понедельник, 8 октября 2012 г.

LOCAL ISSUE: ACCESS TO HEALTH CARE IMPROVES - The Record (Bergen County, NJ)


LINDY WASHBURN; MARY JO LAYTON E-mail: washburn@northjersey.com
The Record (Bergen County, NJ)
11-14-2010
LOCAL ISSUE: ACCESS TO HEALTH CARE IMPROVES
Byline: LINDY WASHBURN; MARY JO LAYTON E-mail: washburn@northjersey.com
Section: LOCAL
Type: News

Federal stimulus spending may not have been popular in some political circles this year, but the extra money expanded care for tens of thousands of low-income patients in North Jersey.

A Hackensack clinic added Saturday hours as well as a woman's health provider and a pediatrician to the practice at East Salem Street.
A doctor was hired to ease long waits at a health center on Midland Avenue in Garfield.

And a clinic on Eighth Street in Passaic added an internist five days a week to provide treatment for adults. The center previously offered pediatrics and women's health care.

Overall, nine clinics operated by the North Hudson Community Action Corp. in Bergen, Passaic and Hudson counties received $3.4 million in federal stimulus funding. The money helped to expand care and upgrade facilities that provide care for the uninsured as well as patients with public insurance who often have trouble finding a physician who accepts their plan.

Christopher F. Irizarry, North Hudson's president and CEO, said the centers cut overall treatment costs because clinics are less expensive to operate than emergency rooms, where many of these patients would otherwise end up. Emergency room visits cost on average $550 -- and taxpayers cover many of the costs for the uninsured and indigent. Yet Federally Qualified Health Centers, like those run by his group, provide treatment at a cost of $140 on average, Irizarry said.

'It's not just helping patients,' Irizarry said. 'People don't realize it, but it's been a lifesaver for taxpayers. We're really part of the solution.'

New Jersey now has 104 health center sites, located in every county except Hunterdon and Somerset. That includes eight 40-foot vans, like one in Paterson that takes dental services to city schools and day-care centers. 'We've been doing ribbon cuttings all over the state,' said Kathy Grant-Davis, president and chief executive officer of the New Jersey Primary Care Association.

In all, these centers in New Jersey received nearly $50 million from the federal Department of Health and Human Services in stimulus funds. And last month, the federal government announced that centers can apply for $335 million more to boost access to primary care.

The Paterson Community Health Center received $1.2 million -- $891,000 to computerize medical records and clinic operations and $306,000 to hire a doctor and increase the use of its facilities.

The center treated nearly 200 patients in a single day recently at its spacious new building near the Riverview Towers housing development and at a smaller site on Broadway. Some patients had public insurance coverage, others were uninsured.

'If you have no income, you will still receive care,' posters in its lobby said. 'You'll love the way we care for you.' A fixture in Paterson for 31 years, the center now cares for the grandchildren of some of its original patients.

Nationwide, community health centers are expected to be a centerpiece of the expansion of health coverage to an estimated 32 million people as a result of federal health care reform. The centers are expected to become the medical homes for most of the newly insured and to treat them in a way that will save money by catching problems early, managing chronic diseases and avoiding costly hospital stays.

The tough economy has led rising numbers of people to seek help at these centers. North Hudson, for instance, expects to log 260,000 patient visits by year's end, up from 240,000 last year.

'People are losing their jobs and they have no alternatives,' Irizarry said. In some cases, patients who find employment must work two jobs and six or seven days a week to keep up, which makes it hard to find time for medical care, he said.

But the centers need doctors. Despite buildings that have room for more patients, there aren't enough primary-care physicians -- especially those bilingual in English and Spanish -- to meet the need. A national shortage of primary care doctors has combined with the difficulty of recruiting physicians to work in under-served areas.

'It's very hard to find primary care providers,' said Grant- Davis. 'One health center is actively recruiting for two full-time physicians in an urban area, and having a hard time filling those jobs.

Mary Garner, the chief executive officer of the Paterson Community Health Center, has been advertising for doctors for two years. 'I need an internist for adult medicine,' she said. 'I really need that person to be fully bilingual, in English and Spanish. We have a lot of Spanish-speaking patients whose English is very limited, and it loses something in translation.' The center's current Spanish-speaking doctors are more than fully booked, she said. And a full-time doctor who had worked at the center recently relocated to Texas.

Nickie Quin, who was recently laid off from her job as a computer programmer, stopped by the Hackensack clinic Friday morning for follow-up treatment of an ovarian cyst. A local hospital had told her she'd have to wait a few weeks for an appointment. The condition has been painful in the past and Quin said she wanted to avoid emergency room treatment if her condition worsens.

Expanded hours at the clinic means patients have the opportunity to seek treatment Saturdays. 'Wow, that's great,' said Quin, a 34- year-old Wallington resident. 'Sometimes that's the only time I can get my kids to the doctor.'

At the pediatric department in the clinic, Dr. Jay Patel said he sees about 20 patients by appointment on Saturdays and treats an additional half-dozen walk-ins. On weekends, he routinely treats children for asthma flare-ups, vomiting and high fevers.

'If the clinic is closed, they would have to go the emergency room,' he said.

Pediatric nurse Joyce Pike said more parents are calling who are new to the clinic system because of unemployment and loss of insurance.

'They want to know how the system works,' she said. The uninsured pay on a sliding scale, with visits costing on average $20, she said. Vaccines are free, she said, a huge cost savings because some inoculations are $80.

'It really starts to add up,' she said.

E-mail: washburn@northjersey.com

Illustrations/Photos:
Caption: Dr. Jay Patel talking with a patient at North Hudson
Community Corp. in Hackensack.

2010

REP. MELANCON SUPPORTS BILL TO IMPROVE ACCESS TO HEALTH CARE IN RURAL AMERICA - US Fed News Service, Including US State News

Rep. Charles Melancon, D-La. (3rd CD), issued the following news release:

U.S. Rep. Charlie Melancon (D-LA) voted today in support of legislation strengthening primary health care for senior citizens enrolled in Medicare. H.R. 6331, the Medicare Improvements for Patients and Providers Act (MIPPA), also takes significant strides in protecting rural seniors' access to care by correcting certain long-standing inequities between rural and urban providers. The bill passed the U.S. House of Representatives today with overwhelming bipartisan support.

'Having lived in a small town my whole life, I understand firsthand the unique challenges that people in rural communities face in accessing much-needed healthcare services,' said Rep. Melancon. 'As a member of the Rural Health Care Coalition, I have worked in Congress to meet healthcare needs in rural Louisiana through increased federal funding and support, so our small towns and communities can stay healthy and thrive. This bill will go far to improve the health of millions of rural Medicare beneficiaries, and I urge the Senate to pass it swiftly.'

MIPPA is a comprehensive piece of legislation that makes a number of improvements to Medicare that will help rural healthcare providers address the challenges associated with delivering quality healthcare close to home in rural communities. The $3.2 billion rural healthcare package includes extensions of current rural Medicare payment policies as well as a number of expansions. The bill also authorizes funding for a federal grant program to help states provide health services, including mental health services, to veterans of the wars in Iraq and Afghanistan who live in rural areas.

In addition, the bill also prevents a scheduled 10.6% cut in payments to physicians treating Medicare patients from going into effect. The measure freezes current payment rates for 18 months and provides for a 1.1% increase in 2009. Preventing this pay cut will allow patients to continue visiting the doctors they trust without worrying that their health care providers will not accept Medicare.

The rural healthcare provisions of the Medicare Improvements for Patients and Providers Act include the following:

* Improves Payments for Sole Community and Critical Access Hospitals. The bill includes provisions that require the Centers for Medicare and Medicaid Services to use updated data when setting reimbursement rates for sole community hospitals. This will mean, in most cases, an increase in payments to these facilities. The bill also directly increases payments for critical access hospitals, particularly for critical lab services such as blood testing and other diagnostic services.

* Extends FLEX Grants for Health Care in Rural Communities. The Medicare Rural Hospital Flexibility Program provides grants that rural health care providers can use to improve the quality of care facilities provide, and to strengthen healthcare networks. Funds can be used for services ranging from ambulance transport to the development of small local hospitals. This bill will extend the FLEX Grant program through 2010, and will add a new component making mental health services more accessible to rural veterans and rural residents.

* Improves Access to Ambulance Services. The legislation increases Medicare payments for ground ambulance services in rural areas by 3 percent, and recognizes the importance of ambulance services to urban seniors with a two percent increase. The bill also protects rural air ambulance providers by requiring more consideration of a physician's recommendation for air ambulance services when Medicare seeks justification for the expense, and by stopping payment cuts to rural providers that have been reclassified as urban air ambulance providers.

* Extends Expiring Rural Provisions. The Medicare Modernization Act of 2003 created a number of provisions benefiting rural providers, several or which are expiring this year. The bill passed by the House today would extend:

* Payments for Rural Physicians. Prior to 2003, the Medicare reimbursement formula penalized doctors for practicing in rural areas by paying them less for their work, even though they have the same training as their urban counterparts. MIPPA extends for 18 months a provision that sets a 'floor,' or minimum payment adjustment, for payments for physicians' work.

* Special Treatment of Certain Physician Pathology Services. Many rural hospitals do not have their own laboratories. Congress has allowed independent labs to bill Medicare directly for the physician pathology services they provide to hospitals, if the hospital was using such a lab prior to the issuance of a particular physician payment rule by the Centers for Medicare and Medicaid Services in November 1999. MIPPA would extend this allowance for direct Medicare billing by independent labs, ensuring that rural hospitals can continue to work with the labs to provide health analysis and care.

* Exceptions Process for Therapy Caps. Medicare sets caps for total expenditures on physical, occupational and speech-language therapies in order to control costs. Some patients, however, legitimately need more therapy than is allowed under the cap. MIPPA extends an exceptions process for the therapy caps through 2009, ensuring providers are properly paid when they give seniors the therapy they need.

