Unauthorized Immigrants Prolong the Life of Medicare's Trust Fund.

BACKGROUND AND OBJECTIVE: Unauthorized immigrants seldom have access to public health insurance programs such as Medicare Part A, which pays hospitals and other health facilities and is funded through the Medicare Trust Fund. DESIGN AND MAIN MEASURES: We tabulated annual and total Trust Fund contributions and withdrawals by unauthorized immigrants (i.e., outlays on their behalf) from 2000 to 2011 using the Current Population Survey and Medical Expenditure Panel Surveys. We estimated when the Trust Fund would be depleted if unauthorized immigrants had neither contributed to it nor withdrawn from it. We estimated Trust Fund surpluses by unauthorized immigrants if 10 % were to become authorized annually over the subsequent 7 years. KEY RESULTS: From 2000 to 2011, unauthorized immigrants contributed $2.2 to $3.8 billion more than they withdrew annually (a total surplus of $35.1 billion). Had unauthorized immigrants neither contributed to nor withdrawn from the Trust Fund during those 11 years, it would become insolvent in 2029-1 year earlier than currently predicted. If 10 % of unauthorized immigrants became authorized annually for the subsequent 7 years, Trust Fund surpluses contributed by unauthorized immigrants would total $45.7 billion. CONCLUSIONS: Unauthorized immigrants have prolonged the life of the Medicare Trust Fund. Policies that curtail the influx of unauthorized immigrants may accelerate the Trust Fund's depletion.

Structural and organizational characteristics associated with performance of essential public health services in small jurisdictions: findings from a statewide study in Massachusetts.

BACKGROUND: This study examined jurisdictional, organizational, and structural characteristics associated with capacity to deliver 10 essential public health services (EPHS) in Massachusetts, a state where a majority of local public health departments serve small municipalities. DESIGN: A survey was administered to local health directors or board of health chairs. MEASURES: The main outcome of the study was capacity to perform EPHS, measured by a 25-item screening tool. RESULTS: Seventy percent of the 351 boards of health in Massachusetts participated in the study. Greatest capacity was demonstrated in EPHS 2 (Diagnose and Investigate Health Problems) and EPHS 6 (Enforce Laws and Regulations). The capacity to perform the 8 other essential services was limited. Bivariate analysis indicates that overall capacity to perform EPHS is significantly associated with population size, poverty rate, annual municipal budget, and perceived understanding of the roles and responsibilities of local boards of health among elected municipal officials. The latter was the strongest predictor of overall capacity in multivariate analysis. CONCLUSIONS: Findings are aligned with studies examining factors associated with capacity to perform EPHS in large public health jurisdictions. The results suggest that one strategy for improving capacity to perform EPHS in smaller jurisdictions is to educate elected municipal leaders about the responsibilities of local health officials. Clarification regarding the role small jurisdictions with limited resources can play to ensure the equitable delivery of essential public health services and a strategy for measuring their contributions is important, especially as the national public health accreditation program gains momentum in the United States.

Mental and behavioral health screening at preventive visits: opportunities for follow-up of patients who are nonadherent with the next preventive visit.

OBJECTIVES: To determine the type of subsequent care received by children nonadherent with their next preventive visit and whether behavioral factors predict use of emergency or acute care in this population. STUDY DESIGN: Data on 1703 children (4-16 years) screened at a preventive visit with the Pediatric Symptom Checklist (PSC)/Youth-PSC were examined to determine subsequent preventive care adherence (10-18 months later). Then, nonadherent children were monitored to determine whether they returned to their medical home for acute care, delayed preventive care, or visited the emergency department (ED). Multivariate analyses were conducted to determine whether demographic and behavioral factors predicted return to either acute care or ED care site. RESULTS: Of the 461 children who were nonadherent with a second preventive care visit, most (85%) subsequently returned for acute, emergency, or delayed preventive care in the same medical system. Predictors of acute care or ED use included behavioral health risk characteristics (positive PSC, counseling, referral, parental concern), as well as adolescent age, self-pay and public insurance status, and living in lower socioeconomic communities. CONCLUSIONS: Pediatricians should consider acute care or ED visits as opportunities for mental health screening follow-up, and intervention in populations at high risk who miss preventive care.

Asian student depression in American high schools: differences in risk factors.

