Nontraditional Providers Research Articles

The Community as Provider: Collaboration and Community Ownership in Northern Maternity Care

Across Canada, researchers and maternity care leaders have identified a crisis in maternity care due to a shortage of skilled providers (obstetricians, family physicians, midwives). For the remote Inuit communities of Nunavut this crisis is about a lack of local maternity care and childbirth brought about by the erosion of local capacity and participation in planning and provision. These communities face difficulties recruiting, training and retaining skilled providers. They also experience a lack of consistency in providers and services within and across Aboriginal communities in Canada, and system dependence on the evacuation of women in remote communities for childbirth. System dependence on evacuation for childbirth has effectively removed childbirth from Nunavut families and communities. Across Nunavut, efforts to return childbirth to communities have been challenged by a lack of mobilization of providers and communities, concerns about safety, and relationships between communities, providers, decision-makers, and various levels of government. From November 2002 to December 2004, through a qualitative consultative methodology we examined current maternity care across ten Nunavut communities and their visions for change. We found that a return of childbirth to communities is thus, not simply about hiring more providers and developing local training. This return will require a rethinking of relationships between and collaboration among communities, providers, and levels of government to determine, plan and implement sustainable maternity care for remote, Inuit communities. While collaboration is crucial to providing sustainable maternity care in remote, Inuit settings, we argue that multidisciplinary collaboration needs to be reframed to include the community. Moreover, we find that collaboration becomes all the more complex in the context of community ownership and historical relationships between traditional and non-traditional providers.

Comparative Analysis of University Accreditation Systems in Nigeria, Egypt, Malawi and Japan: Lessons for Regulatory Authorities

Purpose: Ensuring quality in accreditation standards and process for higher institutions is highly imperative in order to produce qualitative students and staff (national and international), and to securing the recognition of qualifications that institutions are awarding. The objective of this study was to investigates the similarities and differences in the accreditation process in Nigeria, Egypt, Malawi and Japan. Methods: The study was based on qualitative approach. The study adopted the historical method of data collection. This study being descriptive, as well as historical, relied essentially on secondary information sources gathered by the researchers via many books, articles, journal periodicals, internet materials, and notable books. Data were analyzed using a narrative method that leaned more on the interpretivist approach. Results: The study showed that accreditation process in the selected countries has some similarities in process and standards such as setting of minimum standards, self-study, selection and training of reviewers, site visit, reporting, final decision, disclosure, academic matter (curriculum), students, staffing, facilities and funding. Also, there exist some differences in the process and standards across the countries of study in term of preliminary/preassessment visit before actual site visit, factual error checking, virtual visit, third party agencies, verification of external auditor’s report, etc. Conclusion: The study assesses the university accreditation systems in Nigeria, Egypt, Malawi, and Japan. Accrediting agencies need to focus on future accreditation in term of digitalisation of accreditation process, emergence of non-traditional providers of higher education, high demand for competency-based university education/learning, high rate of global competitiveness, and elimination of academic and accreditation corruption in the system.

The acceptability of the Fire and Rescue Service working with primary care to improve identification of mental health problems in older adults. A mixed-method qualitative study.

Mental ill-health in older adults (aged 60 years and over) is often underdiagnosed and undertreated. Older adults are less likely to access mental health services owing to perceived stigma and fear of being a burden. Non-traditional providers of health care, such as the Fire and Rescue Services (FRS), provide a possible solution to facilitate early detection of problems and help-seeking among older adults, especially in the context of pressured statutory services. To examine whether and how FRS Home Fire Safety Visits (HFSV) could be optimised to include detection and signposting for mental health problems - particularly anxiety and depression - in older adults. This mixed-method qualitative study took place in the West Midlands, UK in 2022. This study involved focus groups (n = 24) and interviews with FRS staff (n = 4) to develop an in-depth contextual understanding of he acceptability and feasibility of expanding HFSV to include identification of anxiety and depression. FRS staff were open to expanding their HFSVs to include mental health, provided they had sufficient training and support from partner agencies in primary and social care settings to accept referrals for service users presenting with symptoms of anxiety and/or depression. The positive reputation of FRS staff and engagement with older adults suggests that HFSV could support the detection of anxiety and depression in older adults, and appropriate signposting to other services including primary care.

