Community Health Centers And Medicaid At 50: An Enduring Relationship Essential For Health System Transformation.

Community health centers reach their fiftieth anniversary in 2015, along with Medicaid. Health policy makers have understood the programs' symbiotic connection from the earliest days of their implementation. Medicaid's expansion and growth have made the modern community health center program possible, while health centers represent one of the principal sources of primary care for the nation's Medicaid population. With their shared mission and high level of interdependence, Medicaid and community health centers are essential for continued health system transformation in medically underserved communities nationwide--for example, by implementing delivery system reforms aimed at increasing clinical integration and improving efficiencies and by becoming medical homes for high-risk patients. Achieving this transformation will depend on the ability of community health centers and Medicaid to understand and respond to the challenges that each faces, while fully deploying the strengths that each has to offer.

Food insecurity, food assistance and health status in the U.S. community health center population.

OBJECTIVES: This study explored the relationship between food insecurity, food assistance, and self-reported health status among community health center (CHC) clients. METHODS: Using data from the 2009 Community Health Center Patient Survey (n = 4,562), representing Federally Qualified Health Center clients, we conducted logistic regression analyses to identify the association between food insecurity and fair/poor health status, controlling for food assistance and sociodemographic factors. RESULTS: Approximately 1/3 of the sample (31.9%) reported fair/poor health status, 10.9% reported food insecurity, and 52.6% reported public food assistance. Multivariate analyses revealed that, among women, those with food insecurity had significantly higher odds of reporting fair/poor health status (AOR = 2.14, 95% CI 1.20-3.82). CONCLUSIONS: Expansion of financial access to health care via the Patient Protection and Affordable Care Act coupled with recent funding cuts to the Supplemental Nutrition Assistance Program means that CHCs play an increasingly important role in addressing food insecurity.

Measuring the economic costs of discrimination experienced by people with mental health problems: development of the Costs of Discrimination Assessment (CODA).

PURPOSE: Stigma and discrimination are faced by many with mental health problems and this may affect the uptake of services and engagement in leisure and recreational activities. The aims of this study were to develop a schedule to measure the impact of stigma and discrimination on service use, employment and leisure activities and to estimate the value of such reductions. METHODS: A questionnaire, the Cost of Discrimination Assessment, was developed and piloted in a sample people with mental health problems. Costs were calculated and test-retest reliability assessed. RESULTS: Test-retest reliability was good for most items. A substantial proportion of the sample had experienced negative impacts on employment as a result of stigma and discrimination. Around one-fifth had reduced contacts with general practitioners in the previous 6 months due to stigma and discrimination and the leisure activity most affected was visiting pubs/restaurants/café. CONCLUSIONS: In conclusion, stigma and discrimination result in reduced use of services and reduced engagement in leisure activities. This represents a welfare loss to individuals.

Provision of telemedicine services by community health centers.

The objective of this study was to assess the use of telemedicine services at community health centers. A national survey was distributed to all federally qualified health centers to gather data on their use of health information technology, including telemedicine services. Over a third of responding health centers (37%) provided some type of telemedicine service while 63% provided no telemedicine services. A further analysis that employed ANOVA and chi-square tests to assess differences by the provision of telemedicine services (provided no telemedicine services, provided one telemedicine service, and provided two or more telemedicine services) found that the groups differed by Meaningful Use compliance, location, percentage of elderly patients, mid-level provider, medical, and mental health staffing ratios, the percentage of patients with diabetes with good blood sugar control, and state and local funds per patient and per uninsured patient. This article presents the first national estimate of the use of telemedicine services at community health centers. Further study is needed to determine how to address factors, such as reimbursement and provider shortages, that may serve as obstacles to further expansion of telemedicine services use by community health centers.

Identifying key patient demographics and organizational factors that contribute to health center participation in research.

Federally Qualified Health Centers are well positioned for translational research given their diverse patient population, unique characteristics, and community knowledge. This was the first national survey that assessed their research activities. Those with research experience were more likely to be urban and Health Care for the Homeless grantees and had more patients, minority patients, and physicians relative to nonphysician providers, enabling services providers, Medicaid revenues per Medicaid patient, and total revenues per patient than health centers with no experience and no future interest in research. Only enabling services providers to patient ratios and total patients remained significant after controlling for other factors.

Readiness for meaningful use of health information technology and patient centered medical home recognition survey results.