* Improves Access to Speech-Language Pathology Services. H.R. 6331 allows for speech language pathologists in private practice to bill Medicare directly for their services rather than through a doctor's office, making it easier for speech language pathologists to be paid, and to continue delivering services to seniors in rural areas where doctors may be scarce.

* Improves Access to Tele-health Services. When medical facilities are few and far between, and fewer providers serve a larger region, tele-medicine can bring faraway resources close to rural seniors in need. MIPPA will make tele-health services to seniors available through Medicare at more types of health facilities, including hospital-based renal dialysis facilities, skilled nursing facilities, and community mental health centers.

* Retains Access to Medicare Advantage. The vast majority of rural beneficiaries continue to receive care under the traditional Medicare Fee-For-Service program. Only 6 percent of rural beneficiaries join Medicare Advantage, most of who have joined private fee-for-service plans (PFFS). While MIPPA requires that PFFS plans in counties with several plan choices must create provider networks, PFFS plans in rural areas without other plan options can continue to operate as they do today.

воскресенье, 7 октября 2012 г.

Early access to health care services through a rural school-based health center. - Journal of School Health

School-based health centers (SBHCs) and school-linked health centers (SLHCs) represent a relatively new model of health care service. Former US Surgeon General C. Everrett Koop, MD, advocated for family-centered, community-based, coordinated health care for all children.[1] He stated that care must be accessible. To be accessible, health care services must meet four criteria. The services must be available, community-based, affordable, and culturally acceptable to the population served. Do SBHCs/SLHCs meet these four criteria of accessibility?

This paper addresses this question. First, a literature review is presented on development of SBHCs/SLHCs from a historical perspective, and accessibility of these centers. Second, development and accessibility of one SBHC, serving young children in a rural community, are described.

DEVELOPMENT OF SBHCS

Although traditional school health services have been in place since the 1800s, the first national school health program did not begin until the late 1970s.[2] Serving children in kindergarten through 12th grade, this program was supported by the Robert Wood Johnson Foundation and was '...stimulated by the apparent need for better health services for school-age children in the United States.'[3] Twenty-three public schools at five sites in four states received support to '...determine the feasibility of providing primary health care and health education in the school setting.'[3]

The experience of this first national program supports the role of the school nurse, school nurse practitioner, and school-based primary health services in helping the nation meet its health care goals.[4,5] DeAngelis, Berman, Oda, and Meeker conclude: 'The integration of physical examinations and screenings in a school setting, staffed by nurse practitioners supported by physicians, can maximize the identification and resolution of health problems.'[6] These authors also report that immunization rates increase in schools with SBHCs.[7] Oda, DeAngelis, Berman, and Meeker show that: 'More than 95% of the problems [health problems identified in school-age children] were resolved or in the process of resolution at the end of the school year.'[8]

In 1986, the SBHC movement again was supported by the Robert Wood Johnson Foundation through creation of the School-Based Adolescent Health Program.[9] The focus of this program was on use of primary health services in secondary schools to meet health care needs of adolescents. Each of 18 grantees received financial support for two years to initiate one or more school-based health centers. Twenty-four sites were developed. Through process evaluation, Marks and Marzke identify positive outcomes for adolescents and parents involved and they conclude: 'The sites in this initiative provide a model for an effective way to reach and serve vulnerable adolescents -- one that provides not only health care, but also healthy caring.'[9]

The Support Center for School-Based and School-Linked Health Care, Center for Population Options (CPO), a nonprofit organization, '...provides information, technical assistance, training, policy analysis and advocacy to assist in establishing school-based and school-linked health centers and in enhancing their operation.'[10] Through this organization, McKinney and Peak reported on survey results from 202 of 418 SBHCs and SLHCs in operation during the 1991-1992 school year. Most of these centers were located in urban areas and served adolescent youth attending secondary schools.

In addition to the Robert Wood Johnson Foundation and the CPO, many other groups support the growth of the SBHC movement.[11-13] The American Academy of Pediatrics states: 'The Academy...supports the selective implementation of school-based health clinic programs in areas where the health care needs of the school age population are not being met.'[14] The National Association of School Nurses '...encourages the establishment of integrated school health programs and school based clinics to provide comprehensive health services...'[15] The American School Health Association (ASHA) supports '...the development and implementation of school-based and school-linked health care programs, including medical, social work, and personal counseling (mental health and substance abuse), in areas where children and adolescents lack access to primary health care and comprehensive services.'[16]

Individual leaders in health care also have supported SBHCs. Current US Surgeon General Joycelyn Elders, MD, writes about planning and designing school-based health services. She, states: 'Arkansas has demonstrated that the health care needs of many children can be met effectively through a school-based program of health services.'[17] Nurse leader Judith B. Igoe recommends expanding SBHCs/SLHCs to serve the entire family. She explains: 'The plan sponsored by nursing for school-based and school-linked family health care centers meets all the important criteria for health care reform; moreover, it assists two of the most significant institutions in American society -- the neighborhood and the family.'[18]

In contrast to this support, Rienzo and Button report on four SBHCs which experienced opposition to the planning and implementation of services.[19] They describe opposition to SBHCs from national conservative associations, some local religious organizations, and individual parents and citizens. Most opposition dealt with sexuality issues and parental rights. Other arguments were 1) services not needed, 2) services too costly, 3) services not effective, 4) not the school's responsibility, and 5) too much liability for the school. Rienzo and Button conclude that although organized opposition did affect the health care delivery of some SBHCs, development of key strategies in response to this opposition strengthened the SBHC movement as a whole.

The School-Based Adolescent Health Care Program of the Robert Wood Johnson Foundation describes the SBHC movement as 'an idea whose time has come' and 'the wave of the future.'[11] Support for the movement overcomes opposition to the movement in most communities. SBHCs/SLHCs will continue to proliferate according to a report completed from the US Dept. of Health and Human Services' Inspector General's office in Chicago.[13]

ACCESSIBILITY OF SBHCS

In regard to accessibility, the US Dept. of Health and Human Services' Office of the Inspector General (OIG) conducted 88 structured interviews with SBHC staff and concluded that 'school-based health centers increase access to health care for adolescents.'[13] The OIG study also described the difficulty of studying SBHCs since '...the literature on school-based health centers rarely gives a national perspective and provides little information about health outcomes for adolescents.'[13] McKinlay, Stone, and Zucker also describe the difficulties of school-based research and encourage the researcher '...to make optimal use of a wide variety of experimental designs and observation strategies.'[20]

Despite these difficulties, numerous articles describe SBHCs/SLHCs. This literature is summarized here, to provide an understanding of 'accessibility' as defined as available, community-based, affordable, and culturally acceptable health care.

Available. Recommended available services were identified in August 1993 by the School Health Policy Initiative of the Center for Population and Family Health. This group compiled a comprehensive list of essential, optional preferred, and optional as needed services for SBHCs in elementary, middle, and high schools (unpublished material, August 1993). Although contraceptive services were included in this list, Klein, Starnes, and Kotelchuck et al found that other types of health care centers are more likely than SBHCs/SLHCs to provide these services.[21] The Council on Scientific Affairs(22) and McKinney and Peak[10] reported this same finding.

When looking at services besides contraception, McKinney and Peak demonstrated that comprehensive medical services, counseling or mental health services, and health education services were provided in most SBHCs/SLHCs.[10] McHarney-Brown and Kaufman compared a SBHC with a hospital-based pediatric clinic and discovered '...that the school-based clinic received significantly more visits for counseling and health maintenance while the pediatric clinic received more visits for acute and chronic illness.'[23]

All SBHCs and 75% of SLHCs are located in schools where school-age children spend much of their day.[10] Generally, the site provides convenient access to health care for these children. This location may be threatening, however, to children and families with a negative experience at school. As a result, one SBHC plans to open a branch office in a nearby mall.[24]

Most SBHCs/SLHCs are open during school hours.[10] Ruminski and Klink describe a system for making appointments and meeting urgent health care needs while, at the same time, minimizing disruption of the educational environment. They say, 'Appointments are preferably scheduled for before school, during lunch, during study hall, or after school.'[25] Fifty-three percent of SBHCs/SLHCs are open in the summer; some provide evening and weekend hours while some refer to other sources of care during these time periods.[10]

Although SBHCs/SLHCs appear to have available services, locations, and hours, these services are not available to all children. In 1991, McGinnis and DeGraw reported some 46 million students in 100,000 schools in 15,000 school districts in the US.[26] During this same time period, 418 SBHCs/SLHCs served 1,086 schools.[10] Therefore, 98,914 schools and millions of children are without these comprehensive primary health care services.

Community-Based. Public schools and, therefore, SBHCs/SLHCs are located in the community. In addition, ongoing community involvement is an important part of the SBHC. Local planning groups and community advisory boards include parents, students, health professionals, academic and administrative school staff, and other members of the community.[17] All four SBHCs, studied by Rienzo and Button, identified involvement of these different groups as an important strategy for operating successful SBHCs.[19]

Affordable. In general, children and their families are not billed directly. Revenue sources include support from grants; agencies at the local, state, or federal levels; in-kind contributions; and third party reimbursements.[10,23,24,27] Bocchino states that the cost per pupil is estimated at more than $100 per year.[27] Marks and Marzke looked at three sites and found the cost per enrolled student to be $98.18, $193.12, and $194.06.[9] They attribute this range to labor market differences, cost-of living differences, number of staff at each site, a minimum threshold of costs for services, and economies of scale with larger enrollment sizes. These authors encourage ongoing contributions from medical sponsors as grant funding is predicted to decrease in the future. The US Dept. of Health and Human Services Office of the Inspector General encourages a cooperative relationship between SBHCs and managed care systems.[13]

In the article 'Adolescent Health: A Report to the US Congress,' three findings were presented: one of seven adolescents has no health insurance coverage; one of four adolescents is poor or near poor; and one of three poor adolescents does not receive Medicaid services.[28] Twenty-eight percent of students were covered by Medicaid insurance in the McKinney and Peak study.[10] Others have found the rate of uninsured children to be between 31% and 58%.[7,17,20] For students with private health care coverage, many preventive health services are not reimbursed. Direct billing of the students and families would limit the accessibility of health care.

