Evaluating Interorganizational Collaborations: Lessons Learned from Five California Geriatric Workforce Enhancement Programs.

BACKGROUND: Five Geriatric Workforce Enhancement Programs (GWEPs) in California, funded for 4 years, worked collaboratively across different organizations to provide education on aging issues and/or training to enhance services for older adults. OBJECTIVES: To investigate characteristics of the collaborations that were associated with perceptions and experiences of success for participating organizations. METHODS: A survey distributed to 37 organizations participating in 5 GWEPs measured the correlation of resources and dimensions of collaboration with perceived sense of success of the collaborations. Interviews with 30 representatives of the participating organizations collected information about perceived barriers, impact, and satisfaction with the collaborations. RESULTS: Overall perceptions of interorganizational collaboration success were associated with provision of physical resources and four key measures of collaboration (governance, administration, mutuality, and norms/trust). Barriers to success were described in terms of organization functioning and resources. Strong communication appeared as a facilitator of success, and reciprocity was described as a key experience of satisfaction. CONCLUSIONS: This study highlights the positive effects of shared goals, the experience of reciprocity, and communication during interorganizational collaborations. It also notes the negative effects of having inadequate resources and organizational dysfunction.

Inclusion of the homeless in health equity curricula: a needs assessment study.

Exposure to homeless patients is a potential strategy to teach about social determinants of health and health inequities. Little is known about student attitudes and preferences for learning about the homeless in curricula addressing vulnerable populations. A needs assessment to determine student readiness may inform strategies for teaching. A mixed-methods study of one matriculating physician assistant student class, with a cross-sectional survey and 3 focus groups (FG). The validated 19-item Health Professionals' Attitudes Toward Homelessness inventory (HPATHI) and new 7-item Learning Attitudes scale were administered to explore perceptions and preferences about relevance of caring for the homeless to future practice. FGs were conducted to theme saturation. Verbatim transcripts were independently read and coded by 3 researchers using constant comparison. Survey response rate was 100% (N = 60). Overall HPATHI mean score was 3.97 ± 0.04 of 5, indicating positive attitudes toward the homeless. The highest mean score (4.26 ± 0.04) was for the social advocacy subscale; the lowest (3.02 ± 0.06) for personal advocacy. The Learning Attitude scale (Cronbach's alpha 0.89) mean score was 4.47 ± 0.07 out of 5, showing a positive attitude toward curricular exposure. Older students and those with prior experience with the homeless had higher HPATHI scores (p < 0.05). Four major themes emerged: vulnerable patients cannot advocate for themselves; learning about homelessness is relevant to future practice; preference for multiple teaching strategies and adequate preparation for street rotations; and anticipated anxiety about safety. Students recognize the value of learning from homeless patients as part of gaining skills in caring for vulnerable populations. Experiential learning opportunities focusing on this group are seen as an acceptable and valuable way to gain skills applicable to all vulnerable patients. Students express fear and anxiety around non-traditional settings such as the street. Their anxieties should be adequately addressed when designing clinical rotations.

Occupational Therapy Student Learning on Interprofessional Teams in Geriatric Primary Care.

IMPORTANCE: Geriatric, interprofessional primary care training for occupational therapy students is needed. OBJECTIVE: To measure occupational therapy student-reported knowledge, attitudes, and skills after participation in interprofessional geriatric educational programs. DESIGN: Prospective, observational study with pre- and posttests for the three programs. PARTICIPANTS: Fifty-nine entry-level and postprofessional occupational therapy master's students. OUTCOMES AND MEASURES: Self-reported familiarity with other professionals' roles, perceptions of interprofessional training, capabilities to conduct assessments, and attitudes of older adults. RESULTS: Students of the three programs (Interprofessional Geriatrics Curriculum [IPGC], Student Senior Partnership Program [SSPP], and Geriatric Assessment Program [GAP]) reported different improvements in familiarity of roles, capabilities of assessment, and Geriatric Attitudes Scale (GAS) scores. For example, IPGC and SSPP students had changes in total GAS score (3.91-4.08, p = .002, and 3.84-3.99, p = .003, respectively), but no change was found for GAP students (3.85-3.91, p = .523). CONCLUSIONS AND RELEVANCE: More structured interprofessional education with older adults appeared to help prepare occupational therapy students to work on geriatric interprofessional teams in primary care. WHAT THIS ARTICLE ADDS: This article expands on growing evidence to support occupational therapy's role in primary care by addressing the need to train future generations to work on interprofessional geriatric primary care teams.

