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We previously found that autistic adults who received care through a primary care embedded specialized clinic, called the Center for Autism Services and Transition (CAST), had higher satisfaction, continuity of care, and preventive care use than national samples of autistic adults.Examine the impact of CAST on healthcare utilization and expenditures.Retrospective study of medical billing data.CAST patients (N = 490) were propensity score matched to Medicare-enrolled autistic adults (N = 980) and privately insured autistic adults (N = 980) using demographic characteristics. The median age of subjects was 21 years, 79% were male, and the median duration of observation was 2.2 years.We quantified expenditures and utilization for primary care; emergency department (ED) visits; inpatient hospitalizations; mental health admissions; and outpatient visits.CAST patients had the highest primary care utilization and expenditures. However, CAST patients had significantly lower expenditures than Medicare-enrolled autistic adults for mental health admissions ($1074 vs $1903), outpatient visits ($1671 vs $2979), and total expenditures ($5893 vs $6987), as well as 57% fewer inpatient hospitalizations. Compared to privately insured autistic adults, CAST patients had significantly lower expenditures for mental health admissions ($1074 vs $1362), inpatient hospitalizations ($3851 vs $4513), and outpatient visits ($1671 vs $6070), as well as 16% fewer inpatient hospitalizations, 24% fewer ED visits, and 50% fewer outpatient visits. On average, CAST patients had more ED visits, mental health admissions, and outpatient visits than Medicare-enrolled autistic adults and more mental health admissions than privately insured autistic adults.Although CAST patients had greater primary care utilization and expenditures, our findings suggest embedding specialized clinics within broader primary care settings could be an alternative to current standards of care and may reduce expenditures and healthcare utilization in other areas, particularly relative to standard care for privately insured autistic adults.

Inpatient portals provide patients with clinical data and information about their care and have the potential to influence patient engagement and experience. Although significant resources have been devoted to implementing these portals, evaluation of their effects has been limited.To assess the effects of patient training and portal functionality on use of an inpatient portal and on patient satisfaction and involvement with care.This randomized clinical trial was conducted from December 15, 2016, to August 31, 2019, at 6 noncancer hospitals that were part of a single health care system. Patients who were at least 18 years of age, identified English as their preferred language, were not involuntarily confined or detained, and agreed to be provided a tablet to access the inpatient portal during their stay were eligible for participation. Data were analyzed from May 1, 2019, to March 15, 2021.A 2 × 2 factorial intervention design was used to compare 2 levels of a training intervention (touch intervention, consisting of in-person training vs built-in video tutorial) and 2 levels of portal function availability (tech intervention) within an inpatient portal (all functions operational vs a limited subset of functions).The primary outcomes were inpatient portal use, measured by frequency and comprehensiveness of use, and patients' satisfaction and involvement with their care.Of 2892 participants, 1641 were women (56.7%) with a median age of 47.0 (95% CI, 46.0-48.0) years. Most patients were White (2221 [76.8%]). The median Charlson Comorbidity Index was 1 (95% CI, 1-1) and the median length of stay was 6 (95% CI, 6-7) days. Notably, the in-person training intervention was found to significantly increase inpatient portal use (incidence rate ratio, 1.34 [95% CI, 1.25-1.44]) compared with the video tutorial. Patients who received in-person training had significantly higher odds of being comprehensive portal users than those who received the video tutorial (odds ratio, 20.75 [95% CI, 16.49-26.10]). Among patients who received the full-tech intervention, those who also received the in-person intervention used the portal more frequently (incidence rate ratio, 1.36 [95% CI, 1.25-1.48]) and more comprehensively (odds ratio, 22.52; [95% CI, 17.13-29.62]) than those who received the video tutorial. Patients who received in-person training had higher odds (OR, 2.01 [95% CI, 1.16-3.50]) of reporting being satisfied in the 6-month postdischarge survey. Similarly, patients who received the full-tech intervention had higher odds (OR, 2.06 [95%CI, 1.42-2.99]) of reporting being satisfied in the 6-month postdischarge survey.Providing in-person training or robust portal functionality increased inpatient engagement with the portal during the hospital stay. The effects of the training intervention suggest that providing personalized training to support use of this health information technology can be a powerful approach to increase patient engagement via portals.ClinicalTrials.gov Identifier: NCT02943109.

