Faculty Bibliography

ABSTRACT: BACKGROUND: A small percentage of high-risk patients accounts for a large proportion of Medicaid spending in the United States, which has become an urgent policy issue. Our objective was to pilot a novel patient-centered intervention for high-risk patients with frequent hospital admissions to determine its potential to improve care and reduce costs. METHODS: Community and hospital-based care management and coordination intervention with pre-post analysis of health care utilization. We enrolled Medicaid fee-for-service patients aged 18-64 who were admitted to an urban public hospital and identified as being at high risk for hospital readmission by a validated predictive algorithm. Enrolled patients were evaluated using qualitative and quantitative interview techniques to identify needs such as transportation to/advocacy during medical appointments, mental health/substance use treatment, and home visits. A community housing partner initiated housing applications in-hospital for homeless patients. Care managers facilitated appropriate discharge plans then worked closely with patients in the community using a harm reduction approach. RESULTS: Nineteen patients were enrolled; all were male, 18/19 were substance users, and 17/19 were homeless. Patients had a total of 64 inpatient admissions in the 12 months before the intervention, versus 40 in the following 12 months, a 37.5% reduction. Most patients (73.3%) had fewer inpatient admissions in the year after the intervention compared to the prior year. Overall ED visits also decreased after study enrollment, while outpatient clinic visits increased. Yearly study hospital Medicaid reimbursements fell an average of $16,383 per patient. CONCLUSIONS: A pilot intervention for high-cost patients shows promising results for health services usage. We are currently expanding our model to serve more patients at additional hospitals to see if the pilot's success can be replicated. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT01292096

OBJECTIVE: To explore medical students' perceptions of their future role as physicians as it relates to personal and professional responsibilities toward the underserved. METHODS: The authors conducted a qualitative content analysis of 53 first-year medical students' reflective essays focusing on the question: "Access to health care is a societal problem. Do physicians have a professional obligation to help by participating in free clinics, or otherwise doing some service-type activity? What are your personal feelings about how you might balance service to other people with personal issues like income, family, and career choice?" RESULTS: The student essays revealed students' awareness of the distinct expertise that enables physicians to offset limited access to health care. Although the majority of respondents supported physicians' responsibility to provide uncompensated care, a minority believed that there was no such responsibility attached to being a physician. Students also recognized the competing demands physicians often encounter that conflict with personal desires for service. CONCLUSION: The use of reflective essays in medical school curricula seems promising, in that they elicited students' beliefs on a complex topic with direct implications for professional identity and career decisions.

Nearly 90 million Americans live below 200% of the federal poverty threshold. The links between lower socioeconomic status and poor health are clear, and all physicians face the resulting challenges in patient care. Current medical school curricula do not adequately prepare students to address this issue despite recommendations from the Association of American Medical Colleges and the Institute of Medicine. In response, students and faculty at the University of Michigan Medical Center established the Poverty in Healthcare curriculum, which encompasses required learning experiences spanning all four years of undergraduate medical education. This article describes the design and implementation of this curriculum. The authors provide thorough descriptions of the individual learning experiences, including community site visits, longitudinal cases, mini-electives, and family centered experiences. The authors also discuss the history, costs, challenges, and evaluation process related to the Poverty in Healthcare curriculum, including issues specifically related to medical students' involvement in developing and implementing the curriculum. This information may be used as a guide for other medical schools in the development of curricula to address this current gap in medical student education.