The intensifying workforce crisis in nursing homes (NHs) has prompted state-level interventions such as CareGivers NC, a North Carolina (NC) initiative responding to widespread shortages of certified nursing assistants (CNAs). This study assesses whether participation in the CareGivers NC program resulted in measurable improvements in staffing hours and quality outcomes in NC NHs. Using a difference-in-differences approach with propensity score matching, we analyzed performance indicators from 2019 to Q2 2024. Compared to non-participating NHs, program participants showed a significant reduction in total and employee CNA hours, despite a slight increase in contracted hours. No consistent improvements were observed in CMS quality ratings, with a significant decline in staffing and quality measure ratings. These results highlight the limited effectiveness of workforce-only interventions in improving NH quality and emphasize the need for integrated reforms that couple staffing strategies with operational leadership, environmental assessment, policy reforms, and efforts to mitigate ageism.

BACKGROUND The Comprehensive Addiction and Recovery Act (CARA) of 2016 amended the Child Abuse Prevention and Treatment Act (CAPTA), reinforcing and revising the requirement that states develop policies and procedures to address the needs of substance-affected infants and their caregivers. North Carolina's program, the North Carolina Plan of Safe Care (NC POSC), was implemented in August 2017 and involves coordination between multiple agencies.METHODS We conducted a quality improvement project to assess implementation of the North Carolina Plan of Safe Care in Wake County through interviews with key stakeholders involved in program delivery including health care providers (n = 7), child protective services social workers (CPS; n = 14), and care managers at Care Coordination for Children (CC4C; n = 10). We also analyzed data on Plan of Safe Care notifications to Wake County CPS from January 2018 to October 2019.RESULTS Several key themes emerged in stakeholder interviews, including 1) lack of awareness of the program among health care providers; 2) gaps in information sharing and communication between agencies; 3) concerns regarding CPS notifications for all substance exposure types, including prenatal exposure to medication for opioid use disorder (MOUD); 4) common family needs and service referrals; 5) challenges engaging with families; 6) lack of knowledge among health care providers and CPS social workers regarding CC4C; and 7) benefits of the program for infants and families. From January 2018 to October 2019, 91% of notifications for substance-affected infants received by Wake County CPS as part of the NC POSC were screened-in for a maltreatment assessment. Of those screened-in, more than two-thirds (70%) involved prenatal marijuana exposure only.LIMITATIONS This project was limited to one county.CONCLUSIONS As NC POSC implementation continues, further consideration of the infrastructure and guidance available to address the implementation challenges identified by stakeholders will be essential to meeting family needs and promoting infant safety and well-being.

Measuring maturity in Upland cotton (Gossypium hirsutum L.) cultivar trials is a simple calculation of percentage of first harvest to total harvest when most trials are harvested twice. This provides a rough estimate of maturity. Today, cotton trials are rarely harvested twice because of the use of synthetic boll-opening agents. Breeding programs in states such as Arkansas and North Carolina have estimated maturity by either visually estimating percentage bolls open or actually counting open and closed (green) bolls. This study was conducted to determine the optimum combination of replicates, years, and locations of data needed to show 1 d difference in maturity between cultivars. Data were used from the Arkansas testing program for years 2005 through 2012 and from North Carolina for years 2007 through 2012. Arkansas program estimates percentage bolls open visually in all replicates and North Carolina program counts number of open and closed bolls in a short section of each plot in two replicates. For the Arkansas method, we would need to collect data from four replicates, 2 yr, and five locations or four replicates, 3 yr, and three locations. For North Carolina we would need 3 yr, four replicates, and three locations; or 3 yr, three replicates, and five locations; or 3 yr, five replicates, and two locations to provide the same level of precision. Single-year data could detect a 2 d difference in maturity using the Arkansas method and a 4 d difference in maturity using the North Carolina method. The Arkansas method is quicker and provides fairly accurate data on maturity and would be the recommended method to follow.

