systems with multiple hospitals screened for an additional 0.44 social risks (p = .046) relative to practices of systems without hospitals. Practice characteristics associated with social risk screening included health information technology capacity (β = 0.20, p = .005), innovation culture (β = 0.26, p < .001), and patient engagement strategies (β = 0.57, p < .001).ConclusionsHealth care system capabilities account for less variation in physician practice adoption of social risk screening compared to practice-level capabilities.Practice implicationsEfforts to expand social risk screening among system-owned physician practices should focus on supporting practice capabilities, including enhancing health information technology, promoting an innovative organizational culture, and advancing patient engagement strategies.

BackgroundSocial needs case management programs are a strategy to coordinate social and medical care for high-risk patients. Despite widespread interest in social needs case management, not all interventions have shown effectiveness. A lack of evidence about the mechanisms through which these complex interventions benefit patients inhibits effective translation to new settings. The CommunityConnect social needs case management program in Contra Costa County, California recently demonstrated an ability to reduce inpatient hospital admissions by 11% in a randomized study. We sought to characterize the mechanisms through which the Community Connect social needs case management program was effective in helping patients access needed medical and social services and avoid hospitalization. An in-depth understanding of how this intervention worked can support effective replication elsewhere.MethodsUsing a case study design, we conducted semi-structured, qualitative interviews with case managers (n = 30) and patients enrolled in social needs case management (n = 31), along with field observations of patient visits (n = 31). Two researchers coded all interview transcripts and observation fieldnotes. Analysis focused on program elements identified by patients and staff as important to effectiveness.ResultsOur analyses uncovered three primary mechanisms through which case management impacted patient access to needed medical and social services: [1] Psychosocial work, defined as interpersonal and emotional support provided through the case manager-patient relationship, [2] System mediation work to navigate systems, coordinate resources, and communicate information and [3] Addressing social needs, or working to directly mitigate the impact of social conditions on patient health.ConclusionsThese findings highlight that the system mediation tasks which are the focus of many social needs assistance interventions offered by health care systems may be necessary but insufficient. Psychosocial support and direct assistance with social needs, enabled by a relationship-focused program, may also be necessary for effectiveness.

ObjectiveThis paper identifies implementation leadership characteristics in the school nutrition setting and places findings in the context of implementation leadership literature.MethodsFourteen interviews were conducted with school district leadership/staff in an urban school district. Modified grounded theory was employed.ResultsFour themes emerged: (1) understanding of technical/operational intervention details; (2) ability to proactively develop and communicate plans; (3) supervisory oversight; and (4) intervention framing. Themes were consistent with 4 of the 5 dimensions comprising the Implementation Leadership Scale: knowledgeable, proactive, perseverant, and distributed leadership. The supportive domain was not a major finding. An additional domain, how leaders message the intervention to staff, was identified.Conclusions and implicationsImplementation leadership in school nutrition appears similar, but not identical, to leader behaviors present in the Implementation Leadership Scale. School nutrition leaders might consider involving staff early in implementation planning, incorporating technical expertise, and clearly communicating the intervention purpose to support successful implementation. Future research might explore the interplay between leadership and implementation outcomes.

PurposeClinicians and policy makers are exploring the role of primary care in improving patients' social conditions, yet little research examines strategies used in clinical settings to assist patients with social needs.MethodsStudy used semistructured interviews with leaders and frontline staff at 29 diverse health care organizations with active programs used to address patients' social needs. Interviews focused on how organizations develop and implement case management-style programs to assist patients with social needs including staffing, assistance intensity, and use of referrals to community-based organizations (CBOs).ResultsOrganizations used case management programs to assist patients with social needs through referrals to CBOs and regular follow-up with patients. About one-half incorporated care for social needs into established case management programs and the remaining described standalone programs developed specifically to address social needs independent of clinical needs. Referrals were the foundation for assistance and included preprinted resource lists, patient-tailored lists, and warm handoffs to the CBOs. While all organizations referred patients to CBOs, some also provided more intense services such as assistance completing patients' applications for services or conducting home visits. Organizations described 4 operational challenges in addressing patients' social needs: (1) effectively engaging CBOs; (2) obtaining buy-in from clinical staff; (3) considering patients' perspectives; and (4) ensuring program sustainability.ConclusionAs the US health care sector faces pressure to improve quality while managing costs, many health care organizations will likely develop or rely on case management approaches to address patients' social conditions. Health care organizations may require support to address the key operational challenges.Visual abstract.