There are inconsistent findings about depression in Asians. This study examined risk factors for depression in Asian and Caucasian adolescents. Stratified bivariate secondary analyses of risk indicators and depressed mood were performed in this cross-sectional study of high school survey data (9th to 12th grades) from 2,542 students (198 Asian). Asians had a higher prevalence of depressed symptoms, but similar risk factors as Caucasians. Smoking and injury at work were major risk factors for depressed mood among Asians. Asian-specific risk factors for depression were being foreign-born and having a work-related injury. Asian and Caucasian teens have similar risk factors for depressed mood, though being foreign born and having a work-related injury are risk factors specific to Asian youth, possibly related to social-economic status. Providers of care in school, such as school nurses, can be important primary screeners of depression for Asian students in particular.

Validity of estimated dietary eicosapentaenoic acid and docosahexaenoic acid intakes determined by interviewer-administered food frequency questionnaire among older adults with mild-to-moderate cognitive impairment or dementia.

Epidemiologic research is increasingly being focused on elderly persons, many of whom exhibit mild-to-moderate cognitive impairment. This presents a challenge for collection and interpretation of self-reported dietary data. There are few reports on the impact of cognitive function and dementia on the validity of self-reported dietary intakes. Using plasma phospholipid fatty acid profiles as a biomarker of intake, the authors assessed the validity of an interviewer-administered food frequency questionnaire (FFQ) to estimate intakes of 2 marine-based omega-3 fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), among 273 community-dwelling adults aged > or =60 years participating in the Nutrition, Aging, and Memory in Elders Study (Boston, Massachusetts, 2002-2008). Age- and energy-adjusted Pearson correlation coefficients for correlations between dietary intakes and plasma phospholipids were consistent across categories of high and low cognitive function (r = 0.48), based on Mini-Mental State Examination score, and were similar across clinically diagnosed categories of normal functioning (r = 0.49), mild cognitive impairment (r = 0.45), and dementia (r = 0.52). The FFQ ranked 78% of subjects to within 1 quartile of their plasma phospholipid EPA + DHA quartile. This frequency was consistently high across all cognitive categories. With interviewer administration, this FFQ seems to be a valid method of assessing dietary EPA + DHA intake in older adults with mild-to-moderate cognitive impairment.

Relationship Between Cardiorespiratory Fitness, Weight Status, and Academic Performance: Longitudinal Evidence From 1 School District.

OBJECTIVES: We examined the longitudinal relationship between cardiovascular fitness (CRF) and academic performance (AP) among students in a diverse public school district. Furthermore, we determined whether the relationship between CRF and AP varied by student sociodemographic characteristics. METHODS: This study used data from 2005-2006 to 2008-2009. AP was assessed by Massachusetts Comprehensive Assessment System (MCAS) math (N = 1224) and English Language Arts (ELA) (N = 1248) z-scores. CRF was assessed by an age- and sex-adjusted 20-yard shuttle run (pass/fail). Multilevel growth models were used to estimate the relationship between MCAS z-scores and changes in grade, CRF, and weight status, controlling for student sociodemographic characteristics. RESULTS: Students who passed the fitness test performed better on MCAS tests (ELA: .159, p < .001; Math: 0.346, p < .001) at each study wave relative to those who did not pass. The relationship between AP and fitness was attenuated for low socioeconomic status(ELA: -.111, p < .05) and minority (Math: black -0.249, p < .01; Latino -0.216, p < .01) students. CONCLUSIONS: These results add to the literature highlighting the role of CRF as an important predictor of performance on standardized tests. More research is needed to understand the disparities experienced by low-income and minority students.

The homocysteine hypothesis of depression.

High levels of homocysteine are associated with cerebrovascular disease, monoamine neurotransmitters, and depression of mood. A plausible hypothesis for these associations is that high homocysteine levels cause cerebral vascular disease and neurotransmitter deficiency, which cause depression of mood. The homocysteine depression hypothesis, if true, would mandate inclusions of imaging studies for cerebrovascular disease and measures of homocysteine, folate, and B12 and B6 vitamins in the clinical evaluation of older depressed patients. Longitudinal studies and clinical trials should be designed to challenge the hypothesis.

Effectiveness of IMPACT:Ability to Improve Safety and Self-Advocacy Skills in Students With Disabilities-Follow-Up Study.