National Trends in Indicators of a Medical Home for Children.

OBJECTIVES: The patient centered medical home is now widely supported as a strategy for delivering high quality primary care. The objective of this study was to examine whether children's primary care experiences nationally have become more aligned with the medical home model over time, and how this may have varied for vulnerable children. METHODS: This study analyzed data on 289,672 children, aged 0-17 years, of families responding to one of three iterations of National Survey of Children's Health from 2003, 2007 and 2011-2012. Each year, we assessed indicators of four medical home features (access, continuity, comprehensiveness, and family-centeredness) and a total medical home score for children nationally and for those with a set of social and demographic risk factors. RESULTS: Indicators of access and continuity, and total medical home scores fluctuated but improved overall from 2003 to 2012 (7.1, 6.7 and 1.4 % point increases, respectively), while indicators of comprehensiveness and family-centered care measures declined (2.4 and 1.8 % point decreases, respectively). Children with the highest levels of social and demographic risk experienced larger fluctuations in these measures over time. CONCLUSIONS FOR PRACTICE: There were improvements in the extent to which children's primary care experiences aligned with a medical home model, though not linearly or for all component features. Children with more risk factors experienced more volatile changes, suggesting a particular need to attend to the primary care experiences of the most vulnerable children.

Primary care medical home experience and health-related quality of life among adult medicaid patients with type 2 diabetes.

PURPOSE: To examine whether patient-reported indicators of medical home performance are associated with health-related quality of life (HRQOL) among adults with type 2 diabetes. METHODS: Cross-sectional survey of 540 patients with Medicaid insurance and type 2 diabetes in Los Angeles County. The Primary Care Assessment Tool was used to measure seven features of medical home performance. The EuroQol EQ-5D-3L (EQ-5D) was used to measure HRQOL. RESULTS: Higher total medical home performance was correlated with better overall HRQOL. A one-point change in total medical home score was associated with a 0.06-point higher score on the EQ-5D index [95 % confidence interval (CI): 0.01-0.11], which is a clinically meaningful difference. The total score was also significantly associated with a lower likelihood of problems on one domain of the EQ-5D (pain). Longitudinality was the only medical home feature associated with better general health status (ordered odds ratio = 1.78; 95 % CI: 1.04-3.03). The positive relationship of medical home with the EQ-5D appears to be present predominantly among women. CONCLUSION: Overall medical home experience is favorably associated with HRQOL among vulnerable adult patients with type 2 diabetes. Provider efforts to improve the overall medical home experience for patients may contribute to improvements in HRQOL.

Do experiences consistent with a medical-home model improve diabetes care measures reported by adult Medicaid patients?

OBJECTIVE: The patient-centered medical home has gained much traction. Little is known about the relationship between the model and specific health care processes for chronic diseases such as diabetes. This study assesses the impact of features of a medical home on diabetes care. RESEARCH DESIGN AND METHODS: A cross-sectional survey of 540 patients with Medicaid (Medi-Cal) health insurance and type 2 diabetes in Los Angeles County was performed. The Primary Care Assessment Tools was used to measure seven features of medical-home performance. RESULTS: The response rate of the patient survey was 68.9%. Patient-reported medical-home performance averaged a score of 2.85 ± 0.29 (on a 1-4 scale, with 4 equaling the best care). Patients who received more timely and thorough diabetes care reported higher medical-home performance in every feature except for the comprehensiveness-services available. For example, the first-contact access feature score was higher among patients who had an HbA1c test in the past 6 months versus those who did not (2.38 vs. 2.25; P < 0.05). Before and after adjusting for sociodemographics and health status, total medical-home performance was positively associated with each diabetes care measure. A 1-point increase in total medical-home score was associated with 4.53 higher odds of an HbA1c test in the past 6 months and 1.88 higher odds of an eye exam in the past year. CONCLUSIONS: Features consistent with higher medical-home performance are associated with improvements in patient-reported diabetes care process measures, even in this low socioeconomic status setting. The patient-centered medical-home model may help in caring for people with type 2 diabetes.