832: DOES CHOICE OF SEDATIVE COMBINATIONS AFFECT THE RECOVERY TIME IN PEDIATRIC SEDATION PRACTICES?

Introduction: Pediatric sedation practices have changed drastically, procedure sedation by non-traditional providers have increased markedly. In procedures that require sedation, the type of sedative and its combinations depends on different factors. In this study, we evaluated the prevalence of sedation drugs used and its impact on recovery to discharge time in outpatient MRI studies. We hypothesize, that patients who underwent sedation with a combination of midazolam and propofol, will have a shorter recovery time when compared to the other combinations. Methods: In this retrospective cohort study, we evaluated patients that required sedation for brain MRI in a pediatric procedure center in a tertiary teaching hospital, from December 2021 - April 2022. Patients that required opioids were excluded. We determined the prevalence of medications used, their combinations, and its association with recovery time. Data was expressed as medians ± SD or percentages as appropriate. A Kruskal-Wallis test was used to determine the association between sedation drugs used and recovery time. A p-value < 0.05 was established as statistically significant. Results: During the study period, a total of 179 brain MRIs were evaluated. 170 patients met inclusion criteria. The median age was 44 ± 45.5 months. The total sedation time was 47 ± 24 minutes and recovery time was 110.5 ± 37.4 minutes. The most frequent combination of drugs used was ketamine and dexmedetomidine (35%), followed by ketamine + midazolam + dexmedetomidine, which was used in 15.9% of patients. There was no difference among total sedation time with the different drugs used and its combinations. Conclusions: The data evaluated suggest that there is no difference between drugs combinations. Possibly due to factors not associated to drugs administration. There are different factors that can alter the recovery time outside sedatives drugs combinations, as personnel in the procedure centers, protocols for patient discharge etc. These factors will be further evaluated to have a more accurate estimate for recovery to discharge time. We understand that the creation of a standardized protocol for discharge and pharmacologic combination will drastically improve the recovery to discharge time.

Interventions to identify and manage depression delivered by 'nontraditional' providers to community-dwelling older adults: A realist review.

Mental health problems experienced by older adults (60+ years of age) may remain hidden due to individual and system-level barriers. Opportunities to support early identification and management are therefore crucial. The National Health Servicerecommends wider public services that are embedded within local communities, but are not traditionally part of the healthcare landscape (i.e.,'nontraditional'),could facilitate engagement with healthcare by members of the public. Evidence for interventions involving Fire and Rescue, Police, Library services and postal workers, as nontraditional providers of mental health services, has not been synthesized previously. This review aims to understand how, why and in what contexts mental health interventions delivered by these nontraditional providers, to older adults, work. A realist review of interventions to identify and/or manage mental health problems (depression with or withoutanxiety) experienced by older adults. Systematic, cluster and iterative literature searches were conducted. Intervention evidence was appraised for rigour and explanatory relevance and then coded to inform context-mechanism-outcome configurations (CMOCs). A public advisory group supported our initial evidence search strategy and definition of key terms. This review is registered with PROSPERO (CRD42020212498). Systematic searches revealed a dearth of evidence reporting mental health interventions delivered by nontraditional providers. Our scope was adjusted to consider interventions delivered by Fire and Police services only and for wider health and wellbeing concerns (e.g., dementia, falls prevention, mental health crises). Forty-three pieces of evidence were synthesized. Key themes included: legitimizing expanded roles, focusing on risk, intervention flexibility and organization integration; further subthemes are described. Themes map onto CMOCs and inform a preliminary programme theory. Findings were transposed to mental health contexts. Findings highlight challenges and opportunities for Fire and Police services, as nontraditional providers, to deliver interventions that identify and/or manage mental health problems among older adults. Our programme theory explains what could work, how, for whom and also by whom (i.e., which public services). Further empirical evidence is needed to test interventions, understand acceptability and inform implementation. A public advisory group comprising older adults with lived experience of mental health problemsand informal caregiverscontributed to the original application, reviewed the scopeand informed the approach to dissemination.

Increasing Uptake of Maternal Pertussis Vaccinations through Funded Administration in Community Pharmacies.

