Frontline perspectives on barriers to care for patients with California Medicaid: a qualitative study.

BACKGROUND: While insurance is integral for accessing healthcare in the US, coverage alone may not ensure access, especially for those publicly insured. Access barriers for Medicaid-insured patients are rooted in social drivers of health, insurance complexities in the setting of managed care plans, and federal- and state-level policies. Elucidating barriers at the health system level may reveal opportunities for sustainable solutions. METHODS: To understand barriers to ambulatory care access for patients with Medi-Cal (California's Medicaid program) and identify improvement opportunities, we performed a qualitative study using semi-structured interviews of a referred sample of clinicians and administrative staff members experienced with clinical patient encounters and/or completion of referral processes for patients with Medi-Cal (n = 19) at a large academic medical center. The interview guide covered the four process steps to accessing care within the health system: (1) scheduling, (2) referral and authorization, (3) contracting, and (4) the clinical encounter. We transcribed and inductively coded the interviews, then organized themes across the four steps to identify perceptions of barriers to access and improvement opportunities for ambulatory care for patients with Medi-Cal. RESULTS: Clinicians and administrative staff members at a large academic medical center revealed barriers to ambulatory care access for Medi-Cal insured patients, including lack of awareness of system-level policy, complexities surrounding insurance contracting, limited resources for social support, and poor dissemination of information to patients. Particularly, interviews revealed how managed Medi-Cal impacts academic health systems through additional time and effort by frontline staff to facilitate patient access compared to fee-for-service Medi-Cal. Interviewees reported that this resulted in patient care delays, suboptimal care coordination, and care fragmentation. CONCLUSIONS: Our findings highlight gaps in system-level policy, inconsistencies in pursuing insurance authorizations, limited resources for scheduling and social work support, and poor dissemination of information to and between providers and patients, which limit access to care at an academic medical center for Medi-Cal insured patients. Many interviewees additionally shared the moral injury that they experienced as they witnessed patient care delays in the absence of system-level structures to address these barriers. Reform at the state, insurance organization, and institutional levels is necessary to form solutions within Medi-Cal innovation efforts.

Moving upstream: healthcare partnerships addressing social determinants of health through community wealth building.

BACKGROUND: Healthcare-based interventions addressing social needs such as food and housing generally fail to impact the upstream wealth and power inequities underlying those needs. However, a small number of US healthcare organizations have begun addressing these upstream inequities by partnering with community wealth building initiatives. These initiatives include community land trusts, resident-owned communities, and worker cooperatives, which provide local residents ownership and control over their housing and workplaces. While these partnerships represent a novel, upstream approach to the social determinants of health, no research has yet evaluated them. METHODS: To assess the current state and key aspects of healthcare-community wealth building partnerships, we conducted a multiple case study analysis using semi-structured interviews with thirty-eight key informants across ten partnerships identified through the Healthcare Anchor Network. To analyze the interviews, we used a two-stage coding process. First, we coded responses based on the phase of the intervention to which they corresponded: motivation, initiation, implementation, or evaluation. Then we assessed responses within each aspect for common themes and variation on salient topics. RESULTS: Partnerships were generally motivated by a combination of community needs, such as affordable housing and living wage jobs, and health system interests, such as workforce housing and supply chain resilience. Initiating projects required identifying external partners, educating leadership, and utilizing risk mitigation strategies to obtain health system buy-in. Implementation took various forms, with healthcare organizations providing financial capital in the form of grants and loans, social capital in the form of convening funders and other stakeholders, and/or capacity building support in the form of strategic planning or technical assistance resources. To evaluate projects, healthcare organizations used more process and community-level metrics rather than metrics based on individual health outcomes or returns on investment. Based on best practices from each partnership phase, we provide a roadmap for healthcare organizations to develop effective community wealth building partnerships. CONCLUSIONS: Assessing healthcare partnerships with community wealth building organizations yields key strategies healthcare organizations can use to develop more effective partnerships to address the upstream causes of poor health.

Primary Care Physicians' Conceptualization of Quality in Medicare's Merit-Based Incentive Payment System.

