Transition to other Health Plan disease management programs and/or community resources.

Quality of Life will be assessed using the Quality of Life Enjoyment and Satisfaction Questionnaire - Short Form (Q-LES-Q-SF), which is a self-report measure consisting of 16 questions designed to enable investigators to easily obtain sensitive measures of the degree of enjoyment and satisfaction experienced by subjects in various areas of daily functioning during the past week. The scoring of the Q-LES-Q-SF involves summing only the first 14 items to yield a raw total score, ranging from 14 to 70. The raw total score is calculated into a maximum possible score using the following formula: (raw total score - minimum score)/(maximum possible raw score - minimum score). The minimum raw score on the Q-LES-Q-SF is 14, and the maximum score is 70. Thus, the formula for maximum score can also be written as: (raw score - 14)/56.

Care satisfaction will be assessed using the Patient Assessment of Care for Chronic Conditions (PACIC) Survey. The PACIC Survey consists of 20-items that measures specific actions or qualities of care that patients report they have experienced in the care of their chronic conditions over the past 6 months. Each item is measured on a scale from 1-5 with 5 signifying higher patient satisfaction and 1 being the lowest. Scoring requires obtaining the mean of all 20 items.

Emergent care use will be measured using existing behavioral and physical health claims data to determine the frequency of emergency department visits within 12-months from enrollment.

Engagement in primary care will be measured using existing behavioral and physical health claims determining participant frequency of non-acute visits for participants in the 12 months following enrollment. Because clinical standards of care are 1 primary care (PCP) visit every 12 months, PCP visits are assessed as a Y/N variable at 12-Months.

Engagement in specialty care will be measured using existing behavioral and physical health claims data determining participant frequency of specialty provider visits for participants in the 12 months following enrollment. Specialty care is inclusive of any care provided outside of primary care, physical therapy, or occupational therapy.

Readmissions over 12 months will be measured using an all-cause readmission rate from inpatient claims for physical and behavioral health service use within one year following discharge from the qualifying inpatient admission prior to enrollment in the study. Inpatient readmissions were lower than hypothesized for the population. As such, we assessed a Y/N variable for inpatient readmissions at 12-Months.

Assessed using existing behavioral health claims data determining frequency of mental health care visits for participants in the 12 months following enrollment. Because of the low frequency, we assess mental health care visits as a Y/N variable.

Gaps in care will be assessed using Healthcare Effectiveness Data and Information Set (HEDIS) quality metrics. For asthma, we assess the percentage of members 21-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period. Two rates are reported:

1. The percentage of members who remained on an asthma controller medication for at least 50% of their treatment period (MMA-1a).
2. The percentage of members who remained on an asthma controller medication for at least 75% of their treatment period (MMA-1b).

Gaps in care will be assessed using Healthcare Effectiveness Data and Information Set (HEDIS) quality metrics. For COPD, we assess the percentage of COPD exacerbations for members 40 years of age and older who had an acute inpatient discharge or ED encounter and who were dispensed appropriate medications. Two rates reported:

1. Dispensed a systemic corticosteroid within 14 days of the event (PCE-1)
2. Dispensed a bronchodilator within 30 days of the event (PCE-2)

For Gaps in care related to CHF, we assess readmission rate within 30 days after discharge from inpatient stay for members with a diagnosis of CHF prior index hospitalization.

Gaps in care will be assessed using Healthcare Effectiveness Data and Information Set (HEDIS) quality metrics. For CVD, we assess the percentage of males 21-75 years of age and females 40-75 years of age during the measurement year, who were identified as having clinical atherosclerotic cardiovascular disease (ASCVD) and met the following criteria. The following rates are reported:

1. Received Statin Therapy. Members who were dispensed at least one high-intensity or moderate-intensity statin medication during the measurement year (SPC-1).
2. Statin Adherence 80%. Members who remained on a high-intensity or moderate-intensity statin medication for at least 80% of the treatment period (SPC-2).

Gaps in care will be assessed using Healthcare Effectiveness Data and Information Set (HEDIS) quality metrics. For diabetes, we assess the percentage of members 40-75 years of age during the measurement year with diabetes who do not have clinical atherosclerotic cardiovascular disease (ASCVD) who met the following criteria. Two rates are reported:

1. Received Statin Therapy. Members who were dispensed at least one statin medication of any intensity during the measurement year (SPD-1).
2. Statin Adherence 80%. Members who remained on a statin medication of any intensity for at least 80% of the treatment period (SPD-2).