Culturally acceptable. Enrollment in all SBHCs/SLHCs was voluntary and, in most SBHCs, parental consent was required before students can receive services. Enrollment rates of 50% to 71% are described.[6,10,16,21] In the Baltimore SBHCs, the enrollment rate grew from 12% in year one to 60% by year five.[24] In general, most parents chose to enroll their children in a SBHC when one was available.

McKinney and Peak report that 72% of enrolled students use SBHC services.[10] Ruminski and Klink surveyed students enrolled at one SBHC; 50% had used the service at least once. Ninety percent felt the service increased health care accessibility, while 60% believed that their health was improved because of the service.[25] Concern about reproductive issues, parental rights, and lack of awareness of services have been suggested as barriers for students who do not enroll or use SBHC services.[23,29]

Generally, SBHCs are accessible; they are available, community-based, affordable, and culturally acceptable to most students and families they serve. Many schools are without SBHCs, and therefore, many students are without access to SBHCs. More SBHCs are needed to meet the needs of these students.

DEVELOPING A RURAL SBHC

Background

The following information provides a case study on establishing an SBHC. This SBHC is located in a community of 10,000 persons in a rural area of Pennsylvania. County percentages exceeded the state percentages for the following statistics: children younger than age five years living at or below the poverty level, single-parent families headed by females, low birth weight infants, youth with drug and alcohol dependency, adolescent pregnancies, and adolescent deaths. In addition, the community has limited access to health services because of lack of public transportation and limited hours of some and long waiting hours of other health services (D. Paul, EdD, unpublished data, August 1992). This school district covers more than 160 square miles and enrolls 2,200 students each year. The school board has a history of supporting the physical and emotional needs of children as well as addressing academic concerns. Many innovative programs already are in place in the district: a breakfast program, a full-day kindergarten, a before and after school day care, a summer child care program, a special education service for the county, and a mandatory community service program for all high school students (D. Paul, EdD, unpublished data, August 1992).

Despite these school achievements, other problems exist in the school. In 1991, 28% percent of the district's kindergarten children did not have the academic skills necessary to enter first grade; 74% of these children were predicted to continue to have difficulties in third grade. Forty-five percent of children starting school in 1991-1992 were eligible for free or reduced lunches. In addition, the speech disability rate for the district was 38% higher than the state average (D. Paul, EdD, unpublished data, August 1992, July 1993).

In response to these needs, a kindergarten program for four-year-old children (K-4) began in fall 1992 with an enrollment of 113 children. This program was the second full-day program to be opened in the state. It was the first universal program offered to all four-year-old children in the district, regardless of financial or academic need. This program sought to accomplish Novello's first goal for education which states: 'By the year 2000, all American children will start school ready to learn.'[30] Academic knowledge, physical health, self-confidence, and social competence were encouraged through the program.

In fall 1992, the superintendent also organized a committee of experts to plan a SBHC. Members of the committee included individuals from the area's health planning and community service agencies, health department, and a medical clinic. A three-year grant under the governor's initiative for health care was awarded to the district in January 1993.[31] In the first six months of 1993, personnel were hired, offices and examination rooms were constructed, equipment and supplies were obtained, protocols and collaborative agreements were developed, Medicaid and private insurance provider numbers were secured, and children were enrolled.

The initial staff consisted of a full-time pediatric nurse practitioner, half-time secretary, part-time social worker, and a school nurse who spent one day a week in the building. These staff members were employed by the school district. The collaborating physician, a family medicine specialist, was available by telephone contact. He was employed by a large medical clinic located in the area and also was a community resident and school board member.

During the last two months of the school year, 65 children were seen by the nurse practitioner in the SBHC for state-mandated physical examinations. At the same time, children registering for 1993-1994 K-4 program were offered enrollment in the SBHC.

By the end of the 1992-1993 school year, several strengths of the SBHC model were identified. Location seemed to be one of the most important factors for success of the service. Another strength was a school health software program that made record keeping, tracking, and data collection accurate and efficient. Working relationships between the SBHC, school, medical community, and other community agencies were positive; no opposition occurred to development of the center. In addition, many health problems and health education needs were identified to assist in planning for the 1993-1994 school year.

Three main barriers were revealed, however. Immunization vaccines were not available in the SBHC. Dental services for children with Medicaid health insurance were difficult, if not impossible, to obtain. Finally, many services provided by the nurse practitioner were not reimbursable under private insurance plans.

During summer 1993, children who had attended the K-4 program were promoted to the district's kindergarten program for five-year-old children (K-5). Although these children now attend school in other school buildings, they continue to be served by this SBHC. In addition, 110 new children entered the K-4 program in fall 1993; 99% of these children are White and 99% live within the school district boundaries. One child with special needs is transported to the school from another district.

For this paper, only the charts of the children in the K-4 program during the 1993-1994 school year were reviewed. Data regarding visits made to the center during the first six months of the 1993-1994 school year were examined from the computer record. In the next section of the paper, this information is summarized and examined for evaluation of accessibility.

Accessibility

Available. Services provided in the SBHC were compared to the list of elementary school services identified as essential by the School Health Policy Initiative Project (Center for Population and Family Health, unpublished data, August 1993). All essential services were available except for dispensing of medications and on-site treatment for children who were sexually abused. Medications were prescribed but had to be purchased at one of the community pharmacies. Cost of the medicine was a problem for some families. One child and her mother were referred to the child's primary care provider for a diagnosis of possible sexual abuse.

The SBHC was located in the K-4 building and most services were provided on-site. A few students, needing medical services beyond the scope of the center, were referred to their own primary care provider or to the office of the collaborating physician. The social worker facilitated referrals to community agencies for the students with mental health and social needs that exceeded the scope of the SBHC.

The SBHC was open from 8:30 am to 5 pm, five days a week, and from 5-8 pm, one day a week, for well-child and sick-child visits. The SBHC social worker provided on-site services two days a week. A health education program was developed by the SBHC staff, and a topic was presented weekly to children in their classrooms. In addition, parents were invited to a monthly health talk held during the evening; refreshments and child care were available.

Community-Based. The health center was located in the K-4 building, at the edge of the community. All children were transported to the K-4 program by bus. Some parents received assistance with transportation to the school to be present for their child's well-child examination. At least one parent or guardian was present for every child. Also, parents were involved through a parent advisory board, which met every two months.

SBHC staff worked closely with school personnel. Communication with teachers occurred daily as needed, in addition to scheduled meetings held each month. The nurse practitioner and superintendent met monthly. The SBHC social worker and school counseling staff communicated as needed. The SBHC staff met weekly, while other school staff, including the principal, psychologist, school nurses, speech therapist, and guidance counselor attended these meetings monthly.

The nurse practitioner acted as the liaison between the SBHC and the medical community. The social worker collaborated with community social service agencies. Newsworthy events appeared regularly in the community newspaper and area newsletters.

Affordable. Forty-nine percent of the K-4 children received free or reduced breakfast and lunch. Thirty-nine percent had health coverage through Medicaid. Another 14% of the children were covered under a managed care program. Forty-four percent, however, had no coverage for preventive health care services other than immunizations.

The center began billing medicaid and other third insurance companies in December 1993. In addition to services not reimbursed by the private fee-for-service health insurance plans, the SBHC was not approved as a managed care provider and, therefore, was unable to bill for students with managed care insurance coverage. Families were not billed directly, however, as grant funding was available during this time period.

Table 1Status of Completion of Well-Child Examinations                                                        Occurrence(*)Status                                                        %Completed in SBHC                                            88.0Scheduled in SBHC next month                                  4.6Referred to SBHC social worker for assistance                 3.7Completed in another health facility                          3.7* Percentages were roundedTable 2Problems Identified During Well-Child Visits                                       Occurrence(*)Status                                       %Dental caries                             42.6Hearing loss                              17.6Otitis media                              15.7Speech difficuIties                       12.0Anemia                                    10.2Asthma                                     9.3Overweight                                 8.3Vision problems                            2.8* Percentages were roundedTable 3Common Problems Identified During Sick-Child Visits                                         Occurrence(*)Status                                       %Otitis media                                34.7Upper respiratory infections                11.2Injuries                                     9.8Gastroenteritis                              8.6Asthma                                       5.0Skin disorders                               4.6Conjunctivitis                               3.2Toothache                                    2.1Suspicion of abuse                           0.8* Percentages were rounded

Culturally acceptable. Ninety-eight percent (n = 108) of children were enrolled in the SBHC. Of the children enrolled, 99% (n = 107) used the SBHC for either well-child or sick-child care or both. Table 1 shows that 88% (n = 95) of children received well-child examinations in the SBHC. Table 2 lists common health problems discovered during well-child care. Ninety-four percent (n = 102) of children visited the SBHC at least once for sick-child care. The total number of sick-visits made to the SBHC during this time period was 487, an average of 4.5 visits per enrolled student. Children were referred for these visits by parents, teachers, and health staff. Common problems identified during sick-child visits are presented in Table 3. The SBHC social worker saw 39.8% (n = 43) of enrolled students. Family problems were identified for 38% of these children, developmental or behavioral problems for 31%, and medical access problems for 31%.

During the last week of the study period, surveys were given to 20 parents who visited the SBHC. This survey asked parents to describe benefits and problems associated with having SBHC services in the school. Most parents identified convenience as the greatest benefit. Some parents also reported feeling more comfortable sending their four-year-old child to school knowing that health care needs would be addressed. These parents did not identify any problems.

