Pilot Randomized Controlled Trial of an Intervention to Improve Coping with Intersectional Stigma and Medication Adherence Among HIV-Positive Latinx Sexual Minority Men.

We developed and pilot-tested an eight-session community-based cognitive behavior therapy group intervention to improve coping with intersectional stigma, address medical mistrust, and improve antiretroviral treatment adherence. Seventy-six HIV-positive Latinx sexual minority men (SMM; 38 intervention, 38 wait-list control) completed surveys at baseline, and 4- and 7-months post-baseline. Adherence was electronically monitored. Intention-to-treat, repeated-measures regressions showed improved adherence in the intervention vs. control group from baseline to follow-up [electronically monitored: b (95% CI) 9.24 (- 0.55, 19.03), p = 0.06; self-reported: b (95% CI) 4.50 (0.70, 8.30), p = .02]. Intervention participants showed marginally decreased negative religious coping beliefs in response to stigma [b (95% CI) = - 0.18 (- 0.37, 0.01), p = .06], and significantly lower medical mistrust [b (95% CI) = - 0.47 (- 0.84, - 0.09), p = .02]. Our intervention holds promise for improving HIV outcomes by empowering Latinx SMM to leverage innate resilience resources when faced with stigma.ClinicalTrials.gov ID (TRN): NCT03432819, 01/31/2018.

RESUMEN: Hemos desarrollado un estudio piloto para poner a prueba un programa de ocho-sesiones de terapia cognitivo-conductual basado en un grupo de comunidad para abordar el estigma interseccional, la desconfianza médica y mejorar la adherencia al tratamiento antirretroviral. Setenta y seis hombres Latinos de minorías sexuales VIH positivos (38 en el grupo de intervención, 38 en el grupo de control de lista de espera) completaron encuestas al inicio, y cuatro y siete meses después de la línea de base. La adherencia fue medida electrónicamente. Los resultados del análisis mostraron una mejor adherencia en el grupo de intervención en comparación al grupo de control desde el inicio hasta el seguimiento [monitoreado electrónicamente: b (95% IC) 9.24 (− 0.55, 19.03), p = .06; y autoreporte: b (95% IC) 4.50 (0.70, 8.30), p = .02]. Los participantes del grupo de intervención mostraron una disminución marginal en las creencias negativas de afrontamiento religioso al estigma [b (95% IC) − 0.18 (− 0.37, 0.01), p = .06], y significativamente menor desconfianza médica [b (95% IC) − 0.47 (− 0.84, − 0.09), p = .02]. Nuestra intervención es prometedora para mejorar los resultados del VIH al empoderar a hombres Latinos de minorías sexuales para tomar ventaja de los recursos de resiliencia innatos cuando se enfrentan al estigma.

A Pilot Test of Game Changers, a Social Network Intervention to Empower People with HIV to be Prevention Advocates in Uganda.

We conducted a pilot randomized controlled trial of Game Changers, a 6-session group intervention that empowers people with HIV to be HIV prevention advocates in their social networks. Ninety-nine people with HIV (51 intervention, 48 wait-list control) and 58 of their social network members (alters) completed baseline and 5- and 8-month post-baseline assessments. Results indicated high acceptability, demonstrated by participants' and facilitators' positive attitudes qualitatively and favorable ratings of intervention sessions quantitatively, and high feasibility (76% attended all intervention sessions). Intention-to-treat analyses indicated significantly increased HIV prevention advocacy among HIV-positive participants and alters [b (SE) = 0.4 (0.2), p = .017; b (SE) = 0.4 (0.2), p = .035]; reduced internalized HIV stigma [b (SE) = - 0.3 (0.1), p = .012], increased HIV-serostatus disclosure [b (SE) = 0.1 (0.1), p = .051], and increased social network density among HIV-positive participants [b (SE) = 0.1 (0.03), p = .004]; and marginally reduced condomless sex among alters [OR (95% CI) = 0.3 (0.1-1.2), p = .08]. Positioning people with HIV as central to prevention has the potential to reduce stigma and improve prevention outcomes throughout social networks.

The Paradox of Parks in Low-Income Areas: Park Use and Perceived Threats.

