Improving Disaster Resilience Among Older Adults: Insights from Public Health Departments and Aging-in-Place Efforts.

This study uses interview data collected from public health departments and aging-in-place efforts-specifically, from coordinators of age-friendly communities and village executive directors-to explore how current aging-in-place efforts can be harnessed to strengthen the disaster resilience of older adults and which existing programs or new collaborations among public health departments and these organizations show promise for improving disaster resilience for older populations. Interviews with stakeholders revealed that most age-friendly communities and senior villages did not place a high priority on promoting disaster preparedness. While most public health departments conducted or took the lead on disaster preparedness and resilience activities, they were not necessarily tailored to older adults. Aligning and extending public health departments' current preparedness activities to include aging-in-place efforts and greater tailoring of existing preparedness activities to the needs of older adults could significantly improve their disaster preparedness and resilience. For jurisdictions that do not have an existing aging-in-place effort, public health departments can help initiate those efforts and work to incorporate preparedness activities at the outset of newly developing aging-in-place efforts.

Current and Projected Characteristics and Unique Health Care Needs of the Patient Population Served by the Department of Veterans Affairs.

The Veterans Access, Choice, and Accountability Act of 2014 addressed the need for access to timely, high-quality health care for veterans. Section 201 of the legislation called for an independent assessment of various aspects of veterans' health care. The RAND Corporation was tasked with an assessment of the current and projected demographics and health care needs of patients served by the Department of Veterans Affairs (VA). The number of U.S. veterans will continue to decline over the next decade, and the demographic mix and geographic locations of these veterans will change. While the number of veterans using VA health care has increased over time, demand will level off in the coming years. Veterans have more favorable economic circumstances than non-veterans, but they are also older and more likely to be diagnosed with many health conditions. Not all veterans are eligible for or use VA health care. Whether and to what extent an eligible veteran uses VA health care depends on a number of factors, including access to other sources of health care. Veterans who rely on VA health care are older and less healthy than veterans who do not, and the prevalence of costly conditions in this population is projected to increase. Potential changes to VA policy and the context for VA health care, including effects of the Affordable Care Act, could affect demand. Analysis of a range of data sources provided insight into how the veteran population is likely to change in the next decade.

Balancing Demand and Supply for Veterans' Health Care: A Summary of Three RAND Assessments Conducted Under the Veterans Choice Act.

In response to concerns that the Department of Veterans Affairs (VA) has faced about veterans' access to care and the quality of care delivered, Congress enacted the Veterans Access, Choice, and Accountability Act of 2014 ("Veterans Choice Act") in August 2014. The law was passed to help address access issues by expanding the criteria through which veterans can seek care from civilian providers. In addition, the law called for a series of independent assessments of the VA health care system across a broad array of topics related to the delivery of health care services to veterans in VA-owned and -operated facilities, as well as those under contract to VA. RAND conducted three of these assessments: Veteran demographics and health care needs (A), VA health care capabilities (B), and VA authorities and mechanisms for purchasing care (C). This article summarizes the findings of our assessments and includes recommendations from the reports for improving the match between veterans' needs and VA's capabilities, including VA's ability to purchase necessary care from the private sector.

Access to Behavioral Health Care for Geographically Remote Service Members and Dependents in the U.S.

With many service members now returning to the United States from the recent conflicts in Iraq and Afghanistan, concern over adequate access to behavioral health care (treatment for mental, behavioral, or addictive disorders) has risen. Yet data remain very sparse regarding how many service members (and their dependents) reside in locations remote from behavioral health providers, as well as the resulting effect on their access to and utilization of care. Little is also known about the effectiveness of existing policies and other efforts to improve access to services among this population. To help fill these gaps, a team of RAND researchers conducted a geospatial analysis using TRICARE and other data, finding that roughly 300,000 military service members and 1 million dependents are geographically distant from behavioral health care, and an analysis of claims data indicated that remoteness is associated with lower use of specialty behavioral health care. A review of existing policies and programs discovered guidelines for access to care, but no systematic monitoring of adherence to those guidelines, limiting their value. RAND researchers recommend implementing a geospatial data portal and monitoring system to track access to care in the military population and mark progress toward improvements in access to care. In addition, the RAND team highlighted two promising pathways for improving access to care among remote military populations: telehealth and collaborative care that integrates primary care with specialty behavioral care.

Effects of the Affordable Care Act on Consumer Health Care Spending and Risk of Catastrophic Health Costs.

This study examines the likely effects of the Affordable Care Act (ACA) on average annual consumer health care spending and the risk of catastrophic medical costs for the United States overall and in two large states that have decided not to expand their Medicaid programs (Texas and Florida). The ACA will have varied impacts on individuals' and families' spending on health care, depending on income level and on estimated 2016 insurance status without the ACA. The authors find that average out-of-pocket spending is expected to decrease for all groups considered in the analysis, although decreases in out-of-pocket spending will be largest for those who would otherwise be uninsured. People who would otherwise be uninsured who transition to the individual market under the ACA will have higher total health care spending on average after implementation of the ACA because they will now incur the cost of health insurance premiums. The authors also find that risk of catastrophic health care spending will decrease for individuals of all income levels for the insurance transitions considered; decreases will be greatest for those at the lowest income levels. Case studies found that in Texas and Florida, Medicaid expansion would substantially reduce out-of-pocket and total health care spending for those with incomes below 100 percent of the federal poverty level, compared with a scenario in which the ACA is implemented without Medicaid expansion. Expansion would reduce the risk of high medical spending for those covered under Medicaid who would remain uninsured without expansion.

