Integrating Population Health Strategies into Primary Care: Impact on Outcomes and Hospital Use for Low-Income Adults

Abstract

Objective: Our objectives were two-fold: 1) To evaluate the benefits of population health strategies focused on social de­terminants of health and integrated into the primary care medical home (PCMH) and 2) to determine how these strategies impact diabetes and cardiovascular disease outcomes among a low-income, primarily minority community. We also investigated associations between these outcomes and emergency department (ED) and inpatient (IP) use and costs.Design: Retrospective cohort.Setting: Community-based PCMH: Baylor Scott & White Health and Wellness Center (BSW HWC).Patients/Participants: All patients who attended at least two primary care visits at BSW HWC within a 12-month time span from 2011-2015.Methods: Outcomes for patients participat­ing in PCMH only (PCMH) as compared to PCMH plus population health services (PCMH+PoPH) were compared using elec­tronic health record data.Main Outcomes: Diastolic and systolic blood pressure, hemoglobin A1c, ED visits and costs, and IP hospitalizations and costs were examined.Results: From 2011-2015, 445 patients (age=46±12 years, 63% African American, 61% female, 69.5% uninsured) were includ­ed. Adjusted regression analyses indicated PCMH+PoPH had greater improvement in diabetes outcomes (prediabetes HbA1c= -.65[SE=.32], P=.04; diabetes HbA1c= -.74 [SE=.37], P<.05) and 37% lower ED costs than the PCMH group (P=.01). Worsening chronic disease risk factors was associated with 39% higher expected ED visits (P<.01), whereas improved chronic disease risk was associated with 32% fewer ED visits (P=.04).Conclusions: Integrating population health services into the PCMH can improve chron­ic disease outcomes, and impact hospital utilization and cost in un- or under-insured populations. Ethn Dis. 2022;32(2):91-100; doi:10.18865/ed.32.2.91