BACKGROUND: While administrators of pay-for-performance may have good intentions, physicians may be reluctant to participate for various reasons, including poor program alignment with realities of clinical practice. In this study, we sought to characterize how primary care physicians (PCPs) participating in Medicare's Merit-Based Incentive Payment System (MIPS) conceptualize the quality of health care to help inform future measurement strategies that physicians would understand and appreciate. METHODS: We performed semi-structured qualitative interviews with a nationwide sample of 20 PCPs in MIPS. We asked PCPs how they would characterize quality and what distinguished exceptional, good, and poor quality. Interviews were transcribed and 2 coders independently read transcripts, allowing data to emerge from the interviews and developing theories about the data. The coders met intermittently to discuss findings, harmonize the coding scheme, develop a final list of themes and subthemes, and aggregate a list of representative quotations. RESULTS: Participants described quality as consisting of 2 components: (1) evidence-based care that is safe, which included health maintenance and chronic disease control, accurate diagnoses, and guideline adherence, and (2) patient-centered care, which included spending enough time with patients, responding to patient concerns, and establishing long-term relationships founded on trust. CONCLUSIONS: PCPs consider patient-centered care necessary for the provision of exceptional quality. Program administrators for quality measurement and pay-for-performance programs should explore new ways to reward PCPs for providing outstanding patient-centered care. Future research should be undertaken to determine whether patient-centered activities such as forging long-term, favorable patient-physician relationships, are associated with improved health outcomes.

Barriers and Facilitators to Implementation of Health System Interventions Aiming to Welcome and Protect Immigrant Patients: a Qualitative Study.

BACKGROUND: At the same time that federal policymakers have enforced restrictive immigration policies, healthcare systems across the USA are developing, and have implemented, interventions aimed at addressing immigration-related stressors faced by immigrant communities. Yet, little is known about the contextual determinants that influence their implementation success. Using the Consolidated Framework for Implementation Research (CFIR), this study identifies factors enabling or challenging the implementation of interventions aimed at mitigating immigration-related stressors in the healthcare context. METHODS: We used a qualitative research design to conduct 38 semi-structured interviews with stakeholders involved in implementation of interventions at 25 healthcare facilities across 5 states with the highest undocumented immigrant populations (California, Texas, New York, Florida, and Illinois). Interviews were conducted from May through August 2018. Constant comparative analysis was used to identify barrier and facilitator themes. Deductive coding was thereafter used to categorize themes according to CFIR domain. RESULTS: Barriers to implementation included perceptions of legal complexity and challenges to adopting such systemic strategies. Facilitators included a national policy climate that had brought immigrant health to the forefront, allowing for leveraging momentum towards institutional change; communication among healthcare personnel; existing community partnerships with immigrant rights and service organizations; and a shared sense of mission centering health equity. Local variation in immigration-related policies (e.g., local law agencies enforcing federal immigration laws) and heterogeneity of local immigrant communities also impacted implementation. Champions and informal leaders were integral to institutional efforts but not sufficient for sustainability. Perceived urgency to act superseded evaluation considerations, with all interventions in initial phases of implementation. Future iterations and evaluations of these interventions are needed to establish best practices and implementation determinants. CONCLUSION: This is the first systematic study describing implementation determinants of immigration-related interventions across health systems. Identifying these determinants provides guidance to other healthcare organizations to effectively strategize and ensure implementation success.

A Sector Wheel Approach to Understanding the Needs and Barriers to Services among Homeless-Experienced Veteran Families.

