Department Of Human Services Research Articles

Your Healthiest Self: Wellness Toolkits

The U. S. Department of Health and Human Services compiled a group of wellness toolkits to help find each person’s healthiest self. These toolkits highlight evidence-based tips for living well and improving health. The toolkits include interactive flip cards, checklists, and downloadable content to learn strategies for increasing wellness. The goal of these toolkits is to recognize the different bodies, minds, living situations, and people influencing the lives of the people in the United States and to provide ways in each area to positively impact overall health.

Neurological Care within the Indian Health Service.

American Indians and Alaska Natives (AI/AN) are the Indigenous peoples of the United States. According to the U.S. Census Bureau, approximately 9.7 million people self-identified as AI/AN (alone or in combination with other races), representing 2.9% of the total U.S. population. These people represent diverse groups of discrete Tribes, each with their language, culture, and geographic home. As part of the conquest and settlement of North America, some Indigenous peoples signed treaties with the U.S. government, surrendering their lands in return for various government commitments, including health care. The Indian Health Service (IHS) was born out of these agreements. The IHS is an agency in the U.S. Department of Health and Human Services under the U.S. Public Health Service. The IHS provides a comprehensive health service delivery system for approximately 2.7 million AI/AN who belong to 574 federally recognized Tribes/nations in 37 states. The aim of this paper is to make recommendations regarding the initiation of sustainable neurology care in marginalized or underserved populations by reviewing 40 years of neurology care provision within the IHS. We will discuss (1) the IHS, (2) neurological care provided within the IHS, including midlevel provider extension of neurology care and traditional medical care, and (3) select neurological diagnoses within AI/AN populations. Marginalized populations, including those in the United States that are rural, remote, or low socioeconomic status, lack access to specialty neurology care. This includes many AI/AN. The IHS has developed novel solutions to promote specialty care, including neurology. Notably, initial IHS investments in full-time neurology providers have led to more robust neurology care, often receiving attention from university programs. This suggests that an initial investment in stable on-site full-time neurology services provides a path to potential sustainable care for marginalized populations.

Evaluation of Telehealth Services that are Clinically Appropriate for Reimbursement in the US Medicaid Population: Mixed Methods Study.

When the US Department of Health and Human Services instituted a State of Public Health Emergency (PHE) during the COVID-19 pandemic, many telehealth flexibilities were fast-tracked to allow state Medicaid agencies to reimburse new specialty services, sites of care, and mediums such as FaceTime to communicate with patients.. This resulted in expanded access to care for financially vulnerable Medicaid patients, as evidenced by an uptick in telehealth use. Research has mostly focused on telehealth reimbursement for limited use cases such as rural primary care, without broader consideration for how telehealth can be appropriately mainstreamed and maintained. This study sought to (1) evaluate the continuation of flexible telehealth reimbursement broadly, beyond the COVID-19 pandemic; (2) analyze the clinical effectiveness of the new telehealth services; and (3) offer code-by-code reimbursement guidance to state Medicaid leaders. We surveyed 10 state Medicaid medical directors (MMDs) who are responsible for the scientific and clinical appropriateness of Medicaid policies in their respective states. Participants were asked to complete an internet-based survey with a list of medical billing codes, grouped by service type, and asked if they believed they should be reimbursed by Medicaid on a permanent basis. Additional questions covered more detailed recommendations, such as reimbursing video with audio versus audio-only, guardrails for certain specialty services, and motivations behind responses. The MMDs felt that the majority of services should be reimbursed via some modality of telehealth after the PHE, with the most support for video combined with audio compared to audio-only. There were exceptions on both ends of the spectrum, where services such as pulmonary diagnostics were not recommended to be reimbursed in any form and services such as psychotherapy for mental health had the most support for audio-only. The vast majority of MMDs were supportive of reimbursement for remote monitoring services, but some preferred to have some reimbursement guardrails. We found that 90% (n=9) of MMDs were supportive of reimbursement for telehealth interprofessional services, while half (n=5) of the respondents felt that there should be continued guardrails for reimbursement. Motivations for continuing reimbursement flexibility were largely attributed to improving access to care, improving outcomes, and improving equity among the Medicaid patient population. There is a strong clinical endorsement to continue the telehealth flexibility enabled by the PHE, primarily for video combined with audio telehealth, with caution against audio-only telehealth in situations where hands-on intervention is necessary for diagnosis or treatment. There is also support for reimbursing remote monitoring services and telehealth interprofessional services, albeit with guardrails. These results are primarily from a perspective of improving access, outcomes, and equity; other state-specific factors such as fiscal impact and technical implementation may need to be taken into account when considering reimbursement decisions on telehealth.

