Updating the Chronic Illness and Disability Payment System.

BACKGROUND: Of the 38 Medicaid programs that risk adjust payments to Medicaid managed care organizations (MCOs), 33 of them use the Chronic Illness and Disability Payment System (CDPS). There has been recent interest in adding social determinants of health (SDH) into risk-adjustment models. OBJECTIVE: To update the CDPS models using recent MCO data based on the International Classification of Diseases version 10 coding system and to explore whether indicators of SDH are predictive of expenditures. RESEARCH DESIGN: Data from 3 national Medicaid MCOs and 8 states are used to update the CDPS model. We test whether spending on Medicaid beneficiaries living in economically and socially deprived communities is greater than spending on similar beneficiaries in less deprived communities. SUBJECTS: Medicaid beneficiaries with full benefits and without dual eligibility under Medicare enrolled in Medicaid MCOs in 8 states during 2017-2019, including 1.4M disabled beneficiaries, 9.2M children, and 6.4M adults. MEASURES: Health care eligibility and claims records. Indicators based on the Social Deprivation Index were used to measure SDH. RESULTS: The revised CDPS model has 52 CDPS categories within 19 major categories. Six major categories of CDPS were revised: Psychiatric, Pulmonary, Renal, Cancer, Infectious Disease, and Hematological. We found no relationship between health care spending and the Social Deprivation Index. CONCLUSIONS: The revised CDPS models and regression weights reflect the updated International Classification of Diseases-10 coding system and recent managed care delivery. States should choose alternative payment strategies to address disparities in health and health outcomes.

Lifetime HIV testing among three samples of adults with histories of incarceration in Southern California.

ABSTRACTJustice-impacted persons may inconsistently access HIV testing. This cross-sectional secondary analysis investigates lifetime HIV testing prevalence among adults with prior histories of incarceration in Southern California, United States, participating in health-focused programming (n = 3 studies). Self-reported demographic and lifetime HIV testing data were collected between 2017-2023; descriptive analyses were conducted. Across the three samples, at least 74% of participants were male; Latino and African American individuals accounted for nearly two-thirds of participants. Lifetime HIV testing ranged from 72.8% to 84.2%. Males were significantly more likely than females to report never being tested in two samples and accounted for >95% of those never tested. No statistically significant differences in testing were observed by race/ethnicity. Single young adults (ages 18-26) were less likely than their partnered peers to report testing. HIV testing is critical for ensuring that individuals access prevention and treatment. HIV testing among justice-impacted adults in this study was higher than in the general population, potentially due to opt-out testing in correctional settings. Nevertheless, these findings underscore the importance of implementing targeted interventions to reduce structural (e.g., health insurance, access to self-testing kits) and social barriers (e.g., HIV stigma) to increase HIV testing among justice-impacted males and single young adults.

Mi Puente (My Bridge) Care Transitions Program for Hispanic/Latino Adults with Multimorbidity: Results of a Randomized Controlled Trial.

BACKGROUND: Multimorbidity frequently co-occurs with behavioral health concerns and leads to increased healthcare costs and reduced quality and quantity of life. Unplanned readmissions are a primary driver of high healthcare costs. OBJECTIVE: We tested the effectiveness of a culturally appropriate care transitions program for Latino adults with multiple cardiometabolic conditions and behavioral health concerns in reducing hospital utilization and improving patient-reported outcomes. DESIGN: Randomized, controlled, single-blind parallel-groups. PARTICIPANTS: Hispanic/Latino adults (N=536; 75% of those screened and eligible; M=62.3 years (SD=13.9); 48% women; 73% born in Mexico) with multiple chronic cardiometabolic conditions and at least one behavioral health concern (e.g., depression symptoms, alcohol misuse) hospitalized at a hospital that serves a large, mostly Hispanic/Latino, low-income population. INTERVENTIONS: Usual care (UC) involved best-practice discharge processes (e.g., discharge instructions, assistance with appointments). Mi Puente ("My Bridge"; MP) was a culturally appropriate program of UC plus inpatient and telephone encounters with a behavioral health nurse and community mentor team who addressed participants' social, medical, and behavioral health needs. MAIN MEASURES: The primary outcome was 30- and 180-day readmissions (inpatient, emergency, and observation visits). Patient-reported outcomes (quality of life, patient activation) and healthcare use were also examined. KEY RESULTS: In intention-to-treat models, the MP group evidenced a higher rate of recurrent hospitalization (15.9%) versus UC (9.4%) (OR=1.91 (95% CI 1.09, 3.33)), and a greater number of recurrent hospitalizations (M=0.20 (SD=0.49) MP versus 0.12 (SD=0.45) UC; P=0.02) at 30 days. Similar trends were observed at 180 days. Both groups showed improved patient-reported outcomes, with no advantage in the Mi Puente group. Results were similar in per protocol analyses. CONCLUSIONS: In this at-risk population, the MP group experienced increased hospital utilization and did not demonstrate an advantage in improved patient-reported outcomes, relative to UC. Possible reasons for these unexpected findings are discussed. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02723019. Registered on 30 March 2016.