Duration of a well-child visit: association with content, family-centeredness, and satisfaction.

BACKGROUND: Studies of pediatric primary care suggest that time is an important limitation to the delivery of recommended preventive services. Given the increasingly frenetic pace of pediatric practice, there is an increased need to monitor the length of pediatric visits and the association of visit length with content, family-centered care, and parent satisfaction with care. OBJECTIVE: To examine the length of well-child visits and the associations of visit length with content, family-centered care, and parent satisfaction among a national sample of children. METHODS: We conducted a cross-sectional telephone survey of parents of children aged 4 to 35 months from the 2000 National Survey of Early Childhood Health (n = 2068). RESULTS: One-third (33.6%) of parents reported spending ≤ 10 minutes with the clinician at their last well-child visit, nearly half (47.1%) spent 11 to 20 minutes, and 20.3% spent >20 minutes. Longer visits were associated with more anticipatory guidance, more psychosocial risk assessment, and higher family-centered care ratings. A visit of >20 minutes was associated with 2.4 (confidence interval [CI]: 1.5-3.7) higher odds of receiving a developmental assessment, 3.2 (CI: 1.7-6.1) higher odds of recommending the clinician, and 9.7 (CI: 3.5-26.5) higher odds of having enough time to ask questions. CONCLUSIONS: Many well-child visits are of short duration, and shorter visits are associated with reductions in content and quality of care and parent satisfaction with care. Efforts to improve preventive services will require strategies that address the time devoted to well-child care. The results of this study should be interpreted in light of changes in practice standards, reimbursement, and outcome measurement that have taken place since 2000 and the limitations of the measurement of utilization solely on the basis of parent report.

Association of experiences of medical home quality with health-related quality of life and school engagement among Latino children in low-income families.

OBJECTIVE: This study examines whether patient-reported indicators of a quality medical home are associated with measures of health among Latino children in low-income families. DATA SOURCES: Data on 3,258 children ages 2-18 years are from a cross-sectional survey of parents of children affiliated with California's Healthy Kids insurance. STUDY DESIGN: Medical home quality was assessed using the Parents' Perception of Primary Care and was associated with health-related quality of life (HRQOL) overall and in four domains (physical, emotional, social, and school/daycare) and four measures of school engagement. PRINCIPAL FINDINGS: A higher total medical home score was associated with a higher total Pediatric Quality of Life Inventory score and scores in four subdomains (total beta [B]=1.77, physical B=1.71, social B=1.36, emotional B=2.22, and school/daycare B=1.69, all p<0.001). It was also associated with missing fewer than three school days due to illness (odds ratio [OR]=1.12, 95 percent confidence intervals [CI]: 1.05, 1.19), excellent/above average school performance overall (OR=1.10, 95 percent CI: 1.03, 1.17) and performance in reading (OR=1.13, 95 percent CI: 1.06, 1.20) and math (OR=1.10, 95 percent CI: 1.03, 1.16). CONCLUSIONS: Patient-reported medical home quality indicators are favorably associated with HRQOL and measures of school engagement among Latino children in low-income families.

Healthy Kids insurance and experiences of medical home quality for vulnerable children.

OBJECTIVES: To examine the relationship of enrollment in Healthy Kids insurance (locally funded insurance products for low-income children ineligible for other public insurance) with parent-reported experiences of primary care medical home quality. METHODS: A cross-sectional survey of parents of 4011 children stratified by established enrollees in Healthy Kids (enrolled 1 y or longer), new enrollees (less than 1 y), and children on a waitlist. We examined differences across groups in having an ongoing source of primary care, and experiences of 6 features of a medical home-accessibility, continuity, comprehensiveness, contextual knowledge, communication, and coordination-and a summary medical home measure. RESULTS: Compared with waitlisted children, new and established enrollees were more likely to have a regular source of care [odds ratio (OR)=2.49; 95% confidence interval (CI): 1.74-3.57 and OR=6.51; CI: 4.64-9.13, respectively] and a personal doctor or nurse (OR=3.41; CI: 2.42-4.80 and OR=7.00; CI: 5.07-9.66). Among those with a regular source of care and visit in the past year, new and established enrollees reported better medical home experiences in 4 and 6 of the 7 measures, respectively. CONCLUSIONS: Despite many barriers to care for vulnerable children, Healthy Kids enrollment was positively associated with having an ongoing source of primary care and better medical home experiences. As these children are mostly left out of healthcare reform, Healthy Kids programs may be a good model for other counties and states to help to connect such children to primary care.