Concerns about safety and perceived threats have been considered responsible for lower use of parks in high poverty neighborhoods. To quantify the role of perceived threats on park use we systematically observed 48 parks and surveyed park users and household residents in low-income neighborhoods in the City of Los Angeles. Across all parks, the majority of both park users and local residents perceive parks as safe or very safe. We noted apparently homeless individuals during nearly half of all observations, but very few instances of fighting, intimidating groups, smoking and intoxication. The presence of homeless individuals was associated with higher numbers of park users, while the presence of intoxicated persons was associated with lower numbers. Overall the strongest predictors of increased park use were the presence of organized and supervised activities. Therefore, to increase park use, focusing resources on programming may be more fruitful than targeting perceived threats.

Promotoras as data collectors in a large study of physical activity in parks.

There is a large literature on promotores' involvement in health promotion and a smaller literature on their roles in data collection, most often among predominantly Latino populations. But the extent to which promotores can be successful as the primary data collectors across racially/ethnically and socioeconomically diverse neighborhoods is less well documented. In a study of physical activity in 50 urban neighborhood parks, we found that a team of Spanish/English bilingual promotoras (female promotores) successfully implemented a direct observation protocol in all participant neighborhoods and achieved high interrater reliability (.80-.98). Overall, they were also effective in administering surveys to park users and residents across the racially/ethnically diverse neighborhoods. The promotoras brought to the project important language skills and cultural sensitivity, surveying experience, and familiarity with human subjects and confidentiality issues. Their extensive field experience gained over the course of a long-term collaborative effort helped improve survey and observation protocols. The promotoras reported gaining professional skills, which can strengthen their contributions to other projects. The promotoras were accustomed to being a source of information, and collecting rather than providing information was challenging for some and had to be addressed in order to avoid contamination across study groups.

How much neighborhood parks contribute to local residents' physical activity in the City of Los Angeles: a meta-analysis.

OBJECTIVE: To quantify the contribution of neighborhood parks to population-level, moderate-to-vigorous physical activity (MVPA). METHOD: We studied park use in 83 neighborhood parks in Los Angeles between 2003 and 2014 using systematic observation and surveys of park users and local residents. We observed park use at least 3-4 times per day over 4-7 clement days. We conducted a meta-analysis to estimate total, age group and gender-specific park use and total MVPA time in parks. RESULTS: An average park measuring 10 acres and with 40,000 local residents in a one-mile radius accrued 5301 h of use (SE=1083) during one week, with 35% (1850 h) spent in MVPA and 12% (635 h) spent in vigorous physical activity (VPA). As much as a 10.7-fold difference in weekly MVPA hours was estimated across study parks. Parks' main contribution to population-level MVPA is for males, teenagers, and residents living within a half mile. CONCLUSION: Neighborhood parks contribute substantially to population MVPA. The contribution may depend less on size and facilities than on "demand goods" - programming and activities--that draw users to a park.

Involving community stakeholders to increase park use and physical activity.

OBJECTIVE: The aim of this study is to describe implementation of a randomized controlled trial of community-based participatory research (CBPR) approaches to increase park use and physical activity across 33 diverse neighborhoods in Los Angeles. METHODS: Fifty parks were randomly assigned based on park size, facilities and programs, and neighborhood socio-demographic characteristics to: park director (PD, 17 parks); PD and park advisory board of interested community members (PD+PAB, 16 parks); and no-intervention control (17 parks) arms. Between 2007 and 2012, PDs and PABs from the 33 intervention parks participated in community engagement, baseline assessment, marketing training, intervention design and implementation, and follow-up assessment. RESULTS: Intervention parks (PD and PD+PAB) invested in new and diversified signage, promotional items, outreach or support for group activities like fitness classes and walking clubs, and various marketing strategies. Scaling up CBPR methods across parks in 33 diverse neighborhoods was challenging. Working with departmental management and established structures for community input (PABs) and park policy (PDs) facilitated implementation and sustainability. CONCLUSION: Scaling up CBPR methods across diverse communities involved tradeoffs. CBPR is useful for tailoring research and enhancing community impact and sustainability, but more work is needed to understand how to conduct multi-site trials across diverse settings using CBPR.

Recommendations for Improving Oral Pre-exposure Prophylaxis Implementation and Social Marketing in Ugandan Fisherfolk Communities: A Qualitative Exploration.