BACKGROUND: Veteran family homelessness is a significant issue, yet little is known about the needs and barriers to services of veteran families experiencing homelessness. This qualitative study examined the experiences, needs, and barriers to services among homeless-experienced veteran families to inform providers for this important population. METHODS: Twenty-five semi-structured interviews were conducted from February through September 2016 with 18 veteran parents with a recent history of homelessness (9 mothers, 9 fathers), and 7 homeless service providers throughout Los Angeles County. The "Sector Wheel for Under-Resourced Populations" data elicitation approach was used to conduct the interviews, which allowed the participant to guide the interview by discussing different sectors of a family's life affected by homelessness. The interviews were audio-recorded, transcribed, and themes were coded with Atlas.ti. RESULTS: Interviews revealed parenting stress and worsening family mental health during homelessness. Participants described barriers to navigating housing, social, and health services with children, including not knowing where to seek help, difficulty connecting to health and social services in the community, and a lack of family-focused services. Parents encountered discrimination by landlords and lack of access to permanent housing in safe neighborhoods. CONCLUSIONS: Findings demonstrate a need for delivering family-centered and comprehensive services to homeless-experienced veteran families that recognize the multifaceted needs of this population. Advocacy initiatives are needed to address discrimination against veterans experiencing family homelessness and increase access to affordable permanent housing in safe neighborhoods for families.

Assessment of Perspectives on Health Care System Efforts to Mitigate Perceived Risks Among Immigrants in the United States: A Qualitative Study.

Importance: Increases in the enforcement of immigration policies, deportations, and rhetoric critical of immigration during and after the 2016 US presidential election have been associated with a decrease in health-seeking behaviors and an increase in adverse health outcomes among immigrants. Efforts to address the health care needs of immigrants after the 2016 presidential election have centered on individual-level patient-practitioner strategies or federal- and state-level policy changes. However, these approaches have not captured the role of health care systems and the range of health care facilities encompassed within them. Objective: To characterize policies and actions implemented by health care facilities to address immigration status-related stressors. Design, Setting, and Participants: This exploratory qualitative study involved semistructured interviews in a purposive sample of health care facilities across 5 states (California, Texas, New York, Florida, and Illinois) with the largest populations of individuals with undocumented immigration status. Data from media sources and informational interviews with local immigration advocacy leaders were used to identify health care facilities that had implemented welcoming policies and strategies. Stakeholders, including administrators, frontline clinicians involved in policy implementation, and senior executive leaders, were interviewed. Interviews were conducted between May 1 and August 9, 2018, and were recorded, transcribed, and coded using constant comparative analysis. Data analysis was performed from June 29, 2018, to February 5, 2019. Main Outcomes and Measures: Stakeholder perspectives on the range, scope and content of policies and actions implemented to address immigration-related stressors at health care facilities. Results: A total of 38 in-depth interviews were conducted spanning 25 health care facilities in 5 states; these facilities included 13 federally qualified health centers, 7 academic or private hospitals, and 5 public institutions. Interviewees described policies and actions that mitigated one or more of the following perceived risks: (1) risk of exposure to immigration enforcement personnel at or near facilities, (2) risk of immigration status-related information disclosure, (3) risk associated with patient-level stressors, (4) risk associated with practitioner-level stressors, and (5) coordination of risk mitigation. Most personnel at health care facilities emphasized that their policies and actions fit within a larger mission and history of addressing the social needs of diverse patients and mitigating risks for patients. Conclusions and Relevance: Health care facilities can implement both active and reactive measures to address perceived immigration-associated risks among patients and practitioners. Population health and immigration policies are at the forefront of current policy debates. An understanding of the ways in which health care facilities can serve to mitigate perceived risks among their patients and employees can be one step toward optimizing health care for immigrants.

The impact of patient preferences and costs on the appropriateness of spinal manipulation and mobilization for chronic low back pain and chronic neck pain.

BACKGROUND: Although the delivery of appropriate healthcare is an important goal, the definition of what constitutes appropriate care is not always agreed upon. The RAND/UCLA Appropriateness Method is one of the most well-known and used approaches to define care appropriateness from the clinical perspective-i.e., that the expected effectiveness of a treatment exceeds its expected risks. However, patient preferences (the patient perspective) and costs (the healthcare system perspective) are also important determinants of appropriateness and should be considered. METHODS: We examined the impact of including information on patient preferences and cost on expert panel ratings of clinical appropriateness for spinal mobilization and manipulation for chronic low back pain and chronic neck pain. RESULTS: The majority of panelists thought patient preferences were important to consider in determining appropriateness and that their inclusion could change ratings, and half thought the same about cost. However, few actually changed their appropriateness ratings based on the information presented on patient preferences regarding the use of these therapies and their costs. This could be because the panel received information on average patient preferences for spinal mobilization and manipulation whereas some panelists commented that appropriateness should be determined based on the preferences of individual patients. Also, because these therapies are not expensive, their ratings may not be cost sensitive. The panelists also generally agreed that preferences and costs would only impact their ratings if the therapies were considered clinically appropriate. CONCLUSIONS: This study found that the information presented on patient preferences and costs for spinal mobilization and manipulation had little impact on the rated appropriateness of these therapies for chronic low back pain and chronic neck pain. Although it was generally agreed that patient preferences and costs were important to the appropriateness of M/M for CLBP and CNP, it seems that what would be most important were the preferences of the individual patient, not patients in general, and large cost differentials.

