State Medicaid Research Articles

Outcomes After a Statewide Policy to Improve Evidence-Based Treatment of Back Pain Among Medicaid Enrollees in Oregon.

A novel Oregon Medicaid policy guiding back pain management combined opioid restrictions with emphasis on non-opioid and non-pharmacologic therapies. To examine the effect of the policy on prescribing, health outcomes, and health service utilization. Using Medicaid enrollment, medical and prescription claims, prescription drug monitoring program, and vital statistics files, we analyzed the policy's association with selected outcomes using interrupted time series models. Adult Medicaid patients with back pain enrolled between 2014 and 2018. The Oregon Medicaid back pain policy. Opioid and non-opioid medication prescribing, procedural care, substance use and mental health conditions, and outpatient and inpatient healthcare utilization. The policy was associated with decreases in the percentage of Medicaid enrollees with back pain receiving any opioids (- 2.68 percentage points [95% CI - 3.14, - 2.23] level, - 1.01pp [95% CI - 1.1, - 0.92] slope), days of short-acting opioid use (- 0.4days [95% CI - 0.53, - 0.26] slope), receipt of more than 7days of short-acting opioids (- 2.36pp [95% CI - 2.76, - 1.95] level, - 0.91pp [95% CI - 1, - 0.83] slope), chronic opioid use (- 1.27pp [95% CI - 1.59, - 0.94] level, - 0.46 [95% CI - 0.53, - 0.39 slope), and spinal surgeries and procedures. Among secondary outcomes, we found no increase in opioid overdose and a small, statistically significant trend decrease in opioid use disorders. There were small increases in non-opioid substance use and mental health diagnoses and visits but no increase in self-harm. A state Medicaid policy emphasizing evidence-based back pain management was associated with decreases in opioid prescribing, spinal surgeries, and opioid use disorder trends, but also short-term increases in mental health encounters and an increase in non-opioid substance use disorder trends. Such policies may help reinforce evidence-based care, but must be designed with consideration of potential harms.

Access to PrEP and other sexual health services for cisgender women in the United States: a review of state policy and Medicaid expansion.

Pre-exposure prophylaxis (PrEP) has the potential to prevent new HIV infections, but it is unclear how state policies governing sexual and reproductive health services (SRH) impact access for cisgender women. The objective of this review is to identify barriers to PrEP access for cisgender women in the United States. Using the CDC Atlas Program, 20 states with the highest HIV incidence among cisgender women were included in this analysis. Through a search conducted in May-July 2022 of CDC, PrEPWatch.org, and other State Department and Insurance websites, Medicaid expansion status, pharmacist PrEP prescribing laws, financial support programs, and Traditional Medicaid coverage of PrEP, HIV testing, and emergency contraception were reviewed. Of the included states, nearly half did not expand Medicaid at the state level. Emergency contraception and HIV testing was covered under Traditional Medicaid for almost all included states, but insurance stipulations and eligibility requirements remain. Although PrEP is covered under all Traditional Medicaid plans, six states require pre-authorization. Three states have HIV testing mandates, four allow pharmacists to prescribe PrEP and six have financial support programs to cover the cost of PrEP. Medicaid expansion, pre-authorization requirements for PrEP prescriptions and emergency contraception, and limitations on pharmacist prescribing abilities were identified as barriers to SRH access for cisgender women. Medicaid expansion should be prioritized as an approach to expanding access to HIV prevention services at the state level.

Medicaid Dental Benefits for Pregnant People and Dental Care Use Among Very Young Children.

