In This Issue:
- Integrating Elderly and Mentally Ill Persons in Public Housing
- Assessment of NIH's Women's Health Initiative AND NIH Response to WHI Assessment
- School-Based Health Centers and Managed Care
CREATING COMMUNITY: INTEGRATING ELDERLY AND SEVERELY MENTALLY ILL PERSONS IN PUBLIC HOUSING
As of December 1990, elderly families (those headed by someone aged 62 years or older) occupied over half a million public housing units nationwide, many of which are in developments designed specifically for older adults. However, due to emerging demographic trends and an increased number of housing choices for the low-income older persons, many of these developments have a high vacancy rate. Changes in legislation over the past 30 years allow members of the non-elderly disabled population, including those with severe mental illnesses, to occupy housing units in public housing developments originally slated for older adults.
The report, Creating Community: Integrating Elderly and Severely Mentally Ill Persons in Public Housing, is designed to assist management and staff of public housing agencies (PHA's) and community mental health agencies to integrate these two diverse populations. It examines the challenges to successful integration of older adults and persons with severe mental illnesses into the same public housing developments and innovative approaches to meeting these challenges. The report also profiles eight sites where the two populations have been successfully merged: Boston, Massachusetts; La Salle County and Rockford, Illinois; St. Paul, Minnesota; Danbury, Connecticut; Providence, Rhode Island; Seattle, Washington; and Toledo, Ohio.
The challenges to integrating these two populations include lifestyle differences, the stigma of mental illness, and increased responsibilities for public housing agency staff and community mental health providers. Some older residents of public housing may object to having younger neighbors, regardless of disability status. Others may particularly oppose neighbors with mental illnesses because of safety concerns or because of ignorance about the symptoms, treatment, and rights of persons with mental illnesses.
Public housing agencies and community mental health providers can work together to meet these challenges. Public housing agencies can sponsor initiatives directed at residents with mental illnesses, including needs assessment, thorough pre-housing screening of applicants, increased security, strengthened resident councils, and social or educational opportunities which allow members of the two populations to learn about one another. Community mental health providers can facilitate successful integration of the two populations by creating a centralized mental health system that can offer case management services to residents with mental illnesses; providing services and outreach to persons with mental illnesses, often on-site; and providing specialized training for PHA staff.
This report was prepared by the National Resource Center on Homelessness and Mental Illness, Policy Research Associates, Inc., and was jointly sponsored by the Department of Housing and Urban Development and the Substance Abuse and Mental Health Services Administration. For further information, contact Dr. Walter A. Leginski, Acting Chief of the Center for Mental Health Services's Homeless Programs Section, at (301) 443- 3706. Copies of the report, #5238 are available from the Policy Information Center.
ASSESSMENT OF THE NIH WOMEN'S HEALTH INITIATIVE
The National Institutes of Health launched the Women's Health Initiative (WHI) in September, 1993. The 14-year, $625 million study will involve 160,000 women at 45 clinical centers and thousands more in community studies. It will investigate ways to prevent cardiovascular disease, breast cancer, and osteoporotic fractures in women, and was developed in response to the widespread perception that historically women have been excluded from clinical trials because of the assumption that results obtained in men can be extrapolated to women or because of the difficulty of recruiting and retaining women as study subjects.
The report, Assessment of the NIH Women's Health Initiative, examines the components of the WHI in order to determine whether their current structure is scientifically justified and to make recommendations about necessary changes.
The WHI consists of three components, the Clinical Trial (CT), the Observational Study (OS), and the Community Prevention Study (CPS). The first component is the most expensive and complex, and involves 63,000 post-menopausal women. It tests the hypotheses that (1) a diet with a low fat content reduces the risk of breast and colorectal cancer and of cardiovascular disease; (2) estrogen replacement therapy and progestin and estrogen replacement therapy reduce the risk of cardiovascular disease, and secondarily, of osteoporotic fracture and breast cancer; and (3) calcium and vitamin D supplementation reduces the risk of hip fractures, other fractures, and colorectal disease. The OS follows 100,000 women ineligible or unwilling to participate in the CT in order to generate a database on the CT hypotheses and related health questions. Finally, the CPS involves thousands of other women in the development of community-based strategies and infrastructures designed to promote healthy behaviors.