Impact

Overall, health care services were accessible to children in the K-4 program through this rural SBHC. Comprehensive services were available and location and hours were convenient for students attending the K-4 school. Parents were actively involved. Communication was encouraged among the SBHC, school, and community. No cost accrued to the families of children enrolled in the SBHC. Enrollment and usage rates were outstanding, much higher than those described in the literature. Parents saw the service as beneficial. The community was supportive; no opposition occurred to opening the center. Strategies that contributed to accessibility of this center are summarized in Figure 1.

Some barriers continue to be a problem, however. This site is not as available to the children who have moved to the schools housing the K-5 classes. Reimbursement of services will be a major issue when grant funding ends in two years. In addition, cost of medications and limited access to dental services continue to be a problem. Dental caries, hearing loss, and speech difficulties may have been prevented if children had access to SBHC services at a younger age. Finally, some teachers are concerned that more sick children come to school and that more people, in general, are in the school. Both factors could be disruptive to the educational environment.

In spring 1994, the SBHC enrolled children ages zero to three years through a new family center program to address prevention at an earlier age. Enrollment and usage rates for children attending the K-5 program still need to be analyzed. Also, the effect of a SBHC on the educational environment needs to be studied. Is the school safe with the increase of traffic to the SBHC office? What are the absentee rates? How well are children learning in this setting?

References

1. Koop CE. Closing Session/Shaping the Future of Children's Health Care, audiotape. Denver, Colo: National Nursing Network, Inc; 1990.

2. Mastrangelo R. From sore throats to STD's, NPs make a difference in school-based clinics. Advance for Nurse Practitioners. 1993;1 (9):8-10,28.

3. DeAngelis C. The Robert Wood Johnson Foundation National School Health Program. Clin Pediatr. 1981;20(5):344-348.

4. Oda DS, DeAngelis C, Meeker R, Berman B. Nurse practitioners and primary care in schools. Am J Mat Child Nursing. 1985;10(2):127-131.

5. Oda DS. The invisible nursing practice. Nursing Outlook. 1991;39(1):26-29.

6. DeAngelis C, Berman B, Oda D, Meeker R. Comparative values of school physical examinations and mass screening tests. J Pediatr. 1983;102(3):477-481.

7. DeAngelis C, Berman B, Oda D, Meeker R. Achieving optimal immunization levels in school-age children. J Pediatr. 1983;103(5):811-814.

8. Oda DS, DeAngelis C, Berman B, Meeker R. The resolution of health problems in school children. J Sch Health. 1985;55(3):96-98.

9. Marks E, Marzke CH. Health Caring: Process Evaluation. Princeton, NJ: Mathtech; 1993.

10. McKinney DH, Peak GR. School-based and School-linked Health Centers: Update 1993. Washington, DC: The Center for Population Options; 1994.

11. The Answer is at School: Bringing Health Care to Our Students. Washington, DC: The School-Based Adolescent Program; 1993.

12. School-based and School-linked Health Centers. Washington, DC: The Center for Population Options; 1994.

13. Office of the Inspector General. School-based Health Centers and Managed Care. Chicago, Ill: US Dept of Health and Human Services; 1993. Publication no OEI-05-92-00680.

14. American Academy of Pediatrics. AAP guidelines:School-based health clinics (RE 7090). AAP News. 1987;April:683.

15. Resolutions and Policy Committee. Resolutions and Policy Statements. Scarborough, Maine: National Association of School Nurses, Inc; 1989.

16. American School Health Association. ASHA Compendium of Resolutions, Section II, Position Papers and Policy Statements: School-Based Primary Health Care. Kent, Ohio: American School Health Association; 1993.

17. Elders MJ. Schools and health: A natural partnership. J Sch Health. 1993;63(7):312-315.

18. Igoe JB. School-linked family health centers in health care reform. Pediatr Nursing. 1993; 19(1):67-68.

19. Rienzo BA, Button JW. The politics of school-based clinics: A community-level analysis. J Sch Health. 1993;63(6):266-272.

20. McKinlay SM, Stone EJ, Zucker DM. Research design and analysis issues. Health Educ Q. 1989;16(2):307-313.

21. Klein JD, Starnes SH, Kotelchuck M, et al. Current trends: Availability of comprehensive adolescent health services--United States, 1990. MMWR. 1993;42(26):507,513-515.

22. Council on Scientific Affairs. Providing medical services through school-based health programs. JAMA. 1989;261(13):1939-1942.

23. McHarney-Brown C, Kaufman A. Comparison of adolescent health care provided at a school-based clinic and at a hospital-based pediatric clinic. South Med J. 1991;84(11): 1340-1342.

24. Feroli KL, Hobson SK, Miola ES, et al. School-based clinics: The Baltimore experience. J Pediatr Health Care. 1992;6(3):127-131.

25. Ruminski D, Klink H. School-based health centers: A model for delivery of adolescent health care in Portland, Oregon. J Ambulatory Care Management. 1993;16(1):29-41.

26. McGinnis JM, DeGraw C. Healthy Schools 2000: Creating partnerships for the decade. J Sch Health. 1991;61(7):292-297.

27. Bocchino C. School-based clinics: Ensuring access to the health care for adolescent America. Pediatr Nursing. 1991;17(4):398,418.

28. Dougherty D, Eden J, Kemp KB, et al. Adolescent health: A report to the US Congress. J Sch Health. 1992;62(5):167-174.

29. Gonzales C, Mulligan D, Kaufman A, et al. Adolescent health care: Improving access by school-based service. J Fam Pract. 1985;21(4):263-270.

30. Novello AC. The Surgeon General's Initiative for Children. J Sch Health. 1991;61(8):359-360.

31. Investing in Our Children & Families: Governor Robert P Casey's 1993-1994 Budget Initiatives. Harrisburg, Pa: Office of the Governor; February 1993.

Figure 1

Ten Strategies for a Successful SBHC

* Assess the unique health care needs of the community

* Involve parents, students, and school and community health care staff

* Choose a site in the school

* Obtain a computer system for data collection

* Employ staff familiar with the community

* Start with a small population but plan to expand rapidly

* Enroll students during registration for school or when physical examinations are required by the school

* Provide comprehensive services on site

* Evaluate the program every six months

* Network with other SBHCs

суббота, 6 октября 2012 г.

Easter Seals, American Medical Association and LogistiCare to Conduct Study on Impact of Transportation Access on Health Care.(Clinical report) - Pediatrics Week

Easter Seals, the American Medical Association (AMA) and LogistiCare announced they are working together to conduct a study for the Federal Transit Administration (FTA) on the relationship between transportation access and health and wellness. The study findings are expected to be announced in late 2011.

'Approximately 2.6 million adults in the U.S. don't get the health care they need because they don't have transportation,' said Cecil B. Wilson, president, AMA. 'Understanding the relationship between access to transportation and access to care is key to helping patients get the care they need.'

Physicians and service providers have long noted the absence of transportation resources as a barrier to care. There's also the potential that a lack of transportation access may result in increased hospitalizations and complications from neglected health care. Yet there is still little research available on these issues.

'Lack of access to transportation options is a major barrier to living, learning and working in the community. We consistently hear this message from the many people living with disabilities, older adults and families we serve,' said James E. Williams, Jr., president and chief executive officer, Easter Seals. 'We need to better understand how that lack of access truly impacts people's lives from an economic and quality of life standpoint. Easter Seals is pleased to work with such notable researchers and partners to study this intersection between health, wellness and transportation options and learn how we can better serve our publics.'

Competitively selected, the study's research team is led by Dr. Thomas R. Prohaska of the University of Illinois at Chicago, Center for Research on Health and Aging, within the Institute for Health Research and Policy, and with other notable scholars from participating universities Texas A&M Health Science Center and the University of California, Berkeley. Working with medical transportation data from LogistiCare, the team expects to learn new information regarding the interaction between health and transportation access.

'As the nation's leading client focused medical transportation mobility solution, managing over 26 million medically necessary transports annually, LogistiCare observes first hand the positive results of access to medical treatment for our clients,' said Herman Schwarz, chief executive officer, LogistiCare. 'Our database resources will provide a rich data environment for this study on measuring the importance of transportation in improving healthcare outcomes.'

The study is funded through the Federal Transit Administration Technical Assistance Centers Easter Seals Project ACTION and the National Center on Senior Transportation with significant in-kind support from the AMA and LogistiCare.

About Easter Seals & Easter Seals Project ACTION

Easter Seals is the leading non-profit provider of services for individuals with autism, developmental disabilities, physical disabilities and other special needs. For more than 90 years, we have been offering help and hope to children and adults living with disabilities, and to the families who love them. Funded through its Federal Transit Administration Cooperative Agreements, Easter Seals Project ACTION expands accessible transportation for people living with disabilities through training, technical assistance, outreach and applied research. Easter Seals has collaborated with the Federal Transit Administration for twenty-three years to advance transportation access for people living with disabilities for all ages through close collaboration with the disability and transportation communities. For resources to help expand accessible transportation and transportation options for people living with disabilities and older adults, visit www.projectaction.org and www.seniortransportation.net.

Keywords: Easter Seals, Pediatrics.

пятница, 5 октября 2012 г.

Improving Access to Health Care for Foster Children: The Illinois Model - Child Welfare

Children in foster care have lower health status than do their peers and limited access to health care. The Illinois Department of Children and Family Services developed Health Works, a separate primary care preferred provider system for children in foster care. This study compared claims data for children in Health Works with children not enrolled in HealthWorks and with children in Aid to Families with Dependent Children (AFDC) who had never entered foster care. Children enrolled in Health Works were more likely than were other children to receive all of the services except general inpatient hospitalizations. They had greater odds of receiving general exams and physicians' services and were more likely to visit the emergency room than children who were not enrolled. They were more likely to receive all of the measured services when compared with children receiving Medicaid through AFDC.

