Breadth and Exclusivity of Hospital and Physician Networks in US Insurance Markets.

Importance: Little is known about the breadth of health care networks or the degree to which different insurers' networks overlap. Objective: To quantify network breadth and exclusivity (ie, overlap) among primary care physician (PCP), cardiology, and general acute care hospital networks for employer-based (large group and small group), individually purchased (marketplace), Medicare Advantage (MA), and Medicaid managed care (MMC) plans. Design, Setting, and Participants: This cross-sectional study included 1192 networks from Vericred. The analytic unit was the network-zip code-clinician type-market, which captured attributes of networks from the perspective of a hypothetical patient seeking access to in-network clinicians or hospitals within a 60-minute drive. Exposures: Enrollment in a private insurance plan. Main Outcomes and Measures: Percentage of in-network physicians and/or hospitals within a 60-minute drive from a hypothetical patient in a given zip code (breadth). Number of physicians and/or hospitals within each network that overlapped with other insurers' networks, expressed as a percentage of the total possible number of shared connections (exclusivity). Descriptive statistics (mean, quantiles) were produced overall and by network breadth category, as follows: extra-small (<10%), small (10%-25%), medium (25%-40%), large (40%-60%), and extra-large (>60%). Networks were analyzed by insurance type, state, and insurance, physician, and/or hospital market concentration level, as measured by the Hirschman-Herfindahl index. Results: Across all US zip code-network observations, 415 549 of 511 143 large-group PCP networks (81%) were large or extra-large compared with 138 485 of 202 702 MA (68%), 191 918 of 318 082 small-group (60%), 60 425 of 149 841 marketplace (40%), and 21 781 of 66 370 MMC (40%) networks. Large-group employer networks had broader coverage than all other network plans (mean [SD] PCP breadth: large-group employer-based plans, 57.3% [20.1]; small-group employer-based plans, 45.7% [21.4]; marketplace, 36,4% [21.2]; MMC, 32.3% [19.3]; MA, 47.4% [18.3]). MMC networks were the least exclusive (a mean [SD] overlap of 61.3% [10.5] for PCPs, 66.5% [9.8] for cardiology, and 60.2% [12.3] for hospitals). Networks were narrowest (mean [SD] breadth 42.4% [16.9]) and most exclusive (mean [SD] overlap 47.7% [23.0]) in California and broadest (79.9% [16.6]) and least exclusive (71.1% [14.6]) in Nebraska. Rising levels of insurer and market concentration were associated with broader and less exclusive networks. Markets with concentrated primary care and insurance markets had the broadest (median [interquartile range {IQR}], 75.0% [60.0%-83.1%]) and least exclusive (median [IQR], 63.7% [52.4%-73.7%]) primary care networks among large-group commercial plans, while markets with least concentration had the narrowest (median [IQR], 54.6% [46.8%-67.6%]) and most exclusive (median [IQR], 49.4% [41.9%-56.9%]) networks. Conclusions and Relevance: In this study, narrower health care networks had a relatively large degree of overlap with other networks in the same geographic area, while broader networks were associated with physician, hospital, and insurance market concentration. These results suggest that many patients could switch to a lower-cost, narrow network plan without losing in-network access to their PCP, although future research is needed to assess the implications for care quality and clinical integration across in-network health care professionals and facilities in narrow network plans.

Evaluating Breast Cancer Care Coordination at a Rural National Cancer Institute Comprehensive Cancer Center Using Network Analysis and Geospatial Methods.

BACKGROUND: Variation in cancer care coordination may affect care quality and patient outcomes. We sought to characterize the impact of geographic access to and dispersion of cancer care providers on variation in care coordination. METHODS: Using electronic health record data from 2,507 women diagnosed with breast cancer at a National Cancer Institute Comprehensive Cancer Center from April 2011 to September 2015, a breast cancer patient-sharing physician network was constructed. Patient "care networks" represent the subnetworks of physicians with whom the focal patient had a clinical encounter. Patient care networks were analyzed to generate two measures of care coordination, care density (ratio of observed vs. potential connections between physicians), and clustering (extent to which physicians form connected triangles). RESULTS: The breast cancer physician network included 667 physicians. On average, the physicians shared patients with 12 other physicians. Patients saw an average of 8 physicians during active treatment. In multivariable models adjusting for patient sociodemographic and clinical characteristics, we observed that greater travel burden (>2 hours) and lower geographic dispersion were associated with higher care density (P < 0.05 and P < 0.001, respectively) but lower care network clustering (P < 0.05). CONCLUSIONS: Variation in network-based measures of care coordination is partially explained by patient travel burden and geographic dispersion of care. IMPACT: Improved understanding of factors driving variation in patient care networks may identify patients at risk of receiving poorly coordinated cancer care.

