National Program Office Research Articles

A process evaluation model for patient education programs for pregnant smokers

OBJECTIVE To describe and apply a process evaluation model (PEM) for patient education programs for pregnant smokers. METHODS The preparation of a process evaluation plan required each program to define...

The enigmatic nursing workforce.

Patricia Prescott, PhD, RN, Workforce Consultant, Colleagues in Caring National Program Office, Washington, DC.

The new child health insurance expansions: how will school-based health centers fit in?

In June 1998, the Making the Grade National Program Office and the National Assembly on School-Based Health Care sponsored a workshop on the relationship between the State Child Health Insurance Program (SCHIP) and school-based health centers. Workshop participants used the health centers' experience with Medicaid managed care as a window for understanding their prospects for negotiating contracts with health plans under SCHIP. Speakers representing the federal perspective, state agencies, health plans, and local school-based health centers offered their views on the challenges of developing contracts, incentives, and disincentives that health plans have to contract with school-based health centers, and what has accounted for success where relationships are moving forward. Experiences in Colorado and Connecticut were presented as case studies on these evolving issues.

Overview of the regional collaboratives.

Responding to demands that nursing leaders conduct business in creative, proactive ways, the authors of this department share the work of The Robert Wood Johnson Foundation's national program. Colleagues in Caring: Regional Collaboratives for Nursing Work Force Development. The purpose of this initiative is to enhance regional and state collaborative planning and implement actions and policies to address the rapid changes occurring in the United States nursing labor market. This department presents the ongoing work of the program, highlighting the work of the 20 individual collaboratives. Regional approaches to the expected program outcomes and specific challenges and opportunities that are unique to each region's environment are included. The Colleagues in Caring program is administered by the American Association of Colleges of Nursing. Current information on the initiative can be found at http:/(/)www.aacn.nche.edu under Special Projects. The staff at the National Program Office can be reached at 202/496-1095 (fax: 202/496-1093).

Financial performance among adult day centers: results of a national demonstration program.

This paper describes the financial performance (defined as percent of total expenses covered by net operating revenue) of 16 adult day centers participating in a national demonstration program on day services for people with dementia, including examination of possible predictors of financial performance. Participating sites submitted quarterly financial and utilization reports to the National Program Office. Descriptive statistics summarize the factors believed to influence financial performance. Sites averaged meeting 35% of expenses from self-pay and 29% from government (mainly Medicaid) revenue, totaling 64% of all (cash plus in-kind) expenses met by operating revenue. Examination of center characteristics suggests that factors related to meeting consumer needs, such as being open a full day (i.e., 7:30 am to 6:00 pm) rather than shorter hours, and providing transportation, may be related to improved utilization and, thus, improved financial performance. Higher fees were not related to lower enrollment, census, or revenue. Adult day centers are able to achieve financial viability through a combination of operating (i.e., fee-for-service) and non-operating revenue. Operating revenue is enhanced by placing emphasis on consumer responsiveness, such as being open a full day. Because higher fees were not related to lower utilization, centers should set fees to reflect actual costs. The figure of 64% of expenses met by operating revenue is conservative inasmuch as sites included in-kind revenue as expenses in their budgeting calculations, and percent of cash expenses met by operating revenue would be higher (approximately 75% for this group of centers).

Decategorizing health services: interim findings from the Robert Wood Johnson Foundation's Child Health Initiative.