This study evaluated the financial impact of integrating a systemic care management intervention program (Community Care of North Carolina) with person-centered medical homes throughout North Carolina for non-elderly Medicaid recipients with disabilities during almost 5 years of program history. It examined Medicaid claims for 169,676 non-elderly Medicaid recipients with disabilities from January 2007 through third quarter 2011. Two models were used to estimate the program's impact on cost, within each year. The first employed a mixed model comparing member experiences in enrolled versus unenrolled months, accounting for regional differences as fixed effects and within physician group experience as random effects. The second was a pre-post, intervention/comparison group, difference-in-differences mixed model, which directly matched cohort samples of enrolled and unenrolled members on strata of preenrollment pharmacy use, race, age, year, months in pre-post periods, health status, and behavioral health history. The study team found significant cost avoidance associated with program enrollment for the non-elderly disabled population after the first years, savings that increased with length of time in the program. The impact of the program was greater in persons with multiple chronic disease conditions. By providing targeted care management interventions, aligned with person-centered medical homes, the Community Care of North Carolina program achieved significant savings for a high-risk population in the North Carolina Medicaid program.

Regionalization of trauma care, in which patients are diverted to qualified trauma centers, improves outcomes. The American Heart Association and other groups have advocated similar regionalization of care for ST-segment elevation myocardial infarction (STEMI). The Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments (RACE) initiative was one of the earliest …

Dental caries (tooth decay), the most common chronic disease affecting young children, is exacerbated by limited access to preventive dental services for low-income children. To address this problem, North Carolina implemented a program to reimburse physicians for up to six preventive oral health visits for Medicaid-enrolled children younger than age three. Analysis of physician and dentist Medicaid claims from the period 2000-2006 shows that the program greatly increased preventive oral health services. By 2006 approximately 30percent of well-child visits for children ages six months up to three years included these services. However, additional strategies are needed to ensure preventive oral health care for more low-income children.

Dental caries, the most common chronic disease affecting young children, is exacerbated by limited access to preventive dental services for low-income children. To address this problem, North Carolina implemented a program to reimburse physicians for up to six preventive oral health visits for Medicaid-enrolled children younger than 36 months. Analysis of physician and dentist Medicaid claims from 2000 to 2006 shows the program substantially increased preventive oral health services. By 2006 approximately 30% of well-child visits for 6- to 36-month old children included these services. Additional strategies are needed to ensure preventive oral health care for more low-income children.

Vaccinating Adolescents—New Evidence of Challenges and Opportunities

The S100 calcium-binding proteins S100A8 and S100A9 are elevated systemically in patients with viral infections. The S100A8-S100A9 complex facilitated viral replication in human CD4^+^ T lymphocytes latently infected with HIV-1- and S100A8-induced HIV-1 transcriptional activity. Mechanisms inducing the S100 genes and the potential source of these proteins following viral activation are unknown. In this study, we show that S100A8 was induced in murine macrophages, and S100A8 and S100A9 in human monocytes and macrophages, by polyinosinic:polycytidylic acid, a dsRNA mimetic. Induction was at the transcriptional level and was IL-10 dependent. Similar to LPS-induced S100A8, induction by dsRNA was dependent on p38 and ERK MAPK. Protein kinase R (PKR) mediates antiviral defense and participates in MyD88-dependent/independent signaling triggered by TLR4 or TLR3. Like IL-10, S100 induction by polyinosinic:polycytidylic acid and by LPS was inhibited by the specific PKR inhibitor 2-aminopurine, indicating a novel IL-10, PKR-dependent pathway. Other mediators such as IFN-β, which synergized with dsRNA, may also be involved. C/EBPβ bound the defined promoter region in response to dsRNA. S100A8 was expressed in lungs of mice infected with influenza virus and was maximal at day 8 with strong immunoreactivity in epithelial cells lining the airways and in mononuclear cells and declined early in the recovery phase, implying down-regulation by mediator(s) up-regulated during resolution of the infection. IL-10 is implicated in viral persistence. Since S100A8/S100A9 levels are likely to be maintained in conditions where IL-10 is raised, these proteins may contribute to viral persistence in patients infected by some RNA viruses.

