Associations among claims-based care fragmentation, self-reported gaps in care coordination, and self-reported adverse events.

Background: Fragmentation of care (that is, the use of multiple ambulatory providers without a dominant provider) may increase the risk of gaps in communication among providers. However, it is unclear whether people with fragmented care (as measured in claims) perceive more gaps in communication among their providers. It is also unclear whether people who perceive gaps in communication experience them as clinically significant (that is, whether they experience adverse events that they attribute to poor coordination).

Understanding the Perspectives of Key Stakeholders toward Medicare's Home Health Value-Based Purchasing (HHVBP) in the US.

Objectives: This study examines the perspectives of key stakeholders in home health toward Medicare's Home Health Value Based Purchasing (HHVBP) program, piloted among home health agencies (HHAs) in 9 states from 2016 to 2021, and based on initial performance, was expanded to the remaining 41 (nonpilot) states in January 2023.

Design: We conducted semistructured interviews wherein we inquired participants' views toward and experiences with HHVBP. We used convenience and purposive sampling to obtain diversity in HHA size, geography, and quality.

Gaps in the coordination of care for people living with dementia.

Background: One-third of people living with dementia (PLWD) have highly fragmented care (i.e., care spread across many ambulatory providers without a dominant provider).

Association between Gaps in Care Coordination and Emergency Department Visits Among Children without Chronic Conditions or Special Needs.

Objective: Prior studies and have shown that gaps in care coordination (CC) increase the risk of emergency department (ED) visits among children with special healthcare needs. This study aims to determine if gaps in CC are associated with an increased risk of ED visits among children without special needs (non-CSHCN).

Study Design: We conducted a cross-sectional study using the National Survey of Children's Health (2018-2019), representing children up to age 17.

Ambulatory Care Fragmentation and Total Health Care Costs.

Background: The magnitude of the relationship between ambulatory care fragmentation and subsequent total health care costs is unclear.

Objective: To determine the association between ambulatory care fragmentation and total health care costs.

Research Design: Longitudinal analysis of 15 years of data (2004-2018) from the national Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, linked to Medicare fee-for-service claims.

Adverse Social Determinants of Health and Gaps in Care Coordination Among Children.

Gaps in care coordination (CC) can have detrimental impacts on children's health. It is unclear how much adverse social determinants of health (SDoH) may affect CC gaps. We determined whether exposure to adverse SDoH is associated with experiencing more gaps in CC using a representative national sample of children.

Diabetes, gaps in care coordination, and preventable adverse events.

Objectives: To compare the frequency of self-reported gaps in care coordination and self-reported preventable adverse events among adults with vs without diabetes.

Study Design: Cross-sectional analysis of REasons for Geographic And Racial Differences in Stroke (REGARDS) study participants 65 years and older who completed a survey on health care experiences in 2017-2018 (N = 5634).

Methods: We analyzed the association of diabetes with self-reported gaps in care coordination and with preventable adverse events.

Building research capacity in primary care practices that serve predominantly racial and ethnic minority populations.

Primary care research represents only 1% of all federally funded projects. However, innovation in primary care is central to advancing health care delivery. Indeed, leaders in health care innovation recently called for primary care payment reform proposals to be tested in accountable care organizations (ACOs) consisting of independent practices (ie, practices not owned by hospitals).

Home Health Care Workers' Interactions with Medical Providers, Home Care Agencies, and Family Members for Patients with Heart Failure.

Background: Despite providing frequent care to heart failure (HF) patients, home health care workers (HHWs) are generally considered neither part of the health care team nor the family, and their clinical observations are often overlooked. To better understand this workforce's involvement in care, we quantified HHWs' scope of interactions with clinicians, health systems, and family caregivers.

Methods: Community-partnered cross-sectional survey of English- and Spanish-speaking HHWs who cared for a HF patient in the last year.

Diabetes and cancer co-management: patient-reported challenges, needs, and priorities.

Introduction: Twenty percent of breast cancer survivors have co-occurring diabetes and face a 50% greater risk of 10-year mortality compared to survivors without diabetes. Individuals with cancer are often overwhelmed during cancer treatment and have less time for their diabetes, contributing to worse outcomes. We elicited perspectives of breast cancer survivors with diabetes regarding their specific needs for diabetes and cancer co-management.

Self-reported gaps in care coordination and preventable adverse outcomes among older adults receiving home health care.

Background: Older adults see multiple outpatient providers and increasingly use home health care (HHC) services. Previous studies attempting to draw inferences about the association between HHC use and patient outcomes have been mixed. Whether HHC is associated with care coordination and how both influence outcomes are unknown.

