Foreword to: Indiana University's Response to the Addictions Crisis: A Grand Challenge Initiative.

Use of heroin, prescription painkillers, methamphetamines, and fentanyl led to a national health crisis in 2017, resulting in 1852 overdose deaths in Indiana. Governor Eric J. Holcomb made tackling substance use in the state one of his highest priorities, calling on all Hoosiers to collaborate. In October 2017, Indiana University (IU) President Michael A. McRobbie responded, announcing that the University would be initiating the Responding to the Addictions Crisis Grand Challenge (AGC). Partners included Governor Holcomb, IU Health, and Eskenazi Health. Leveraging the university's research strengths and partnering with more than 160 community organizations across the state, the AGC sought to address substance use facing Indiana and beyond. Fifty interdisciplinary research projects were created through the AGC, focusing on IU's greatest strength in five areas: (1) education, training, and certification; (2) data science and analysis; (3) policy analysis, economics, and law; (4) basic, applied, and translational research; (5) community engagement and workforce development. Diversity, equity, and inclusion implications were often considered. This supplement describes the IU approach to address the health of the people of the State, investigator initiated projects and research conducted to inform practice, strategy and policy.

Outcome Evaluation of a Health System Clinical Nurse Specialist Fellowship Program.

PURPOSE: Healthcare is a complex adaptive system, requiring agile, innovative leaders to transform care. Clinical nurse specialists (CNSs) are uniquely positioned to influence change and achieve high-quality outcomes. Nurse leaders need strategies to onboard and retain CNSs considering high demand across the nation. The purpose of this program evaluation was to describe the core components and outcomes of CNS fellowship programs. DESIGN: This program evaluation used the Kirkpatrick Model as a framework to assess learning and knowledge translation. METHODS: The study was conducted within 3 Indiana healthcare organizations. Clinical nurse specialist leaders from each organization identified fellowship core components and analyzed team composition (ie, percentage of CNS team that was current/past fellows). Current and past CNS fellows were invited to participate in a survey evaluating program effectiveness, impact on role transition, project leadership, and outcomes achieved. RESULTS: Overlap was identified among 85% (17/20) of the core components, team composition was 71% (25/35) past/current fellows, and retention was 100% (12/12). Of the 23 invited, 18 (78%) participated in the program evaluation. Program effectiveness was evaluated as very/extremely effective by 94% (17/18) of participants. Themes salient to independent practice transition were applying learning, achieving influence, and developing relationally, contributing to incremental gain of the CNS perspective (ie, CNS values and guiding principles influencing critical thinking and behavior). CONCLUSION: Nurse leaders should consider fellowship implementation to recruit and retain CNS talent within organizations.

Indiana's Public Health Investment Holds Insights For Other States.

Indiana has a business-friendly environment, but historical underinvestment in public health has yielded poor health outcomes. In 2023, when trust in governmental public health was strained nationwide, Indiana increased public health spending by 1,500 percent. In this article, we explain how Indiana achieved this unprecedented legislative victory for public health, describing the context, approach, and lessons learned. Specifically, an Indiana University report linking economic vitality and overall health sparked the creation of a governor's commission charged with exploring ways to address Indiana's shortcomings. Working with the Indiana Department of Health, the commission developed multisectoral coalitions and business and government partnerships, and it maintained consistent and coordinated communication with policy makers. Lessons learned included the value of uncoupling public health from partisan narratives, appointing diverse commission membership with strategically selected cochairs, involving local leaders, and ensuring local decision-making control. We believe that Indiana's approach holds insights for other states interested in strengthening public health funding in the current era.

Validation of a low-cost lead hazard screening kit for the home environment.

