Patricia Hayes, MD


Contributor: Improving Seniors’ Health and Outcomes With a Value-Based Care Team Approach

A value-based care team approach can be utilized to adequately treat patients’ medical problems, particularly by addressing the social, economic, and environmental challenges they’re facing in their everyday lives.

Cara McDonnell, MPH


Assessment of Structured Data Elements for Social Risk Factors

An expert panel identified and assessed electronic health record and health information exchange structured data elements to support future development of social risk factor computable phenotyping.

Robert Pittman


Contributor: Technology, Supplemental Services in MA Can Help Improve Participant Health

Social determinants of health present many health-related challenges for Medicare Advantage (MA) plan members, something these plans are looking to overcome by diversifying their service offerings.

Jay Anders, MD


Contributor: Giving Clinicians Top-line Data to Help Manage Chronic Conditions

To accurately understand the progression or control of a condition, physicians require ready access to key indicators relevant to that illness. The industry should do a better job of making them available.

Weihao Zhou, MS


Intersection of Complexity and High Utilization Among Health Center Patients Aged 18 to 64 Years

This paper utilizes latent class analysis to identify subgroups of complex conditions and of super-utilizers among health center patients to inform clinically tailored efforts.

Pei Ting Tan, MSc


Evaluating Smoking Cessation Service at an Emergency Department Clinical Observation Unit

This study aimed to evaluate the impact of a smoking cessation service in a group of patients admitted to a short-stay unit in the emergency department.

Jeremy Rubel


Contributor: Using Technology to Streamline Enrollment Into Available Medicare Subsidy Programs

Medicare Advantage plans can drive significant, sustainable, and scalable improvements to health outcomes; reduce cost; and boost retention and top-line revenue by enrolling beneficiaries into the comprehensive set of state and federal low-income programs available to them.

Yolaine Jeune-Smith, PhD


Oncologists’ Perceptions and Utilization of US Therapeutic Oncology Biosimilars

Biosimilar use in clinical practice is determined by oncologists’ perceptions of and willingness to prescribe them. The authors investigated US oncologists’ perceptions and use of biosimilars.

Sean M. Reed, PhD, APRN


Modeling of an Alternative Reimbursement Method for Palliative Care

The authors modeled a version of the Patient and Caregiver Support for Serious Illness alternative reimbursement structure for palliative care using data from the Statin Trial.

Heidy Medina, MPH


Social Determinants of Health Score: Does It Help Identify Those at Higher Cardiovascular Risk?

Calculating a social score is feasible and it predicts cardiovascular outcomes. In order to do this, institutions have to collect social determinants of health.

Benjamin Ukert, PhD


On the Impact of Predictive Analytics–Driven Disease Management Interventions

Predictive analytics–driven disease management outperforms standard of care among patients with chronic heart failure.

Loida Tamayo, PhD


Sex Differences in Medicare Beneficiaries’ Experiences by Low-Income Status

Only low-income male Medicare beneficiaries had worse patient experience than their female counterparts. The authors discuss opportunities to improve experiences for all patients.

Yi Li, PhD


Effective Prevention and Management of COVID-19 in Outpatient Hemodialysis Patients

The authors introduce a mobile phone app that may effectively prevent and manage coronavirus disease 2019 (COVID-19) in outpatient hemodialysis patients in Sichuan Province, China.

Peter F. Cronholm, MD, MSCE


Patient Perspectives on Technology-Based Approaches to Social Needs Screening

Patients are essential stakeholders in designing systems to capture social needs. The authors present key findings from patient interviews regarding social needs screening through technology-based modalities.

Stephen J. Bartels, MD, MS


The Essential Role of Population Health During and Beyond COVID-19

The authors detail how population health management enables health systems to promote public health, strengthen health system resiliency, and support financial recovery during and beyond coronavirus disease 2019 (COVID-19).

Todd Burkard, MBA


Improving Risk Stratification Using AI and Social Determinants of Health

Prediction models combining claims data with social determinants of health and additional, more-timely data sources using artificial intelligence (AI) can better identify individuals with the highest future medical spending.

Suet Lim, PhD


The Implementation of Opioid Prescribing Report Cards in Medicaid Managed Care: A Community Quality Collaborative

This article describes the Philadelphia Medicaid Opioid Prescribing Initiative that was launched by a multidisciplinary team and mailed local Medicaid providers individualized prescribing report cards.

Sonia Tadjalli Oskouei, PharmD, BCMAS


Oncologists’ Perceptions and Utilization of US Therapeutic Oncology Biosimilars

Biosimilar use in clinical practice is determined by oncologists’ perceptions of and willingness to prescribe them. The authors investigated US oncologists’ perceptions and use of biosimilars.

Tejal Patel, MPH


Patient-Centered Oncology Care: Impact on Utilization, Patient Experiences, and Quality

Practices implementing a patient-centered oncology care pilot had improved quality, but utilization and patient experiences did not differ from comparison practices.

Robert Moore, MD


Evaluation of a Pediatric Asthma High-risk Scoring Algorithm

An asthma risk score using 7 clinically relevant parameters evaluated in a pediatric Medicaid managed care population can stratify risk for following-year asthma hospitalization.

Ken Travis, MS-ODL


Discharge Before Noon: Is the Sun Half Up or Half Down?

Discharge before noon was associated with longer length of stay in patients with medical diagnoses and shorter length of stay in surgical patients.

Michele L. Hamburger, MA, MFS


Using Telemedicine Interventions During COVID-19 to Expand Care Post COVID-19

The Patient-Centered Rheumatology Collaborative identified several critical areas for further intervention to improve the delivery of high-quality, patient-centered care during the COVID-19 pandemic and beyond.

Nabeel Qureshi, MPH


Using CAHPS Patient Experience Data for Patient-Centered Medical Home Transformation

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) Patient-Centered Medical Home survey assists practices by targeting improvement, standardizing care delivery, discussing best practices, improving provider-patient communication, coordinating care, and supporting patient self-management.

Gary Hamilton


Contributor: The Role of Patient Engagement in Creating Active Patients

As health care shifts reimbursement models from fee-for-service to value-based care, new terms and phrases have been surfacing across the industry. Two of the terms emerging with increased usage are “patient engagement” and an “active patient.” But what do they mean? And why are they important?

Marlene Millen, MD


Implementing Clinical Informatics Tools for Primary Care–Based Diabetic Retinopathy Screening

The authors describe a primary care–based diabetic retinopathy screening program incorporating telemedicine, strong health information technology engagement, and development of clinical informatics tools.

Holly S. Kidrowski, MPH


Using a Brief Tool to Assess Healthy School Environments: A Pilot Study

The authors evaluated a brief assessment tool that accountable care organizations can use to help elementary schools improve student nutrition and increase physical activity.

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