A Chronic Care Management Framework Bridging Clinic, Home, and Community Care in a Mexican American Population.

Despite evidence that chronic care management improves outcomes, a framework designed for low income, uninsured populations is still needed to improve health disparities and guide further replication. We describe the Innovative Care for Chronic Conditions framework implemented by a coalition of clinics and agencies to address chronic care management for Mexican Americans with Type 2 diabetes mellitus who have low income and primarily uninsured. The core elements of the framework are described by clinic, home and community settings with community health workers playing an essential role in the delivery of community-based services that address the social determinants of health. Promising results are described. This framework expands the understanding of chronic care management approaches and contributes to further replication of the framework in diverse settings.

Social Development in Children With Early Cochlear Implants: Normative Comparisons and Predictive Factors, Including Bilateral Implantation.

OBJECTIVES: There are mixed results regarding psychosocial development in children with cochlear implants (CIs) compared with children with normal hearing (NH), and the effect of bilateral CIs has not yet been investigated. This study aimed to investigate whether social development differed between NH children and those with early CIs, and to identify new predictors of psychosocial development in children with early CIs. DESIGN: The psychosocial development, cognitive and language abilities of 159 children were measured as part of a longitudinal outcomes study of children with CIs. Parental involvement was also assessed. RESULTS: The children in this study did not differ significantly from their peers with NH in terms of their psychosocial development, except with regard to Prosocial Behavior, with parents reporting significantly poorer development in this area. Having bilateral CIs predicted significantly fewer difficulties with psychosocial development, with earlier age at implantation increasing the effect size of the second CI for Emotional Symptoms and Peer Problems. Receptive language ability, higher parent education, later birth order, high parent involvement, and female gender predicted significantly fewer parent reports of psychosocial problems. Higher child cognitive ability and greater screen time predicted significantly greater reported psychosocial difficulties. Marginal effects modeling quantified the effects of changes in the predictive factors examined. CONCLUSIONS: Psychosocial development in these children with early CIs was found to be similar to that for peers with NH, with the exception of delayed Prosocial Behavior development. Having bilateral CIs predicted significantly better emotional outcomes. A number of new predictive factors were found for psychosocial development. The results of the marginal effects modeling should be shared with parents and professionals to increase their understanding of the impact of changes in predictive factors, particularly in terms of their own contribution to psychosocial outcomes for children with CIs.

Academic Outcomes for School-Aged Children With Severe-Profound Hearing Loss and Early Unilateral and Bilateral Cochlear Implants.

PURPOSE: This study sought to (a) determine whether academic outcomes for children who received early cochlear implants (CIs) are age appropriate, (b) determine whether bilateral CI use significantly improves academic outcomes, and (c) identify other factors that are predictive of these outcomes. METHOD: Forty-four 8-year-old children with severe-profound hearing loss participated in this study. Their academic development in mathematics, oral language, reading, and written language was assessed using a standardized test of academic achievement. RESULTS: (a) Across all academic areas, the proportion of children in the average or above-average ranges was lower than expected for children with normal hearing. The strongest area of performance was written language, and the weakest was mathematics. (b) Children using bilateral CIs achieved significantly higher scores for oral language, math, and written language, after controlling for predictive factors, than did children using unilateral CIs. Younger ages at second CI predicted the largest improvements. (c) High levels of parental involvement and greater time spent by children reading significantly predicted academic success, although other factors were identified. CONCLUSIONS: Average academic outcomes for these children were below those of children with normal hearing. Having bilateral CIs at younger ages predicted the best outcomes. Family environment was also important to children's academic performance.

Bilateral versus unilateral cochlear implants in children: a study of spoken language outcomes.

OBJECTIVES: Although it has been established that bilateral cochlear implants (CIs) offer additional speech perception and localization benefits to many children with severe to profound hearing loss, whether these improved perceptual abilities facilitate significantly better language development has not yet been clearly established. The aims of this study were to compare language abilities of children having unilateral and bilateral CIs to quantify the rate of any improvement in language attributable to bilateral CIs and to document other predictors of language development in children with CIs. DESIGN: The receptive vocabulary and language development of 91 children was assessed when they were aged either 5 or 8 years old by using the Peabody Picture Vocabulary Test (fourth edition), and either the Preschool Language Scales (fourth edition) or the Clinical Evaluation of Language Fundamentals (fourth edition), respectively. Cognitive ability, parent involvement in children's intervention or education programs, and family reading habits were also evaluated. Language outcomes were examined by using linear regression analyses. The influence of elements of parenting style, child characteristics, and family background as predictors of outcomes were examined. RESULTS: Children using bilateral CIs achieved significantly better vocabulary outcomes and significantly higher scores on the Core and Expressive Language subscales of the Clinical Evaluation of Language Fundamentals (fourth edition) than did comparable children with unilateral CIs. Scores on the Preschool Language Scales (fourth edition) did not differ significantly between children with unilateral and bilateral CIs. Bilateral CI use was found to predict significantly faster rates of vocabulary and language development than unilateral CI use; the magnitude of this effect was moderated by child age at activation of the bilateral CI. In terms of parenting style, high levels of parental involvement, low amounts of screen time, and more time spent by adults reading to children facilitated significantly better vocabulary and language outcomes. In terms of child characteristics, higher cognitive ability and female sex were predictive of significantly better language outcomes. When family background factors were examined, having tertiary-educated primary caregivers and a family history of hearing loss were significantly predictive of better outcomes. Birth order was also found to have a significant negative effect on both vocabulary and language outcomes, with each older sibling predicting a 5 to 10% decrease in scores. CONCLUSIONS: Children with bilateral CIs achieved significantly better vocabulary outcomes, and 8-year-old children with bilateral CIs had significantly better language outcomes than did children with unilateral CIs. These improvements were moderated by children's ages at both first and second CIs. The outcomes were also significantly predicted by a number of factors related to parenting, child characteristics, and family background. Fifty-one percent of the variance in vocabulary outcomes and between 59 to 69% of the variance in language outcomes was predicted by the regression models.