The Institute of Medicine assessment raises several concerns about the structure and budgeting of the WHI. It finds that (1) the informed consent process needs modification; (2) a CT hypothesis, that there is a link between diet and breast cancer, should be modified to reflect the hypothesis that there is a link between diet and coronary heart disease (CHD); (3) the CT should be scheduled to end after six years, as opposed to the nine years as designed by NIH; and (4) the cost of the WHI, especially the cost of the CT, will exceed the $625 million budgeted. The report also finds that the WHI had inadequate peer review within NIH and from outside scientists; that the factorial design, sample characteristics, outcome definitions and measurements, and recruitment, retention and adherence procedures of the CT are inadequate; and that the OS and CPS components of the Initiative have been given inadequate attention, and, possibly, funding. Finally, the report recommends several strategies which may be used to improve the structure and implementation of the WHI. It suggests that each component of the Initiative undergo further refinement and redefinition.
NIH RESPONDS TO IOM ASSESSMENT
Dr. Harold Varmus, Director, NIH, appeared before the House Subcommittee on Appropriations on April 20, 1994 to address the concerns raised by the IOM report. During that appearance, Dr. Varmus stated that, with appropriate modifications, the study will proceed as planned. Sixteen Vanguard Clinics are already in operation and twenty-nine more are slated to open by the end of September 1994.
NIH believes that the development of the informed consent process was extremely thorough. Any changes which might be needed due to study results or information gathered from outside the study will be included as they become available. Second, NIH believes that evidence of a link between diet and coronary heart disease (CHD) is clear and that the WHI CT is not needed to prove it. On the other hand, evidence linking diet and cancer is conflicting and inconclusive and makes a random clinical trial necessary. Furthermore, NIH believes that duration of the CT should remain at nine years, unless compelling evidence of definitive benefit or harm calls for the suspension of the entire study or of one of its constituent parts. Finally, NIH does not share IOM's financial concerns, asserting that the contract mechanism which was used is appropriate to fund large, multicenter clinical trials, and that the proper financial controls are in place to prevent waste or abuse.
The initial study was performed by the Institute of Medicine, and was sponsored by the National Institutes of Health's National Center for Research Resources. The agency contact for this project is Dr. Loretta Finnegan, Director of the Women's Health Initiative. She may be reached at 301-402-2900. Copies of the Executive Summary and of NIH's response are available from the Policy Information Center under PIC ID Number # 5237.
SCHOOL-BASED HEALTH CENTERS AND MANAGED CARE
Between 200 and 500 school-based health centers exist across the country, and this number is rapidly expanding. These centers, as well as Community and Migrant Health Centers funded by the federal government, seek to provide health care to children and adolescents in low-income communities where access to health care may be limited. Nearly all school-based health centers and Community and Migrant Health Center school-linked services provide general, primary health care ranging from general physicals to chronic illness management. However, while the Department of Health and Human Services (HHS) supports increased access to health care for adolescents, it also seeks to control such access through the Medicaid Managed Care delivery systems. Managed care systems stipulate that recipients may receive their health care only from specified providers, which may cause a conflict for students seeking care from school-based health care centers which are not specified providers.
This report, School-Based Health Centers and Managed Care, describes school-based health centers and the degree of their coordination with managed care providers.
The report finds that school-based health centers are successful in reaching their goals. They increase access to health care for adolescents by specializing in adolescent medicine and by virtue of their location in schools. The majority of parents asked agree to allow these centers to provide health care for their children. Finally, early assessments suggest that school-based health centers can be more successful at delivering needed services to adolescents than even managed care programs.
However, there is little coordination between managed care providers and school based health centers. There are few formal or informal agreements to cooperate; little exchange of information occurs; and poor communication, financial constraints, legal issues, and the confidentiality of medical records inhibit fuller coordination of services. Furthermore, although initial efforts demonstrate that the potential benefits of cooperation are great for adolescents, managed care providers, and school-based health centers, HHS has no departmental focal point to facilitate in such coordination, despite the rapid expansion of both school-based health centers and managed care programs.
This report was prepared by the Office of Inspector General of the Department of Health and Human Services. Copies of the Executive Summary, # 5177, are available from the Policy Information Center.
Recently Acquired Reports
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SERVICES AVAILABLE FROM THE PIC
The Policy Information Center (PIC) is a centralized source of information on in-process, completed, and on-going evaluations; short-term evaluative research and; policy-oriented projects conducted by HHS as well as other Federal departments and agencies. The PIC on-line database provides project descriptions of these studies. It is available on-line at: http://aspe.hhs.gov/PIC/. Inquiries regarding PIC services should be directed to Carolyn Solomon, Technical Information Specialist, at 202-690-5694. Or E-mail PIC at: email@example.com