Dear Mr. President, Congratulations on your election. We, the nation’s departments of family medicine, look forward to giving you a hand with health care reform. Compared to other rich nations, we know that our health outcomes fall far short, our health care costs are very high, and access to care is altogether inequitable. Rectifying these problems seems a daunting task, but when attention is paid to the abundant evidence, the solution boils down to 2 simple essentials—universal access to healthcare for all Americans, and much more emphasis on primary care, preventive medicine, and public health. You may ask: “How will we pay for greater access and for more primary care?” Solid evidence shows that the initial cost for this type of reform is recouped within 2 years and then there are substantial savings. Just ask Senator Richard Burr of North Carolina. He can tell you about his state’s great Community Care of North Carolina program.1 Like oil companies, we in academic family medicine are concerned about pipelines. For the best health care system, we need to train more family physicians. Ask Senator Edward Kennedy of Massachusetts. His state introduced a program of universal health care coverage in 2006, but it failed to flourish because there were not enough primary care physicians to care for all of the people suddenly insured.2 And guess what? It’s going to get worse. Currently, 32% of US physicians practice primary care. Over the last 3 years, the number of medical school graduates who will practice primary care is only 16%, and federal programs that will reverse the trend have been eviscerated. Here’s an example: Since 2000, the funding for Federally Qualified Health Centers (FQHCs) has nearly doubled to almost $2 billion. This is laudable. However, over the same time period, the funding for the programs that train the physicians most likely to practice in FQHCs (Title VII, Section 747) has been cut by 55%. This is appalling. Ask Senator Evan Bayh of Indiana if the new Lucas Oil Stadium would have been built if Indianapolis didn’t have a pipeline of loyal Colt fans or the promise of a pipeline of conventions. The pipeline of family physicians is running dry. Would you like some good reading? We recommend an article by Barbara Starfield, pediatrician and one of the nation’s foremost clinical epidemiologists. Her comprehensive review of the literature on systems of effective health care is in The Milbank Quarterly.3 Here’s what our country needs: Patient-Centered Medical Homes. Ubiquitous physician-directed practices that emphasize first-contact care, patient-centered care over time, comprehensive care, integration of care among health care disciplines and within communities, family and community orientation, and cultural competence. (You don’t need to measure much here; practices like these improve outcomes and lower costs by their very nature.) Universal access to care guaranteed by publicly accountable bodies. We don’t necessarily need a single payer; we just need public accountability for those who do pay. Low or no copays or deductibles for primary health services. Led by the growth of Health Savings Accounts (HSAs), out-of-pocket expenses are soaring. The GAO found that HSAs are nothing more than veiled tax shelters.4 Similar professional earnings for primary care physicians relative to other specialists. Recent RVU updates, care coordination payments and pay-for-performance are right on target. Make sure they measure and reward practices that in reality improve the health care system. Here’s what is really amazing: These things naturally occur when there is an adequate workforce of family physicians. If you want an illustration, ask Leiyu Shi of the Johns Hopkins Bloomberg School of Public Health. His studies consistently find that poor health care outcomes due to gaps in socioeconomic status are eliminated by high concentrations of primary care physicians.5 Well, that’s about it. In the long run, these changes will pay for themselves many times over. And the measurements won’t be nearly as cumbersome as you might think. It will take some guts to take on the special interests that will be resistant to such change, but family medicine is ready to step up to the plate.