Background: HIV is hyperendemic among fisherfolk in Sub-Saharan Africa, especially around Lake Victoria, Uganda. Purpose/Research Design: We conducted cross-sectional semi-structured interviews about oral pre-exposure prophylaxis (PrEP) implementation with 35 Ugandan fisherfolk (15 women, 20 men) and 10 key stakeholders (healthcare providers, policymakers, community leaders). We used a directed content analysis approach based on implementation science and social marketing frameworks. Results: Participants showed high acceptability for PrEP. Anticipated barriers among fisherfolk included stigma (due to similar medications/packaging as HIV treatment); misconceptions; mobility, competing needs, poverty, and partner conflict. Anticipated provider barriers included insufficient staffing and travel support. Recommendations included: change PrEP packaging; integrate PrEP with other services; decrease PrEP refill frequency; give transportation resources to providers; train more healthcare workers to provide PrEP to fisherfolk; and use positively framed messages to promote PrEP. Conclusions: Results can inform policymakers and healthcare organizations on how to overcome barriers to PrEP scale-up in most at-risk populations with poor healthcare access.

Health and Social Services in Puerto Rico Before and After Hurricane Maria: Predisaster Conditions, Hurricane Damage, and Themes for Recovery.

"In September 2017, Puerto Rico was struck by two major hurricanes-Irma and Maria-that intensified existing challenges in Puerto Rico's health and social services infrastructure. In the aftermath, the government of Puerto Rico created a long-term recovery plan built on an evidence-based assessment of the damage from the hurricanes and the ongoing needs across Puerto Rico. Development of the recovery plan was supported by the Federal Emergency Management Agency, other federal agencies, local stakeholders, and analysis from the Homeland Security Operational Analysis Center (HSOAC), operated by RAND Corporation under contract with the U.S. Department of Homeland Security. HSOAC research provided the foundation for the 31 courses of action in the recovery plan addressing the health and social services sector. These actions are a mix of social, governmental, fiscal, and economic policies and reforms. This collection of actions presents an opportunity to build a more resilient health and social services infrastructure and regional health care networks to ensure reliable access to services, promote health and well-being, and more efficiently and effectively respond to public health crises and future disasters. The actions span the areas of health care, public health and emergency preparedness, environmental health, mental and behavioral health, and social services. The damage and needs assessment and courses of actions cover four major themes: building system capacity to respond both during disasters and routine times; strengthening the health and social services workforce; strengthening support services for at-need populations; and creating health-promoting communities.

Parks and physical activity: why are some parks used more than others?

OBJECTIVE: To assess how park characteristics and demographic factors are associated with park use. METHODS: We studied a diverse sample of parks in a Southern California metropolitan area in 2006-2008 representing a variety of racial and ethnic communities of different socioeconomic strata. We surveyed 51 park directors, 4257 park users and local residents, and observed 30 parks. We explored relationships among the number of people observed, the number of park programs offered, number of organized activities observed, park size, existence of park advisory board, perceptions of safety, and population density and characteristics. RESULTS: The strongest correlates of the number of people using the park were the park size and the number of organized activities observed. Neighborhood population density, neighborhood poverty levels, perceptions of park safety, and the presence of a park advisory board were not associated with park use. CONCLUSION: While perceptions of low safety have been considered a barrier to park use, perceptions of high safety do not appear to facilitate park use. Having events at the park, including sports competitions and other attractions, appears to be the strongest correlate of park use and community-level physical activity.

New recreational facilities for the young and the old in Los Angeles: policy and programming implications.

It is assumed that higher quality recreation facilities promote physical activity and serve communities better. We tested this assumption by comparing changes in the use of an expanded and renovated skate park (a facility for skateboarding) and a modernized senior citizen's center to two similar facilities that were not refurbished. The skate park was nearly tripled in size, and the senior center was remodeled and received new exercise equipment, a courtyard garden, and modern architectural features. We assessed use of these facilities through direct observation and surveyed both facility users and residents living within 2 miles of each facility. We found that making improvements to facilities alone will not always guarantee increased use. Although there was a 510% increase in use of the expanded skate park compared to a 77% increase in the comparison skate park, the senior center had substantially fewer users and provided fewer hours of exercise classes and other programmed activities after the facility was renovated. The implication of our study is that use results from a complex equation that includes not only higher quality recreation facilities but also progamming, staffing, fees, hours of operation, marketing, outreach, and perhaps a host of other human factors.

Promoting physical activity in high-poverty neighborhood parks: A cluster randomized controlled trial.