OBJECTIVE: Determine the factors that impact HIT use and MU readiness for community health centers (CHCs). BACKGROUND: The HITECH Act allocates funds to Medicaid and Medicare providers to encourage the adoption of electronic health records (EHR), in an effort to improve health care quality and patient outcomes, and to reduce health care costs. METHODS: We surveyed CHCs on their Readiness for Meaningful Use (MU) of Health Information Technology (HIT) and Patient Centered Medical Home (PCMH) Recognition, then we combined responses with 2009 Uniform Data System data to determine which factors impact use of HIT and MU readiness. RESULTS: Nearly 70% of CHCs had full or partial EHR adoption at the time of survey. Results are presented for centers with EHR adoption, by the length of time that their EHR systems have been in operation.

Increased use of dental services by children covered by Medicaid: 2000-2010.

This report analyzes the use of dental services by children enrolled in Medicaid from federal fiscal years (FFY) 2000 to 2010. The number and percent of children receiving dental services under Medicaid climbed continuously over the decade. In FFY 2000, 6.3 million children ages 1 to 20 were reported to receive some form of dental care (either preventive or treatment); the number more than doubled to 15.4 million by FFY 2010. Part of the increase was because the overall number of children covered by Medicaid rose by 12 million (50%), but the percentage of children who received dental care climbed appreciably from 29.3% in FFY 2000 to 46.4% in FFY 2010. In that same time period, the number of children ages 1 to 20 receiving preventive dental services climbed from a reported 5.0 million to 13.6 million, while the percentage of children receiving preventive dental services rose from 23.2% to 40.8%. For children ages 1 to 20 who received dental treatment services, the reported number rose from 3.3 million in FFY 2000 to 7.6 million in FFY 2010. The percentage of children who obtained dental treatment services increased from 15.3% to 22.9%. In FFY 2010, about one sixth of children covered by Medicaid (15.7%) ages 6-14 had a dental sealant placed on a permanent molar. While most states have made steady progress in improving children's access to dental care in Medicaid over the past decade, there is still substantial variation across states and more remains to be done.

Service and wider societal costs of very young children with autism in the UK.

Autism spectrum disorders (ASD) are associated with a substantial economic burden, but there is little evidence of the costs in the early years; the period in which children are increasingly likely to be diagnosed. We describe the services used by 152 children aged 24-60 months with autism, report family out-of-pocket expenses and productivity losses, and explore the relationship between family characteristics and costs. Children received a wide range of hospital and community services including relatively high levels of contact with speech and language therapists and paediatricians. Total service costs varied greatly (mean £430 per month; range £53 to £1,116), with some families receiving little statutory support. Higher costs were associated with increasing age and symptom severity.

Enhancing Adoptive Parenting: A Cost-Effectiveness Analysis.

BACKGROUND: Children adopted from care often exhibit behavioural difficulties. There is however limited cost-effectiveness evidence regarding different interventions to address this. This paper reports a cost-effectiveness analysis of parenting programmes for these children. METHOD: Adoptive parents of children aged between 3 and 8 years participated in home-based, manualised, parenting programmes delivered by trained family social workers. The adopters were randomly allocated to one of two interventions (n = 19) or to a 'services as usual' control group (n = 18). Baseline, immediate post-intervention and 6-month follow-ups were assessed by questionnaires and adopter interviews. Economic costs were calculated. RESULTS: At 6-month follow-up, a significant difference (p < .007) was found for 'satisfaction with parenting' in favour of the intervention group. No significant differences were found on child measures between the combined intervention groups and control group, adjusting for baseline scores. The mean costs for the combined intervention group were £1528 higher than for the control group at the post-intervention point, which was statistically significant (95% CI, £67 to £2782). However, over the entire follow-up period the difference (£1652) was not statistically significant (-£1709 to £4268). The cost-effectiveness analysis showed that costs of £731 would be incurred to achieve a point improvement in satisfaction with parenting compared to routine care by the end of treatment, whilst the figure was £337 for a point improvement by the 6-month follow-up. CONCLUSIONS: Findings suggest that a home-based parenting programme for adopters caring for difficult children in the first 18 months of placement may be cost-effective in enhancing satisfaction with parenting, but not in reducing child behavioural problems, compared with 'services-as-usual'.

Enhancing adoptive parenting: a randomized controlled trial.

The aim was to conduct a pragmatic randomized controlled trial (RCT) to evaluate two parenting programmes designed for adopters of children late placed from care. Adoptive parents, with children between 3 and 8 years who were screened to have serious behavioural problems early in the placement, participated in home-based, manualized, parenting programmes delivered by trained and supervised family social workers. The adopters who agreed to join the study were randomly allocated to one of two parenting interventions or to a "services as usual" group. Baseline, immediate post-intervention and six-month follow-ups were assessed using questionnaires and adopter interviews. No cases were lost to follow-up at any point and satisfaction was high with both parenting interventions. At the six-month follow-up, a significant difference (p < 0.007) was found for "satisfaction with parenting" in favour of the intervention group (Effect Size d = 0.7). Negative parenting approaches were reduced in the intervention group. However, no significant differences in child problems were found between the intervention groups and control group, adjusting for baseline scores. Costs analysis showed that a relatively modest investment in post-adoption support would be well spent in improving adopters' satisfaction with parenting in the intervention group compared to the routine service group.

