Implementation, Maintenance, and Outcomes of an Electronic Referral to a Tobacco Quitline Across Five Health Systems.

INTRODUCTION: Electronic referral (e-referral) to quitlines helps connect tobacco-using patients to free, evidence-based cessation counseling. Little has been published about the real-world implementation of e-referrals across U.S. health systems, their maintenance over time, and the outcomes of e-referred patients. AIMS AND METHODS: Beginning in 2014, the University of California (UC)-wide project called UC Quits scaled up quitline e-referrals and related modifications to clinical workflows from one to five UC health systems. Implementation strategies were used to increase site readiness. Maintenance was supported through ongoing monitoring and quality improvement programs. Data on e-referred patients (n = 20 709) and quitline callers (n = 197 377) were collected from April 2014 to March 2021. Analyses of referral trends and cessation outcomes were conducted in 2021-2022. RESULTS: Of 20 709 patients referred, the quitline contacted 47.1%, 20.6% completed intake, 15.2% requested counseling, and 10.9% received it. In the 1.5-year implementation phase, 1813 patients were referred. In the 5.5-year maintenance phase, volume was sustained, with 3436 referrals annually on average. Among referred patients completing intake (n = 4264), 46.2% were nonwhite, 58.8% had Medicaid, 58.7% had a chronic disease, and 48.8% had a behavioral health condition. In a sample randomly selected for follow-up, e-referred patients were as likely as general quitline callers to attempt quitting (68.5% vs. 71.4%; p = .23), quit for 30 days (28.3% vs. 26.9%; p = .52), and quit for 6 months (13.6% vs. 13.9%; p = .88). CONCLUSIONS: With a whole-systems approach, quitline e-referrals can be established and sustained across inpatient and outpatient settings with diverse patient populations. Cessation outcomes were similar to those of general quitline callers. IMPLICATIONS: This study supports the broad implementation of tobacco quitline e-referrals in health care. To the best of our knowledge, no other paper has described the implementation of e-referrals across multiple U.S. health systems or how they were sustained over time. Modifying electronic health records systems and clinical workflows to enable and encourage e-referrals, if implemented and maintained appropriately, can be expected to improve patient care, make it easier for clinicians to support patients in quitting, increase the proportion of patients using evidence-based treatment, provide data to assess progress on quality goals, and help meet reporting requirements for tobacco screening and prevention.

Ethics of organ procurement from the unrepresented patient population.

The shortage of organs for transplantation by its nature prompts ethical dilemmas. For example, although there is an imperative to save human life and reduce suffering by maximising the supply of vital organs, there is an equally important obligation to ensure that the process by which we increase the supply respects the rights of all stakeholders. In a relatively unexamined practice in the USA, organs are procured from unrepresented decedents without their express consent. Unrepresented decedents have no known healthcare wishes or advance care planning document; they also lack a surrogate. The Revised Uniform Anatomical Gift Act (RUAGA) of 2006 sends a mixed message about the procurement of organs from this patient population and there are hospitals that authorise donation. In addition, in adopting the RUAGA, some states included provisions that clearly allow organ procurement from unrepresented decedents. An important unanswered question is whether this practice meets the canons of ethical permissibility. The current Brief Report presents two principled approaches to the topic as a way of highlighting some of the complexities involved. Concluding remarks offer suggestions for future research and discussion.

Assessing and improving organizational readiness to implement substance use disorder treatment in primary care: findings from the SUMMIT study.

BACKGROUND: Millions of people with substance use disorders (SUDs) need, but do not receive, treatment. Delivering SUD treatment in primary care settings could increase access to treatment because most people visit their primary care doctors at least once a year, but evidence-based SUD treatments are underutilized in primary care settings. We used an organizational readiness intervention comprised of a cluster of implementation strategies to prepare a federally qualified health center to deliver SUD screening and evidence-based treatments (extended-release injectable naltrexone (XR-NTX) for alcohol use disorders, buprenorphine/naloxone (BUP/NX) for opioid use disorders and a brief motivational interviewing/cognitive behavioral -based psychotherapy for both disorders). This article reports the effects of the intervention on key implementation outcomes. METHODS: To assess changes in organizational readiness we conducted pre- and post-intervention surveys with prescribing medical providers, behavioral health providers and general clinic staff (N = 69). We report on changes in implementation outcomes: acceptability, perceptions of appropriateness and feasibility, and intention to adopt the evidence-based treatments. We used Wilcoxon signed rank tests to analyze pre- to post-intervention changes. RESULTS: After 18 months, prescribing medical providers agreed more that XR-NTX was easier to use for patients with alcohol use disorders than before the intervention, but their opinions about the effectiveness and ease of use of BUP/NX for patients with opioid use disorders did not improve. Prescribing medical providers also felt more strongly after the intervention that XR-NTX for alcohol use disorders was compatible with current practices. Opinions of general clinic staff about the appropriateness of SUD treatment in primary care improved significantly. CONCLUSIONS: Consistent with implementation theory, we found that an organizational readiness implementation intervention enhanced perceptions in some domains of practice acceptability and appropriateness. Further research will assess whether these factors, which focus on individual staff readiness, change over time and ultimately predict adoption of SUD treatments in primary care.