Gaps in care will be assessed using Healthcare Effectiveness Data and Information Set (HEDIS) quality metrics. For depression, we assess the percentage of members diagnosed with a new episode of major depression, treated with antidepressant medication, and who remained on an antidepressant medication for:

1. Effective Acute Phase Treatment - 84 days of continuous treatment during 114-day period following the Index Prescription Start Date (AMM-1).
2. Effective Continuation Phase Treatment - 180 days of continuous treatment during 231-day period following the Index Prescription Start Date (AMM-2).

Delivered via Health Plan support and resources within 14-30 days of an initial home or telephonic visit.

Optimal Discharge Planning: Transition to other Health Plan disease management programs and/or community resources.

Total of all reporting groups

The Charlson Comorbidity Index (age-adjusted) is designed to predict survival rates for patients with multiple comorbidities after a hospitalization. A scores range from 0 to 37, with a higher score indicating a higher mortality risk. We assess CCI based on the previous 12 months of claims.

The Area Deprivation Index (ADI) is a measure used to account for the impact of resources in a geographic area that influence an individual's health, such as income, education, employment, and housing quality. Available ADI data ranges from -48 to 129, with higher numbers indicating a more resourced area of residence.

The definition of engagement is as follows:

1. ODP Engagement: In-home or telephonic visit or video visit occurred within 1 week of initial visit
2. High Touch Engagement: In-home or telephonic visit occurred within 4 weeks of the initial visit.
3. High-Tech Engagement: Telephonic visit or video visit occurred within 4 weeks of Initial Visits.

Note: Care activities also occurred outside of visits; a follow-up visit was not a requirement of ODP.

Delivered via a remote care management platform and digital health tools. Remote care support interactions to occur for at least a four-month period.

High-Tech: Remote care management and self-directed digital tools.

Delivered via Health Plan support and resources within 14-30 days of an initial home or telephonic visit.

Optimal Discharge Planning: Transition to other Health Plan disease management programs and/or community resources.

Assessed using the RAND 36-Item Short Form Survey 1.0 (SF-36). The SF-36 is a set of 36 health status and quality-of-life measures that are patient self-reported and measure functional health and well-being within eight domains, including physical functioning, role limitations due to physical health, role limitations due to emotional problems, energy/fatigue, emotional well-being, social functioning, pain, and general health. Values are recoded per the scoring key relating each item to the appropriate subscale. All items are scored so that a high score defines a more favorable health state. We assess a global scale with a 0 to 100 range with 0 being worst possible health status and 100 being the best possible health status.

Includes all individuals who completed the measure at least one timepoint.

90-Day Readmissions will be measured using an all-cause readmission rate from inpatient claims for physical and behavioral health service use within 90 days following discharge from the qualifying inpatient admission prior to enrollment in the study.

8 participants (0.57%) have missing readmission data. Since 31 participants had more than one admission within 90 days, a binary indicator of readmission within 90 days was generated and used as a primary outcome.

30-Day Readmissions will be measured using an all-cause readmission rate in claims for physical and behavioral health service use within 30 days following discharge from the qualifying inpatient admission prior to enrollment in the study.

Since only 2 participants had more than one admission (2 admissions) within 30 days, a binary indicator of readmission within 30 days was generated and used as the outcome.

Assessed using the PROMIS Physical Function - Short Form 6b with six self-reported physical function measures to assess current function, including activities of daily living. Each question has five response options (a 5-point Likert scale) ranging from one to five with 5 being the highest level of physical function and 1 being the lowest. Per best practices, the instrument is scored by Health Measures Scoring Service, using item-level calibrations using responses to each item for each participant, producing a T-score. The highest possible T-score score is 59, indicating the highest level of physical function, and the lowest is 21, indicating the lowest level of physical function.

Includes all individuals who completed the measure at least one timepoint.

Quality of Life will be assessed using the Quality of Life Enjoyment and Satisfaction Questionnaire - Short Form (Q-LES-Q-SF), which is a self-report measure consisting of 16 questions designed to enable investigators to easily obtain sensitive measures of the degree of enjoyment and satisfaction experienced by subjects in various areas of daily functioning during the past week. The scoring of the Q-LES-Q-SF involves summing only the first 14 items to yield a raw total score, ranging from 14 to 70. The raw total score is calculated into a maximum possible score using the following formula: (raw total score - minimum score)/(maximum possible raw score - minimum score). The minimum raw score on the Q-LES-Q-SF is 14, and the maximum score is 70. Thus, the formula for maximum score can also be written as: (raw score - 14)/56.

Includes all individuals who completed the measure at least one timepoint.

Care satisfaction will be assessed using the Patient Assessment of Care for Chronic Conditions (PACIC) Survey. The PACIC Survey consists of 20-items that measures specific actions or qualities of care that patients report they have experienced in the care of their chronic conditions over the past 6 months. Each item is measured on a scale from 1-5 with 5 signifying higher patient satisfaction and 1 being the lowest. Scoring requires obtaining the mean of all 20 items.