Comprehensive Cancer Control Partners' Use of and Attitudes About Evidence-Based Practices.

INTRODUCTION: National Comprehensive Cancer Control Program (NCCCP) awardees are encouraged to work with partners (eg, nonprofit organizations) to develop and implement plans to reduce the cancer burden in their jurisdictions using evidence-based practices (EBPs). However, the extent of EBP use among awardees and their partners is not well understood. METHODS: From March through July 2012, we conducted a web-based survey of program partners referred by NCCCP program directors who were involved in implementation of cancer control plans. RESULTS: Approximately 53% of referred partners (n = 83) completed surveys, 91.6% of whom represented organizations. Most partners reported involvement in helping to identify (80.5%), adapt (81.7%), implement (90.4%), and evaluate (81.9%) EBPs. The factors rated most frequently as very important when selecting EBPs were "consistent with our organization's mission" (89.2%) and "cost-effective" (81.9%). Although most respondents said that their organizations understood the importance of using EBPs (84.3%) and had adequate access to cancer registry data (74.7%), few reported having sufficient financial resources to develop new EBPs (7.9%). The most frequently mentioned benefit of using EBPs was that they are proven to work. Resource limitations and difficulty adapting EBPs for specific populations and settings were challenges. CONCLUSIONS: Our findings help indicate how NCCCP partners are involved in using EBPs and can guide ongoing efforts to encourage the use of EBPs for cancer control. The challenges of using EBPs that partners identified highlight the need to improve strategies to translate cancer prevention and control research into practice in real-world settings and for diverse populations.

Identifying clinical and support service resources and network practices for cancer patients and survivors in southern Puerto Rico.

OBJECTIVE: The objectives of this study were to identify cancer-related health care services and to explore the presence of inter-organizational interactions among clinical and support oncology services in southern Puerto Rico. METHODS: From January through July of 2010, a survey was completed by 54 health care organizations offering clinical, supportive, or both services to cancer patients/survivors (CPS) in southern PR. Survey data were compiled and descriptive analyses performed using the software Statistical Package for a Social Science (SPSS), version 18.0. RESULTS: The distribution of the primary services provided by the participating organizations was the following: 26 had clinical services, 16 had support services, and 12 offered a combination of clinical and support services. Only 24 % of the surveyed organizations offered their services exclusively to patients diagnosed with cancer. In terms of referral practices, 61 % of the responses were for medical specialists, 43 % were for mental health services, and 37 % were referrals for primary care services. The most common reason for interacting (n = 27) was to provide a given patient both a referral and information. CONCLUSION: Findings suggest gaps in both the availability of oncology services and the delivery of integrated health care. Lack of communication among clinical and support organizations (for cancer patients, specifically) could negatively impact the quality of the services that they offer. Further network analysis studies are needed to confirm these gaps. Until systemic, structural changes occur, more efforts are needed to facilitate communication and collaboration among these kinds of organization.

[Evaluation and socio-economic relevance of an integrated osteoporosis health care network]. / Evaluation und sozio-ökonomische Bewertung eines Modells zur Integrierten Versorgung zur Behandlung der Osteoporose.

During the last 6 to 7 years, integrated health care has become more and more important in Germany. In August 2005 we initiated a collaborative project involving two orthopaedic clinics in Hanover and one rehabilitation clinic in Bad Pyrmont specialising in the treatment of osteoporosis. Here, we report the results of 633 women (83 ± 7 years) and 162 men (75 ± 10 years) who participated in this programme between August 2005 and August 2012. All participants gave informed consent. All patients were supplemented with 1200 mg of calcium and 800 IU of vitamin D. Intravenous bisphosphonates were given to 91% and parathyroid hormone to 7% of the patients. Two per cent received miscellanous therapeutic agents. Follow-up visits were attended by 89% of the patients after one year and 78% after two years. During this time, a significant improvement was observed in vitamin D, parathyroid hormone and the bone marker desoxypyridinoline. DXA measurements were falsified by degenerative disease or fractures. In the men, however, a significant increase was observed in the total hip. Over the two-year period, 16 vertebral and 3 non-vertebral fractures occurred in the women. In the men, one non-vertebral and 5 vertebral fractures were noted. Among the women, 18 died and 6 were admitted to a nursing home. The corresponding figures among the men were 7 and 4, respectively. According to the figures provided by the central German institute for statistics, the death rates among the women were significantly lower than expected, whereas a tendency toward lower death rates was seen in the men. In addition, the number of new hip fractures in the women was lower than the epidemiological data suggest. This was also noted in the men. Even among the very old, a musculoskeletal rehabilitation programme combined with adequate pharmaceutical therapy may prove very successful when it comes to death rates and nursing home admissions. The latter in particular may be very expensive in the long run and our longitudinal follow-up study may demonstrate cost-effectiveness if the rehabilitation programme is commenced as early as possible.