Building trust: Leadership reflections on community empowerment and engagement in a large urban initiative.

BACKGROUND: Trust is essential for healthy, reciprocal relationships; creating safe environments; engaging in transparent interactions; successfully negotiating power differentials; supporting equity and putting trauma informed approaches into practice. Less is known, however, about the ways that trust-building may be at the forefront of consideration during community capacity building efforts, what trust-building elements are perceived as essential for optimally engaging communities, and what practices might support these efforts. METHODS: The present study examines an evolving understanding of trust-building over the course of 3 years, from qualitative data derived during interviews with nine agency leads from a large and diverse urban community, who are spearheading community-based partnerships to create more trauma-informed communities and foster resiliency. RESULTS: Data reflected fourteen trust-building elements, captured by three themes: 1) Building relationships and engagement (e.g., behavioral practices such as meeting people "where they are at" and creating safe spaces), 2) Embodying core values of trustworthiness (e.g., traits such as being transparent and embodying benevolence), and 3) Sharing decision-making, championing autonomy, and addressing barriers to trust (e.g., collaborative practices such as creating a shared vision and goals and addressing systemic inequities). These trust-building elements are presented in the Community Circle of Trust-Building, which provides an accessible, visual format that can facilitate capacity building efforts within organizations and with the broader community; guide the selection of training opportunities that support healthy interpersonal relationships; and aid in the identification of relevant, supporting frameworks (e.g., health equity, trauma-informed practices, inclusive leadership models). CONCLUSIONS: Community engagement and trust are essential for overall health and well-being, increasing equitable access to resources, and supporting an effective and connected citizenry. These data shed light on opportunities for trust-building and thoughtful engagement among agencies working directly with community members in large urban areas.

Barriers to Accessing Mental Health Care Under the Mental Health Services Act: A Qualitative Case Study in Orange County, California.

Despite progress made under California's Mental Health Services Act, limited access to care for cultural and linguistic minority groups remains a serious issue in community mental health. In this qualitative study we report findings from a large-scale community-level assessment that explored barriers to accessing care from the perspectives of multiple stakeholders including county advisors, advocates, community members, and consumers representing a range of cultural and linguistic communities in Orange County, California. We conducted 14 focus groups with N = 112 participants. Qualitative analysis revealed that system fragmentation, limited availability of linguistically appropriate care, and stigma continue to undermine access to mental health care. Peer health navigation and culturally responsive peer support are potential ways to promote service engagement with persons from cultural and linguistic minority groups that encounter barriers when accessing mental health services.

Programmatic Support for Peer Specialists that Serve Transition Age Youth Living with Serious Mental Illness: Perspectives of Program Managers from Two Southern California Counties.

Peer Specialists (PS) often work in outpatient mental health programs serving transition age youth (TAY). This study examines program managers' perspectives on efforts to strengthen PS' professional development. In 2019, we interviewed program managers (n = 11) from two Southern California Counties employed by public outpatient mental health programs (n = 8) serving TAY and conducted thematic analyses. We present themes and illustrative quotes. PS' roles are highly flexible; thus, PM support PS to strengthen skills to address organization-facing and client-facing responsibilities. PM addressed time management, documentation, PS integration into the organization, and workplace relationships. Trainings to better support clients included addressing cultural competency to serve LGBTQ TAY and racial/ethnic subgroups. Diverse supervision modalities address PS' diverse needs. Supporting PS' technical and administrative skills (e.g., planning, interpersonal communication skills) may aid their implementation of a complex role. Longitudinal research can examine the impact of organizational supports on PS' job satisfaction, career trajectories, and TAY clients' engagement with services.