Although maternal pertussis vaccination is recommended, uptake is suboptimal in New Zealand (NZ), despite full funding in general practice and hospitals. We determined whether funding maternal pertussis vaccination in community pharmacy increases its uptake. Pertussis vaccination during pregnancy was compared between non-contiguous, demographically similar regions of NZ. The pertussis vaccine was funded at pharmacies from Nov 2016 in one NZ region (Waikato), but not in comparator regions (Northland, Hawkes Bay). Vaccinations during pregnancy were determined from the National Immunisation Register, general practice and pharmacy claims data, and a maternity database. Comparisons were made using adjusted odds ratios (OR) and 95% confidence intervals (CI) for Nov 2015 to Oct 2016 versus Nov 2016 to Oct 2019. The odds of pregnancy pertussis vaccination increased in the post-intervention versus pre-intervention period with this increase being larger (p = 0.0014) in the intervention (35% versus 21%, OR = 2.07, 95% CI 1.89–2.27) versus the control regions (38% versus 26%, OR = 1.67, 95% CI 1.52–1.84). Coverage was lower for Māori versus non-Māori, but increased more for Māori in the intervention versus control regions (117% versus 38% increase). It was found that funding maternal pertussis vaccination in pharmacy increases uptake, particularly for Māori women. Measures to increase coverage should include reducing barriers to vaccines being offered by non-traditional providers, including pharmacies.

Emergence of Non-Traditional Financial Service Providers in the Market - A Threat or An Opportunity for the Georgian Banking Industry

Abstract Each banking institution has a customer-oriented strategic plan, although the sudden emergence of competition does not allow them to relax. The explosion of new technologies and the rise in consumer demand have been putting pressure on banks since the 2008 recession. Retail banking customers are constantly expecting new, improved, affordable, convenient continuous service from the bank. In an environment of increasingly competitive, innovative financial services, banks need to be able to maintain not only customers but also brand awareness. The emergence of non-traditional financial service providers in the market such as FinTech, NEO Banks, Challenger Banks, BigTech, which reduces the relationship between banks and their customers, completely changes the banking industry. Today we face a new open ecosystem of consumers, traditional banks, FinTech and BigTech companies, regulators, developers, non-banking firms and other players, with customers at the center. Banks will have to significantly change their commercial and operating models to retain customers and remain active players in the market. The presented paper examines the development trends of new players in the financial industry - non-traditional financial service providers and the readiness of the banking industry to respond to these trends. The paper is a study of the impact of digitalization of financial services on the banking sector based on the study and analysis of reports of the various international organizations, local policy documents, reports and regulations of the National Bank, the papers of various researchers and their secondary data. Based on the research, suggestions have been made on how Georgian banks should strategically approach non-traditional providers of financial services to avoid losses, withstand competition and remain active market players.

HCV Elimination in the US Department of Veterans Affairs.

HCV Elimination in the US Department of Veterans Affairs.

Chinese Experience of Advancing Financial Inclusion in Light of Foster’s Three Limiting Conditions in Institutional Change

:China has been developing “financial inclusion” since the 1990s so as to deal with financial exclusion, a problem that faces rural residents and small and micro enterprises as well as the poor. Analysis is conducted in light of John Foster’s theory of institutional change, especially the three limiting conditions, which are, the availability of knowledge, people’s capacity for understanding and adaptation, and the principle of minimal dislocation. Digital finance, introduced into China in the early 2000s, is thought to be the innovative and sustainable means of financial inclusion and was boldly encouraged with very loose regulation, especially before 2015. Many of the nontraditional providers of internet financial services, including nonbank digital payment, internet-based lending, crowd funding, and virtual coins, etc. had boomed like mushroom since 2013. While social permission has been granted to such well-intentioned but poorly understood social experiments, unprecedent internet financial chaos have emerged and spread raising serious social concern. Since 2015, new policy bundles have been developed in China, and the concept and practice of financial inclusion has been transformed greatly. As China is still facing challenges marching toward financial inclusion, the three limiting conditions must be carefully considered in formulating policies.

