Community-based Care

Massachusetts residents are frequent users of emergency department (ED) care, with high levels of use continuing despite significant improvements in access to care as a result of the state’s 2006 health reform initiative. In an effort to better understand ED use in Massachusetts, this policy brief looks at ED use among working-age adults, focusing on reported reasons for using the ED and barriers to obtaining needed health care among ED users. Findings show adult ED users in Massachusetts are a sicker, more disabled, and more chronically ill population and report more difficulties obtaining care in the community and more unmet need for care than other adults in the state. Potential strategies for addressing preventable ED use include efforts targeted to specific care settings and particular population groups.

Nurses are health care's backbone, spending the most time with patients, and working with teams of caregivers in institutions and serving as advanced practice nurses in primary care settings. Short-term shortages wax and wane, but concerns about a shortage are more serious now because the next decade may see more older nurses retiring than new ones entering the workforce. Education needs to be augmented and improved, but no precise estimation method can show how many nurses society "should" produce. Policy should focus more on nurses' scopes of practice and aligning how they are treated and paid with the value they add to patient care.

This report presents early findings of an evaluation of San Mateo County's Health System Redesign and Adult Coverage Initiative (ACE), an effort to improve effectiveness, efficiency, and care coordination among uninsured and underserved adults in the county. Enrollment in the ACE program has exceeded expectations, yet sustained financing for the program has yet to be identified. We have observed reforms in scheduling, team-based care, and the implementation of electronic medical records. However, we found significant barriers to access for primary care and specialty appointments. This analysis is the first of several ongoing evaluation reports by the Urban Institute and UCSF.

In 2005, Missouri adopted sweeping Medicaid cutbacks. More than 100,000 people lost coverage, and many more faced reduced benefits and higher cost-sharing. Using a range of data sources, we show that the cutbacks were followed by a major increase in the numbers of uninsured people, greater uncompensated care burden on hospitals, and revenue shortfalls that forced community health centers to obtain larger state grants and charge patients more. Competing demands on state budgets and the need to balance budgets even during recessions could result in policies that disadvantage those with great needs as well as the providers who serve them.

In 2005 The Children's Trust of Miami-Dade County initiated HealthConnect in Our Community, designed to improve the health of children and adolescents in the county. The program uses community workers to reach out to underserved children and their families. The Urban Institute and three local consultants conducted a formative assessment the program's first year of operation. In a six-day site visit we interviewed 26 individuals, observed program operations in 19 separate locations, and conducted five focus groups, three with clients and two with program staff. This report summarizes the findings from the evaluation, and provides recommendations for improving the program.