Understanding VA's Use of and Relationships With Community Care Providers Under the MISSION Act.

BACKGROUND: Congress has enacted 2 major pieces of legislation to improve access to care for Veterans within the Department of Veterans Affairs (VA). As a result, the VA has undergone a major transformation in the way that care is delivered to Veterans with an increased reliance on community-based provider networks. No studies have examined the relationship between VA and contracted community providers. This study examines VA facility directors' perspectives on their successes and challenges building relationships with community providers within the VA Community Care Network (CCN). OBJECTIVES: To understand who VA facilities partner with for community care, highlight areas of greatest need for partnerships in various regions, and identify challenges of working with community providers in the new CCN contract. RESEARCH DESIGN: We conducted a national survey with VA facility directors to explore needs, challenges, and expectations with the CCN. RESULTS: The most common care referred to community providers included physical therapy, chiropractic, orthopedic, ophthalmology, and acupuncture. Open-ended responses focused on 3 topics: (1) Challenges in working with community providers, (2) Strategies to maintain strong relationships with community providers, and (3) Re-engagement with community providers who no longer provide care for Veterans. CONCLUSIONS: VA faces challenges engaging with community providers given problems with timely reimbursement of community providers, low (Medicare) reimbursement rates, and confusing VA rules related to prior authorizations and bundled services. It will be critical to identify strategies to successfully initiate and sustain relationships with community providers.

Estrategia nacional de redes integradas de servicios de salud de Guatemala, ENRISSG / National strategy of integrated health services networks of Guatemala, ENRISSG

(Acuerdo ministerial No. 246-2019) Este documento propone un marco conceptual y operativo para entender las RISS desde la perspectiva y realidad de Guatemala, brinda los lineamientos orientadores y las acciones estratégicas para que los actores y prestadores de salud de un distrito o departamento se articulen en redes, optimicen las capacidades instaladas, garanticen la continuidad de la atención y consoliden vínculos interinstitucionales e intersectoriales que permitan abordajes integrales para mejorar la calidad de vida de las personas, las familias y las comunidades. La Estrategia de RISS se promueve como uno de los mecanismos para reducir la fragmentación de los sistemas de salud y como una de las principales expresiones operativas del enfoque de la APS en el proceso de atención integral, integrada y continua a las personas; contribuyendo a hacer una realidad varios de sus elementos más esenciales, tales como la cobertura y el acceso universal; la atención integral, integrada y continua; el cuidado apropiado, y la organización y gestión de los servicios de salud. El objetivo general del acuerdo ministerial que la avala es lograr acceso y cobertura de la salud, a través de la implementación de la Estrategia de Redes integradas, basada en la atención primaria de la salud, que permita una atención de salud equitativa, integral, integrada, continua y de calidad con en el derecho de la salud. Es de aplicación obligatoria para todas las dependencias que organicen e implementen redes integradas de servicios de salud a nivel de la república y permitirá orientar a los gerentes y los equipos multidisciplinarios, interinstitucionales e intersectoriales de un territorio definido, con lineamientos y acciones para el reordenamiento, articulación, coordinación, fortalecimiento y funcionamiento de los servicios de salud en red, fomentando la planificación, implementación, monitoreo, evaluación y rendición de cuentas.

Reducing Racial Inequities in Health: Using What We Already Know to Take Action.

This paper provides an overview of the scientific evidence pointing to critically needed steps to reduce racial inequities in health. First, it argues that communities of opportunity should be developed to minimize some of the adverse impacts of systemic racism. These are communities that provide early childhood development resources, implement policies to reduce childhood poverty, provide work and income support opportunities for adults, and ensure healthy housing and neighborhood conditions. Second, the healthcare system needs new emphases on ensuring access to high quality care for all, strengthening preventive health care approaches, addressing patients' social needs as part of healthcare delivery, and diversifying the healthcare work force to more closely reflect the demographic composition of the patient population. Finally, new research is needed to identify the optimal strategies to build political will and support to address social inequities in health. This will include initiatives to raise awareness levels of the pervasiveness of inequities in health, build empathy and support for addressing inequities, enhance the capacity of individuals and communities to actively participate in intervention efforts and implement large scale efforts to reduce racial prejudice, ideologies, and stereotypes in the larger culture that undergird policy preferences that initiate and sustain inequities.

Practice-based Research Networks (PBRNs) Bridging the Gaps between Communities, Funders, and Policymakers.