Non-traditional support workers delivering a brief psychosocial intervention for older people with anxiety and depression: the NOTEPAD feasibility study

BackgroundAnxiety and depression often coexist in older people. These disorders are often underdiagnosed and undertreated, and are associated with increased use of health and social care services, and raised mortality. Barriers to diagnosis include the reluctance of older people to present to their general practitioner (GP) with mood symptoms because of the stigma they perceive about mental health problems, and because the treatments offered are not acceptable to them.ObjectivesTo refine a community-based psychosocial intervention for older people with anxiety and/or depression so that it can be delivered by non-traditional providers such, as support workers (SWs), in the third sector. To determine whether or not SWs can be trained to deliver this intervention to older people with anxiety and/or depression. To test procedures and determine if it is feasible to recruit and randomise patients, and to conduct a process evaluation to provide essential information to inform a randomised trial.DesignThree phases, all informed by a patient and public involvement and engagement group. Qualitative work with older people and third-sector providers, plus a consensus group to refine the intervention, training, SW manuals and patient participant materials (phase 1). Recruitment and training of SWs (phase 2). Feasibility study to test recruitment procedures and assess fidelity of delivery of the intervention; and interviews with study participants, SWs and GPs to assess acceptability of the intervention and impact on routine care (phase 3).SettingNorth Staffordshire, in collaboration with Age UK North Staffordshire.InterventionA psychosocial intervention, comprising one-to-one contact between older people with anxiety and/or depression and a SW employed by Age UK North Staffordshire, based on the principles of behavioural activation (BA), with encouragement to participate in a group activity.ResultsInitial qualitative work contributed to refinement of the psychosocial intervention. Recruitment (and retention) of the SWs was possible; the training, support materials and manual were acceptable to them, and they delivered the intervention as intended. Recruitment of practices from which to recruit patients was possible, but the recruitment target (100 patients) was not achieved, with 38 older adults randomised. Retention at 4 months was 86%. The study was not powered to demonstrate differences in outcomes. Older people in the intervention arm found the sessions with SWs acceptable, although signposting to, and attending, groups was not valued by all participants. GPs recognised the need for additional care for older people with anxiety and depression, which they could not provide. Participation in the study did not have an impact on routine care, other than responding to the calls from the study team about risk of self-harm. GPs were not aware of the work done by SWs with patients.LimitationsTarget recruitment was not achieved.ConclusionsSupport workers recruited from Age UK employees can be recruited and trained to deliver an intervention, based on the principles of BA, to older people with anxiety and/or depression. The training and supervision model used in the study was acceptable to SWs, and the intervention was acceptable to older people.Future workFurther development of recruitment strategies is needed before this intervention can be tested in a fully powered randomised controlled trial.Trial registrationCurrent Controlled Trials ISRCTN16318986.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 7, No. 25. See the NIHR Journals Library website for further project information.

A feasibility study for NOn-Traditional providers to support the management of Elderly People with Anxiety and Depression: The NOTEPAD study Protocol

BackgroundAnxiety and depression are common among older people, with up to 20% reporting such symptoms, and the prevalence increases with co-morbid chronic physical health problems. Access to treatment for anxiety and depression in this population is poor due to a combination of factors at the level of patient, practitioner and healthcare system.There is evidence to suggest that older people with anxiety and/or depression may benefit both from one-to-one interventions and group social or educational activities, which reduce loneliness, are participatory and offer some activity. Non-traditional providers (support workers) working within third-sector (voluntary) organisations are a valuable source of expertise within the community but are under-utilised by primary care practitioners. Such a resource could increase access to care, and be less stigmatising and more acceptable for older people.MethodsThe study is in three phases and this paper describes the protocol for phase III, which will evaluate the feasibility of recruiting general practices and patients into the study, and determine whether support workers can deliver the intervention to older people with sufficient fidelity and whether this approach is acceptable to patients, general practitioners and the third-sector providers.Phase III of the NOTEPAD study is a randomised controlled trial (RCT) that is individually randomised. It recruited participants from approximately six general practices in the UK. In total, 100 participants aged 65 years and over who score 10 or more on PHQ9 or GAD7 for anxiety or depression will be recruited and randomised to the intervention or usual general practice care. A mixed methods approach will be used and follow-up will be conducted 12 weeks post-randomisation.DiscussionThis study will inform the design and methods of a future full-scale RCT.Trial registrationISRCTN, ID: ISRCTN16318986. Registered 10 November 2016. The ISRCTN registration is in line with the World Health Organization Trial Registration Data Set. The present paper represents the original version of the protocol. Any changes to the protocol will be communicated to ISRCTN.

