Policy makers are increasingly investing in programs focused on identifying and addressing the nonmedical needs of high-utilizing Medicaid beneficiaries, yet little is known about these programs' implementation. This study provides an overview of early progress in and strategies used to implement California's Whole Person Care (WPC) Pilot Program, a $3 billion Medicaid Section 1115(a) waiver demonstration project focused on improving the integrated delivery of health, behavioral health, and social services for Medicaid beneficiaries who use acute and costly services in multiple service sectors. WPC pilots reported significant progress in developing partnerships, data-sharing infrastructure, and services needed to coordinate care for identified patient populations. We also identified major barriers to WPC implementation, such as difficulty identifying and engaging eligible beneficiaries and the lack of affordable housing. Our findings offer insights to leaders and policy makers interested in testing new approaches for improving the health and well-being of medically and socially complex patients.

Objective

To investigate the differential associations of homelessness with emergency department (ED) visits and hospitalizations by race, ethnicity, and gender.

Data sources

California Medicaid enrollment and claims.

Study design

We identified beneficiaries experiencing homelessness (BEH) and those who did not (NBEH) using diagnosis and place of service codes and residential addresses. Outcomes include four ED visit measures and four hospitalization measures. We compared the use of these services by BEH to NBEH overall and by race, ethnicity, and gender groups in regression models controlling for covariates.

Data collection

We used a sample of Medicaid beneficiaries who met eligibility criteria for a California Medicaid demonstration program in 2017 and 2018 but were not enrolled in the program. We identified 473,069 BEH, and the rest (1,948,422) were considered NBEH. We used the 2018 data for utilization analyses and most covariates. We constructed lagged measures of health conditions using 2017 data.

Principal findings

We found that homelessness was significantly associated with 0.34 more ED visits (p < 0.01) and a higher likelihood of frequent ED visits (2.77 percentage points [pp], p < 0.01), any ED visits due to mental health conditions (0.79 pp, p < 0.01), and any ED visits due to substance use disorders (1.47 pp, p < 0.01). Experiencing homelessness was also significantly associated with 0.03 more hospitalizations (p < 0.01), a higher likelihood of frequent hospitalizations (0.68 pp, p < 0.01) and high frequent hospitalizations (0.28 pp, p < 0.01), and a longer length of stay (0.53 days, p < 0.01). We found a larger association for American Indian and Alaska Native, Black, Native Hawaii or Pacific Islander, and White populations than that for Asian and Hispanic populations. The associations are larger for males than females.

Conclusions

Our findings identified distinct utilization patterns by race, ethnicity, and gender. They indicated the need for developing race, ethnicity, and gender-specific strategies to reduce ED visits and hospitalizations of BEH.

Recognizing that social factors influence patient health outcomes and utilization, health systems have developed interventions to address patients' social needs. Care coordination across the health care and social service sectors is a distinct and important strategy to address social determinants of health, but limited information exists about how care coordination operates in this context. To address this gap, the authors conducted a systematic review of peer-reviewed publications that document the coordination of health care and social services in the United States. After a structured elimination process, 25 publications of 19 programs were synthesized to identify patterns in care coordination implementation. Results indicate that patient needs assessment, in-person patient contact, and standardized care coordination protocols are common across programs that bridge health care and social services. Publications discussing these programs often provide limited detail on other key elements of care coordination, especially the nature of referrals and care coordinator caseload. Additional research is needed to document critical elements of program implementation and to evaluate program impacts.

Background

The opioid epidemic and subsequent mortality is a national concern in the U.S. The burden of this problem is disproportionately high among low-income and uninsured populations who are more likely to experience unmet need for substance use services. We assessed the impact of two Health Resources and Services Administration (HRSA) substance use disorder (SUD) service capacity grants on SUD staffing and service use in HRSA -funded health centers (HCs).

Methods and findings

We conducted cross-sectional analyses of the Uniform Data System (UDS) from 2010 to 2017 to assess HC (n = 1,341) trends in capacity measured by supply of SUD and medication-assisted treatment (MAT) providers, utilization of SUD and MAT services, and panel size and visit ratio measured by the number of patients seen and visits delivered by SUD and MAT providers. We merged mortality and national survey data to incorporate SUD mortality and SUD treatment services availability, respectively. From 2010 to 2015, 20% of HC organizations had any SUD staff, had an average of one full-time equivalent SUD employee, and did not report an increase in SUD patients or SUD services. SUD capacity grew significantly in 2016 (43%) and 2017 (22%). MAT capacity growth was measured only in 2016 and 2017 and grew by 29% between those years. Receipt of both supplementary grants increased the probability of any SUD capacity by 35% (95% CI: 26%, 44%) and service use, but decreased the probability of SUD visit ratio by 680 visits (95% CI: -1,013, -347), compared to not receiving grants.

Conclusions

The significant growth in HC specialized SUD capacity is likely due to supplemental SUD-specific HRSA grants and may vary by structure of grants. Expanding SUD capacity in HCs is an important step in increasing SUD access for low income and uninsured populations broadly and for patients of these organizations.

Aims: This paper examines the association of multimorbidity, mental health (MH) conditions, and obesity severity among health center (HC) patients in the United States. Methods: We used cross-sectional data from the 2014 Health Center Patient Survey (n = 5370). We examined the independent association of multimorbidity and MH conditions with obesity severity using a multinomial logistic regression model, controlling for potential confounders. Results: More than half (50.4%) of HC patients had obesity, including 15% with severe obesity. In addition, 41% had multimorbidity and 49% had one of five diagnosed MH conditions. We found higher odds of having mild (OR = 4.06), moderate (OR = 3.39), and severe (OR = 4.93) obesity with the presence of both multimorbidity and MH conditions. Multimorbidity alone was also associated with higher odds of obesity, but MH conditions alone were only associated with having moderate obesity. Conclusions: Findings show a higher burden of comorbidity and MH conditions given the severity of obesity among HC patients. This complex patient profile highlights the need for innovative approaches in effective care delivery and management of HC patients who are primarily low-income or uninsured. Approaches may include further integration of behavioral health and social services with primary care and the need for targeted practice guidelines for providers managing such patients.