Robert Wood Johnson Foundation Research Articles

WHO CARES? RETENTION STRATEGIES FOR DIRECT CARE WORKERS

Abstract More than 30 years ago the Gerontological Society sponsored a congressional briefing about a growing problem; concerns about the adequacy and quality of the direct care workforce in long-term care. In 2002 the Robert Wood Johnson Foundation sponsored the Better Jobs, Better Care demonstration, in response to this continued challenge. Today recruiting and retaining high quality workers in the long-term services system has moved beyond a challenge to an all-out crisis. The initial paper of the symposium presents recent retention and work culture data highlighting todays’ hurdles, collected from more than 80% of long-term care facilities across Ohio. The second presentation provides a comprehensive review of state-level initiatives and innovations aimed at improving recruitment and retention for direct care workers (DCWs) in both facility-based long-term care and home and community-based long-term services across the country. A third paper focuses on retention-promoting factors from the perspective of providers and DCWs working in high-performing long-term care facilities in Ohio. In-depth interviews with 37 providers and DCWs revealed an overarching theme of the importance of work culture, highlighting the modifiable, intangible aspects for promoting DCW retention. The final paper introduces a tip sheet with practical strategies for providers who are seeking to retain direct care workers. Symposium findings will include both practical implications for long-term care providers and ideas for future studies. The direct care workforce crisis is the result of an array of challenges, which means that there will not be one solution, but rather many ideas will be needed.

A Mentoring Initiative for Students at Historically Black Colleges and Universities: One Strategy to Increase Nursing Workforce Diversity and Advance Health Equity.

This article addresses low retention and graduation rates among historically marginalized students in nursing programs at Historically Black Colleges and Universities (HBCUs). Mentoring is a proven success strategy to support systems for historically marginalized students, helping them navigate challenges, improving academic outcomes, and increasing the diversity of the nursing workforce. The article highlights the mentoring initiative of AARP's Center for Health Equity through Nursing and the Future of Nursing: Campaign for Action, an initiative of AARP Foundation, AARP, and the Robert Wood Johnson Foundation, and the outcomes of this collaboration. The paper details the implementation of a mentoring initiative to enhance graduation rates and National Council Licensure Examination (NCLEX) success among historically marginalized students and emphasizes collaboration among institutions and organizations, as well as strategies for funding, mentor recruitment, and NCLEX preparation. Recommendations include promoting robust mentoring programs, preparing mentors, and conducting further research on the effects of mentoring on student outcomes in HBCUs.

Inappropriate Prescribing to Older Patients by Nurse Practitioners and Primary Care Physicians.

Many U.S. states have legislated to allow nurse practitioners (NPs) to independently prescribe drugs. Critics contend that these moves will adversely affect quality of care. To compare rates of inappropriate prescribing among NPs and primary care physicians. Rates of inappropriate prescribing were calculated and compared for 23 669 NPs and 50 060 primary care physicians who wrote prescriptions for 100 or more patients per year, with adjustment for practice experience, patient volume and risk, clinical setting, year, and state. 29 states that had granted NPs prescriptive authority by 2019. Medicare Part D beneficiaries aged 65 years or older in 2013 to 2019. Inappropriate prescriptions, defined as drugs that typically should not be prescribed for adults aged 65 years or older, according to the American Geriatrics Society's Beers Criteria. Mean rates of inappropriate prescribing by NPs and primary care physicians were virtually identical (adjusted odds ratio, 0.99 [95% CI, 0.97 to 1.01]; crude rates, 1.63 vs. 1.69 per 100 prescriptions; adjusted rates, 1.66 vs. 1.68). However, NPs were overrepresented among clinicians with the highest and lowest rates of inappropriate prescribing. For both types of practitioners, discrepancies in inappropriate prescribing rates across states tended to be larger than discrepancies between these practitioners within states. The Beers Criteria addresses the appropriateness of a selected subset of drugs and may not be valid in some clinical settings. Nurse practitioners were no more likely than physicians to prescribe inappropriately to older patients. Broad efforts to improve the performance of all clinicians who prescribe may be more effective than limiting independent prescriptive authority to physicians. The Robert Wood Johnson Foundation and National Science Foundation.