BACKGROUND: While in some studies, the patient-centered medical home has been linked with increased receipt of preventive services among other populations, there is a paucity of literature testing the effectiveness of medical homes in serving the healthcare needs of autistic adults. OBJECTIVE: To compare the receipt of preventive services by patients at a patient-centered medical home specifically designed for autistic adults (called the Center for Autism Services and Transition “CAST”) to US national samples of autistic adults with private insurance or Medicare. DESIGN: Retrospective study of medical billing data. SAMPLE: The study sample included CAST patients (N = 490) who were propensity score matched to Medicare-enrolled autistic adults (N = 980) and privately insured autistic adults (N = 980) using demographic characteristics. The median age of subjects was 21 years old, 79% were male, and the median duration of observation was 2.2 years. MAIN MEASURES: The primary outcome measure was the receipt of any preventive service, as defined by the Medicare Learning Network and AAPC (formerly the American Academy of Professional Coders). Secondary outcome measures included receipt of specific preventive service types (i.e., general health and wellness services, screenings, counseling and therapies, vaccinations, and sexual/reproductive health services). KEY RESULTS: CAST patients had significantly greater odds of receiving any preventive service than Medicare-enrolled (OR = 10.3; 95% CI = 7.6–13.9) and privately insured (OR = 3.1; 95% CI = 2.3–4.2) autistic adults. CAST patients were also significantly more likely to receive screenings and vaccinations than either Medicare beneficiaries (screenings OR = 20.3; 95% CI = 14.7–28.0; vaccinations OR = 5.5; 95% CI = 4.3–7.0) or privately insured beneficiaries (screenings OR = 2.0; 95% CI = 1.6–2.5; vaccinations OR = 3.3; 95% CI = 2.6–4.1). CONCLUSIONS: Autistic adults receiving care through CAST were significantly more likely to recieve preventive care services than national samples of autistic adults. Future comparative effectiveness trials are needed to rigorously assess the impact of primary care-based initiatives to improve care for autistic adults. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-020-06513-7.

While the medical home has proven effective at improving continuity of care among other populations, there is a paucity of literature testing the effectiveness of medical homes in serving the healthcare needs of autistic adults. We conducted a retrospective cohort study to compare the continuity of care of autistic adult patients at a specialized primary care medical home designed to remove barriers to care for autistic adults, called the Center for Autism Services and Transition (CAST), to propensity score matched national samples of autistic adults with private insurance or Medicare. The unadjusted median Bice–Boxerman continuity of care index was 0.6 (interquartile range = 0.4–1.0) for CAST patients, 0.5 (interquartile range = 0.3–1.0) for Medicare beneficiaries, and 0.6 (interquartile range = 0.4–1.0) for privately insured autistic adults. In multivariable models controlling for demographic characteristics, on average, CAST patients had continuity of care indices that were 10% higher than national samples of autistic adult Medicare beneficiaries (p Lay abstract There is a nationally recognized need for innovative healthcare delivery models to improve care continuity for autistic adults as they age out of pediatric and into adult healthcare systems. One possible model of care delivery is called the “medical home”. The medical home is not a residential home, but a system where a patient’s healthcare is coordinated through a primary care physician to ensure necessary care is received when and where the patient needs it. We compared the continuity of care among autistic adult patients at a specialized primary care medical home designed to remove barriers to care for autistic adults, called the CAST, to matched national samples of autistic adults with private insurance or Medicare. Continuity of primary care among CAST patients was significantly better than that of matched national samples of autistic adult Medicare beneficiaries and similar to that of privately insured autistic adults. Our findings suggest that medical homes, like CAST, are a promising solution to improve healthcare delivery for the growing population of autistic adults.