Although results from the evaluation are preliminary thus far, certain tentative conclusions can be reached. First, both care coordination on a small scale and the production of community health report cards are achievable within the relatively short life of a foundation grant. Moreover, both efforts can result in tangible improvements for children and their families. Report cards associated with the initiative have made children's issues more prominent and appear to have led many community leaders to focus greater attention on children's needs. Likewise, many of the care coordination systems developed under the initiative have produced real change for children and their families by guiding them to needed health care and other services. It is important, however, to keep these accomplishments in perspective. While of significant benefit to demonstration communities, the monitoring and care coordination components of this initiative are not unique. A large number of communities have adopted monitoring and reporting programs in recent years. Similarly, care coordination efforts are well established in many communities. What is unique about the RWJF initiative is its attempt at decategorization, and much less progress has been demonstrated for this component. The less-than-hoped-for progress in implementing decategorization at the original sites appears to be the product of a number of interrelated factors. These include an absence of existing models and appropriate technical assistance; political difficulties in gaining cooperation from multiple local agencies involved in service provision; limited progress in establishing needed connections with the state and federal agencies that have authority over categorical programs; and difficulties in implementing major programatic changes when the health care system itself is undergoing rapid change. In combination, these barriers have proven to be largely insurmountable for the originally funded sites, although it is too early in the project to determine which of these factors is predominantly responsible for the lack of success. Whether the newer sites can learn from the experience of the first group and adapt strategies to overcome the multiple hurdles involved remains to be seen. Decategorization is a tool that has the potential to rationalize a fragmented service system by facilitating the coordination of services, especially for children and families with multiple needs. The need for decategorization of funds will not disappear, even if the federal government chooses to combine more of its grant programs to the states into block grants.(ABSTRACT TRUNCATED AT 400 WORDS)

Bench-Scale Testing of Selected Remediation Alternatives for Contaminated Sediments

The Assessment and Remediation of Contaminated Sediments (ARCS) Program within the U.S. Environmental Protection Agency's Great Lakes National Program Office (GLNPO) contained a component for demonstrating and evaluating sediment remediation technologies. Toward this end, bench-scale tests of solvent extraction, thermal desorption, and wet air oxidation technologies were conducted. Contaminated sediments were tested from the Grand Calumet River, Indiana; Buffalo River, New York; Saginaw River, Michigan; and Ashtabula River, Ohio. The primary contaminants of concern in these sediments were polychlorinated biphenyls (PCBs) and polynuclear aromatic hydrocarbons (PAHs). The solvent extraction tests were conducted with sediments from the Grand Calumet, Buffalo, and Saginaw rivers. The thermal desorption studies were conducted with sediments from the Grand Calumet, Buffalo, and Ashtabula rivers. The wet air oxidation testing was performed with the Grand Calumet River sediment. Raw sediment contaminant concentrations ranged from 0.32-21.9 mg/kg dry mass for PCBs and 2.70-266 mg/kg dry mass for PAHs. PCB removal or destruction efficiencies ranged from approximately 6-99%. PAH removal or destruction efficiencies ranged from 65-99%. Mass balance closures ranged from 40-99% for solids; 59-139% for water; 29-3500% for oil; 16-129% for PCBs; and 69-3170% for PAHs.

SITE Demonstration of the Basic Extractive Sludge Treatment Process

The Superfund Innovative Technology Evaluation (SITE) Program, in cooperation with EPA Region 5, the Great Lakes National Program Office (GLNPO), and the U.S. Army Corps of Engineers (COE) planned and executed a pilot-scale evaluation of the Basic Extractive Sludge Treatment (B.E.S.T.®) process on sediment samples obtained from the Grand Calumet River in Gary, Indiana. Two separate sampling locations were selected based upon previous data. One location had sediments with total polychlorinated biphenyl (PCB) concentrations averaging 10 mg/kg, and total polynuclear aromatic hydrocarbon (PAH) concentrations averaging 520 mg/kg. The other location had sediments with average total PCB and PAH concentrations of 427 mg/kg and 72,000 mg/kg, respectively. The sediment samples were segregated by location, then screened, homogenized, and stored prior to treatment. A total of ten batches of sediments were treated (five for each sample location). Results showed that of the samples which had low original contaminants concentrations, 96 percent of the PAHs and >99 percent of the PCBs were removed following seven sequential extractions. Treated samples which had high original contaminant concentrations were found to have removal efficiencies of >99 percentfor both PAHs and PCBs. Costs for applying this technology were estimated at $94.19/ton (assuming the system is on-line 80 percent of the time) excluding fixed costs associated with system mobilization/ demobilization and setup, and profit.

Observations from the program on chronic mental illness.

