Sara S. Bachman

Cross-Disability Experiences of Barriers to Health-Care Access

In this article, we present the results of a series of focus groups with people with disabilities, in which we took a cross-disability, lifespan perspective of disability. Consumers were asked about a broad set of barriers, such as problems with communication, transportation, and insurance, as well as about barriers related to physical accessibility. We used the Institute of Medicines framework to categorize barriers as either structural, financial, or personal/cultural. Our results suggest that individuals with disabilities experience multiple barriers to obtaining health care and that these barriers are more pronounced for some types of health care than others. In addition, regardless of disability type, consumers consistently spoke about similar barriers. The results underscore the importance of taking a broad perspective when making policy decisions and the need for continued change and improvement in this area.

Effect of aging on the electrocardiogram

Previous cross-sectional population studies have shown age differences in electrocardiographic wave patterns, including lower wave amplitudes and a leftward shift of the frontal plane axis in older people. However, cross-sectional results may be due to cohort differences and the data imply only that these changes actually occur in persons as they age. In order to examine electrocardiographic changes with aging in the same persons, serial recordings, obtained 10 years apart, were taken in 440 healthy male participants of the Normative Aging Study, who were 23 to 66 years old on their first examination. At examination 1, R and S wave amplitudes were smaller and frontal plane axis measurements were shifted to the left in older men. Longitudinal changes in these same variables were consistent with the cross-sectional results. In addition, the P-R and Q-T interval durations were longer, the QRS duration was shorter and the T wave amplitude was smaller at the second examination. The longitudinal rate of change of S wave amplitude varied among age groups, decreasing more in younger men. Thus, some previously described cross-sectional age differences truly represent longitudinal age trends in electrocardiographic patterns.

Provider Perceptions of Their Capacity to Offer Accessible Health Care for People With Disabilities

The purpose of this article is to provide preliminary data about the results of a comprehensive survey of providers regarding their perceptions of access to health care for people with a broad range of disabilities. We conducted a mail and telephone follow-up survey of providers that contract with two managed care organizations, the Massachusetts Division of Medical Assistance, and the Assisted Living Association (36% response rate). Data were analyzed using standard methods. Results suggest that providers are more likely to provide services to patients with chronic illness, mobility, cognitive, or psychiatric impairments than they are to serve individuals with communication limitations or visual impairments. Providers also reported that people with communication impairments are the most difficult to serve. However, respondent perceptions also suggest that individuals with disabilities do not have easy access to health-care providers, despite changes brought on by the Americans with Disabilities Act.

The Complexities of Elder Homelessness, a Shifting Political Landscape and Emerging Community Responses

Despite their growing numbers, homeless older adults remain largely invisible in society and there has been a pervasive lack of public focus on elder homelessness. In this article, we seek to shine light on this forgotten population and deepen understanding of difficult challenges they confront in regaining housing security. We also examine the shifting political climate regarding homelessness, particularly the enactment and subsequent reauthorizations of the McKinney–Vento Homeless Assistance Act, and how these shifts are influencing community responses to elder homelessness. Finally, future challenges and policy directions for breaking the cycle of elder homelessness in the U.S. are discussed.

Increasing Access to Oral Health Care for People Living with HIV/AIDS in the U.S.: Baseline Evaluation Results of the Innovations in Oral Health Care Initiative

Objectives. We provide an overview of the Health Resources and Services Administration HIV/AIDS Bureaus Special Projects of National Significance Innovations in Oral Health Care Initiative, describe the models developed by the 15 demonstration sites and associated evaluation center, and present initial descriptive data about the characteristics of the multisite evaluation study sample. Methods. Baseline data were collected from May 2007–August 2009 for 2,469 adults living with HIV/AIDS who had been without dental care, except for emergency care, for 12 months or longer. Variables included sociodemographic characteristics, HIV status, medical care, history of dental care and oral health symptoms, oral health practices, and physical and mental health quality of life. Descriptive statistics of baseline variables were calculated. Results. The study sample included 2,469 adults who had been HIV-positive for a decade; most were engaged in HIV care. The majority (52.4%) of patients had not seen a dentist in more than two years; 48.2% reported an unmet oral health-care need since testing positive for HIV, and 63.2% rated the health of their teeth and gums as “fair” or “poor.” Conclusions. This study is the largest to examine oral health care among people living with HIV/AIDS in more than a decade. The need for access to oral health care among members of this HIV-positive patient sample is greater than in the general population, following previous trends. Findings from our study reinforce the necessity for continued federal and statewide advocacy and support for oral health programs targeting people living with HIV/AIDS; findings can be extended to other vulnerable populations.