Abstract P197: Dietary Quality Determined by Healthy Eating Index-2015 and Endothelial Function in Healthy Adults

The Healthy Eating Index (HEI) is a measure of diet quality based on Dietary Guidelines for Americans and developed in collaboration with the US Department of Health and Human Services and the US Department of Agriculture. Clinical interest in HEI has increased due to its association with obesity, inflammatory biomarkers and risk of coronary heart disease and stroke. Indeed, higher HEI-2015 score has been linked with reduced cardiovascular risk, morbidity, and mortality. Endothelial dysfunction, particularly impaired endothelium-dependent vasodilation, is a central etiological factor underlying cardiovascular risk and events. We and others have previously demonstrated that diets high in saturated fat and other proatherogenic diets are associated with endothelial vasodilator dysfunction. It is currently unknown whether HEI-2015 dietary score is associated with endothelial function. If so, assessing dietary quality based on HEI-2015 may provide targeted nutritional guidance for enhancing vascular health and mitigating cardiovascular risk. The aim of this study was to determine whether HEI-2015 score is associated with endothelial vasodilator function in healthy adults. Using data from 4-day dietary records, HEI-2015 scores were determined in 103 adults (65 M/38 F; age 44-68 years) free of overt cardiometabolic disease. The HEI-2015 score is based on 13 components summed to yield a total score from 0 to 100; higher score representing higher diet quality. The adults were stratified by HEI-2015 score quartiles: Q1: HEI < 52.5 (n=25; 23 M/2 F); Q2: HEI 52.6-59.1 (n=26; 14 M/12 F); Q3: HEI 59.2-66.0 (n=26; 15 M/11 F); and Q4: HEI > 66.0 (n=26; 13 M/13 F). Endothelium-dependent vasodilation was determined by forearm blood flow (FBF) (via plethysmography) responses to intra-arterial infusion of acetylcholine (ACh: 4.0, 8.0, and 16.0 μg/100 mL tissue/min) and sodium nitroprusside (NTP: 1.0, 2.0, and 4.0 μg/100 mL tissue/min). There were no significant differences in endothelium-dependent vasodilation across the HEI-2015 score quartiles. FBF blood responses to ACh were remarkably similar between Q1 (5.1±0.2 to 13.0±0.7 mL/100 mL tissue/min), Q2 (4.3±0.2 to 12.1±0.7 mL/100 mL tissue/min), Q3 (4.4±0.2 to 13.0±0.7 mL/100 mL tissue/min) and Q4 (4.5±0.2 to 14.4±0.6 mL/100 mL tissue/min). Moreover, HEI scores were not significantly associated with the vasodilator response to either ACh (r=0.15, P=0.13) or NTP (r=-0.04; P=0.72). In summary, although diet quality determined by HEI-2015 score has been shown to be associated with increased risk of cardiovascular disease and events, HEI-2015 was not associated endothelial function in mid-life and older adults. Given the established experimental and pathophysiological evidence linking between diet, endothelial vasodilator function and cardiovascular risk, HEI-2015 score is not a sensitive dietary indicator/biomarker of vascular function.

Identifying High-Risk ZIP Codes for Childhood Lead Exposure: A Statewide ZCTA-Level Priority List for North Carolina.