Finding the perfect doctor: identifying lesbian, gay, bisexual, and transgender-competent physicians.

OBJECTIVES: We assessed the existence of procedures and policies for identifying lesbian, gay, bisexual, and transgender (LGBT)-competent physicians at US academic faculty practices, and sought to identify physician training programs that enhance LGBT competency. METHODS: We invited all 138 Liaison Committee on Medical Education-accredited US academic faculty practices to participate in a survey in 2012. We systematically assessed their procedures and policies to identify LGBT-competent physicians and their LGBT-competency training. We also assessed geographic region, funding source, and an LGBT health center in the same state. We performed univariate, bivariate, and multivariate logistic regression analyses. RESULTS: The response rate was 50%. Few participants had existing procedures (9%) or policies (4%) to identify LGBT-competent physicians. Procedures included online directories with self-identified LGBT-competent physicians available to the public. Sixteen percent of participants reported having comprehensive LGBT-competency training, and 52% reported having no training. Of note, 80% of participants indicated interest to do more to address these issues. CONCLUSIONS: There exist both need and interest for US academic faculty practices to develop procedures, policies, and programs that improve access to LGBT-competent physicians and to train physicians to become LGBT-competent.

Neighborhood, family and individual characteristics related to adolescent park-based physical activity.

BACKGROUND: Local parks are an important community resource that may influence levels of physical activity among youth. However, few population-based studies have investigated park-based physical activity among youth. PURPOSE: This study examines sociodemographic, family, and neighborhood characteristics associated with park-based physical activity among adolescents. METHODS: Data were from the 2007 California Health Interview Survey (CHIS), a population-based survey of California households, and were analyzed in 2012-2013 and 2015. This study examined individual (age, gender, race/ethnicity, and nativity), family (household income, parental education, and nativity), and neighborhood characteristics (urbanicity, perceived park availability, perceived park safety, neighborhood income, and racial composition) associated with engaging in park-based physical activity among adolescents. RESULTS: In California, 71% of adolescents reported being physically active the last time they visited a park. In adjusted multinomial logistic regression analyses, older adolescents and females were less likely to be physically active in parks. Adolescents with a park within walking distance of home and those with a safe park nearby were more likely to be physically active during a park visit. CONCLUSIONS: Park availability and perceptions of park safety are important predictors of engaging in park-based physical activity among adolescents. These findings provide information that can help inform interventions intended to increase physical activity among youth. Strategies that increase availability and safety of parks and other recreation spaces may be particularly effective.

Opioid prescribing: a systematic review and critical appraisal of guidelines for chronic pain.