This study investigates the opinions of the Early Head Start (EHS) staff about physicians and nurses providing preventive dental services for children in EHS. A cross-sectional survey was undertaken of the EHS staff having contact with families in EHS programs in North Carolina (NC). A self-completed questionnaire solicited their opinions (agree, disagree, don't know) about whether physicians and nurses can "provide preventive dental care" and "identify dental problems" in infants and toddlers. Staff knowledge (four items) and attitudes (five items) were tested for their association with whether staff had an opinion (agree/disagree versus don't know) and if so, what that opinion was (agree versus disagree) using the generalized estimating equation method. Questionnaires were completed by 476 staff (98 percent response) in 18 programs (100 percent response). The majority of staff believed that physicians and nurses can provide preventive dental services (66 percent) and identify dental problems (52 percent). Staff placing importance on ensuring access to dental care and who were knowledgeable about fluoride uses were more likely to have an opinion. Among staff with an opinion, those familiar with the NC program where these services are provided in medical offices were more likely to agree that physicians and nurses can provide preventive services and identify problems. Although the opinions of the majority of the EHS staff are not a barrier to using primary medical care providers to deliver preventive dental care, education is needed for staff who are unfamiliar with this approach.

The purpose of this study was to describe cardiac rehabilitation programming, barriers to participation, and reasons for dropout in North Carolina from a program director's perspective and to compare those results with those of a similar statewide survey conducted 5 years earlier. In 1999 and 2004, a survey was mailed to all North Carolina program directors of outpatient cardiac rehabilitation programs. The response rate was 85% (61/72) in 1999 and 79% (61/77) in 2004. More than 85% of North Carolinians older than 40 years lived within a 15-mile buffer of an outpatient cardiac rehabilitation program in 2004. Most programs were staffed with personnel trained in nursing, exercise physiology, and nutrition in 1999 and 2004. Women and African Americans remained disproportionately underrepresented as participants in the program for both years. In 2004, approximately one third of cardiac rehabilitation programs reported having a referral to rehabilitation on the hospital discharge plan for myocardial infarction and coronary artery bypass surgery. In 1999 and 2004, the most frequently reported barrier to participation remained financial, followed by lack of interest or motivation and workplace conflicts. Work conflicts, lack of interest, and comorbidities were the most frequently reported reasons for dropping out from cardiac rehabilitation programs in both 1999 and 2004. Increasing participation in cardiac rehabilitation programs by addressing barriers at multiple levels may facilitate greater patient participation. This statewide survey could be used in other states as a surveillance tool, to track changes in rehabilitation over time from a program director's perspective.

Nationally, less than 50 percent of children reenroll in the State Children's Health Insurance Program (SCHIP), a program for children from families with incomes too high to qualify for Medicaid, but too low to afford private health insurance. To identify why, we surveyed parents who disenrolled children from a North Carolina program in 2004. Seventy-two percent of the respondents knew that their children were disenrolled and 28 percent did not know. The most common reasons parents reported for not reenrolling their children were that they never received the reenrollment forms, or they submitted their forms late. Most said they would pay out of pocket now to purchase health care services for their children. Most respondents took their children to see a provider while enrolled in SCHIP in the last year, and most were satisfied with the care received. We conclude that the goal of increasing children's reenrollment in public health insurance programs requires an improvement in health insurance information, an increase in trust in our social and health institutions, and a reorganization of the reenrollment process.

Piloting Mental Health Integration in the Community Care of North Carolina Program

North Carolina’s program of court-ordered mediation of general civil cases originated in the advocacy of attorneys, including those interested in the private practice of mediation. The state court system sponsored the program by certifying mediators, issuing procedural rules, and ordering cases to mediate. The goals of the program were to make litigation more efficient, less costly, and more satisfying to litigants. A controlled study of the North Carolina program indicates that although it shortened case-processing time, it did not reduce the trial rate or litigants’ legal fees. Most cases that settled in mediation probably would have settled conventionally without mediation. While most participating litigants liked their experience in mediation, it did not increase their satisfaction with their entire case nor was it more satisfactory than conventional settlement. About half of eligible cases actually participated in mediation, fewer than had been expected. Serving the public interest is the court’s foremost concern. Court administrators and judges need to think through the implications of public sponsorship of civil case mediation.