Although physical activity can help mitigate or prevent multiple chronic diseases, most people in the U.S., especially high-poverty minority groups, engage in insufficient levels of physical activity. To test ways to promote more physical activity in high-poverty area public parks we conducted a randomized controlled intervention trial. After completing baseline measures of park-based physical activity using systematic direct observation three times/day each month for six months and assessing preferences for park programming among 1445 residents living within 1 mile of study parks, we randomized 48 parks in high poverty neighborhoods in the City of Los Angeles, California during 2013-2014 to four study arms: 1) free physical activity classes over a 6-month period, 2) a frequent user program where participants could win prizes based upon the number of visits they made to the park, 3) both the programs, and 4) neither one (control condition). We re-measured park use in 2014-2015 using the same methods during the six months the intervention programs were in operation. A total of 2047 free park classes were offered attracting 16,718 participants. The frequent user programs enrolled 1452 individuals and prizes were awarded to 830. Residents in the two study arms with free classes were more likely to report being aware of and participating in park-based physical activity programs; however, overall observed park-based physical activity increased similarly across all study arms. The process evaluation uncovered several barriers to program implementation, including inconsistent scheduling of classes, partly due to safety concerns among instructors. Multiple social factors interfere with leisure time physical activity among low-income populations, suggesting modest interventions may be insufficient to overcome these issues. Although new park programs can attract users, new programs alone may be insufficient to increase overall park use in low-income neighborhoods at times when the programs are not taking place.

City of Los Angeles Neighborhood Parks: Research Findings and Policy Implications (2003-2015).

This study summarizes more than a decade of research on how well neighborhood parks in Los Angeles support physical activity. Between 2003 and 2015, researchers at the RAND Corporation studied 83 parks in the city of Los Angeles, conducting thousands of observations and fielding nearly 28,000 surveys of park users and local residents. About half of all residents said that they used their neighborhood parks, most of them routinely. Parks are also the top venue that people choose for engaging in routine exercise. The majority of residents, including residents of low-income, high-crime neighborhoods, consider their neighborhood parks safe or very safe. We also found that parks get more use when they are larger, when they have more facilities, when they offer more planned activities and events, and when their services and activities are marketed to the public. While there is frequent activity in city parks, there is room for improvement. Parks are underutilized by girls and teenage girls, and they are especially underutilized by seniors. Overall, nearly half of all Los Angeles city residents living within 1 mile of a park did not use that park. Most did not know about the activities that were offered, and the majority of residents and more than a third of park users did not know the park's staff. Recommendations include devoting more resources to outreach and marketing. Los Angeles should also devote a larger proportion of its budget to city parks: Park spending per capita in Los Angeles is currently less than half of the per capita amounts that are spent by New York, Seattle, and San Francisco.

The Prevalence and Use of Walking Loops in Neighborhood Parks: A National Study.

BACKGROUND: Previous studies indicate that the design of streets and sidewalks can influence physical activity among residents. Park features also influence park use and park-based physical activity. Although individuals can walk on streets and sidewalks, walking loops in parks offer a setting to walk in nature and to avoid interruptions from traffic. OBJECTIVES: Here we describe the use of walking loops in parks and compare the number of park users and their physical activity in urban neighborhood parks with and without walking loops. METHODS: We analyzed data from the National Study of Neighborhood Parks in which a representative sample of neighborhood parks (n = 174) from 25 U.S. cities with > 100,000 population were observed systematically to document facilities and park users by age group and sex. We compared the number of people and their physical activity in parks with and without walking loops, controlling for multiple factors, including park size, facilities, and population density. RESULTS: Overall, compared with parks without walking loops, on average during an hourly observation, parks with walking loops had 80% more users (95% CI: 42, 139%), and levels of moderate-to-vigorous physical activity were 90% higher (95% CI: 49, 145%). The additional park use and park-based physical activity occurred not only on the walking loops but throughout the park. CONCLUSIONS: Walking loops may be a promising means of increasing population level physical activity. Further studies are needed to confirm a causal relationship. Citation: Cohen DA, Han B, Evenson KR, Nagel C, McKenzie TL, Marsh T, Williamson S, Harnik P. 2017. The prevalence and use of walking loops in neighborhood parks: a national study. Environ Health Perspect 125:170-174; http://dx.doi.org/10.1289/EHP293.

The First National Study of Neighborhood Parks: Implications for Physical Activity.