Three Nontraditional Approaches to Improving the Capacity, Accessibility, and Quality of Mental Health Services: An Overview.

To provide evidence for wider use of peer workers and other nonprofessionals, the authors examined three approaches to mental health service provision-peer support worker (PSW) programs, task shifting, and mental health first-aid and community advocacy organizations-summarizing their effectiveness, identifying similarities and differences, and highlighting opportunities for integration. Relevant articles obtained from PubMed, MEDLINE, and Google Scholar searches are discussed. Studies indicate that PSWs can achieve outcomes equal to or better than those achieved by nonpeer mental health professionals. PSWs can be particularly effective in reducing hospital admissions and inpatient days and engaging severely ill patients. When certain care tasks are given to individuals with less training than professionals (task shifting), these staff members can provide psychoeducation, engage service users in treatment, and help them achieve symptom reduction and manage risk of relapse. Mental health first-aid and community organizations can reduce stigma, increase awareness of mental health issues, and encourage help seeking. Most PSW programs have reported implementation challenges, whereas such challenges are fewer in task-shifting programs and minimal in mental health first-aid. Despite challenges in scaling and integrating these approaches into larger systems, they hold promise for improving access to and quality of care. Research is needed on how these approaches can be combined to expand a community's capacity to provide care. Because of the serious shortage of mental health providers globally and the rising prevalence of mental illness, utilizing nontraditional providers may be the only solution in both low- and high-resource settings, at least in the short term.

Missed Opportunities for HIV Diagnosis.

It has been previously shown that patients may present for multiple health issues in the years preceding their initial HIV diagnosis. This retrospective cohort study analyzed the data of patients with a new HIV diagnosis, at Ochsner Health System between January 1, 2011, and December 31, 2012. The primary end point was missed opportunities, the number of healthcare visits these patients made in the 2 years prior to being diagnosed with HIV. The 125 patients in the study cohort had 649 healthcare visits during which an HIV test was not performed. These missed opportunities are the key to capturing the undiagnosed and unaware HIV-positive individual. Primary care is an ideal setting to conduct HIV testing for those who have access to regular health care. However, nontraditional providers should also be encouraged to conduct HIV testing regardless of their ability to provide treatment because evidence shows that knowledge of the diagnosis may change behavior.

Provision of Preventive Dental Services in Children Enrolled in Medicaid by Nondental Providers.

Aims of this study are to determine (1) the association of oral health services (OHS) provided by nontraditional providers with the percentage of Medicaid children 0 to 5 years of age who receive ≥1 preventive services from all provider types in the United States; and (2) characteristics of state Medicaid policies associated with provision of OHS. We conducted a time-series cross-sectional study of preventive services provided by nontraditional (OHS) and dental (PDS) providers for Medicaid-enrolled children from birth to 5 years of age in all states during 2010 to 2013 (204 observations). We applied panel data multiple regression analysis techniques to exploit year and state variation in aggregate data available in Centers for Medicare and Medicaid Services reports (form CMS-416). Total preventive dental services (TPDS =OHS + PDS) was predicted by months since state enactment of a policy to reimburse medical providers for OHS. The 44 states with a policy reported 4.3% of children per state per year with any OHS. For all states, an average of 30.1% received PDS and 34.5% TPDS. The delivery of OHS was associated with a small increase in percentage with TPDS. One year of Medicaid OHS availability was associated with an increase of 1.5% in the percentage of children with TPDS per state per year. Implementation of policies by Medicaid programs to support integration of OHS into primary care is associated with increases in overallTPDS use, but efforts are needed to improve implementation in practice to achieve national impact on access.

Marginally scientific? Genetic testing of children and adolescents for lifestyle and health promotion.

