Chapter I –
Overview of Completed Evaluations—Selected Highlights

Chapter I presents highlights from the findings of the studies included in this Performance Improvement 2007 report. These examples were selected to emphasize the breadth of subject areas addressed by the studies and showcase the diverse methodologies used.

The studies examined important management, programmatic, policy, and factual circumstances faced by programs administered by the Department of Health and Human Services. The studies employed a wide range of methods in seeking accurate information about internal and external agency environments, including literature review, focus groups, surveys, microsimulation analyses, field visits, and case studies. Some of the studies were carried out by agency staff; most were completed with the assistance of contract support expertise; all the completed studies reflect an intense, creative and collaborative effort of technical expertise and programmatic knowledge and experience regarding the importance of effective and efficient programs that achieve targeted objectives and that serve the public purposes for which they were established.

While most studies in this collection focus on process and output activites or program environments, some also aim at program outcomes and cost-effectiveness analysis. Several studies, seeking efficient use of resources, were preliminary feasibility or evaluability studies (examinations of the practical means by which a program might be evaluated) rather than full-fledged (and more expensive) evaluations. These studies typically led to advice and recommendations regarding how best to proceed with more in-depth studies.

Studies examined how to communicate important health and human services information to both the professional and general public. Several surveys provided valuable information about the nature of social behaviors or the numbers of institutional clients that are public beneficiaries in order to provide more solid bases for advice to policy decision-makers. Examinations of agency administrative activities also yielded valuable information and recommendations for improving the management of programs.

The studies in Performance Improvement 2007 support the eight important goals articulated in the Department of Health and Human Services’ Fiscal Year 2004-2009 Strategic Plan. The remainder of Chapter I provides highlights of interesting and significant evaluations and findings from the past year, organized under these eight goals:

Preventing Disease and Illness

Several studies focused on ways to better communicate with consumers. A post-cancer treatment education booklet was shown to be useful for both patients and families. A tribally-based diabetes science education program advanced toward operational status. Research supported important actions to advance public health. A study of the cost-effectiveness of routine childhood vaccination for Hepatitis A in the United States resulted in a decision to extend hepatitis A immunization nationwide.

As a result of a research project to evaluate online information used to communicate human immunodeficiency virus (HIV) prevention messages, researchers recommended drafting professionally designed advertisements for various media settings.

The Office of Public Health and Science examined how to better prevent violence in families between intimate partners. The study identified promising practices including: efforts to recognize patients experiencing family or intimate partner violence and helping women safely and confidentially leave abusive situations. Another study, of couples-focused family planning services, found that serving males and building staff capacity to provide these services requires significant effort and more staff development/training. A study of family planning underscored the importance of the program for low-income populations, the uninsured, and teens.

Survey data, essential to budget and administrative planning, was obtained in several studies of drug taking behavior. During 2005, over 13,000 alcohol and drug abuse treatment facilities were operating. At any one time, these facilities served over a million, mostly outpatient, clients. Half of the clients were treated for both alcohol and drug abuse. Two-thirds of the treatment facilities were private non-profits and a quarter were for-profit private facilities. During the same year, illicit drug and alcohol use and binge drinking among youth had declined from the previous years. However, 25 million adults (11 percent of the population) experienced severe psychological distress.

Building Health Care Capacity

Regarding how to best support health professions education, one study provided advice on how to enhance the current system of graduate medical education financing and recommended criteria to use in evaluating the alternatives.

Long-term care needs are expected to grow dramatically; staffing needs are at the center of concerns about this fact. One study concluded that the number of Americans needing long-term care will double from 13 to 27 million during the next 40 plus years, increasing the need to recruit, train, and retain direct care workers, especially considering that some organizations currently experience 100% turnover annually. By 2020, over 300,000 additional direct care staff will be needed to care for individuals with either cognitive or developmental disabilities. Achieving this 37% increase will be difficult because the projected increase in overall labor supply is only 7%. A related study concluded that as many as 50,000 more social workers will be needed to serve in long-term care settings during the coming four decades.

Another study showed the success of small grants for behavioral cancer control research to increase the number of scientists working in the field.

Closing the Gaps in Health Care

A major success revealed by one study supported by the Centers for Disease Control and Prevention of a United States-Mexico bilateral tuberculosis case management and referral project was the project’s formal integration into the detainee screening process at immigration control and enforcement facilities.

Researchers found that residential care patients differ from individuals living at home in a number of ways. They had a greater likelihood of:

having incomes below $10,000;
receiving help with activities of daily living;
being over age 85, female, and widowed; and
being far more likely to suffer from Alzheimer’s disease or other dementias.

A study exploring what the United States can do to make sure it has a qualified long-term care workforce observed that criminal background checks are valuable during the hiring process to prevent or reduce abuse of vulnerable adults needing long-term care. Another study concluded that greater efforts are needed to more fully advance the use innovative technologies in residential long term care settings. A third study concluded that agreements between patients and assisted living facilities, in which patients or their representatives directly hire individuals to help them, can allow residents a way to be both more independent and safe.

Improving Health Science

To actively advance essential biomedical research, the National Institutes of Health conducts many intramural (internal) clinical research studies for which it needs thousands of willing patient volunteers annually. A feasibility study provided information with which to design an effective evaluation of how best to solicit these new clinical study participants. Protecting volunteer patients is also critical. A study seeking to identify concerns patients may have about potential conflicts of interest on the part of their health care team members found that patients were not worried about this as long as they knew that an oversight system was in place.

Other feasibility studies in the health sciences area included one that provided information to design an evaluation of how most efficiently to operate 15 cancer incidence and treatment tracking systems. Advice was also obtained about how to better evaluate the functioning of bioengineering research partnership grants in the heart, lung and blood institute. In another critical area, consultant advisors concluded that it was feasible and desirable to conduct an outcome study regarding how productive clinical acquired immune deficiency syndrome (AIDS) research is and how it could be improved.

Essential biomedical research discovery and infrastructure depends on expanding the numbers of individuals doing health sciences research and the number of institutions capable of competing for grants. A graduate partnership program was shown to be effective at recruiting and selecting students and providing them with high-quality research training experiences. One study provided guidance on carrying out an evaluation of a program intended to foster health-related research and enhance competitiveness of investigators at institutions located in states which have historically received fewer research grants.

Two studies by the Food and Drug Administration enabled the agency to refine its review and approval processes. The first concluded that the indifferent results of a pilot program to speed drug approvals did not appear to justify the added costs. The second supported developing a full evaluation of the agency processes through which it achieves efficient first-cycle review approvals.

Realizing the Possibilities of 21st Century Health Care

Several studies for the National Institutes of Health examined how to make informational Web sites more useful, accessible, and effective. Health science information important to both medical professionals, patients, and other consumers underscores the value of Web-based as well as other methods of information dissemination. Online health information on toxic substances was refined based on a study of site users. The usability of an NIH stem cell information Web site was examined and recommendations for improving the site obtained. Collaboration between the National Institute on Aging, the Census Bureau, and the National Center for Health Statistics was examined and advice provided for strengthening this information dissemination project. A plan for evaluating how to improve educational outreach at over 100 conferences each year was developed.

One study confirmed the effectiveness and appeal of a curriculum to train older adults to access health information on the Web for both seniors and trainers. A study about accessing key medical information from the National Library of Medicine via handheld computers found that the information retrieved was useful in answering clinical questions and that special software designed for the purpose, worked well.

A study about providing information on clinical trials to Spanish-speaking users both confirmed the effectiveness of the Web site and identified areas for further attention. An examination of how educational efforts to prevent noise-induced hearing loss could be strengthened recommended focusing on youth. Studies targeted specific groups such as one for the Food and Drug Administration examining information health professionals need in order to talk clearly with their patients about the risks of heart defibrillators.

The success of efforts by state medical boards to discipline physicians was examined to see whether these efforts contributed to safeguarding medical quality and patient safety. Researchers on the study recommended that demonstrations be conducted to see how well some of the more effective strategies worked elsewhere.

A study to determine what could be learned from employer-provided health insurance data concluded that several research questions could be pursued with the available data, including: the magnitude of costs that are passed along to employees and how such increases affect employee participation in employer-offered health insurance plans. A study to determine how the business case for using health information technology in long-term care settings could be evaluated advised that a small retrospective study with 10-20 nursing homes or home health settings could both make relevant information about this subject available and keep research costs low.

A study was supported by the Office of the Assistant Secretary for Planning and Evaluation to determine how barriers to interoperable health information technology in post-acute and long-term care could be reduced and to determine whether patient data could be made to comply with health information technology standards. The study led to the identification of standards that were subsequently recommended for adoption and use. A second study, funded by the Office of Public Health and Science, that explored the role the federal government should play in developing electronic personal health records resulted in several important findings and recommendations, including that the government could be most effective by avoiding two possible pitfalls: sponsoring a superficial, one-size-fits-all public health record, and allowing many agencies to offer independent public health records with little coordination or strategic vision.

Working Toward Independence

The Department explored circumstances that prevented, and explored ways to support, greater independence on the part of both young and old. A study of what might happen if states allowed welfare recipients to keep more of their child support money found that average annual cash income for the families would increase. Another study, looking at whether the risk of legal responsibility for injury increases when disabled Medicaid clients manage their own personal assistants found that, in general, the risks did not increase.