INTRODUCTION: An extensive infrastructure of neighborhood parks supports leisure time physical activity in most U.S. cities; yet, most Americans do not meet national guidelines for physical activity. Neighborhood parks have never been assessed nationally to identify their role in physical activity. METHODS: Using a stratified multistage sampling strategy, a representative sample of 174 neighborhood parks in 25 major cities (population >100,000) across the U.S. was selected. Park use, park-based physical activity, and park conditions were observed during a typical week using systematic direct observation during spring/summer of 2014. Park administrators were interviewed to assess policies and practices. Data were analyzed in 2014-2015 using repeated-measure negative binomial regressions to estimate weekly park use and park-based physical activity. RESULTS: Nationwide, the average neighborhood park of 8.8 acres averaged 20 users/hour or an estimated 1,533 person hours of weekly use. Walking loops and gymnasia each generated 221 hours/week of moderate to vigorous physical activity. Seniors represented 4% of park users, but 20% of the general population. Parks were used less in low-income than in high-income neighborhoods, largely explained by fewer supervised activities and marketing/outreach efforts. Programming and marketing were associated with 37% and 63% more hours of moderate to vigorous physical activity/week in parks, respectively. CONCLUSIONS: The findings establish national benchmarks for park use, which can guide future park investments and management practices to improve population health. Offering more programming, using marketing tools like banners and posters, and installing facilities like walking loops, may help currently underutilized parks increase population physical activity.

Effectiveness of a Free Exercise Program in a Neighborhood Park.

BACKGROUND: Faculty, students, and alumni in a university-based kinesiology program developed an innovative model for health promotion practice by partnering with the local park administration in San Fernando, California to offer these exercise classes for free in a low-income, predominantly Latino neighborhood park. The classes were taught by students as practical training for academic credit. PURPOSE: To evaluate the effectiveness of this pilot program in promoting moderate-to-vigorous physical activity. METHODS: We used the System for Observing Play and Recreation in Communities (SOPARC) to assess physical activity in the park during the summer of 2013. We evaluated the effectiveness of the free classes by a within-park comparison and by comparing findings with 50 other parks. RESULTS: The classes substantially increased moderate-to-vigorous physical activities, in particular, for female park users. However, when classes were not offered there were no differences in park-based physical activity across parks. CONCLUSIONS: Active programming can increase park-based moderate-to-vigorous physical activity, but without programming, people may lack the motivation to exercise on their own. Creating a partnership between parks and kinesiology programs is a promising health promotion model. Replicating this type of program could yield important health dividends.

Impact of park renovations on park use and park-based physical activity.

BACKGROUND: Given the concerns about low rates of physical activity among low-income minority youth, many community-based organizations are investing in the creation or renovation of public parks to encourage youth to become more physically active. To what degree park renovations accomplish this goal is not known. METHODS: We used the System for Observing Play and Recreation in Communities (SOPARC) to measure park users and their physical activity levels before and after 2 parks were renovated. We compared findings with 4 parks: 2 that were unrenovated parks and 2 that were undergoing renovation. We also surveyed park users and local residents about their use of the parks. RESULTS: Compared with parks that had not yet been renovated, the improved parks saw more than a doubling in the number of visitors and a substantial increase in energy expended in the parks. Increased park use was pronounced in adults and children, but was not seen in teens and seniors. Park renovations were associated with a significantly increased perception of park safety. CONCLUSIONS: Park improvements can have a significant impact on increasing park use and local physical activity.

Partnerships for parks and physical activity.

PURPOSE: Given the need for comprehensive and multidisciplinary active living interventions, this article describes an innovative partnership for park design and evaluation. DESIGN: The Trust for Public Land partnered with the RAND Corporation and the San Francisco Department of Public Health to generate context-sensitive active park design, establish evaluation methods, and build the framework for future collaboration. SETTING: These partners worked together from 2009 to 2012 to design, renovate, and study parks in San Francisco, California. SUBJECTS: The three partnering organizations are the focus of this article. INTERVENTION: The Trust for Public Land's Parks for People-Bay Area Program raised more than $16 million to renovate three San Francisco parks, which served as the intervention for a study that initially brought the three partnering organizations together. MEASURES: The authors, who represent the three partners, collaborated to develop the lessons learned. ANALYSIS: This article is a description and commentary about a partnership that emphasized community involvement and rigorous evaluation. RESULTS: Lessons learned and elements for successful partnerships include collaborating with organizations with differing expertise, deciding upon goals initially, finding a common language, involving local communities, and recognizing the importance and appropriate role of evaluations. CONCLUSION: The model for collaboration and community involvement presented supports and encourages other organizations to use strategic, multidisciplinary partnerships and highlights the importance of evaluation.

The potential for pocket parks to increase physical activity.

