Disability, Hospital Care, and Cost: Utilization of Emergency and Inpatient Care by a Cohort of Children with Intellectual and Developmental Disabilities.

OBJECTIVE: To use medical claims data to determine patterns of healthcare utilization in children with intellectual and developmental disabilities, including frequency of service utilization, conditions that require hospital care, and costs. STUDY DESIGN: Medicaid administrative claims from 4 states (Iowa, Massachusetts, New York, and South Carolina) from years 2008-2013 were analyzed, including 108 789 children (75 417 male; 33 372 female) under age 18 years with intellectual and developmental disabilities. Diagnoses included cerebral palsy, autism, fetal alcohol syndrome, Down syndrome/trisomy/autosomal deletions, other genetic conditions, and intellectual disability. Utilization of emergency department (ED) and inpatient hospital services were analyzed for 2012. RESULTS: Children with intellectual and developmental disabilities used both inpatient and ED care at 1.8 times that of the general population. Epilepsy/convulsions was the most frequent reason for hospitalization at 20 times the relative risk of the general population. Other frequent diagnoses requiring hospitalization were mood disorders, pneumonia, paralysis, and asthma. Annual per capita expenses for hospitalization and ED care were 100% higher for children with intellectual and developmental disabilities, compared with the general population ($153 348 562 and $76 654 361, respectively). CONCLUSIONS: Children with intellectual and developmental disabilities utilize significantly more ED and inpatient care than other children, which results in higher annual costs. Recognizing chronic conditions that increase risk for hospital care can provide guidance for developing outpatient care strategies that anticipate common clinical problems in intellectual and developmental disabilities and ensure responsive management before hospital care is needed.

Factors related to high dental caries experience in Palestinian pregnant women in the Jerusalem governorate: a cross-sectional study.

BACKGROUND: Beliefs about oral health during pregnancy demographic factors, such as level of education and socioeconomic status, are associated with an increased risk of oral diseases during pregnancy. The aim of this study was to assess the oral health status of pregnant women and the relation to the women's oral health knowledge, beliefs, behaviour, and access to dental care. METHODS: For this cross-sectional study, pregnant women visiting pre-natal care clinics at the Palestinian Ministry of Health centres in the Jerusalem governorate were invited to complete a structured interview with questions about beliefs about oral health care and their oral hygiene practices. Screening for oral health conditions was done using the Decayed, Missed and Filled Teeth (DMFT) index to assess the women's dental caries experience, and gingival health indices (plaque, gingival, and calculus) were measured to assess gingival health. Ethical approval was obtained from Al-Quds University Ethics Committee. FINDINGS: 152 pregnant women agreed to participate in this study. Participants had a mean DMFT score of 15·5 (SD 4·5). Bivariate analysis showed that women who had completed a degree after high school had a lower DMFT score than women who did not (F=4; p=0·024). Women who had visited a dentist in the past 6 months had a higher DMFT score than women who had never visited a dentist (F=2·4, p=0·05). Additionally, women who believed they could lose a tooth just because they are pregnant scored high DMFT scores (t=-4; p=0·037). Results of the multivariable analysis showed that age, level of education, recent dental visit, and the belief that it is unsafe to get routine dental care during pregnancy explained 25% of the variation in the DMFT score. INTERPRETATION: Women in this study had high prevalence of dental disease and knew little about dental care during pregnancy. Faulty beliefs about oral health care and barriers to dental care were major factors in the high prevalence of the disease. FUNDING: This project was partially funded by 2016 International Dental Federation FDI SMILE Award.

Completion of Requirements in Iowa's Medicaid Expansion Premium Disincentive Program, 2014-2015.

OBJECTIVES: To evaluate rates of member compliance with Iowa's Medicaid expansion premium disincentive program. METHODS: We used 2014 to 2015 Iowa Medicaid data to construct rolling 12-month cohorts of Wellness Plan and Marketplace Choice members (Iowa's 2 Medicaid expansion waiver programs for individuals ≤ 100% and 101%-138% of the federal poverty level, respectively), calculated completion rates for required activities (i.e., wellness examinations and health risk assessments), and identified factors associated with program compliance. RESULTS: Overall, 18.5% of Wellness Plan and 12.5% of Marketplace Choice members completed both activities (P < .001). From 2014 to 2015, completion rates for both activities decreased for Wellness Plan members but increased for Marketplace Choice members. Members who were younger, male, or non-White were less likely to complete required activities. CONCLUSIONS: Approximately 81% of Wellness Plan members and 87% of Marketplace Choice members failed to comply with program requirements and should have been subject to paying premiums the following year or face disenrollment. Disparities in completion rates may exacerbate disparities in insurance coverage and health outcomes. Public Health Implications. As states consider establishing Medicaid premium disincentive programs, they should anticipate challenges to successful implementation.