Pharmacoeconomic considerations in the treatment of multiple sclerosis.

Multiple sclerosis (MS) is a disorder that incurs high costs to individuals, health systems and society as a whole. A growing number of studies have measured the costs of MS and assessed the cost effectiveness of different treatments. This review summarizes the evidence from these studies. Electronic databases were searched and a total of 51 studies were included, 32 of which were cost-of-illness studies. The cost-of-illness studies took different perspectives (health service or societal) and the annual costs per person with MS ranged between $US6511 and $US77,938 (year of cost 2008). Economic evaluations of interferon (IFN)-beta-1a, IFNbeta-1b, glatiramer acetate, natalizumab, mitoxantrone and cyclophosphamide were identified. The results of the cost effectiveness of drug interventions were mixed. Most results comparing a drug with placebo related to IFNbeta-1b and the results usually revealed cost-effectiveness ratios that were above usual willingness-to-pay thresholds of public decision makers. The limited evidence on glatiramer acetate suggests that this may be cost effective. Head-to-head drug comparisons produced varying results, although the findings for natalizumab appear favourable compared with other drugs. Further trial-based comparisons are required to increase the evidence base regarding drug treatments for MS.

Alternatives to standard acute in-patient care in England: readmissions, service use and cost after discharge.

BACKGROUND: Residential alternatives to standard psychiatric admissions are associated with shorter lengths of stay, but little is known about the impact on readmissions. AIMS: To explore readmissions, use of community mental health services and costs after discharge from alternative and standard services. METHOD: Data on use of hospital and community mental health services were collected from clinical records for participants in six alternative and six standard services for 12 months from the date of index admission. RESULTS: After discharge, the mean number and length of readmissions, use of community mental health services and costs did not differ significantly between standard and alternative services. Cost of index admission and total 12-month cost per participant were significantly higher for standard services. CONCLUSIONS: Shorter lengths of stay in residential alternatives are not associated with greater frequency or length of readmissions or greater use of community mental health services after discharge.

Nurse and patient activities and interaction on psychiatric inpatients wards: a literature review.

BACKGROUND: Despite major developments in community mental health services, inpatient care remains an important yet costly part of the service system and patients who are admitted frequently spend a long period of time in hospital. It is, therefore, crucial to have a good understanding of activities that take place on inpatient wards. OBJECTIVE: To review studies that have measured nursing and patient activity and interaction on psychiatric inpatient wards. DATA SOURCES AND REVIEW METHODS: This literature review was performed by searching electronic databases and hand-checking reference lists. RESULTS: The review identified 13 relevant studies. Most used observational methods and found that at best 50% of staff time is spent in contact with patients, and very little time is spent delivering therapeutic activities. Studies also showed that patients spend substantial time apart from staff or other patients. CONCLUSION: On inpatient psychiatric wards, evidence over 35 years has found little patient activity or patient social engagement. The reasons for this trend and recommendations for the future are discussed.

The economic impact of mental health stigma and discrimination: a systematic review.

UNLABELLED: People with mental illness face stigma and discrimination in a variety of settings which can have an economic impact. AIM: The aim of this paper was to identify literature on the economic impact of mental illness stigma. METHODS: A systematic review of the literature identified 30 papers from 27 studies by searching electronic databases and hand searching reference lists. RESULTS: Mental illness stigma/discrimination was found to impact negatively on employment, income, public views about resource allocation and healthcare costs. CONCLUSIONS: Stigma and discrimination regarding mental health problems lead to adverse economic effects for people with these conditions. Interventions that reduce stigma may therefore also be economically beneficial.

Adoption of health center performance measures and national benchmarks.

This study examines the adaptability of standardized performance measurement tools in 3 community-based health centers. Although health centers have considerable experience in the area of performance reporting, they do not currently participate in a national reporting system that is transparent and standardized. The analysis of the data collected from health centers indicates that not only can these safety net providers readily integrate standardized measures, the quality of care being provided compare favorably to national benchmarks. With evidence of solid performance may come the types of financial adjustments essential to permitting health centers to move more decisively into the broader private health insurance markets that may exist in their service areas.