Findings that challenge assumptions about likely program effectiveness are also important. A study by the Administration for Children and Families that looked at a community college approach designed to improve welfare recipients’ employment prospects found that the program did not produce better economic outcomes. Other individual ACF studies ranged from finding positive program effects, as did a study of a program intended to encourage former welfare recipients to obtain jobs, retain employment and advance into better paying jobs, to finding no program effects. A study analyzing data from 30 welfare-to-work programs identified common aspects of these demonstrations that positively impacted employment outcomes.

A study of adult day services in the context of health care and long-term care systems found that cost and lack of transportation were the two chief barriers to expansion of such services. An examination of the Web site, “My Family Health Portrait,” that helps people record and display their family health history revealed several features that needed to be modified and provided specific recommendations for doing so. A study of how Texas modified its Medicaid program to have funds move with nursing home residents who chose to live in the community found that this program could easily be incorporated into Medicaid long-term care programs in other states.

Another study revealed three broad strategies for overcoming barriers that Native American Tribes and organizations face trying to access discretionary grants: obtaining information regarding applying for grants; dealing with the grant review process; and managing grants.

Using micro-simulation analyses and a variety of data sources, the Office of the Assistant Secretary for Planning and Evaluation arrived at summary conclusions regarding the extent to which Americans were dependent on social welfare programs. Overall, 3.4 million fewer Americans were dependent on welfare in 2003 than in 1996. Another study about how states pay for services for children and youth with serious emotional disorders arrived at three major findings: sustained program improvement will depend on effective partnerships among community organizations; demonstration projects will continue to play an important role in improving services; and states should replace residential care with more effective home and community services.

Leaving No Child Behind

A study about the characteristics of children being served by the Head Start program found that most children entered the program with math and literacy levels well below national averages. Children made gains toward national averages during the time they spent in Head Start, but still lagged behind national averages.

A study of child welfare agency efforts to identify, locate and involve nonresident fathers found that nearly half the fathers were never contacted by the agency. The study observed that by not reaching out to fathers, caseworkers may overlook potential social connections and resources that could help to achieve permanency for the children.

Improving Department Management

The National Institutes of Health conducted a mission risk assessment that provided the basis for further systematic investigation and development of ways to assure improved risk protection.

More details on the studies highlighted above, and descriptions of other studies completed during Fiscal Year 2006, are provided in Chapter II. In addition, all the studies and final reports issued for these studies can be found online at http://aspe.hhs.gov/pic/performance.

Chapter II –
Summaries of Completed Evaluations – What Was Studied and the Key Findings

Evaluation is an essential means of achieving outstanding program performance. Without questions, there would be no need to study how well programs perform, what they accomplish, and what the circumstances are in which they operate. For each of the studies summarized below, the question that motivated each is identified. The summaries then provide a brief but vivid synopsis of the facts about the study, including, as specified in law, its key findings. These studies emerge as significiant signposts along the path of program review and improvement efforts. Evaluation implies critical judgement and reaching conclusions about merit and value. This year’s collection of completed studies include a wide range of significant findings that are potentially of broad interest.

Each study is listed under the strategic goal and objective it most clearly supports (see Appendix A for all the goals and objectives). Evaluation priorities respond to and are guided by Congressional oversight, Executive Branch decision-making, program management needs and performance measurement systems such as the Performance Assessment Reporting Tool and the Government Performance and Reports Act. Evaluation activities also respond to changing realities in the programs themselves and in the environments in which the programs operate as well as in response to advice and recommendations from earlier evaluations.

To view the studies conducted or supported by specific agencies, see the list in Appendix C. In addition to the studies in this report, available online are previous studes and preliminary entries for studies that are ongoing or too recently concluded to be included here. These can be found at http://aspe.hhs.gov/pic/performance.

Goal 1: Reduce the major threats to the health and well-being of Americans

Objective 1.1: Reduce behavioral and other factors that contribute to the development of chronic diseases

How Can Managers and Evaluators Better Understand, Design, and Perform Cost Effectiveness Evaluations of Community Public Health Prevention Programs?

Summary:

The purpose of this project was to develop a guide stressing the importance of planning for cost effectiveness studies, early in the life of community based prevention programs, for use by program managers and local evaluators.

The Department of Health and Human Services encourages health promotion and disease prevention in a variety of programs targeted to communities. At the community level, managers need to be able to assess whether health promotion and disease prevention interventions are having the desired effect and are a good use of scarce resources. Cost effectiveness analysis is one tool for answering these questions. In cost effectiveness analyses program costs are quantified in dollars and program outcomes are quantified in non-monetary units such as life-years gained. The guide was to offer checklists for the reader, identifying the steps that needed to be taken. It was also to offer advice on how to develop a cost-effectiveness study, including determining the time frame for the intervention and the time frame for the analysis; use of discounting in considering future costs and benefits; and various types of economic studies and their potential use. It also was to offer guidance on identifying outcome measures, citing programs such as the Centers for Disease Control and Prevention's (CDC's) Steps to a Healthier US, and the National Cancer Institute’s American Stop Smoking Intervention Study as examples. It was also to offer criteria for selecting among candidate outcome measures. In a similar vein, it would offer advice on how to quantify program costs, and isolate costs by program component.

Guidance was developed by the contractor, including specific advice on conducting cost-effectiveness analyses, focusing on issues local evaluators are likely to encounter such as how to compare programs that target different health conditions; issues that arise in comparing programs that target the same condition and equity and efficiency concerns. The contractor offered various allocation scenarios that a decision-maker could face and examples of how cost effectiveness studies could inform decision making. The contractor also prepared an annotated bibliography of cost-effectiveness analyses of community prevention strategies from the formal literature as well as worksheets for quantifying program costs.

Report Title: Guide to Analyzing the Cost Effectiveness of Community Public Health Prevention Approaches http://aspe.hhs.gov/health/reports/06/cphpa/index.htm
Agency Sponsor: ASPE-Office of the Assistant Secretary for Planning and Evaluation
Federal Contact: Tilson, Wilma, 202-205-8841
Performer: Research Triangle Institute International; Research Triangle Park, NC
PIC ID: 8483

Which Interventions Best Improve Communication, Contraceptive Use, and HIV and Sexually Transmitted Disease Prevention Among Couples?

Summary:

The study assessed use and effectiveness of "couples-focused" family planning program services supported with federal funds. A couples-focused service provider addresses issues related to a relationship by working either directly with both partners or indirectly by working with only one partner. The study examined several questions. What couples-focused approaches were being used in family planning clinics? How were couples-focused approaches viewed? What challenges were couples-focused efforts by family planning clinics coming up against and how could they be overcome? What ways could family planning clinics and programs involve couples in services? The study included: (1) literature review; (2) interviews with key sources, including Federal program administrators, researchers, and grantees working in various clinic settings; (3) site visits to four grantees; and (4) a day-long meeting with federal, academic, and service delivery participants.

There were three key findings. The definition and implementation of couples-focused services isn't uniform. Serving males in family planning clinic settings and building staff capacity to provide couples-focused services requires more effort. Providers of couples-focused services need more training to enable them to better serve their clients' communication, relationship and negotiation development skills.

Report Title: A Collaborative Evaluation of Strategies to Encourage Couples-focused Health Service Delivery in a Sample of Title X-supported Family Planning Clinics http://aspe.hhs.gov/pic/fullreports/06/8278.pdf
Agency Sponsor: OPHS-OPA, Office of Population Affairs
Federal Contact: Panda, Pankaja, 240-453-2820
Performer: Health Systems Research, Inc.; Washington, DC
PIC ID: 8278

What Messages Are Most Effective in Encouraging HIV-Positive Persons and Others to Act in Ways That Will Prevent Further HIV Transmission?

Summary:

This three-phase multi-year study identified and developed human immuno-virus (HIV) prevention strategies and arguments that would be effective in encouraging prevention behaviors among HIV-positive persons. Findings from each phase of the formative research (concept generation, concept screening, and concept testing) were each used to develop the next phase of the study. This research project developed and evaluated online brochures used to communicate HIV prevention messages. The messages were tested in experimental studies to evaluate their efficacy among men who have sex with men. Three separate studies examined different ways of communicating, framing, and displaying the messages. Outcomes examined included behavioral intentions, attitudes, response efficacy, perceived behavioral control, perceived social norms, perceived risk, message appeal, message clarity, perceived effectiveness of the message, and source credibility.

Researchers recommended that the next step involve working with a creative team to further develop the "raw" message concepts into professionally designed advertisements (print, outdoor, radio, television). The advertisements would then need to be further tested with the target audience before being launched as elements of a campaign. (Additional related reports can be found at PIC 8297, 8297.1, and 8297.2)

Report Title: Developing Message Concepts for HIV-Positive Persons; Phase III Final Report http://aspe.hhs.gov/pic/fullreports/06/8297.doc
Agency Sponsor: CDC-OD-OSI, Office of the Director, Office of Strategy Innovation
Federal Contact: Slaton, Terrie, 404-639-7647
Performer: Research Triangle Institute International; Research Triangle Park, NC
PIC ID: 8297.3

What Is the Diabetes-Based Science Education Program for Tribal Schools Curriculum Project?