BACKGROUND: Deaths due to prescription opioid overdoses have increased dramatically. High-quality guidelines could help clinicians mitigate risks associated with opioid therapy. PURPOSE: To evaluate the quality and content of guidelines on the use of opioids for chronic pain. DATA SOURCES: MEDLINE, National Guideline Clearinghouse, specialty society Web sites, and international guideline clearinghouses (searched in July 2013). STUDY SELECTION: Guidelines published between January 2007 and July 2013 addressing the use of opioids for chronic pain in adults were selected. Guidelines on specific settings, populations, and conditions were excluded. DATA EXTRACTION: Guidelines and associated systematic reviews were evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument and A Measurement Tool to Assess Systematic Reviews (AMSTAR), respectively, and recommendations for mitigating opioid-related risks were compared. DATA SYNTHESIS: Thirteen guidelines met selection criteria. Overall AGREE II scores were 3.00 to 6.20 (on a scale of 1 to 7). The AMSTAR ratings were poor to fair for 10 guidelines. Two received high AGREE II and AMSTAR scores. Most guidelines recommend that clinicians avoid doses greater than 90 to 200 mg of morphine equivalents per day, have additional knowledge to prescribe methadone, recognize risks of fentanyl patches, titrate cautiously, and reduce doses by at least 25% to 50% when switching opioids. Guidelines also agree that opioid risk assessment tools, written treatment agreements, and urine drug testing can mitigate risks. Most recommendations are supported by observational data or expert consensus. LIMITATION: Exclusion of non-English-language guidelines and reliance on published information. CONCLUSION: Despite limited evidence and variable development methods, recent guidelines on chronic pain agree on several opioid risk mitigation strategies, including upper dosing thresholds; cautions with certain medications; attention to drug-drug and drug-disease interactions; and use of risk assessment tools, treatment agreements, and urine drug testing. Future research should directly examine the effectiveness of opioid risk mitigation strategies. PRIMARY FUNDING SOURCE: California Department of Industrial Relations and California Commission on Health and Safety and Workers' Compensation.

Adherence to adjuvant hormone therapy in low-income women with breast cancer: the role of provider-patient communication.

To assess the impact of patient-provider communication on adherence to tamoxifen (TAM) and aromatase inhibitors (AIs) 36 months after breast cancer (BC) diagnosis in a low-income population of women. California statewide surveys were conducted among 921 low-income women with BC at 6, 18, and 36 months after BC diagnosis. A subset of 303 women with stage I-III BC who initiated hormone treatment after diagnosis was identified. Bivariate and multivariate logistic regression analyses were performed, and adjusted adherence rates were calculated. The main outcome measure was self-reported hormone use at 36 months after BC diagnosis and the chief independent variables were patient-centered communication after diagnosis by patient report as measured by the Consumer Assessment of Healthcare Providers and Systems (CAHPS) and patients' self-efficacy in patient-physician interactions (PEPPI). Overall adherence to TAM/AI was relatively high (88 %). Adjusted rates of adherence were 59 and 94 % for patients with the lowest versus highest scores on the CAHPS communication scale (AOR = 1.22, P = 0.006) and 72 versus 91 % for patients with the lowest and highest rating of PEPPI (AOR = 1.04, P = 0.04). Having at least one comorbid condition also increased the odds of adherence to hormonal therapy (AOR = 3.14, P = 0.03). Having no health insurance and experiencing side-effects from hormone treatment were barriers for adherence (AOR = 0.12, P = 0.001; AOR = 0.26, P = 0.003, respectively). Patient-centered communication and perceived self-efficacy in patient-physician interaction were significantly associated with patient adherence to ongoing TAM/AI therapy among low-income women with BC. Interventions on patient-provider communication may provide opportunities to improve patient outcomes in this vulnerable population.

Estimates of smoking-related property costs in California multiunit housing.

We systematically evaluated smoking-related costs in multiunit housing. From 2008 to 2009, we surveyed California multiunit housing owners or managers on their past-year smoking-related costs and smoke-free policies. A total of 27.1% of respondents had incurred smoking-related costs (mean $4935), and 33.5% reported complete smoke-free policies, which lowered the likelihood of incurring smoking-related costs. Implementing statewide complete smoke-free policies may save multiunit housing property owners $ 18,094,254 annually.

Validity of self-reports of breast cancer treatment in low-income, medically underserved women with breast cancer.

Few studies have assessed the agreement between subjects' self-report and medical records among patients with breast cancer (BC), and none has addressed this issue in low-income women with BC. We assessed the level of agreement between self-report and medical records data for key BC treatment and prognostic characteristics using correct proportion and the Kappa statistic, among 726 low-income BC patients. Unconditional regression was used to investigate the association between accuracy of self-report and potential explanatory factors. Overall agreement between self-report and medical records was 95.3-99.6% for BC treatments including surgery, chemotherapy, radiotherapy and hormone therapy (Kappa = 0.79-0.99). Specific agreement was 87-89.5% for surgery type (Kappa = 0.51-0.96); 86.3% for chemotherapy completion (Kappa = 0.46) and 98.7% for radiotherapy completion (Kappa = 0.43); 95.2% for medical oncologist consultation (Kappa = 0.59) and 96% for radiation oncologist consultation; 97.3% for metastasis (Kappa = 0.56); and 93.6% for recurrence (Kappa = 0.30). When accepting answers within 15 days of the medical record date, 78.2% of women correctly reported surgery date, yet only around 55% of women correctly reported the start and/or end date of radiotherapy. Older age, less education, BC recurrence and poor patient-physician communication were associated with the lesser accuracy of patients' self-report compared to medical records (P < 0.05). The results of this study suggest that self-reporting of key treatment and prognostic information is relatively accurate among low-income women with BC. Self-report seems to be a reliable source for accurate information when medical record review is unavailable or unfeasible. Interventions to enhance patient-physician communication may facilitate more accurate information reporting among vulnerable populations.