The main sources of lead exposure for children occur in the home environment, yet no low-cost analytical methods exist to screen homes for lead hazards. Previously, an inexpensive (~$20), quantitative lead screening kit was developed in which residents collect soil, paint, and dust samples that are returned to a laboratory for lead analysis using X-ray fluorescence spectroscopy (XRF). This screening kit was initially validated in 2020; it was determined that in situ and ex situ XRF lead measurements on the same samples exhibited strong sensitivity, specificity, and accuracy. As a follow-up to the initial validation, an implementation study and further statistical analyses were conducted. Correlation analysis using the results from nearly 400 screening kits identified an overall lack of correlation between sample types, reinforcing the utility of all eight sample locations. Principal component analysis searched for underlying correlations in sample types and provided evidence that both interior and exterior paint are major sources of lead hazards for Indiana homes. The implementation study compared the results of the government-standard lead inspection and risk assessment (LIRA) and the lead screening kit in 107 Indiana homes. In the United States, the LIRA is a thorough inspection of paint, dust, and soil that is usually state mandated in response to a child's elevated blood level and is used to identify where remediation efforts should be focused. The lead screening kit and LIRA agreed on the presence of lead in 79 of the 107 homes tested (74%). Discrepancies in agreement are likely the result of differences in the sample location and number of samples collected by each method. Overall, these results suggest that the lead screening kit is an acceptable resource that could be used to expand the services health departments provide for lead prevention. Integr Environ Assess Manag 2024;20:1504-1513. © 2024 The Authors. Integrated Environmental Assessment and Management published by Wiley Periodicals LLC on behalf of Society of Environmental Toxicology & Chemistry (SETAC).

The Relationship Between Dental Provider Density and Receipt of Dental Care Among Medicaid-enrolled Adults.

OBJECTIVE: We sought to measure the association of dental provider density and receipt of dental care among Medicaid-enrolled adults. METHODS: We used four years of Indiana Medicaid claims and enrollment data (2015 to 2018) and the Area Health Resources File to examine the relationship between any dental visit (ADV) or any preventive dental visit (PDV) and three county-level measures of dental provider density (the total number of Medicaid-participating dentists, a binary indicator of a federally qualified health center (FQHC) with a Medicaid-participating dentist, and the overall county dentist-to-population ratio). RESULTS: The likelihood of ADV or PDV increased with greater density of Medicaid-participating dentists as well as dentists accepting Medicaid working at an FQHC within the county. The overall dentist-to-population ratio was not associated with dental care use among the adult Medicaid population. CONCLUSION: Dentist participation in Medicaid program may be a modifiable barrier to Medicaid-enrolled adults' receipt of dental care.

A Comparative Analysis of the Demographics and Zip Codes of Patients Seen at the Indiana University Student Outreach Clinic.

Within a small geographic area, Marion County contains a stark spectrum of health outcomes and socioeconomic statuses. The Indiana University Student Outreach Clinic (IUSOC) serves as a safety net provider, offering free health and social services in the Near Eastside neighborhood of Indianapolis. The aim of this study was to characterize the demographics and geographic distribution of the IUSOC's patient population. From January to September 2023, 612 patients visited the IUSOC, and 460 self-identified as Marion County residents. 63.9% of patients were between 45 and 64 years old. 66.8% were Non-Hispanic (NH) Black, and 23.3% were Hispanic. 18.9% spoke Spanish and had limited English proficiency. Based on the Distressed Communities Index (DCI), 58.7% lived in "Distressed" zip codes, indicating economic vulnerability and disparities. The zip code with the greatest number of IUSOC patients had the highest rate of uninsured adults in Marion County. IUSOC patients are primarily middle-aged minorities who live in zip codes with low socioeconomic rankings by DCI. This information can be used to improve community resource referral pathways in the clinic.

County-Level Factors Associated With Influenza and COVID-19 Vaccination in Indiana, 2020‒2022.