Summary:

This study continued the multi-year development and evaluation of a K-12 diabetes education curriculum for use in Tribal schools and schools with a significant percentage of American Indian students. Nearly 15% (100,000) American Indian and Alaska Native adults receiving health care from the Indian Health Service have diabetes. It has become one of the most common and serious illnesses found among this population. This Phase III stage of the study documented the development process of the curriculum through the beta and field testing stages. Next, researchers and schools will conduct implementation testing of the (revised) curriculum during the fall of 2007. National launch of the curriculum is expected for the fall, 2008. Beta and field testing consisted of small curriculum components tested at different tribal sites at different times, to accommodate the fact that not all materials were available at the same time or were all sites ready to proceed on a single schedule.

The testing answered three broad questions. Is the program being developed as planned? Are program critical processes being implemented? Has the curriculum been developed into the expected output that meets its general goals? Data sources for the evaluation included: lesson-specific evaluation forms; web-based test forms generalized across several lessons; discussions at quarterly meetings; external advisory committee reviews; and site visits to classrooms. Based on the testing, researchers recommended adding a nationally focused teacher professional development component, developing a strategy for generalizing cultural components and applying these components from within the community where the curriculum will be taught, and maintaining a simple, clean, concise appearance to the curriculum materials.

Report Title: Phase III Evaluation Report: September 2006 Diabetes-Based Science Education Program for Tribal Schools http://aspe.hhs.gov/pic/fullreports/06/8460.pdf
Agency Sponsor: NIH, National Institutes of Health
Federal Contact: Garfield, Sanford, 301-594-8803
Performer: PS International, Doug Coulson; Arnold, MD
PIC ID: 8460

Objective 1.2: Reduce the incidence of sexually transmitted diseases and unintended pregnancies

What Were the Short-term Impacts of Providing a Life Skills Education Component to Middle and High School Youth?

Summary:

This study was part of a larger evaluation of a select group of abstinence education programs authorized and funded under Section 510 of the Maternal and Child Health Services Block Grant program in the Social Security Act.

The study examined the short-term effects on the target student audiences of providing a life skills (e.g.: marriage and the family, coping with employment issues, dealing with adversity) education component to middle and high school youth in Edgefield, South Carolina. All the youth participating in the Life Skills Education Component also participated in other components of a broader training program ("Heritage Keepers®"), specifically, the core abstinence education component. This study examined the impact that the program had on students, over and above the impact of other components of the Heritage Keepers® Program.

Researchers found that the Life Skills Education Component had a positive impact on the whether the students viewed the rest of the program services as helpful. However, the education component did not increase participation by the youth in health, family life, and sex education classes. The program generally did not affect the intermediate outcomes thought to be related to teen sexual activity. The one exception was a positive impact on support for abstinence among middle school youths' five closest friends. This last finding was consistent with the program's goals of influencing youth peer groups. However, there were no impacts on this measure for high school youth or on other measures of peer influence and relations examined.

Report Title: First Year Impacts of the Heritage Keepers Life Skills Education Component http://aspe.hhs.gov/hsp/05/abstinence2/index.htm
Agency Sponsor: ASPE, Office of the Assistant Secretary for Planning and Evaluation
Federal Contact: Kelsey, Meredith, 202-690-6652
Performer: Mathematica Policy Research, Inc.; Princeton, NJ
PIC ID: 8481

Objective 1.3: Increase immunization rates among adults and children

What Is the Cost-Effectiveness of Routine Childhood Vaccination for Hepatitis A in the United States?

Summary:

Hepatitis A has been one of the most frequently reported vaccine-preventable diseases in the United States. Each year, from 1980 to 1999, there were on average 26,000 cases of acute hepatitis A reported to public health agencies. This corresponds to a rate of approximately 10 cases per 100,000. However, the true number of hepatitis A cases in the United States is believed to be 3-6 times this number. This study developed a detailed report of the model of vaccine prevention including a description of the model, the assumptions of the model, the results of the analysis, a sensitivity analysis, and conclusions. Two manuscripts resulting from this study have been accepted for publication in the journal "Pediatrics." The data from this project were pivotal in the Advisory Committee on Immunization Practices' (ACIP) decision to extend hepatitis A immunization nationwide. ACIP consists of 15 experts in fields associated with immunization who have been selected by the Secretary of the U. S. Department of Health and Human Services to provide advice and guidance on the most effective means to prevent vaccine-preventable diseases.

Report Title: The Cost-Effectiveness of Routine Childhood Vaccination for Hepatitis A in the United States http://aspe.hhs.gov/pic/fullreports/06/8298.htm
Agency Sponsor: CDC-OD-OSI, Office of the Director, Office of Strategy Innovation
Federal Contact: Slaton, Terrie, 404-639-7647
Performer: Research Triangle Institute; Research Triangle Park, NC
PIC ID: 8298

Objective 1.4: Reduce substance abuse

What Were the Characteristics of Individuals Discharged From Substance Abuse Treatment Facilities During 2004?

Summary:

This study examined data on clients discharged from substance abuse treatment in 2004 in the United States, as reported to the Treatment Episode Data Set. In general, this data set includes information on clients treated at facilities that receive State alcohol and/or drug agency funds (including Block Grant funds) for the provision of substance abuse treatment services. In 2004, twenty-eight States provided data on 1,105,644 discharges. The data include demographic and substance abuse characteristics of discharged clients, reasons for discharge (including treatment completion), and length of stay in treatment.

The study found that treatment was completed by 40 percent of the discharged clients in 2004. Twenty-two percent dropped out of treatment, 12 percent were transferred to further treatment, 8 percent had their treatment ended by the facility, 1 percent had treatment ended because of incarceration, less than 1 percent died, 8 percent failed to complete treatment for other reasons, and the reason for discharge was unknown for the remaining 9 percent of discharged clients. Except for discharges from methadone treatment, the median length of stay in treatment was greatest for discharges from outpatient treatment (69 days), followed by long-term residential treatment (46 days), and intensive outpatient treatment (42 days). The median length of stay in treatment for discharges from short-term residential treatment was 20 days. Discharges from detoxification had the shortest median length of stay (3 days).

Report Title: Treatment Episode Data Set (TEDS) 2004: Discharges from Substance Abuse Treatment Services http://wwwdasis.samhsa.gov/teds04/tedsd2k4web.pdf
Agency Sponsor: SAMHSA, Substance Abuse and Mental Health Services Administration
Federal Contact: Trunzo, Deborah, 240-276-1267
Performer: Synectics for Management Decisions, Inc.; Arlington, VA
PIC ID: 8301

What Is the Extent of Non-Medical Use of Prescriptions Drugs in the United States?

Summary:

An analysis was carried out on combined data from the 2002, 2003, and 2004 National Surveys on Drug Use and Health. The analysis examined the non-medical use of prescription psychotherapeutic drugs (pain relievers, tranquilizers, stimulants, and sedatives). Non-medical use is defined as the use of medications without a prescription or merely for the experience or feeling the drug causes, rather than for its intended medical purpose. The annual surveys, including a combined total of over 200,000 respondents, collected information about drug use and health among representative samples of the civilian, non-institutionalized population of the United States aged 12 and older.

Perhaps the most important finding of this study is that the non-medical use of prescription psychotherapeutic drugs—and of pain relievers in particular—is now second only to marijuana use among the Nation's most prevalent drugs. In addition, the annual average number of persons who started using pain relievers non-medically in the past year exceeded the number for marijuana (2.4 million vs. 2.1 million). An estimated 2 million persons were determined to be dependent on or to abuse prescription psychotherapeutics in the past year. Among those who abused or were dependent on prescription psychotherapeutics, only an estimated 290,000 persons received treatment for illicit drug use during the past year.

Report Title: Misuse of Prescription Drugs:Data from the 2002, 2003, and 2004 National Surveys on Drug Use and Health http://oas.samhsa.gov/prescription/toc.htm
Agency Sponsor: SAMHSA, Substance Abuse and Mental Health Services Administration
Federal Contact: Colliver, James, 240-276-1252
Performer: RTI International; Research Triangle Park, NC
PIC ID: 8302

What Were the Characteristics of Substance Abuse Treatment Facilities in the United States in 2005?

Summary:

This survey collected information on the location of alcohol and drug abuse treatment facilities, details about the services offered, and number of clients they treated. The survey is conducted annually of all identified alcohol and drug abuse treatment facilities in the 50 States, the District of Columbia and other U.S. jurisdictions. The number of facilities remained relatively constant between 2000 and 2005. There were 13,428 reporting facilities in 2000 and 13,371 facilities in 2005. The number of clients in treatment on the survey reference date (the date the survey was conducted or from which the data was taken) increased by 8 percent over the same period, to 1,081,049 in 2005. Approximately 8 percent of persons in treatment on the survey reference date were under the age 18. Eighty-nine percent of all clients in treatment were in outpatient treatment, 10 percent were in non-hospital residential treatment, and 1 percent was in hospital inpatient treatment. Nearly half (47 percent) of all clients were in treatment for both alcohol and drug abuse. One-third (34 percent) of clients were in treatment for drug abuse only, and 19 percent were in treatment for abuse of alcohol alone. The majority of facilities in the treatment system (59 percent of all facilities in 2005) were operated by private non-profit organizations. For-profit private facilities made up 27 percent of all facilities.