Association between Racial Residential Segregation and COVID-19 Mortality.

This study investigates the impact of racial residential segregation on COVID-19 mortality during the first year of the US epidemic. Data comes from the Center for Disease Control and Prevention (CDC), and the Robert Wood Johnson Foundation's and the University of Wisconsin's joint county health rankings project. The observation includes a record of 8,670,781 individuals in 1488 counties. We regressed COVID-19 deaths, using hierarchical logistic regression models, on individual and county-level predictors. We found that as racial residential segregation increased, mortality rates increased. Controlling for segregation, Blacks and Asians had a greater risk of mortality, while Hispanics and other racial groups had a lower risk of mortality, compared to Whites. The impact of racial residential segregation on COVID-19 mortality did not vary by racial group.

Nurse scholars of the Robert Wood Johnson Foundation Harold Amos Medical Faculty Development Program

BackgroundThe challenge to increase the diversity, inclusivity, and equity of nurse scientists is a critical issue to enhance nursing knowledge development, health care, health equity, and health outcomes in the United States. PurposeThe purpose of this paper is to highlight the current nurse scholars in the Robert Wood Johnson Foundation (RWJF) Harold Amos Medical Faculty Development Program (AMFDP). DiscussionProfiles and the programs of research and scholarship of the current AMFDP nurse scholars are described and discussed. Scholars share lessons learned, and how the AMFDP program has influenced their thinking and commitments to future action in service of nursing science, diversity efforts, legacy leadership, issues of health equity. ConclusionRWJF has a history of supporting the development of nursing scholars. AMFDP is an example of legacy leadership program that contributes to a culture of health and the development of next-generation nursing science scholars.

Effects of state reinsurance programs on health insurance exchange premiums and insurer participation.

The aim of the study was to estimate the effect of the state-based reinsurance programs through the section 1332 State Innovation Waivers on health insurance marketplace premiums and insurer participation. 2015 to 2022 Robert Wood Johnson Foundation Health Insurance Exchange Compare Datasets. An event study difference-in-differences (DD) model separately for each year of implementation and a synthetic control method (SCM) are used to estimate year-by-year effects following program implementation. Not applicable. Reinsurance programs were associated with a decline in premiums in the first year of implementation by 10%-13%, 5%-19%, and 11%-17% for bronze, silver, and gold plans (p < 0.05). There is a trend of sustained declines especially for states that implemented their programs in 2019 and 2020. The SCM analyses suggest some effect heterogeneity across states but also premium declines across most states. There is no evidence that reinsurance programs affected insurer participation. State-based reinsurance programs have the potential to improve the affordability of health insurance coverage. However, reinsurance programs do not appear to have had an effect on insurer participation, highlighting the need for policy makers to consider complementary strategies to encourage insurer participation.

EPH180 Examinination of Social Determinants of Health in Women's Health Cancer Screening

Multiple factors can impact cancer screening, which is important in early detection and morality reduction. This study linked social determinants of health data (SDoH) from the Robert Wood Johnson Foundation (RWJF) County Health Rankings to the MerativeTM MarketScan® Commercial and Medicare Databases to investigate how SDoH may influence screening rates.

The Untapped Potential of the Quadruple Aim of Primary Care to Foster a Culture of Health.

In 2015, the Robert Wood Johnson Foundation introduced the Culture of Health (CoH) action model to inform its grantmaking decisions in the United States. The essential principles of this model fall into four action dimensions: 1) making health a shared value, 2) fostering cross-sector collaboration, 3) creating more equitable communities, and 4) transforming healthcare systems. Although considerable success has been achieved since introduction of the CoH model, the pace of progress has been slower on the fourth dimension, since work in this area involves shifting mindsets from the acute care paradigm to one that focuses on prevention, by addressing the "upstream factors", including social and behavioral determinants impacting health. Moreover, despite its academic prominence, the CoH model remains restricted to the research realm, with limited translation to practice. By comparison, the Quadruple Aim (QA) is a four-dimensional framework that has been successfully translated into primary healthcare practice. Introduced in 2008, the QA entails the adoption of four principles in delivering healthcare: 1) improved patient experience, 2) population health, 3) lower costs, and 4) care team well-being, to achieve value in healthcare. The four principles of the QA could be viewed as analogous to the four principles of the CoH, given the inherent synergies in the underlying philosophy of the two frameworks. It is also noteworthy that both healthcare leadership (physician champions) and legislative reform had significant roles to play in the successful translation of the QA into mainstream practice. This in turn suggests that the primary healthcare system has potential to play an instrumental role in accelerating the pace of progress towards a culture of health by extending the scope of influence of the QA. This paper explores the inherent synergies between the QA and CoH models, and the untapped potential of the QA to foster a culture of health in the United States.