Objectives. To assess COVID-19 and influenza vaccination rates across Indiana's 92 counties and identify county-level factors associated with vaccination. Methods. We analyzed county-level data on adult COVID-19 vaccination from the Indiana vaccine registry and 2021 adult influenza vaccination from the Centers for Disease Control and Prevention. We used multiple linear regression (MLR) to determine county-level predictors of vaccinations. Results. COVID-19 vaccination ranged from 31.2% to 87.6% (mean = 58.0%); influenza vaccination ranged from 33.7% to 53.1% (mean = 42.9%). In MLR, COVID-19 vaccination was significantly associated with primary care providers per capita (b = 0.04; 95% confidence interval [CI] = 0.02, 0.05), median household income (b = 0.23; 95% CI = 0.12, 0.34), percentage Medicare enrollees with a mammogram (b = 0.29; 95% CI = 0.08, 0.51), percentage uninsured (b = -1.22; 95% CI = -1.57, -0.87), percentage African American (b = 0.31; 95% CI = 0.19, 0.42), percentage female (b = -0.97; 95% CI = -1.79, ‒0.15), and percentage who smoke (b = -0.75; 95% CI = -1.26, -0.23). Influenza vaccination was significantly associated with percentage uninsured (b = 0.71; 95% CI = 0.22, 1.21), percentage African American (b = -0.07; 95% CI = -0.13, -0.01), percentage Hispanic (b = -0.28; 95% CI = -0.40, -0.17), percentage who smoke (b = -0.85; 95% CI = -1.06, -0.64), and percentage who completed high school (b = 0.54; 95% CI = 0.21, 0.87). The MLR models explained 86.7% (COVID-19) and 70.2% (influenza) of the variance. Conclusions. Factors associated with COVID-19 and influenza vaccinations varied. Variables reflecting access to care (e.g., insurance) and higher risk of severe disease (e.g., smoking) are notable. Programs to improve access and target high-risk populations may improve vaccination rates. (Am J Public Health. 2024;114(4):415-423. https://doi.org/10.2105/AJPH.2023.307553).

Evidence on COVID-19 Mortality and Disparities Using a Novel Measure, COVID excess mortality percentage: Evidence from Indiana, Wisconsin, and Illinois.

COVID-19 mortality rates increase rapidly with age, are higher among men than women, and vary across racial/ethnic groups, but this is also true for other natural causes of death. Prior research on COVID-19 mortality rates and racial/ethnic disparities in those rates has not considered to what extent disparities reflect COVID-19-specific factors, versus preexisting health differences. This study examines both questions. We study the COVID-19-related increase in mortality risk and racial/ethnic disparities in COVID-19 mortality, and how both vary with age, gender, and time period. We use a novel measure validated in prior work, the COVID Excess Mortality Percentage (CEMP), defined as the COVID-19 mortality rate (Covid-MR), divided by the non-COVID natural mortality rate during the same time period (non-Covid NMR), converted to a percentage. The CEMP denominator uses Non-COVID NMR to adjust COVID-19 mortality risk for underlying population health. The CEMP measure generates insights which differ from those using two common measures-the COVID-MR and the all-cause excess mortality rate. By studying both CEMP and COVID-MRMR, we can separate the effects of background health from Covid-specific factors affecting COVID-19 mortality. We study how CEMP and COVID-MR vary by age, gender, race/ethnicity, and time period, using data on all adult decedents from natural causes in Indiana and Wisconsin over April 2020-June 2022 and Illinois over April 2020-December 2021. CEMP levels for racial and ethnic minority groups can be very high relative to White levels, especially for Hispanics in 2020 and the first-half of 2021. For example, during 2020, CEMP for Hispanics aged 18-59 was 68.9% versus 7.2% for non-Hispanic Whites; a ratio of 9.57:1. CEMP disparities are substantial but less extreme for other demographic groups. Disparities were generally lower after age 60 and declined over our sample period. Differences in socio-economic status and education explain only a small part of these disparities.

Sexual Behavior and Sexual Decision-Making Among Gay, Bisexual, and Other Men Who Have Sex with Men During the COVID-19 Pandemic: Observations from a Rapid Ethnographic Assessment in Marion County, Indiana, October-November 2021.

From 2020 to 2021, Marion County, Indiana, USA, saw an increase in early syphilis diagnoses, primarily among gay, bisexual, and other men who have sex with men (GBMSM). This rapid ethnographic assessment combines survey data from GBMSM with data from key informant interviews with multiple groups of stakeholders, including GBMSM, to describe how COVID-19 impacted sexual behaviors, sexual decision-making, and access to sexually transmitted disease (STD) services among GBMSM in Marion County, Indiana. A total of 62 virtual, semi-structured qualitative interviews with 72 key respondents including health department staff, medical providers, community-based organization staff, and GBMSM were conducted from October 14 to November 22, 2021. Modifications to partner-seeking and sexual behaviors attributable to the pandemic were associated with the way in which individuals reacted to the pandemic in general. Some GBMSM adopted mitigation strategies to avoid COVID-19 when meeting sex partners, such as creating a "sex pod." Effects on mental health included increased loneliness, heightened anxiety, and a sense of hopelessness regarding the perceived inevitability of acquiring COVID-19. For some, the latter prompted decreased engagement in preventive measures when engaging in sexual activity. The pandemic decreased access to STD services and significantly curtailed public health outreach efforts, which may have limited access to needed STD treatment and care. Efforts focusing on ongoing public health concerns during extreme health events like COVID-19 may want to consider the many ways these events affect ancillary behaviors, such sexual decision-making and sexual behaviors. The role of mental health is key; messaging and guidance may benefit from a trauma-informed approach.