We previously reported on the lung cancer mortality through 1983 of 760 males who were diagnosed with silicosis during 1930-1983 by the State of North Carolina's medical examination program for dusty trades workers. The lung cancer SMR (95% confidence interval) was 2.6 (1.8-3.6) among 655 white members of this group. In this paper, we report the results of a reanalysis of mortality among a subgroup for whom chest radiographs were currently available for rereading. Technically acceptable radiographs were available for 306 white males and were independently reclassified for pneumoconiosis by 3 "B" readers using the 1980 ILO Classification. Lung cancer SMRs were 1.7 (0.8-3.1) for the entire group of 306 white males, 2.5 (1.1-4.9) for 143 subjects reclassified as simple silicosis, and 1.0 (0.1-3.5) for 96 subjects whose radiographs were reclassified as ILO category 0. There were no lung cancer deaths among 67 subjects whose radiographs were reclassified as progressive massive fibrosis. Corresponding lung cancer SMRs for subjects who had never been employed in a job with exposure to known occupational carcinogens were 1.2 (0.2-4.4) for those reclassified as category 0, and 2.4 (1.0-5.0) for those reclassified as having simple silicosis. The age-adjusted lung cancer rate ratio among subjects with simple silicosis compared to those with category 0 was 1.5 (0.4-5.8). Our findings from this reanalysis, which effectively controls for misclassification of silicosis due to errors in radiograph interpretation by North Carolina program readers, offer additional evidence consistent with the hypothesis of an association between silicosis and lung cancer in this study group.

Controversy still exists as to the best laboratory method to use to screen newborns for sickle cell disease and other hemoglobinopathies. The proposed methods include hemoglobin electrophoresis, column chromatography, isoelectric focusing, and high performance liquid chromatography. There is also debate concerning the preferred method of sample collection. The proposed methods of sample collection include cord blood or blood obtained from the infant collected in a tube with anticoagulant or on filter paper. We compared hemoglobin electrophoresis patterns from infant blood samples collected in heparinized capillary tubes and on filter paper. This comparison was performed because hemoglobin electrophoresis of dried blood samples collected on filter paper has been advocated as a practical, reliable, and inexpensive method for mass screening programs, although the limitations of this technique have not been explored fully. We also summarize data from the North Carolina Newborn Hemoglobinopathy Screening Program, which relates to the advantages and limitations of hemoglobin electrophoresis from filter paper blood specimens. MATERIALS AND METHODS Specimens Four sets of specimens were used for this study: (1) specimens collected at Duke University Medical Center to compare hemoglobin electrophoresis patterns of hemolysates from filter paper and heparinized capillary tubes, (2) specimens collected by the North Carolina program for hemoglobinopathy screening, (3) specimens routinely collected at Duke University in heparinized capillary tubes for newborn hemoglobinopathy screening, and (4) samples for retesting to examine the error rate of the state program and to confirm screening results compatible with a hemoglobinopathy. Samples for Direct Comparison Between Filter Paper and Heparinized Specimens

Effect of Lighting Program and Nutrition on Reproductive Performance of Molted Single Comb White Leghorn Hens ,

The evaluation of Regionalized Perinatal Health Care Programs

Data on work-release prisoners are used to illustrate a concep tion of correctional reform as a process of accommodations and new relationships among groups. Reform stimulated by the correctional agency is viewed as preferable to reform externally induced. In North Carolina, changes in the economic base of the Prison Department motivated other agencies to support work- release as a new strategy. Although opportunism was prominent in the interest, the introduction of work-release initiated a series of accommodations resulting in changes that promise to be genuine reform. New relationships have emerged among the prisons, the parole board, the courts, and private employers. Within the prison, new relationships between staff and inmates support the growth of a motivational system conducive to rehabilitation. Current limitations of the North Carolina pro gram, successful when measured against its original goals, in clude the restricted place of work-release within the labor-force structure of the state. Further development of the work-release concept requires extension of vocational training and other rehabilitation programs in prison to broaden the job skills of prisoners as candidates for work-release.