After the fire: A qualitative study of the role of long-term recovery organizations in addressing rural communities’ post-wildfire needs

U.S. wildfire activity has increased over the past several decades, disrupting the systems and infrastructure that support community health and resilience. As the cumulative burden of wildfire damage is projected to increase, understanding an effective community recovery process is critically important. Through qualitative interviews with leaders of long-term recovery organizations (LTROs), a key component of wildfire recovery, we explored barriers and facilitators to LTROs’ ability to support post-wildfire needs among rural communities. Between February-May 2022, we conducted surveys and semi-structured interviews with 18 leaders from six LTROs serving rural communities in Washington, Oregon, and California impacted by wildfires between 2015–2020. The Robert Wood Johnson Foundation’s Culture of Health Framework informed the semi-structured interview guide and a priori codebook, to examine LTROs’ ability to address post-wildfire community needs from a health equity perspective. Additional codes were added through an inductive approach, and emerging themes were identified. Our findings indicate that LTROs face many barriers in addressing community needs post-wildfire, including the policies governing access to and the slow arrival of recovery resources, the intertwined nature of community economic health and built environment restoration, and the challenge of forming a functional LTRO structure. However, participants also identified facilitators of LTROs’ work, including the ability of LTROs and their government partners to adapt policies and procedures, and close collaboration with other community organizations. Factors both internal and external to the community and LTROs’ organizational characteristics influence their ability to address community needs, essential to health, post-wildfire. This study’s findings suggest the need for policy improvements to promote more equitable recovery resource access, that economic recovery should be a core LTRO function, and that recovery planning should be incorporated into community disaster preparedness activities. Future research should focus on LTROs’ role in other contexts and in response to other disasters.

Insulin-regulated aminopeptidase (IRAP) is required for appropriate dilution of urine after an acute water load

Study Objective: Understand the response to acute water load in mice lacking the insulin-regulated aminopeptidase (IRAP). Hypothesis: IRAP degrades vasopressin in vivo, therefore, mice lacking IRAP would have impaired ability to dilute urine and to excrete water. Methods: Age matched 8–10-week-old IRAP WT and KO male mice were used for all experiments. Immunofluorescence and immunoblotting were performed on kidneys at baseline and after 1-hr acute water load (2ml sterile water/IP). Urine/serum electrolytes and urine osmolality were measured before and after water load. Urine was collected from IRAP WT and KO mice before and after 1-hr administration of OPC 31260 (10mg/kg/IP) and furosemide (2.5mg/ml/IP) for urine osmolality and electrolyte measurements. Results: IRAP is expressed in the glomerulus, thick ascending loop of Henle, distal tubule, connecting and collecting ducts. At baseline, IRAP WT and KO mice have similar systolic blood pressure (122 ± 6.6 vs 128 ± 1.9 mmHg), glomerular filtration rate (251 ± 20 vs 254 ± 16 uL/min), and serum Na + levels (142 ± 1.9 vs 143 ± 2.6 mmol/L), but KO mice have reduced proteinuria (3.3 ± 0.57 vs 4.5 ± 1.6 mg/mg). At baseline, IRAP KO have elevated serum copeptin levels (111 ± 43 vs 53 ± 31 pg/mL) and urine osmolality compared to respective IRAP WT (2506 ± 310 vs 1007 ± 212 mOsm/L). Urine osmolality decreased in IRAP KO after administration of vasopressin type 2 receptor antagonist, OPC 31260 (473 ± 341 vs 2479 ± 215 mOsm/L) and loop diuretic, furosemide (517 ± 96 vs 2750 ± 414 mOsm/L). After an acute water load, IRAP KO have lower serum Na + levels (127 ± 3.8 vs 134 ±3.1 mmol/L) and increased urine osmolality compared to IRAP WT (2741 ± 400 vs 577 ± 274 mOsm/L). Additionally, after an acute water load, IRAP KO mice also have higher protein abundance of the Na + /K + /2Cl - (NKCC2) co-transporter (0.36 ± 0.04 vs 0.20 ± 0.03 AU) and phosphorylation of water channel, AQP2 (0.032 ± 0.005 vs 0.025 ± 0.003 AU). Conclusions: IRAP is required to dilute urine and to increase water excretion in response to an acute water load due to persistent activation of NKCC2 and AQP2. Funding Sources: Harold Amos Medical Faculty Development Award - Robert Wood Johnson Foundation; Vanderbilt Center for Kidney Disease This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Seizures in Dementia are Associated with Worse Clinical Outcomes, Higher Mortality and Shorter Lifespans (P3-1.001)