Community level morbidity control of lymphoedema using self care and integrative treatment in two lymphatic filariasis endemic districts of South India: a non randomized interventional study.

BACKGROUND: Currently there is no global program to manage lymphoedema as a result of lymphatic filariasis (LF). The primary aim of this study was to determine the efficacy of a previously proposed integrative treatment protocol, using locally available resources to address the morbidity, in a community village setting. METHODS: Two LF endemic districts of south India, Gulbarga in Karnataka (GK) and Alleppey in Kerala (AK), were selected for the study. All known patients were invited to an LF camp. Patients with grade two late or three lymphoedema were enrolled. All patients were given training in the integrative procedure which involved patient education and the domiciliary protocol. RESULTS: A total of 730 patients (851 limbs) completed the three and half month follow up. There was a statistically significant (1%) reduction up to mid thigh level volume measurement for both small (0.7-1.1 liters) and large (1.8-5.0 liters) limbs, p < 0.000. In AK inflammatory episodes at the three months interval reduced from 37.5% (127 patients) to 28.3% (96 patients) and in GK from 37.6% (147 patients) to 10.2% (40 patients), p < 0.000. All patients had reduced bacterial entry points. There was an overall improvement in quality of life in all domains of LF specific quality of life questionnaire p < 0.000. CONCLUSIONS: Self care and integrative treatment is possible in resource poor Indian village settings. Further work is needed to explore factors leading to better compliance by randomizing the interventions such as washing and emollient compression vs Ayurvedic and yoga interventions before integrative treatment is considered for national health programmes in developing countries.

Comparing patient and provider perceptions of home- and community-based services: social network analysis as a service integration metric.

Integrated home- and community-based services (HCBS) for frail seniors require a unique style of teamwork and collaboration. In four case studies, patient perceptions of teamwork and collaboration among their HCBS care providers are compared with those of the providers themselves using network analysis. The degree of coherence between these perceived networks are examined using network analytics, and network visualizations are discussed. The value of network analysis in research on HCBS is considered.

[Project "FrühStart"--family midwives in Saxony-Anhalt. Their networking with other health care and child welfare professionals and subjective view of the families]. / Modellprojekt FrühStart--Evaluation der Familienhebammen in Sachsen-Anhalt. Vernetzung, Sichtweise der Klientinnen und Verankerung im Netzwerk Früher Hilfen.

The project "Family midwives in Saxony-Anhalt" was evaluated by a multidimensional approach in order to document the subjective perspective of the mothers as well as the networking of health care and child welfare professionals, while caring for highly vulnerable families. The documentation of 734 cases and quantitative data of 33 family midwives were analyzed. Ten mothers were interviewed and problem-focused expert interviews were carried out with 39 health care and child welfare professionals. The method of coding the interview texts was both open and guided by the research questions. After finishing the qualification course and while caring for highly vulnerable families, the networking of family midwives with child welfare professionals significantly increased. Besides the family midwives and the youth welfare office, the antenatal counseling centers were important "gatekeepers". An important ingredient for constructive networking and care for families is trust which draws on client-oriented care, availability, and advocacy by the family midwives. While the family midwives are respected as partners by the professionals of the child welfare system, networking with obstetricians and hospitals is unsatisfactory. In order to improve this, the latter must be a future goal.

Cancer control planners' perceptions and use of evidence-based programs.