Report Title: National Survey of Substance Abuse Treatment Services: 2005 -- Data on Substance Abuse Treatment Facilities http://oas.samhsa.gov/DASIS/2k5nssats.cfm
Agency Sponsor: SAMHSA, Substance Abuse and Mental Health Services Administration
Federal Contact: Trunzo, Deborah, 240-276-1267
Performer: Synectics for Management Decisions, Inc.; Arlington, VA
PIC ID: 8303

What Were the Trends in Admissions to Substance Abuse Treatment Facilities in the United States from 1994 to 2004?

Summary:

This study examined data from clients admitted to substance abuse treatment between 1994 and 2004, as reported to the Treatment Episode Data Set. The data include demographic and substance abuse characteristics of the 1.9 million annual admissions to treatment for abuse of alcohol and drugs. This system is based on treatment admissions. An individual who is admitted multiple times in a year would be counted once for each admission.

Five substances accounted for 95 percent of the 1,875,026 treatment admissions in 2004. Alcohol was the primary substance of abuse for 40 percent of admissions. Opiates (primarily heroin) accounted for 18 percent of admissions. Marijuana (16 percent) and cocaine (14 percent) were the next most frequent substances of abuse. Stimulants (primarily methamphetamine) made up another 8 percent of admissions. The alcohol admission rate declined by 28 percent between 1994 and 2004, from 430 to 308 per 100,000 population aged 12 and older. The methamphetamine/amphetamine admission rate increased 182 percent, from 22 to 62 per 100,000 population aged 12 and older. Adolescent (age 12-17) treatment admissions increased 43 percent. The increase in adolescent admissions was largely due to an increase in the number of adolescent admissions for marijuana use (115 percent increase). The proportion of adolescent admissions for marijuana increased from 43 percent of all adolescent admissions in 1994 to 64 percent in 2004.

Report Title: Treatment Episode Data Set (TEDS) 1994-2004 - National Admissions to Substance Abuse Treatment Services http://wwwdasis.samhsa.gov/teds04/TEDSAd2k4TOC.htm
Agency Sponsor: SAMHSA, Substance Abuse and Mental Health Services Administration
Federal Contact: Trunzo, Deborah, 240-276-1267
Performer: Synectics for Management Decisions, Inc.; Arlington, VA
PIC ID: 8304

What Was the Prevalence of Substance Abuse and Mental Health Problems in the United States During 2005?

Summary:

This survey sought information on: use of illicit drugs; use of alcohol; use of tobacco products; initiation of substance use; prevention-related issues; and substance dependence, abuse, and treatment. Measures related to mental health problems also included data on: depression, severe psychological distress, and the co-occurrence of substance use and mental health problems. This is an annual survey of the civilian, non-institutionalized population of the United States aged 12 years old or older. In 2005, approximately 67,500 individuals responded to the survey. The survey collects data in order to produce national prevalence and incidence estimates.

Analysis of 2005 data found that illicit drug use in the past month among youth ages 12-17 continued to decline when compared to survey results from previous years. The rate has declined from 11.6 percent using drugs in the past month in 2002 to 9.9 percent in 2005. Similarly, the rate of past month marijuana use among youth ages 12 to 17 declined from 8.2 percent in 2002 to 6.8 percent in 2005. Drinking among teens also declined, with 16.5 percent of youth ages 12-17 reporting past month alcohol use in 2005, down from 17.6 percent of this age group reporting drinking in 2004. In 2005, 9.9 percent of youth reported past month binge drinking (5 or more drinks at one sitting). This was a decrease from 2004 when 11.1 percent of youth reported this behavior. In 2005 an estimated 24.6 million adults aged 18 or older (11.3 percent of all adults in the nation), met criteria for severe psychological distress in the past year.

Report Title: Results from the 2005 National Survey on Drug Use and Health: National Findings http://oas.samhsa.gov/NSDUH/2k5NSDUH/2k5results.htm
Agency Sponsor: SAMHSA, Substance Abuse and Mental Health Services Administration
Federal Contact: Hughes, Art, 240-276-1261
Performer: RTI International; Research Triangle Park, NC
PIC ID: 8305

What Are the Local Area Prevalence Rates of Substance Use, Abuse and Dependence and Mental Health Problems in the United States?

Summary:

An analysis was carried out on combined 2002, 2003, and 2004 survey data. The annual survey collects information about drug use, abuse and dependence, and mental health based on samples representative at the national, state and local levels of the civilian, non-institutionalized population of the United States aged 12 and older. This multi-year analysis estimates the prevalence of substance use, abuse and dependence, and mental health problems in 357 substate areas. These areas were defined by officials from each State and were typically based on the substance abuse treatment planning areas specified by the States in their applications for the Substance Abuse Prevention and Treatment Block Grant. This analysis includes local level estimates for 22 measures of substance use or mental health problems based on more than 200,000 respondents.

During 2002-2004, 8.1 percent of persons in the United States aged 12 or older used illicit drugs in the month before the survey. Of the 15 areas with the lowest rates of illicit drug use in the previous month, 6 were from four Midwestern States: Iowa, Kansas, Nebraska, and South Dakota. Moreover, South Dakota had three eastern regions among those with the lowest rates of illicit drug use. The highest rate (13.6 percent) of illicit drug use among persons 12 and older was reported by northern California (the 14 northernmost counties). The 15 areas with the highest rates of illicit drug in the past month were dispersed among 10 States, with Alaska accounting for 3 areas and Michigan accounting for 3 areas. Of the top 15 areas, 11 were metropolitan areas or parts of a metropolitan area. Utah County, Utah had the lowest rate of past month alcohol use (19.8 percent), and Ward 3 in the District of Columbia had the highest rate (74.7 percent). Tobacco is the second most commonly used substance in the United States after alcohol. The 15 substate areas with the lowest rates of past month tobacco use were in California and Utah, and Maryland (Montgomery County). The two highest areas were in Kentucky.

Report Title: Substate Estimates from the 2002-2004 National Surveys on Drug Use and Health http://oas.samhsa.gov/substate2k6/toc.cfm
Agency Sponsor: SAMHSA, Substance Abuse and Mental Health Services Administration
Federal Contact: Wright, Douglas, 240-276-1259
Performer: RTI International; Research Triangle Park, NC
PIC ID: 8306

How Many Drug-Related Emergency Department Visits Were There in the United States During 2004?

Summary:

Data on drug-related emergency department visits are collected on an ongoing basis as part of the Drug Abuse Warning Network from a national sample of general, non-Federal hospitals operating 24-hour emergency departments. National estimates for 2004 are based on data submitted by 417 hospitals. In participating hospitals, medical records are reviewed retrospectively to find emergency department visits that were related to recent drug use. All emergency department visits where a drug was implicated are included, regardless of the reason the patient took the drug. Emergency department visits related to drug abuse/misuse, as well as adverse reactions to drugs taken as prescribed/directed, drug-related suicide attempts, accidental ingestions, underage drinking, and malicious poisonings are captured in this data system. All types of drugs (illegal, prescription, over-the-counter, etc.) are included.

The study found that there were an estimated 106 million emergency department visits in the United States during 2004. Of these, almost 2 million were drug-related and nearly 1.3 million emergency department visits were associated with drug misuse or abuse. Of those involving drug misuse or abuse, 30 percent involved illicit drugs only, 25 percent involved pharmaceuticals (prescription or over-the-counter medications) only, 15 percent involved illicit drugs and alcohol, 8 percent involved illicit and pharmaceuticals, and 14 percent involved illicit drugs and/or alcohol and pharmaceuticals.

Report Title: Drug Abuse Warning Network, 2004: National Estimates of Drug-Related Emergency Department Visits http://dawninfo.samhsa.gov/files/DAWN2k4ED.htm
Agency Sponsor: SAMHSA, Substance Abuse and Mental Health Services Administration
Federal Contact: Ball, Judy, 240-276-1250
Performer: RTI International; Research Triangle Park, NC
PIC ID: 8307

What Were the Characteristics of Discharges from Substance Abuse Treatment Facilities During 2003?

Summary:

This study examined data on clients discharged from substance abuse treatment in 2003 in the United States, as reported to the Treatment Episode Data Set. In 2003, twenty-six States provided data on 937,499 discharges. The data include information on the demographic and substance abuse characteristics of discharged clients, reasons for discharge (including treatment completion), and length of stay in treatment. The study found that treatment was completed by 41 percent of the clients discharged in 2003. Twenty-six percent dropped out of treatment, 11 percent were transferred to further treatment, 8 percent had their treatment ended by the facility, 1 percent had treatment ended because of incarceration, less than 1 percent died, 6 percent failed to complete treatment for other reasons, and the reason for discharge was unknown for the remaining 8 percent of discharged clients. Except for discharges from methadone treatment, the median length of stay in treatment was greatest for discharges from outpatient treatment (64 days), followed by long-term residential treatment (42 days), and intensive outpatient treatment (41 days). The median length of stay in treatment for discharges from short-term residential treatment was 20 days. Discharges from detoxification had the shortest median length of stay (3 days).