Objective: To investigate Covid‐19 vaccination as a potential secondary public health benefit of case management for Medicaid beneficiaries with health and social needs. Data Sources and Study Setting: The CommunityConnect case management program for Medicaid beneficiaries is run by Contra Costa Health, a county safety net health system in California. Program enrollment data were merged with comprehensive county vaccination records. Study Design: Individuals with elevated risk of hospital and emergency department use were randomized each month to a case management intervention or usual care. Interdisciplinary case managers offered coaching, community referrals, healthcare connections, and other support based on enrollee interest and need. Using survival analysis with intent‐to‐treat assignment, we assessed rates of first‐dose Covid‐19 vaccination from December 2020 to September 2021. In exploratory sub‐analyses we also examined effect heterogeneity by gender, race/ethnicity, age, and primary language. Data Collection and Extraction Methods: Data were extracted from county and program records as of September 2021, totaling 12,866 interventions and 25,761 control enrollments. Principal Findings: Approximately 58% of enrollees were female and 41% were under age 35. Enrollees were 23% White, 12% Asian/Pacific Islander, 20% Black/African American, and 36% Hispanic/Latino, and 10% other/unknown. Approximately 35% of the intervention group engaged with their case manager. Approximately 56% of all intervention and control enrollees were vaccinated after 9 months of analysis time. Intervention enrollees had a higher vaccination rate compared to control enrollees (adjusted hazard ratio [aHR]: 1.06; 95% confidence interval [CI]: 1.02–1.10). In sub‐analyses, the intervention was associated with stronger likelihood of vaccination among males and individuals under age 35. Conclusions: Case management infrastructure modestly improved Covid‐19 vaccine uptake in a population of Medicaid beneficiaries that over‐represents social groups with barriers to early Covid‐19 vaccination. Amidst mixed evidence on vaccination‐specific incentives, leveraging trusted case managers and existing case management programs may be a valuable prevention strategy. [ABSTRACT FROM AUTHOR]

Background and Objectives Area Agencies on Aging (AAAs) have funded, coordinated, and provided services since the 1960s, evolving in response to changes in policy, funding, and the political arena. Many of their usual service delivery programs and processes were severely disrupted with the onset of the coronavirus disease 2019 pandemic. Increasing evidence suggests the importance of partnerships in AAA's capacity to adapt services; however, specific examples of adaptations have been limited. We sought to understand how partnerships may have supported adaptation during the pandemic, from the perspectives of both AAAs and their partners. Research Design and Methods We conducted a secondary analysis of qualitative data from an explanatory sequential mixed-methods parent study. Data were collected from 12 AAAs diverse in terms of geographic region, governance structure and size, as well as a range of partner organizations. We completed 105 in-depth interviews from July 2020 to April 2021. A 5-member multidisciplinary team coded the data using a constant comparative method of analysis, supported by ATLAS.ti Scientific Software. Results AAAs and their partners described strategies and provided examples of ways to rapidly transform service delivery including reducing isolation, alleviating food insecurity, adapting program design and delivery, and leveraging partnerships and repurposing resources. Discussion and Implications AAAs and partner organizations are uniquely positioned to innovate during times of disruption. Findings may enhance AAA and partner portfolios of evidence-based and evidence-supported programs. [ABSTRACT FROM AUTHOR]

I Background: i Social needs case management is an increasingly common strategy used by health care organizations to address integrated health and social needs ([1]). Thus, social needs case management may increase primary care use and reduce acute care use by flexibly helping patients overcome social barriers to care. [Extracted from the article]