The Robert Wood Johnson Foundation (RWJF) Program on Chronic Mental Illness has come to an end. Launched in December 1986, it was the foundation’s first multisite national venture into mental health care. The program sought to establish improved systems of care for persons with serious and long-term mental disorders in nine major cities across the country. Now, almost six years later, the grant period has ended, and it is time to take stock. The nine demonstration programs are still intact, with more than 250 staff in place at the sites. Throughout the program’s lifetime it received $22.5 million in RWJF grant funds, $9 million in foundation loan funds to stimulate housing development, and 1,200 Section 8 housing certificates, issued by the U.S. Department of Housing and Urban Development (HUD). One view of the impact of this program is offered by Howard Goldman and his colleagues, based on a formal evaluation funded by RWJF and a consortium of federal agencies.’ But there is another view of the program’s impact: the subjective impressions of the national program office staff and the staff at the nine demonstration sites. This perspective has been enriched by RWJF’s style of grant management, which is to fund a partnership between the national program office (typically in a university) and the demonstration sites. Instead of awarding the grant and coming back later to assess the results, RWJF requires that each demonstration site develop its program in collaboration with the national program staff. The national office maintains constant contact with the sites to monitor progress and solve immediate problems and carries out numerous site visits, with special conferences among the sites and other direct contact as needed. This management style affords the national program staff an intimate view of the demonstration sites and an opportunity to compare them as they face common situations.

On the sources of fine and coarse carbon particles in the Great Lakes

During 1988–1989 The Great Lakes National Program Office of the US EPA established a monitoring site in Green Bay, Wisconsin, for the measurement and apportionment of pollutants and toxic compounds to their sources. These studies will assist in providing the data needed to develop mass balance model for toxic chemicals reaching the Great Lakes through atmospheric transport and deposition. Aerosol instruments included dichotomous sampler, high-volume virtual impactor (HVVI), and a regular high-volume sampler. Elemental, carbonate and volatilizable carbon (C v) present in the fine (<2.5 μm) and coarse (2.5–10 μm) fraction samples, and collected by the HVVI, sampler were determined by combustion procedures. Electron microscopy coupled with X-ray energy dispersive analyzer were applied to parallel samples to observe carbon particles of biological origin, such as spores, pollen, and plant debris. Analysis of several samples collected during an intensive study in September 1989 led to the following conclusions: (a) volatilizable carbon in the coarse fraction is mostly of biological origin ; (b) C v in the fine fraction is related to anthropogenic emissions; (c) carbonate carbon is related to soil minerals found in the coarse fraction.

Grants and Outcomes

Grants and Outcomes

Contaminant trends in lake trout (Salvelinus namaycush) from the Upper Great Lakes

Contaminant body burdens in lake trout (Salvelinus namaycush) from the Upper Great Lakes have been monitored since 1970 on Lake Michigan and since 1977 and 1978 on Lakes Superior and Huron by United States Environmental Protection Agency (USEPA), Great Lakes National Program Office and U.S. Fish and Wildlife Service (USFWS), Great Lakes Fishery Laboratory. Analysis of the Lake Michigan data shows that mean polychlorobiphenyl (PCB) concentrations declined from a maximum of 22.91 mg/kg in 1974 to 5.63 mg/kg in 1982. Mean total DDT concentrations declined from 19.19 mg/kg in 1970 to 2.74 mg/kg in 1982. The decline in both contaminants closely followed first order loss kinetics. If the current declines continue, PCB concentrations will decline to the U.S. Food and Drug Administration (USFDA) tolerance of 2.0 mg/kg in 1988. Mean total DDT concentrations will fall to the International Joint Commission (IJC) objective of 1.0 mg/kg by 1991. Mean dieldrin concentrations increased significantly from 0.20 mg/kg in 1971 to 0.58 mg/kg in 1979 before declining to 0.21 mg/kg in 1982. The decline from 1979–1982 followed first order loss kinetics. As this decline is not reflected in other species (bloater chubs, smelt) it will require additional years of monitoring to determine if dieldrin concentrations between 1979 and 1982 truly represents a declining trend. The only statistically significant trend other than in Lake Michigan was for total DDT which declined significantly in Lake Superior lake trout. Large data variance and the short time frame covered (1977–1982) interfered with detection of trends on Lakes Superior and Huron.