<h3>Objective:</h3> To study impact of seizures on clinical and mortality outcomes in dementia patients. <h3>Background:</h3> Dementia and seizures are both public health imperatives. Seizures occur in 10–64% of those with dementia and accelerate cognitive decline. However, the impact of seizures on clinical and mortality outcomes in dementia patients has not been studied. <h3>Design/Methods:</h3> We analyzed longitudinal data from 39 Alzheimer’s disease Centers from 9/2005–12/2021, maintained by National Alzheimer’s Coordinating Center. We included patients with cognitive impairment at initial visit. We compared cognitive, functional and mortality outcomes among those with and without seizures. <h3>Results:</h3> At the initial visit, among 26,425 cognitively impaired patients, 374(1.4% point prevalence) had seizures. Seizure patients were significantly younger (62.91 vs 68.4 years, p&lt;0.001) at onset of cognitive decline. In multivariate regression analysis, dominant Alzheimer’s disease(AD) mutation(OR: 5.55, CI: 2.39–12.89, p &lt; 0.001), stroke (OR: 3.17, CI: 2.35–4.27, p &lt; 0.001), transient ischemic attack[TIA] (OR: 1.72, CI: 1.21–2.46, p = 0.003), traumatic brain injury[TBI] (OR: 1.92, CI: 1.48–2.50, p &lt; 0.001), Parkinson’s disease [PD] (OR: 1.79, CI: 1.07–2.98, p = 0.025), depression (OR: 1.61, CI: 1.30–1.99, p &lt; 0.001) and lower education (OR: 0.97, CI: 0.95–0.99, p = 0.043) were associated with seizures. Patients with seizures performed worse on mini-mental-status examination(18.50 vs 22.88, <i>p</i> &lt; 0.001) and Clinical-Dementia-Rating Sum-of-boxes(7.95 vs 4.28, p &lt; 0.001); and had more physical dependence(OR: 2.52, CI: 1.99–3.19, p &lt; 0.001) compared to those without seizures after adjusting for age and dementia duration using generalized linear model. Analysis of longitudinal mortality data showed that a higher proportion of seizure patients had died (OR: 1.56, CI: 1.27–1.91, p &lt; 0.0001),and they were younger at death(72.99 vs 79.72years, p &lt; 0.001). Multivariate survival analysis using Cox regression was conducted to study age at death and seizure status. We adjusted the model for sex, disease duration, stroke, TIA, TBI, depression, education and dominant AD mutation. Despite adjustment, patients with seizures were at a higher risk of dying at a younger age(hazard ratio: 1.76, CI: 1.49–2.08, p&lt;0.001). <h3>Conclusions:</h3> Our study shows that dementia patients with seizures have worse cognition and higher mortality rates at a younger age compared to dementia patients without seizures. Dementia patients with early onset of dementia, dominant AD mutation, stroke, TIA, TBI, PD, depression, and/or lower education are more likely to have seizures. Dementia patient with these risk factors may be routinely considered for EEG for early identification and treatment of seizures to improve outcomes. <b>Disclosure:</b> Dr. Zawar has nothing to disclose. Dr. Quigg has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Cerebral Therapeutics. Dr. Quigg has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Cerebral Therapeutics. Dr. Quigg has received personal compensation in the range of $500-$4,999 for serving as an Expert Witness for Finnigen and Harrison. Dr. Quigg has received research support from NIH. Dr. Quigg has received publishing royalties from a publication relating to health care. The institution of Dr. Manning has received research support from Department of Defense. The institution of Dr. Kapur has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Marinus. Dr. Kapur has received personal compensation in the range of $5,000-$9,999 for serving as an officer or member of the Board of Directors for Robert Wood Johnson Foundation . Dr. Kapur has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Elsevier. The institution of Dr. Kapur has received research support from NIH. Dr. Kapur has received intellectual property interests from a discovery or technology relating to health care. Dr. Kapur has a non-compensated relationship as a Chair, Board North America with International League against Epilepsy that is relevant to AAN interests or activities. Dr. Kapur has a non-compensated relationship as a Board of Directors with American Epilepsy Society that is relevant to AAN interests or activities.