Measuring the impact of outreach and enrollment strategies for public health insurance in California.

UNLABELLED: OBJECTIVE AND STUDY SETTING: To evaluate the effectiveness of different approaches to outreach on public health insurance enrollment in 25 California counties with a Children's Health Initiative. DATA SOURCE: Administrative enrollment databases. STUDY DESIGN: The use of eight enrollment strategies were identified in each quarter from 2001 to 2007 for each of 25 counties (county quarter). Strategies were categorized as either technology or nontechnology. New enrollments were obtained for Medi-Cal, Healthy Families, and Healthy Kids. Bivariate and multivariate analyses assessed the link between each strategy and new enrollments rates of children. DATA COLLECTION: Methods Surveys of key informants determined whether a specific outreach strategy was used in each quarter. These were linked to new enrollments in each county quarter. PRINCIPAL FINDINGS: Between 2001 and 2007, enrollment grew in all three children's health programs. We controlled for the effects of counties, seasons, and county-specific child poverty rates. There was an increase in enrollment rates of 11 percent in periods when technology-based systems were in use compared with when these approaches were inactive. Non-technology-based approaches, including school-linked approaches, yielded a 12 percent increase in new enrollments rates. Deploying seven to eight strategies yielded 54 percent more new enrollments per 10,000 children compared with periods with none of the specific strategies. CONCLUSIONS AND IMPLICATIONS: National health care reform provides new opportunities to expand coverage to millions of Americans. An investment in technology-based enrollment systems will maximize new enrollments, particularly into Medicaid; nontechnological approaches may help identify harder-to-reach populations. Moreover, incorporating several strategies, whether phased in or implemented simultaneously, will enhance enrollments.

Relationship of medical home quality with school engagement and after-school participation among children with asthma.

OBJECTIVES: To examine the relationship between medical home quality and measures of daily life experiences among children with asthma. METHODS: A nationally representative sample of children from the 2007 National Survey of Children's Health (NSCH), aged 6-17 years (n = 6357), who have asthma was used to assess the relationship of a quality medical home and its features with their daily life experiences. Five medical home features - access, continuity, comprehensiveness, family-centered care, and coordination of care - were examined individually and in total in relation to measures of school engagement (missed school days, parents contacted about problems with the child, repeating a grade since kindergarten) and after-school activity participation (physical activity, sports participation, and community service or volunteer work). RESULTS: Before and after adjustment for personal characteristics, health insurance status, family environment, neighborhood variables, and asthma severity, total medical home score was associated with more days exercised [beta (B) = 0.10, p < .05] and a greater likelihood of having performed community service or volunteer work [odds ratio (OR) = 1.16, CI: 1.02-1.31]. Additionally, the medical home features of access, comprehensiveness, and family-centered care remained favorably associated with three of the six measures of school engagement and after-school activity participation, even after adjustment. CONCLUSION: Medical home quality - particularly the features of access, comprehensiveness, and family-centered care - is positively associated with the daily life experiences of children with asthma. Working to enhance these aspects of primary care might be one place to start in improving the management of children's chronic conditions and their quality of life.

Does health care setting matter in reports of discrimination?

We investigated the associations between the health care setting types that California adults report as their regular source of care, socioeconomic status, and perceived racial/ethnic medical care-related discrimination. Data were analyzed from the 2005 California Health Interview Survey (n = 36,694). Adults who identified clinics/health centers/hospital clinics or "other settings" as their usual source of health care had increased odds for perceived racial/ethnic discrimination compared with those who utilized private and health maintenance organizations doctors' offices, although this was true only for middle, but not lower or higher, socio-economic respondents. We suggest several explanations for these findings and improvements for assessing health care-based racial discrimination.