Primary Care Physicians in the Merit-Based Incentive Payment System (MIPS): a Qualitative Investigation of Participants' Experiences, Self-Reported Practice Changes, and Suggestions for Program Administrators.

BACKGROUND: While both administrators of pay-for-performance programs and practicing physicians strive to improve healthcare quality, they sometimes disagree on the best approach. The Medicare Access and CHIP Reauthorization Act of 2015 mandated the creation of the Merit-Based Incentive Payment System (MIPS), a program that incentivizes more than 700,000 physician participants to report on four domains of care, including healthcare quality. While MIPS performance scores were recently released, little is known about how primary care physicians (PCPs) and their practices are being affected by the program and what actions they are taking in response to MIPS. OBJECTIVES: To (1) describe PCP perspectives and self-reported practice changes related to quality measurement under MIPS and (2) disseminate PCP suggestions for improving the program. DESIGN: Qualitative study employing semi-structured interviews. PARTICIPANTS: Twenty PCPs trained in internal medicine or family medicine who were expected to report under MIPS for calendar year 2017 were interviewed between October 2017 and June 2018. Eight PCPs self-reported to be knowledgeable about MIPS. Seven PCPs worked in small practices. KEY RESULTS: Most PCPs identified advantages of quality measurement under MIPS, including the creation of practice-level systems for quality improvement. However, they also cited disadvantages, including administrative burdens and fears that practices serving vulnerable patients could be penalized. Many participants reported using technology or altering staffing to help with data collection and performance improvement. A few participants were considering selling small practices or joining larger ones to avoid administrative tasks. Suggestions for improving MIPS included simplifying the program to reduce administrative burdens, protecting practices serving vulnerable populations, and improving communication between program administrators and PCPs. CONCLUSIONS: MIPS is succeeding in nudging PCPs to develop quality measurement and improvement systems, but PCPs are concerned that administrative burdens are leading to the diversion of clinical resources away from patient-centered care and negatively impacting patient and clinician satisfaction. Program administrators should improve communication with participants and consider simplifying the program to make it less burdensome. Future work should be done to investigate how technical assistance programs can target PCPs that serve vulnerable patient populations and are having difficulty adapting to MIPS.

Perceptual and Structural Facilitators and Barriers to Becoming a Surgeon: A Qualitative Study of African American and Latino Surgeons.

PURPOSE: As racial and ethnic heterogeneity in the United States increases, it is important that the health care workforce, including surgery, mirror that diversity. Structural and perceptual barriers may contribute to an underrepresentation of African American and Latino surgeons. Understanding these barriers may translate into interventions and, in turn, improved diversification of the U.S. surgery workforce. METHOD: In 2016, the authors conducted in-depth semistructured interviews, exploring structural and perceptual barriers that African American and Latino surgeons face. The authors used conventional qualitative techniques to analyze data and identify themes. RESULTS: The authors interviewed 23 participants and observed three major themes characterizing the path to becoming a surgeon: creating a path to medicine, surgical culture, and mentorship. Subthemes provided further nuance. For creating a path to medicine, the subthemes were personal attributes, family support, community assets/barriers, and minority experience. For surgical culture, the subthemes comprised quality of life, surgeon-patient relationship, and restoring health. For mentorship, the subthemes were aspirational figures, formal programs/peer support, and professional opportunities. Experiences described by African Americans and Latinos were similar, but the experiences of participants of different self-identified childhood socioeconomic status were dissimilar. CONCLUSIONS: The path to a surgical career as experienced by African American and Latino surgeons is heavily influenced by mentors mediating their integration into surgical culture and engendering a feeling of belonging. Future surgeons from groups underrepresented in medicine would benefit from identifying aspirational figures early, a structured introduction into the rigors of the profession, and a deconstruction of negative surgical norms.

