Impactability Modeling for Reducing Medicare Accountable Care Organization Payments and Hospital Events in High-Need High-Cost Patients: Longitudinal Cohort Study.

Background: Impactability modeling promises to help solve the nationwide crisis in caring for high-need high-cost patients by matching specific case management programs with patients using a "benefit" or "impactability" score, but there are limitations in tailoring each model to a specific program and population.

Objective: We evaluated the impact on Medicare accountable care organization savings from developing a benefit score for patients enrolled in a historic case management program, prospectively implementing the score, and evaluating the results in a new case management program.

Methods: We conducted a longitudinal cohort study of 76,140 patients in a Medicare accountable care organization with multiple before-and-after measures of the outcome, using linked electronic health records and Medicare claims data from 2012 to 2019.

Risk from delayed or missed care and non-COVID-19 outcomes for older patients with chronic conditions during the pandemic.

Background: During the COVID-19 pandemic, patients with chronic illnesses avoided regular medical care, raising concerns about long-term complications. Our objective was to identify a population of older patients with chronic conditions who may be at risk from delayed or missed care (DMC) and follow their non-COVID outcomes during the pandemic.

Methods: We used a retrospective matched cohort design using Medicare claims and electronic health records at a large health system with community and academic clinics.

Using Statewide Electronic Health Record and Influenza Vaccination Data to Plan and Prioritize COVID-19 Vaccine Outreach and Communications in Wisconsin Communities.

The University of Wisconsin Neighborhood Health Partnerships Program used electronic health record and influenza vaccination data to estimate COVID-19 relative mortality risk and potential barriers to vaccination in Wisconsin ZIP Code Tabulation Areas. Data visualization revealed four groupings to use in planning and prioritizing vaccine outreach and communication based on ZIP Code Tabulation Area characteristics. The program provided data, visualization, and guidance to health systems, health departments, nonprofits, and others to support planning targeted outreach approaches to increase COVID-19 vaccination uptake.

Reducing Fall-related Revisits for Elderly Diabetes Patients in Emergency Departments: A Transition Flow Model.

This paper introduces a transition flow model to study fall-related emergency department (ED) revisits for elderly patients with diabetes. Five diabetes classes are used to classify patients at discharge, within 7-day revisits, and between 8 and 30-day revisits. Analytical formulas to evaluate patient revisiting risks are derived.