A Mixed-method Evaluation of the Behavioral Health Integration and Complex Care Initiative Using the Consolidated Framework for Implementation Research.

BACKGROUND: Integrated behavioral health and primary care can improve the health of persons with complex chronic conditions. The Behavioral Health Integration and Complex Care Initiative (BHICCI) implemented integrated care across a large health system. Whether Behavioral Health Organizations (BHOs) and Federally Qualified Health Centers (FQHCs) implemented the BHICCI differently is unclear. OBJECTIVES: The objective of this study was to evaluate integration under the BHICCI and to understand implementation differences between BHOs and FQHCs. METHODS: We used a convergent parallel mixed-method design. Integration was measured quantitatively using the Maine Health Access Site Self-Assessment (SSA), which was completed by clinic teams at baseline and 24 months, and through n=70 qualitative interviews with initiative stakeholders, which were organized using the Consolidated Framework for Implementation Research. Results were compared to understand how qualitative findings explained quantitative results. RESULTS: Data were collected in 7 clinics (n=2 FQHC; n=5 BHOs). FQHCs reported greatest improvement in the client centered subscale, with a baseline score of 4.6 (SD=0.64) and 7.8 (SD=0.89) at 24 months. BHOs reported greatest improvement in the organizational supports for integration subscale, with a baseline score of 4.8 (SD=1.07) and 7.9 (SD=1.1) at 24 months. Our Consolidated Framework for Implementation Research analysis illustrates contextual factors, such as insurance plan supports and clinic-level challenges, that explain these scores. CONCLUSIONS: All clinical settings received support from the health plan, but differences between BHOs and FQHCs affected integration progress. Study results can help identify organizational practices that advance or undermine the delivery of integrated care across multiple clinical settings.

Developing trauma resilient communities through community capacity-building.

BACKGROUND: Trauma is a significant public health issue, negatively impacting a range of health outcomes. Providers and administrators in public mental health systems recognize the widespread experience of trauma, as well as their limited ability to address trauma within their communities. In response, the Los Angeles County Department of Mental Health funded nine regionally based community partnerships to build capacity to address trauma. We describe partnership and community capacity-building efforts and examine community impact, defined as successful linkages to resources and changes in stress tolerance capacities among community members. METHODS: We conceptualized community capacity-building as dissemination of trauma-informed education and training, community outreach and engagement, and linkage of community members to resources. We measured trauma-informed trainings among partnership members (N = 332) using the Trauma-Informed Organizational Toolkit. Outreach, engagement and linkages were documented using Event and Linkage Trackers. We examined changes in the type of successful linkage after the issuance of statewide mandatory restrictions in response to COVID-19. We examined changes in stress tolerance capacities among community members (N = 699) who were engaged in ongoing partnership activities using the 10-item Conner-Davidson Resilience Scale; the 28-item Coping Orientation to Problems; and the pictorial Inclusion of Community in Self Scale. RESULTS: Training and education opportunities were widespread: 66% of members reported opportunities for training in 13 or more trauma-informed practices. Partnerships conducted over 7800 community capacity-building events with over 250,000 attendees. Nearly 14,000 successful linkages were made for a wide range of resources, with consistent linkage success prior to (85%) and during (87%) the pandemic. In response to COVID-19, linkage type significantly shifted from basic services and health care to food distribution (p < .01). Small but significant improvements occurred in coping through emotional and instrumental support; and sense of community connectedness (p < .05 each). CONCLUSIONS: Community-based partnerships demonstrated effective capacity-building strategies. Despite the pandemic, community members did not report reduced stress tolerance, instead demonstrating gains in external help-seeking (use of emotional and instrumental supports) and perception of community connectedness. Future work will use qualitative methods to examine the impact of community capacity-building and the sustainability of this approach for addressing the impact of trauma within communities.

The Availability of Peer Support and Disparities in Outpatient Mental Health Service Use Among Minority Youth with Serious Mental Illness.