The Cancer Prevention and Control Research Network surveyed 282 cancer control planners to inform its efforts to increase the use of evidence-based cancer control programs (EBPs; programs that have been scientifically tested and have successfully changed behavior). Respondents included planners from organizations in state Comprehensive Cancer Control coalitions as well as other governmental and nongovernmental organizations and community-based coalitions. Respondents provided information about personal and organizational characteristics, their cancer control programs, their attitudes toward EBPs, and their awareness and use of Web-based resources for EBPs. Although findings showed strong preferences for cancer control programs that have been shown to work, less than half of respondents (48%) had ever used EBP resources. Regardless of whether they had used EBP resources, almost all respondents (97%) indicated that further training would help them and their organizations adopt and adapt EBPs for use in their communities. The most frequently endorsed training needs were finding and securing additional resources (such as funding and technical assistance), followed by adapting EBPs for cultural appropriateness. The Cancer Prevention and Control Research Network consortium is using these findings to develop a Web-based interactive training and decision support tool that is responsive to the needs identified by the survey respondents.

A contribuição da atenção domiciliar para a configuração de redes substitutivas de saúde: desinstitucionalização e transformação de práticas / Home care's contribution to alternative health care networks: deinstitutionalization and transformation of practices

OBJETIVO: Identificar o estado da arte da atenção domiciliar no âmbito do sistema público de saúde no Brasil, analisar o seu potencial de inovação no sentido da integralidade e da humanização da atenção e indicar pistas para a sua ampliação. MÉTODOS: Sete experiências de cuidado domiciliar em cinco municípios brasileiros foram analisadas por meio de estudos de caso, com base em entrevistas com os cinco gestores municipais e os sete coordenadores dos serviços, com todos os componentes das equipes de atenção domiciliar e com os usuários e os familiares dos 27 casos selecionados. Todas as entrevistas foram gravadas e depois transcritas. Foram ainda analisados documentos produzidos pelos serviços (proposta política, relatórios de gestão, relatórios de avaliação, rotinas e protocolos de atenção), observados atendimentos (ao menos um de cada uma das equipes em todos os sete serviços) e analisados os casos traçadores. RESULTADOS: Foram identificados os seguintes tipos de atendimento domiciliar: cuidado paliativo, cuidado a pacientes com AIDS, cuidado a portadores de feridas e lesões de pele, acompanhamento de bebês prematuros, acompanhamento de acamados crônicos, antibioticoterapia endovenosa como complementação do tratamento para infecções agudas. São aspectos a destacar: a qualidade e a humanização da atenção, o trabalho em equipe, o desenvolvimento de vínculo e a responsabilização por parte dos trabalhadores e a participação efetiva dos cuidadores e das famílias na produção dos projetos terapêuticos. CONCLUSÃO: As iniciativas examinadas mostraram que a atenção domiciliar é possível até em ambientes economicamente precários e que pode contribuir efetivamente para a produção de integralidade e de continuidade do cuidado, devendo ser ampliada no âmbito do sistema público de saúde.

OBJECTIVE: To identify state-of-the-art home care within Brazil's public health system, evaluate its potential for improving the comprehensiveness and humanization of care, and identify areas for expanding this care modality. METHODS: Seven home care initiatives were examined and cases were analyzed through interviews with five municipal services managers, seven service coordinators, all home-care team members, and with the service recipients, as well as the family members of the 27 cases selected. All of the interviews were recorded and transcribed. We also analyzed documents created by the home care services (policy manuals, management reports, evaluation reports, and care protocols), observed each team providing care (at least once for each of the seven service types), and analyzed the selected cases. RESULTS: The following types of home care were identified: palliative, AIDS, skin lesions/wounds, premature infant, bedridden patient, and supplemental intravenous antibiotic therapy for acute infection. The following positive aspects should be highlighted: the quality and humanization of care, team work, the bond developed with patients and family, the sense of responsibility taken on by the health workers, and the effective participation of caretakers and families in carrying out therapy plans. CONCLUSION: The initiatives examined show that home care is possible even in economically disadvantaged environments and that it may effectively contribute to providing integrated and continued care. Home care should be expanded in the context of the public health system.

Do 'alternative' help-seeking strategies affect primary care service use? A survey of help-seeking for mental distress.