Palliative care needs and preferences of older adults with advanced or serious chronic illnesses and their families in rural communities of Indiana, USA.

PURPOSE: To explore the palliative care needs and preferences of older adults with advanced or serious chronic illnesses and their families. Also, to propose strategies to promote supportive palliative care in the rural communities of Indiana, USA. METHOD: We conducted qualitative interviews to gather rural caregivers' experiences of palliative care. Recruitment was done in collaboration with community partners using social media, flyers, emails, invitations, and word-of-mouth. A purposive sample of family caregivers was obtained. All the interviews were conducted online. The average interview was 30-45 minutes. Data were analyzed using a thematic analysis approach. FINDINGS: Our findings showed 6 major themes that indicated several palliative care needs and preferences of older patients and their families in rural communities that include: (1) difficulties in pain and symptom burden; (2) perceived discrimination and lack of trust; (3) longer distances to care facilities; (4) difficult conversations; (5) caregiving burden; and (6) use of telehealth in a rural palliative care context. CONCLUSION: Rural family caregivers experience several social inequities and disparities causing a lack of access to and low utilization of palliative care. All these disparities cause several challenges for patients and their families trying to manage serious illnesses and die in place with peace and comfort. Inadequate access and lack of resources cause pain and distress for both patients and their families. Provider education and trainings, initiating early palliative care models, integrating behavioral health in palliative care, and using culturally congruent care delivery approaches in support of community partners can improve palliative care services in rural communities.

Investigations into Economic Returns Resulting from Foliar Fungicides and Application Timing on Management of Tar Spot in Indiana Hybrid Corn.

Tar spot, caused by Phyllachora maydis, is the most significant yield-limiting disease of corn (Zea mays L.) in Indiana. Currently, fungicides are an effective management tool for this disease, and partial returns from their use under different disease severity conditions has not previously been studied. Between 2019 and 2021, two separate field experiments were conducted in each year in Indiana to assess the efficacy of nine foliar fungicide products and nine fungicide application timings based on corn growth stages on tar spot symptoms and stromata, canopy greenness, yield, and influence on partial returns. All fungicides evaluated significantly suppressed tar spot development in the canopy and increased canopy greenness over the nontreated control. Additionally, applications of mefentrifluconazole + pyraclostrobin, metconazole + pyraclostrobin, cyproconazole + picoxystrobin at tassel, and propiconazole + benzovindiflupyr + azoxystrobin between the tassel and dough growth stages were the most effective at significantly reducing disease severity, increasing canopy greenness, protecting yield, and offered the greatest partial return. Fungicide products varied in their ability to protect yield under low and high disease severity conditions relative to the nontreated control. Consistently, positive yield increases were observed when disease severity was high, which translated to greater profitability relative to low severity conditions. On average, the yield increases across foliar fungicide products and timed application treatments were 544.6 and 1,020.7 kg/ha greater, and partial returns using a grain value of $0.17/kg were $92.6/ha and $173.5/ha greater, respectively, when high severity conditions occurred. This research demonstrates that foliar fungicides and appropriately timed fungicide applications can profitably be used to manage tar spot in Indiana under high disease severity conditions.

Pronounced Regional Variation in Esketamine and Ketamine Prescribing to US Medicaid Patients.