Report Title: Treatment Episode Data Set (TEDS) 2003: Discharges from Substance Abuse Treatment Services http://wwwdasis.samhsa.gov/teds03/tedsdischweb2k3.pdf
Agency Sponsor: SAMHSA, Substance Abuse and Mental Health Services Administration
Federal Contact: Trunzo, Deborah, 240-276-1267
Performer: Synectics for Management Decisions, Inc.; Arlington, VA
PIC ID: 8308

What Were the Characteristics of Individuals Admitted to Substance Abuse Treatment Facilities in 2004?

Summary:

This study presents summary data on clients admitted to substance abuse treatment facilities in 2004 in the United States, as reported to the Treatment Episode Data Set. In general, these data include information on clients treated at facilities that receive State alcohol and/or drug agency funds (including Block Grant funds) for the provision of substance abuse treatment services. Information on the demographic and substance abuse characteristics is included on the 1.9 million annual admissions to treatment for abuse of alcohol and drugs. This system is based on treatment admissions only. An individual who is admitted multiple times in a year would be counted once for each admission.

Five substances accounted for 95 percent of the 1,875,026 treatment admissions in 2004. Alcohol was the primary substance of abuse for 40 percent of admissions. Opiates (primarily heroin) accounted for 18 percent of admissions. Marijuana (16 percent) and cocaine (14 percent) were the next most frequent substances of abuse. Stimulants (primarily methamphetamine) made up another 8 percent of admissions. In 2004, admissions to substance abuse treatment involving methamphetamine and narcotic pain medications continued to rise compared with previous years. The number of methamphetamine admissions rose 25 percent between 2002 and 2004 to 129,179. For opiates other than heroin (largely prescription pain medications), there was a 42 percent increase in the number of admissions to treatment between 2002 and 2004 to 63,243. Between 1994 and 2004, the proportion of admissions for primary alcohol and cocaine abuse declined while the proportion of admissions for marijuana, stimulants, and opiates increased.

Report Title: Treatment Episode Data Set (TEDS) Highlights - 2004 http://oas.samhsa.gov/TEDS/2k4TEDS/TEDShi2k4toc.htm
Agency Sponsor: SAMHSA, Substance Abuse and Mental Health Services Administration
Federal Contact: Trunzo, Deborah, 240-276-1267
Performer: Synectics for Management Decisions, Inc.; Arlington, VA
PIC ID: 8309

What Are the Prevalence Rates of Substance Use, Abuse and Dependence, and Mental Health Problems by State?

Summary:

An analysis was carried out on combined 2003 and 2004 survey data. The annual survey collects information about substance use, abuse and dependence and mental health from samples representative at national, state and local levels of the civilian, non-institutionalized population of the United States aged 12 and older. This analysis estimates the prevalence of substance use and mental health problems in the 50 States and District of Columbia. Twenty-two measures of substance use, abuse and dependence, and mental health problems were estimated for each State based on approximately 135,500 respondents. Estimates for four age groups (12 to 17, 18 to 25, 26 or older, and all persons 12 or older) were produced for each measure.

Use, in the month before the survey, of any illicit drug in 2003 and 2004 ranged from a low of 5.8 percent in Mississippi to a high of 11.8 percent in Alaska for persons aged 12 or older. Among youths aged 12 to 17, the percentage of past month drug use decreased from 11.4 percent in 2002-2003 to 10.9 percent in 2003-2004. While the national rate did not change, four States showed decreases from 2002-2003 to 2003-2004 in the percentage of persons 12 or older that used an illicit drug in the past month: the District of Columbia, Florida, Nevada, and Washington. Six States showed decreases in past month illicit drug use among youths 12 to 17: Illinois, Nebraska, North Carolina, South Dakota, Vermont, and Virginia. There were no increases among States in any of the age groups. In 2003-2004, the rate of previous month alcohol use in States among persons aged 12 or older ranged from a low of 29.3 percent in Utah to a high of 62.1 percent in Wisconsin. Although national alcohol use rates remained unchanged, four States experienced changes in alcohol use among persons 12 or older. Missouri, Nevada, and New Jersey had decreases. Wisconsin had the only increase in alcohol use for those 12 or older. In 2003-2004, West Virginia had the highest rate of serious psychological distress in the last year (12.7 percent), while Hawaii had the lowest (7.1 percent). Ten states showed increases between 2002-2003 and 2003-2004.

Report Title: State Estimates of Substance Use from the 2003-2004 National Surveys on Drug Use and Health http://oas.samhsa.gov/2k4State/toc.htm
Agency Sponsor: SAMHSA, Substance Abuse and Mental Health Services Administration
Federal Contact: Wright, Douglas, 240-276-1259
Performer: RTI International; Research Triangle Park, NC
PIC ID: 8310

Objective 1.6: Reduce the incidence and consequences of injuries and violence

How Can Public Health Clinics Better Prevent Violence in Families and Between Intimate Partners?

Summary:

This study identified promising practices in family and intimate partner violence prevention. These practices can be used by reproductive health clinics funded under Title X (“Population Research and Voluntary Family Planning Programs”) of the Public Health Act. The clinics are important access points because they typically serve young, low-income women. This population is at-risk for violence. The clinics may be the only contact that the women have with a health care provider. The clinics often have resource constraints. To be promising, a practice must be effective, possible and financially sustainable.

To identify promising practices, evaluators explored family and intimate partner violence prevention programs at nine clinics. Clinic directors, nurse practitioners, physicians, social workers, and health educators were interviewed. They were asked about policies, training materials and resources, and relationships with other organizations. They were also asked about barriers to and ways to facilitate violence prevention activities. The research team toured the clinics and reviewed materials and resources used by them. The team conducted a literature review of the topic under study and interviewed state and federal staff overseeing the clinics.

The study identified promising practices in four areas: training, screening and intake, clinical evaluation, and follow-up and referral. Examples of these promising practices identified included: role playing as part of clinician prevention training, recognizing patients experiencing family or intimate partner violence, methods to help women safely and confidentially leave abusive situations, and ways to identify and work with community organizations to extend clinic services.

Report Title: A Collaborative Evaluation of Family and Intimate Partner Violence Prevention Activities in Title X Clinics http://aspe.hhs.gov/pic/fullreports/06/8277.doc
Agency Sponsor: OPHS-OPA, Office of Population Affairs
Federal Contact: Panda, Pankaja, 240-453-2820
Performer: Battelle; Arlington, VA
PIC ID: 8277

Goal 2: Enhance the ability of the Nation's health care system to effectively respond to bioterrorism and other public health challenges

Objective 2.1: Build the capacity of the health care system to respond to public health threats, especially bioterrorism threats, in a more timely and effective manner

How Is Influenza Vaccine Produced and Disseminated in the United States?

Summary:

This project clarified our understanding of the system by which the United States produces and disseminates influenza vaccine. The system is marked by a complex set of relationships between the vaccine makers, sellers, buyers, healthcare providers and consumers as well as federal and state governments. The contractor prepared five issue briefs regarding these relationships. The intended audiences for the briefs included policymakers and others with an interest in, but limited knowledge of, these topics. For the initial issue brief, "Influenza Vaccine: Summary and Assessment," the contractor reviewed the subject area broadly and identified a number of important subtopics. It examined the roles and responsibilities of the influenza vaccine stakeholders. It described key issues relevant to influenza vaccine manufacturing and supply and outlined factors impacting purchasing and distribution of influenza vaccine. The contractor also presented a case study of the influenza seasons from 1999 through 2005 highlighting the important challenges that arose during each season. It discussed the impact of bioterrorism preparedness planning on influenza planning during that period, and presented key issues for consideration by policymakers.

For the remaining four issues briefs, the contractor looked in-depth at key areas summarized in the first issue brief. For the second issue brief, "Influenza Vaccine Economics," the contractor analyzed the characteristics of the influenza vaccine market; industry regulatory requirements for vaccine production; and factors affecting the profitability of vaccine production compared to producing other biologic products or pharmaceuticals. The contractor also considered factors affecting the decisions of individual suppliers about how much vaccine to produce in a given year and possible policy approaches to prevent future shortages of influenza vaccine. In the third issue brief, "Influenza Vaccine: Who Buys It and Who Sells It," the contractor considered the vaccine supply chain as well as potential means for facilitating vaccine purchase and distribution. For the fourth issue brief, "Influenza Vaccine Manufacturing," the contractor identified the unique characteristics of the influenza vaccine and discussed the structure of the vaccine manufacturing industry, the nature of the market, decisions about the amount of vaccine produced each year, investments in new technologies to produce vaccine, the implications of relying on global manufacturers for the U.S. domestic vaccine supply, and the factors that influence manufacturers' decisions to enter or exit the market. To prepare the final issue brief, "Influenza Vaccine Demand: The Chicken and the Egg," the contractor looked at the factors that impact the demand for influenza vaccine and how these factors can affect supply.

Report Title: Understanding the Dynamics of Influenza Vaccine Supply and Demand -- Five Issue Briefs http://aspe.hhs.gov/pic/fullreports/06/8476.htm
Agency Sponsor: ASPE, Office of the Assistant Secretary for Planning and Evaluation
Federal Contact: Nevel, Amy, 202-690-7795
Performer: RTI International; Research Triangle Park, NC
PIC ID: 8476

How Should Graduate Medical Education in the United States Best Be Financed?

