"Anything that Benefits the Workers Should Benefit the Client": Opportunities and Constraints in Self-Directed Care During the COVID-19 Pandemic.

Self-directed care (SDC) models allow Home and Community Based Services (HCBS) consumers to direct their own care, thus supporting flexible, person-centered care. There are many benefits to the SDC model but access to resources is essential to successful outcomes. Considering the autonomy and flexibility associated with SDC, it is important to understand how SDC responded to the COVID-19 pandemic and the resources available to help manage this situation. We conducted 54 in-depth interviews with HCBS consumers, direct support workers, family caregivers, and providers to examine the impact of COVID-19 on HCBS services in Kansas. Findings illuminate how self-directed consumers carried a lot of employer responsibility, with limited resources and systemic barriers constraining self-determination and contributing to unmet care needs, stress, and burden. Policy flexibilities expanding the hiring of family members were beneficial but insufficient to address under-resourced working conditions and labor shortages that were exacerbated by the pandemic.

Comparing the Canadian and US systems of health care in an era of health care reform.

The purpose of this article is to provide an informed comparison of health care in the United States and Canada along multiple dimensions. Specifically this article looks at coverage, access, cost, health outcomes, satisfaction, and underlying ideology. Canada fares better than the United States with regard to coverage, cost, and health outcomes. While overall access is better in Canada, patients are sometimes required to endure longer wait times than in the United States. Reports of satisfaction levels vary across studies, but most evidence points toward comparable levels of satisfaction in Canada and the United States. Strong ideological differences underlie the Canadian and American systems, making the acceptance and implementation of certain reforms difficult. The potential impact of the US Patient Protection and Affordable Care Act (PPACA), as well as recent Canadian health care reforms on coverage, access, cost, and health outcomes are also discussed.

Grandparents Providing Care to Grandchildren: A Population-Based Study of Continuity and Change.

This study examines transitions in grandchild care and the characteristics of grandparents making these transitions, using longitudinal data from a nationally representative sample of 13,626 grandparents in the 1998-2008 Health and Retirement Study. More than 60% of grandparents provided grandchild care over the 10-year period; more than 70% of those did it for 2 years or more. Grandparents with fewer functional limitations and more economic resources were more likely to start or continue nonresidential care, whereas relatively disadvantaged grandparents were more likely to start and continue coresidential care. Grandparents who were African American, younger, married, living with fewer minor children of their own, or had more grandchildren were more likely to start care, particularly nonresidential care. African Americans and Hispanics were more likely than Whites to start and continue coresidential care. These findings demonstrate the heterogeneity of caregiving and point to the lack of resources among those who provide coresidential care.

Medicaid managed care: issues for enrollees with serious mental illness.

OBJECTIVES: To inform state Medicaid programs and managed care organizations, as well as to build their capacity to serve enrollees with complex needs related to serious mental illness (SMI). STUDY DESIGN: Quantitative and qualitative analyses of survey results from a sample of Medicaid enrollees with SMI in Kansas in 2016 and 2017 (N = 189). METHODS: Surveys were conducted by telephone or in person at community mental health centers. Analyses of descriptive statistics from closed-item responses and coded transcripts were used to identify major themes in open-item responses. RESULTS: Respondents reported high rates of comorbid physical and mental health conditions and current or past tobacco use. Most were unemployed, and some were homeless or living in unstable conditions. Participants indicated a need for better information and communication; improved access to prescriptions, dental care, reliable transportation, medical supplies, and equipment; and a wider physician/provider network. They wanted care coordinators to provide more frequent and responsive contact, better information about benefits and resources, and help navigating the system. CONCLUSIONS: Individuals with chronic and complex conditions can be challenging for managed care organizations to support, especially Medicaid enrollees with SMI, who experience high rates of comorbid physical health conditions and complex healthcare needs. To the extent that managed care organizations can help this population navigate their coverage and use more of the available benefits, barriers to care and unmet needs can be reduced or eliminated and outcomes subsequently improved.

Oral Health Needs and Experiences of Medicaid Enrollees With Serious Mental Illness.

INTRODUCTION: Chronic dental diseases are among the most prevalent chronic conditions in the U.S., despite being largely preventable. Individuals with mental illness experience multiple risk factors for poor oral health and need targeted intervention. This study investigated experiences of Kansas Medicaid enrollees with serious mental illness in accessing dental services, examined their oral health risk factors, and identified oral health needs and outcomes. METHODS: Survey data were collected from October 2016 through February 2017 from 186 individuals in Kansas with serious mental illness enrolled in Medicaid. Data were analyzed quantitatively (descriptive and bivariate statistics) and qualitatively (for major themes). RESULTS: Despite Medicaid coverage of dental cleanings, 60.2% of respondents had not seen a dentist in the last 12 months. Reasons included out-of-pocket costs, lack of perceived need, uncertainty about coverage, difficulty accessing providers, fear of the dentist, and transportation issues. High rates of comorbid physical health conditions, including diabetes and cardiovascular disease, and current or former tobacco use were also observed. CONCLUSIONS: Medicaid dental benefits that cover only dental cleanings and low levels of oral health knowledge create barriers to utilizing needed preventive dental care. Lack of perceived need for preventive dental services and lack of contact with dentists necessitates the development of targeted oral health promotion efforts that speak to the specific needs of this group and are disseminated in locations of frequent contact. The Medicaid population with serious mental illness would be an ideal group to target for the integration of chronic oral, physical, and mental health prevention services and control.