BACKGROUND: Epidemiological studies suggest that only some distressed individuals seek help from primary care and that pathways to mental health care appear to be ethnically patterned. However few research studies examine how people with common mental disorder manage their mental distress, which help-seeking strategies they employ and whether these are patterned by ethnicity? This study investigates alternative help-seeking strategies in a multi-ethnic community and examines the relationship with primary care use. METHODS: Participants were recruited from four GP practice registers and 14 community groups in East London. Of 268 participants, 117 had a common mental disorder according to a valid and structured interview schedule (CIS-R). Participants were of Bangladeshi, black Caribbean and White British ethnic background. For those with a common mental disorder, we examined self-reported help-seeking behaviour, perceived helpfulness of care givers, and associations with primary care service use. RESULTS: We found that alternative help-seeking such as talking to family about distress (OR 15.83, CI 3.9-64.5, P < .001), utilising traditional healers (OR 8.79, CI 1.98-38.93, p = .004), and severity of distress (1.11, CI 1.03-1.20, p = .006) was positively associated with primary care service use for people with a common mental disorder. Ethnic background influenced the choice of help-seeking strategies, but was less important in perceptions of their helpfulness. CONCLUSION: Primary care service use was strongly correlated with lay and community help-seeking. Alternative help-seeking was commonly employed in all ethnic groups. A large number of people believed mental distress could not be resolved or they did not know how to resolve it. The implications for health promotion and integrated care pathways are discussed.

[Home care's contribution to alternative health care networks: deinstitutionalization and transformation of practices]. / A contribuição da atenção domiciliar para a configuração de redes substitutivas de saúde: desinstitucionalização e transformação de práticas.

OBJECTIVE: To identify state-of-the-art home care within Brazil's public health system, evaluate its potential for improving the comprehensiveness and humanization of care, and identify areas for expanding this care modality. METHODS: Seven home care initiatives were examined and cases were analyzed through interviews with five municipal services managers, seven service coordinators, all home-care team members, and with the service recipients, as well as the family members of the 27 cases selected. All of the interviews were recorded and transcribed. We also analyzed documents created by the home care services (policy manuals, management reports, evaluation reports, and care protocols), observed each team providing care (at least once for each of the seven service types), and analyzed the selected cases. RESULTS: The following types of home care were identified: palliative, AIDS, skin lesions/wounds, premature infant, bedridden patient, and supplemental intravenous antibiotic therapy for acute infection. The following positive aspects should be highlighted: the quality and humanization of care, team work, the bond developed with patients and family, the sense of responsibility taken on by the health workers, and the effective participation of caretakers and families in carrying out therapy plans. CONCLUSION: The initiatives examined show that home care is possible even in economically disadvantaged environments and that it may effectively contribute to providing integrated and continued care. Home care should be expanded in the context of the public health system.

CLSCs in Quebec: thirty years of community action.

Local community service centres (CLSCs) emerged in Quebec in the early 1970s, in the context of the reform of Quebec's healthcare system and the North American movement for popular clinics or Neighbourhood Health Centers. The first CLSCs-primary healthcare institutions before the World Health Organization (WHO) popularized the concept-were mandated to offer a range of basic health and social services, while developing community action. The latter, defined as the art and method of getting the population to take part in identifying and solving health and social problems through information, education and group discussions, gradually asserted itself, thanks to the activism of a new category of professionals: community practitioners. Covering the entire province, throughout their existence, the 160 CLSCs were veritable laboratories for community organizations and a remarkable creative force behind the development of a policy of home support services and mental health in the community. Although their structure changed many times, particularly in the current context of reform to implement 95 local integrated service networks in the province, it continues to be a source of inspiration and of major actors.

[Social functions of the longevous elderly population in Dujiangyan].

OBJECTIVE: To describe the social functions of the longevous elderly population in Dujiangyan. METHODS: A questionnaire survey was undertaken in Dujiangyan in 875 elderly people who were over 90 years old. RESULTS: Poor social economic status was prevalent in the longevous elderly population. The elderly people had limited social contacts except from their families. The daily lives of 65. 0% of the longevous elderly were taken care of by their families. More than 81. 8% of the longevous elderly people were financially supported by their families. About 89. 2% of the longevous elderly people had accessed to spiritual supports in difficult circumstances, among 88. 7% came from families. CONCLUSION: Thanks to the family supports, the longevous people in Dujiangyan have maintained good social functions.

[Organisational diagnosis of a home care-coordinating unit in oncology: which choices for the comprehensive cancer center of Lyon?]. / Diagnostic organisationnel d'un service hospitalier de coordination des soins à domicile en cancérologie. Quels choix stratégiques pour le Centre régional de lutte contre le cancer de Lyon?