Dental caries experience and associated risk indicators among Palestinian pregnant women in the Jerusalem area: a cross-sectional study.

BACKGROUND: This study described the dental caries experience of Palestinian pregnant women and examined its relationships to their oral health knowledge, beliefs, behavior, and access to dental care. METHODS: Pregnant women receiving prenatal care at the Ministry of Health (MOH) centers in the Jerusalem Governorate were invited to participate in this study. Structured interviews were conducted to assess pregnant mothers' beliefs about oral health care and their oral hygiene practices. Screening for mothers' dental caries experience was carried out using the Decayed, Missing and Filled Teeth/Surfaces (DMFT/S) index. Univariate, bi-variate and multi-variable analysis were conducted to explain the high level of disease in this population. RESULTS: A total of 152 pregnant women participated in this study. Mean DMFT in this sample was 15.5 ± 4.5 and an average DMFS of 31.8 ± 21. According the World Health Organization (WHO) criteria, 89% of our sample were categorized in the "Extremely High" dental caries experience. Fifty-eight percent of the DMFT scores among this sample were due to untreated dental decay, while 22% of the same DMFT scores demonstrated restorative care received by this sample. Bivariate analysis showed that mothers who completed a degree after high school had lower DMFT scores than mothers who did not (F = 4, n = 152, p = .024). In addition, mothers who believed they could lose a tooth just because they are pregnant had higher DMFT scores (t = - 4, n = 152, p = .037). The final model found that age, level of education, providers' advice on utilizing dental care during pregnancy, and the belief that a woman can lose a tooth just because she is pregnant explained 22% of the variation in DMFT scores. CONCLUSIONS: Women in this study had a high prevalence of dental diseases and knew little about dental care during pregnancy. Faulty beliefs about dental care during pregnancy among women and health care providers were major factors in the high levels of disease.

Medicaid Health Home Reducing Costs and Reliance on Emergency Department: Evidence From Iowa.

BACKGROUND: The Affordable Care Act allowed an optional Medicaid State Plan benefit for states to establish Health Homes coordinating care for people who have chronic conditions. Differences in medical home program incentives and implementation styles are important to understand in evaluating effects on key outcomes such as cost and acute care. In Iowa, a Medicaid Health Home (MHH) program was developed targeting Medicaid members with multiple chronic conditions. Provider patient management payments were tied to the number of chronic conditions of MHH members. OBJECTIVES: To assess the effects of an Iowa MHH program on total spending, emergency department (ED) utilization, and ED spending. DATA: Claims data from January 2011 through December 2013; per member per month unit of analysis. RESEARCH DESIGN: We use a difference-in-difference regression design comparing pre/post outcomes for MHH members to pre/post outcomes for Medicaid members not participating in the MHH. We include individual fixed effects and matched controls to minimize the potential for confounding. In addition, we include a series of administrative covariates to control for individual demographic and geographic variation. RESULTS: Participation in the MHH program reduced spending by $132 per member per month. There is also evidence that the largest cost savings occur with a lag, as those in the program longer than a year showed the most savings. Members were less likely to visit the ED compared with traditional Medicaid recipients and ED spending was also lower for MHH members. CONCLUSIONS: Participation in a MHH program led to fewer ED visits and lower overall spending among Medicaid recipients in Iowa.

Understanding Clinic Practices for Human Papilloma Virus Vaccination Series Completion in Clinics That Provide Primary Care: Survey of Clinic Managers in Iowa.