Autistic adults experience barriers to primary care, including distant/inaccessible clinics, sensory stressors, and communication barriers with providers. Synchronous telehealth visits, termed “virtual visits,” may be a way to minimize these barriers. We investigated the advantages and disadvantages of primary care virtual visits using a phenomenological approach. We interviewed autistic adults ( n = 7) and caregivers of autistic adults ( n = 12) from one primary care clinic. Using thematic analysis, we identified three advantages to virtual visits: (1) increased patient comfort from avoiding travel to the clinic, crowded waiting rooms, and other sensory stressors; (2) increased safety by avoiding physical contact with others who may be sick; and (3) similar or better patient–provider communication than in-person visits. Disadvantages included the following: (1) Internet instability and other technological issues, (2) the inability to receive hands-on care from the provider, and (3) reduced patient engagement due to environmental distractions. Virtual visits may minimize barriers to care for autistic adults by reducing travel time, exposure to sensory stressors, and barriers to communication with the provider. While we recognize that virtual visits may not be appropriate for all patients or in all situations, they may be a promising model of health care delivery for autistic adults. Lay abstract Autistic adults face many barriers to receiving quality primary health care like clinics that are far away and sensory sensitivities. Real-time telehealth visits, called “virtual visits,” are live video chats between the patient and provider. Virtual visits may minimize barriers to care for autistic adults. We wanted to describe advantages and disadvantages of using virtual visits for delivering primary health care for autistic adults. We interviewed 7 autistic adults and 12 caregivers of autistic adults who receive primary care through one clinic. Autistic adults and caregivers said advantages to virtual visits were that (1) patients were more comfortable at home, (2) patients could get health care while avoiding physical contact with other people during the pandemic, and (3) virtual visits were similar to or better than in-person visits. The disadvantages included that (1) there could be technology problems like grainy video, (2) the doctor could not physically examine the patient (e.g. look in ears), and (3) patients sometimes participated less in the virtual visit than they would in person. Virtual visits may be beneficial for autistic adults by eliminating travel to the clinic and avoiding stressful sensory stimuli. We recognize that virtual visits may not work for all patients or in all situations. However, our study shows that primary care virtual visits may be beneficial for autistic adults during and beyond the pandemic.

BACKGROUND: Autistic adults have complex physical and mental healthcare needs that necessitate specialized approaches to healthcare. One promising approach is to embed providers with specialized training or specialty clinics for autistic adults within general primary care facilities. We previously found that autistic adults who received their healthcare through one specialty clinic designed with and for autistic adults had better continuity of care and more preventive service utilization than national samples of autistic adults. OBJECTIVE: To characterize factors that increased or decreased satisfaction with healthcare received through a specialty clinic for autistic adults. METHODS: We conducted 30–60-minute semi-structured interviews with autistic adults (N=9) and parents of autistic adults (N=12). We conducted an inductive thematic analysis, using a phenomenological approach. RESULTS: Factors that increased participants’ satisfaction included: (1) receiving personalized care from the provider; (2) spending quality time with the provider; and (3) having strong, positive patient-provider relationships. Factors that decreased participants’ satisfaction included: (1) lack of access to services due to scarcity of trained providers; (2) difficulty at times communicating with the provider; and (3) system-level barriers such as policies, practices, or procedures. CONCLUSION: Our findings highlight the importance of providers using personalized approaches to care that meet patients’ sensory and communication needs and spending quality time with patients to establish strong, positive patient-provider relationships. Our findings also underscore the critical scarcity of healthcare providers who are trained to deliver care for the growing population of autistic adults.

BACKGROUND: Accurate and timely surveillance and diagnosis of healthcare-facility onset Clostridium difficile infection (HO-CDI) is vital to controlling infections within the hospital, but there are limited tools to assist with timely outbreak investigations. OBJECTIVES: To integrate spatiotemporal factors with HO-CDI cases and develop a map-based dashboard to support infection preventionists (IPs) in performing surveillance and outbreak investigations for HO-CDI. METHODS: Clinical laboratory results and Admit-Transfer-Discharge data for admitted patients over two years were extracted from the Information Warehouse of a large academic medical center and processed according to Center for Disease Control (CDC) National Healthcare Safety Network (NHSN) definitions to classify Clostridium difficile infection (CDI) cases by onset date. Results were validated against the internal infection surveillance database maintained by IPs in Clinical Epidemiology of this Academic Medical Center (AMC). Hospital floor plans were combined with HO-CDI case data, to create a dashboard of intensive care units. Usability testing was performed with a think-aloud session and a survey. RESULTS: The simple classification algorithm identified all 265 HO-CDI cases from 1/1/15-11/30/15 with a positive predictive value (PPV) of 96.3%. When applied to data from 2014, the PPV was 94.6% All users “strongly agreed” that the dashboard would be a positive addition to Clinical Epidemiology and would enable them to present Hospital Acquired Infection (HAI) information to others more efficiently. CONCLUSIONS: The CDI dashboard demonstrates the feasibility of mapping clinical data to hospital patient care units for more efficient surveillance and potential outbreak investigations.