Public Health and Social Work: Training Dual Professionals for the Contemporary Workplace

Objectives. The emergence of new, complex social health concerns demands that the public health field strengthen its capacity to respond. Academic institutions are vital to improving the public health infrastructure. Collaborative and transdisciplinary practice competencies are increasingly viewed as key components of public health training. The social work profession, with its longstanding involvement in public health and emphasis on ecological approaches, has been a partner in many transdisciplinary community-based efforts. The more than 20 dual-degree programs in public health and social work currently offered reflect this collaborative history. This study represents an exploratory effort to evaluate the impact of these programs on the fields of public health and social work. Methods. This study explored motivations, perspectives, and experiences of 41 graduates from four master of social work/master of public health (MSW/MPH) programs. Four focus groups were conducted using traditional qualitative methods during 2004. Results. Findings suggest that MSW/MPH alumni self-selected into dual programs because of their interest in the missions, ethics, and practices of both professions. Participants highlighted the challenges and opportunities of dual professionalism, including the struggle to better define public health social work in the workplace. Conclusions. Implications for academic public health focus on how schools can improve MSW/MPH programs to promote transdisciplinary collaboration. Increased recognition, better coordination, and greater emphasis on marketing to prospective employers were suggested. A national evaluation of MSW/MPH graduates could strengthen the roles and contributions of public health social work to the public health infrastructure. A conceptual framework, potentially based on developmental theory, could guide this evaluation of the MSW/MPH training experience.

Why Do States Privatize Mental Health Services? Six State Experiences

State governments fund more than one-half of public mental health service system costs through mental health departments, other state agencies, and the Medicaid program. They use some of these resources to finance community-based mental health services through purchase-of-service contracts. I explored the reasons why states privatize mental health services and focused on political, economic, and organizational theories as possible frameworks for contracting. I gathered data during site visits to Massachusetts, Michigan, New York, Oregon, Tennessee, and Texas, where I interviewed more than one hundred individual stakeholders about mental health purchase-of-service contracting. I also examined relevant documents about contracting practices for mental health services in each state. My results suggest that state policy makers can use mental health contracting to effect multiple goals. Contracting helps states achieve political, economic, and organizational objectives, such as avoiding the influence of interest groups and leveraging state resources, while avoiding conflict. With contracting, state policy makers can also continue the ongoing mental health policy paradigm shift begun during deinstitutionalization, in which persons with serious and persistent mental illnesses receive services from community-based providers rather than in state hospitals. Finally, my results suggest that contracting will continue to be an important state policy tool in further development of state-supported mental health systems.

Long-term retention in Office Based Opioid Treatment with buprenorphine

BACKGROUND Guidelines recommend long-term treatment for opioid use disorder with buprenorphine; however, little is known about patients in long-term treatment. The aim of this study is to examine the prevalence and patient characteristics of long-term treatment retention (≥1year) in an Office Based Opioid Treatment (OBOT) program with buprenorphine. METHODS This is a retrospective cohort study of adults on buprenorphine from January 2002 to February 2014 in a large urban safety-net primary care OBOT program. The primary outcome was retention in OBOT for at least one continuous year. Potential predictors included age, race, psychiatric diagnoses, hepatitis C, employment, prior buprenorphine, ever heroin use, current cocaine, benzodiazepine and alcohol use on enrollment. Factors associated with ≥1year OBOT retention were identified using generalized estimating equation logistic regression models. Patients who re-enrolled in the program contributed repeated observations. RESULTS There were 1605 OBOT treatment periods among 1237 patients in this study. Almost half, 45% (717/1605), of all treatment periods were ≥1year and a majority, 53.7% (664/1237), of patients had at least one ≥1year period. In adjusted analyses, female gender (Adjusted Odds Ratio [AOR] 1.55, 95% CI [1.20, 2.00]) psychiatric diagnosis (AOR 1.75 [1.35, 2.27]) and age (AOR 1.19 per 10year increase [1.05, 1.34]) were associated with greater odds of ≥1year retention. Unemployment (AOR 0.72 [0.56, 0.92]), Hepatitis C (AOR 0.59 [0.45, 0.76]), black race/ethnicity (AOR 0.53 [0.36, 0.78]) and Hispanic race/ethnicity (AOR 0.66 [0.48, 0.92]) were associated with lower odds of ≥1year retention. CONCLUSIONS Over half of patients who presented to Office Based Opioid Treatment with buprenorphine were ultimately successfully retained for ≥1year. However, significant disparities in one-year treatment retention were observed, including poorer retention for patients who were younger, black, Hispanic, unemployed, or with hepatitis C.

Overcoming Treatment Barriers to Providing Services for Adults With Dual Diagnosis: Three Approaches

A large and growing proportion of individuals with permanent and total disability are adults dually diagnosed with mental illness and substance-abuse disorders. These dually diagnosed individuals are frequently hospitalized, often unable to work, and thus are dependent on public systems for care. As the prevalence of clients with dual diagnosis continues to increase, states must examine how to best manage services for these individuals. This paper discusses some issues involved in serving this population, barriers to treatment, and program approaches for overcoming the barriers to providing effective services to individuals who are dually diagnosed.

Failure to receive health care among people with mental illness: theory and implications.

ABSTRACT Often individuals with serious mental illness suffer from comorbid physical health problems but fail to receive necessary health care services. This article explores the major factors associated with the failure to receive adequate medical care using 3 theories of health care utilization: Andersens behavioral model of health services use, the health belief model, and the avoidance and approach framework. Finding these theories inadequate to fully explain the failure to receive adequate care on their own, a new intervention model incorporating an individual and context-specific dimension is proposed as a comprehensive way of conceptualizing how people with mental illness may be effectively engaged with the health care system.