BACKGROUND: Research shows that individuals with disabilities are more likely to experience abuse than their peers without disabilities. Yet, few evidenced-based abuse prevention interventions exist. This study examines whether positive outcomes identified previously in an evaluation of IMPACT:Ability were maintained 1 year later. METHODS: A survey measuring safety and self-advocacy knowledge, confidence, and behaviors among special education high-school students was administered 12 months post-training. Paired samples t-tests were used to compare baseline to follow up and postsurvey to follow up and repeated measures analyses were conducted to test the effect of time across the 3 time points (baseline, post, and 1-year follow up) (N = 47). RESULTS: Follow-up study participants had a range of disabilities, just over half were boys, and most were either black or Latino/Hispanic. Difference between scores at baseline and follow-up for all the measures of interest represented gains from baseline. Statistically significant post-training improvements in participants' safety and self-advocacy knowledge and confidence were maintained 1-year later. CONCLUSIONS: These results provide additional support for the case that IMPACT:Ability is a promising safety and self-advocacy training program for diverse groups of students with disabilities.

Developing High-Functioning Teams: Factors Associated With Operating as a "Real Team" and Implications for Patient-Centered Medical Home Development.

Team-based care is a foundation of health care redesign models like the patient-centered medical home (PCMH). Yet few practices rigorously examine how the implementation of PCMH relates to teamwork. We identified factors associated with the perception of a practice operating as a real team. An online workforce survey was conducted with all staff of 12 primary care sites of Cambridge Health Alliance at different stages of PCMH transformation. Bivariate and multivariate analyses of factors associated with teamwork perceptions were conducted. In multivariate models, having effective leadership was the main factor associated with practice teamwork perceptions (odds ratio [OR], 10.49; 95% confidence interval [CI], 5.39-20.43); in addition, practicing at a site in an intermediate stage of PCMH transformation was also associated with enhanced team perceptions (OR, 2.44; 95% CI, 1.28-4.64). In a model excluding effective leadership, respondents at sites in an intermediate stage of PCMH transformation (OR, 1.95; 95% CI, 1.1-3.4) and who had higher care team behaviors (such as huddles and weekly meetings; OR, 3.41; 95% CI, 1.30-8.92), higher care team perceptions (OR, 2.65; 95% CI, 1.15-6.11), and higher job satisfaction (OR, 2.00; 95% CI, 1.02-3.92) had higher practice teamwork perceptions. This study highlights the strong association between effective leadership, care team behaviors and perceptions, and job satisfaction with perceptions that practices operate as real teams. Although we cannot infer causality with these cross-sectional data, this study raises the possibility that providing attention to these factors may be important in augmenting practice teamwork perceptions.

Does behavioral health integration improve primary care providers' perceptions of health-care system functioning and their own knowledge?

OBJECTIVE: To examine the impact of behavioral health integration (BHI) on primary care providers' (PCPs') (1) perceptions of behavioral health (BH)-primary care (PC) system functioning and (2) perceptions of their own knowledge regarding how to manage, triage, and access help in caring for patients with mental health conditions and substance use disorders. METHODS: We implemented BHI based on evidence-based models consisting of seven elements: (1)Screening for mental health and substance use disorders, (2)Training of PC teams, (3)Integration of BH providers into PC teams, (4)Roll-out of unlicensed mental health care managers and establishment of a BH registry, (5)Psychiatry consult service, (6)Site-based BHI meetings, and (7)Site self assessments. The intervention was rolled out in early integration sites during two years and late integration sites during the subsequent two years. In this observational pre-post study, we administered an anonymous online survey annually to PCPs; 381 PCPs at 11 primary care clinics participated. RESULTS: The proportion of PCPs with high perceived BH-PC systems functioning scores quadrupled from 14% to 55% (p<0.0001) and high perceived knowledge scores increased from 63 to 85% (p<0.001). Larger increases were demonstrated in early integration sites during the first two years and in late integration sites during the latter two years of the survey. Adjusting for participant and site level characteristics did not change these outcomes. CONCLUSIONS: BHI improves PCP perceptions of BH-PC system functioning and perceptions of knowledge.

The Impact of the Massachusetts Behavioral Health Child Screening Policy on Service Utilization.