Summary:

This study evaluated the current system, and assessed the strengths and weaknesses of different methods for financing graduate medical education. Researchers performed a literature review and held discussions with experts in the United States and abroad. The study identified a number of ways in which the Medicare program's nearly $8 billion annual support for graduate medical education could be improved. Most of these improvements centered on changes to the formulas used to determine the level of payments Medicare makes to teaching hospitals. The researchers observed that the current system for financing graduate medical education is complicated and the costs of the activities it supports are difficult to measure.

The study identified five elements on which to evaluate any alternatives to the current system: equity, adequacy, efficiency, accountability, and administrative feasibility. Three different models identified in the study for financing graduate medical education were: market-, incentive-, and regulatory-based approaches. Researchers did not recommend replacing the current system, but suggested changes to address limitations in the present system and to achieve particular policy goals. The study cited two policy directions for making refinements for Medicare policies: either emphasizing that Medicare's purpose is to pay for patient care provided to Medicare beneficiaries or using graduate medical education payments to achieve health care workforce needs. The study concluded that any changes in funding policies should occur gradually in order to allow program sponsors and affiliated teaching institutions time to adjust to any redistribution of funds.

Report Title: Alternative Ways of Financing Graduate Medical Education http://aspe.hhs.gov/health/reports/06/AltGradMedicalEdu/
Agency Sponsor: ASPE, Office of the Assistant Secretary for Planning and Evaluation
Federal Contact: Nonnemaker, Lynn, 202-690-7807
Performer: Rand Corporation; Santa Monica, CA
PIC ID: 8294

Why Do Individuals Choose and Remain in Nursing Assistant Careers and Work in Nursing Homes?

Summary:

This survey was the first national survey of certified nursing assistants working in nursing homes. It represents a major advance in the data available about certified nursing assistants and has the potential for numerous studies to improve our understanding of the direct care workforce. This survey provided a basis for future evidence-based policy, practice, and applied research to address the shortage of long-term direct care works. The survey involved a stratified, multistage probability design sampling nursing facilities and nursing assistants within these facilities. A sub-sample of 790 facilities was selected. Of those eligible, 187 did not participate in all or a portion of the survey. This resulted in a facility response rate of 76%. A total of 582 facilities agreed to participate, and from these facilities, 4,542 nursing assistants were selected to participate. Among these, 4,274 were eligible and 3,017 completed an interview, yielding a response rate of 71%.

The total number of Americans in need of long-term care is projected to more than double from 13 million in 2000 to 27 million in 2050. Long-term care providers face tremendous challenges each day trying to provide high-quality care to clients. One of the greatest challenges is staff retention among direct care workers -- nursing assistants, personal care attendants and home health aides -- who provide hands-on services to clients. Annual turnover among direct care workers is high and can reach rates of over 100% in some organizations. If left unaddressed, this emerging care gap could severely restrict the ability of providers to deliver adequate long-term care. This introductory study examined the relevant research that led to federal interest in sponsoring the survey, provided a comprehensive overview of the procedures undertaken, addressed the advantages of combining nursing home facility and nursing home worker surveys, and highlighted the potential uses of the data. Subsequent papers will report on survey findings to inform improved planning, decision-making and policy development.

Report Title: An Introduction to the National Nursing Assistant Survey http://aspe.hhs.gov/daltcp/reports/2006/NNASintro.htm
Agency Sponsor: ASPE, Office of the Assistant Secretary for Planning and Evaluation
Federal Contact: Squillace, Marie, 202-690-6250
Performer: Department of Health and Human Services (HHS); Washington, DC
PIC ID: 8317

Did Small Grants for Behavioral Cancer Control Research Increase the Number of Scientists Working in This Field?

Summary:

This study assessed the effectiveness of a cancer control behavioral research grant funding program intended to facilitate the growth of a nationwide cohort of scientists with a high level of expertise in behavioral cancer control research. The study found that the program was important in providing early stage investigators with funding opportunities for independent, innovative research. The program offered critical support for career development, and encouraged investigation of new cancer control research questions. The program also prompted more behavioral-focused research, and opportunities to interact with researchers in the field. Grantees were successful in continuing research in the field. For example, researchers were able to obtain additional funding as principal investigators for their research questions. Overall, the findings supported the claim that the program fulfilled its original intent. The grant program advanced the field of behavioral research in cancer control. The program's success provided a strong basis for its continuation in the subsequent budget year.

Report Title: Outcome Evaluation of the Small Grants Program for Behavioral Research in Cancer Control http://aspe.hhs.gov/pic/fullreports/06/8355.doc
Agency Sponsor: NIH, National Institutes of Health
Federal Contact: Chollette, Veronica, 301-435-2837
Performer: Battelle Center for Research and Evaluation; Arlington, VA
PIC ID: 8355

Goal 3: Increase the percentage of the Nation's children and adults who have access to health care services, and expand consumer choices

Objective 3.2: Strengthen and expand the health care safety net

How Can the United States Make Sure That It Has a Qualified Workforce to Provide Services to Those Needing Long-Term Care?

Summary:

This study assessed the contributions and effectiveness of existing federal mandates and state and provider based strategies for preventing or reducing the abuse of vulnerable adults. The study pursued this objective in three ways. It examined the usefulness of nurse aide registries and criminal background checks as ways to reduce abuse of nursing facility residents. The study also determined the relationship between past criminal background (or previous incidences of abuse) and the proclivity toward subsequent abuse, neglect or exploitation. Finally, the study identified how states and nursing facilities could improve screening and monitoring processes to ensure a qualified workforce.

The study found that federal and state governments, education and training centers, and employers have created a variety of formal ways to prevent abuse, neglect and exploitation in patients in nursing homes and other long-term care settings. These diverse mechanisms include: certification and licensure of paraprofessional long-term care workers, pre-employment screening (e.g., nurse aide registries, criminal background checks and drug tests) systems, and on-the-job training and personnel monitoring. Using data from two states, a correlation was found between criminal history and incidence of abuse. The study determined that while criminal background checks are only one component of preventing abuse, such checks are valuable during the hiring process. Use of background checks did not appear to limit the pool of potential job applicants. Finally, the study found that there are few federal, state or employer policies in place that support or reinforce post-hiring strategies to ensure a qualified workforce.

Report Title: Ensuring a Qualified Long-Term Care Workforce: From Pre-Employment Screens to On-the-Job Monitoring http://aspe.hhs.gov/daltcp/reports/2006/LTCWqual.htm
Agency Sponsor: ASPE, Office of the Assistant Secretary for Planning and Evaluation
Federal Contact: Rosenoff, Emily, 202-690-6443
Performer: The Lewin Group; Falls Church, VA
PIC ID: 8330

What Is the Current Supply of Professional Social Workers in Long-Term Care Settings and What Is the Expected Future Supply?

Summary:

This study assessed the availability of professional social workers in long-term care settings. The study quantified the current and future supply and demand for professional social workers serving older adults across the continuum of long-term care services. The study prepared recommendations for addressing any identified future shortage areas, including cooperative strategies involving Federal agencies, professional associations, and schools of social work. Generally, there were limited research findings across the range of long-term care services that demonstrated the efficacy of using professional social workers (and which could be considered in projecting supply or demand). In the absence of data to the contrary, the researchers assumed that the current conditions vis-à-vis substitution, regulation, licensure, and reimbursement of professional social workers in long-term care would stay constant going forward. Using data from the most recent National Industry-Occupation Employment Matrix, the 2004 Current Population Survey, and the 1% Public Use Microdata Sample from the 2000 Census, it was estimated that approximately 36,100 to 44,200 professional social workers were employed in long-term care settings.

If the ratio of professional social workers to the population age 65 and older remains constant, then approximately 82,000 to 98,400 professional social workers will be needed in long-term care settings by 2050. While their educational preparation, training and clinical orientation may be unique, social workers in long-term care settings often perform tasks, including assessment, psychosocial support, active treatment, and case management that may also be performed by other disciplines. There are efforts underway to include additional aging-related content in social work curriculum and to encourage professional social workers to seek employment in long-term care settings. It is unclear whether these efforts will make a substantial impact on the future supply of professional social workers in long-term care. Because of the uncertainties noted above, it is difficult to determine whether or not the future number of professional social workers will be adequate to care for an increasingly older American population. However, the likely increased demand for social work services will provide a strong impetus for continued job growth in the future.

Report Title: The Supply and Demand of Professional Social Workers Providing Long-Term Care Services: Report to Congress http://aspe.hhs.gov/daltcp/reports/2006/SWsupply.htm
Agency Sponsor: ASPE, Office of the Assistant Secretary for Planning and Evaluation
Federal Contact: Bergofsky, Linda, 202-690-6443
Performer: Department of Health and Human Services (Office of the Assistant Secretary for Planning and Evaluation in consultation with Centers for Medicare and Medicaid Services, Administration on Aging and Health Resources and Services Administration), the Department of Veterans Affairs and the Department of Labor Bureau of Labor Statistics.; Washington, DC
PIC ID: 8348

Objective 3.4: Eliminate racial and ethnic health disparities

What Can Hospitals Do to Assure Their Policies and Practices Are Culturally and Linguistically Appropriate?