Using Beta-Version mHealth Technology for Team-Based Care Management to Support Stroke Prevention: An Assessment of Utility and Challenges.

BACKGROUND: Beta versions of health information technology tools are needed in service delivery models with health care and community partnerships to confirm the key components and to assess the performance of the tools and their impact on users. We developed a care management technology (CMT) for use by community health workers (CHWs) and care managers (CMs) working collaboratively to improve risk factor control among recent stroke survivors. The CMT was expected to enhance the efficiency and effectiveness of the CHW-CM team. OBJECTIVE: The primary objective was to describe the Secondary Stroke Prevention by Uniting Community and Chronic Care Model Teams Early to End Disparities (SUCCEED) CMT and investigate CM and CHW perceptions of the CMT's usefulness and challenges for team-based care management. METHODS: We conducted qualitative interviews with all users of the beta-version SUCCEED CMT, namely two CMs and three CHWs. They were asked to demonstrate and describe their perceptions of the CMT's ease of use and usefulness for completing predefined key care management activities. They were also probed about their general perceptions of the CMT's information quality, ease of use, usefulness, and impact on CM and CHW roles. Interview transcripts were coded using a priori codes. Coded excerpts were grouped into broader themes and then related in a conceptual model of how the CMT facilitated care management. We also conducted a survey with 14 patients to obtain their perspective on CHW tablet use during CHW-patient interactions. RESULTS: Care managers and community health workers expressed that the CMT helped them keep track of patient interactions and plan their work. It guided CMs in developing and sharing care plans with CHWs. For CHWs, the CMT enabled electronic collection of clinical assessment data, provided decision support, and provided remote access to patients' risk factor values. Long loading times and downtimes due to outages were the most significant challenges encountered. Additional issues included extensive use of free-text responses and manual data transfer from the electronic medical record. Despite these challenges, patients overall did not perceive the tablet as interfering with CHW-patient interactions. CONCLUSIONS: Our findings suggest useful functionalities of CMTs supporting health care and community partners in collaborative chronic care management. However, usability issues need to be addressed during the development process. The SUCCEED CMT is an initial step toward the development of effective health information technology tools to support collaborative, team-based models of care and will need to be modified as the evidence base grows. Future research should assess the CMT's effects on team performance.

Fostering a Commitment to Quality: Best Practices in Safety-net Hospitals.

In 2007, the Martin Luther King, Jr.-Harbor Hospital (MLK-Harbor), which served a large safety-net population in South Los Angeles, closed due to quality challenges. Shortly thereafter, an agreement was made to establish a new hospital, Martin Luther King, Jr. Community Hospital (MLKCH), to serve the unmet needs of the community. To assist the newly appointed MLKCH Board of Directors in building a culture of quality, we conducted a series of interviews with five high-performing hospital systems. In this report, we describe our findings. The hospitals we interviewed achieved a culture of quality by: 1) developing guiding principles that foster quality; 2) hiring and retaining personnel who are stewards of quality; 3) promoting efficient resource utilization; 4) developing a well-organized quality improvement infrastructure; and 5) cultivating integrated, patient-centric care. The institutions highlighted in this report provide important lessons for MLKCH and other safety-net institutions.

A Qualitative Inquiry on Palliative and End-of-Life Care Policy Reform.