The aim of this study was to examine the association between Medicaid dental benefits for pregnant people and dental care use among very young children in Medicaid. We hypothesized that children living in states with more generous dental benefits for Medicaid-enrolled pregnant people would be more likely to have a recent dental visit. This national cross-sectional study used pooled2017-2019 data from the National Survey of Children's Health, as well as state Medicaid policy data. The study sample included children aged 0-2 enrolled in Medicaid. Multivariable logistic regression models estimated the association between Medicaid dental benefit generosity for pregnant people and the child having a dental visit in the past year. Children in states with emergency-only dental coverage for pregnant people were 2.5 times as likely to have had a dental visit than children in states with extensive coverage (OR 2.48, 95% CI 1.35-4.53). In supplemental analyses excluding children living in Texas, there was no longer an association between dental coverage for pregnant people and dental utilization among young children (OR 1.52, 95% CI 0.82-2.83). Young children in states that provided emergency-only dental benefits for pregnant people in Medicaid had significantly higher odds of dental utilization than young children in states with more generous dental benefits for pregnant people. This relationship disappeared after excluding the state Texas, which had the highest rate of child dental utilization in the country and provided emergency-only dental benefits for pregnant people in Medicaid.

The impact of different strategies for modeling associations between medications at low doses and health outcomes: a simulation study and practical application to postpartum opioid use.

Pharmacoepidemiological studies commonly examine the association between drug dose and adverse health outcomes. In situations where no safe dose exists, the choice of modeling strategy can lead to identification of an apparent safe low dose range in the presence of a non-linear relationship or due to the modeling strategy forcing a linear relationship through a dose of 0. We conducted a simulation study to assess the performance of several regression approaches to model the drug dose-response curve at low doses in a setting where no safe range exists, including the use of a (1) linear dose term, (2) categorical dose term, and (3) natural cubic spline terms. Additionally, we introduce and apply an expansion of prior work related to modeling dose-response curves at low and infrequently used doses in the setting of no safe dose ("spike-at-zero" and "slab-and-spline"). Furthermore, we demonstrate and empirically assess the use of these regression strategies in a practical scenario examining the association between the dose of the initial postpartum opioid prescribed after vaginal delivery and the subsequent total dose of opioids prescribed in the entire postpartum period among a cohort of opioid-naïve women with a vaginal delivery enrolled in a State Medicaid program (2007-2014).

Racial-Ethnic Disparities in Quality of Care Among Medicaid Beneficiaries With Schizophrenia.

The authors sought to update and expand the evidence on the quality of health care and disparities in care among Medicaid beneficiaries with schizophrenia. Adult beneficiaries of New York State Medicaid with schizophrenia receiving care during 2016-2019 were identified. Composite quality scores were derived from item response theory models by using evidence-based indicators of the quality of mental and general medical health care. Risk-adjusted racial-ethnic differences in quality were estimated and summarized as percentiles relative to White beneficiaries' mean quality scores. The study included 71,013 beneficiaries; 42.8% were Black, 22.9% Latinx, 27.4% White, and 6.9% other race-ethnicity. Overall, 68.8% had a mental health follow-up within 30 days of discharge, and 90.2% had no preventable hospitalizations for chronic obstructive pulmonary disease or asthma. Among beneficiaries receiving antipsychotic medications, medication adherence was adequate for 43.7%. Fourteen indicators for mental and general medical health care quality yielded three composites: two for mental health care (pharmacological and ambulatory) and one for acute mental and general medical health care. Mean quality of pharmacological mental health care for Black and Latinx beneficiaries was lower than for White beneficiaries (39th and 44th percentile, respectively). For Black beneficiaries, mean quality of ambulatory mental health care was also lower (46th percentile). In New York City, Black beneficiaries received lower-quality care in all domains. The only meaningful group difference in the quality of acute mental and general medical health care indicated higher-quality care for individuals with other race-ethnicity. Disparities in the quality of Medicaid-financed health care persist, particularly for Black beneficiaries. Regional differences merit further attention.

The Spectrum of State Approaches to Medicaid Maternity Care Contracting.