PURPOSE: To assess the use of new pocket parks in low-income neighborhoods. DESIGN: The design of the study was a quasi-experimental post-test only comparison. SETTING: Los Angeles, California, was the setting for the study. SUBJECTS: Subjects were park users and residents living within .5 mile of three pocket parks and 15 neighborhood parks. INTERVENTION: The creation of pocket parks. MEASURES: We used the System of Observing Play and Recreation in Communities (SOPARC) tool to measure park use and park-based physical activity, and then surveyed park users and residents about their park use. ANALYSIS: We surveyed 392 and 432 household members within .5 mile of the three pocket parks before and after park construction, respectively, as well as 71 pocket park users, and compared them to 992 neighborhood park users and 342 residents living within .5 mile of other neighborhood parks. We compared pocket park use to playground area use in the larger neighborhood parks. We used descriptive statistics and generalized estimating equations for the analysis. RESULTS: Overall, pocket park use compared favorably in promoting moderate-to-vigorous physical activity with that of existing playground space in nearby parks, and they were cost-effective at $0.73/MET hour (metabolic equivalent hour) gained. Pocket park visitors walked an average of .25 miles to get to a park. CONCLUSIONS: Pocket parks, when perceived as attractive and safe destinations, may increase physical activity by encouraging families with children to walk there. Additional strategies and programs may be needed to encourage more residents to use these parks.

Physical activity in parks: A randomized controlled trial using community engagement.

BACKGROUND: Physical inactivity is an important health risk factor that could be addressed at the community level. PURPOSE: The goal of the study was to determine whether using a community-based participatory approach with park directors and park advisory boards (PABs) could increase physical activity in local parks. Whether involving PABs would be more effective than working with park directors alone was also tested. DESIGN: An RCT intervention from October 2007 to April 2012 was used, with partial blinding of observers to the condition. All data were analyzed in 2012. SETTING/PARTICIPANTS: Of 183 eligible parks in the City of Los Angeles, 50 neighborhood park/recreation centers serving diverse populations participated. Parks were randomized to three study arms: (1) park-director intervention (PD-only); (2) PAB intervention (PAB/PD); and (3) a control arm. Physical activity in each park was systematically observed, and park users and residents living within 1 mile of the park were interviewed. INTERVENTION(S): The intervention included assessing park use, obtaining feedback from park users and community residents, training on outreach and marketing, and giving each intervention park $4000 to increase park-based physical activity. The PAB/PD arm required participation and concurrence on all purchases by the PAB. MAIN OUTCOME MEASURE(S): Change in the number of park users and change in the level of park-based physical activity, expressed as MET-hours. RESULTS: Relative to control parks where physical activity declined, in both the PD-only and PAB/PD parks, physical activity increased, generating an estimated average of 600 more visits/week/park, and 1830 more MET-hours of physical activity/week/park. Both residents and park users in the intervention arms in the intervention arms reported increased frequency of exercise. No differences were noted between the PD-only and PAB/PD study arms. CONCLUSIONS: Providing park directors and PABs with training on outreach and marketing, feedback on park users, and modest funds increased the amount of physical activity observed in parks.

CMS Innovation Center Health Care Innovation Awards: Evaluation Plan.

The Center for Medicare and Medicaid Innovation within the Centers for Medicare & Medicaid Services (CMS) has funded 108 Health Care Innovation Awards, funded through the Affordable Care Act, for applicants who proposed compelling new models of service delivery or payment improvements that promise to deliver better health, better health care, and lower costs through improved quality of care for Medicare, Medicaid, and Children's Health Insurance Program enrollees. CMS is also interested in learning how new models would affect subpopulations of beneficiaries (e.g., those eligible for Medicare and Medicaid and complex patients) who have unique characteristics or health care needs that could be related to poor outcomes. In addition, the initiative seeks to identify new models of workforce development and deployment, as well as models that can be rapidly deployed and have the promise of sustainability. This article describes a strategy for evaluating the results. The goal for the evaluation design process is to create standardized approaches for answering key questions that can be customized to similar groups of awardees and that allow for rapid and comparable assessment across awardees. The evaluation plan envisions that data collection and analysis will be carried out on three levels: at the level of the individual awardee, at the level of the awardee grouping, and as a summary evaluation that includes all awardees. Key dimensions for the evaluation framework include implementation effectiveness, program effectiveness, workforce issues, impact on priority populations, and context. The ultimate goal is to identify strategies that can be employed widely to lower cost while improving care.