‘Genetic testing can reveal crucial information to guide your training and nutrition strategies based on predispositions built into your DNA. Genetic testing identifies the ideal nutrition, training and recovery strategies for you and helps explain why athletes given the same training and nutrition plans respond differently. In short gene testing provides the ultimate in personalized nutrition and training guidance…’1 Direct-to-consumer (DTC) genetic testing has been in the news in recent years, especially since November 2013, when the US Food and Drug Administration (FDA) shut down 23andMe, one of several firms that offered people general health information based on their genetic test results.2 Much attention has been paid to the accuracy of these tests in predicting future risk of disease. This is understandable as the first wave of DTC companies, including 23andMe, eventually focused on providing genetic information of this nature. And much of the existing literature on the possible harms and benefits of DTC testing is largely an analysis of disease-oriented testing.3 But it should not be forgotten that many other DTC genetic testing products are being marketed throughout the world that are not focused on disease risk but instead offer information—of varying degrees of scientific legitimacy—relevant to things like fitness, diet, and athletic ability. In addition, non-traditional providers, such as homeopaths,4 naturopaths,5 and chiropractors,6 increasingly are offering genetic tests for the purpose of providing health and lifestyle advice. It seems inevitable that, unless the regulatory environment changes, this trend will continue, with genetic testing being offered to the public for an ever-increasing range of reasons not directly related to disease. In this paper, we map the policy issues associated with the marketing and use of genetic testing products outside of the context of disease risk. We focus on companies and providers that offer testing for a wide range of genetic traits, and consider the potential implications of offering these products for use in children and adolescents. While the size of the market for these services remains unknown, it is probably still relatively small.7 Nonetheless, an analysis of genetic testing in this broader context provides an opportunity to consider issues that are likely to increase in significance as genetic testing technologies become more affordable and as the idea of genetic testing becomes more socially acceptable.8 For example, the present analysis affords an opportunity to consider the possible harms, if any, and available policy options for regulating genetic testing services not focused on disease risk and that reside on the margins of credibility. As we will see, some tests are being marketed for purposes that are clearly scientifically absurd (eg for targeting homeopathic therapies and naturopathic detoxification regimens)9 while others have more scientific plausibility, at least theoretically (eg testing for genes related to obesity and athletic characteristics like sprinting ability). Obviously, not all of these services will raise the same issues. But what they do have in common is the provision of genetic information. Are most of these companies and providers simply leveraging the excitement surrounding genetics to market services with unproven utility that are largely harmless? Is there something about genetic testing, as opposed to other forms of equally predictive information, which justifies heightened regulatory oversight? Looking at these, and other,10 issues through the lens of children and adolescents highlight potential policy challenges that may be especially problematic.11 While one could argue that legally competent adults should have the right to choose whatever service they have an interest in (however useless), this may not be the case in the context of children and adolescents who lack legal capacity and may be particularly vulnerable to DTC industry marketing strategies. We will examine whether, in the context of genetic testing services that have little scientific data to support their purported uses, any regulatory or policy response is appropriate and the potential forms such a response could take.

National Strategy on HIV/AIDS Geared Toward Elimination of HIV

National Strategy on HIV/AIDS Geared Toward Elimination of HIV

Community-based wellness and prevention programs: the role of medicare.

Community-based wellness and prevention programs: the role of medicare.

The Southeastern Minnesota Beacon Project for Community-driven Health Information Technology: Origins, Achievements, and Legacy

Introduction:The Southeastern (SE) Minnesota Beacon organized all the health care providers, county public health organizations, and school districts in the deployment and integration of health information exchange (HIE) and targeted health communication around childhood asthma and diabetes. The community cooperated to establish a clinical data repository for all residents in the 11-county region. Through this community of practice approach that involved traditional and nontraditional providers, the SE Minnesota Beacon was able to realize unique applications of this technology. This manuscript overviews the associated organization and infrastructure of this community collaboration.Background:The Office of the National Coordinator for Health Information Technology (ONC), as part of the American Recovery and Reinvestment Act of 2009 (ARRA) stimulus, established 17 projects throughout the United States targeting the introduction and meaningful use of health information technology (HIT). These 17 communities were intended to serve as an example of what could be accomplished. The SE Minnesota Beacon is one of these communities.Methods:The community ultimately opted for peer-to-peer HIE, using Nationwide Health Information Network (NwHIN) Connect software. The clinical data repository was established using the infrastructure developed by the Regenstrief Institute, which operated as a trusted third party. As an extension to HIE, the consortium of county public health departments created a patient data portal for use by school nurses and parents. Childhood asthma was addressed by creating, exchanging, and maintaining an “asthma action plan” for each affected child, shared throughout the community, including through the patient portal. Diabetes management introduced patient treatment decision tools and patient quality of life measures, facilitating care. Influenza vaccination was enhanced by large-scale community reporting in partnership with the state vaccination registry. The methodology and principles for arriving at these solutions included community engagement, sustainability, scalability, standards, and best practices that fit a variety of organizations—from large, robust providers to small organizations.Findings:The SE Minnesota Beacon demonstrated that all providers for a geographically defined population can cooperate in the development and shared governance of a low-cost, sustainable HIE, and the operation of a community-managed clinical data repository. Furthermore, these infrastructures can be leveraged to collaboratively improve the care of patients, as demonstrated for childhood asthma and adult diabetes mellitus.Conclusion:The shared governance of HIT by a community can palpably change the scope and success of collaborations targeted to improve patient and community health care.