Research has consistently shown that there is no safe blood lead level (BLL) for children. Despite progress in lead poisoning prevention, lead exposure remains a persistent threat to the health and neurological development of children. To identify high-risk ZIP codes for use by families and health care providers for the entire state of North Carolina, we developed a risk model using ZIP Code Tabula-tion Area (ZCTA)-level census data. We obtained all available BLL testing data from the North Carolina Department of Health and Human Services for the years 2010-2015 via data use agreement. We fit a multivariable regression model with the ZCTA-level mean of log normalized BLLs as the de-pendent variable and ZCTA-level census data for known risk factors of childhood lead exposure as predictors. We used this model to create a priority risk categorization. We organized ZCTAs into 20 quantiles, or priority risk categories, that can be used in local and statewide screening programs. The first six (of 20) quantiles were identified as particularly high-risk areas for childhood lead exposure. Because BLL testing is not universal, the BLL testing data used in this study are likely biased toward those most at risk for lead exposure. This study demonstrates the utility of ZCTA-level census data in identifying high-risk ZIP codes for childhood lead exposure, which can be used to ensure that the highest-risk children are tested in a timely manner. This approach can be replicated to address lead exposure nationally.

Reflecting on Nearly Two Years of North Carolina's Healthy Opportunities Pilots.

In March 2022, the North Carolina Department of Health and Human Services launched a first-in-the-nation program, the Healthy Opportunities Pilots, to reimburse for evidence-based, non-medical services through Medicaid. This article reflects on nearly two years of the pilot, including early findings and lessons learned to date.

HHS Office for Civil Rights opens investigation into UnitedHealthcareGroup cyberattack

Last week, the U.S. Department of Health and Human Services' Office for Civil Rights (OCR) issued a “Dear Colleague” letter addressing the cybersecurity incident impacting Change Healthcare, a unit of UnitedHealthcare Group (UHG), and many other health care entities. The cyberattack is disrupting health care and billing information operations nationwide and poses a direct threat to critically needed patient care and essential operations of the health care industry. OCR enforces the HIPAA Privacy, Security, and Breach Notification Rules, which require that HIPAA covered entities – virtually all health care providers, clearinghouses, and insurance companies – protect the privacy and security of protected health information. The likelihood that substance use disorder (SUD) treatment information was included in the breach is very likely. However, OCR does not mention 42 CFR Part 2, just HIPAA. HHS views ransomware and hacking as the “primary cyber threats in health care.” There has been a 256% increase in large breaches involving hacking, and a 264% increase in ransomware, over the last 5 years, and this only includes those breaches OCR was notified of. $22 million was reportedly paid to the Change Healthcare hackers, in the form of bitcoin, likely from UHG, according to news reports. HHS OCR says: “If you believe that your or another person's health information privacy or civil rights have been violated, you can file a complaint with OCR at https://www.hhs.gov/ocr/complaints/index.html.” The one bright side of the new Part 2 rules are that OCR now enforces the regulation.

In Case You Haven't Heard…

ADAW readers have heard, even if nobody else has, that the federal Department of Health and Human Services and the Substance Abuse and Mental Health Services Administration omitted one important piece from their 42 CFR Part 2 final rule. Congress, in the 2020 CARES Act, required that the agencies make it easier to share information about patients' treatment for substance use disorders. The final rule does that — one initial consent, and your treatment can be shared freely with anyone except law enforcement, forever, without your repeated consent or even your knowledge. In the same law, Congress also required the agencies to strengthen anti‐discrimination provisions in Part 2. The agencies did not do that. We have asked both to respond to our question about this omission every week for a month and will continue to do so until we get an answer. For more information, go to https://onlinelibrary.wiley.com/doi/10.1002/adaw.34040.

Outbreak Linked to Morel Mushroom Exposure - Montana, 2023.

During March-April 2023, a total of 51 persons reported mild to severe gastrointestinal illness after eating at restaurant A in Bozeman, Montana. The outbreak resulted in multiple severe outcomes, including three hospitalizations and two deaths. After an inspection and temporary restaurant closure, the Montana Department of Public Health and Human Services and Montana's Gallatin City-County Health Department collaborated with CDC to conduct a matched case-control study among restaurant patrons to help identify the source of the outbreak. Consumption of morel mushrooms, which are generally considered edible, was strongly associated with gastrointestinal illness. A dose-response relationship was identified, and consumption of raw morel mushrooms was more strongly associated with illness than was consumption of those that were at least partially cooked. In response to the outbreak, educational public messaging regarding morel mushroom preparation and safety was shared through multiple media sources. The investigation highlights the importance of prompt cross-agency communication and collaboration, the utility of epidemiologic studies in foodborne disease outbreak investigations, and the need for additional research about the impact of morel mushroom consumption on human health. Although the toxins in morel mushrooms that might cause illness are not fully understood, proper preparation procedures, including thorough cooking, might help to limit adverse health effects.