In this commentary, we propose that practice-based research networks (PBRNs) engage with funders and policymakers by applying the same engagement strategies they have successfully used to build relationships with community stakeholders. A community engagement approach to achieve new funding streams for PBRNs should include a strategy to engage key stakeholders from the communities of funders, thought leaders, and policymakers using collaborative principles and methods. PBRNs that implement this strategy would build a robust network of engaged partners at the community level, across networks, and would reach state and federal policymakers, academic family medicine departments, funding bodies, and national thought leaders in the redesign of health care delivery.

The "Picardie en Forme" Network: Federating Regional Health-enhancing Sports Resources / Fédérer les ressources régionales du sport-santé : le réseau Picardie en Forme.

Initiated by the Regional Olympic and Sports Committee and the Regional Directorate of Youth, Sports and Social Cohesion, the "Picardie en Forme" network has been working since 2011 in favour of adults of all ages, with chronic noncommunicable or similar diseases, to encourage a gradual return to reassuring and perennial regular physical activity,. A first step consisted of organizing a care pathway based on two principles: inform general practitioners so that they can encourage their patients to be physically active by referring them to the network, develop a range of local sports by accrediting certain clubs with sports instructors who have been trained in the management of this specific population. In 2013, 121 users entered the network at the request of 61 doctors. 48 sports instructors were trained and 20 associations obtained the Picardie en Forme label. Comparison of the results of tests performed on entry in the network and then eight months later shows a general physical reconditioning of users, increasing their motivation and perceived physical value. However, despite these encouraging results, the network has difficulty retaining users, and maintaining the involvement of general practitioners and certain local partners. This article discusses the relevance of initial approaches and describes the changes made to sustain this regional network, which, for the first time, links sport, health and users.

Multiple streams approach to tobacco control policymaking in a tobacco-growing state.

Smokefree policies (SFPs) have diffused throughout the US and worldwide. However, the development of SFPs in the difficult policy environment of tobacco-producing states and economies worldwide has not been well-explored. In 2007, Tennessee, the third largest tobacco producer in the US, enacted the Non-Smoker Protection Act (NSPA). This study utilizes the multiple streams model to provide understanding of why and how this policy was developed by triangulating interviews with key stakeholders and legislative debates with archival documents. In June 2006, the Governor unexpectedly announced support for SFP, which created a window of opportunity for policy change. The Campaign for Healthy and Responsible Tennessee, a health coalition, seized this opportunity and worked with the administration and the Tennessee Restaurant Association to negotiate a comprehensive SFP, however, a weaker bill was used by the legislative leadership to develop the NSPA. Although the Governor and the Tennessee Restaurant Association's support generated an environment for 100% SFP, health groups did not fully capitalize on this environmental change and settled for a weak policy with several exemptions. This study suggests the importance for proponents of policy change to understand changes in their environment and be willing and able to capitalize on these changes.

How are state insurance marketplaces shaping health plan design?

Part of states' roles in administering the new health insurance marketplaces is to certify the health plans available for purchase. This analysis focuses on how state-based and state partnership marketplaces are using their flexibility in setting certification standards to shape plan design in the individual market. It focuses on three aspects of certification: provider networks; inclusion of essential community providers; and benefit substitution, which allows plans to offer benefits that differ from a state's benchmark plan. A review of documents collected from 18 states and the District of Columbia finds that 13 states go beyond the minimum federal requirements with respect to provider network standards, four states specify additional standards for including essential community providers, and five states and Washington, D.C., bar benefit substitution. These interstate variations in plan design reflect the challenges policymakers face in balancing health care affordability, benefit coverage, and access to care through the marketplace plans.

The role of advocacy in occasioning community and organizational change in a medical-legal partnership.

Health disparities among low-income individuals remain a significant problem. A number of social determinants are associated with adverse health outcomes. Medical-legal partnerships address legal concerns of low-income individuals to improve health and wellness in adults and children. The Medical-Legal Partnership at Legal Aid of Western Missouri provides free direct legal services for patients with legal concerns affecting health. There is limited evidence regarding the association between advocacy-related efforts and changes within both the medical-legal partnership structure and in health-care facilities. Three health-care organizations in Kansas City, MO participated in implementing the medical-legal partnership model between 2007 and 2010. Advocacy efforts conducted by key medical-legal partnership personnel were strongly associated with changes in health-care organizations and within the medical-legal partnership structure. This study extends the current evidence base by examining the types of advocacy efforts required to bring about community and organizational changes.