OBJECTIVE: In 2008, Massachusetts Medicaid implemented a pediatric behavioral health (BH) screening mandate. This study conducted a population-level, longitudinal policy analysis to determine the impact of the policy on ambulatory, emergency, and inpatient BH care in comparison with use of these services in California, where no similar policy exists. METHODS: With Medicaid Analytic Extract (MAX) data, an interrupted time-series analysis with control series design was performed to assess changes in service utilization in the 18 months (January 2008-June 2009) after a BH screening policy was implemented in Massachusetts and to compare service utilization with California's. Outcomes included population rates of BH screening, BH-related outpatient visits, BH-related emergency department visits, BH-related hospitalizations, and psychotropic drug use. Medicaid-eligible children from January 1, 2006, to December 31, 2009, with at least ten months of Medicaid eligibility who were older than 4.5 years and younger than 18 years were included. RESULTS: Compared with rates in California, Massachusetts rates of BH screening and BH-related outpatient visits rose significantly after Massachusetts implemented its screening policy. BH screening rose about 13 per 1,000 youths per month during the first nine months, and BH-related outpatient visits rose to about 4.5 per 1,000 youths per month (p<.001). Although BH-related emergency department visits, hospitalization and psychotropic drug use increased, there was no difference between the states in rate of increase. CONCLUSIONS: The goal of BH screening is to identify previously unidentified children with BH issues and provide earlier treatment options. The short-term outcomes of the Massachusetts policy suggest that screening at preventive care visits led to more BH-related outpatient visits among vulnerable children.

Effect of Pediatric Behavioral Health Screening and Colocated Services on Ambulatory and Inpatient Utilization.

OBJECTIVE: The study sought to determine the impact of a pediatric behavioral health screening and colocation model on utilization of behavioral health care. METHODS: In 2003, Cambridge Health Alliance, a Massachusetts public health system, introduced behavioral health screening and colocation of social workers sequentially within its pediatric practices. An interrupted time-series study was conducted to determine the impact on behavioral health care utilization in the 30 months after model implementation compared with the 18 months prior. Specifically, the change in trends of ambulatory, emergency, and inpatient behavioral health utilization was examined. Utilization data for 11,223 children ages ≥4 years 9 months to <18 years 3 months seen from 2003 to 2008 contributed to the study. RESULTS: In the 30 months after implementation of pediatric behavioral health screening and colocation, there was a 20.4% cumulative increase in specialty behavioral health visit rates (trend of .013% per month, p=.049) and a 67.7% cumulative increase in behavioral health primary care visit rates (trend of .019% per month, p<.001) compared with the expected rates predicted by the 18-month preintervention trend. In addition, behavioral health emergency department visit rates increased 245% compared with the expected rate (trend .01% per month, p=.002). CONCLUSIONS: After the implementation of a behavioral health screening and colocation model, more children received behavioral health treatment. Contrary to expectations, behavioral health emergency department visits also increased. Further study is needed to determine whether this is an effect of how care was organized for children newly engaged in behavioral health care or a reflection of secular trends in behavioral health utilization or both.

A planned care approach and patient registry to improve adherence to clinical guidelines for the diagnosis and management of attention-deficit/hyperactivity disorder.

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) affects almost 2.4 million US children. Because American Academy of Pediatrics guidelines for ADHD recommend use of standardized diagnostic instruments, regular follow-up and the chronic care model, this pilot project sought to implement and assess an electronic registry of patients with ADHD combined with care coordination by a planned care team. METHODS: This quality improvement project was structured with 2 intervention and 2 control clinics to facilitate evaluation of the use of a planned care system for management of ADHD. Care teams included a pediatrician, nurse, medical assistant, and care coordinator and tracked patients using an electronic registry with data drawn from the EMR. Clinical work flows were pilot tested to facilitate use of the Vanderbilt scales and their incorporation into the EMR at intervention sites. Outcome measures included 2 recommended clinical follow-ups based on HEDIS measures as well as use of the Vanderbilt rating scales. Initiation phase measure was for follow-up after initiating medication, while the continuation phase measure was for subsequent follow-up during the first year of treatment. Measures were monitored during the project year and then also in the ensuing period of spread of the intervention to other sites. RESULTS: Although the modified HEDIS initiation phase measure for patients newly on medication remained static at approximately 50% throughout the project period, the continuation phase measure showed improvement from 35% at baseline to 45% at the end of the project assessment year, a 29% increase. Follow-up for patients stable on medications also remained unchanged during the project period, but during subsequent spreading of the intervention to nonproject sites, follow-up of these patients improved to over 90%. In adjusted analyses, patients with ADHD at intervention sites were over 2 times more likely than patients at control sites to have had a Vanderbilt score documented in their records. CONCLUSIONS: The project achieved modest improvements in the diagnostic and treatment process for patients with ADHD. The use of a planned care system and electronic patient registry shows promise for improving the diagnosis and treatment process for patients with ADHD.

Effectiveness of the IMPACT:Ability program to improve safety and self-advocacy skills in high school students with disabilities.