BACKGROUND: Rates for human papilloma virus (HPV) vaccination are low across the United States. Evidence-based-practices to increase immunization coverage have been recommended by public health organizations, yet many primary care clinics do not follow these practices. The purpose of this study was to examine if primary care clinics use these best practices to promote completion of the HPV vaccine series for their adolescent patients. Understanding the prevalence of evidence-based immunization strategies is key to increasing vaccination coverage. METHODS: We mailed 914 surveys to clinic managers of clinics that provide primary care in Iowa. The survey content was based on immunization strategies related to clinic practice and policies that have been proven effective to promote the completion of the HPV vaccination series. RESULTS: Survey responses from 127 clinics were used in the final analysis. Most clinics always used the state's immunization information system to record HPV vaccinations (89.4%). Over a quarter of clinics (27.6%) did not use any type of reminder or recall system to alert parents or providers that an HPV vaccine was due, and 35.0% did not give the vaccine at sick visits. CONCLUSIONS: Clinics need to focus more on the recommended logistics and processes to ensure that patients receive the entire HPV vaccination series. Survey results indicate that clinics are not consistently implementing the recommended best practices to ensure that vaccination series are completed.

Parental perceptions of avoidability of their child's emergency department visit.

OBJECTIVES: To identify the factors associated with paediatric emergency department (ED) visits and parental perceptions of the avoidability of their child's ED visit. DESIGN: Cross-sectional study by performing secondary analysis of 2010-2011 Iowa Child and Family Household Health Survey data. SETTING: State-wide representative population-based sample of families with at least one child in the state of Iowa in the USA. PATIENTS/PARTICIPANTS: Among the eligible households, 2386 families completed the survey, yielding a cooperation rate of 80%. EXPOSURE/INTERVENTION: Presence of a medical home. MAIN OUTCOME MEASURES: Child visiting an ED in the past year; parents believing that ED care could have been provided in a primary-care setting. RESULTS: Among children who needed medical care in the past year, 26% visited an ED. Younger children, non-Hispanic black children, non-Hispanic others, children whose parents were not married, children who were from food-insecure households and had poorer health status were more likely to visit an ED. Having a medical home was not associated with ED visits (OR=0.80, 95% CI 0.61 to 1.04), even after stratifying by the child's health status. About 69% of parents who took their child to an ED agreed that ED care could have been provided in a primary-care setting. Parents of children with public insurance, those who were not referred to the ED and those who could not get routine care appointments were more likely to report a primary-care preventable ED visit. CONCLUSIONS: The majority of parents believed that paediatric ED visits could be avoided if adequate primary-care alternatives were available. Expanding access to primary care could lead to a reduction in avoidable ED visits by children.

Exploring the Effect of Anti-immigration Rhetoric on Emergency Department Use by Undocumented Adults.

An unwelcoming policy climate can create barriers to health care access and produce a 'Chilling Effect' among immigrant communities. For undocumented immigrants, barriers may be unique and have a greater impact. We used administrative emergency department (ED) data from 2015 to 2019 for a Midwestern state provided under a data use agreement with the state hospital association. General linear modelling was used to estimate the impact of anti-immigrant rhetoric on ED visit intensity among non-elderly adults who were likely Hispanic/Latino with undocumented status. Compared to 2015, the average ED visit intensity among adults who were likely Hispanic/Latino with undocumented status was significantly higher during 2016-2019 when anti-immigrant rhetoric was heightened. The magnitude of this change increased over time (0.013, 0.014, 0.021, and 0.020, respectively). Additionally, this change over time was not observed in the comparison groups. Our findings suggest that anti-immigrant rhetoric may alter health care utilization for adults who are likely Hispanic/Latino with undocumented status. Limitations to our findings include the use of only those likely to be Hispanic/Latino, data from only one Midwestern state and the loss of data due to non-classification using the NYU ED algorithm. Further research should focus on validating these findings and investigating these identification methods and anti-immigrant rhetoric effects among other undocumented groups including children and adults of different race or ethnicity such as black, both those that identify as Hispanic/Latino and those that do not. Developing strategies to improve health care access for undocumented Hispanic/Latino adults also warrants future research.

Relationship between medical well baby visits and first dental examinations for young children in Medicaid.