Outdoor brothel culture: the un/making of a transsexual stroll in Vancouver's West End, 1975­1984.

In the mid-1970s, following a series of police raids on prostitution inside downtown nightclubs, a community of approximately 200 sex workers moved into Vancouver's West End neighborhood, where a small stroll had operated since the early 1970s. This paper examines the contributions made by three male-to-female (MTF) transsexuals of color to the culture of on-street prostitution in the West End. The trans women's stories address themes of fashion, working conditions, money, community formation, violence, and resistance to well-organized anti-prostitution forces. These recollections enable me to bridge and enrich trans history and prostitution history ­ two fields of inquiry that have under-represented the participation of trans women in the sex industry across the urban West. Acutely familiar with the hazards inherent in a criminalized, stigmatized trade, trans sex workers in the West End manufactured efficacious strategies of harm reduction, income generation, safety planning, and community building. Eschewing the label of "victim", they leveraged their physical size and style, charisma, contempt towards pimps, earning capacity, and seniority as the first workers on the stroll to assume leadership within the broader constituency of "hookers on Davie Street". I discover that their short-lived outdoor brothel culture offered only a temporary bulwark against the inevitability of eviction via legal injunction in July 1984, and the subsequent rise in lethal violence against all prostitutes in Vancouver, including MTF transsexuals.

Putting the market in its place: food security in three Mapuche communities in southern Chile.

This article analyzes the impact of state policies since the 1970s on household food security in several Mapuche communities in the Araucanía region of Chile (Region IX). The author highlights key transformations in the national economy and food system and endeavors to link those to local phenomena, in particular the absorption of the local livelihood strategies and food systems into capitalist markets and the high incidences of food insecurity. The article concludes that a reconceptualization of macroeconomic and indigenous policies are required to rebuild the material and social foundations of rural Mapuche communities that provide the bases from which their inhabitants can reconstruct a mutually beneficial relationship with the broader Chilean society and avert the continued acceleration of tension and violence.

Social capital and women's reduced vulnerability to HIV infection in rural Zimbabwe.

Social capital­especially through its "network" dimension (high levels of participation in local community groups)­is thought to be an important determinant of health in many contexts. We investigate its effect on HIV prevention, using prospective data from a general population cohort in eastern Zimbabwe spanning a period of extensive behavior change (1998­2003). Almost half of the initially uninfected women interviewed were members of at least one community group. In an analysis of 88 communities, individuals with higher levels of community group participation had lower incidence of new HIV infections and more of them had adopted safer behaviors, although these effects were largely accounted for by differences in socio-demographic composition. Individual women in community groups had lower HIV incidence and more extensive behavior change, even after controlling for confounding factors. Community group membership was not associated with lower HIV incidence in men, possibly refecting a propensity among men to participate in groups that allow them to develop and demonstrate their masculine identities­often at the expense of their health. Support for women's community groups could be an effective HIV prevention strategy in countries with large-scale HIV epidemics.

The Colorado Crisis Education and Response Network: an analysis of policy and practices.

The Federal government has recognized the importance of including behavioral health in disaster response plans and policies. Many states have responded to these directives with the development and implementation of disaster behavioral health response teams. The Colorado Crisis Education and Response Network (CoCERN) is a statewide asset that is based in community partnerships formed to deliver effective, efficient, and professional disaster behavioral health services to communities impacted by a disaster Using the K. McInnis-Dittrich model of policy analysis, this paper analyzes this approach to disaster behavioral health response. Strengths and weaknesses of the program, as well as implications for practice are discussed.

Feeding the family during times of stress: experience and determinants of food insecurity in an Inuit community.

This paper uses a mixed methods approach to characterise the experience of food insecurity among Inuit community members in Igloolik, Nunavut, and examine the conditions and processes that constrain access, availability, and quality of food. We conducted semi-structured interviews (n= 66) and focus groups (n= 10) with community members, and key informant interviews with local and territorial health professionals and policymakers (n= 19). The study indicates widespread experience of food insecurity. Even individuals and households who were food secure at the time of the research had experienced food insecurity in the recent past, with food insecurity largely transitory in nature. Multiple determinants of food insecurity operating over different spatial-temporal scales are identified, including food affordability and budgeting, food knowledge and preferences, food quality and availability, environmental stress, declining hunting activity, and the cost of harvesting. These determinants are operating in the context of changing livelihoods and climate change, which in many cases are exacerbating food insecurity, although high-order manifestations of food insecurity (that is, starvation) are no longer experienced.