Children in foster care are one of America's most vulnerable populations, one often overlooked by policymakers. Previous research in several states has shown that children in foster care have a high rate of unmet health care needs and underused health services (Halfon, English, Alien, & DeWoody, 1994; Kass, Weinick, & Monheit, 1999; Schor, 1982; Simms, 1991; Swire & Kavaler, 1977; U.S. General Accounting Office, 1995; Weinstein & LaFleur, 1990; White, Benedict, & Jaffe, 1987).

Not only does this population have a high rate of unmet need, it has higher rates of health care needs in general. Research using health care use as a proxy for need consistently demonstrates that children in foster care have considerably more health care needs than other low-income children. Research in Washington State revealed higher rates of use and health care expenditures among children in foster care when compared with other Medicaid-eligible children, (Takayama, Bergman, & Connell, 1994). In Illinois, Bilaver, Jaudes, Koepke, and Goerge (1999) showed that children in foster care use more health care services than did other lowincome children receiving Medicaid. In addition, research in Illinois demonstrated that children who went on to enter foster care revealed more use of mental health and supportive services than other Medicaid-eligible children in the year prior to their entry into out-of-home care. These children in foster care have far lower health status than did their peers and often have endured documented adverse physical, psychological, and social situations throughout their short lives (Halfon, Mendonca, & Berkowitz, 1995).

In response to the increasing body of knowledge about the health problems of children in foster care, agencies have made concerted efforts to define guidelines for addressing their health care needs. In 1988, the Child Welfare League of America (CWLA) released its Standards for Health Care Services for Children in Outof-Home Care, which called on states to design systems that included four basic components: initial health screening, comprehensive health assessment, developmental and mental health evaluation, and ongoing monitoring of health status. Many states responded by implementing health care policies and programs that addressed their systems' shortcomings and offered innovative approaches to serving the health care needs of children in foster care.

A common model described in the literature is the implementation of a community-based clinic that targets the service of foster children. Simms (1989) described one of the earliest models. In Waterbury, Connecticut, planners established a multiagency, multidisciplinary foster care clinic to identify medical, behavioral, and developmental problems among preschool-age children in foster care. This special clinic assembled a group of key practitioners to identify health care needs, provide appropriate referrals for treatment, and communicate with the children's social workers and primary care providers. Planners established other models designed to identify the needs of children entering foster care in Chicago, Baltimore, and Ramsey County, Minnesota (Chernoff, Combs-Orme, Risley-Curtiss, & Heisle, 1994; Flaherty & Weiss, 1990; Hobbie, Braddock, & Henry, 2000).

Other community-based models not only served as centers for assessment and referral but also delivered primary care. In Onondaga County, New York, children ages 12 and younger were served by a multidisciplinary team of experts that provided assessment and primary care (Blatt et al., 1997). A liaison between the social service agency and the medical staff coordinated the effort. In San Diego County, California, the social service department turned to the state's Early and Periodic Screening, Diagnosis, and Treatment Program (EPSDT) to ensure the primary care of children in foster care (Ruptier, 1997). By housing social workers and public health nurses in the same location, staff were better able to work together to address the health needs of children in foster care, with an emphasis on preventive service.

Fewer programs designed to serve children in foster care have experimented with fiscal incentives. Schor, Nerf, and LaAsmar (1984) described a very early example in which children in foster care in Baltimore were enrolled in an HMO established to serve foster children. Schor et al. found that the health plan was a successful, workable model to address the needs of foster children.

Although past research has presented data on service model participants, no research has relied on a comparison group to examine the reach and effectiveness of a particular model. This article describes a program involving fiscal incentives that was established in Illinois in July 1995 and provides evidence of its effectiveness. Because of the large number of children already in foster care at the start of the program, the planners enrolled children over the course of four years. The authors took advantage of the staged enrollment practices to compare the health care use of enrolled and nonenrolled children. Unlike previous models described in the literature, this program, known as Health Works, is a statewide program.

Illinois's Health Works Initiative

The Illinois Department of Children and Family Services (DCFS), through contractual relationships with lead agencies statewide (local health departments and community-based agencies), recruited and organized a network of well-qualified health care providers and community agencies to ensure access to comprehensive health care for children in the care of the state. The separate health system for children in foster care is called Health Works.

The model for Health Works is a primary care, preferred provider approach similar to managed care. The system is financed, however, by fee-for-service payments through public-private partnerships with four objectives: develop an accessible network of quality health care providers, coordinate the delivery of comprehensive health care services to children in foster care, ensure continuity in the delivery of care, and improve the health status of children in state custody. These goals are all in accordance with the standards of care produced by the American Academy of Pediatrics Committee on Early Childhood, Adoption and Dependant Care (1994); CWLA (1988); and experts in the field (Simms, Freundlich, Battistelli, & Kaufman, 1999).

The program includes a community-based medical case management component for all children in foster care younger than 6 years of age. Children ages 6 and older receive medical case management by the DCFS caseworker. Participating providers sign an agreement that outlines both the providers' and Health Works' responsibilities and ensures cooperation with the case management component. In addition to an initial screening, participating providers must provide annual or interperiodic screenings that follow the basic EPSDT standards, including unclothed physical exams, behavioral health and developmental screens, maintenance of specially designed medical records, compliance with Advisory Committee on Immunization Practices immunization standards, and hearing and vision screenings. These standard components are provided on the customary EPSDT schedule, annually after 2 years of age or more often as risk assessment dictates.

Health Works has been designed with six interrelated key program features.

1. An Initial Health Screen (IHS). IHS is required for all children and doctors must complete it within 24 hours of a child entering custody and before foster home placement. IHS treats any acute medical illnesses, including any infectious or communicable diseases; documents any signs of maltreatment; and provides the child -welfare caseworker with medical information for making placement decisions. A 24-hour Healthline phone system facilitates IHS, linking children to hospitals and clinics with short waiting times. The children are to be seen within one hour of arrival at the IHS site.

2. A Comprehensive Health Evaluation. In addition to IHS, doctors conduct a comprehensive health evaluation within 21 days of placement in state custody. The comprehensive exam includes a full EPSDT examination and mental health, developmental, alcohol, and substance abuse screenings when appropriate. Doctors make referrals for specialized services as needed.

3. Primary Care Physicians (PCPs). Foster parents select a PCP for their foster child from the Health Works network of participating providers. If they already have a PCP, the lead agency attempts to enroll the provider in the network, assuming they meet the specific enrollment criteria. Criteria for physicians to enroll in Health Works are more stringent than for Medicaid. Participating physicians must complete a residency that includes pediatric training, offer 24-hour availability, and have hospital admitting privileges. Providers receive enhanced Medicaid rates (8% to 10% higher than standard fees) as well as a monthly $5 fee per child for completion of the paperwork and coordination with community-based medical case management agencies. In addition, providers receive a one-time $15 fee per child for initiation of the Health Passport-a portable medical record summary that follows the child regardless of placement location or provider. Participating PCPs receive orientation and training from the lead agency on the use and distribution of DCFS forms and age-appropriate medical records. Providers must sign an agreement with the lead agency that clearly defines the obligations of the lead agency and the provider.

4. Specialty and Subspecialty Care. Specialty and subspecialty care is available through the Health Works program. These referrals include dental care, optometric care, and other pediatric subspecialty care that PCPs arrange.

5. Medical case Management. Children younger than 6 years of age receive medical case management provided by community-based agencies. case managers promote preventive strategies directed at improving access to needed services identified in the care plan individualized for each child. The child welfare worker provides case management for children older than 6 years of age.

6. Standardized Health Forms and Educational Materials. A Health Passport with information about each child's medical problems, past medical and family history, immunization records, and diagnostic studies, recorded in a standardized consistent manner, serves as a portable medical record. The child's Health Passport follows the child from substitute parent to substitute parent and physician to physician. In addition, physicians developed standardized, age-specific medical records. The planners designed educational materials about Health Works and distributed them to caseworkers, foster parents, and physicians.

The health care information system captures computerized service delivery data, including IHS, comprehensive health evaluation, initiation of the Health Passport, PCP selection, and assignment of a medical case management agency. Workers send all other documents to the lead agency. They copy and distribute these records to foster care providers, caseworkers, and PCPs as appropriate. The lead agency maintains the original records in a central file. Planning is under way for the implementation of an electronic Health Passport.

Health Works Implementation

More than 70% of the children in foster care in Illinois are placed in Cook County. The complexities of the health care delivery system in Cook County made this an excellent proving ground for the design and initial implementation of Health Works. Implementation began in Chicago with the formal development of networks of IHS sites, PCPs, and community-based medical case management agencies. At this time, Health Works has been fully implemented in Cook County and most other Illinois counties.

In FY1995, only 43% of children in foster care in Cook County were enrolled in Health Works. By FY 1997, 61% were. More recently, enrollment in Cook County has reached levels greater than 90%. At the same time enrollment was increasing, the network of PCPs expanded. In FY 1995, two years after program implementation, 51 clinics, 13 hospitals, and 257 PCPs participated in the Health Works initiative. In 1999, Health Works had grown to include 94 clinics, more than 100 hospitals, and more than 3,400 PCPs statewide.

The study used no controlled process to enroll children in Health Works. Ideally, random assignment would be the preferred selection method used to make decisions about which children were enrolled. The lack of such a controlled process makes it difficult to draw conclusions about any differences in outcomes between children enrolled in the program and children not enrolled. This study instead takes advantage of the administrative data available on the entire population of children in foster care in Cook County during the study period. With the population data, the authors could determine rates of health service use that are adjusted for differences in demographic and case characteristics between children enrolled in Health Works and children not enrolled. In this way, they could control for differences in the two populations that may have an effect on health care use.