We examine whether the availability of peer support reduces disparities in service use among minority youth ages 16-24 with serious mental illness in Los Angeles and San Diego Counties. Administrative data from 2015-2018 was used to summarize service use among 13,363 transition age youth age 16-24 with serious mental illness who received services from 183 outpatient public mental health programs; 17.2% were Black, 67.4% were Latinx, and 15.4% were non-Latinx white. The availability of peer support was assessed via a program survey. Generalized linear models were used to assess the relationship between availability of peer support, defined as having a peer specialist on staff, and the annual number of outpatient mental health visits. We also examined the relationship between racial/ethnic concordance of youth and peer specialists and use of outpatient services. Forty-six percent of youth received services from programs that employed peer specialists. Among youth in both counties, the availability of peer support was associated with an increase in annual outpatient visits (P ≤ .05 each). Peer support was associated with reductions in service use disparities among Black and Latinx youth in Los Angeles County (P < .001 each). Peer concordance was associated with an increase in outpatient service use among Latinx youth in both counties (P < .05 each). Peer support was associated with increases in use of outpatient mental health services. Detailed examination of the context for youth peer support implementation is merited to identify the specific pathways that improve outcomes.

The effects of financial incentives on diabetes prevention program attendance and weight loss among low-income patients: the We Can Prevent Diabetes cluster-randomized controlled trial.

BACKGROUND: Penetration and participation of real life implementation of lifestyle change programs to prevent type 2 diabetes has been challenging. This is particularly so among low income individuals in the United States. The purpose of this study is to examine the effectiveness of financial incentives on attendance and weight loss among Medicaid beneficiaries participating in the 12-month Diabetes Prevention Program (DPP). METHODS: This is a cluster-randomized controlled trial with two financial incentive study arms and an attention control study arm. Medicaid beneficiaries with prediabetes from 13 primary care clinics were randomly assigned to individually earned incentives (IND; 33 groups; n = 309), a hybrid of individual- and group-earned incentives (GRP; 30 groups; n = 259), and an attention control (AC; 30 groups; n = 279). Up to $520 in incentives could be earned for attaining attendance and weight loss goals over 12 months. Outcomes are percent weight loss from baseline, achieving 5% weight loss from baseline, and attending 75% of core and 75% of maintenance DPP sessions. Linear mixed models were used to examine weight change and attendance rates over the 16 weeks and 12 months. RESULTS: The percent weight change at 16 weeks for the IND, GRP, and AC participants were similar, at - 2.6, - 3.1%, and - 3.4%, respectively. However, participants achieving 5% weight loss in the IND, GRP, and AC groups was 21.5, 24.0% (GRP vs AC, P < 0.05), and 15.2%. Attendance at 75% of the DPP core sessions was significantly higher among IND (60.8%, P < 0.001) and GRP (64.0%, P < 0.001) participants than among AC (38.6%) participants. Despite substantial attrition over time, attendance at 75% of the DPP maintenance sessions was also significantly higher among IND (23.0%, P < 0.001) and GRP (26.1%, P < 0.001) participants than among AC (11.0%) participants. CONCLUSIONS: Financial incentives can improve the proportion of Medicaid beneficiaries attending the 12-month DPP and achieving at least 5% weight loss. TRIAL REGISTRATION: ClinicalTrials.gov NCT02422420 ; retrospectively registered April 21, 2015.

Rehabilitation After Total Knee Arthroplasty: Do Racial Disparities Exist?