Treatment-related symptoms among underserved women with breast cancer: the impact of physician-patient communication.

Low-income, minority women are more likely to be undertreated for breast cancer (BC) treatment-related symptoms than whites. This study assessed the impact of patient-physician communication on symptom resolution. A cross-sectional, California statewide survey was conducted among 921 low-income women with BC. Ethnic/racial differences in BC treatment-related symptoms (pain, nausea/vomiting, depression) reporting and physician' awareness of these symptoms were assessed by patient report. Multivariate logistic regression models were used to investigate the impact of patient-physician communication on symptom resolution. Depression was the most common symptom reported by patients (66%), yet physicians were the least aware of it (26.3%), especially among less-acculturated Latinas (18.9%) and Asian/Pacific Islanders (14%; P < 0.001). Greater patient-perceived self-efficacy in communication with physicians and greater physician awareness of the symptom positively predicted pain resolution, controlling for sociodemographic variables, comorbidity, and treatment received (AOR = 1.05, P < 0.0001; AOR = 6.12, P < 0.001). Physician awareness was a significant determinant of depression resolution (AOR = 13.46, P < 0.001). Yet patient-perceived self-efficacy played a much more important role than physicians' awareness in nausea resolution (AOR = 1.04, P = 0.0002). Less-acculturated Latinas tended to achieve less symptom resolution than whites, while this negative impact disappeared or was moderated after patient-physician communication was considered. This study suggests that physicians under-recognized depression, especially among Latinas. The resolution of BC treatment-related symptoms can be addressed by appropriate educational interventions targeted at patient-physician communication. Effective patient-physician communication can moderate disparities in symptom resolution among Latinas, regardless of language acculturation.

Income disparities in obesity trends among California adolescents.

OBJECTIVES: We assessed income-specific trends in obesity rates among a diverse population of California adolescents. METHODS: We used data from 17,535 adolescents who responded to the California Health Interview Survey between 2001 and 2007 to examine disparities in obesity prevalence by family income and gender. RESULTS: Between 2001 and 2007, obesity prevalence significantly increased among lower-income adolescents but showed no statistically significant differences among higher-income adolescents after adjustment for age, gender, and race/ethnicity. Although the overall disparity in obesity by family income doubled in this time period, trends were more consistent among male adolescents than among female adolescents. CONCLUSIONS: The magnitude of the income disparity in obesity prevalence among California adolescents more than doubled between 2001-2007. The overall leveling off of adolescent obesity prevalence rates could indicate that efforts to decrease childhood obesity are having an impact; however, our results suggest that efforts to prevent childhood obesity may be failing to help adolescents from lower-income families, particularly male adolescents.

Is incarceration a contributor to health disparities? Access to care of formerly incarcerated adults.

Despite the disproportionate prevalence of incarceration in communities of color, few studies have examined its contribution to health disparities. We examined whether a lifetime history of incarceration is associated with recent access to medical and dental care. We performed a secondary data analysis of the 2007 Los Angeles County Health Survey, a population-based random-digit-dialing telephone survey of county households. Any history of incarceration in a prison/jail/detention center as an adult was assessed for a random subsample. Bivariate and multivariate logistic regression analyses examined whether incarceration history was associated with access to care, controlling for other characteristics. Ten percent of our study population reported a history of incarceration. While persons with an incarceration history were similar to their peers with regard to health and insurance status, their access to medical and dental care was worse. Incarceration history was independently associated with disparities in access to care. Interventions to improve the health of communities affected by high rates of incarceration could include efforts that enable access to care for formerly incarcerated adults.

Genetic Variation and Hot Flashes: A Systematic Review.