Protecting Confidentiality in the Digital Ecosystem of Humanitarian Aid

Protecting Confidentiality in the Digital Ecosystem of Humanitarian Aid

Genomic characterisation of the population structure and antibiotic resistance of Salmonella enterica serovar Infantis in Chile, 2009–2022

Multidrug-resistant (MDR) Salmonella Infantis has disseminated worldwide, mainly linked to the consumption of poultry products. Evidence shows dissemination of this pathogen in Chile; however, studies are primarily limited to phenotypic data or involve few isolates. As human cases of Salmonella Infantis infections have substantially increased in recent years, this study aimed to characterise the genomic epidemiology and antimicrobial-resistance profiles of isolates obtained from different sources, aiming to inform effective surveillance and control measures. We sequenced 396 Salmonella Infantis genomes and analysed them with all publicly available genomes of this pathogen from Chile (440 genomes in total), representing isolates from environmental, food, animal, and human sources obtained from 2009 to 2022. Based on bioinformatic and phenotypic methods, we assessed the population structure, dissemination among different niches, and antimicrobial resistance (AMR) profiles of Salmonella Infantis in the country. The genomic and phylogenetic analyses showed that Salmonella Infantis from Chile comprised several clusters of highly related isolates dominated by sequence type 32. The HC20_343 cluster grouped an important proportion of all isolates. This was the only cluster associated with pESI-like megaplasmids, and up to 12 acquired AMR genes/mutations predicted to result in an MDR phenotype. Accordingly, antimicrobial-susceptibility testing revealed a strong concordance between the AMR genetic determinants and their matching phenotypic expression, indicating that a significant proportion of HC20_343 isolates produce extended-spectrum β-lactamases and have intermediate fluoroquinolone resistance. HC20_343 Salmonella Infantis were spread among environmental, animal, food, and human niches, showing a close relationship between isolates from different years and sources, and a low intra-source genomic diversity. Our findings show a widespread dissemination of MDR Salmonella Infantis from the HC20_343 cluster in Chile. The high proportion of isolates with resistance to first-line antibiotics and the evidence of active transmission between the environment, animals, food, and humans highlight the urgency of improved surveillance and control measures in the country. As HC20_343 isolates predominate in the Americas, our results suggest a high prevalence of ESBL-producing Salmonella Infantis with intermediate fluoroquinolone resistance in the continent. Partially supported by the Food and Drug Administration (FDA) of the U.S. Department of Health and Human Services as part of an award, FDU001818, with 30% percentfundedby FDA/HHS; and by Agencia de Investigación y Desarrollo de Chile (ANID) through FONDECYT de Postdoctorado Folio 3230796 and Folio 3210317, FONDECYT Regular Folio 1231082, and ANID-Millennium Science Initiative Program-ICN2021_044.

OTP leaders on Part 2: Tell patients what consent means

The confidentiality regulation governing substance use disorder (SUD) treatment records has been constantly weakened since 2010. Most recently, the final rule came out (see https://onlinelibrary.wiley.com/doi/10.1002/adaw.34035) which further weakens privacy, most importantly by allowing the first initial consent to release of patient information, signed by the patient, to be used forever, to go to almost anyone, except for law enforcement. When the Department of Health and Human Services (HHS) and the Substance Abuse and Mental Health Services Administration (SAMHSA) jointly released that final rule, they did not comply with the requirement by Congress in the CARES Act that while sharing of information should be easier, anti‐discrimination provisions needed to be tightened. There was no addition of anti‐discrimination provisions.

Increased mortality in infants with abnormal T-cell receptor excision circles.