Managed care is how Medicaid agencies principally furnish maternity care. For this reason, the contracts that Medicaid agencies enter into with managed care organizations have attracted strong interest as a means of improving maternal health access, quality, and equity. However, limited research has documented the extent to which states use these agreements to set binding expectations across the maternal health continuum and how states approach the task of maternal health contracting. To explore maternal health contracting within Medicaid Managed Care, this study took a three-phase, sequential approach: (1) an extensive literature review to identify clinical guidelines and expert recommendations regarding maternal health "best practices" for people with elevated health and social needs, (2) a review of the managed care contracts in use across 40 states and Washington, DC, to determine the extent to which they incorporate these best practices, and (3) interviews conducted with four state Medicaid agencies to better understand how states approach maternal health when developing their contracts. The evidence on maternal health best practices reveals nearly 60 "best practices," although the literature review also underscored the extent to which these recommendations are fragmented across numerous professional bodies and government agencies and are thus difficult for Medicaid agencies to ascertain. The contracts themselves reflect an approach to the maternal health continuum in a fragmented and incomplete way. Thematic analysis of interviews with state Medicaid agencies revealed three key approaches to contracting for maternity care: an "organic" approach, an "intentional" approach, and an approach "grounded" in state strategy. The absence of comprehensive, integrated guidelines reflecting the full maternal health continuum likely complicates the contracting task and contributes to incomplete, ambiguous contracts. A major step would be the development of a "best practices tool" that helps state Medicaid agencies translate evidence into comprehensive, clear contracting expectations.

Experiences and Interest in Value-Based Payment Arrangements for Medical Products Among Medicaid Agencies: An Exploratory Analysis.

To date, uptake of value-based payment (VBP) arrangements for medical products and knowledge of their design and impact have been mainly concentrated among private payers. Interest and activity are expanding to Medicaid; however, their experiences and approaches to VBP arrangements for medical products are not well characterized. This study sought to characterize the use of VBP arrangements for medical products among state Medicaid agencies through the use of a two-staged, mixed-methods approach. A survey and semistructured interviews were conducted to gain an understanding of state experiences with VBP arrangements for medical products. The survey and interviews were directed at senior leaders from nine states through the survey, with respondents from seven of these states additionally participating in the semistructured interviews. Although experience with VBP arrangements for medical products among states varied, there were similarities across their motivations and general processes or phases employed in their design and implementation. States collectively identified a number of significant challenges to VBP arrangements, such as manufacturer engagement, outcomes measurement, and the time, expertise, and resources required to design and implement them. We outline a range of strategies to help address these gaps and make it easier for states to pursue VBP arrangements, including more direct engagement from the Center for Medicare and Medicaid Services, state-to-state peer learning and collaboration, data infrastructure and sharing, and additional research to inform fit-for-purpose VBP arrangement approaches. Findings from this study suggest that it may be easier for states to pursue VBP arrangements for medical products if there is greater clarity on processes employed that support design and implementation as well as effective strategies to address common challenges associated with contract negotiations. As states gain more experience, it will be important to monitor the design and implementation of common VBP arrangements to assess impact on the Medicaid program and the populations it serves.

Comparison of two propensity score-based methods for balancing covariates: the overlap weighting and fine stratification methods in real-world claims data