Background: Little is known about the extent to which patient-centered medical homes meet the needs of autistic adults. Materials & methods: We conducted a cross-sectional survey of autistic adult patients (n = 47) and caregivers of autistic adult patients (n = 66) receiving care through one patient-centered medical home specifically designed to meet the needs of this population. We performed post hoc comparisons of our results to previously published data from a national sample of autistic adults. Results: Participants reported high levels of satisfaction with care, frequent preventive healthcare use and few unmet healthcare needs. Autistic adults in our sample reported significantly higher satisfaction and fewer unmet healthcare needs. Conclusion: A patient-centered medical home tailored to the needs of autistic adults is a promising approach to healthcare delivery for meeting this population’s needs.

Many are interested in how to safely ramp up elective surgeries after national, state, and voluntary shutdowns of operating rooms to minimize the spread of COVID-19 infections to patients and providers. We conducted an analysis of diverse perspectives from stakeholders regarding how to trade off risks and benefits to patients, healthcare providers, and the local community. Our findings indicate that there are a large number of different categories of stakeholders impacted by the post-pandemic decisions to reschedule delayed treatments and surgeries. For a delayed surgery, the primary stakeholders are the surgeon with expertise about the clinical benefits of undergoing an operation and the patient’s willingness to tolerate uncertainty and the increased risk of infection. For decisions about how much capacity in the operating rooms and in the inpatient setting after the surgery, the primary considerations are minimizing staff infections, preventing patients from getting COVID-19 during operations and during post-surgical recovery at the hospital, conserving critical resources such as PPE, and meeting the needs of hospital staff for quality of life, such as child care needs and avoiding infecting members of their household. The timing and selection of elective surgery cases has an impact on the ability of hospitals to steward finances, which in turns affects decisions about maintaining employment of staff when operating rooms and inpatient rooms are not being used.

Background A total of 17,000 patients receive kidney transplants each year in the United States. The 30-day readmission rate for kidney transplant recipients is over 30%. Our research focuses on the relationship between the quality of care delivered during the patient's hospital stay for a kidney transplant, and the patient health outcomes and readmissions related to the transplant. Methods We interviewed 20 kidney transplant recipients at a major transplant center in the United States. Findings from these interviews were used to inform the data collection using structured surveys, which were administered to an additional 77 kidney transplant recipients. We used ordinary least squares regression to predict the effects of two dimensions of in-hospital care quality–information consistency and empathetic care delivery–on level of patient anxiety 1 week following discharge. Further, we estimated a logistic regression to predict the effect of anxiety, combined with the two dimensions of in-hospital care quality, on occurrence of 30-day readmissions. Results Patient anxiety levels 1 wk after discharge are significantly associated with information consistency and empathetic delivery of care. Patient anxiety 1 wk after discharge is associated with occurrence of 30-d readmissions. The logistic regression model indicates that the risk of getting readmitted is 110% higher for a one unit increase in patient anxiety level 1 wk after discharge. Finally, patient anxiety fully mediates the effects of consistency of information and empathetic care delivery on occurrence of 30-d readmissions (50.96% of the effect is mediated). Conclusions Our study suggests two ways of preventing readmissions through reduction of postdischarge anxiety: (1) standardizing in-hospital care, so that information received by patients is consistent, and (2) by training caregivers to be more empathetic toward patients during the delivery of this information.