The authors also compared the levels of service use for children in foster care with children receiving Aid to Families with Dependent Children (AFDC) whose health care service is also funded through Medicaid. Although past research on use rates shows that children in foster care have a higher level of need than children receiving AFDC, approximately 70% of children in foster care came from families that received AFDC (U.S. Department of Health and Human Services, 2000). This comparison will provide a measure of Health Works' effect in relation to a socioeconomically similar population.

The authors chose to focus on health service use (outpatient and inpatient services) as the outcome measure because each of the Health Works program components was designed to improve access to health care, which would lead to higher rates of appropriate health care use. Appropriate refers to higher rates of preventive health care services; higher rates of needed specialized services, including mental health; and lower rates of nonemergency emergency room (ER) visits. Key to this distinction, however, is the ability to recognize services as being appropriate. Unfortunately, the administrative data on health service use do not permit a measure of the need for services. To the extent that children in Health Works have greater health care needs than children who were not enrolled, one must use caution in interpreting the results. We believe, however, that no systematic enrollment of children with greater health needs in the program existed.*

To assess the effect of Health Works on health services use, the authors analyzed Medicaid-paid claims for the population of children who had been in foster care or AFDC for at least one day during FY 1997. In Illinois, all children become eligible for Medicaid on entry to the system. The authors performed a cross-sectional analysis to measure the effect of Health Works on the entire population of children in foster care rather than only on children new to the system.

The authors defined three study populations for comparison: (1) children in foster care from Cook County enrolled in Health Works during the fiscal year (n = 28,844), (2) children in foster care from Cook County not enrolled in Health Works during the fiscal year (n = 18,187), and (3) children from Cook County eligible for Medicaid through the AFDC program during the fiscal year (n = 601,772). Because computerized data on Health Works were only available for children in Cook County cases at the time of the study, this analysis does not represent an assessment of the program for the entire Illinois foster care population; however, Cook County does include Chicago and 71% of the foster care caseload in Illinois.

Data

The researchers identified the study populations from the Integrated Database on Children's Services (IDB) in Illinois. IDB is a relational database that combines administrative data collected by the state public welfare agencies for administrative purposes (Goerge, Van Voorhis, & Lee, 1994). IDB comprises data from child welfare, juvenile justice, AFDC and Temporary Aid for Needy Families, Medicaid, special education, mental health, and disability systems. Information in the database includes individual demographic information, such as age, race or ethnicity, and family composition, and information on case histories both in foster care and public assistance.

Part of the foster care case history are data on Health Works participation in Cook County. Data on health care use stem from extracts of Medicaid claims from the Illinois Department of Public Aid. The Medicaid claims data maintained in IDB include all paid claims for individuals younger than age 21 in Illinois excluding prescription claims. Key variables in the claims data include category of service, primary International Classification of Diseases, Clinical Modification diagnosis code, primary procedure code, and dates of service.

Because IDB includes data from multiple human service agencies, much of the data is not linked by a common identification number. To identify the Medicaid-paid claims of children in foster care, the authors linked records using a technique called probabilistic record-matching. Used widely in epidemiology and demography (Newcombe, 1993; Roos & Wajda, 1991; Roos, Wajda, Nicol, & Roberts, 1992), probabilistic record-matching assumes that no comparison between fields common to the source databases will link an individual's records with complete confidence. Instead, the method calculates the likelihood that two records belong to the same person by matching as many pieces of identifying information as possible from each database. This study used first and last name, birth date, gender, race or ethnicity, Social Security number, and county of residence to link the foster care data to the Medicaid claims.

Data Analysis

The authors analyzed the rates of service use of 10 different categories of health services paid by Medicaid: EPSDT exams, physicians' services, psychiatric clinic services, services of mental health providers, hearing exams, eye exams, lead screenings, ER visits, general inpatient hospitalizations, and psychiatric hospitalizations. Mental health services comprise the diagnosis and treatment of mental health problems provided to clients of agencies, including DCFS and the Department of Mental Health and Developmental Disabilities. For each of these service categories, the authors assessed whether children enrolled in Health Works reported different rates of service use than a comparison group.

The authors used logistic regression models to estimate the odds of service receipt while controlling for differences among the three groups of children. They used two types of models in each fiscal year. The first model included children in Cook County foster care cases; the second included children participating in the Health Works program and children receiving AFDC. They estimated a separate model for each of the 10 service categories. In each model, an indicator of whether a child received the particular service during the fiscal years served as the dependent variable. One disadvantage of the cross-sectional design is that it did not allow the researchers to precisely model the time of Health Works enrollment during the year.*

The authors examined the following independent variables for inclusion in the model depending on fit to the data: race/ethnicity (white, black, Hispanic, and other), continuous age at the beginning of the fiscal year, categorical age at the beginning of the fiscal year (infant or ages 1-3, 4-6, 7-9, 10-12, 13-15, and older than 15), continuous proportion of the year in foster care or AFDC, categorical time in foster care or AFDC (less than 3 months, 3-6 months, 6-9 months, and 9-12 months), an indicator of the child's first entry to foster care or AFDC (1 = new to the system, O = not new), gender, and group membership (enrolled in Health Works, not enrolled in Health Works, or in AFDC). From each model, the adjusted odds ratio (OR) of service receipt for those enrolled in Health Works describes the odds that children enrolled in Health Works will receive services compared with either children not enrolled or children participating in AFDC, while controlling for differences between the three groups.

The authors used goodness-of-fit measures to evaluate the model fit for each service and each fiscal year. They evaluated both the Hosmer and Lemeshow goodness-of-fit tests for all of the models and the deviance chi-square statistic for models not including the continuous form of age and time in foster care or AFDC. In many cases, the authors could not specify models that had insignificant deviance chi-square statistics with the available covariates. In nearly all cases, the Hosmer and Lemeshow tests indicated adequate fit for at least one model for each service type. If at least one of the models that they tested indicated adequate fit (p = .05), the authors selected the model with the greatest fit based on this test. If the authors could not achieve adequate fit, they estimated the fullest model. This method provided controls for the greatest number of covariates for each service as deemed necessary by the goodness-of-fit measures.

Results

Demographics of Children

In FY 1997, 61% of children ever served in Cook County foster care were enrolled in HealthWorks. The authors found several substantial differences in the characteristics of the study groups that they believed could affect health care service use. They were concerned about differences in the racial and ethnic composition, given that national estimates show that African American children have poorer access to health care than children of other races and ethnicities (Kass et al, 1999). Only 59% of the AFDC child population served in FY 1997 were African American compared with 85% to 87% of the Cook County foster care population (see Table 1). Differences also existed in the length of time that children were served in either foster care or AFDC during the study period. The duration of services during the fiscal year would have a direct effect on the opportunity that children had to receive health care services. In FY 1997, 80% of children enrolled in Health Works had been in foster care for the entire fiscal year compared with 73%; of children not enrolled in Health Works, and children receiving AFDC during FY 1997 were served for the entire year.

Children enrolled in Health Works tended to be younger than children not enrolled. This was especially true of children between ages 1 and 6. Of children in Health Works, 45% were ages 1 to 6, compared with just 22% of children not enrolled in Health Works. The age distribution of children served in AFDC was similar to children enrolled in Health Works.

Service Use

Levels of service use varied considerably across the comparison groups. More than 70% of children in Health Works received a general exam or physician service during the fiscal year compared with approximately 50% of children not enrolled and 40% of children in the AFDC program (see Table 2). Other primary care services such as hearing and eye exams and lead screenings were used 2 to 2.5 times as often by children in foster care than by children in AFDC. A much larger percentage of children in foster care used psychiatric and mental health services, compared with children in AFDC. The percentage of children using ER services and requiring general inpatient hospitalization was similar across the three groups. Between 16% and 23% of children in foster care and AFDC in Cook County visited the ER, and nearly 8% required hospitalization.

Even after controlling for differences across the comparison groups, children in Health Works were significantly more likely to receive 9 of the 10 services measured compared with children not enrolled in Health Works. In terms of primary care, children in Health Works had approximately two times the odds of receiving general exams and physicians' services after controlling for race and ethnicity, age, gender, time in care, and whether the case was new (see Table 3). Hearing and eye exams were approximately 20% more likely for children in Health Works than for children not in Health Works (ORs = 1.22 and 1.27, respectively). Children in Health Works also had 49% greater odds of being screened for elevated lead levels. In terms of mental health services, the authors found that children enrolled in Health Works were more likely to use psychiatric clinic services (OR = 1.49), use outpatient mental health services (OR = 1.28), and experience inpatient psychiatric hospitalizations (OR = 1.26) than children not enrolled. Despite the assignment of PCPs, children enrolled in Health Works had 12% greater odds of using ER services than children not enrolled. General inpatient hospitalization, however, was just as likely among children enrolled and not enrolled in Health Works. An appendix -with the full set of parameter estimates for the best fitting model can be requested from the authors.

Children in Health Works had even greater odds of service receipt in all 10 of the services measured than children in the AFDC program (see Table 3). Children in Health Works were more than five times more likely to receive general exams or physician service during the fiscal year than children in AFDC were (OR = 5.15, OR = 5.46). The authors observed even more dramatic differences in the adjusted odds of mental health service receipt. Children in Health Works had 22 times the odds of receiving a mental health service and more than 9 times the odds of receiving a psychiatric clinic service, compared with children in the AFDC program. The authors observed the smallest differences in ER services and general inpatient hospitalization. Although still more likely to receive service, children in Health Works were 55% more likely to use the ER during the fiscal year and 2.32 times as likely to experience a general inpatient hospitalization than children in AFDC were.

Discussion

Children in foster care are not just like other children. To appreciate the significance of the Health Works program, one must understand two factors: First, children in foster care are among the unhealthiest in the United States, and second, children in foster care have been underserved for years both by the physical and mental health care fields. Therefore, increased use of health care services for this population is desirable.