Summary:

This project developed a survey instrument for use by hospitals to better determine whether their practices are culturally and linguistically appropriate. The assessment tool, the Cultural Competency Assessment Tool for Hospitals (CCATH) was based on the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care that were developed by the Office of Minority Health. The survey instrument enables hospital administrators, other health care managers, and health policymakers to assess whether their policies and practices are culturally and linguistically appropriate, compare cultural and linguistic quality improvement and monitoring efforts to regional and national benchmarks or norms, and examine the relationship between the standards and key outcomes that may be related to diversity management/cultural competency. Researchers described the protocols used to develop the assessment tool and conducted a comprehensive review of cultural competence assessment tools, pilot tested the instrument in six hospitals, and qualitatively tested the instrument using focus groups and cognitive interviews.

This project successfully initiated development of a survey to assess cultural competency in the provision of hospital care. Additionally, the project provided a solid support for administering the survey broadly. Key findings included: enthusiasm for the assessment instrument by hospital administrators but a recommendation that participating hospitals be provided comparative data to assess their performance; variability in the preferred method of distribution and survey administration, and difficulty on the part of respondents in completing it; and the need to develop a completion guide to facilitate the administration of the survey. Future use of the survey by the same hospitals should be easier. As a result of this study, the Office of Minority Health intends to continue refining and shortening the survey further to the extent possible in order to expedite data collection further. In addition, , a follow-up study was funded by the Commonwealth Fund that will allow the survey to be administered in a large scale field test. This next step will provide an opportunity to conduct extensive empirical analyses of the items in the Survey.

Report Title: Cultural Competency Assessment Tool for Hospitals: An Application of the Culturally and Linguistically Appropriate Services (CLAS) Standards in Health Care http://aspe.hhs.gov/pic/fullreports/06/7865.htm
Agency Sponsor: OPHS-OMH, Office of Minority Health
Federal Contact: Pacheco, Guadalupe, 240-453-2882
Performer: Rand Corporation; Santa Monica, CA
PIC ID: 7865

Do the Benefits That Result from Using Languages Familiar to Patients Outweigh Costs Health Care Providers Face by So Doing?

Summary:

This project developed and tested a model for examining costs associated with medical errors related to (A) barriers to physician-patient communications and understanding versus (B) the provision of a variety of language appropriate services to promote communication and understanding in clinical encounters. An expert panel with expertise in physician-patient communications, language barriers, medical errors, health care quality, cost-benefit analyses and econometrics collaborated in the development of an approach to examining language barriers in various clinical health care settings. The panel determined that the project should address health care service utilization and established measures of both quality and medical error. The panel developed a conceptual model that could serve as a research framework for studies of the impacts of provider-patient language barriers on health care quality and costs. A limited study conducted to test the model, showed that the model worked.

The expert panel subsequently made 38 recommendations relative to the scope of future research, conceptual model, localized study and its findings, further research, and other programmatic and policy-relevant actions. Examples of panel recommendations include: broadening research to include all the patient-provider interactions; expanding examination of impact to include health care outcomes; examining different approaches to providing language support; broadening research beyond mere linguistic issues (to culture, etc.); applying quality indicators identified by the Institute of Medicine; and considering using randomized control trials in future research. The project demonstrated that the model could be used to conduct research to answer questions about costs and other impacts of language barriers in health care. More well-controlled studies utilizing the model are needed to investigate the impacts of these barriers in order to better inform health care policy and programmatic decision-making for racial, ethnic, and linguistic minorities in the United States. Panel members expect that future studies will likely produce findings that will build support for the notion that understanding and being understood is a critical component of health care quality, regardless of primary language spoken or English proficiency status.

Report Title: Assessing the Impact of Provider-Patient Language Barriers on Health Care Costs and Quality http://aspe.hhs.gov/pic/fullreports/06/7711.htm
Agency Sponsor: OPHS-OMH, Office of Minority Health
Federal Contact: Hawks, Betty, 240-453-2882
Performer: Cosmos Corporation; Bethesda, MD
PIC ID: 7711

Objective 3.5: Expand access to health care services for targeted populations with special health care needs

How Successful Has the U.S.-Mexico Tuberculosis Referral and Case Management Project Been and What Changes Are Needed?

Summary:

Established in 2003, the goal of the US-Mexico Binational Tuberculosis Referral and Case Management Project was to build a system to ensure continuity of care for tuberculosis patients who cross the US-Mexico border. The project was a partnership between the Centers for Disease Control and Prevention and the National Tuberculosis Program in Mexico. In the project, referral systems in each country registered eligible patients in a central database and provided data about their treatment to one another. An important outcome of the Project was the effective collaboration between health officials in the United States and Mexico. Patients were not asked about their immigration status. Health officials were able to bring infected tuberculosis patients to treatment regardless of their immigration status. Ongoing dialogue among health and government officials across the border ensured an understanding of the prevailing conditions affecting the health of people in the border area.

A major success of the Project was its formal integration into the detainee screening process at immigration control and enforcement facilities. The evaluators recommended expanding the Project to other areas, agencies, and diseases. Public health professionals and other involved public and private participants urged providing more information to the community about tuberculosis, the Project, and the health benefits of the Project. The majority of participants and community members interviewed felt that more funding was needed. Community participants agreed that efforts should be made to increase funding for program expansion, improve communication, support fieldwork, and bring additional sites into the Project.

Report Title: Evaluation of the U.S.-Mexico Binational TB Referral and Case Management Project http://aspe.hhs.gov/pic/fullreports/06/7985.1.doc
Agency Sponsor: CDC-OD-OSI, Office of the Director, Office of Strategy Innovation
Federal Contact: Slaton, Terrie, 404-639-7647
Performer: Battelle; Arlington, VA
PIC ID: 7985.1

What Are the Barriers to Implementing Innovative Technology in Residential Long-Term Care Settings?

Summary:

Approximately two million older Americans live in nursing homes and other residential care settings. Innovative technology can play a vital role in the lives of these individuals. Persons in residential long-term care settings have physical or cognitive limitations that may be compensated through use of technologies. Technology may offer ways to provide lower cost interventions and address the needs of a growing number of individuals who are expected to need long-term care residence. This study sought to: (1) describe a range of existing and emerging technological solutions for select care issues appropriate for residential care settings; (2) identify barriers to the successful implementation of technology in residential care settings; and (3) propose initial steps to address the barriers. To identify technologies, the project team conducted literature and internet searches, consulted long-term care buyer's guides, and spoke with technology manufacturers and vendors. To identify barriers, the project team conducted a literature review and spoke with experts representing four distinct perspectives in long-term care--regulators, providers, technology manufacturers, and other experts--about their experience implementing technology in long-term care settings.

Assistive technologies are being developed to help older adults remain more independent, safer, and connected to the rest of the world. There are a small but growing number of technologies designed mainly to help caregivers in residential care settings. Five aspects of care in residential settings--wander management, fall prevention, incontinence care, assistance calls, and bathing--were identified as key areas in which to investigate technological developments.

The study identified a complex set of circumstances contributing to barriers to the implementation of technology in long-term care settings, including: lack of information about technologies and the residential long-term care market; perceived lack of financial resources to develop and buy residential long-term care technologies; failure of the regulatory process to keep pace with technological advances; industry's lack of standards for technologies in residential long-term care; and providers' lack of experience implementing and managing technological changes. In light of these findings, a series of educational and collaborative activities should be developed to: remedy existing gaps in knowledge about technologies in residential long-term care settings; explore ways to encourage development and implementation of cost-effective technological innovations in residential long-term care settings; explore how best to reduce regulatory barriers to innovation; encourage development of industry standards for residential care technologies; and educate providers about implementing and managing technological change.

Report Title: Barriers to Implementing Technology in Residential Long-Term Care Settings http://aspe.hhs.gov/daltcp/reports/techbarr.htm
Agency Sponsor: ASPE, Office of the Assistant Secretary for Planning and Evaluation
Federal Contact: Aykan, Hakan, 202-690-6443
Performer: Polisher Research Institute; North Wales, PA
PIC ID: 8319

What Role Do Negotiated Risk Agreements Play in Assisted Living?

Summary:

Negotiated risk agreements were developed as a mechanism to enable older persons residing in regulated assisted living settings to make choices, even when they entail some risk. Negotiated risk agreements are written documents that list: the behavior or resident preference of concern to the provider; the potential or actual risk; the resident preferences and potential provider accommodations or suggested alternatives to the behavior that reduce risk while meeting resident preferences; a negotiated resolution; and the resident's acknowledgement and acceptance of the potential negative consequences of his or her actions. The study examined states' statutory and regulatory provisions related to negotiated risk agreements and analyzed the policy objectives that the agreements were designed to meet. The study also analyzed the debate surrounding these agreements; and gained an understanding of how assisted living providers, staff and residents viewed and used such agreements. This study was designed to inform state policymakers, assisted living providers, and key stakeholders about agreements and issues related to their use.