Includes all individuals who completed the measure at least one timepoint.

Emergent care use will be measured using existing behavioral and physical health claims data to determine the frequency of emergency department visits within 12-months from enrollment.

For each timepoint, participants who were eligible for Medicaid/Medicaid-Medicare with available claims data during at least 9 months (non-continuous) of the past 12 months.

Engagement in primary care will be measured using existing behavioral and physical health claims determining participant frequency of non-acute visits for participants in the 12 months following enrollment. Because clinical standards of care are 1 primary care (PCP) visit every 12 months, PCP visits are assessed as a Y/N variable at 12-Months.

For each timepoint, participants who were eligible for Medicaid/Medicaid-Medicare with available claims data during at least 9 months (non-continuous) of the past 12 months.

Engagement in specialty care will be measured using existing behavioral and physical health claims data determining participant frequency of specialty provider visits for participants in the 12 months following enrollment. Specialty care is inclusive of any care provided outside of primary care, physical therapy, or occupational therapy.

For each timepoint, participants who were eligible for Medicaid/Medicaid-Medicare with available claims data during at least 9 months (non-continuous) of the past 12 months.

Readmissions over 12 months will be measured using an all-cause readmission rate from inpatient claims for physical and behavioral health service use within one year following discharge from the qualifying inpatient admission prior to enrollment in the study. Inpatient readmissions were lower than hypothesized for the population. As such, we assessed a Y/N variable for inpatient readmissions at 12-Months.

For each timepoint, participants who were eligible for Medicaid/Medicaid-Medicare with available claims data during at least 9 months (non-continuous) of the past 12 months.

Assessed using existing behavioral health claims data determining frequency of mental health care visits for participants in the 12 months following enrollment. Because of the low frequency, we assess mental health care visits as a Y/N variable.

For each timepoint, participants who were eligible for Medicaid/Medicaid-Medicare with available claims data during at least 9 months (non-continuous) of the past 12 months.

Gaps in care will be assessed using Healthcare Effectiveness Data and Information Set (HEDIS) quality metrics. For asthma, we assess the percentage of members 21-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period. Two rates are reported:

1. The percentage of members who remained on an asthma controller medication for at least 50% of their treatment period (MMA-1a).
2. The percentage of members who remained on an asthma controller medication for at least 75% of their treatment period (MMA-1b).

Only a very small portion of our total sample size was eligible for Gaps in Care analyses.

Gaps in care will be assessed using Healthcare Effectiveness Data and Information Set (HEDIS) quality metrics. For COPD, we assess the percentage of COPD exacerbations for members 40 years of age and older who had an acute inpatient discharge or ED encounter and who were dispensed appropriate medications. Two rates reported:

1. Dispensed a systemic corticosteroid within 14 days of the event (PCE-1)
2. Dispensed a bronchodilator within 30 days of the event (PCE-2)

Only a very small portion of the total sample was eligible for COPD Gaps in Care analyses.

For Gaps in care related to CHF, we assess readmission rate within 30 days after discharge from inpatient stay for members with a diagnosis of CHF prior index hospitalization.

Only a small portion of the total sample was eligible for CHF Gaps in Care analyses.

Gaps in care will be assessed using Healthcare Effectiveness Data and Information Set (HEDIS) quality metrics. For CVD, we assess the percentage of males 21-75 years of age and females 40-75 years of age during the measurement year, who were identified as having clinical atherosclerotic cardiovascular disease (ASCVD) and met the following criteria. The following rates are reported:

1. Received Statin Therapy. Members who were dispensed at least one high-intensity or moderate-intensity statin medication during the measurement year (SPC-1).
2. Statin Adherence 80%. Members who remained on a high-intensity or moderate-intensity statin medication for at least 80% of the treatment period (SPC-2).

Only a very small portion of the total sample was eligible for CVD Gaps in Care analyses.

Gaps in care will be assessed using Healthcare Effectiveness Data and Information Set (HEDIS) quality metrics. For diabetes, we assess the percentage of members 40-75 years of age during the measurement year with diabetes who do not have clinical atherosclerotic cardiovascular disease (ASCVD) who met the following criteria. Two rates are reported:

1. Received Statin Therapy. Members who were dispensed at least one statin medication of any intensity during the measurement year (SPD-1).
2. Statin Adherence 80%. Members who remained on a statin medication of any intensity for at least 80% of the treatment period (SPD-2).

Only a very small portion of the total sample was eligible for Diabetes Gaps in Care analyses.