by health systems, which may support or hinder adoption of innovative care processes for adults with chronic conditions. We examined health system-- and physician practice--level capabilities associated with adoption of (1) patient engagement strategies and (2) chronic care management processes for adult patients with diabetes and/or cardiovascular disease. STUDY DESIGN: We analyzed data collected from the National Survey of Healthcare Organizations and Systems, a nationally representative survey of physician practices (n = 796) and health systems (n = 247) (2017-2018). METHODS: Multivariable multilevel linear regression models estimated system- and practice-level characteristics associated with practice adoption of patient engagement strategies and chronic care management processes. RESULTS: Health systems with processes to assess clinical evidence (β = 6.54 points on a 0-100 scale; P = .004) and with more advanced health information technology (HIT) functionality (β = 2.77 points per SD increase on a 0-100 scale; P = .03) adopted more practice-level chronic care management processes, but not patient engagement strategies, compared with systems lacking these capabilities. Physician practices with cultures oriented to innovation, more advanced HIT functionality, and with a process to assess clinical evidence adopted more patient engagement strategies and chronic care management processes. CONCLUSIONS: Health systems may be better able to support the adoption of practice-level chronic care management processes, which have a strong evidence base for implementation, compared with patient engagement strategies, which have less evidence to guide effective implementation. Health systems have an opportunity to advance patient-centered care by expanding practice-level HIT functionality and developing processes to appraise clinical evidence for practices. [ABSTRACT FROM AUTHOR]

Introduction: Improving performance often requires health care teams to employ creativity in problem solving, a key attribute of learning health systems. Despite increasing interest in the role of creativity in health care, empirical evidence documenting how this concept manifests in real‐world contexts remains limited. Methods: We conducted a qualitative study to understand how creativity was fostered during problem solving in 10 hospitals that took part in a 2‐year collaborative to improve cardiovascular care outcomes. We analyzed interviews with 197 hospital team members involved in the collaborative, focusing on work processes or outcomes that participants self‐identified as creative or promoting creativity. We sought to identify recurrent patterns across instances of creativity in problem solving. Results: Participants reported examples of creativity at both stages typically identified in problem solving research and practice: uncovering non‐obvious problems and finding novel solutions. Creativity generally involved the assembly of an "ecological view" of the care process, which reflected a more complete understanding of relationships between individual care providers, organizational sub‐units, and their environment. Teams used three prominent behaviors to construct the ecological view: (a) collecting new and diverse information, (b) accepting (rather than dismissing) disruptive information, and (c) employing empathy to understand and share feelings of others. Conclusions: We anticipate that findings will be useful to researchers and practitioners who wish to understand how creativity can be fostered in problem solving to improve clinical outcomes and foster learning health systems. [ABSTRACT FROM AUTHOR]

Context Methods Findings Conclusions Policy Points What are the facilitators and barriers of physician group participation in a performance‐based financial incentive program aimed at improving equity of care by patient race and ethnicity? Launching financial incentives to improve racial equity has required extensive organizational change management for participating physician groups, including major investments to improve quality management systems. Carefully designing financial incentives to encourage equity improvement while managing unintended consequences, and considering physician groups’ populations served, baseline maturity of quality management systems, and efforts to assess and address patients’ social risk factors have been central to prepare physician groups for financial incentives to improve equity of care. Given the major investments required of physician groups to prepare for financial incentives that reward equity improvement, alignment of equity of care measure specifications and reporting requirements across payers could facilitate physician group engagement. Evidence about how baseline physician group capabilities, including the maturity of their quality management systems, impact equity improvement may help health plans prioritize and target their investments to advance equity of care by patient race and ethnicity. What are the facilitators and barriers of physician group participation in a performance‐based financial incentive program aimed at improving equity of care by patient race and ethnicity? Launching financial incentives to improve racial equity has required extensive organizational change management for participating physician groups, including major investments to improve quality management systems. Carefully designing financial incentives to encourage equity improvement while managing unintended consequences, and considering physician groups’ populations served, baseline maturity of quality management systems, and efforts to assess and address patients’ social risk factors have been central to prepare physician groups for financial incentives to improve equity of care. Given the major investments required of physician groups to prepare for financial incentives that reward equity improvement, alignment of equity of care measure specifications and reporting requirements across payers could facilitate physician group engagement. Evidence about how baseline physician group capabilities, including the maturity of their quality management systems, impact equity improvement may help health plans prioritize and target their investments to advance equity of care by patient race and ethnicity. Blue Cross Blue Shield of Massachusetts (BCBSMA), a large commercial health insurer, is using financial incentives to advance equity of care by patient race and ethnicity. Understanding experiences of this payer and its contracted physician groups can inform efforts elsewhere. We qualitatively assess physician groups’ barriers and facilitators of planning and implementing BCBSMA's financial incentives to improve equity of ambulatory care quality by patient race and ethnicity.Key informant interviews (n = 44) of the physician group, BCBSMA, and external stakeholders were conducted, equity initiative meetings were observed, and documents were analyzed to identify barriers and facilitators of designing and preparing for financial incentives to advance racial equity. Physician group experiences of preparing for and responding to financial incentives for equity improvement were assessed.Analyses revealed 1) the central importance of valid and reliable equity performance measurement and carefully designed equity improvement incentives for physician group buy‐in, 2) that prior to implementing financial incentives for equity improvement, physician groups needed to improve their quality management systems and the accuracy and completeness of patient race and ethnicity data, and 3) physician groups’ populations served, baseline maturity of quality management systems, and efforts to assess and address patients’ social risk factors were central to consider to plan for physician group financial incentives to improve racial equity.Given the major infrastructure investments and organizational change management resources required of physician groups to participate in a financial incentive program designed to reward equity improvement, alignment of equity measurement and performance requirements across payers would facilitate physician groups’ engagement in efforts to improve quality of care for racial and ethnic minority patients. [ABSTRACT FROM AUTHOR]