BACKGROUND: Racial disparities in functional outcomes after total knee arthroplasty (TKA) exist. Whether differences in rehabilitation utilization contribute to these disparities remains to be investigated. METHODS: Among 8349 women enrolled in the prospective Women's Health Initiative cohort who underwent primary TKA between 2006 and 2013, rehabilitation utilization was determined through linked Medicare claims data. Postacute discharge destination (home, skilled nursing facility, and inpatient rehabilitation facility), facility length of stay, and number of home health physical therapy (HHPT) and outpatient physical therapy (OPPT) sessions were compared between racial groups. RESULTS: Non-Hispanic black women had worse physical function (median score, 65 vs 70) and higher likelihood of disability (13.2% vs 6.9%) than non-Hispanic white women before surgery. After TKA, black women were more likely to be discharged postacutely to an institutional facility (64.3% vs 54.5%) than white women, were more likely to receive HHPT services (52.6% vs 47.8%), and received more HHPT and OPPT sessions. After stratification by postacute discharge setting, the likelihood of receipt of HHPT or OPPT services was similar between racial groups. No significant difference in receipt of HHPT or OPPT services was found after use of propensity score weighting to balance health and medical characteristics indicating severity of need for physical therapy services. CONCLUSION: Rehabilitation utilization was generally comparable between black and white women who received TKA when accounting for need. There was no evidence of underutilization of post-TKA rehabilitation services, and thus disparities in post-TKA functional outcomes do not appear to be a result of inequitable receipt of rehabilitation care.

Predictors of Nebulized Arformoterol Treatment: A Retrospective Analysis of Medicare Beneficiaries with Chronic Obstructive Pulmonary Disease.

This study examined sociodemographic and clinical characteristics, treatment patterns, and health resource utilization among Medicare beneficiaries with chronic obstructive pulmonary disease (COPD) to identify predictors of nebulized arformoterol treatment. Using Medicare administrative data from 2010 to 2014, beneficiaries with ≥2 COPD outpatient visits ≥30 d apart or ≥1 COPD-related hospitalization(s) (ICD-9-CM 491.xx, 492.xx, and 496) were identified. Inclusion criteria required ≥1 COPD medication claim(s) and continuous enrollment in Parts A, B, and D. Four cohorts were identified: (a) 11,887 arformoterol users, (b) a subsample of arformoterol users (n = 1,778) who were hospitalized and discharged 30 d before initiating arformoterol, (c) 450,178 controls who had not received arformoterol, and (d) a subsample of controls (n = 21,910) who had hospitalizations. Logistic regression analysis was used to evaluate predictors of arformoterol treatment. The majority of beneficiaries were older than 70 years of age, female, Caucasian, and 47% were dual-eligible. The strongest predictors of arformoterol treatment were oxygen therapy, systemic corticosteroid or methylxanthine use, an exacerbation, a COPD-related hospitalization, and receiving care from a pulmonologist (all p < .001). Dual-eligibility, being a racial/ethnic minority, and having severe psychiatric comorbidity or immunodeficiency lowered the odds of receiving nebulized arformoterol (all p < .001). Among beneficiaries with recent hospitalizations, exacerbations and COPD-related admissions increased the odds of receiving arformoterol (p < .001). Nebulized arformoterol treatment was more likely to be initiated in sicker patients with COPD. Ensuring access to nebulized maintenance therapy is important and particularly warranted for COPD populations with greater medical needs.

Peer Respites: A Qualitative Assessment of Consumer Experience.

This qualitative study explored the experiences of persons staying at two peer respites through interviews with 27 respite guests near the end of their stay and at 2-6 months following their stay. Trained peer interviewers conducted baseline and follow-up interviews. Peer respites can be beneficial spaces within the mental health system for guests to temporarily escape stressful situations while building relationships with other persons with mental illness, though some respondents were uncomfortable receiving services from peers, and several guests did not want to leave after their stay. Ongoing training of peers and orientations for respite guests can help ensure optimal respite experiences.

A Web-Based Physical Activity Intervention for Spanish-Speaking Latinas: A Costs and Cost-Effectiveness Analysis.