Children in Health Works used more health care services than both children in foster care not enrolled in Health Works and children in AFDC. This is significant because it offers some evidence that the increased oversight and attention given to health care use through the Health Works program has affected outcomes for children in care. Of course, this research does not address how the Health Works model affects outcomes. Future research, as called for by Simms, Dubowitz, and Szilagyi (2000), should take these initial findings a step further by comparing various models of health care delivery.

Although the increase in use of mental health services by children in Health Works is encouraging, the levels fall far below the level of need reported for this population. Between 30% and 70% of children in foster care have behavioral or mental health problems (Dubowitz, Feigelman, Zuravin, & Tepper, 1992; Gruber, 1973; Hochstadt, Jaudes, Zimo, & Schachter, 1987; Horwitz, Simms, & Farrington, 1994; Mclntyre & Keesler, 1986; Schor, 1982; Simms, 1989; Takayama et al., 1994; White & Benedict, 1986). Some would say all children in foster care require some mental health intervention. In Illinois, as in most states, no mental health system is designed to meet these needs; Health Works is currently designed only to meet the physical health requirements of these children. A future challenge is to take a disjointed approach to children in foster care with emotional problems and coordinate a comprehensive behavioral and mental health system to include these services for all children in foster care.

Health Works provides primary care and encourages foster parents and children to use it, thus ensuring that they will have access to health care services. Increased use is positive, and the program is beginning to meet these children's health care needs. Increased access over time would also provide for better health care by providing preventive medicine. The real test of the system is to measure health outcomes to assess if children in foster care are truly healthier after they enter custody than before. The authors are establishing systems to monitor and track health status indicators and perform a cost-benefit analysis of this model.

Children in Health Works used hospital services, including ER visits and inpatient medical and psychiatric hospitalization, slightly more frequently than children in the AFDC population. Considering their increased access to health care, it was surprising that a more substantial increase in hospital services did not exist, because these children are truly unhealthy.

The goal of this study was to assess if children in foster care enrolled in a noncapitated managed care system received more health care services than children in foster care who were not yet enrolled in the health care system and children in AFDC. Some assumptions must be noted. Many children in AFDC probably did not have easy access to health care. This could account for some proportion of children in AFDC receiving less than the study group; however, the socioeconomic characteristics of children in foster care in Illinois suggest that a clear majority were AFDC eligible or enrolled prior to being in state custody.

In addition, only Medicaid claims that were submitted and paid were available for analysis. This would lead to an underestimation of service use. The study did not measure compliance for IHSs, comprehensive evaluations, or care provided specifically by the Health Works PCP. The Illinois Medicaid system does have a case management component, but it is limited in the scope of service and by the age of participant and is much less intense than the HealthWorks' model. Medicaid managed care is not compulsory, and enrollment is on a steady decline. No children in foster care are enrolled in the state's Medicaid managed care programs.

Conclusion

Providing health care to this high-risk population of children has been attempted by very few groups, predominately on a community level (Blatt et al., 1997; Chernoff et al, 1994; Horwitz et al, 1994; Ruptier, 1997; Schor et al., 1984; Simms, 1989). Studies have shown that children in foster care are not provided the health care services they need (Dubowitz, Feigelman, Tepper, Sawyer, & Davidson, 1990; Frank, 1980; Gruber, 1978; Kavaler & Swire, 1983; Moffatt, Peddie, Stulginskas, Pless, & Steinmeitz, 1985; Risley-Curtiss, Combs-Orme, Chernoff, & Heisler, 1996; Schor, 1982). Most child welfare agencies depend on their state's public aid system to provide health care for children in foster care. Typically, states issue a Medicaid card for the children and leave the foster parents to manage the complex issues associated with finding qualified providers. Having a Medicaid card alone, however, is not sufficient to obtain health care because many health care providers will not take the Medicaid card. In general, Medicaid is ill prepared or unable to meet the unique needs of this growing population.

Due to a federal waiver, children in foster care are not subject to compulsory managed care enrollment, so capitated rates are not yet available for this population. Unlike any other city, county, or state, Illinois developed a separate health system through public-private partnerships to ensure access to comprehensive, quality care for children in state custody. This study clearly demonstrates a model of care that has addressed these issues of access and use outside of compulsory managed care enrollment.

As a separate health care system, Health Works has adapted the primary care case management model of service delivery. States will find it relatively easy to replicate Health Works because children who enter foster care are immediately eligible for Medicaid. This translates to a form of health insurance that ensures payment for all medical services that are in the state health care plan or identified through an EPSDT screening and case management that is eligible for federal matching funds. Although Health Works was designed in the context of a large, urban foster care system, most child welfare systems could benefit from a focus on primary care and case management. Even in rural areas where the provider network is not as vast as in Illinois, child welfare systems can benefit by establishing formal agreements and incentives with PCPs to care for children in foster care. This model identifies medical professionals assigned to provide health care, thereby giving caseworkers and foster parents much needed direction as to appropriate access to health care.

Each component of the Health Works model provides support to child welfare practitioners and foster parents, many of whom serve an ever-changing caseload of children. By developing a network of PCPs, agencies have greater incentives to promote continuity of care among children who may experience a lack of continuity in their family lives. Even if a child changes placements while in foster care, the child's caseworker can rely on the assigned PCP to continue providing health care. Primary care in conjunction with medical case management should reduce the likelihood that foster parents visit ERs for primary or nonurgent care. Based on the increases in service delivery identified in the Illinois' Health Works model, child welfare practitioners and the children and families they serve should expect to experience improved access to care. Although access alone does not necessarily translate to improved health status, it represents a major hurdle that can be mitigated through this model.

With relatively few additional dollars, states can leverage their medical insurance funds to develop a cadre of qualified providers, offer incentives for timely access to preventive services, and use a customized set of child-oriented medical records (including a Health Passport) for systemwide tracking of service delivery and health status indicators. Although the process may take several years to develop and implement, a separate primary care-managed health care system, with Medicaid funds at its core, offers public child welfare agencies substantially improved control over access to and quality of the health care of children in foster care.

* Based on an indicator of disability found in the child welfare records, 62% of children without a disability who were in care at the beginning of FY 1997 were enrolled in Health Works, compared with 58% of children who had a disability (p < .001). Among children who entered during FY 1997, 55% of those with no disability and 58% of those with a disability were enrolled in the program (p < .13).

* The authors tested other modeling techniques including proportional hazard regression models incorporating entry to Health Works as a time-varying covariate. Results were similar to the logistic regression results presented here.

[Reference]

References

American Academy of Pediatrics, Committee on Early Childhood, Adoption and Dependent Care. (1994). Health care of children in foster care. Pediatrics, 93, 335-338.

Bilaver, L. A., Jaudes, P. K., Koepke, D., & Goerge, R. M. (1999). The health of children in foster care. Social Service Revieio, 73, 301-417.

Blatt, S. D., Saletsky, R. D., Meguid, V., Church, C. C, O'Hara, M. T., Anderson, J. M., et al. (1997). A comprehensive multidisciplinary approach to providing health care for children in out-of-home care. Child Welfare, 76, 331-347.

Chernoff, R., Combs-Orme, T., Risley-Curtiss, C., & Heisle, A. (1994). Assessing the health status of children entering foster care. Pediatrics, 93, 594-601.

Child Welfare League of America. (1988). Standards for health care services for children in out-of-home care. Washington, DC: Author.

Dubowitz, H., Feigelman, S., Tepper, V, Sawyer, R., & Davidson, N. (1990). The physical and mental health and education status of children placed with relatives. Final report. Baltimore: Maryland Department of Human Resources and Baltimore City Department of Social Services.

Dubowitz, H., Feigelman, S., Zuravin, S., & Tepper, V. (1992). The physical health of children in kinship care. American Journal of Disease of Children, 146, 603-610.

Flaherty, E. G., & Weiss, H. (1990). Medical evaluation of abused and neglected children. American Journal of Disease of Children, 144, 330-334.

Frank, G. (1980). Treatment needs of children in foster care. American Journal ofOrthopsychiatry, 50, 256-263.

Goerge, R., Van Voorhis, J., & Lee, B. J. (1994). Illinois's longitudinal and relational child and family research database. Social Science Computer Review, 12, 351-365.

Gruber, A. R. (1973). Foster home care in Massachusetts: A study of foster children-Their biologicnl and foster parents. Boston: Governor's Commission on Adoption and Foster Care.

Gruber, A. R. (1978). Children infester care: Destitute, neglected,...betrayed. New York: Human Sciences Press.

Halfon, N., English, A., Alien, M., & DeWoody, M. (1994). National health care reform, Medicaid, and children in foster care. Child Welfare, 73, 99-115.

Halfon, N., Mendonca, A., & Berkowitz, G. (1995). Health status of children in foster care: The experience of the Center for the Vulnerable Child. Archives of Pediatrie & Adolescent Medicine, 149, 386-392.

Hobbie, C., Braddock, M., & Henry, J. (2000). Medical assessment of children going into emergency out-of-home placement. Journal of Pediatrie Health Care, 24(4), 172-179.

Hochstadt, N. J., Jaudes, P. K., Zimo, D. A., & Schachter, J. (1987). The medical and psychosocial needs of children entering foster care. Child Abuse & Neglect, 11, 53-62.

Horwitz, S. M., Simms, M. D., & Farrington, R. (1994). Impact of developmental problem on young children's exits from foster care. Journal of Developmental and Behavioral Pediatrics, 15(2), 105-110.

Kass, B. L., Weinick, R. M., & Monheit, A. C. (1999). Racial and ethnic differences in health, 1996 (MEPS Chartbook No. 2, AHCPR Pub. No. 99-0001). Rockville, MD: Agency for Health Care Policy and Research.