State-based Medicaid costs for pediatric asthma emergency department visits.

IntroductionThe prevalence of childhood asthma in the United States increased from 8.7% in 2001 to 9.5% in 2011. This increased prevalence adds to the costs incurred by state Medicaid programs. We provide state-based cost estimates of pediatric asthma emergency department (ED) visits and highlight an opportunity for states to reduce these costs through a recently changed Centers for Medicare and Medicaid Services (CMS) regulation.MethodsWe used a cross-sectional design across multiple data sets to produce state-based cost estimates for asthma-related ED visits among children younger than 18, where Medicaid/CHIP (Children’s Health Insurance Program) was the primary payer.ResultsThere were approximately 629,000 ED visits for pediatric asthma for Medicaid/CHIP enrollees, which cost $272 million in 2010. The average cost per visit was $433. Costs ranged from $282,000 in Alaska to more than $25 million in California.ConclusionsCosts to states for pediatric asthma ED visits vary widely. Effective January 1, 2014, the CMS rule expanded which type of providers can be reimbursed for providing preventive services to Medicaid/CHIP beneficiaries. This rule change, in combination with existing flexibility for states to define practice setting, allows state Medicaid programs to reimburse for asthma interventions that use nontraditional providers (such as community health workers or certified asthma educators) in a nonclinical setting, as long as the service was initially recommended by a physician or other licensed practitioner. The rule change may help states reduce Medicaid costs of asthma treatment and the severity of pediatric asthma.

LAY PROVIDERS CAN DELIVER EFFECTIVE COGNITIVE BEHAVIOR THERAPY FOR OLDER ADULTS WITH GENERALIZED ANXIETY DISORDER: A RANDOMIZED TRIAL

The Institute of Medicine recommends developing a broader workforce of mental health providers, including nontraditional providers, to expand services for older adults. Cognitive behavior therapy (CBT) is effective for late-life generalized anxiety disorder (GAD), but no study has examined outcomes with delivery by lay providers working under the supervision of licensed providers. The current study examined the effects of CBT delivered by lay, bachelor-level providers (BLP) relative to Ph.D.-level expert providers (PLP), and usual care (UC) in older adults with GAD. Participants were 223 older adults (mean age, 66.9 years) with GAD recruited from primary care clinics at two sites and assigned randomly to BLP (n = 76), PLP (n = 74), or UC (n = 73). Assessments occurred at baseline and 6 months. CBT in BLP and PLP included core and elective modules (3 months: skills training; 3 months: skills review) delivered in person and by telephone, according to patient choice. CBT in both BLP and PLP groups significantly improved GAD severity (GAD Severity Scale), anxiety (Spielberger State-Trait Anxiety Inventory; Structured Interview Guide for the Hamilton Anxiety Scale), depression (Patient Health Questionnaire), insomnia (Insomnia Severity Index), and mental health quality of life (Short-Form-12), relative to UC. Response rates defined by 20% reduction from pre- to posttreatment in at least three of four primary outcomes were higher for study completers in BLP and PLP relative to UC (BLP: 38.5%; PLP: 40.0%; UC: 19.1%). Lay providers, working under the supervision of licensed providers, can deliver effective CBT.