James R. Knickman

Predictors of homelessness among families in New York City: from shelter request to housing stability.

OBJECTIVES This study examined predictors of entry into shelter and subsequent housing stability for a cohort of families receiving public assistance in New York City. METHODS Interviews were conducted with 266 families as they requested shelter and with a comparison sample of 298 families selected at random from the welfare caseload. Respondents were reinterviewed 5 years later. Families with prior history of shelter use were excluded from the follow-up study. RESULTS Demographic characteristics and housing conditions were the most important risk factors for shelter entry; enduring poverty and disruptive social experiences also contributed. Five years later, four fifths of sheltered families had their own apartment. Receipt of subsidized housing was the primary predictor of housing stability among formerly homeless families (odds ratio [OR] = 20.6, 95% confidence interval [CI] = 9.9, 42.9). CONCLUSIONS Housing subsidies are critical to ending homelessness among families.

Social relationships and vulnerability to becoming homeless among poor families.

This study compares social relationships of 677 mothers in families requesting shelter with those of 495 mothers in housed families, randomly selected from the public assistance caseload in New York City. As hypothesized, women seeking shelter had experienced higher levels of a variety of childhood and adult events indicative of disruptions in social relationships. Contrary to our hypothesis, they were more likely than were housed mothers to have had recent contact with parents, other relatives, and friends, although they felt less able to draw on these resources for help with their current housing needs. More than three fourths of families seeking shelter had already stayed with members of their social network in the past year. The data suggest that they had used up potential sources of support before turning to public shelter.

Transforming the Delivery of Care in the Post–Health Reform Era: What Role Will Community Health Workers Play?

The Patient Protection and Affordable Care Act (PPACA) affords opportunities to sustain the role of community health workers (CHWs). Among myriad strategies encouraged by PPACA are prevention and care coordination, particularly for chronic diseases, chief drivers of increased health care costs. Prevention and care coordination are functions that have been performed by CHWs for decades, particularly among underserved populations. The two key delivery models promoted in the PPACA are accountable care organizations and health homes. Both stress the importance of interdisciplinary, interprofessional health care teams, the ideal context for integrating CHWs. Equally important, the payment structures encouraged by PPACA to support these delivery models offer the vehicles to sustain the role of these valued workers.

Predictors of Shelter Use among Low-Income Families: Psychiatric History, Substance Abuse, and Victimization.

For poor housed and homeless families in New York City, NY, we examined the degree to which psychiatric and substance-abuse problems and victimization placed the families at elevated risk of requiring emergency housing, and we documented the prevalence of such problems. These problems were infrequently reported by both groups. However, past mental hospitalization, treatment in a detoxification center, childhood sexual abuse, and adult physical abuse were associated with increased risk of homelessness.

Patterns of expenditures among high utilizers of medical care services. The experience of Medicare beneficiaries from 1974 to 1977.

The authors of this study examine temporal patterns of medical expenditures by Medicare beneficiaries. A random sample of 204,917 individuals who were alive and in the program from 1974 to 1977 was investigated. Individuals hospitalized in 1974 were found to have twice the rate of hospitalization in 1975, 1976, or 1977 compared with individuals who were not hospitalized in 1974. The increased rate of hospitalization remained constant throughout the 3 years. Individuals with large medical expenditures in 1974 were 20 times more likely to have large medical expenditures the following year, and this rate declined slowly in the following 2 years. The results suggest that the value of a Medicare voucher or the level of Medicares payment to health maintenance organizations should include an adjustment factor for prior health care utilization. The results also suggest that multiyear limits on total Medicare coinsurance and deductible payments would be more equitable than single-year limits.

Improving Access to Effective Care for People With Mental Health and Substance Use Disorders

The United States needs to do more to help improve the outcomes of people with mental health disorders, substance use disorders, or both. In 2014, approximately 18% of US adults experienced some form of mental health disorder and 8% had a substance use disorder.1 Mental health disorders are among the most expensive conditions; in 2013, annual health spending on mental health disorders in the United States was approximately

Epilogue: Four Lessons from Evaluating Controversial Programs

201 billion.2 Importantly, behavioral health and overall health are fundamentally linked. Mental health and substance use disorders are often accompanied by comorbidities, such as cardiovascular disease and diabetes, and the additional costs associated with behavioral comorbidities are

The Partnership for Long-Term Care: Who are the Partnership Policy Purchasers?

293 billion.3 Patients seen in primary care settings with chronic medical conditions, such as diabetes, asthma, and cardiovascular disorders, have a higher probability of having a substance use disorder or more common mental health conditions, such as depression and anxiety disorders. Coexistence of mental health or substance use disorders with general medical conditions complicates the management of both and is associated with reduced life expectancy. For example, a 35-year-old man with schizophrenia, diabetes, and tobacco dependence can expect an up to 25-year shortened life span.4 Systems of care for general medical, mental health, and substance use disorders are fragmented. The United States has various problems impeding its efforts to improve care for people with behavioral health problems. Effective treatments are available, but there is limited success in getting these treatments to many of the people who can benefit from them. Despite the availability of effective care models, identifying and engaging patients in primary care with behavioral health problems has proven difficult. Moreover, the United States needs to solve the problem of providing access and building the capacity to meet the needs of even those who are already engaged in care. At the same time, individuals with severe mental health and substance use disorders have difficulty accessing effective primary and preventive care for chronic medical conditions.5,6 The goal should be better life outcomes and access to effective integrated care for every person.

The implementation of school finance reform

Abstract The papers in the final section of this volume describe in great detail the major methods of program evaluation. In this epilogue, we discuss how we grappled with various evaluation design issues within the context of one demonstration program. We conclude by sharing four lessons we learned along the way, lessons that we believe will be useful to those who evaluate programs as well as to consumers of such evaluations.

Medical vulnerability in America: how does the health system respond?

Policymakers are increasingly looking toward expanding the role of private insurance in the financing of long-term care. One effort to blend public and private insurance is the Partnership for Long-Term Care sponsored by the Robert Wood Johnson Foundation. This article examines the characteristics of individuals who purchased long-term care insurance through the Partnership for Long-Term Care, as well as their motivation for purchase. Partnership purchasers are found to be a healthier, higher educated, and wealthier group than a comparison group of 55- to 75-year-olds. Partnership purchasers are also more active financial planners, have more self-reliant attitudes, and are more knowledgeable about long-term care. Findings also suggest that the Partnership for Long-Term Care attracts a substantial number of beneficiaries who would not have purchased long-term care insurance in the absence of the Partnership program.