Access to a novel first-line single-tablet HIV antiretroviral regimen in Affordable Care Act Marketplace plans, 2018–2020

BackgroundA pillar of the United States’ Ending the HIV Epidemic (EHE) initiative is to rapidly provide antiretroviral therapy (ART) in order to achieve HIV viral suppression. However, insurance benefit design can impede ART access. The primary objective of this study is to understand how Affordable Care Act (ACA) Marketplace qualified health plan (QHP) formularies responded to two new ART single tablet regimens (STRs): dolutegravir/abacavir/lamivudine (DTG/ABC/3TC; approved in 2014) and bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF; approved in 2018).MethodsWe conducted a descriptive study of individual and small group QHPs to assess coverage, cost sharing (coinsurance vs. copay), specialty tiering, prior authorization, and out-of-pocket (OOP) costs for DTG/ABC/3TC and BIC/FTC/TAF. All individual and small group QHPs offered in state ACA Marketplaces from 2018–2020 were identified using plan-level formulary data from Ideon linked to end-of-year data from Robert Wood Johnson Foundation’s Individual Market Health Insurance Exchange (HIX).ResultsFor 2018, 2019, and 2020, respectively, we identified 19,533, 17,007, and 21,547 QHPs. While DTG/ABC/3TC coverage was above 91% from 2018–2020, BIC/FTC/TAF coverage improved from 60 to 86%. Coverage of BIC/FTC/TAF improved in EHE priority jurisdictions from 73 to 90% driven by increased coverage with coinsurance. Although BIC/FTC/TAF had a higher wholesale acquisition cost than DTG/ABC/3TC, monthly OOP cost trends differed regionally in the Midwest but did not differ by EHE priority jurisdiction status.ConclusionsQHP coverage of STRs is heterogeneous across the US. While coverage of BIC/FTC/TAF increased over time, many QHPs in EHE priority jurisdictions required coinsurance. Access to new ART regimens may be slowed by delayed QHP coverage and benefit design.

RWJF Future of Nursing Scholars experience and recommendations: Focus group results at final convening

BackgroundThe Robert Wood Johnson Foundation launched the Future of Nursing Scholars program to support nurses to complete PhDs in 3 years in schools across the United States. PurposeTo explore why scholars participated in the program and to articulate challenges and facilitators to successful completion of their doctoral degrees. MethodThirty-one scholars representing 18 different schools participated in focus groups at a convening in January 2022. FindingsScholars identified that funding and planned length of degree completion were important factors in their choosing the accelerated program. Mentorship, networking, and support were identified as facilitators to program completion with the tight timeline of three years noted as a challenge. DiscussionAccelerated students require adequate resources including access to data, mentoring, and financing to overcome challenges presented by accelerated PhD training programs. Cohort models provide support and clarity of expectations for both students and mentors is critical.

Health Systems Need to Transform Data Collection to Advance Health Equity.

Health Systems Need to Transform Data Collection to Advance Health Equity.

Advancing health equity through partnerships of state Medicaid agencies, Medicaid managed care organizations, and health care delivery organizations.