Objectives: We identify the association between high- and low-intensity case management services on hospital and emergency department (ED) use among CommunityConnect patients., Background: Social needs case management services vary in intensity, including the modality, workforce specialization, and maximum caseload. CommunityConnect is a social needs case management program implemented by Contra Costa Health, a county safety-net health system in California's San Francisco Bay Area., Methods: Due to the endogeneity of high-intensity services assigned to high-risk patients, we instrument for service intensity using the number of specialist case managers hired each month of enrollment. Zero-inflated negative binomial models with 2-stage residual inclusion estimated total and avoidable hospital admissions and ED visits 12 months post-enrollment for adult Medicaid beneficiaries enrolled between August 2017 and December 2018 (n = 19,782)., Results: Compared with low-intensity case management, high-intensity services were associated with a reduction in the incidence rates of inpatient admissions [incidence rate ratio (IRR) = 0.341, 95% CI: 0.106-1.102; P = 0.072], ED visits (IRR = 0.608, 95% CI: 0.188-1.965; P = 0.058), and avoidable ED visits (IRR = 0.579, 95% CI: 0.179-1.872; P = 0.091). No significant association was found between service intensity and the likelihood of an event being an excess zero., Conclusions: High-intensity social needs case management may be more effective than low-intensity service at reducing health care use for individuals with non-zero use, suggesting that intensive case management may be especially helpful in supporting discharge and transitions of care., Competing Interests: All work is the author’s own and does not represent the views of the funders. Authors have no conflict of interest to declare. The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Many patients offered case management services to address their health and social needs choose not to engage. Factors that drive engagement remain unclear. We sought to understand patient characteristics associated with engagement in a social needs case management program and variability by case manager., Methods: Between August 2017 and February 2021, 43,347 Medicaid beneficiaries with an elevated risk of hospital or emergency department use were offered case management in Contra Costa County, California. Results were analyzed in 2022 using descriptive statistics and multilevel logistic regression models to examine 1) associations between patient engagement and patient characteristics and 2) variation in engagement attributable to case managers. Engagement was defined as responding to case manager outreach and documentation of at least 1 topic to mutually address. A sensitivity analysis was performed by stratifying the pre-COVID-19 and COVID-19 cohorts., Results: A total of 16,811 (39%) of eligible patients engaged. Adjusted analyses indicate associations between higher patient engagement and female gender, age 40 and over, Black/African American race, Hispanic/Latino ethnicity, history of homelessness, and a medical history of certain chronic conditions and depressive disorder. The intraclass correlation coefficient indicates that 6% of the variation in engagement was explained at the case manager level., Conclusions: Medicaid patients with a history of housing instability and specific medical conditions were more likely to enroll in case management services, consistent with prior evidence that patients with greater need are more receptive to assistance. Case managers accounted for a small percentage of variation in patient engagement., Competing Interests: Conflict of interest: None., (© Copyright 2024 by the American Board of Family Medicine.)