Health insurance and access to care for families with young children in California, 2001-2005: differences by immigration status.

OBJECTIVES: To examine differences and trends in health insurance coverage and access to care for California families by immigration status. METHODS: Cross-sectional data on 37,236 families with young children <18 years of age from the 2001, 2003 and 2005 California Health Interview Survey are used to assess trends in health insurance and access to care for children and their parents by four immigration dyads: (1) both are Citizens; (2) child is a legal resident/citizen, and parent is legal resident (Documented); (3) child is a citizen, and parent is undocumented (Mixed); and (4) both are Undocumented. RESULTS: Before and after adjustment for covariates, only children in Undocumented dyads were less likely than Citizen dyads to have insurance (OR = 0.20, CI: 0.16-0.26) and all three measures of access: physician visits (OR = 0.69, CI: 0.52-0.91), dental visits (OR = 0.47, CI: 0.35-0.63), and a regular source of care (OR = 0.51, CI: 0.37-0.69). Parents in all non-Citizen dyads had poorer access than Citizen dyads across all measures, with the exception of dental visits and a regular source for parents in Documented dyads. Children of all dyads except Citizens were more likely to be insured in 2005 vs. 2001. The largest gain was for undocumented dyad children with 2.77 times higher odds (CI: 1.62-4.75) of being insured in 2005 vs. 2001. All children dyads except Mixed were also more likely to have a physician visit. For parents, there was only a decrease in insurance coverage for Citizen dyads (OR = 0.79, CI: 0.67-0.93) and few changes in access. Conclusions While there were relatively few disparities and some improvements in insurance coverage and access for children in California (except for undocumented children), concomitant changes for parents were not observed. Without attention to the family in health care reforms, disparities may not fully resolve for children and may continue or even increase for parents.

National disparities in the quality of a medical home for children.

OBJECTIVES: To examine socio-demographic disparities associated with a quality medical home. METHODS: A nationally representative sample of children ages 0-17 years (n = 102,353) from the 2003 National Survey of Children's Health. Risk factors including non-white race/ethnicity, income <200% of the federal poverty level (FPL), uninsured, parent education lesser than high school, and non-English primary household language, were examined in relation to a quality medical home separately and together as a "profile" of risk. Fourteen questions were used to measure five medical home features: access, continuity, comprehensiveness, family-centered care, and coordination. Quality was defined as a value greater than median for each feature and for an overall score. RESULTS: Before and after adjustment for child demographics and health status, all studied risk factors were associated with poorer quality medical home features. Uninsured [odds ratio (OR) = 0.43, 95% confidence interval (CI): 0.40-0.47] and low-income children (OR = 0.65, CI: 0.62-0.69) had among the lowest odds of a quality medical home overall and across most features, except coordination that showed an opposite trend. Summarized through risk profiles, children experiencing all five risk factors had 93% lower odds of a quality medical home overall (OR = 0.07, CI: 0.04-0.25) compared to zero risk children. CONCLUSION: This study demonstrates large national disparities in the quality of a medical home for children. That disparities were most prevalent for the uninsured and those in or near poverty, both modifiable risk factors, suggests that reforms to increase coverage and to lift families out of poverty are essential to assuring that children have access to the full complement of appropriate health care services including a quality medical home.

Improvements in access to care for vulnerable children in California between 2001 and 2005.