Ambulatory Care Fragmentation, Emergency Department Visits, and Race: a Nationwide Cohort Study in the U.S.

Background: It is unclear whether highly fragmented ambulatory care (i.e., care spread across multiple providers without a dominant provider) increases the risk of an emergency department (ED) visit.

Development and Piloting of a Community-Partnered Heart Failure Training Course for Home Health Care Workers.

Background: Despite their unique contributions to heart failure (HF) care, home healthcare workers (HHWs) have unmet educational needs and many lack HF caregiving self-efficacy. To address this, we used a community-partnered approach to develop and pilot a HF training course for HHWs.

Methods: We partnered with the Training and Employment Fund, a benefit fund of the largest healthcare union in the United States, to develop a 2-hour virtual HF training course that met HHWs' job-specific needs.

Predicting Fragmented Care: Beneficiary, Physician, Practice, and Market Characteristics.

Background: Understanding what drives fragmented ambulatory care (care spread across multiple providers without a dominant provider) can inform the design of future interventions to reduce unnecessary fragmentation.

Objectives: To identify the characteristics of beneficiaries, primary care physicians, primary care practice sites, and geographic markets that predict highly fragmented ambulatory care in the United States.

Research Design: Cross-sectional analysis of Medicare claims data for beneficiaries attributed to primary care physicians and practices in 2018.

Veterans' ambulatory care experience during COVID-19: veterans' access to and satisfaction with primary care early in the pandemic.

Background: The COVID-19 pandemic caused widespread changes to healthcare, but few studies focus on ambulatory care during the early phase of the pandemic. We characterize veterans' ambulatory care experience, specifically access and satisfaction, early in the pandemic.

Methods: We employed a semi-structured telephone interview to capture quantitative and qualitative data from patients scheduled with a primary care provider between March 1 - June 30, 2020.

Nearly All Cancer Survivors Return to Primary Care.

Background: During cancer treatments, patients often defer primary care and comorbidity management, which may not be optimal for overall health when patients transition into survivorship. We sought to quantify primary care utilization among cancer survivors who are ≥2 years post cancer treatments.

Methods: 951 cancer survivors were included in this national, prospective cohort study using the Regional Geographic and Racial Differences in Stroke (REGARDS) data.

Communication Gaps Persist Between Primary Care and Specialist Physicians.

A survey conducted with data from 2008 found that physicians often do not communicate with each other at the time of referral or after consultation. Communication between physicians might have improved since then, with the dissemination of electronic health records (EHRs), but this is not known. We used 2019 survey data to measure primary care physicians' perceptions of communication at the time of referral and after consultation.

Frailty, gaps in care coordination, and preventable adverse events.

Background: Older US adults often receive care from multiple ambulatory providers. Seeing multiple providers may be clinically appropriate but creates challenges for communication. Whether frailty is a risk factor for gaps in communication among older adults and subsequent preventable adverse events is unknown.

Managing diabetes during treatment for breast cancer: oncology and primary care providers' views on barriers and facilitators.

Purpose: Diabetes is a prevalent comorbid condition among many women with breast cancer. The roles and responsibilities of managing diabetes during cancer care are unclear, as oncologists lack interest and clinical expertise and many patients stop seeing their primary care providers (PCPs). Uncertainty around who should manage diabetes for cancer patients can result in gaps in care for survivors.

Primary care redesign and care fragmentation among Medicare beneficiaries.

Objectives: To determine associations between a large-scale primary care redesign-the Comprehensive Primary Care Plus (CPC+) Initiative-and the extent of continuity or fragmentation of ambulatory care for Medicare fee-for-service beneficiaries during the first 3 years of CPC+.

Study Design: We used a difference-in-differences framework with a comparison group of practices that were similar to CPC+ practices at baseline (eg, practice size, demographics, Medicare spending). Regressions controlled for clustering, baseline patient characteristics, and practice fixed effects.

Health care fragmentation and blood pressure control among adults taking antihypertensive medication.

Objectives: To determine the association of fragmented ambulatory health care with uncontrolled blood pressure (BP) and apparent treatment-resistant hypertension (aTRH) among older adults taking antihypertensive medication, overall and by race and gender.

Study Design: Cross-sectional study using data from 2868 REasons for Geographic And Racial Differences in Stroke (REGARDS) study participants 66 years and older who completed a study examination in 2013-2016, had Medicare fee-for-service coverage, and were taking antihypertensive medication.

Methods: We used logistic regression to analyze the association of fragmented health care with uncontrolled BP and aTRH.