BACKGROUND: Individuals with disabilities experience higher rates of abuse than the nondisabled. Few evidence-based prevention interventions have been published despite a need for such work. This study evaluated IMPACT: Ability, a safety and self-advocacy training for individuals with cognitive and/or physical disabilities. METHODS: A quasi-experimental design was used to assess change in safety and self-advocacy knowledge, confidence, and behaviors among special education high school students in Boston, MA. Instruments were interviewer-administered at 3 time points. Analysis of covariance (ANCOVA) was used to compare change between the intervention (N = 21) and wait-list (N = 36) groups. Repeated measures analysis was used to test change in the complete sample (N = 57). RESULTS: Students were diverse (58% males, 82% nonwhite) with a range of disabilities. Significantly greater improvement in key outcomes, including safety and self-advocacy knowledge, confidence, and behavior, were observed in intervention students compared to the wait-list group. Results in the complete sample showed evidence of further improvements in students' sense of safety and general self-efficacy. CONCLUSIONS: These findings are encouraging given the effects were demonstrated in a heterogeneous urban population. IMPACT: Ability may be an effective safety and self-advocacy training for students with disabilities. Further research will be required to determine effectiveness within particular subpopulations of students.

Parents' obesity-related behavior and confidence to support behavioral change in their obese child: data from the STAR study.

OBJECTIVE: Successful childhood obesity interventions frequently focus on behavioral modification and involve parents or family members. Parental confidence in supporting behavior change may be an element of successful family-based prevention efforts. We aimed to determine whether parents' own obesity-related behaviors were related to their confidence in supporting their child's achievement of obesity-related behavioral goals. METHODS: Cross-sectional analyses of data collected at baseline of a randomized control trial testing a treatment intervention for obese children (n = 787) in primary care settings (n = 14). Five obesity-related behaviors (physical activity, screen time, sugar-sweetened beverage, sleep duration, fast food) were self-reported by parents for themselves and their child. Behaviors were dichotomized on the basis of achievement of behavioral goals. Five confidence questions asked how confident the parent was in helping their child achieve each goal. Logistic regression modeling high confidence was conducted with goal achievement and demographics as independent variables. RESULTS: Parents achieving physical activity or sleep duration goals were significantly more likely to be highly confident in supporting their child's achievement of those goals (physical activity, odds ratio 1.76; 95% confidence interval 1.19-2.60; sleep, odds ratio 1.74; 95% confidence interval 1.09-2.79) independent of sociodemographic variables and child's current behavior. Parental achievements of TV watching and fast food goals were also associated with confidence, but significance was attenuated after child's behavior was included in models. CONCLUSIONS: Parents' own obesity-related behaviors are factors that may affect their confidence to support their child's behavior change. Providers seeking to prevent childhood obesity should address parent/family behaviors as part of their obesity prevention strategies.

Behavioral health services following implementation of screening in Massachusetts Medicaid children.

OBJECTIVES: To determine the relationship of child behavioral health (BH) screening results to receipt of BH services in Massachusetts Medicaid (MassHealth) children. METHODS: After a court decision, Massachusetts primary care providers were mandated to conduct BH screening at well-child visits and use a Current Procedural Terminology code along with a modifier indicating whether a BH need was identified. Using MassHealth claims data, a cohort of continuously enrolled (July 2007-June 2010) children was constructed. The salient visit (first use of the modifier, screening code, or claim in fiscal year 2009) was considered a reference point to examine BH history and postscreening BH services. Bivariate and multivariate logistic regression analyses were performed to determine predictors of postscreening BH services. RESULTS: Of 261,160 children in the cohort, 45% (118,464) were screened and 37% had modifiers. Fifty-seven percent of children screening positive received postscreening BH services compared with 22% of children screening negative. However, only 30% of newly identified children received BH services. The strongest predictors of postscreening BH services for children without a BH history were being in foster care (odds ratio, 10.38; 95% confidence interval, 9.22-11.68) and having a positive modifier (odds ratio, 3.79; 95% confidence interval, 3.53-4.06). CONCLUSIONS: Previous BH history, a positive modifier, and foster care predicted postscreening BH services. Only one-third of newly identified children received services. Thus although screening is associated with an increase in BH recognition, it may be insufficient to improve care. Additional strategies may be needed to enhance engagement in BH services.

Referral and follow-up after mental health screening in commercially insured adolescents.