Reducing health inequities in marginalized populations, including people with Medicaid insurance, requires care transformation to address medical and social needs that is supported and incentivized by tailored payment methods. Collaboration across health care stakeholders is essential to overcome health system fragmentation and implement sustainable reform in the United States (U.S.). This paper explores how multi-stakeholder teams operationalized the Roadmap to Advance Health Equity model during early stages of their journey to (a) build cultures of equity and (b) integrate health equity into care transformation and payment reform initiatives. Advancing Health Equity: Leading Care, Payment, and Systems Transformation is a national program in the U.S. funded by the Robert Wood Johnson Foundation that brings together multi-stakeholder teams to design and implement initiatives to advance health equity. Each team consisted of representatives from state Medicaid agencies, Medicaid managed care organizations, and health care delivery organizations in seven U.S. states. Between June and September 2021, semi-structured interviews were conducted with representatives (n = 23) from all seven teams about experiences implementing the Roadmap to Advance Health Equity model with technical assistance from Advancing Health Equity. Facilitators of building cultures of equity included (1) build upon preexisting intra-organizational cultures of equity, (2) recruit and promote diverse staff and build an inclusive culture, and (3) train staff on health equity and anti-racism. Teams faced challenges building inter-organizational cultures of equity. Facilitators of identifying a health equity focus area and its root causes included (1) use data to identify a health equity focus and (2) overcome stakeholder assumptions about inequities. Facilitators of implementing care transformation and payment reform included (1) partner with Medicaid members and individual providers and (2) support and incentivize equitable care and outcomes with payment. Facilitators of sustainability planning included (1) identify evidence of improved health equity focus and (2) maintain relationships among stakeholders. Teams faced challenges determining the role of the state Medicaid agency. Multi-stakeholder teams shared practical strategies for implementing the Roadmap to Advance Health Equity that can inform future efforts to build intra- and inter-organizational cultures of equity and integrate health equity into care delivery and payment systems.

Current patterns of trauma center proliferation have not led to proportionate improvements in access to care or mortality after injury: An ecologic study.

Timely access to high-level (I/II) trauma centers (HLTCs) is essential to minimize mortality after injury. Over the last 15 years, there has been a proliferation of HLTC nationally. The current study evaluates the impact of additional HLTC on population access and injury mortality. A geocoded list of HLTC, with year designated, was obtained from the American Trauma Society, and 60-minute travel time polygons were created using OpenStreetMap data. Census block group population centroids, county population centroids, and American Communities Survey data from 2005 and 2020 were integrated. Age-adjusted nonoverdose injury mortality was obtained from CDC Wide-ranging Online Data for Epidemiologic Research and the Robert Wood Johnson Foundation. Geographically weighted regression models were used to identify independent predictors of HLTC access and injury mortality. Over the 15-year (2005-2020) study period, the number of HLTC increased by 31.0% (445 to 583), while population access to HLTC increased by 6.9% (77.5-84.4%). Despite this increase, access was unchanged in 83.1% of counties, with a median change in access of 0.0% (interquartile range, 0.0-1.1%). Population-level age-adjusted injury mortality rates increased by 5.39 per 100,000 population during this time (60.72 to 66.11 per 100,000). Geographically weighted regression controlling for population demography and health indicators found higher median income and higher population density to be positively associated with majority (≥50%) HLTC population coverage and negatively associated with county-level nonoverdose mortality. Over the past 15 years, the number of HLTC increased 31%, while population access to HLTC increased only 6.9%. High-level (I/II) trauma center designation is likely driven by factors other than population need. To optimize efficiency and decrease potential oversupply, the designation process should include population level metrics. Geographic information system methodology can be an effective tool to assess optimal placement. Prognostic and Epidemiological; Level IV.

Building an Equitable Future Through Data Disaggregation.

Building an Equitable Future Through Data Disaggregation.

Disaggregating Racial and Ethnic Data: A Step Toward Diversity, Equity, and Inclusion

Disaggregating Racial and Ethnic Data: A Step Toward Diversity, Equity, and Inclusion

Society for Education and the Advancement of Research in Connected Health SEARCH 2022 – The National Telehealth Research Symposium Abstracts Virtual Meeting November 16–18, 2022

Society for Education and the Advancement of Research in Connected Health SEARCH 2022 – The National Telehealth Research Symposium Abstracts Virtual Meeting November 16–18, 2022

Paying for Nursing Home Quality: An Elusive But Important Goal.

Paying for Nursing Home Quality: An Elusive But Important Goal.