Participant Perspectives on Community Health Workers' Critical Role in Their Experience of the Pathways Program to Address Complex Needs.

This study aimed to describe participants' experiences of Pathways, a community hub care coordination model, including its impact on their lives and their relationship with the Pathways community health worker (CHW). The research team conducted semistructured, in-depth interviews with Pathways participants (n = 13) and analyzed interviews using thematic analysis. Interviews reveal how Pathways helps individuals navigate systems more confidently, increases access to needed resources, and improves well-being. CHWs defined participants' experience, providing a safe, reliable setting to make progress toward goals. Our findings support the evidence base for Pathways as an effective model of care coordination for people with complex needs.

Impact of oral health integration training on children's receipt of oral assessment, fluoride varnish and dental services.

OBJECTIVES: To evaluate the impact of an oral health integration training program on children's receipt of oral health and dental services in Southern Oregon. METHODS: Children under 19 years with at least 6 months of Medicaid enrolment and at least one healthcare visit from 2014 to 2018 were included. The treatment group included children with at least one visit with a trained provider (n = 5541); children with no visits with trained providers (n = 8273) were the control group. The percentage of the treatment group who received oral health assessments was calculated, and regression models were developed to estimate the difference in likelihood of receiving fluoride varnish and dental services between treatment and control groups. RESULTS: The percentage of children receiving oral health assessments increased over time. Visiting a trained provider was consistently associated, each year, with a greater likelihood of receipt of fluoride varnish and preventive and diagnostic dental services but was not associated with treatment dental services or dental sealants. CONCLUSIONS: This study reports evidence for the overall impact of an oral health integration training on children's receipt of oral and dental services. Health systems implementing these types of training strategies should consider how to reach specific underserved subgroups, increase paediatric dentists, and expand efforts to include older children.

Associations between Adverse Childhood Experiences and Emergency Department Utilization in an Adult Medicaid Population.

Adverse childhood experiences (ACEs) are widely prevalent but unevenly distributed in the United States, with disadvantaged groups, especially those with low socioeconomic status, being more likely to experience them. ACEs have been linked to poor health outcomes in adulthood. In this study, we examined the association between ACEs and emergency department (ED) utilization using a cross-sectional life-course survey of low-income adults matched to Medicaid enrollment and claims data. Surveys were obtained from 2348 Medicaid-enrolled adults in the Portland, OR metropolitan area; 1133 were used in this analysis. We used a two-part regression model to estimate the association between ACE score and both ever using the ED and frequency of ED use in the year after survey completion. We also evaluated a set of potentially protective factors to see if they impacted the relationship between ED use and ACE score. We found that participants with a higher ACE score were more likely to obtain any emergency services care (odds ratio (OR) = 1.11, p = 0.011), but ACE score did not predict how frequently they would utilize those services. Close social relationships were found to be protective against high ED utilization for those with high ACE scores. Upstream prevention efforts that identify places to intervene in childhood and incorporate trauma-informed strategies into ED care in adulthood have the potential to decrease ED use.

Local Housing Choice Voucher Distribution Policies Impact Healthcare Utilization: a Randomized Natural Experiment.

While associations between obtaining affordable housing and improved health care are well documented, insufficient funding often forces housing authorities to prioritize limited housing vouchers to specific populations. We assessed the impact of obtaining housing on health care utilization at two urban housing authorities with different distribution policies: Housing Authority A prioritized seniors and people with disabilities, while Housing Authority B prioritized medically complex individuals and families with school-aged children. Both housing authorities used random selection to distribute vouchers, allowing us to conduct a randomized natural experiment of cases and waitlisted controls. No significant demographic differences were present between those receiving vouchers and waitlisted controls. Housing Authority A vouchers were associated with increased outpatient visits (OR = 1.19; P = 0.051). Housing Authority B vouchers decreased the likelihood of emergency department visits (OR = 0.61; P = 0.042). This study provides evidence that, while obtaining housing can result in better health care outcomes overall, local prioritization policies can influence that impact.

Characteristics and Factors Associated with COVID-19 Infection, Hospitalization, and Mortality Across Race and Ethnicity.

