The Impact of Home and Community Based Settings (HCBS) Final Settings Rule Outcomes on Health and Safety.

Despite physically relocating into the community, many people with intellectual and developmental disabilities (IDD) fail to be meaningfully included in the community. The Home and Community Based Services (HCBS) Settings Rule was introduced to expand community integration, person-centered services, and choice. The aim of this exploratory study is to examine the potential impact of HCBS Settings Rule implementation, specifically by examining how the presence of HCBS Settings Rule outcomes impact three areas of health and safety. We analyzed secondary Personal Outcome Measures data relating to the HCBS Settings Rule, and emergency room visits, abuse and neglect, and injuries data from 251 people with IDD. Findings indicate a clear need to improve HCBS Settings Rule related areas of people's lives.

Economics of decriminalizing mental illness: when doing the right thing costs less.

The United States' criminal justice system has seen exponential growth in costs related to the incarceration of persons with mental illness. Jails, prisons, and state hospitals' resources are insufficient to adequately treat the sheer number of individuals cycling through their system. Reversing the cycle of criminalization of mental illness is a complicated process, but mental health diversion programs across the nation are uniquely positioned to do just that. Not only are these programs providing humane treatment to individuals within the community and breaking the cycle of recidivism, the potential fiscal savings are over 1 billion dollars.

Multidimensional measure of immigrant integration.

The successful integration of immigrants into a host country's society, economy, and polity has become a major issue for policymakers in recent decades. Scientific progress in the study of immigrant integration has been hampered by the lack of a common measure of integration, which would allow for the accumulation of knowledge through comparison across studies, countries, and time. To address this fundamental problem, we propose the Immigration Policy Lab (IPL) Integration Index as a pragmatic and multidimensional measure of immigrant integration. The measure, both in the 12-item short form (IPL-12) and the 24-item long form (IPL-24), captures six dimensions of integration: psychological, economic, political, social, linguistic, and navigational. The measure can be used across countries, over time, and across different immigrant groups and can be administered through short questionnaires available in different modes. We report on four surveys we conducted to evaluate the empirical performance of our measure. The tests reveal that the measure distinguishes among immigrant groups with different expected levels of integration and also correlates with well-established predictors of integration.

Costs, needs, and integration efforts shape helping behavior toward refugees.

Recent political instabilities and conflicts around the world have drastically increased the number of people seeking refuge. The challenges associated with the large number of arriving refugees have revealed a deep divide among the citizens of host countries: one group welcomes refugees, whereas another rejects them. Our research aim is to identify factors that help us understand host citizens' (un)willingness to help refugees. We devise an economic game that captures the basic structural properties of the refugee situation. We use it to investigate both economic and psychological determinants of citizens' prosocial behavior toward refugees. In three controlled laboratory studies, we find that helping refugees becomes less likely when it is individually costly to the citizens. At the same time, helping becomes more likely with the refugees' neediness: helping increases when it prevents a loss rather than generates a gain for the refugees. Moreover, particularly citizens with higher degrees of prosocial orientation are willing to provide help at a personal cost. When refugees have to exert a minimum level of effort to be eligible for support by the citizens, these mandatory "integration efforts" further increase prosocial citizens' willingness to help. Our results underscore that economic factors play a key role in shaping individual refugee helping behavior but also show that psychological factors modulate how individuals respond to them. Moreover, our economic game is a useful complement to correlational survey measures and can be used for pretesting policy measures aimed at promoting prosocial behavior toward refugees.

Decision support for evidence-based integration of disease control: A proof of concept for malaria and schistosomiasis.

AUTHOR SUMMARY: Designing and implementing effective programs for infectious disease control requires complex decision-making, informed by an understanding of the diseases, the types of disease interventions and control measures available, and the disease-relevant characteristics of the local community. Though disease modeling frameworks have been developed to address these questions and support decision-making, the complexity of current models presents a significant barrier to on-the-ground end users. The picture is further complicated when considering approaches for integration of different disease control programs, where co-infection dynamics, treatment interactions, and other variables must also be taken into account. Here, we describe the development of an application available on the internet with a simple user interface, to support on-the-ground decision-making for integrating disease control, given local conditions and practical constraints. The model upon which the tool is built provides predictive analysis for the effectiveness of integration of schistosomiasis and malaria control, two diseases with extensive geographical and epidemiological overlap. This proof-of-concept method and tool demonstrate significant progress in effectively translating the best available scientific models to support pragmatic decision-making on the ground, with the potential to significantly increase the impact and cost-effectiveness of disease control.

Costs of implementing integrated community case management (iCCM) in six African countries: implications for sustainability.