Balancing the need to assure both autonomy and safety is a major challenge when providing long-term care services to older persons who live in licensed group settings. Provider policies and state regulations intended to ensure safety can conflict with individuals' ability to make the choices they prefer. Negotiated risk was conceived to help assisted living programs provide residential alternatives to institutional care. Residential assisted living programs provide frail and cognitively impaired older persons an option that maximizes their privacy, independence, choice, and enables them to maintain a normal lifestyle. These qualities are generally lacking in institutional long-term care settings.

Over the past decade, many assisted living providers have adopted negotiated risk agreements, and several states have regulatory provisions regarding their use. However, their use is not without controversy. Assisted living providers, policy makers, aging advocates, and long-term care experts have defined negotiated risk agreements as a mechanism to enhance resident choice by providing a rigorous process designed to balance autonomy and risk for residents and providers in assisted living. While the sample is small and not representative, the findings suggest that negotiated risk agreements can be a useful means to help residents and providers achieve a balance between desires for autonomy and concerns about safety. At the same time, they suggest that the negotiated risk agreement concept is proving difficult to broadly and consistently apply.

Report Title: Study of Negotiated Risk Agreements in Assisted Living Facilities http://aspe.hhs.gov/daltcp/reports/2006/negrisk.htm
Agency Sponsor: ASPE, Office of the Assistant Secretary for Planning and Evaluation
Federal Contact: Kennedy, Gavin, 202-690-6443
Performer: Research Triangle Institute; Research Triangle Park, NC
PIC ID: 8345

Who Lives in Residential Care Facilities and How Disabled Are They?

Summary:

This study examined estimates from three major national surveys of the number of persons living in residential care facilities, often called "assisted living facilities." The surveys identified such facilities through a number of questions about housing and services provided. Estimates from the surveys of the older population examined were in substantial agreement. About 6.5 percent of persons 65 or older, about 2.2 million persons, lived in some type of residential care other than settings for special populations (such as persons with mental illness or intellectual disabilities). The estimates indicated that most, about 1.45 million, lived in nursing homes, but more than 750,000 lived in alternative residential care settings.

In recent years, an increasing number of persons with disabilities have chosen to live in residential care settings. For the elderly, these facilities offer help with activities of daily living (bathing, taking medication, etc.) as well as providing oversight and opportunities for social activities and interaction. It has been hypothesized that people in these facilities, which range in size from small homes to large campuses, were more disabled than persons living in traditional houses or apartments, but were less disabled than persons living in nursing homes. However, relatively little has been known about the characteristics of persons in these facilities for three reasons: (1) the national Census Bureau classifies such persons as living in housing units and no data are collected to indicate that they are receiving services; (2) people typically pay for their care themselves, so there is no record of their care in a government database, as there would be in the case of a nursing home; and (3) if the facilities are regulated at all, they are regulated by the states, and each state has its own system.

The three surveys provided a consistent picture of the characteristics of the residential care population. Persons living in residential care facilities were more likely to be over age 85, female, and widowed, than were persons residing in their own homes. Residential care facilities served a broad income range. Persons living in those facilities were more likely to have incomes below $10,000, roughly approximating the federal poverty level for older couples. Relative to older persons remaining in traditional private housing, the residential care population was far more likely to receive help with activities of daily living, and to suffer from Alzheimer's disease or other dementias. Estimates from the two surveys that included the facility or institutional population, indicated that the prevalence of disability and dementias was dramatically higher among those living in residential care facilities than in community care settings, and highest in nursing homes.

Report Title: The Size and Characteristics of the Residential Care Population: Evidence from Three National Surveys http://aspe.hhs.gov/daltcp/reports/2006/3natlsur.htm
Agency Sponsor: ASPE, Office of the Assistant Secretary for Planning and Evaluation
Federal Contact: Drabek, John, 202-690-6443
Performer: Urban Institute; Washington, DC
PIC ID: 8347

Who Has an Intellectual or Developmental Disability, Who Provides Their Care, and How Will That Change in the Future?

Summary:

This study provided a comprehensive view of the supply and demand for "direct service professionals," individuals who help persons with intellectual or developmental disabilities. Intellectual disability consists of having low intellectual functioning and limitations in conceptual, social, and practical skills needed for everyday life. Individuals with developmental disabilities have limited functioning in three or more "activities of daily living." These activities are: capacity for independent living, economic self-sufficiency, learning, mobility, receptive and expressive language, self-care, and self-direction. Direct support professionals are paid to provide a wide range of day-to-day services to persons with intellectual or developmental disabilities. These professionals include direct care staff, aides, home health assistants, respite care providers, and personal care attendants. By providing services such as habilitation, health needs, personal hygiene, employment, transportation, recreation, house-keeping, and home management support, they enable individuals to live, work and function in their communities.

Direct support professionals are essential to the quality of life, health and safety of more than 1 million Americans with intellectual or developmental disabilities in need of long-term services and support. An estimated 4.3 million Americans with intellectual and/or developmental disabilities live in residential settings, their own homes or with other members of their families. Ensuring access to and quality of professional support is key to realizing goals established in various statements of national purpose with regard to full citizenship and inclusion of individuals with intellectual or developmental disabilities. In June 2003 there were an estimated 874,000 full-time equivalent direct support personnel assisting intellectually and/or developmentally disabled individuals in group residential settings, family homes, their own homes, community jobs, vocational and day training settings, and other service settings.

The current study estimated that by 2020, 1.2 million direct service professionals will be needed in order to provide an estimated 1.4 million individuals with intellectual or developmental disabilities with needed residential, vocational and other support. This is an increase of about 323,000 jobs, roughly 37% more such professionals than in 2003. Most of the increase will be due to increases in population, life expectancy among persons with the disabilities, aging of family caregivers, and use of increased types of home and community-based services. This increased demand will occur at a time when the labor supply of adults age 18-39 years, who traditionally have filled these jobs, is expected to increase only by 7%. Meeting future demand for support professionals will be difficult to achieve through regular recruitment alone. Attracting new personnel and improving retention will be essential.

Many industries will compete for the direct care workers, including the rapidly growing long term services and supports systems for aging persons with disabilities. Compensation, working conditions, career opportunities and job design will be key to retaining personnel and attracting new workers. Providing adequate levels of high quality, committed and stable direct support will need sustained effort by many actors. Work will be needed across federal, state and local governments, education and training institutions, workforce investment systems, faith-based organizations, service provider organizations and support professionals themselves. These groups and institutions will need to shape support roles into ones that offer those who enter these positions enough opportunity and respect to consider them viable careers.

Report Title: The Supply of Direct Support Professionals Serving Individuals with Intellectual Disabilities and Other Developmental Disabilities: Report to Congress http://aspe.hhs.gov/daltcp/reports/2006/DSPsupply.htm
Agency Sponsor: ASPE, Office of the Assistant Secretary for Planning and Evaluation
Federal Contact: Drabek, John, 202-690-6443
Performer: Department of Health and

Table of Contents

Introduction

What This Report Is About

Chapter I –
Overview of Completed Evaluations—Selected Highlights

Chapter II –
Summaries of Completed Evaluations – What Was Studied and the Key Findings

Goal 1: Reduce the major threats to the health and well-being of Americans

Objective 1.1: Reduce behavioral and other factors that contribute to the development of chronic diseases

Objective 1.2: Reduce the incidence of sexually transmitted diseases and unintended pregnancies

Objective 1.3: Increase immunization rates among adults and children

Objective 1.4: Reduce substance abuse

Objective 1.6: Reduce the incidence and consequences of injuries and violence

Goal 2: Enhance the ability of the Nation's health care system to effectively respond to bioterrorism and other public health challenges

Objective 2.1: Build the capacity of the health care system to respond to public health threats, especially bioterrorism threats, in a more timely and effective manner

Goal 3: Increase the percentage of the Nation's children and adults who have access to health care services, and expand consumer choices

Objective 3.2: Strengthen and expand the health care safety net

Objective 3.4: Eliminate racial and ethnic health disparities

Objective 3.5: Expand access to health care services for targeted populations with special health care needs

Table of Contents

Introduction

What This Report Is About

Chapter I – Overview of Completed Evaluations—Selected Highlights

Chapter II – Summaries of Completed Evaluations – What Was Studied and the Key Findings

Goal 1: Reduce the major threats to the health and well-being of Americans

Objective 1.1: Reduce behavioral and other factors that contribute to the development of chronic diseases

Objective 1.2: Reduce the incidence of sexually transmitted diseases and unintended pregnancies

Objective 1.3: Increase immunization rates among adults and children

Objective 1.4: Reduce substance abuse

Objective 1.6: Reduce the incidence and consequences of injuries and violence

Goal 2: Enhance the ability of the Nation's health care system to effectively respond to bioterrorism and other public health challenges

Objective 2.1: Build the capacity of the health care system to respond to public health threats, especially bioterrorism threats, in a more timely and effective manner

Goal 3: Increase the percentage of the Nation's children and adults who have access to health care services, and expand consumer choices

Objective 3.2: Strengthen and expand the health care safety net

Objective 3.4: Eliminate racial and ethnic health disparities

Objective 3.5: Expand access to health care services for targeted populations with special health care needs

Chapter I –
Overview of Completed Evaluations—Selected Highlights

Chapter II –
Summaries of Completed Evaluations – What Was Studied and the Key Findings