BACKGROUND: Latinas report particularly low levels of physical activity and suffer from greater rates of lifestyle-related conditions such as obesity and diabetes. Interventions are needed that can increase physical activity in this growing population in a large-scale, cost-effective manner. Web-based interventions may have potential given the increase in Internet use among Latinas and the scalability of Web-based programs. OBJECTIVE: To examine the costs and cost-effectiveness of a Web-based, Spanish-language physical activity intervention for Latinas compared to a wellness contact control. METHODS: Healthy adult Latina women (N=205) were recruited from the community and randomly assigned to receive a Spanish-language, Web-based, individually tailored physical activity intervention (intervention group) or were given access to a website with content on wellness topics other than physical activity (control group). Physical activity was measured using the 7-Day Physical Activity Recall interview and ActiGraph accelerometers at baseline, 6 months (ie, postintervention), and 12 months (ie, maintenance phase). Costs were estimated from a payer perspective and included all features necessary to implement the intervention in a community setting, including staff time (ie, wages, benefits, and overhead), materials, hardware, website hosting, and routine website maintenance. RESULTS: At 6 months, the costs of running the intervention and control groups were US $17 and US $8 per person per month, respectively. These costs fell to US $12 and US $6 per person per month at 12 months, respectively. Linear interpolation showed that intervention participants increased their physical activity by 1362 total minutes at 6 months (523 minutes by accelerometer) compared to 715 minutes for control participants (186 minutes by accelerometer). At 6 months, each minute increase in physical activity for the intervention group cost US $0.08 (US $0.20 by accelerometer) compared to US $0.07 for control participants (US $0.26 by accelerometer). Incremental cost-per-minute increases associated with the intervention were US $0.08 at 6 months and US $0.04 at 12 months (US $0.16 and US $0.08 by accelerometer, respectively). Sensitivity analyses showed variations in staffing costs or intervention effectiveness yielded only modest changes in incremental costs. CONCLUSIONS: While the Web-based physical activity intervention was more expensive than the wellness control, both were quite low cost compared to face-to-face or mail-delivered interventions. Cost-effectiveness ranged markedly based on physical activity measure and was similar between the two conditions. Overall, the Web-based intervention was effective and low cost, suggesting a promising channel for increasing physical activity on a large scale in this at-risk population. CLINICALTRIAL: Clinicaltrials.gov NCT01834287; https://clinicaltrials.gov/ct2/show/NCT01834287 (Archived by WebCite at http://www.webcitation.org/6nyjX9Jrh).

Peer Support in Full-Service Partnerships: A Multiple Case Study Analysis.

Peer providers are integral to Full Service Partnerships (FSPs), which are team-based mental health service models. Peer providers use principles of recovery to engage clients, but FSPs can vary in their recovery orientation. Whether and how peer recovery orientation reflects the organizational environments of FSPs is unclear. This qualitative study explored peer provider attitudes towards recovery within the organizational contexts of FSPs where they are employed. Case study analysis was conducted on eight purposively sampled FSPs using qualitative interviews with peer providers and program directors. In two cases, peer recovery attitudes diverged from those of their organizational context. In these cases, peer providers were champions for recovery, and used practice-based strategies to promote client autonomy despite working in settings with lower recovery orientation. Peer providers could be uniquely positioned to promote client autonomy in settings where organizational factors limit consumer choice.

Health Outcomes and Costs Associated with the Provision of Culturally Competent Services for Underrepresented Ethnic Populations with Severe Mental Illness.

Underrepresented racial/ethnic populations (UREPs) face disparities in their use of behavioral health services for multiple reasons including lack of culturally competent services and stigma. This paper employs mixed methods to compare health outcomes and costs among clients in 14 culturally competent behavioral health programs targeting specific UREPs to five programs without a specific racial or ethnic focus. We found that UREP-focused programs were associated with similar improvements in health outcomes, but greater costs relative to the comparison programs. Main themes from the qualitative analysis included: addressing stigma, building trust and understanding confidentiality, looking for a cure, and moving beyond linguistic competency.

Implementation and Outcomes of Forensic Housing First Programs.

This mixed-method study used administrative data from 68 supportive housing programs and evaluative and qualitative site visit data from a subset of four forensic programs to (a) compare fidelity to the Housing First model and residential client outcomes between forensic and nonforensic programs and (b) investigate whether and how providers working in forensic programs can navigate competing Housing First principles and criminal justice mandates. Quantitative findings suggested that forensic programs were less likely to follow a harm reduction approach to substance use and clients in those programs were more likely to live in congregate settings. Qualitative findings suggested that an interplay of court involvement, limited resources, and risk environments influenced staff decisions regarding housing and treatment. Existing mental health and criminal justice collaborations necessitate adaptation to the Housing First model to accommodate client needs.

Cost effectiveness of a mail-delivered individually tailored physical activity intervention for Latinas vs. a mailed contact control.