OBJECTIVE: We examined population changes in access to care for children in California during a period of major efforts to improve access to care for children. METHODS: We used cross-sectional data on 36,010 children aged 0-19 years from the 2001 and 2005 California Health Interview Survey to assess population changes in access to care. We assessed changes in access by individual risk factors and a composite risk profile. RESULTS: In 2005, a smaller proportion of children were uninsured (8.2% vs. 10.9% in 2001), living in poverty (20.7% vs. 23.2% in 2001), and in families without a high school education (20.8% vs. 23.6% in 2001), all p<0.001. Before and after adjusting for these changes in risk, children were more likely in 2005 to have had a physician visit (odds ratio [OR] = 1.09, 95% confidence interval [CI] 1.07, 1.12) and dental visit (OR=1.11, 95% CI 1.08, 1.14). Children were slightly less likely in 2005 to have a regular source of care (OR=0.94, CI 0.91, 0.96). Children who had the highest risk profiles (> or = 4 risk factors) experienced the largest gains in access. For example, children with three and > or = 4 risk factors had gains in dental visits of 11 and 20 percentage points, respectively (p<0.001 for each), compared with < or = 3 percentage points for children with fewer risk factors. CONCLUSIONS: This study found improvements in physician and dental visits between 2001 and 2005 that were not fully explained by changes in insurance coverage or other demographic risk factors. Vulnerable children fared well during this period, suggesting that California may be making important and potentially replicable strides in reducing disparities.

Disparities in the national prevalence of a quality medical home for children with asthma.

OBJECTIVE: The aim of this study was to examine sociodemographic disparities in having a quality medical home among a nationally representative sample of children with asthma. METHODS: The study examined data from the 2003 National Survey of Children's Health to identify 8360 children aged 2-17 years with asthma. Risk factors including nonwhite race/ethnicity, income <200% of the federal poverty level (FPL), uninsured, parent education less than high school, and non-English language, were examined individually and as a profile of risk in relation to a quality medical home. Fourteen questions were used to measure 5 medical home features: access, continuity, comprehensiveness, family-centered care, and coordination. A poorer quality medical home was defined as < or =66 on a 100-point scale-corresponding to the feature being present less than "usually"-for each feature and for an overall score. RESULTS: Before and after adjustment for demographics and asthma difficulties, most risks except less than high school parent education were related to a poorer quality medical home. Uninsured children had the highest odds of a poorer quality medical home overall (adjusted odds ratio [OR] 5.19, 95% confidence interval [CI] 3.52-7.65) and across most features, except for coordination. Children experiencing 3+ risks had 8.56 times the odds of a poorer quality medical home overall (95% CI 4.95-14.78) versus zero risks. CONCLUSIONS: This study demonstrates large national disparities in a quality medical home for children with asthma. That disparities were most prevalent for the uninsured (insurance being a modifiable risk factor) suggests increasing coverage is essential to assuring that children obtain a quality medical home.

Enhancing the measurement of health disparities for vulnerable populations.

This article presents a mechanism for tracking and reporting health disparities data that are based on a general model of vulnerability. We briefly discuss the origins of this model and describe its focus on the cumulative impact of multiple risk factors on health-related outcomes. We then demonstrate how the model can be applied to inform the collection and reporting of health disparities data by providing three examples. Since national and state datasets contain information on a wide range of risk factors, researchers and policy makers would benefit from examining the multiple risks that affect vulnerable populations simultaneously, as we have demonstrated in the three examples. These examples suggest that the determinants of health and healthcare problems are multifactorial and that they can be studied in an integrative approach using risk profiles. This research methodology can strengthen our existing knowledge of health disparities and aid in the recognition of points of intervention to successfully improve health and healthcare for vulnerable populations.

Collaboration and competition in a children's health initiative coalition: a network analysis.

Activating communities to achieve public health change and initiate policy reform usually requires collective action from many entities. This case study analyzes inter-organizational networks among members of a coalition created to expand health insurance coverage to uninsured children in a large metropolitan area. Six networks were measured: collaboration, competition, formal agreements, receive funding from, send funding to, and greater communication. The response rate was 65.8% (50 of the 76 active members). Positive network questions such as "who do you collaborate with" elicited many network choices whereas negative ones such as "who do you compete with" elicited few. The collaboration network had a core-periphery structure and analysis showed that a large network can be reduced to a small set of core organizations one-sixth the size of the whole. Centrality (out- and in-degree) was associated with perceived organizational function and perceived barriers to success. For example, organizations that received many choices as collaboration partners were more likely to perceive the coalition functioned well than those who received few choices. The study suggests that perceptions of organizational performance are associated with position in the network, central members are more likely to perceive the organization performs well than those on the periphery.