PURPOSE: Although mental health screening is recommended for adolescents, little is known about the predictors of referral to mental health services or engagement in treatment. We examined predictors of mental health referral from primary care and service use for commercially insured youth who had been screened using the Pediatric Symptom Checklist or Youth-Pediatric Symptom Checklist. METHODS: A retrospective chart review was conducted of commercially insured patients 14-17 years of age who were newly identified by the Pediatric Symptom Checklist or Youth-Pediatric Symptom Checklist at a well-child visit. Comparisons were made with propensity-matched negative adolescents meeting the same criteria. Bivariate analyses were conducted to examine differences between positives and negatives and between referred and nonreferred positives. Logistic regression analyses were performed to assess predictors of mental health referral for positive youth. RESULTS: Medical records of 117 positive and 110 negative youth were examined. Compared with negative youth, positive youth were significantly more likely to be referred for mental health treatment (p < .0001) and receive specialty mental health services (p < .0001). Of the positives, 54% were referred for mental health care and 67% of them accepted. However, only 18% completed a face-to-face mental health visit in the next 180 days. Pediatric Symptom Checklist score (odds ratio, 1.21; confidence interval, 1.03-1.42), parental or personal concern (odds ratio, 10.87; confidence interval, 2.70-43.76), and having depressive symptoms (odds ratio, 9.18; confidence interval, 1.49-56.60) were predictive of referral. CONCLUSIONS: Despite identification after behavioral health screening, limited treatment engagement by referred patients persists. Primary care physicians and mental health specialists must enhance their efforts to engage and monitor identified patients.

Screening for behavioral health issues in children enrolled in Massachusetts Medicaid.

OBJECTIVES: To understand mandated behavioral health (BH) screening in Massachusetts Medicaid including characteristics of screened children, predictors of positive screens, and whether screening identifies children without a previous BH history. METHODS: Massachusetts mandated BH screening in particularly among underidentified groups. 2008. Providers used a billing code and modifier to indicate a completed screen and whether a BH need was identified. Using MassHealth claims data, children with ≥ 300 days of eligibility in fiscal year (FY) 2009 were identified and categorized into groups based on first use of the modifier, screening code, or claim. Bivariate analyses were conducted to determine differences among groups. BH history was examined by limiting the sample to those continuously enrolled in FY 2008 and 2009. Multivariate logistic regression was used to determine predictors of positive screens. RESULTS: Of 355,490 eligible children, 46% had evidence of screening. Of those with modifiers, 12% were positive. Among continuously enrolled children (FY 2008 and FY 2009) with evidence of screening, 43% with positive modifiers had no BH history. This "newly identified" group were more likely to be female, younger, minority, and from rural residences (P < .0001). Among children with modifiers; gender (male), age (5-7), being in foster care, recent BH history, and Hispanic ethnicity predicted having a positive modifier. CONCLUSIONS: The high rate of newly identified Medicaid children with a BH need suggests that screening is performing well, particularly among underidentified groups. To better assess screening value, future work on cost-effectiveness and the impact on subsequent mental health treatment is needed.

Provider's perspectives on the impact of Immigration and Customs Enforcement (ICE) activity on immigrant health.

INTRODUCTION: Increasing Immigration and Customs Enforcement (ICE) activities such as raids, detention, and deportation may be affecting the health and well-being of immigrants. This study sought to understand the impact of ICE activities on immigrant health from the perspective of health care providers. METHODS: An online survey of primary care and emergency medicine providers was conducted to determine whether ICE activity was negatively affecting immigrant patients. RESULTS: Of 327 providers surveyed, 163 responded (50%) and 156 (48%) met criteria for inclusion. Seventy-five (48%) of them observed negative effects of ICE enforcement on the health or health access of immigrant patients. Forty-three providers gave examples of the impact on emotional health, ability to comply with health care recommendations, and access. CONCLUSIONS: Health care providers are witnessing the negative effects of ICE activities on their immigrant patients' psychological and physical health. This should be considered an important determinant of immigrant health.

Investigating the myth of the "model minority": a participatory community health assessment of Chinese and Vietnamese adults.

Despite the persistent belief that Asians are the "model minority" there is accumulating evidence of health concerns within Asian subgroups. In this study, we implemented a cross-sectional participatory community health assessment in an urban city in Massachusetts, to understand differences and similarities in demographics, health and healthcare access in Chinese and Vietnamese adults. We gathered qualitative data from community stakeholders to inform the development of a community health assessment tool. The tool elicited information on healthcare access, health status, behavioral health and chronic disease history and treatment. Healthcare access issues and poor health status, particularly among Chinese participants and mental health symptomotology in both groups were areas of concern. These findings revealed important health concerns in two Asian ethnic groups. Studies are needed to better understand these concerns and inform programs and policies to improve health outcomes in these Asian ethnic groups.