Kavaler, F., & Swirc, M. R. (1983). Foster-child health care. Lexington, MA: DC Health.

McIntyre, A., & Keesler, T. Y. (] 986). Psychological disorders among foster children. Journal of Clinical Child Psychology, 15(4), 297-303.

Moffatt, M. E. K., Peddie, M., Stulginskas, J., Pless, I. B., & Steinmeitz, N. (1985). Health care delivery to foster care children: A study. Health and Social Work, 10,129-137.

Newcombe, H. B. (1993). Distinguishing individual linkages of personal records from family linkages. Methods of Information in Medicine, 32, 358-364.

Risley-Curtiss, C., Combs-Orme, T., Chernoff, R., & Heisler, A. (1996). Health care utilization by children entering foster care. Research on Social Work Practice, 6, 442-461.

Roos, L. L., & Wajda, A. (1991). Record linkage strategies. Methods of Information in Medicine, 30(2), 117-123.

Roos, L. L, Wajda, A., Nicol, J. P., & Roberts, J. (1992). Record linkage: An overview. In H. A. Schwartz & M. L. Grady (Eds.), Medical effectiveness research data methods (pp. 119-135). Rockville, MD: U.S. Department of Health and Human Services.

Ruptier, N. M. (1997). Ensuring health care for foster children through Medicaid's EPSDT program. American Journal of Public Health, 87, 290-291.

Schor, E. L. (1982). The foster care system and health status of foster children. Pediatrics, 69, 521-528.

Schor, E. L., Nerf, J. M., & LaAsmar, J. L. (1984). The Chesapeake health plan: An HMO model for foster children. Child Welfare, 63, 431-440.

Simms, M. D. (1989). The foster care clinic: A community program to identify treatment needs of children in foster care. Journal of Developmental and Behavioral Pediatrics, 20(3), 121-128.

Simms, M. D. (1991). Foster children and the foster care system, Part II: Impact on the child. Current Problems in Pediatrics, 22(8), 345-369.

Simms, M. D., Dubowitz, H., & Szilagyi, M. A. (2000). Health care needs of children in the foster care system. Pediatrics, 106, 909-918.

Simms, M. D., Freundlich, M., Battistelli, E. S., & Kaufman, M. D. (1999). Delivering health and mental health care services to children in family foster care after welfare and health care reform. Child Welfare, 78, 166-183.

Swire, M. R., & Kavaler, F. (1977). The health status of foster children. Child Welfare, 56(10), 635-653.

Takayama, J. L., Bergman, A. B., & Connell, F. A. (1994). Children in foster care in the state of Washington: Health care utilization and expenditures, journal of the American Medical Association, 271, 1850-1855.

U.S. Department of Health and Human Services/Office of the Assistant secretary for Planning and Evaluation. (2000, March 31). Dynamics of children's movement among the AFDC, Medicaid, and foster care programs: (1995-1996). Available from http://aspe.hhs.gov/hsp/movementOO/.

U.S. General Accounting Office. (1995). Foster care: Health needs of many young children are unknown and unmet. Report to the ranking minority member, Subcommittee on Human Resources, Committee on Ways and Means, House of Representatives (GAO-HEHS-95-114). Washington, DC: Author.

Weinstein, J., & LaFleur, J. (1990). Caring for our children: An examination of Healthcare services for foster children. California Western Law Review, 26, 319-349.

White, R., & Benedict, M. (1986). Health status and utilization of patterns of children in foster care: Executive summary (Grant #90-PD-86509). Washington, DC: U.S. Department of Health and Human Services Administration for Children, Youth and Families.

White, R. B., Benedict, M. I., & Jaffe, S. M. (1987). Foster child health care supervision policy. Child Welfare, 66, 387-398.

[Author Affiliation]

Paula Kienberger Jaudes, MD, is Medical Director of the Illinois Department of Family Service, Professor of Pediatrics, Department of Pediatrics at the University of Chicago, and President and CEO of La Rabida's Children's Hospital, Chicago, IL. Lucy A. Bilaver, MA, is Senior Research Associate at the Chapin Hall Center for Children at the University of Chicago. Robert M. Goerge, PhD, is Research Fellow at the Chapin Hall Center for Children at the University of Chicago and Faculty Associate at the Northwestern University/University of Chicago Joint Center for Poverty Research, Chicago. James W. Masterson, MPH, former First Deputy Commissioner of the Chicago Department of Health, and Charles R. Catania, MA, former Bureau Chief of Community Health Services at the Chicago Department of Health, are currently Senior Partners at Hamilton Bell Associates, Chicago.

[Author Affiliation]

четверг, 4 октября 2012 г.

TECHNOLOGY IS RIGHT PRESCRIPTION FOR EASY ACCESS TO HEALTH CARE - US Fed News Service, Including US State News

AKRON, Ohio, Aug. 19 -- University of Akron issued the following news release:

The large monitor mounted on the wall of a conference room in the Musson Military Veterans Lounge looks like any other flat-screen TV. But it is going to offer much more than images - it is a direct video link for veterans at UA to access health care services without leaving campus.

This telehealth program, which begins in the fall, is being made possible through a partnership with The University of Akron and the Cleveland Veterans Affairs Medical Center. UA is believed to be the VA's first college site in the country for a telehealth program.

The initiative is part of the University's growing range of services for returning military veterans pursuing degrees here. In addition to the enrollment and academic support provided by the Military Services Center and Adult Focus to UA's approximately 1,400 student-veterans, there is the lounge. It opened in InfoCision Stadium in 2011, thanks to $220,000 in donations from the community, including the R.

C. Musson and Katharine M. Musson Charitable Foundation.

TECHNOLOGY = ACCESS

'With this partnership, we will provide VA patients enrolled at The University of Akron with increased access to high quality health care that could previously only be received by traveling to one of our 13 outpatient clinics or our Wade Park Medical Center here in Cleveland,' says David Chmielewski, the Cleveland telehealth facility lead.

'There are a variety of health services we can offer, but we're going to begin with speech-language pathology because there's a wonderful program in place on campus and we know we have the right people on both ends to support it,' adds Chmielewski, who has earned two degrees at UA, including an MBA in Management - Health Services Administration in 2009.

In fact, it is through the School of Speech-Language Pathology and Audiology that telehealth is already in use on campus. In the school's Audiology and Speech Center in the Polsky Building, students observe and provide diagnostic and treatment services to children and adults with language, speech and hearing conditions. Most of the appointments are handled on-site, but others are delivered via video conferencing.

Jennifer Skaggs and Emily Lowe, both graduate students in speech-language pathology who will have internships with the VA this year, expect that some of their clients will be student-veterans at UA and they will work with them via the video link. They are the first of many students in UA's new College of Health Professions who will gain telehealth experience as the program expands to meet veterans' various health needs.

PROVIDING NEEDED SERVICES

The telehealth appointments Skaggs and Lowe will conduct with UA veterans could be handled one of two ways. They might work directly with a client in the Musson conference room while a supervisor at the VA observes the session via the video link, or they might be at the VA providing the services with a supervisor seated next to them.

When the program expands, a doctor or other medical professional at the VA will meet with a client via the video link at UA while a nursing student could provide clinical assistance.

'There are many advantages to telehealth,' says Skaggs, who has worked with clients via video conferencing at the Audiology and Speech Center. 'If people have access to the Internet, they can be seen for an appointment when they're on vacation, home with a sick child or if they don't have access to transportation.'

In addition to easy access, telehealth offers anonymity that is not always possible in a clinic setting, notes Lowe. 'Technology is so prominent in our daily lives - why not administer health services that way when you can? It is user friendly and takes away any stigma.'

After graduating in Spring 2013, both hope to work in the area of rehabilitative therapy. Skaggs, who will intern in the spring, hopes to stay in the VA system and work with individuals with traumatic brain injuries. Lowe, who will be at the VA this fall, is looking forward to the experience she will gain.

'It's such a fast-pace medical environment - I'll see so many people with so many different types of disabilities,' notes Lowe. 'I want to work with people who have cognitive dysfunctions - people who were, quote, unquote normal before their accident or injury. My desire is to help them get back to where they were.'

HEALTH PROFESSIONS STUDENTS CAN GAIN EXPERIENCE

Gaining telehealth experience is important training for UA's graduates in the health professions to have, says Charles Carlin, an assistant professor of speech-language pathology and audiology who provides clinical supervision to the students.

'Telehealth is not new, but it is still very unique, and to have that kind of experience on your resume will open doors for our graduates, whether they are applying for positions or they are opening a private practice and can make that service available to their patients,' notes Carlin, who is a member of UA's Telehealth Implementation Task Force.

As veteran enrollment continues to increase at UA, the telehealth program is expected to expand into such specialties as counseling, pain management, endocrinology and physical therapy, and could serve those with traumatic brain injuries and spinal cord injuries.

Carlin also hopes that when the telehealth equipment is not in use for medical appointments, the VA will stream the study skills sessions it already offers to veterans via the video link.

'With traumatic brain injuries, for example, there can be cognitive issues - difficulty maintaining attention, being organized, taking notes, studying for a test, problem solving, even social skills,' explains Carlin. 'With our academic setting, it's a perfect fit.'

To Steve Motika, the telehealth program looks to be a win-win - helping the VA to better reach veterans who need services, and helping the veterans themselves, who are often juggling their studies with family time and jobs.

'The telehealth program will allow our student-veterans to schedule appointments around their classes by eliminating travel time to Cleveland's Wade Park facility for many services,' says Motika, assistant dean of student success for Summit and University Colleges. A veteran himself, he serves as the faculty adviser to the Military Veterans Association on campus, co-chairs the campus-wide Veterans Steering Committee and chairs the Telehealth Implementation Task Force. 'The telehealth program will save our student-veterans time and resources by allowing them to receive VA medical services from a location on campus that is both convenient and comfortable for them.'