OBJECTIVES: We examined the relationship between preventive well baby visits (WBVs) and the timing of first dental examinations for young Medicaid-enrolled children. METHODS: The study focused on children born in 2000 and enrolled continuously in the Iowa Medicaid Program from birth to age 41 months (n = 6322). The main predictor variables were number and timing of WBVs. The outcome variable was timing of first dental examination. We used survival analysis to evaluate these relationships. RESULTS: Children with more WBVs between ages 1 and 2 years and ages 2 and 3 years were 2.96 and 1.25 times as likely, respectively, to have earlier first dental examinations as children with fewer WBVs. The number of WBVs before age 1 year and the timing of the WBVs were not significantly related to the outcome. CONCLUSIONS: The number of WBVs from ages 1 to 3 years was significantly related to earlier first dental examinations, whereas the number of WBVs before age 1 year and the timing of WBVs were not. Future interventions and policies should actively promote first dental examinations by age 12 months at WBVs that take place during the first year of life.

An explanatory model of factors related to well baby visits by age three years for Medicaid-enrolled infants: a retrospective cohort study.

BACKGROUND: Well baby visits (WBVs) are a cornerstone of early childhood health, but few studies have examined the correlates of WBVs for socioeconomically vulnerable infants. The study objective was to identify factors related to the number of WBVs received by Medicaid-enrolled infants in the first three years of life and to present a preliminary explanatory model. METHODS: We analyzed Iowa Medicaid claims files and birth certificate data for infants born in calendar year 2000 (N = 6,085). The outcome measure was the number of well baby visits (WBVs) received by Medicaid-enrolled infants between age 1 and 41 months (range: 0 to 10). An ecological health model and existing literature were used to evaluate 12 observed factors as potential WBV correlates. We ran multiple variable linear regression models with robust standard errors (α = 0.05). RESULTS: There were a number of infant, maternal, and health system factors associated with the number of WBVs received by Medicaid-enrolled infants. Infants whose mothers had a greater number of prenatal healthcare visits (ß = 0.24 to 0.28; P = .001) or were married (ß = 0.20; P = .002) received more WBVs. Having a chronic health condition (ß = 0.51; P < .0001) and enrollment in a case management program (ß = 0.48; P < .0001) were also positively associated with WBVs. Eligibility for Medicaid through the Supplemental Security Income Program (ß = -0.70; P = .001), increased maternal age (ß = -0.27 to -0.35; P = .004), higher levels of maternal education (ß = -0.18; P = .005), maternal smoking (ß = -0.13; P = .018), and enrollment in a health maintenance organization plan (ß = -1.15; P < .0001) were negatively associated with WBVs. There was a significant interaction between enrollment in a health maintenance organization plan and enrollment in a Medicaid case management program (P = .015). Maternal race, maternal alcohol use during pregnancy, and rurality were not significantly related to the number of WBVs. CONCLUSIONS: Multiple infant, maternal, and health system variables were related to the number of WBVs received by Medicaid-enrolled infants. Additional research is needed to develop strategies to optimize access to WBVs for Medicaid-enrolled infants at risk for poor use of preventive medical care services.

Testing dental quality measures: Emergency department visits for nontraumatic dental conditions and subsequent follow-up dental visits.

BACKGROUND: The goal of this study was to test the feasibility, reliability, and validity of the Dental Quality Alliance's adult dental quality measures for system-level implementation for ambulatory care sensitive (ACS) emergency department (ED) visits for nontraumatic dental conditions (NTDCs) in adults and follow-up after ED visits for NTDCs in adults. METHODS: Medicaid enrollment and claims data from Oregon and Iowa were used for measure testing. Testing included validation of diagnosis codes in claims data through patient record reviews of ED visits and calculations of κ statistic, sensitivity, and specificity. RESULTS: Adult Medicaid enrollees' ACS NTDC ED visits ranged from 209 through 310 per 100,000 member-months. In both states, patients in the age category 25 through 34 years and non-Hispanic Black patients had the highest rates of ACS ED visits for NTDCs. Only one-third of all ED visits were associated with a follow-up dental visit within 30 days, decreasing to approximately one-fifth with a 7-day follow-up. The agreement between the claims data and patient records for identification of ACS ED visits for NTDCs was 93%, κ statistic was 0.85, sensitivity was 92%, and specificity was 94%. CONCLUSIONS: Testing revealed the feasibility, reliability, and validity of 2 DQA quality measures. Most beneficiaries did not have a follow-up with a dentist within 30 days of an ED visit. PRACTICAL IMPLICATIONS: Adoption of quality measures by state Medicaid programs and other integrated care systems will enable active tracking of beneficiaries with ED visits for NTDCs and develop strategies to connect them to dental homes.