Ketamine and esketamine are efficacious for treatment-resistant depression. Unlike other antidepressants, ketamine lacks a therapeutic delay and decreases the risk for suicide. This cross-sectional study geographically characterized ketamine and esketamine prescribing to United States (US) Medicaid patients. Ketamine and esketamine prescription rates and spending per state were obtained. Between 2009 and 2020, ketamine prescribing rates peaked in 2013 followed by a general decline. For ketamine and esketamine in 2019, Montana (967/million enrollees) and Indiana (425) showed significantly higher prescription rates, respectively, relative to the national average. A total of 21 states prescribed neither ketamine nor esketamine in 2019. There was a 121.3% increase in esketamine prescriptions from 2019 to 2020. North Dakota (1,423) and North Carolina (1,094) were significantly elevated relative to the average state for esketamine in 2020. Ten states prescribed neither ketamine nor esketamine in 2020. Medicaid programs in 2020 spent 72.7-fold more for esketamine ($25.3 million) than on ketamine (0.3 million). Despite the effectiveness of ketamine and esketamine for treatment-resistant depression and anti-suicidal properties, their use among Medicaid patients was limited and highly variable in many areas of the US. Further research to better understand the origins of this state-level variation is needed.

Conducting a Comprehensive Assessment of the Public Health Workforce: Lessons Learned and Opportunities for the Future.

Indiana was one of the earliest states to conduct a comprehensive public health workforce assessment in preparation for the use of federal funds for infrastructure strengthening. Experiences from this assessment provide insights that may be useful to other public health agencies and partners. This brief summarizes key lessons and highlights opportunities for improved workforce assessments. For example, the lack of standardized job titles within local health departments (LHDs) can be mitigated by collecting the top 3 job tasks employees engage in daily and reassigning standardized titles based on nationally collected workforce data. This facilitates comparisons across LHD employees nationally. In addition, many employees felt their job tasks did not align well with the Foundational Public Health Services (FPHS) areas and capabilities, which contributed to the likely overestimation of effort. Further consideration of how to better align and/or integrate FPHS assessment within current practice is needed in addition to improved ways of assessing efforts toward FPHS.

Adequacy of SNAP Benefits for Indiana Households, 2022.

We investigated the adequacy of Supplemental Nutrition Assistance Program (SNAP) benefits for Indiana households. Methods included focus groups, interviews, and a statewide survey of 652 households. SNAP benefit-level increases over the course of the COVID-19 pandemic increased their adequacy overall yet were still inadequate for some households. As of June 2022, Indiana households reported their SNAP benefits lasting 13 days a month. The inadequacy of SNAP benefits reveals that some participating households still experience food insecurity, which has adverse public health implications. (Am J Public Health. 2023;113(S3):S224-S226. https://doi.org/10.2105/AJPH.2023.307408).

Economic Burden Associated With Untreated Mental Illness in Indiana.

Importance: There is a paucity of systematically captured data on the costs incurred by society-individuals, families, and communities-from untreated mental illnesses in the US. However, these data are necessary for decision-making on actions and allocation of societal resources and should be considered by policymakers, clinicians, and employers. Objective: To estimate the economic burden associated with untreated mental illness at the societal level. Design, Setting, and Participants: This cross-sectional study used multiple data sources to tabulate the annual cost of untreated mental illness among residents (≥5 years old) in Indiana in 2019: the US National Survey on Drug Use and Health, the National Survey of Children's Health, Indiana government sources, and Indiana Medicaid enrollment and claims data. Data analyses were conducted from January to May 2022. Main Outcomes and Measures: Direct nonhealth care costs (eg, criminal justice system, homeless shelters), indirect costs (unemployment, workplace productivity losses due to absenteeism and presenteeism, all-cause mortality, suicide, caregiver direct health care, caregiver productivity losses, and missed primary education), and direct health care costs (disease-related health care expenditures). Results: The study population consisted of 6 179 105 individuals (median [SD] age, 38.0 [0.2] years; 3 132 806 [50.7%] were women) of whom an estimated 429 407 (95% CI, 349 526-528 171) had untreated mental illness in 2019. The economic burden of untreated mental illness in Indiana was estimated to be $4.2 billion annually (range of uncertainty [RoU], $2.1 billion-$7.0 billion). The cost of untreated mental illness included $3.3 billion (RoU, $1.7 billion-$5.4 billion) in indirect costs, $708.5 million (RoU, $335 million-$1.2 billion) in direct health care costs, and $185.4 million (RoU, $29.9 million-$471.5 million) in nonhealth care costs. Conclusion and Relevance: This cross-sectional study found that untreated mental illness may have significant financial consequences for society. These findings put into perspective the case for action and should be considered by policymakers, clinicians, and employers when allocating societal resources and funding. States can replicate this comprehensive framework as they prioritize key areas for action regarding mental health services and treatments.