Background: Data on the characteristics of COVID-19 patients disaggregated by race/ethnicity remain limited. We evaluated the sociodemographic and clinical characteristics of patients across racial/ethnic groups and assessed their associations with COVID-19 outcomes. Methods: This retrospective cohort study examined 629,953 patients tested for SARS-CoV-2 in a large health system spanning California, Oregon, and Washington between March 1 and December 31, 2020. Sociodemographic and clinical characteristics were obtained from electronic health records. Odds of SARS-CoV-2 infection, COVID-19 hospitalization, and in-hospital death were assessed with multivariate logistic regression. Results: 570,298 patients with known race/ethnicity were tested for SARS-CoV-2, of whom 27.8% were non-White minorities. 54,645 individuals tested positive, with minorities representing 50.1%. Hispanics represented 34.3% of infections but only 13.4% of tests. While generally younger than White patients, Hispanics had higher rates of diabetes but fewer other comorbidities. 8,536 patients were hospitalized and 1,246 died, of whom 56.1% and 54.4% were non-White, respectively. Racial/ethnic distributions of outcomes across the health system tracked with state-level statistics. Increased odds of testing positive and hospitalization were associated with all minority races/ethnicities. Hispanic patients also exhibited increased morbidity, and Hispanic race/ethnicity was associated with in-hospital mortality (OR: 1.39 [95% CI: 1.14-1.70]). Conclusion: Major healthcare disparities were evident, especially among Hispanics who tested positive at a higher rate, required excess hospitalization and mechanical ventilation, and had higher odds of in-hospital mortality despite younger age. Targeted, culturally-responsive interventions and equitable vaccine development and distribution are needed to address the increased risk of poorer COVID-19 outcomes among minority populations.

Understanding the Socioeconomic and Health Challenges of the Medicaid Expansion Population in Oregon.

Following the Patient Protection and Affordable Care Act, Medicaid eligibility in the United States expanded to include low-income adults. One key challenge for organizations and providers serving the Medicaid population was predicting if and how this change would alter the composition of enrollees. This study characterized demographics, socioeconomic challenges, and health of the expansion and non-expansion Medicaid populations in a metropolitan area in Oregon using a survey and Medicaid claims. Results showed that the expansion population has more men and non-English speakers than the non-expansion population. They also have greater education and employment, but face similar socioeconomic challenges including struggling to meet basic needs and housing instability. This study also found comparable self-reported physical and mental health, but lower prevalence of physical or mental health diagnoses and several ambulatory care reactive conditions including hypertension, obesity, and type 2 diabetes. The authors concluded that expansion and non-expansion populations differ in sex, language, education, employment, and health, but they face similar socioeconomic challenges. This information is useful for organizations coordinating and providing care to Medicaid members so they can understand the needs of the population and set appropriate population health management strategies.

Identifying underlying constructs of childhood adversity in a low-income population.

BACKGROUND: Extensive research has documented the association between adverse childhood experiences (ACEs) and poor outcomes later in life, as well as the high prevalence of ACEs in the American population. Studies consistently find that over half of American adults have experienced at least one ACE. Despite this, research on the long-term impacts of ACEs is challenging due to the complex nature of adversity. OBJECTIVE: Our study aimed to define underlying constructs of adversity, and explore how they changed throughout childhood, in a low-income population. PARTICIPANTS AND SETTING: We fielded a survey to Medicaid-enrolled adults in the Portland, OR metropolitan area. METHODS: Our survey captured different experiences in childhood, including relationships and support, educational challenges, housing and employment stability, neighborhood environment, discrimination, abuse, neglect, and household dysfunction; questions were asked for 6-12 and 13-18 years of age. We then used factor analysis to identify underlying constructs of adversity in the two age ranges. RESULTS: We identified two factors - Inadequate Emotional Support and Instability - in each age range. Inadequate Emotional Support remained consistent in both time periods while the Instability factor changed, expanding from household-centric experiences in childhood to a wider variety of experiences in adolescence. Additionally, a number of variables did not load on either factor in either age range. CONCLUSIONS: These results underscore the importance of expanding how we think about instability specifically, and childhood adversity in general.

Associations between neighbourhood characteristics and depression: a twin study.

BACKGROUND: Depression is an important contributor to the global burden of disease. Besides several known individual-level factors that contribute to depression, there is a growing recognition that neighbourhood environment can also profoundly affect mental health. This study assessed associations between three neighbourhood constructs-socioeconomic deprivation, residential instability and income inequality-and depression among adult twin pairs. The twin design is used to examine the association between neighbourhood constructs and depression, controlling for selection factors (ie, genetic and shared environmental factors) that have confounded purported associations. METHODS: We used multilevel random-intercept Poisson regression among 3738 same-sex twin pairs from a community-based twin registry to examine the association between neighbourhood constructs and depression. The within-pair association controls for confounding by genetic and environmental factors shared between twins within a pair, and is the main parameter of interest. Models were adjusted for individual-level income, education and marital status, and further by neighbourhood-level population density. RESULTS: When twins were analysed as individuals (phenotypic model), all neighbourhood constructs were significantly associated with depression. However, only neighbourhood socioeconomic deprivation showed a significant within-pair association with depression. A 10-unit within-pair difference in neighbourhood socioeconomic deprivation was associated with 6% greater depressive symptoms (1.06, 95% CI 1.01 to 1.11); the association did not substantially change in adjusted models. CONCLUSION: This study provides new evidence linking neighbourhood socioeconomic deprivation with greater depression. Future studies should employ longitudinal designs to better test social causation versus social selection.