Lyon comprehensive cancer center developed a home care-coordinating unit (HCCU) allowing a wide range of cancer care at home. We present the results of an organisational and strategical analysis of the unit, in relation with internal and external contexts. We describe the functioning of the unit, modelled from the daily follow-up of professionnels. Patient discharge is initiated by the oncologist at the inpatient clinic, at the day-hospital or at outpatient visit. After consent of the patient and relatives, the HCCU (nurses and medical oncologists) evaluates patient's needs, organises hospital discharge (contacts with community nurses and general practitioner, supply of medical appliances and drugs), and provides follow-up and counselling to patient and caregivers. The HCCU works in a challenging environment, with both partners and competitors. Within the hospital, it collaborates with all other units. Outside the hospital, partners are, besides patients themselves; general practitioners and community nurses home care agencies and network services, private medical appliance providers, and public health authorities. The unit might evolve towards formal home hospitalisation or community-hospital network. Collaboration of both structure closely associated with hospital could allow to provide continuous and graduated care by the same caregivers even if administrative structures change.

Profiling resource use: do different outcomes affect assessments of provider efficiency?

OBJECTIVES: To examine whether 2 outcome measures result in different assessments of efficiency across 22 service networks within the Department of Veterans Affairs (VA). STUDY DESIGN: A retrospective analysis using VA inpatient and outpatient administrative databases. METHODS: A 60% random sample of veterans who used healthcare services during fiscal year 1997 was split into a 40% sample (n = 1,046,803) for development and a 20% sample (n = 524,461) for validation. Weighted concurrent case-mix models using adjusted clinical groups were developed to explain variation in 2 outcomes: "days of care"--the sum of a patient's inpatient and outpatient annual visit days, and "average accounting costs"--the sum of the average service costs multiplied by the units of service for each patient. Two profiling indicators were calculated for each outcome: an unadjusted efficiency index and an adjusted efficiency index. These indices were compared to examine network efficiency. RESULTS: Although about half the networks were identified as "efficient" before and after case-mix adjustment, assessments of individual network efficiency were affected by the adjustment. The 2 outcomes differed on which networks were efficient. For example, 4 networks that appeared as efficient based on days of care appeared as inefficient based on average costs. CONCLUSIONS: Assessments of provider efficiency across the 22 networks depended on the outcome measure used. Knowledge about the extent to which assessments of provider efficiency depend on the outcome measure used is an important step toward improved and more equitable comparisons across providers.

Risk-sharing integration efforts in the hospital sector.

The extent of hospital involvement in integrated delivery systems (IDSs) during 1996 was assessed by a national sample of 235 short-term private general hospitals. Two out of five hospitals were participating in networks with some financial risk sharing, and another third reported membership in IDS networks without financial obligations. Managed care's presence was the only significant factor moving hospitals from a stand-alone status to network membership. The decision to share financial risk was influenced not only by managed care pressures, but also by the level of local hospital competition and the severity of the inpatient case mix.

Service system performance and integration: a baseline profile of the ACCESS demonstration sites. Access to Community Care and Effective Services and Supports.

OBJECTIVE: Networks of agencies at the 18 demonstration sites in the Access to Community Care and Effective Services and Supports (ACCESS) program for homeless persons with serious mental illness were surveyed to profile baseline levels of systems performance and integration as part of a longitudinal evaluation of systems change and client outcomes. METHODS: Interviews were conducted with a representative from each of 875 agencies in the 18 service networks. Information was obtained about the perceived performance of the service system and the extent of systems integration as measured by client referrals, funds exchanges, and information sharing between agencies. Measures consisted of two multi-item scales assessing the accessibility and coordination of services for the target population in each community and four indexes of interagency relationships. RESULTS: Services at baseline for homeless mentally ill persons at the program sites were rated as relatively inaccessible, and the coordination of services between agencies was rated as even more problematic. Interagency ties were largely based on client referrals and information exchanges, with very few instances of funding transfers in the form of contracts or grants. On average, at baseline agencies that had received an ACCESS grant were better connected to their local service network than were other agencies. CONCLUSIONS: Consistent with the premise of the ACCESS demonstration, services for persons who are homeless and mentally ill in urban America are fragmented and not very accessible. The longitudinal design of the evaluation will allow for an assessment of efforts to improve services and systems integration and of the effects of these improvements on client outcomes.