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Impact of Health Home and transition of care programs on diabetic patients' care and health outcomes
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Reynolds, Simone, Rosenberg, Carl, Ehlke, Daniel
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Summer 2025
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Abstract
A small proportion of patients accounts for a disproportionately large share of healthcare spending,
often due to multiple chronic conditions and frequent hospital use. In response, New York State
implemented the Health Home (HH) program to improve care coordination and reduce
unnecessary hospital utilization among high-need Medicaid enrollees. This study evaluated
whether early and consistent access to Primary Care Providers (PCPs) and care coordinators
through the HH program improves outcomes for patients with diabetes mellitus and high acute
care use, specifically by reducing hospital admissions and shortening the length of stay for
readmissions.
A retrospective cohort study was conducted using electronic medical record (EMR) data from a
major New York healthcare system, including 16,229 diabetic patients eligible for Health Home
(HH) services. The data were limited to patients over the age of 19 who were eligible for Health
Home services during hospital visits between June 1, 2018, and December 31, 2019. The objective
was to evaluate whether the HH program, developed by New York State to improve outcomes for
high-need Medicaid patients, is achieving its intended goals. The following outcome measures
were explored: hospital readmissions within 60 days post-discharge, the number of days from
discharge to readmission, and the length of stay for readmitted visits. Covariates included age
group, gender, race/ethnicity, primary language, marital status, LACE index (Length of stay,
Acuity of admission, Comorbidities, and recent Emergency department use), and comorbidities
indicated by the Charlson Comorbidity Index (CCI). All analyses were conducted using SAS
software.
The study found that enrollment in Health Home (HH) was significantly associated with an
increase in the likelihood of readmission within 60 days in the unadjusted model (estimate =
1.0720, p <0.0001). After adjusting for race/ethnicity, age range, LACE, and CCI as confounders,
the association remained significant, though attenuated (estimate =0.923; p<0.0001). Regarding
the number of days between index admission and readmission, the unadjusted model indicated that
HH enrollment significantly decreased the days between index discharge and readmission within
60 days, with an estimated -1.22 days (p = 0.0234). However, after accounting for LACE and CCI
as confounders, the association between HH enrollment and days to readmission was no longer
statistically significant (estimate = - 0.86, p = 0.1122). Similarly, the association between HH
enrollment and length of stay (LOS) for readmitted visits was positive (estimate 0. 234, p= 0. 044);
however, after controlling for age group, LACE, and CCI as confounders, it was no longer
statistically significant (p= 0.493) and the relationship was reversed (estimate = -0.077). The
findings suggest that demographic factors (specifically race/ethnicity and patient age), prior high
utilization of hospital services (indicated by LACE score), and clinical burden (as indicated by
CCI) significantly influence readmission outcomesindependent of HH program enrollment. While
the unadjusted associations appeared statistically significant, the adjusted models underscore the
role of these confounders. The results highlight the need for more tailored interventions that
account for patients' demographic and clinical risk profiles to improve outcomes among diabetic
patients enrolled in the HH program.
Citation
Saraya, A. (2025) Impact of Health Home and transition of care programs on diabetic patients' care and health outcomes. [Doctoral Dissertation, SUNY Downstate Health Sciences University]. SUNY Open Access Repository. http://hdl.handle.net/20.500.12648/16662