County-level correlates of completed HPV vaccination in Indiana.

The Healthy People 2030 goal is for 80% of all adolescents to complete their HPV vaccination series. Per the 2021, National Immunization Survey-Teen (NIS-Teen), 61.7% of adolescents have completed the series, and Indiana lags below the national average (55.2%). The present study estimated the 2-dose HPV vaccine series completion rates across Indiana counties among individuals aged 9-14 years who received their first dose of vaccine and determined what factors were associated with series completion at the county level. The association of county-level sociodemographic and health measures with series completion was also examined. Data were extracted from the Indiana Immunization Information System (IIS), administered by the Indiana Department of Health. All vaccine providers are required to report all immunizations to the system for any patient under age 19 years. All Indiana children ages 9-14 years at the time of first dose who had initiated HPV vaccination in 2017 or 2018 were included. Two-dose series completion was evaluated through October of 2020, allowing a minimum gap of 22 months from first dose administration. All statistical analyses were conducted at the county-level. The Indiana HPV vaccination series completion rate among individuals that received the first dose was on average 73% across counties, ranging from 55.7% to 90.4%. Higher series completion was positively associated with primary care providers per capita, participation in mammography screening among Medicare enrollees, median household income, life expectancy, percentage of residents with some college, percentage of adults up-to-date with colonoscopy screening, and percentage of adults with flu vaccine. There was wide variability in series completion across Indiana counties. HPV series completion was associated with county-level sociodemographic and health measures, particularly variables reflecting difficulties with access to care and lack of financial resources.

Hoosier Sport: a research protocol for a multilevel physical activity-based intervention in rural Indiana.

Introduction: Currently, only 1 in 4 children in the U.S. engage in the recommended amount of physical activity (PA) and disparities in PA participation increase as income inequities increase. Moreover, leading health organizations have identified rural health as a critical area of need for programming, research, and policy. Thus, there is a critical need for the development and testing of evidence-based PA interventions that have the potential to be scalable to improve health disparities in children from under-resourced rural backgrounds. As such, the present study utilizes human-centered design, a technique that puts community stakeholders at the center of the intervention development process, to increase our specific understanding about how the PA-based needs of children from rural communities manifest themselves in context, at the level of detail needed to make intervention design decisions. The present study connects the first two stages of the NIH Stage Model for Behavioral Intervention Development with a promising conceptual foundation and potentially sustainable college student mentor implementation strategy. Methods: We will conduct a three-phase study utilizing human-centered community-based participatory research (CBPR) in three aims: (Aim 1) conduct a CBPR needs assessment with middle school students, parents, and teachers/administrators to identify perceptions, attributes, barriers, and facilitators of PA that are responsive to the community context and preferences; (Aim 2) co-design with children and adults to develop a prototype multi-level PA intervention protocol called Hoosier Sport; (Aim 3) assess Hoosier Sport's trial- and intervention-related feasibility indicators. The conceptual foundation of this study is built on three complementary theoretical elements: (1) Basic Psychological Needs mini-theory within Self-Determination Theory; (2) the Biopsychosocial Model; and (3) the multilevel Research Framework from the National Institute on Minority Health and Health Disparities. Discussion: Our CBPR protocol takes a human-centered approach to integrating the first two stages of the NIH Stage Model with a potentially sustainable college student mentor implementation strategy. This multidisciplinary approach can be used by researchers pursuing multilevel PA-based intervention development for children.

Use of Intergovernmental Transfers-based Medicaid Supplemental Payments to Boost Nursing Home Finances: Evidence From Indiana Nursing Homes.