Gaps in care will be assessed using Healthcare Effectiveness Data and Information Set (HEDIS) quality metrics. For depression, we assess the percentage of members diagnosed with a new episode of major depression, treated with antidepressant medication, and who remained on an antidepressant medication for:

1. Effective Acute Phase Treatment - 84 days of continuous treatment during 114-day period following the Index Prescription Start Date (AMM-1).
2. Effective Continuation Phase Treatment - 180 days of continuous treatment during 231-day period following the Index Prescription Start Date (AMM-2).

Only a very small portion of the total sample was eligible for Depression Gaps in Care analyses.

Delivered via a remote care management platform and digital health tools. Remote care support interactions to occur for at least a four-month period.

High-Tech: Remote care management and self-directed digital tools.

Delivered via Health Plan support and resources within 14-30 days of an initial home or telephonic visit.

Optimal Discharge Planning: Transition to other Health Plan disease management programs and/or community resources.

Test for significant change over time when the treatment-by-time interaction effect is not significant.

F-statistics 16.97 with degrees of freedom (3, 3160).

Controlling for: age, sex, race, ethnicity, insurance, engagement at baseline, comfortability with technology, tech literacy (HINTS), social support at baseline (ISEL), health literacy (AAHLS), illness burden (CCI), and area deprivation index (ADI).

Test for significant change by treatment when the treatment-by-time interaction effect is not significant.

F-statistics 0.14 with degrees of freedom (2, 1229).

Controlling for: age, sex, race, ethnicity, insurance, engagement at baseline, comfortability with technology, tech literacy (HINTS), social support at baseline (ISEL), health literacy (AAHLS), illness burden (CCI), and area deprivation index (ADI).

Test for group difference in the change from baseline to 12-Months using the linear contrasts.

F-statistics 0.51 with degrees of freedom (1, 3154)

Controlling for: age, sex, race, ethnicity, insurance, engagement at baseline, comfortability with technology, tech literacy (HINTS), social support at baseline (ISEL), health literacy (AAHLS), illness burden (CCI), and area deprivation index (ADI).

Test for group difference in the change from baseline to 12-Months using the linear contrasts.

F-statistics 0.27 with degrees of freedom (1, 3154).

Controlling for: age, sex, race, ethnicity, insurance, engagement at baseline, comfortability with technology, tech literacy (HINTS), social support at baseline (ISEL), health literacy (AAHLS), illness burden (CCI), and area deprivation index (ADI).

Test for group difference in the change from baseline to 12-Months using the linear contrasts.

F-statistics 0.07 with degrees of freedom (1, 3154).

Controlling for: age, sex, race, ethnicity, insurance, engagement at baseline, comfortability with technology, tech literacy (HINTS), social support at baseline (ISEL), health literacy (AAHLS), illness burden (CCI), and area deprivation index (ADI).

Test for the Treatment Effect

Chi-square statistics 0.8 with degrees of freedom (2).

Controlling for: age, sex, race, ethnicity, insurance, engagement at baseline, comfortability with technology, tech literacy (HINTS), social support at baseline (ISEL), health literacy (AAHLS), illness burden (CCI), and area deprivation index (ADI).

Test for the Treatment Effect

Chi-square statistics 0.80 with degrees of freedom (2).

Controlling for: age, sex, race, ethnicity, insurance, engagement at baseline, comfortability with technology, tech literacy (HINTS), social support at baseline (ISEL), health literacy (AAHLS), illness burden (CCI), and area deprivation index (ADI).

Test for the Treatment Effect

Chi-square statistics 0.8 with degrees of freedom (2).

Controlling for: age, sex, race, ethnicity, insurance, engagement at baseline, comfortability with technology, tech literacy (HINTS), social support at baseline (ISEL), health literacy (AAHLS), illness burden (CCI), and area deprivation index (ADI).

Test for the treatment effect

Chi-squared statistics 0.59 with degrees of freedom (2).

Controlling for: age, sex, race, ethnicity, insurance, engagement at baseline, comfortability with technology, tech literacy (HINTS), social support at baseline (ISEL), health literacy (AAHLS), illness burden (CCI), and area deprivation index (ADI).

Test for the treatment effect.

Chi-squared statistics 0.59 with degrees of freedom (2).

Controlling for: age, sex, race, ethnicity, insurance, engagement at baseline, comfortability with technology, tech literacy (HINTS), social support at baseline (ISEL), health literacy (AAHLS), illness burden (CCI), and area deprivation index (ADI).

Test for the treatment effect.

Chi-squared statistics 0.59 with degrees of freedom (2).

Test for the change over time when the treatment-by-time interaction effect is not significant.

F-statistics 6.74 with degrees of freedom (3, 3063).

Controlling for: age, sex, race, ethnicity, insurance, engagement at baseline, comfortability with technology, tech literacy (HINTS), social support at baseline (ISEL), health literacy (AAHLS), illness burden (CCI), and area deprivation index (ADI).