Successes, Challenges, and Considerations for Integrating Referral into Food Insecurity Screening in Pediatric Settings.

Food insecurity, lack of access to enough food for an active and healthy life, is associated with poor child health. Three pediatric clinics implemented a two-question food insecurity screening of 7,284 families with children younger than five years. Over one thousand (1,133, 15.6%) reported food insecurity and 630 (55.6%) were referred to a benefits access organization for connection to public benefits and community resources. This study evaluated the efficacy of screening and referral through process evaluation, key informant interviews, and focus groups with 19 caregivers and 11 clinic staff. Using grounded theory, transcript themes were coded into facilitators and barriers of screening and referral. Facilitators included trust between caregivers and staff, choice of screening methods, and assistance navigating benefits application. Barriers included complex administration of referral, privacy and stigma concerns, and caregivers' current benefit enrollment or ineligibility. Results demonstrate importance of integrated screening and referral consent processes, strong communication, and convenient outreach for families.

Does the Supplemental Nutrition Assistance Program Affect Hospital Utilization Among Older Adults? The Case of Maryland.

This study sought to examine whether Supplemental Nutrition Assistance Program (SNAP) participation and benefit levels are associated with reduced subsequent hospital and emergency department utilization in low-income older adults. Study participants were 68,956 Maryland residents aged ≥65 years who were dually enrolled in Medicare and Medicaid (2009-2012). Annual inpatient hospital days and costs and emergency department visits were modeled as a function of either 1-year lagged SNAP participation or lagged SNAP benefit amounts, controlling for sociodemographic characteristics, autoregressive effects, year, health status, and Medicaid participation. SNAP participation (adjusted odds ratio [aOR] = 0.96, 95% confidence interval [CI]: 0.93, 0.99), and, among participants, each $10 increase in monthly benefits (aOR = 0.99, 95% CI: 0.99-0.99) are associated with a reduced likelihood of hospitalization, but not emergency department use. The authors estimate that enrolling the 47% of the 2012 population who were eligible nonparticipants in SNAP could have been associated with $19 million in hospital cost savings. Accounting for the strong effects of health care access, this study finds that SNAP is associated with reduced hospitalization in dually eligible older adults. Policies to increase SNAP participation and benefit amounts in eligible older adults may reduce hospitalizations and health care costs for older dual eligible adults living in the community.

Food assistance is associated with decreased nursing home admissions for Maryland's dually eligible older adults.

BACKGROUND: Although it has long been known that a broad range of factors beyond medical diagnoses affect health and health services use, it has been unclear whether additional income can decrease health service use. We examined whether Supplemental Nutrition Assistance Program (SNAP) receipt is associated with subsequent nursing home entry among low income older adults. METHODS: We examined the 77,678 older adults dually eligible for Medicaid and Medicare in Maryland, 2010-2012. Zero inflated negative binomial regression, adjusting for demographic and health factors, tested the association of either lagged SNAP enrollment or lagged benefit amount with nursing home admission. We used Heckman two-step model results to calculate potential savings of SNAP enrollment through reduced nursing home admissions and reduced duration. RESULTS: Only 53.4% received SNAP in 2012, despite being income-eligible. SNAP participants had a 23% reduced odds of nursing home admission than nonparticipants (95% CI: 0.75-0.78). For SNAP participants, an additional $10 of monthly SNAP assistance was associated with lower odds of admission (OR = 0.93, 95% CI: 0.93-0.93), and fewer days stay among those admitted (IRR = 0.99, 95% CI: 0.98-0.99). Providing SNAP to all 2012 sample nonparticipants could be associated with $34 million in cost savings in Maryland. CONCLUSIONS: SNAP is underutilized and may reduce costly nursing home use among high-risk older adults. This study has policy implications at the State and Federal levels which include expanding access to SNAP and enhancing SNAP amounts.

Effect of Outreach Messages on Medicaid Enrollment.