T-Cell Receptor Excision Circles based newborn screening (TREC-NBS) allows for early detection of T-cell lymphopenia in infants with primary immunodeficiency disorders (PIDD). The utility of abnormal TREC-NBS in infants without PIDD is not well studied. We sought to evaluate the association of abnormal TREC-NBS with mortality. 365,207 TREC-NBS from October 2011 to December 2014 were reviewed. 467 newborns had abnormal screens and did not meet the criteria for a PIDD diagnosis. Cases were matched to controls (1:3) based on gestational age, birth weight, neonatal intensive care unit status (NICU), and race. Data were obtained through NBS, birth and death certificates records from the Michigan Department of Health and Human Services (MDHHS) databases. Infants with abnormal TREC-NBS had higher mortality even when PIDD was ruled-out. Transient abnormal TREC-NBS was not associated with higher mortality, but unresolved or late abnormal TREC-NBS was associated with higher mortality. Infants with late abnormal TREC-NBS had severe prematurity, lower birth weight, lower Apgar scores, and higher percentage of congenital anomalies. Infants with abnormal TREC-NBS may be at a higher risk of morbidity and mortality and should be carefully followed, especially if discharged home before a repeat screen can be completed. This study explores the risk factors and mortality for newborns with secondary T-cell lymphopenia captured on T-Cell Receptor Excision Circles based newborn screening (TREC-NBS). Abnormal TREC-NBS allows for prompt life-saving interventions for primary immunological conditions such as Severe Combined Immunodeficiency (SCID), but can also be associated with non-immunologic conditions. Unresolved and late abnormal TREC-NBS is associated with higher mortality even without primary immunodeficiency, likely detected in infants with more severe prematurity, lower birth weight, and congenital anomalies. TREC-NBS positive infants with secondary T-cell lymphopenia require special attention and close monitoring.

In Case You Haven't Heard…

ADAW asked representatives of the press offices of the Substance Abuse and Mental Health Services Administration and its parent agency, the Department of Health and Human Services, to respond to our question: Why did they weaken the privacy and not strengthen the anti‐discrimination provisions of 42 CFR Part 2 in their final rule issued last month? Congress required this to be done in the 2020 CARES Act. Neither office responded to our question. ADAW asked again this week, as promised. Still no response. We will continue to push for an answer. This time, we're also asking what they're going to do about it. Patients lose confidentiality for the rest of their lives with the first consent to release substance use disorder treatment information. And it can go to anyone, anywhere, anytime if they do consent. It's not only patients who don't like this; treatment providers don't either, because patients aren't going to want to go to treatment if this will happen. Still no response.

Tailoring HIV Care for Black Populations: A Pilot Feasibility Prospective Cohort Study.

Research has shown that integrating community health workers (CHWs) into the formal health care system can improve outcomes for people living with HIV, yet there is limited literature exploring this framework among marginalized minority populations. Herein, we discuss the feasibility of a clinic-embedded CHW strategy to improve antiretroviral therapy adherence among Black people living with HIV in Miami-Dade County, Florida, a designated priority region for the US Department of Health and Human Services' Ending the HIV Epidemic Initiative. From December 2022 to September 2023, three CHWs were trained and integrated into the hospital workflow to provide support as members of the clinical team. Ten Black adults with an HIV viral load over 200 copies/mL were enrolled to received 3 months of CHW support focused on navigating the health system and addressing poor social determinants of health. Intervention feasibility was based on 4 criteria: recruitment rate, demographic composition, study fidelity, and qualitative feedback on CHW perceptions. Participants were recruited at a rate of 5.7 participants per month, with the sample evenly distributed between men and women. Retention was moderately strong, with 7 (70%) of the 10 participants attending more than 75% of CHW sessions. Qualitative feedback reflected CHW perceptions on clinical interactions and intervention length. Outcomes indicate that a clinic-integrated CHW approach is a feasible and acceptable methodology to address adverse social determinants and improve HIV treatment adherence. By offering targeted social and clinical support, CHWs may be a promising solution to achieve sustained viral suppression and care engagement for Black people living with HIV.

HIV Care Continuum and Preexposure Prophylaxis Program in Federal Bureau of Prisons, United States.