Food Insecurity Is Prevalent in Iowa's Medicaid Expansion Population.

BACKGROUND: Food insecurity has been identified as an important social determinant of health and is associated with many health issues prevalent in Medicaid members. Despite this, little research has been done around food insecurity within Medicaid populations. OBJECTIVE: Our objective was to estimate the prevalence of household food insecurity and identify factors associated with experiencing food insecurity in Iowa's Medicaid expansion population. DESIGN: We conducted a cross-sectional telephone survey between March and May of 2019. PARTICIPANTS: Our sample was drawn from Medicaid members enrolled in Iowa's expansion program at least 14 months, stratified by Federal Poverty Level (FPL) category. Members who did not have valid contact information were excluded. We selected one individual per household to reduce the interrelatedness of responses. We sampled 6,000 individuals and had 1,349 respondents in the analytic sample. MAIN OUTCOME MEASURE: Our main outcome was whether a respondent's household experienced food insecurity in the previous year, using the Hunger Vital Sign screening tool. STATISTICAL ANALYSES PERFORMED: We weighted responses to account for the sampling design and differential nonresponse between strata. We estimated the prevalence of food insecurity and used logistic regression to model food insecurity as a function of demographic (age, FPL category, gender, employment, education, race, rurality, and Supplemental Nutrition Assistance Program [SNAP] participation) and health-related (self-rated health, self-rated oral health, health literacy) factors. RESULTS: The estimated prevalence of experiencing food insecurity was 51.3%. Race, gender, education, employment, health literacy, and self-rated health were all significantly associated with food insecurity. CONCLUSIONS: Our findings show that food insecurity is prevalent in Iowa's Medicaid expansion population. Food insecurity should be more widely measured as a critical social determinant of health in Medicaid populations. Policymakers and clinicians should consider interventions that connect households experiencing food insecurity to food resources (eg, produce prescriptions and food pantry referrals) and policies that increase food access. ABBREVIATIONS: Iowa Wellness Plan (IWP); Federal Poverty Level (FPL); Healthy Behavior Program (HBP); Supplemental Nutrition Assistance Program (SNAP).

Time trends in emergency department use among adults with intellectual and developmental disabilities.

BACKGROUND: Emergency Department (ED) visits are common among adults with intellectual and developmental disabilities (IDD). However, little is known about how ED use has varied over time in this population, or how it has been affected by recent Medicaid policy changes. OBJECTIVE: To examine temporal trends in ED use among adult Medicaid members with IDD in eight states that ranged in the extent to which they had implemented state-level Medicaid policy changes that might affect ED use. METHODS: We conducted repeated cross-sectional analyses of 2010-2016 Medicaid claims data. Quarterly analyses included adults ages 18-64 years with IDD (identified by diagnosis codes) who were continuously enrolled in Medicaid for the past 12 months. We assessed change in number of ED visits per 1000 member months from 2010 to 2016 overall and interacted with state level policy changes such as Medicaid expansion. RESULTS: States with no Medicaid expansion experienced an increase in ED visits (linear trend coefficient: 1.13, p < 0.01), while states operating expansion via waiver had a much smaller (non-significant) increase, and states with ACA-governed expansion had a decrease in ED visits (linear trend coefficient: 1.17, p < 0.01). Other policy changes had limited or no association with ED visits. CONCLUSIONS: Medicaid expansion was associated with modest reduction or limited increase in ED visits compared to no expansion. We found no consistent decrease in ED visits in association with other Medicaid policy changes.

Impact of chronic condition status and severity on dental utilization for Iowa Medicaid-enrolled children.

