Vulnerable Populations

An Intervention to Improve Care and Reduce Costs for High Risk Patients with Frequent Health Services Use

An Intervention to Improve Care and Reduce Costs for High Risk Patients with Frequent Health Services Use
BMC Health Serv Res. 2011; 11: 270.

Maria C Raven, Kelly M Doran, Shannon Kostrowski, Colleen C Gillespie and Brian D Elbel
10/13/2011

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.

A School-Randomized Clinical Trial of an Integrated Social-Emotional Learning and Literacy Intervention: Impacts on Third-Grade Outcomes

A School-Randomized Clinical Trial of an Integrated Social-Emotional Learning and Literacy Intervention: Impacts on Third-Grade Outcomes
Journal of Consulting and Clinical Psychology, 78(6): 829-842

Jones, S.M., Brown, J.L, Hoglund, W.L.G., & J.L. Aber.
12/01/2010

Objective: To report experimental impacts of a universal, integrated school-based intervention in social–emotional learning and literacy development on change over 1 school year in 3rd-grade children's social–emotional, behavioral, and academic outcomes. Method: This study employed a school-randomized, experimental design and included 942 3rd-grade children (49% boys; 45.6% Hispanic/Latino, 41.1% Black/African American, 4.7% non-Hispanic White, and 8.6% other racial/ethnic groups, including Asian, Pacific Islander, Native American) in 18 New York City public elementary schools. Data on children's social–cognitive processes (e.g., hostile attribution biases), behavioral symptomatology (e.g., conduct problems), and literacy skills and academic achievement (e.g., reading achievement) were collected in the fall and spring of 1 school year. Results: There were main effects of the 4Rs Program after 1 year on only 2 of the 13 outcomes examined. These include children's self-reports of hostile attributional biases (Cohen's d = 0.20) and depression ( d = 0.24). As expected based on program and developmental theory, there were impacts of the intervention for those children identified by teachers at baseline with the highest levels of aggression ( d = 0.32–0.59) on 4 other outcomes: children's self-reports of aggressive fantasies, teacher reports of academic skills, reading achievement scaled scores, and children's attendance. Conclusions: This report of effects of the 4Rs intervention on individual children across domains of functioning after 1 school year represents an important first step in establishing a better understanding of what is achievable by a schoolwide intervention such as the 4Rs in its earliest stages of unfolding. The first-year impacts, combined with our knowledge of sustained and expanded effects after a second year, provide evidence that this intervention may be initiating positive developmental cascades both in the general population of students and among those at highest behavioral risk.

At Rope’s End: Single Women Mothers, Wealth and Asset Accumulation in the United States

At Rope’s End: Single Women Mothers, Wealth and Asset Accumulation in the United States

Mariko Chang, PhD and C. Nicole Mason, PhD
10/01/2010

A commissioned report for the Opportunity Series of the Women of Color Policy Network, this report examines the economic security and vulnerability of single mothers through the lens of wealth and asset accumulation as opposed to income and employment.

Calorie Labeling And Food Choices: A First Look At The Effects On Low-Income People In New York City

Calorie Labeling And Food Choices: A First Look At The Effects On Low-Income People In New York City
Health Affairs (Millwood). 2009;28(6):w1110-21 (published online October 6; 10.1377/ hlthaff.28.6.w1110)

Elbel, B., Kersh, R., Brescoll, V.L. & Dixon, L.B.
10/06/2009

We examined the influence of menu calorie labels on fast food choices in the wake of New York City's labeling mandate. Receipts and survey responses were collected from 1,156 adults at fast-food restaurants in low-income, minority New York communities. These were compared to a sample in Newark, New Jersey, a city that had not introduced menu labeling. We found that 27.7 percent who saw calorie labeling in New York said the information influenced their choices. However, we did not detect a change in calories purchased after the introduction of calorie labeling. We encourage more research on menu labeling and greater attention to evaluating and implementing other obesity-related policies.

 

Adherence to antiretroviral therapy among older children and Adolescents with HIV: A qualitative study of psychosocial contexts

Adherence to antiretroviral therapy among older children and Adolescents with HIV: A qualitative study of psychosocial contexts
AIDS Patient Care & STDs. 22: 977-987.