BACKGROUND: There is increasing recognition of the role of palliative care (PC) in health care delivery, but priorities for state and federal policy to support PC are unclear and have sometimes engendered controversy. We canvassed experts to shed light on general recommendations for improving PC. OBJECTIVE: The study objective was to identify challenges to and potential solutions for promoting, adopting, and implementing policies that would support or expand high-quality PC. METHODS: Semistructured telephone interviews were used to solicit challenges to and potential solutions for promoting, adopting, and implementing policies that would support or expand high-quality PC. Interviews were analyzed using qualitative methods. The subjects were a purposive sample of 22 professional state and federal-level advocates who work in the field of aging and/or PC. RESULTS: Respondents identified four central challenges to advancing PC policies: (1) knowledge about PC in the health care setting, (2) cultural beliefs about PC, (3) payment/reimbursement for PC services, and (4) public understanding of PC. Of the wide range of solutions proposed by respondents, we present the eight most frequently discussed solutions to these challenges targeted towards policymakers, health care professionals, research, and the general public. Respondents' understanding of the relationships between problems and solutions revealed many dependencies and interconnectedness. CONCLUSIONS: A qualitative approach of querying experts identified multiple significant challenges to improving and expanding PC, most of which are acknowledged in existing consensus statements. Proposed solutions were more numerous and diffuse than descriptions of the problems, signaling the need for further consensus building around actionable policy, and better understanding of how to advance a PC policy agenda.

Improving Health Care for the Future Uninsured in Los Angeles County: A Community-Partnered Dialogue.

OBJECTIVE: To understand the health care access issues faced by Los Angeles (LA) County's uninsured and residually uninsured after implementation of the Affordable Care Act (ACA) and to identify potential solutions using a community-partnered dialogue. DESIGN: Qualitative study using a community-partnered participatory research framework. SETTING: Community forum breakout discussion. DISCUSSANTS: Representatives from LA County health care agencies, community health care provider organizations, local community advocacy and service organizations including uninsured individuals, and the county school district. MAIN OUTCOME MEASURES: Key structural and overarching value themes identified through community-partnered pile sort, c-coefficients measuring overlap between themes. RESULTS: Five overarching value themes were identified - knowledge, trust, quality, partnership, and solutions. Lack of knowledge and misinformation were identified as barriers to successful enrollment of the eligible uninsured and providing health care to undocumented individuals. Discussants noted dissatisfaction with the quality of traditional sources of health care and a broken cycle of trust and disengagement. They also described inherent trust by the uninsured in "outsider" community-based providers not related to quality. CONCLUSIONS: Improving health care for the residually uninsured after ACA implementation will require addressing dissatisfaction in safety-net providers, disseminating knowledge and providing health care through trusted nontraditional sources, and using effective and trusted partnerships between community and health care agencies with mutual respect. Community-academic partnerships can be a trusted conduit to discuss issues related to the health care of vulnerable populations.

Risk evaluations and condom use decisions of homeless youth: a multi-level qualitative investigation.

BACKGROUND: Homeless youth are at higher risk for sexually transmitted infections and unwanted pregnancy than non-homeless youth. However, little is known about how they evaluate risk within the context of their sexual relationships. It is important to understand homeless youths' condom use decisions in light of their sexual relationships because condom use decisions are influenced by relationship dynamics in addition to individual attitudes and event circumstances. It is also important to understand how relationship level factors, sexual event circumstances, and individual characteristics compare and intersect. METHODS: To explore these issues, we conducted semi-structured interviews with 37 homeless youth in Los Angeles County in 2011 concerning their recent sexual relationships and analyzed the data using systematic methods of team-based qualitative data analysis. RESULTS: We identified themes of risk-related evaluations and decisions at the relationship/partner, event, and individual level. We also identified three different risk profiles that emerged from analyzing how different levels of risk intersected across individual respondents. The three profiles included 1) Risk Takers, who consistently engage in risk and have low concern about consequences of risk behavior, 2) Risk Avoiders, who consistently show high concern about protection and consistently avoid risk, and 3) Risk Reactors, those who are inconsistent in their concerns about risk and protection and mainly take risks in reaction to relationship and event circumstances. CONCLUSIONS: Interventions targeting homeless youth should reflect multiple levels of risk behavior and evaluation in order to address the diversity of risk profiles. Relationship/partner-, event-, and individual-level factors are all important but have different levels of importance for different homeless youth. Interventions should be tailored to address the most important factor contributing to homeless youth reproductive needs.

Data-driven decision-making tools to improve public resource allocation for care and prevention of HIV/AIDS.