BACKGROUND: Although Medicaid-enrolled children with a chronic condition (CC) may be less likely to use dental care because of factors related to their CC, dental utilization for this population is poorly understood. OBJECTIVE: To assess the relationship between CC status and CC severity, respectively, on dental utilization for Iowa Medicaid-enrolled children. RESEARCH DESIGN: Retrospective cohort study of Iowa Medicaid data (January 1, 2003 to December 31, 2006). SUBJECTS: Medicaid-enrolled children aged 3 to 14 (N = 71,115) years. MEASURES: The 3M Corporation Clinical Risk Grouping methods were used to assess CC status (no/yes) and CC severity (episodic/life-long/malignancy/complex). The outcome variable was any dental utilization in 2006. Secondary outcomes included use of diagnostic, preventive, routine restorative, or complex restorative dental care. RESULTS: After adjusting for model covariates, Iowa Medicaid-enrolled children with a CC were significantly more likely to use each type of dental care except routine restorative care (P = 0.86) than those without a CC, although the differences in the odds were small (4%-6%). Compared with Medicaid-enrolled children with an episodic CC, children with a life-long CC were less likely to use routine restorative care (P < 0.0001), children with a malignancy were more likely to use complex restorative care (P < 0.03), and children with a complex CC were less likely to use each type of dental care except complex restorative care (P = 0.97). CONCLUSIONS: There were differences in dental utilization for Iowa Medicaid-enrolled children by CC status and CC severity. Children with complex CCs were the least likely to use dental care. Future research efforts should seek to understand why subgroups of Medicaid-enrolled children with a CC exhibit lower dental utilization.

Timing of first dental visits for newly Medicaid-enrolled children with an intellectual or developmental disability in Iowa, 2005-2007.

OBJECTIVES: We evaluated the relationship between having an intellectual or developmental disability (IDD) and the timing of the first dental visit for children who were newly enrolled in Medicaid in Iowa. METHODS: We identified children aged 3 to 8 years with and without IDD who were newly enrolled in the Iowa Medicaid program in 2005 (N = 5391). We gathered data on presence of IDD, health status, age at baseline, gender, length of Medicaid enrollment, medical care visits, household Medicaid enrollment, urbanization, residence in a federally designated Health Professional Shortage Area (HPSA), and time of first dental visit through 2007. RESULTS: About 32% of children had a first dental visit within 6 months of enrollment; this proportion increased to 49%, 64%, and 74% by years 1, 2, and 3, respectively. In the unadjusted models, there was no significant difference between children with and without IDD in time to first dental visit (P = .22). After adjusting for model covariates, however, children with IDD were 31% more likely to have a delayed first dental visit (P = .04). CONCLUSIONS: Newly Medicaid-enrolled children aged 3 to 8 years with IDD in Iowa were significantly more likely to have a later first dental visit. Future interventions should focus on ensuring timely access to first dental visits for all Medicaid-enrolled children, with an emphasis on those with IDD.

Significant indicators of intent to leave among Army Dental Corps junior officers.

OBJECTIVE: To identify the significant predictors associated with Army Dental Corps junior officers' intent to leave (ITL) the military. METHODS: A secondary data analysis of the 2009 Army Dental Officer Retention Survey was conducted. Frequencies, bivariate, linear, and logistic regression analyses were calculated. RESULTS: Forty-six percent of junior officers completed the survey (N = 577; n = 267). Fifty-eight percent of respondents reported an ITL the military before retirement. The following variables were positively associated (p < 0.05) with ITL: unit of assignment, specialty training status or area of concentration, military lifestyle, and residency training. Age and benefits were negatively associated with ITL. CONCLUSION: This study suggests that ITL is a multifactorial issue.

Applying "Stages of Readiness to Change" Model to Dentists' Decisions to Participate in Medicaid: An Exploratory Study.

