Association Between the Affordable Care Act and Emergency Department Visits for Psychiatric Disease.

INTRODUCTION: Emergency department (ED) utilization for psychiatric disease is increasing, and a lack of health insurance has been identified as a potential cause of preventable or avoidable ED use. Through the Affordable Care Act (ACA), more uninsured individuals gained health insurance; however, the effects of increased health insurance coverage on ED utilization for psychiatric disease have not been examined. METHODS: We performed a longitudinal, cross-sectional analysis of data from the Nationwide Emergency Department Sample, the largest all-payer ED database in the US, which contains data on over 25 million ED visits each year. We examined ED utilization for psychiatric disease as the primary reason for visit among adults aged 18-64. We compared the proportion of ED visits with a psychiatric diagnosis during post-ACA years (2011-2016) to pre-ACA (2009) using logistic regression adjusted for age, gender, payer, and hospital region. RESULTS: The proportion of ED visits with psychiatric diagnosis increased from pre-ACA (4.9%) to post-ACA years (ranging from 5.0-5.5%). There was a significant difference in the proportion of ED visits with a psychiatric diagnosis when comparing each post-ACA year with pre-ACA, with adjusted odds ratios ranging from 1.01-1.09. Among ED visits with a psychiatric diagnosis, the most common age group was 26-49 years, and patients were more likely to be male than female and to have visited urban rather than rural hospitals. During post-ACA years (2014-2016), private and uninsured payers decreased, Medicaid payers increased, and Medicare payers increased in 2014 and decreased in 2015-2016 compared to pre-ACA. CONCLUSION: With the ACA more people gained health insurance, yet ED visits for psychiatric disease continued to increase. These results suggest that increasing access to health insurance alone is not sufficient to reduce ED utilization for patients with a psychiatric disease.

Evidence-Based Policymaking: What Human Service Agencies Can Learn from Implementation Science and Integrated Data Systems.

The evidence-based policymaking movement compels government leaders and agencies to rely on the best available research evidence to inform policy and program decisions, yet how to do this effectively remains a challenge. This paper demonstrates how the core concepts from two emerging fields-Implementation Science (IS) and Integrated Data Systems (IDS)-can help human service agencies and their partners realize the aims of the evidence-based policymaking movement. An IS lens can help agencies address the role of context when implementing evidence-based practices, complement other quality and process improvement efforts, simultaneously study implementation and effectiveness outcomes, and guide de-implementation of ineffective policies. The IDS approach offers governance frameworks to support ethical and legal data use, provides high-quality administrative data for in-house analyses, and allows for more time-sensitive analyses of pressing agency needs. Ultimately, IS and IDS can support human service agencies in more efficiently using government resources to deliver the best available programs and policies to the communities they serve. Although this paper focuses on examples within the United States context, key concepts and guidance are intended to be broadly applicable across geographies, given that IS, IDS, and the evidence-based policymaking movement are globally relevant.

Integrating Assessment and Evaluation Into Partnership Initiatives: Lessons From the Community Partnerships for Older Adults.

Communities nationwide have formed cross-sector partnerships to face the needs of an aging population, particularly for the purpose of improving long-term supportive service systems. Research is limited on how evaluation strategies are incorporated into partnership work, especially in the field of aging. This retrospective qualitative study reviewed administrative and key informant interview data to examine how 15 community partnerships (CPs) within the Community Partnerships for Older Adults (CPFOA) national program incorporated evaluation into their work. The four overarching lessons drawn from our inquiry suggest that effective CPs: (a) incorporate both formative and summative methods into evaluation, (b) use and develop the knowledge and skills of its members, (c) support flexible and creative evaluation methods and strategies, and (d) use internal and external resources to support evaluation efforts, particularly with nontraditional partners. There is a need for continued research to capture the methodological complexity of partnership evaluation.

Meeting the Housing and Care Needs of Older Homeless Adults: A Permanent Supportive Housing Program Targeting Homeless Elders.

The homeless population is aging faster than the general population in the United States. As this vulnerable population continues to age, addressing complex care and housing needs will become increasingly important. This article reviews the often-overlooked issue of homelessness among older adults, including their poor health status and unique care needs, the factors that contribute to homelessness in this population, and the costs of homelessness to the U.S. health care system. Permanent supportive housing programs are presented as a potential solution to elder homelessness, and Hearth, an outreach and permanent supportive housing model in Boston, is described. Finally, specific policy changes are presented that could promote access to housing among the growing older homeless population.