In 2019, the US Department of Health and Human Services launched the Ending the HIV Epidemic in the US initiative (EHE) with the goal of reducing new HIV infections by 90% by 2030. This initiative identifies 4 pillars (diagnose, treat, prevent, and respond) to address the HIV epidemic in the United States. To advance the EHE goals, the Federal Bureau of Prisons (FBOP) has implemented interventions at all points of the HIV care continuum. The FBOP has addressed the EHE pillar of prevention through implementing preexposure prophylaxis, developing a strategy to decrease the risk of new HIV infection, and providing guidance to FBOP healthcare providers. This article describes the implementation of programs to improve the HIV care continuum and end the epidemic of HIV within the FBOP including a review of methodology to implement an HIV preexposure prophylaxis program.

Trends in the Annual Incidence Rates of Child Sexual Abuse and Child Maltreatment over the Past 25 Years in the United States

AbstractExperiencing child sexual abuse is associated with increased risk for a range of short‐ and long‐term negative effects. This short report defines and explores the annual incidence rates of child sexual abuse in the United States over 25 years between 1996 and 2021 (the most recent data released) and, comparatively, annual incidence rates of child maltreatment, more generally. A retrospective trend analysis of Child Maltreatment Reports, produced by the Department of Health and Human Services with data from the National Child Abuse and Neglect Data System, was conducted to compile and analyse rates of child sexual abuse and child maltreatment over time. In general, the rates of reported child maltreatment and child sexual abuse have declined, on average, since the 1990s. We, then, discuss these trends in connection with research documenting societal and family factors that may have contributed to these declines.

HHS approves New Mexico's community‐based care expansion

The U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services, has approved a proposal from New Mexico for community‐based mobile crisis intervention teams to provide Medicaid crisis services, a cms.gov news release stated. The Feb. 6 announcement is the latest in HHS' ongoing efforts to support President Biden's whole‐of‐government strategy to transform mental health services for all Americans — a key part of the President's Unity Agenda, the news release stated. New Mexico is the 15th state to expand access to community‐based mental health and substance use crisis care through President Biden's American Rescue Plan. With this approval, the state will be able to provide Medicaid services through mobile crisis teams by connecting eligible individuals in crisis to a behavioral health provider 24 hours per day, 365 days a year. This work builds on HHS' broader work to expand dramatically the full continuum of mental health crisis services, including through the nationwide launch of the 988 Suicide & Crisis Lifeline and expansion of Certified Community Behavioral Health Clinics under the Bipartisan Safer Communities Act, providing crisis services 24 hours a day, 7 days a week, regardless of a person's ability to pay.

Part 2 Final Rule: Where are the anti‐discrimination provisions?

The Legal Action Center has been a central resource for information on 42 CFR Part 2, the regulation protecting (ostensibly, now) confidentiality of substance use disorder (SUD) treatment records, for more than three decades. This article is our 350th one on Part 2 since 2010, when the move to weaken the consent part of the regulations began. So we talked to Legal Action Center attorneys Jacqueline Seitz and Deborah A. Reid last week about the Final Rule for Part 2, issued this month by the Department of Health and Human Services (HHS) (see Confidentiality for SUD records: Final rule issued, ADAW Feb. 19; https://onlinelibrary.wiley.com/doi/10.1002/adaw.34035).

Confidentiality for SUD records: Final rule issued

A week after the federal Department of Health and Human Services (HHS) issued a final rule liberalizing treatment for opioid use disorder (OUD) in opioid treatment programs, it issued a less patient‐friendly rule. ADAW has written about 400 articles on confidentiality and substance use disorder treatment, an area that has seen continued erosion since 2010 when the government started acceding to claims that requiring a patient to consent to the release of his or her substance use disorder (SUD) treatment information in a digital age (think “Electronic Health Record”) would be just too inconvenient. The most recent step came in the Federal Register issued Feb. 8, which changes the confidentiality rules to align with those of HIPAA. The rule, through the HHS Office for Civil Rights (OCR) and the Substance Abuse and Mental Health Services Administration (SAMHSA), finalized modifications to the Confidentiality of Substance Use Disorder (SUD) Patient Records regulations at 42 CFR part 2 (“Part 2”), which protect the privacy of patients' SUD treatment records. In a press release about the rule, HHS said this: “Specifically, today's final rule increases coordination among providers treating patients for SUDs, strengthens confidentiality protections through civil enforcement, and enhances integration of behavioral health information with other medical records to improve patient health outcomes.”