BACKGROUND: The Stages of Readiness to Change (SOC) behavioral model describes behavior change as a process and distinguishes individuals based on their current behavior and readiness to change that behavior. SOC can be used to improve dentists' participation in a state public dental benefit program (Medicaid) by targeting them at different SOC with interventions, strategies, and tools tailored to those stages. Therefore, this study assessed the usefulness of using SOC to describe dentists' attitudes towards and participation in Medicaid. Dentists' participation in Medicaid is of interest to policymakers, and this study demonstrates a method to identify potential opportunities for intervention. METHODS: A modified SOC algorithm used data from a periodic survey of Iowa Dentists to categorize dentists (N=514) into: 1) pre-contemplation, 2) considering participation (SOC contemplation and preparation), 3) acting (SOC action and maintenance), and 4) risk of relapse (at risk for discontinuing participation). The four SOC stages were compared using ANOVA and post hoc Tukey's test among: practice characteristics, Dentists Altruism scale, Attitude about Program Administration scale, Attitude about Medicaid patients scale and Perception of Importance of Medicaid Problems scale. RESULTS: Among survey respondents, 36% were categorized as pre-contemplation, 6% were considering Medicaid participation, 12% were acting as Medicaid providers with minimal risk of relapse, and 46% were participating and at risk of discontinuing. Dentists' attitudes towards program administration, Medicaid patients, and access to care varied across the SOC cycle. CONCLUSION: Nearly, 46% dentists in this analysis were identified as at risk of discontinuing participation - a much larger proportion than dentists considering Medicaid participation. Categorizing dentists using this approach has important implications for programmatic interventions. For example, policymakers targeting our study population could focus their efforts on reducing the likelihood of dentists dropping out of the program, with less emphasis targeting dentists in the precontemplation stage.

Health Service Utilization Patterns Among Medicaid-Insured Adults With Intellectual and Developmental Disabilities: Implications for Access Needs in Outpatient Community-Based Medical Services.

Limited existing evidence suggests that adults with intellectual and developmental disabilities (IDD) experience substantial disparities in numerous areas of health care, including quality ambulatory care. A multistate cohort of adults with IDD was analyzed for patterns of inpatient admissions and emergency department utilization. Utilization was higher (inpatient [RR = 3.2], emergency department visits [RR = 2.6]) for adults with IDD, particularly for ambulatory care-sensitive conditions (eg, urinary tract [RR = 6.6] and respiratory infections [RRs = 5.5-24.7]), and psychiatric conditions (RRs = 5.8-15). Findings underscore the importance of access to ambulatory care skilled in IDD-related needs to recognize and treat ambulatory care-sensitive conditions and to manage chronic medical and mental health conditions.

Communicating a Complicated Medicaid Waiver Program to Enrollees in Iowa: How Federally Qualified Health Centers Support Medicaid Members.

Iowa expanded Medicaid eligibility with a waiver including a personal responsibility component. Early program evaluation revealed low compliance and awareness among members. There is little research on leveraging existing contact points in the health care system to effectively communicate with Medicaid enrollees. We interviewed outreach and enrollment staff at Federally Qualified Health Centers (FQHCs) to explore their work. We show that FQHCs use several strategies to enroll individuals in appropriate programs and support them in understanding and navigating their health insurance coverage. With increasingly complex Medicaid programs, this support will be more widely needed to prevent hardship and loss of coverage.

Dental Care in Programs of All-Inclusive Care for the Elderly: Organizational Structures and Protocols.

OBJECTIVES: This study uses a national model of community-based long-term services and supports, the Program of All-inclusive Care for the Elderly (PACE), to identify organizational structures and protocols that can facilitate the delivery of dental examinations. DESIGN: We developed an online survey instrument and conceptual model for this study representing 10 domains believed to characterize a quality PACE dental program. SETTING AND PARTICIPANTS: The Qualtrics survey was distributed nationally to all 124 PACE programs in the 31 states PACE was available. Respondents in this study represented 35 programs (program response rate = 28.2%) in 23 states (state response rate = 74.2%). METHODS: Selected independent variables from each of the 10 domains were tested against the reported delivery of dental examinations variable using the Kendall τ and χ2. Twenty-nine programs were included in the final analysis. RESULTS: Most programs mandated a dental examination within 31-60 days of enrollment (63.6%). Few programs had a dental manual (15.6%) or any quality assurance for dental care (32.3%). A majority of programs (58.8%) stated that they had a protocol for enrollees to receive a cleaning every 6-12 months. Having a system for quality assurance for dental care, protocol for a cleaning every 6-12 months, mandating a comprehensive dental examination and providing preventive dental services onsite with built-in equipment, were all statistically associated with a higher reported delivery of dental examinations. CONCLUSION AND IMPLICATIONS: Organizations providing long-term services and supports, including PACE, can use these identified domains to develop minimal standards to ensure dental care is part of innovative models of community-based long-term services and supports. Implementing these domains can facilitate effective delivery of dental examinations that have the potential to support positive oral health and general health outcomes.