BACKGROUND: Indiana provides intergovernmental transfers-based supplemental payment to nursing homes owned/operated by the nonstate governmental organization (NSGO) but NSGOs may divert substantial supplemental payments away from participating nursing homes. OBJECTIVE: The aim of this study was to estimate the effect of participation in the intergovernmental transfers-based Medicaid supplemental payment program on nursing home revenue and expenditures. RESEARCH DESIGN: Difference-in-differences regressions using Callaway and Sant'Anna method accounting for treatment effect heterogeneity across groups and over time. SUBJECTS: All 410 Medicare and Medicaid-certified nursing homes in Indiana from 2009 to 2017 with nonmissing data (N=3170). MEASURES: The key independent variable is a binary variable indicating NSGO ownership. Outcome variables include total revenue, total operating, clinical, hotel, and administrative expenses as well as profit margins extracted from Medicare Cost Report. Control variables include facility and resident characteristics from Nursing Home Compare and LTCfocus data. RESULTS: Supplemental payments increased nursing home revenues by about $0.58 million on average but payments were larger in later years. On a per-person per day basis, nursing home revenue increased by $21.9 dollars with an increase in administrative ($11.3), and hotel ($6.9) expenses but a decrease in clinical ($4.67) expenses. CONCLUSIONS: NSGO-owned/operated nursing homes received only a fraction of the total supplemental payments on average, but we observed increased payments to nursing homes in later years. Participating nursing homes did not increase clinical expenses. Our findings raise questions on the transparency of the financing arrangements between NSGOs and nursing homes and the need to link supplemental payments to clinical expenses.

Financial Impact of the Indiana University Student-Run Free Clinic.

Student-run free clinics (SRFCs) serve as an important public safety-net for un- and under-insured patients. Few studies have investigated their financial impact or return of investment to the community. The aim of this study was to estimate the financial impact of the Indiana University Student Outreach Clinic (IUSOC) using national market values of medical visits and lab services in 2021.From internal triage classification records maintained from March to December 2021, Current Procedural Terminology (CPT) codes were assigned corresponding to "New Patient," "Returning Quick or Long" and "Fast Track" visits. Total Work Relative Value Units (wRVUs) were calculated to then estimate the total monetary value for medical services. Similarly, the collection of laboratory services rendered from March to December 2021 were assigned costs using the 2021 Center for Medicare and Medicaid Services (CMS) fee schedule.There were a total of 1475 medical visits identified in this study under the triage categories of interest, with 440 New Patient visits, 1032 Returning Quick and Long visits, and 3 Fast Track visits. From the calculated total wRVUs, the estimated monetary value for medical services was $95,413.79. Additionally, there were 3633 eligible lab tests ordered; almost half of these (1523, 41.9%) were categorized as routine lab tests (CMP, BMP, CBC, lipid panel). The estimated value of lab services was $56,296.81.Our estimates reveal that the IUSOC provided nearly $150,000 worth of free healthcare to the community in 2021. Further, most patients were seen for return visits, revealing the opportunity to streamline logistics.

HEALTH ASSESSMENT OF PAINTED TURTLES (CHRYSEMYS PICTA) IN A RESTORED WETLAND HABITAT IN NORTHWESTERN INDIANA, USA.

Freshwater turtles are sensitive to environmental changes and can serve as sentinel species for ecosystem health assessments. The Efroymson Restoration at Kankakee Sands in northwestern Indiana, USA has been restored in the past 25 yr from primarily agricultural land to a mosaic of prairie and wetland habitats. Health assessments of 40 free-ranging painted turtles (Chrysemys picta) at Kankakee Sands were performed in May 2021 to evaluate overall health status, screen for infectious diseases, and obtain baseline clinical pathology values in this population. Assessment of each turtle included a physical examination, complete blood count, plasma biochemistry panel, blood lactate level, venous blood gas analysis, serum trace mineral panel, serum vitamin D3 level, and plasma protein electrophoresis. Oral and cloacal swabs were tested for adenoviruses, herpesviruses, frog virus 3, and Mycoplasmopsis species by PCR in 39 painted turtles. Four turtles were positive for adenovirus, which shared 100% homology to Sulawesi tortoise adenovirus. Two turtles were herpesvirus-positive with 100% homology to emydid herpesvirus 1. No Mycoplasmopsis spp. or frog virus 3 was detected. Female turtles had significantly higher manganese, prealbumin, uric acid, triglycerides, and ionized calcium levels, while male turtles had significantly higher cholesterol, glutamate dehydrogenase, and CO2 levels. These baseline data can be used for future research into freshwater turtle health in restored wetland habitats.