BackgroundTwo propensity score (PS) based balancing covariate methods, the overlap weighting method (OW) and the fine stratification method (FS), produce superb covariate balance. OW has been compared with various weighting methods while FS has been compared with the traditional stratification method and various matching methods. However, no study has yet compared OW and FS. In addition, OW has not yet been evaluated in large claims data with low prevalence exposure and with low frequency outcomes, a context in which optimal use of balancing methods is critical. In the study, we aimed to compare OW and FS using real-world data and simulations with low prevalence exposure and with low frequency outcomes.MethodsWe used the Texas State Medicaid claims data on adult beneficiaries with diabetes in 2012 as an empirical example (N = 42,628). Based on its real-world research question, we estimated an average treatment effect of health center vs. non-health center attendance in the total population. We also performed simulations to evaluate their relative performance. To preserve associations between covariates, we used the plasmode approach to simulate outcomes and/or exposures with N = 4,000. We simulated both homogeneous and heterogeneous treatment effects with various outcome risks (1-30% or observed: 27.75%) and/or exposure prevalence (2.5-30% or observed:10.55%). We used a weighted generalized linear model to estimate the exposure effect and the cluster-robust standard error (SE) method to estimate its SE.ResultsIn the empirical example, we found that OW had smaller standardized mean differences in all covariates (range: OW: 0.0–0.02 vs. FS: 0.22–3.26) and Mahalanobis balance distance (MB) (< 0.001 vs. > 0.049) than FS. In simulations, OW also achieved smaller MB (homogeneity: <0.04 vs. > 0.04; heterogeneity: 0.0-0.11 vs. 0.07–0.29), relative bias (homogeneity: 4.04–56.20 vs. 20–61.63; heterogeneity: 7.85–57.6 vs. 15.0-60.4), square root of mean squared error (homogeneity: 0.332–1.308 vs. 0.385–1.365; heterogeneity: 0.263-0.526 vs 0.313-0.620), and coverage probability (homogeneity: 0.0–80.4% vs. 0.0-69.8%; heterogeneity: 0.0-97.6% vs. 0.0-92.8%), than FS, in most cases.ConclusionsThese findings suggest that OW can yield nearly perfect covariate balance and therefore enhance the accuracy of average treatment effect estimation in the total population.

Demographics of cancer screening in Providence’s homeless population.

1585 Background: Adults experiencing homelessness have a higher incidence and mortality from cancer. It is estimated that almost 60% of homeless people in the US are from racial and ethnic minorities. Therefore, cancer mortality among the homeless may be an important disparity. In recent years homelessness has increased in Providence RI due to high rents and end of covid subsidies. The objective of this project was to learn about the demographics of the homeless population in Providence, focusing on risk factors for cancer and barriers to screening, to acquire the necessary information to develop interventions to improve cancer screening in the unhoused population. Methods: We conducted a cross-sectional survey of homeless individuals in Providence, RI. Survey data was obtained at homeless shelters, on the street, at soup kitchens and at other community events supporting the homeless. The largest single source of participants was those attending the Matthewson Street Church Friendship Breakfast on Sunday mornings. Results: Data was obtained from 278 homeless individuals from September 2023 to December 2023. 70% were male, 30% female. Age ranges included 28 (10%) &lt; 40 years, 78 (28%) 40-49 years, 88 (32%) 50-59 years, 74 (27%) 60-69 years and 10 (4%) &gt; 70 years. Race/ethnicity included 56% White, 18% Black, 13% Hispanic/Latino, 2% Native American, 9% multiracial and 2% other. 51% were sleeping in a shelter, 29% were unsheltered (including outside, car or tent), 12% “couch surfing”, and 7% were recently housed. Most participants (92%) had health insurance, the majority being state Medicaid, and had PCP visits (59%), mostly to community health centers, within the last 12 months. 72% of individuals were current cigarette smokers and 45% currently used alcohol. Among women, only 32% were on schedule for mammogram and 61% were on schedule for cervical cancer screening. Colon cancer screening rate for individuals &gt; 45 years was 32%. Only 32% of males over 50 had prostate cancer screening. Barriers identified included needing to have other needs met such as food and housing, lack of transportation to healthcare facilities, and lack of awareness about the need to undergo screening. Conclusions: The most common age range of homelessness in Providence, ages 50-59, is when cancer screening should be ongoing. There is a higher incidence of homelessness among minorities. The homeless population have high risk factors for cancer but screening rates for breast, cervical, lung, prostate and colon cancer are well below national guidelines. This represents a health disparity. Given the proportion of participants with a PCP and health insurance, interventions to improve cancer screening in this population may be feasible. We plan to develop educational partnerships with community health centers during the next phase of this initiative to increase awareness and uptake of screening recommendations.

State mandatory paid medical leave policies and cancer stage at diagnosis in US adults.