OBJECTIVES: To measure the impact of different outreach messages on health insurance enrollment among Medicaid-eligible adults. METHODS: Between March 2015 and April 2016, we conducted a series of experiments using mail-based outreach that encouraged individuals to enroll in Pennsylvania's expanded Medicaid program. Recipients were randomized to receive 1 of 4 different messages describing the benefits of health insurance. The primary outcome was the response rate to each letter. RESULTS: We mailed outreach letters to 32 993 adults in Philadelphia. Messages that emphasized the dental benefits of insurance were significantly more likely to result in a response than messages emphasizing the health benefits (odds ratio = 1.33; 95% confidence interval = 1.10, 1.61). CONCLUSIONS: Medicaid enrollment outreach messages that emphasized the dental benefits of insurance were more effective than those that emphasized the health-related benefits. Public Health Implications. Although the structure and eligibility of the Medicaid program are likely to change, testing and identifying successful outreach and enrollment strategies remains important. Outreach messages that emphasize dental benefits may be more effective at motivating enrollment among individuals of low socioeconomic status.

New Medicaid Enrollees See Health and Social Benefits in Pennsylvania's Expansion.

Understanding how new Medicaid enrollees are approaching their own health and health care in the shifting health care landscape of the Affordable Care Act has implications for future outreach and enrollment efforts, as well as service planning for this population. The objective of this study was to explore the health care experiences and expectations of new Medicaid expansion beneficiaries in the immediate post-enrollment period. We conducted semistructured, qualitative interviews with a random sample of 40 adults in Philadelphia who had completed an application for Medicaid through a comprehensive benefits organization after January 1, 2015, when the Medicaid expansion in Pennsylvania took effect. We conducted an inductive, applied thematic analysis of interview transcripts. The new Medicaid beneficiaries described especially high levels of pent-up demand for care. Dental care was a far more pressing and motivating concern than medical care. Preventive services were also frequently mentioned. Participants anticipated that insurance would reduce both stress and financial strain and improve their experience in the health care system by raising their social standing. Participants highly valued the support of telephone application counselors in the Medicaid enrollment process to overcome bureaucratic obstacles they had encountered in the past. Dental care and preventive services appear to be high priorities for new Medicaid enrollees. Telephone outreach and enrollment support services can be an effective way to overcome past experiences with administrative barriers.

Extended producer responsibility for packaging wastes and WEEE - a comparison of implementation and the role of local authorities across Europe.

A comparison of the implementation of extended producer responsibility (EPR) to packaging waste and waste electrical and electronic equipment (WEEE) is presented for a representative sample of eleven European Union countries based on five indicators: stakeholders and responsibilities; compliance mechanisms; role of local authorities; financing mechanisms and merits and limitations, with four countries selected for more detailed case study analysis. Similarities, trends and differences in national systems are highlighted with particular focus on the role of local authorities and their relationship with obligated producers and the effect on the operation and success of each system. The national systems vary considerably in design, in terms of influence of pre-existing policy and systems, methods of achieving producer compliance (multiple or single collective schemes), fee structures, targets, waste stream prioritization and local authority involvement. Differing approaches are evident across all member states with respect to the role played by local authorities, responsibility apportioned to them, and the evolution of working relationships between obligated producers and municipalities. On the whole, EPR for packaging and WEEE has been successfully implemented throughout Europe in terms of Directive targets. It is, however, clear that the EPR systems currently in application across Europe differ primarily due to contrasting opinion on the legitimacy of local authorities as stakeholders and, in some cases, a fear on the part of industry of associated costs. Where local authorities have been engaged in the design and implementation of national systems, existing infrastructure used and defined roles established for producers and local authorities, results have been significantly more positive than in the cases where local authorities have had limited engagement.

Substance use disorders and employability among welfare recipients.