BACKGROUND: Physical inactivity is high in Latinas, as are chronic health conditions. There is a need for physical activity (PA) interventions that are not only effective but have potential for cost-effective widespread dissemination. The purpose of this paper was to assess the costs and cost effectiveness of a Spanish-language print-based mail-delivered PA intervention that was linguistically and culturally adapted for Latinas. METHODS: Adult Latinas (N = 266) were randomly assigned to receive mail-delivered individually tailored intervention materials or wellness information mailed on the same schedule (control). PA was assessed at baseline, six months (post-intervention) and 12 months (maintenance phase) using the 7-Day Physical Activity Recall Interview. Costs were calculated from a payer perspective, and included personnel time (wage, fringe, and overhead), materials, equipment, software, and postage costs. RESULTS: At six months, the PA intervention cost $29/person/month, compared to $15/person/month for wellness control. These costs fell to $17 and $9 at 12 months, respectively. Intervention participants increased their PA by an average of 72 min/week at six months and 94 min/week at 12 months, while wellness control participants increased their PA by an average of 30 min/week and 40 min/week, respectively. At six months, each minute increase in PA cost $0.18 in the intervention group compared to $0.23 in wellness control, which fell to $0.07 and $0.08 at 12 months, respectively. The incremental cost per increase in physical activity associated with the intervention was $0.15 at 6 months and $0.05 at 12 months. CONCLUSIONS: While the intervention was more costly than the wellness control, costs per minute of increase in PA were lower in the intervention. The print-based mail-delivered format has potential for broad, cost-effective dissemination, which could help address disparities in this at-risk population. TRIAL REGISTRATION: NCT01583140; Date of Registration: 03/06/2012; Funding Source of Trial: National Institute of Nursing Research (NINR); Name of Institutional Review Board: Brown University IRB; Date of Approval: 05/19/2009.

Aging in place within permanent supportive housing.

OBJECTIVES: This study examined whether and how permanent supportive housing (PSH) programs are able to support aging in place among tenants with serious mental illness. DESIGN: Investigators used a mixed-method approach known as a convergent parallel design in which quantitative and qualitative data are analyzed separately and findings are merged during interpretation. Quantitative analysis compared 1-year pre-residential and post-residential outcomes for PSH program enrollees, comparing adults aged 35-49 years (n = 3990) with those aged 50 years or older (n = 3086). Case study analysis using qualitative interviews with staff of a PSH program that exclusively served older adults identified challenges to providing support services. RESULTS: Substantial declines in days spent homeless and in justice system settings were found, along with increases in days living independently in apartments and in congregate settings. Homelessness and justice system involvement declined less for older adults than younger adults. Qualitative themes related to working with older adults included increased attention to medical vulnerability, residual effects of institutional care, and perceived preference for congregate living. CONCLUSIONS: PSH is an effective way to end homelessness, yet little is known about how programs can support housing stability among aging populations. Additional support and training for PSH staff will better promote successful aging in place.

Stigma experienced by people using mental health services in San Diego County.

OBJECTIVE: This paper describes how individuals struggling with severe mental illness experience stigma along multiple dimensions including their experiences of discrimination by others, their unwillingness to disclose information about their mental health, and their internalization or rejection of the negative and positive aspects of having mental health problems. METHODS: This cross-sectional study employs descriptive analyses and linear regression to assess the relationship between demographics, mental health diagnoses and self-reported stigma among people receiving mental health services in a large and ethnically diverse county public mental health system (n = 1,237) in 2009. We used the King Stigma Scale to measure three factors related to stigma: discrimination, disclosure, and positive aspects of mental illness. RESULTS: Most people (89.7 %) reported experiencing some discrimination from having mental health problems. Regression analyses revealed that younger people in treatment experienced more stigma related to mental health problems. Women reported experiencing more stigma than men, but men were less likely to endorse the potentially positive aspects of facing mental health challenges than women. Although people with mood disorders reported more discomfort with disclosing mental illness than people with schizophrenia, they did not report experiencing more discrimination than people with schizophrenia. CONCLUSIONS: Study findings suggest that the multidimensional experiences of stigma differ as a function of age, gender, and diagnosis. Importantly, these findings should inform anti-stigma efforts by describing different potential treatment barriers due to experiences of stigma among people using mental health services, especially among younger people and women who may be more susceptible to stigma.