CONTEXT: Approximately 70% of women report experiencing vasomotor symptoms (VMS, hot flashes and/or night sweats). The etiology of VMS is not clearly understood but may include genetic factors. EVIDENCE ACQUISITION: We searched PubMed and Embase in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance. We included studies on associations between genetic variation and VMS. We excluded studies focused on medication interventions or prevention or treatment of breast cancer. EVIDENCE SYNTHESIS: Of 202 unique citations, 18 citations met the inclusion criteria. Study sample sizes ranged from 51 to 17 695. Eleven of the 18 studies had fewer than 500 participants; 2 studies had 1000 or more. Overall, statistically significant associations with VMS were found for variants in 14 of the 26 genes assessed in candidate gene studies. The cytochrome P450 family 1 subfamily A member 1 (CYP1B1) gene was the focus of the largest number (n = 7) of studies, but strength and statistical significance of associations of CYP1B1 variants with VMS were inconsistent. A genome-wide association study reported statistically significant associations between 14 single-nucleotide variants in the tachykinin receptor 3 gene and VMS. Heterogeneity across trials regarding VMS measurement methods and effect measures precluded quantitative meta-analysis; there were few studies of each specific genetic variant. CONCLUSIONS: Genetic variants are associated with VMS. The associations are not limited to variations in sex-steroid metabolism genes. However, studies were few and future studies are needed to confirm and extend these findings.

Protecting the gains: What changes are needed to prevent a reversal of the downward cardiovascular disease mortality trend?

AIMS: Cardiovascular disease (CVD) mortality has decreased over 60% over the past 50 years in the United States; however, emerging data indicate CVD incidence may be rising because of shifting demographics, increasing risk factor prevalence, and competing needs for limited resources. We projected CVD mortality from 2015 to 2040 given varying informed assumptions regarding changes in risk factor prevalence, uptake of current therapeutic options, and future innovations. METHODS: A microsimulation model was used to project US CVD mortality trends. National Health and Nutrition Examination Survey data were used to estimate population-level trends in CVD risk factors. Risk factors were used to generate Framingham Risk Scores for cohorts of 1 000 000 individuals from the general population to determine each individuals' CVD risk. Annual cardiovascular incidence, prevalence, and mortality were projected for scenarios differing by uptake of current therapies, anticipated pharmaceutical innovations with variable efficacy, risk factor prevalence, and changes in health disparities. RESULTS: When incorporating a demographic shift, continued changes in risk factors, current treatment utilization, and no major innovations, we predicted the CVD mortality rate would increase 41% by 2040. If innovations providing incremental benefits equal to those associated with the introduction of statins are identified and widely utilized, CVD mortality could remain constant through 2040. With more efficacious innovations, CVD mortality could be further reduced. CONCLUSIONS: Given demographic and risk prevalence changes, increasing access and adherence to current preventative therapeutics could slow the expected mortality increase, but new therapies may be needed to maintain the downward trend in CVD deaths.

Few California Children and Adolescents Meet Physical Activity Guidelines.

This policy brief describes physical activity among California children and adolescents. Using data from the California Health Interview Survey (CHIS), the study found that only 31 percent of children ages 5-11 and 18 percent of adolescents ages 12-17 meet the physical activity guidelines of engaging in at least one hour of physical activity every day. Neighborhood characteristics, including safety and proximity to parks, are related to physical activity levels among youth. Also, among older children, boys are more active than girls. Additional efforts by state and local policymakers, as well as communities, are needed to promote physical activity to increase the proportion of children and adolescents achieving recommended amounts of physical activity.

Walking Among California Adults.

This policy brief describes two types of walking among California adults: walking for transportation and walking for leisure. Using data from the 2013-14 California Health Interview Survey, the study found that the prevalence of both types of walking has increased since 2003. The prevalence of walking for both transportation and leisure varies with age, income, race/ethnicity, and neighborhood safety and cohesion. Additional efforts by state and local policymakers, as well as by communities, are needed to reduce disparities and promote walking among adults.

Disparities in Health Care Access and Health Among Lesbians, Gay Men, and Bisexuals in California.