The 2006 welfare reform legislation (Deficit Reduction Act of 2005) imposed more stringent work requirements and defined the amount of time cash assistance recipients are allowed to be exempted from the work requirement because of substance use treatment. As there is little empirical literature on the employability of substance users, it is difficult to know whether it is realistic to expect individuals with substance use disorders to meet the increased work requirement. Based on a comprehensive evaluation of nearly 9,000 substance-misusing welfare recipients from 2001 to 2007, University Behavioral Associates (UBA) Comprehensive Services Model program in Bronx, New York, found that 60% of recipients were not exempted from the work requirement owing to substance misuse at the outset, and an additional 24% were found nonexempt after 3 months of intensive outpatient treatment coupled with case management, resulting in a total of 84% of the UBA clients not being exempted from the work requirement because of substance misuse by Day 90. UBA also found that 25% of substance-misusing clients were able to obtain employment, and most successfully retained those jobs over the course of 6 months. These findings are discussed in relation to the new law's work requirements and the issue of the employability of substance misusers. Finally, the value of case management in serving this hard-to-engage population is discussed.

Helicobacter pylori has stimulatory effects on naive T cells.

BACKGROUND: Despite an apparently active host response, Helicobacter pylori infection can persist for life. Unexpectedly, T cells from apparently uninfected individuals respond to H. pylori antigen by proliferating. Also, the T-cell proliferative response appears to be less in infected compared with uninfected individuals. MATERIALS AND METHODS: We have investigated the T-cell response of isolated human peripheral blood, naive, and memory CD4+ T cells to H. pylori antigen in infected and uninfected subjects. RESULTS: In agreement with previous findings, the peripheral blood proliferative response was higher in uninfected compared with infected subjects. Interestingly, there was a response in CD4+ CD45RO+ (memory) and CD4+CD45RA+ (naive) subsets. The RO/RA ratio of the response to H. pylori antigen was 0.8-2.1 in both H. pylori-positive and H. pylori-negative subjects, which was similar to that of a known superantigen (2.5 and 2.2 in Helicobacter-positive and -negative subjects, respectively) whereas the RO/RA response ratio to a recall antigen (tetanus toxoid) was 9.8 and 18.7 in Helicobacter-positive and -negative subjects, respectively. Mononuclear cells isolated from cord blood also responded to H. pylori antigen, whereas there was no response to tetanus toxoid. The cord blood response and CD4+ CD45RA+ cell response to H. pylori antigen were inhibited predominantly by anti-HLA-DR and to some extent by anti-HLA-DQ antibodies. Investigation of the response to five different recombinant H. pylori antigens identified two that produced a response in naive T cells. CONCLUSIONS: These data suggest that H. pylori possesses molecules that cause higher than expected proliferation of naive T cells.

Interaction between protein subunits of the type IV secretion system of Bartonella henselae.

In this study we used the yeast two-hybrid system to identify interactions between protein subunits of the virB type IV secretion system of Bartonella henselae. We report interactions between inner membrane and periplasmic proteins, the pilus polypeptide, and the core complex and a novel interaction between VirB3 and VirB5.

CD4+CD25+ T(R) cells suppress innate immune pathology through cytokine-dependent mechanisms.

CD4(+)CD25(+) regulatory T (T(R)) cells can inhibit a variety of autoimmune and inflammatory diseases, but the precise mechanisms by which they suppress immune responses in vivo remain unresolved. Here, we have used Helicobacter hepaticus infection of T cell-reconstituted recombination-activating gene (RAG)(-/-) mice as a model to study the ability of CD4(+)CD25(+) T(R) cells to inhibit bacterially triggered intestinal inflammation. H. hepaticus infection elicited both T cell-mediated and T cell-independent intestinal inflammation, both of which were inhibited by adoptively transferred CD4(+)CD25(+) T(R) cells. T cell-independent pathology was accompanied by activation of the innate immune system that was also inhibited by CD4(+)CD25(+) T(R) cells. Suppression of innate immune pathology was dependent on T cell-derived interleukin 10 and also on the production of transforming growth factor beta. Thus, CD4(+)CD25(+) T(R) cells do not only suppress adaptive T cell responses, but are also able to control pathology mediated by innate immune mechanisms.