11008 Background: Since 2012, several states implemented mandatory paid medical leave policies. Mandatory paid medical leave may alleviate time and financial burdens, enabling patients to undergo screening and/or timely diagnostic workup for new cancer-related symptoms. These policies have been associated with increased cancer screening. We investigated whether state mandatory paid medical leave policies were associated with stage at cancer diagnosis. Methods: Adults ages 18-64 years diagnosed with cancer from 2010-2019 were identified from the Surveillance, Epidemiology, and End Results program. Differences-in-differences (DID) analyses using the updated method of accounting for heterogeneity in policy enactment compared proportions of stage I and IV cancer diagnoses from pre- to post-policy implementation in states with vs. without paid medical leave policies. Analyses adjusted for age, sex, race, ethnicity, rurality, cancer site, county-level income, and time-varying state Medicaid eligibility levels. Since some cities enacted city-wide policies prior to state-wide implementation, cases from affected states between the time of city and state policy enactment were excluded. Sensitivity analyses were conducted excluding counties with cities that enacted paid leave policies. The plausibility of the parallel trends assumption was assessed by comparing stage at diagnosis between state groups in the pre-policy period and was satisfied for all reported results. Results: A total of 1,052,307 adults with cancer were identified. 39.8% and 19.7% of patients were diagnosed with stage I and IV cancers, respectively. In adjusted DID analyses, there was a 1.34 percentage point (PP) increase in stage I diagnoses and a 2.05 PP decrease in stage IV diagnoses associated with mandatory paid medical leave policy implementation (Table). Results were similar in sensitivity analyses. In subgroup analyses, policy-associated stage shifts were seen in males, Hodgkin lymphoma, and liver and lung cancers, with less clear patterns for cervix and pancreas cancers. Conclusions: State mandatory paid medical leave was associated with increased early-stage cancer diagnoses and decreased late-stage diagnoses. Paid leave policies may promote earlier detection of non-screenable cancers by enabling employees to promptly seek care for new cancer-related symptoms. Policies that improve opportunities to seek medical care may facilitate earlier cancer detection and ultimately contribute to better patient outcomes. [Table: see text]

Déprotection sanitaire des étrangers, de quoi la démission d’Aurélien Rousseau est-elle le nom ?

In late December 2023, the French parliament debated legislation that would endanger access to state medical aid (AME) for seriously ill migrants living undocumented in France. The limits of an over-restrictive approach to health care are well known: poorer access to care, additional burden on public hospitals, and the weakening of the whole system. The risks weigh particularly heavily on migrants living with HIV. Yet we know that the number of HIV-positive diagnoses continues to rise among men who have sex with men and who were born abroad. This situation raises public health concerns and risks undermining the ethical foundations of medicine. The French health minister, Aur&#233;lien Rousseau, resigned the day after the bill was passed last December, having repeatedly stated his opposition to measures abolishing or weakening AME. In doing so, he demonstrated his commitment to the humanist foundations of medicine, setting an example for all political leaders.

Identifying Post-Acute Sequelae of SARS-CoV-2 Among Children in New York State Medicaid Managed Care.

Persons who contract COVID-19 are at risk of developing post-acute sequelae of SARS-CoV-2 (PASC). The objective of this study was to describe the incidence of PASC in a pediatric Medicaid population. Using a retrospective cohort of children enrolled in New York State Medicaid Managed Care we compared incident diagnoses between children with a positive laboratory test for SARS-CoV-2 in 2021 to children without a positive test in 2021 and children with a viral respiratory diagnosis in 2019. Logistic regression models estimated adjusted odds ratios using the Cohen's d statistic to assess the strength of associations. Most unadjusted incidence of clinical outcomes were less than 1% for all cohorts. Relative to the 2021 comparison cohort, significant increases among SARS-CoV-2 cases were observed in sequela of infectious disease conditions, general signs and symptoms, and pericarditis and pericardial disease and for the 2019 comparison, sequela of infectious disease conditions and suicidal ideation. However, associations were mostly determined to be weak or marginal. In this low socioeconomic status pediatric population, incidence of new clinical sequelae was low with mostly weak or marginal increases associated with SARS-CoV-2 infection. Though the incidence was low, some outcomes may be severe. Observed associations may have been impacted by pandemic behavior modification including social distancing policies.