A Systematic Process to Facilitate Evidence-Informed Decisionmaking Regarding Program Expansion.

While the Department of Defense supports more than 200 psychological health and traumatic brain injury programs, it lacks an approach and process to systematically develop, track, and assess the performance of this portfolio of programs. Further, there is not yet a uniform approach to decisionmaking around program support and expansion of particularly promising, evidence-based programs. This lack of centralized oversight may result in the proliferation of untested programs that are developed without an evidence base; an inefficient use of resources; and added cost and administrative inefficiencies. RAND researchers developed a potential model and tools to support a centralized, systematic, and ongoing process to help in making decisions around continued program support, and by which expansion can be facilitated. This study includes two tools. The first is a Program Abstraction Form, which collects relevant background information from programs and asks explicitly about program effectiveness and the design of the program evaluation used to assess program effectiveness, as a poor evaluation design may lead to incorrect conclusions about the effectiveness of the program. The second is the RAND Program Expansion Tool, which provides a standardized summary of the quality and outcome of a program evaluation. The focus of these tools is on decisionmaking around program expansion, and does not preclude or address initial funding decisions of particularly promising new programs that may not yet have a solid evidence base.

A Program Manager's Guide for Program Improvement in Ongoing Psychological Health and Traumatic Brain Injury Programs.

Between 2001 and 2011, the U.S. Department of Defense has implemented numerous programs to support service members and their families in coping with the stressors from a decade of the longstanding conflicts in Iraq and Afghanistan. These programs, which address both psychological health and traumatic brain injury (TBI), number in the hundreds and vary in their size, scope, and target population. To ensure that resources are wisely invested and maximize the benefits of such programs, RAND developed a tool to help assess program performance, consider options for improvement, implement solutions, then assess whether the changes worked, with the intention of helping those responsible for managing or implementing programs to conduct assessments of how well the program is performing and to implement solutions for improving performance. Specifically, the tool is intended to provide practical guidance in program improvement and continuous quality improvement for all programs.

Behavioral Health in the District of Columbia: Assessing Need and Evaluating the Public System of Care.

This article shares findings from a study of the public behavioral health care system in the District of Columbia, including the prevalence of mental health disorders and substance use, the organization and financing of public behavioral health services, utilization of public behavioral health services, and priorities for improvement. The authors' analyses found that prevalence of mental health conditions resembles patterns nationally, among both adults and youth. Substance use disorders are more prevalent among adults and comparatively lower for the youth population, compared to national patterns. Potentially 60 percent of adults and 72 percent of adolescents enrolled in Medicaid managed care may have unmet need for depression services. Based on claims data, 45 percent of children and 41 percent of adults enrolled in Mental Health Rehabilitation Services programs have gaps in care that exceed six months during a 12-month period. Participants in focus groups and stakeholder interviews highlighted such challenges as gaps in care and difficulties in coordination of care for particular populations and services. High-level priorities include reducing unmet need for public mental health care, tracking and coordinating care, improving the availability and accessibility of substance use treatment services, and upgrading the data infrastructure.

Enhancing Public Health Emergency Preparedness for Special Needs Populations: A Toolkit for State and Local Planning and Response.

Experiences from recent emergencies, such as Hurricanes Katrina and Rita, have shown that current emergency preparedness plans are inadequate to address the unique issues of special needs populations. This article shares details about a toolkit meant to assist state and local public health agencies improve their emergency preparedness activities. It distills the most relevant strategies, practices, and resources from a variety of sources, including peer-reviewed research, government reports, the trade literature, and public health leaders, to identify priority populations and critical strategies. The contents include potential strategies for addressing special needs, summaries of promising practices implemented in communities across the country, information on how to select one or more practices that will work in a specific community, information on how to determine whether a practice is working, and a Web-based Geographic Information Systems (GIS) tool to identify and enumerate those with special needs in communities across the United States. Used together, the toolkit and the GIS tool are intended to provide a comprehensive resource to enable public health planners to account for special needs populations in their emergency preparedness efforts.

Common factors in effective HIV prevention programs.

We propose a set of common factors in evidence-based interventions (EBI) for HIV prevention, which cut across theoretical models of behavior change. Three existing literatures support this agenda: (1) Common factors in psychotherapy; (2) core elements from the Centers for Disease Control and Prevention EBIs; and (3) component analyses of EBI. To stimulate discussion among prevention researchers, we propose a set of common factors at the highest level of abstraction that describe what all effective programs do: (1) establish a framework to understand behavior change; (2) convey issue-specific and population-specific information necessary for healthy actions; (3) build cognitive, affective, and behavioral self-management skills; (4) address environmental barriers to implementing health behaviors; and (5) provide tools to develop ongoing social and community support for healthy actions. A focus on common factors will enhance research on new HIV prevention interventions, encourage collaboration among researchers, provide guidelines for adapting EBI, and simplify and speed the adoption of EBI for providers.