The impact of housing rehabilitation on local neighborhoods: the case of small community development organizations.

Across the nation, nonprofit organizations located in poor and declining neighborhoods are promoting homeownership in the hopes that their efforts will stave off decline and contribute to neighborhood stability. A common homeownership strategy among nonprofits is to acquire boarded-up or deteriorated homes at a low price, rehabilitate them, and then sell them at an affordable price. As these programs continue, nonprofit organizations want to show quantitatively that neighborhood revitalization works­that the funds devoted to an area stabilize neighborhoods or, even more, that they initiate a surge of continued upward progress. But, unlike their larger counterparts, smaller community development organizations are usually at a disadvantage in undertaking such an evaluation. This study will help illustrate what might be done. It focuses on the case of St. Joseph's Carpenter Society (SJCS) in Camden, New Jersey and assesses the quantitative impact that SJCS has on its target neighborhoods. A three-tiered approach is adopted that ranges from a target and comparison area analysis, to regression analysis of SJCS's impact on local housing prices, and finally to an examination of the relative market performance of SJCS's houses. All told, the analysis suggests that SJCS's rehabilitation and homeownership education activities appear to have a positive influence on the neighborhoods in its target area.

Should diabetes be commissioned through multidisciplinary networks, rather than Practice Based Commissioning?

AIMS: Diabetes is recognized as a complex, long term, largely asymptomatic condition requiring self management skills, a range of health care professionals and articulated health services. Diabetes Networks have been introduced to provide guidance from people with diabetes and local health professionals with different skills to ensure that diabetes care is well organized, sustainable and delivers quality care. We have considered the role of Diabetes Networks in the English setting. METHODS: Drawing on studies of health service organization and health policy, we describe the context in which diabetes commissioning is currently occurring in England, the role of Diabetes Networks and key components for an effective Diabetes Network. RESULTS: We have identified that Diabetes Networks are not currently mandatory and discovered policy approaches that are likely to work against safe, timely, integrated approaches to diabetes services with potentially harmful impacts on people with diabetes in the future. Practice Based Commissioning, where it sidelines Diabetes Networks, is a particular concern. We have identified key components of Diabetes Networks including explicit frameworks for leadership, membership, funding, decision making, communication and action. CONCLUSIONS: Diabetes is a condition requiring collaboration between all involved. Diabetes Networks include patients and all relevant health professionals and should dictate what and how diabetes care should be commissioned within the local health economy.

Workforce professionalism in drug treatment services: impact of California's Proposition 36.

This article investigates whether California's Proposition 36 has promoted the workforce professionalism of drug treatment services during its first 5 years of implementation. Program surveys inquiring about organizational information, Proposition 36 implementation, and staffing were conducted in 2003 and 2005 among all treatment providers serving Proposition 36 clients in five selected California counties (San Diego, Riverside, Kern, Sacramento, and San Francisco). A 1-hour self-administered questionnaire was completed by 118 treatment providers representing 102 programs. This article examines five topics that are relevant to drug treatment workforce professionalism: resources and capability, standardized intake assessment and outcome evaluation, staff qualification, program accreditation, and information technology. Results suggest that Proposition 36 had a positive influence on the drug treatment workforce's professionalism. Improvements have been observed in program resources, client intake assessment and outcome evaluation databases, staff professionalization, program accreditation, and information technology system. However, some areas remain problematic, including, for example, the consistent lack of adequate resources serving women with children.

Race, urban governance, and crime control: creating model cities.

In the late 1960s and early 1970s, the city of Seattle received federal Department of Housing and Urban Development "Model cities" funds to address issues of racial disenfranchisement in the city. Premised under the "Great Society" ethos, Model cities sought to remedy the strained relationship between local governments and disenfranchised urban communities. Though police-community relations were not initially slated as an area of concern in the city's grant application, residents of the designated "model neighborhood" pressed for the formation of a law and justice task force to address the issue. This article examines the process and outcome of the two law-and-justice projects proposed by residents of the designated "model neighborhood": the Consumer Protection program and the Community Service Officer project. Drawing on the work of legal geographies scholars, I argue that the failure of each of these efforts to achieve residents' intentions stems from the geographical imagination of urban problems. Like law-and-order projects today, the geographical imagination of the model neighborhood produced a discourse of exceptionality that subjected residents to extraordinary state interventions. The Model cities project thus provides an example of a "history of the present" of mass incarceration in which the geographical imagination of crime helps facilitate the re-creation of a racialized power structure.