Merzel C., N. VanDevanter, and M. Irvine.
12/01/2008

Abstract Survival among perinatally infected children and youth with HIV has been greatly extended since the advent of highly active antiretroviral therapies. Yet, adherence to HIV medication regimens is suboptimal and decreases as children reach adolescence. This paper reports on a qualitative study examining psychosocial factors associated with adherence among perinatally infected youth ages 10-16 years. The study was based on in-depth interviews with a sample of 30 caregivers participating in a comprehensive health care program in New York City serving families with HIV. A subsample comprising 14 caregivers of children ages 10 and above is the focus of this paper. The analysis identified a number of themes associated with the psychosocial context of managing adherence among older children. Maintaining adherence was an ongoing challenge and strategies evolved as children matured. Regimen fatigue and resistance to taking the medications were major challenges to maintaining adherence among the oldest children. In other cases, caregivers developed a kind of partnership with their child for administering the medications. Disclosure to the child of his or her HIV status was used as a strategy to promote adherence but seemed to be effective only under certain circumstances. Social support appeared to have an indirect influence on adherence, primarily by providing caregivers with temporary help when needed. Health care professionals were an important source of disclosure and adherence support for parents. The study illustrates the interplay of maturational issues with other contextual psychosocial factors as influences on adherence among older children and adolescents.

Race, Segregation, and Physicians' Participation in Medicaid

Race, Segregation, and Physicians' Participation in Medicaid
The Milbank Quarterly Vol. 84, Iss. 2, June

Greene, J., Blustein, J. & Weitzman, B.C.
06/01/2006

Many studies have explored the extent to which physicians’ characteristics and Medicaid program factors influence physicians’ decisions to accept Medicaid patients. In this article, we turn to patient race/ethnicity and residential segregation as potential influences. Using the 2000/2001 Community Tracking Study and other sources we show that physicians are significantly less likely to participate in Medicaid in areas where the poor are nonwhite and in areas that are racially segregated. Surprisingly—and contrary to the prevailing Medicaid participation theory—we find no link between poverty segregation and Medicaid participation when controlling for these racial factors. Accordingly, this study contributes to an accumulating body of circumstantial evidence that patient race influences physicians’ choices, which in turn may contribute to racial disparities in access to health care.

Academic Achievement Among Formerly Homeless Adolescents and Their Continuously Housed Peers

Academic Achievement Among Formerly Homeless Adolescents and Their Continuously Housed Peers
Journal of School Psychology, Vol. 42, No. 3, pp. 179-199.

Rafferty, Y., Shinn, M. & Weitzman, B.
01/01/2004

This study examined the school experiences and academic achievement of 46 adolescents in families who experienced homelessness and 87 permanently housed adolescents whose families received public assistance. Measures taken after the homeless students were rehoused showed that both groups valued school highly and were similar in cognitive abilities assessed with the similarities subtest of the Wechsler Intelligence Scale for Children—Revised (WISC-R). Formerly homeless students had more school mobility, more grade retention, and worse school experiences by mother report and lower plans for post secondary education by self-report. Both groups scored poorly on standardized tests of academic achievement. Homelessness was associated with further declines in achievement during the period of maximal residential disruption, but did not have effects 5 years later.

Dept. of Building, Winning the West

Dept. of Building, Winning the West
The New Yorker, July 5,

Whitagker, C. & Finnegan, W.
01/01/2004

Both sides have started punching harder lately in the brawl over whether or not to build a seventy-five-thousand-seat football stadium over the Hudson rail yards on Manhattan’s far West Side. The New York Jets, who would own the place, will be taking computers from the mouths of needy schoolchildren if the state and the city are forced to provide the six hundred million dollars that would be their part of the deal—or, at least, that’s what the television ads paid for by the Dolan family, the owners of Madison Square Garden, say. Nonsense, say the Jets and their supporters, who include Mayor Bloomberg, Governor Pataki, and the construction unions. The stadium will be such a financial success that it will end up giving computers to needy schoolchildren. Opponents say that the stadium will sink New York City’s bid to host the 2012 Olympics (the International Olympic Committee does not like controversy). No, say the stadium’s backers, it is the centerpiece of the city’s Olympic hopes.

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