This policy brief examines differences in health care access, health behaviors, and health outcomes by sexual orientation among California adults. Using data from the California Health Interview Survey, the study finds that although lesbian, gay, and bisexual women and men have similar or better rates of insurance coverage compared to straight women and men, they are more likely to experience delays in getting needed health care. Lesbians, bisexual women, and bisexual men have higher rates of smoking and binge drinking than straight women and men; however, gay men are less likely to consume sugary beverages and to be physically inactive. Lesbians and bisexuals had poorer health status and higher rates of disability than straight adults. Future research is needed to explain these disparities, as well as to identify health care and structural interventions that will improve access to care and health outcomes for this population.

Healthcare Experiences of Underrepresented Lesbian and Bisexual Women: A Focus Group Qualitative Study.

Purpose: To understand the complex healthcare experiences of women identifying as lesbian or bisexual. who are also women of color, veterans, and/or 65 years of age and older. Methods: Inclusion criteria were age 25 or older, Los Angeles County resident, self-identification as a lesbian or bisexual woman, and as an African American, Latina, Asian-Pacific Islander, and/or a veteran. For the age 65 years and older group, participants were eligible regardless of their veteran status or race/ethnicity. Five focus groups were conducted (n=35) and the same questions were asked addressing their comfort interacting with healthcare providers, the provider knowing their sexual orientation, characteristics of a perfect provider, and barriers to care. Structured qualitative analyses were performed. Results: Participants identified concerns that providers often hold to heterosexual cultural norms. Participants varied on preferences for providers of the same race/ethnicity as themselves. Lesbians who are 65 years and older identified legal barriers as major concerns. All groups identified incorrect provider assumptions about sexual orientation and sexual practices as frequently compromising their care. Participants supported the idea of certification for providers skilled in lesbian, gay, bisexual, transgender, and queer (LGBTQ) health, but expressed skepticism that such programs would necessarily result in better care. Conclusion: Healthcare provider trainings need to address the specific concerns and experiences of underrepresented lesbian and bisexual women. Healthcare environments must be transformed to effectively address their needs. More research is needed on the separate healthcare experiences of specific marginalized populations related to their sexual orientation and/or gender identity.

Adolescent participation in preventive health behaviors, physical activity, and nutrition: differences across immigrant generations for Asians and Latinos compared with Whites.

OBJECTIVES: We investigated preventive health behaviors (bicycle helmet, seat belt, and sunscreen use), physical activity, television viewing or video game playing, and nutrition (fruit, vegetable, milk, and soda consumption) among Asian and Latino adolescents living in the United States; assessed trends across generations (first-, second-, and third-generation immigrants or later); and compared each generation with White adolescents. METHODS: We used data from 5801 adolescents aged 12 to 17 years in the representative 2001 California Health Interview Survey. RESULTS: In multivariate analysis, first-generation Asians measured worse than Whites for preventive health behaviors (lower participation), physical activity (less activity), and television viewing or video game playing (more hours), but improved across generations. For these same behaviors, Latinos were similar to or worse than Whites, and generally showed no improvement across generations. First-generation Asians and Latinos had healthier diets than Whites (higher fruit and vegetable consumption, lower soda consumption). With succeeding generations, Asians' fruit, vegetable, and soda consumption remained stable, but Latinos' fruit and vegetable consumption decreased and their soda consumption increased, so that by the third generation Latinos' nutrition was poorer than Whites'. CONCLUSIONS: For the health behaviors we examined, Asian adolescents' health behaviors either improved with each generation or remained better than that of Whites. Latino adolescents demonstrated generally worse preventive health behaviors than did Whites and, in the case of nutrition, a worsening across generations. Targeted interventions may be needed to address behavioral disparities.

Providing health care services to the formerly homeless: a quasi-experimental evaluation.

We performed a quasi-experiment to assess the effects of a focused health care intervention delivered in transitional housing facilities in Sacramento, California. Four transitional housing facilities (THFs) receiving the intervention were compared with 2 THFs that did not receive it. A multidisciplinary team provided a diverse package of services to residents at the intervention sites. Residents at comparison sites received usual care. Survey and physical examination data were collected in repeated cross-sectional surveys at baseline (pre-intervention) and after 6 and 18 months of follow-up (post-intervention). Using analysis of covariance techniques, our statistical models showed improved odds of receiving recommended gynecologic preventive care and decreased odds of frequent Emergency Department use at 18 months among residents at the intervention sites. At 6 months, residents at the intervention sites also experienced improved blood pressure control. There was no intervention effect on residents' access to specialists or on physical functioning, mental health, or dental health.