Advancing Access to Cell and Gene Therapies in Medicaid

This Viewpoint presents the components of the payment model and the implementation challenges among the Center for Medicare and Medicaid Innovation, state Medicaid agencies, patients, and manufacturers.

Social Work and the New York State Medical Aid in Dying Act

Medical Aid in Dying (MAiD) is garnering increasing attention throughout the world. Since 1998, 14 states and Washington D.C. have MAiD laws in the United States. For the eighth time in as many years, the NewYork State legislature has introduced MAiD legislation, and the Medical Aid in Dying Act is currently in committee in both the Assembly and the Senate. Although this legislation has failed in New York State in the past, it is increasingly supported by New York voters (Granquist, 2024). The MAiD debates in New York state, along with data from U.S. jurisdictions with MAiD laws, highlight important considerations about end-of-life choices and how they intersect with social work values. Social workers can gain valuable insight into supporting people at the end of life, engage in self-reflection on their own beliefs and biases related to end- of-life choices, encourage self-reflection of medical professionals, and advocate for equity in healthcare within medical institutions and through social welfare policy (Schroepfer et al., 2022). This discourse can benefit patients interacting with the health care system regardless of MAiD’s outcome in New York State.

By the people, for the people: Local government's representation of voter preferences under the Affordable Care Act

AbstractDecentralized government is hypothesized to lead public service investments to better align with political preferences across geographical regions, yet there has been limited rigorous testing of this hypothesis. We examine how local public provision of hospital services varied according to political preferences between 2006 and 2016. We use state Medicaid expansion under the Affordable Care Act (ACA) as a source of exogenous variation. Consistent with the motivation for federalism, we find that areas less supportive of the ACA tended to convert the state expansion into lower property taxes with lower public hospital expenditures, whereas, in states that expanded Medicaid, local governments tended to increase public provision of healthcare.

United States Doula Programs and Their Outcomes: A Scoping Review to Inform State-Level Policies

BackgroundThe field of maternal health has advanced significantly over the past decades. However, the United States continues to have poor outcomes in comparison with other industrialized nations. With emerging evidence on the promise of doula care, states are including doula care under their Medicaid programs. MethodsWe conducted a scoping review across four academic databases and gray literature published between January 1, 2012, and March 10, 2022, to describe the landscape of literature on U.S. doula programs and their outcomes in order to inform state policy makers considering laws or programs related to doula care. FindingsOf 740 records identified, 100 met inclusion criteria. Outcomes fell into four areas: birthing people's outcomes, infant outcomes, systems of care and implementation, and cross-cutting issues. Data on outcomes related to doula care in the literature were predominantly clinical, even though doulas are not clinical providers. Although some studies have found associations between doula care and improved clinical outcomes for birthing people and infants, the evidence is limited due to small sample sizes, study methodology, or conflicting conclusions. Doula outcomes are underexplored in the literature, with mainly qualitative data describing low levels of diversity and equity within the doula workforce and ineffective payment models. When cost-effectiveness estimates have been calculated, they largely rely on savings realized from averted cesarean births, preterm births, and neonatal intensive care unit admissions. ConclusionsAs state Medicaid programs expand to include doula care, policymakers should be aware of the limitations in the evidence as they plan for successful implementation, such as the narrow focus on certain clinical outcomes to quantify cost savings and conflicting conclusions on the impact of doula care. An important consideration is the impact of the reimbursement rate on the adoption of doula care, which is why it is important to engage doulas in compensation determinations, as well as the development of improved metrics to untangle the components that contribute to maternal health outcomes in the United States.