Public health agencies face difficult decisions when allocating scarce resources to control the spread of HIV/AIDS. Decisions are often made with few local empirical data. We demonstrated the use of the robust decision making approach in Los Angeles County, an approach that is data driven and allows decision makers to compare the performance of various intervention strategies across thousands of simulated future scenarios. We found that the prevailing strategy of emphasizing behavioral risk reduction interventions was unlikely to achieve the policy goals of the national HIV/AIDS strategy. Of the alternative strategies we examined, those that invested most heavily in interventions to initiate antiretroviral treatment and support treatment adherence were the most likely to achieve policy objectives. By employing similar methods, other public health agencies can identify robust strategies and invest in interventions more likely to achieve HIV/AIDS policy goals.

Provider barriers and facilitators to screening for intimate partner violence in Bogotá, Colombia.

We conducted interviews with 27 health care personnel in Bogotá, Colombia, to examine provider barriers and facilitators to screening for intimate partner violence (IPV). We used systematic qualitative analysis to identify the range and consistency of beliefs. We found that respondents did not routinely screen for IPV. Providers listed numerous barriers to screening. Ways to improve screening included increased clinician training, installing systematic IPV screening, providing patient education, and implementing health care setting interventions. Improving the care for IPV survivors will involve translating health care personnel preferred solutions into more systematic IPV screening interventions.

Assessment of food offerings and marketing strategies in the food-service venues at California Children's Hospitals.

OBJECTIVE: Marketing strategies and food offerings in hospital cafeterias can impact dietary choices. Using a survey adapted to assess food environments, the purpose of this study was to assess the food environment available to patients, staff, and visitors at the food-service venues in all 14 California children's hospitals. METHODS: We modified a widely-used tool to create the Nutritional Environment Measures Survey for Cafeterias (NEMS-C) by partnering with a hospital wellness committee. The NEMS-C summarizes the number of healthy items offered, whether calorie labeling is present, if there is signage promoting healthy or unhealthy foods, pricing structure, and the presence of unhealthy combination meals. The range of possible scores is zero (unhealthy) to 37 (healthy). We directly observed the food-service venues at all 14 tertiary care children's hospitals in California and scored them. RESULTS: Inter-rater reliability showed 89% agreement on the assessed items. For the 14 hospitals, the mean score was 19.1 (SD = 4.2; range, 13-30). Analysis revealed that nearly all hospitals offered diet drinks, low-fat milk, and fruit. Fewer than one-third had nutrition information at the point of purchase and 30% had signs promoting healthy eating. Most venues displayed high calorie impulse items such as cookies and ice cream at the registers. Seven percent (7%) of the 384 entrees served were classified as healthy according to NEMS criteria. CONCLUSIONS: Most children's hospitals' food venues received a mid-range score, demonstrating there is considerable room for improvement. Many inexpensive options are underused, such as providing nutritional information, incorporating signage that promotes healthy choices, and not presenting unhealthy impulse items at the register.

Value for Money in Donor HIV Funding.

Countries with the highest burden of human immunodeficiency virus (HIV) disease are heavily reliant on donor funding from such sources as the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria for their HIV programs. In recent years, commitments from these organizations have flattened while demand for HIV/AIDS care continues to rise. To meet the continued need for more HIV services in developing countries, existing resources need to be better leveraged, i.e., to provide improved value for the money. This article examines options for improving value for money in HIV funding by using a case study that focuses on the two largest funders, PEPFAR and the Global Fund, with funding for antiretroviral therapy (ART) as its leading example. The authors' assessment of available input and output data suggests that current spending allocations across direct and indirect services are not based on increasing value for money. The authors recommend that expenditure data for PEPFAR be made available to the public in a transparent fashion on an annual basis in a usable format and that the Global Fund make its data accessible for each program funded. They find that program output indicators to track indirect services are incomplete and need to be further developed. The trade-off between providing current services and providing future ones needs to be stated clearly, and funding decisions made accordingly. Finally, given projections that funding for HIV will likely not increase, particularly for low-income countries facing the highest HIV burden, an explicit emphasis on improving value for money by finding ways to better leverage existing monies is imperative.