BACKGROUND: Sub-Saharan Africa still reports the highest rates of under-five mortality. Low cost, high impact interventions exist, however poor access remains a challenge. Integrated community case management (iCCM) was introduced to improve access to essential services for children 2-59 months through diagnosis, treatment and referral services by community health workers for malaria, pneumonia and diarrhea. This paper presents the results of an economic analysis of iCCM implementation in regions supported by UNICEF in six countries and assesses country-level scale-up implications. The paper focuses on costs to provider (health system and donors) to inform planning and budgeting, and does not cover cost-effectiveness. METHODS: The analysis combines annualised set-up costs and 1 year implementation costs to calculate incremental economic and financial costs per treatment from a provider perspective. Affordability is assessed by calculating the per capita financial cost of the program as a percentage of the public health expenditure per capita. Time and financial implications of a 30% increase in utilization were modeled. Country scale-up is modeled for all children under 5 in rural areas. RESULTS: Utilization of iCCM services varied from 0.05 treatment/y/under-five in Ethiopia to over 1 in Niger. There were between 10 and 603 treatments/community health worker (CHW)/y. Consultation cost represented between 93% and 22% of economic costs per treatment influenced by the level of utilization. Weighted economic cost per treatment ranged from US$ 13 (2015 USD) in Ghana to US$ 2 in Malawi. CHWs spent from 1 to 9 hours a week on iCCM. A 30% increase in utilization would add up to 2 hours a week, but reduce cost per treatment (by 20% in countries with low utilization). Country scale up would amount to under US$ 0.8 per capita total population (US$ 0.06-US$0.74), between 0.5% and 2% of public health expenditure per capita but 8% in Niger. CONCLUSIONS: iCCM addresses unmet needs and impacts on under 5 mortality. An economic cost of under US$ 1/capita/y represents a sound investment. Utilization remains low however, and strategies must be developed as a priority to improve demand. Continued donor support is required to sustain iCCM services and strengthen its integration within national health systems.

Community integration of people with intellectual and developmental disabilities: A national longitudinal analysis.

BACKGROUND: Medicaid Home and Community Based Services (HCBS) 1915(c) waivers are the largest providers of long-term supports and services (LTSS) for people with intellectual and developmental disabilities (IDD) in the United States. National and longitudinal analyses of HCBS 1915(c) waivers for people with IDD are critical because of changes in the fiscal landscape, the variability produced by states ability to flexibly customize their programs, and the significant changes required by the HCBS final settings rule. OBJECTIVE/HYPOTHESIS: The aim of this study was to determine spending allocations and state priorities for LTSS for people with IDD through Medicaid HCBS waivers over a five-year period (fiscal year 2011 to fiscal year 2015). METHODS: Medicaid HCBS 1915(c) waivers for people with IDD from fiscal year (FY) 2011 to FY 2015 were analyzed to determine total projected spending, unduplicated participants, and average spending per participant across fiscal years and states. Over 10,000 services from the five years were also analyzed to determine service priorities. RESULTS: This longitudinal analysis of HCBS IDD waiver allocation revealed large fluctuation across five years in terms of total participants, total spending, and average spending per participant. Trends also revealed a shifting away from residential habilitation settings towards supports for living in one's own home. CONCLUSIONS: When revising waivers to meet the Final Settings Rule, states should utilize our findings to determine areas of need and how to best apply limited funding.

A menu with prices: Annual per person costs of programs addressing community integration.

Information on costs of programs addressing community integration for persons with serious mental illness in the United States, essential for program planning and evaluation, is largely lacking. To address this knowledge gap, community integration programs identified through directories and snowball sampling were sent an online survey addressing program costs and organizational attributes. 64 Responses were received for which annual per person costs (APPC) could be computed. Programs were categorized by type of services provided. Program types differed in median APPCs, though median APPCs identified were consistent with the ranges identified in the limited literature available. Multiple regression was used to identify organizational variables underlying APPCs such as psychosocial rehabilitation program type, provision of EBPs, number of volunteers, and percentage of budget spent on direct care staff, though effects sizes were moderate at best. This study adds tentative prices to the menu of community integration programs, and the implications of these findings for choosing, designing and evaluating programs addressing community integration are discussed.

Public support of community corrections in China.

There are a variety of factors that have been associated with support for the use of community corrections in the West. However, little research has been completed to examine if these same factors are also associated with support for the use of community corrections in China. This exploratory study examined the degree of agreement and support of 764 Chinese citizens on the use of community corrections methods. Results indicated that most respondents supported the use of community corrections methods rather than traditional incarceration methods. In addition, five attitudes (the punishment perspective, the rehabilitation perspective, the humanitarian perception, cost-effectiveness, and risk) toward the use of community corrections methods were examined and all were found to be significantly associated with the support of community corrections in present-day China.