Risk of Hospitalization Associated with Use of Consumer-Directed Attendant Care

ABSTRACT Older people with disabilities living independently often use attendant care, also known as Personal Assistive Services (PAS). The aides providing care can come from a home health agency contracted by the state Medicaid authority, known as agency-directed PAS, or the Medicaid recipient can receive a monthly budget and arrange their own care, known as consumer-directed care. Consumer-directed care is hypothesized to have some possible benefits but could also potentially lead to health hazards. This study examined whether people receiving consumer-directed PAS versus people receiving agency-directed PAS faced a higher risk of hospitalization. The data for this study came from Pennsylvania Medicaid claims, enrollment files, standardized assessments, and hospitalization claims from Medicare and Medicaid. The analysis used two-stage least square regression, with the percentage of people in a county using consumer-directed care as an instrument for the type of PAS. People using consumer-directed care did not have a statistically significant difference in risk for hospitalization compared to people using agency-directed PAS (p = .976). Risk of hospitalization was not different for people using consumer-directed care compared to people using agency-directed care.

Retrospective study investigating naloxone prescribing and cost in US Medicaid and Medicare patients

BackgroundOpioid overdoses in the USA have increased to unprecedented levels. Administration of the opioid antagonist naloxone can prevent overdoses.ObjectiveThis study was conducted to reveal the pharmacoepidemiologic patterns in naloxone prescribing...

'Tausi Feagaiga: A Project to Train Caregivers and Empower the American Samoan Community.

The 'Tausi Feagaiga (Covenant Keeper) project was a partnership to support the traditional values of tausi matua (caring for one's elders). The partners included a non-governmental organization (Pacific Youth and Community Development), a faith-based organization (Roman Catholic Diocese of Samoa-Pago Pago), and an institute of higher education (University of Hawai'i John A. Burns School of Medicine). The project was created to address the lack of community-based health care such as home health or hospice, and families needing to work outside the home. A culturally based caregiving curriculum was developed to educate caregivers and improve their knowledge and skills. Using a train-the-trainer model, 125 caregivers were trained in family caregiving from 2016-2020. Training was conducted through an intensive workshop followed by practicum at Hope House, the Catholic Diocese home for the aged. Participants who expressed a willingness and competency were mentored to be trainers to continue the 'Tausi Feagaiga project. The mean self-rated confidence in caregiving improved significantly from 3.17 ± 1.02 (mean SD) pre workshop to 3.53 ± 0.71 post workshop (P = .001). Competence in geriatric syndromes was improved from 18.04 ± 4.27 to 21.31 ± 4.30 after attending the workshop (P < .001) and the feedback was extremely positive. Technical assistance was provided to obtain funding through American Samoa Medicaid State Agency to improve the existing infrastructure of Hope House, obtain much needed supplies, and increase ability to hire the participants. 'Tausi Feagaiga positively impacted the lives of the residents of Hope House, the course participants, the elders in the community, and those who care for them.

A census tract-level assessment of social determinants of health, traffic exposure, and asthma exacerbations in New York State's Medicaid Population (2005–2015)

This study aims to evaluate the association between social determinants, environmental exposure metrics, and the risk of asthma emergency department (ED) visits in the New York State (NYS) Medicaid population using small-area analysis. Traffic densities for each census tract in NYS were calculated using the length of road segments within each tract and total area of the tract to produce a measure of average number of vehicles per square meter per day. Data on social determinants of health including internal and external environments and other demographic factors were obtained from various sources. Poisson regression analyses were conducted to identify significant factors associated with asthma ED visits in Medicaid claim and encounter data for years 2005–2015. High traffic density in NYS excluding New York City (NYC) correlated with increased risk of asthma ED visits (RR 1.69; 95% CI: 1.42, 2.00), mitigated by adjusting for environmental and social determinants (RR 1.00; 95% CI: 0.85, 1.19). Similar trends were observed in NYC only (RR 1.19; 95% CI: 1.00, 1.41), with the adjusted risk remaining elevated (RR 1.14; 95% CI: 0.98, 1.33) albeit not statistically significant. Living in census tracts with high concentrated disadvantage index, high proportions of minorities, and less green space predicted higher asthma ED visits. We mapped predicted rates and model residuals to identify areas of high risk. Our results support previous findings that environmental and social risk factors in poor and urban areas contribute to asthma exacerbations in the NYS Medicaid population, even if they may not necessarily contribute to its development.