All in the family: the impact of caring for grandchildren on grandparents' health.

OBJECTIVES: The purpose of this study was to examine the effects of caring for grandchildren on health behaviors and mental and physical health among older adults. METHODS: Using a sample of 12,872 grandparents aged 50 through 80 from the Health and Retirement Study, we examined the relationship between stability and change in various types of grandchild care and subsequent health, controlling for covariates and earlier health. RESULTS: We found no evidence to suggest that caring for grandchildren has dramatic and widespread negative effects on grandparents' health and health behavior. We found limited evidence that grandmothers caring for grandchildren in skipped-generation households are more likely to experience negative changes in health behavior, depression, and self-rated health. We also found some evidence of benefits to grandmothers who babysit. DISCUSSION: Our findings suggest that the health disadvantages found previously among grandparent caregivers arise from grandparents' prior characteristics, not as a consequence of providing care. Health declines as a consequence of grandchild care appear to be the exception rather than the rule. These findings are important given continuing reliance on grandparents for day care and increasing reliance on grandparents for custodial care. However, the findings should be tempered by the recognition that for a minority of grandparents, coresidential grandchild care may compromise health.

"Paying the price to get there": Motherhood and the dynamics of pregnancy deliberations among women with disabilities.

BACKGROUND: Women with disabilities report fewer pregnancies than those without disabilities. OBJECTIVE: To explore the range of factors involved in pregnancy decision-making among women with disabilities, and give insight into the decision making process. METHODS: Data were obtained from 4 focus groups conducted with 22 women of child-bearing age, who had a chronic physical or mental health condition or disability that influenced their pregnancy decisions. Group transcripts were analyzed using conventional content analysis to identify the types of factors that influence pregnancy decisions and themes related to pregnancy decision-making. RESULTS: Most had a strong desire for motherhood, although there were varied decisions and some ambivalence over whether or not to attempt pregnancy. Decisions were influenced by an interplay of biomedical, social and personal factors that shaped assessments of three key areas of consideration: importance, feasibility, and costs of pregnancy/motherhood. CONCLUSIONS: It is not just the 'biomedical facts' of health conditions that are relevant, but rather the meaning attributed to these facts and how they are weighed in relation to other significant non-medical factors. By moving beyond the medical model of disability to recognize the importance of social and personal factors, and engaging in patient-centered communication, healthcare providers can facilitate pregnancy decision-making that is consistent with the values and preferences of women with disabilities and improve quality of care and support. In order to make motherhood a more viable option for women with disabilities, societal attitudes and a lack of role models for these women also need to be addressed.

Lessons from a Broad-based ACA Outreach Effort: Promises and Pitfalls.

The Marketplace Coverage Initiative (MCI) sought to expand awareness and ACA Marketplace enrollment in the greater Kansas City Area. The MCI was evaluated through interviews, surveys, and focus groups. Two main findings are particularly relevant for future Marketplace enrollment efforts. First, the link between contacting someone and actual enrollment is tenuous as follow-up is challenging. Outreach efforts that only track contacts, such as appointments and email addresses, lack information needed to assess enrollment. Linking outreach activities to enrollment outcomes leads us to a dramatically different conclusion about using big data and campaign-style tactics than evaluations of similar techniques such as that pioneered by Enroll America in 11 states. Second, there is a large chasm between the knowledge levels of the uninsured and the decisions they face on the Marketplace. Based on these findings, outreach efforts were redesigned for the 2014 open enrollment period to focus on smaller, community-driven projects.

The enduring effects of marital status on subsequent depressive symptoms among women: investigating the roles of psychological, social and financial resources.

OBJECTIVES: To investigate the mechanisms through which marital status exerts long-term effects on depressive symptoms among women and to evaluate the relative importance of psychological, social and financial resources in mediating this relationship. METHODS: Data came from 6107 female respondents to a nationally representative longitudinal data set from the USA (National Survey of Families and Households 1987-1988/1992-1994). Mediation was investigated using semi-longitudinal structural equation modelling and bias-corrected bootstrapped CIs. Latent constructs with multiple indicators were used to measure depressive symptoms, primary and secondary social integration and self-esteem. RESULTS: The total effect of marital status on subsequent depressive symptoms was statistically significant for all marital statuses relative to those in first marriages controlling for age, education, race, number of children younger than 5 in the household, T1 depressive symptoms and marital status transitions between waves; all groups experienced higher levels of depressive symptoms than those in first marriages. These effects were completely mediated for never-married women and partially mediated for separated/divorced, widowed and cohabiting women. Adjusted household income was the largest mediator for the separated/divorced, widowed and never-married, but primary social integration also played a role. Self-esteem was the only significant mediator for the remarried and cohabiting and was also important in explaining differences between the first-married and separated/divorced. CONCLUSION: This study demonstrates that the reasons why marital status has an influence on subsequent depressive symptoms varies depending on the specific marital status being compared with the married.