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A Model for Advocacy: Advancing Policy Change in Support for Patients with Medicaid
Get PDFThere are differences in access and utilization of care for patients with Medicaid. When patients cannot access timely therapeutic care, the resulting outcomes are often poor. Because a major limiting factor in accessing services is insurance type, investigating optimal coverage practices is an important first step in advocating for change. This abstract reports on Phase One of a larger collaboration with state professional associations for physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) to present a model that describes Medicaid authorization services for PT, OT, and SLP, serving as a guide for policy change.
We collaborated with the reference librarians at the Academic Health Science Center library, using 29 search terms to find 22 papers. An additional 7 articles from non-indexed journals were discovered. After reviewing the abstracts, we found 14 relevant papers; full texts were available for 12, while 2 were abstracts only. A literature table was created. Team members independently developed themes based on the findings, then jointly discussed, prioritized and defined these themes in relation to the collaborative purpose.
The model is grounded in six themes that emerged from the literature review: 1) Why patients need PT, OT, and/or SLP (utilization), 2) Optimal number of PT visits and access to care, 3) Administrative costs/burden, 4) Disparities in care based on sociodemographic status, 5) Insurance coverage policies and delay of care, and 6) Facilitators/barriers to policy change and advocacy. Visualized as a Venn diagram, the model illustrates the optimal number of PT visits before requiring pre-authorization, overlapping with three key factors: reducing administrative burden, aligning with policy facilitators, and promoting care for all sociodemographic groups.
Our model is a first step for creating an effective tool that will serve as a guide for policy change. With patient-centered policies that recognize all themes of our proposed model, PTs can advocate for timely, accessible care for all patients.
This project includes two areas of clinical relevance: First, the project consists of three phases. Phase One involved creating the model. The next phase will apply the model to actual claims data to analyze patient visits, considering variations in common medical diagnoses and age. The final phase involves sharing the findings with stakeholders to guide policy decisions.
Change is complex and must be data-driven, requiring the investment of stakeholders at multiple levels. Second, this project exemplifies leadership and collaboration between an academic health science center, state professional associations, and a state’s designated Medicaid plan (United Healthcare) to achieve a model based on data to guide optimal decision-making for patient/client access for PT services. This work showcases the integration of clinical perspectives and rigorous research methods to inform change
Demographic Groups’ Use of Agency Intimate Partner Violence (IPV) Services: A Quality Improvement Project to Identify and Engage Local Underserved Populations
Get PDFThis quality improvement project intended to identify populations of adult intimate partner violence (IPV) survivors in Spokane County, Washington, by race/ethnicity and sex who are underserved by a local victim service agency and provide action-oriented, evidence-informed recommendations that the agency may utilize to increase engagement with these local underserved populations. Methods used include secondary data analysis, timeline creation, literature review, and interpretation of quantitative and qualitative data analysis. This was a capstone project designed to demonstrate multiple public health competencies
Identification and Preclinical Assessment of Novel Therapeutic Modalities in Environmental Exposure-induced Lung Disease
Get PDFEnvironmental lung diseases are preventable respiratory conditions either caused or made worse by inhaled environmental exposures. Contemporarily, environmental lung diseases are most associated with workplace exposures given specific occupational processes aerosolize inflammatory agents that can be inhaled at high concentrations. Although a considerable amount is known regarding immunoglobulin (Ig)E-mediated responses to environmental exposures, little is known about non-IgE mediated respiratory conditions resulting from lipopolysaccharide (LPS)-enriched organic dust exposure(s). Chronic respiratory diseases such as asthma, hypersensitivity pneumonitis, chronic obstructive pulmonary disease (COPD), and pulmonary fibrosis have all been identified as environmental lung diseases caused or exacerbated by such environmental dusts. Therapeutic approaches for the management of environmental exposure induced lung inflammation are limited and without evidence of chronic disease risk mitigation. The work herein aims to address this knowledge gap by furthering mechanistic understanding of environmental exposure-induced lung inflammation while also identifying and assessing targeted therapeutic approaches to mitigate inflammatory consequences resulting from inhaled environmental exposure(s) and decrease chronic lung disease risk.
First, we delineated the magnitude and distribution of C-C motif chemokine receptor 2 (CCR2)+ inflammatory monocytes and monocyte-derived macrophages trafficked to the lung following environmental exposures. These cell populations have been implicated in facilitating the transition from acute inflammation to chronic disease development, so we subsequently determined whether targeting these lung populations would attenuate inflammatory consequences induced by these environmentally derived exposures. Secondly, we assessed the therapeutic potential of the anti-inflammatory and anti-fibrotic interleukin (IL)-10 in an acute organic dust extract (ODE) and repeated LPS exposure contexts to determine its ability to mitigate local and systemic inflammatory consequences resulting from these exposures. Finally, we characterized the role of aconitate decarboxylase 1 (ACOD1) in mediating lung inflammatory processes resulting from inhaled exposures and then assessed the therapeutic potential of a cell-permeable itaconate formulation, 4-octyl itaconate (4OI), post-environmental exposure. Notably, we corroborated a role for recruited, transitioning monocyte-macrophages in environmental exposure induced lung disease, established preclinical groundwork demonstrating the ability of IL-10 to mitigate environmental exposure induced lung disease and associated pathologic consequences, and demonstrated that ACOD1 plays a central role in mediating the lung pro-inflammatory response to inhaled environmental exposures
Neuroplasticity in Motion: Exploring Neural Oscillatory Activity and Physical Therapy Interventions in Adolescents and Adults with Cerebral Palsy
No full textCerebral palsy (CP) results from a perinatal brain injury and is one of the most prevalent and costly developmental disabilities in the United States. As persons with CP transition from adolescence into adulthood they continue to be faced with prominent mobility challenges. Despite the increased recognition of the mobility deteriorations, NIH funding related to transition aged persons with CP is remarkably low. Thus, research focused on enhancing the mobility of persons with CP during this critical transition period is sorely needed to help narrow the gap and eliminate this disparity. Additionally, a better understanding of the neurophysiology surrounding physical therapy interventions is needed to develop neuroscience-informed treatment approaches for beneficial neuroplasticity. We sought to address these knowledge gaps by using state-of-the-art brain imaging technology (i.e., magnetoencephalography (MEG)), novel therapeutic paradigms, and clinical assessment outcomes. Overall, we observed decreased functional mobility and aberrant cortical activity in adolescents and adults with CP compared to neurotypical controls pre-therapy and observed beneficial clinical and neuroplastic changes post-therapy. Specifically in chapter 1, we identified that therapeutic power training appears to optimize the sensorimotor cortical oscillations of persons with CP, and these neuroplastic changes partly contribute to improvements in the leg peak power production of these individuals. In chapter 2, a gait training protocol was shown to enhance clinical outcomes and sensorimotor cortical oscillatory activity during an adaptive motor control MEG paradigm. Additionally, changes in the beta event-related desynchronization during the planning period were associated with improvements in the Timed Up and Go test in persons with CP. In chapter 3, we demonstrated that following a gait training paradigm focused on enhancing sensorimotor integration, no changes were observed in the somatosensory cortex when a paired-pulse stimulation paradigm was utilized. However, whole-brain analysis revealed increased activity in the anterior cingulate post-therapy in persons with CP. Lastly, chapter 4 highlighted the beneficial gait adaptation and overall functional mobility changes associated with a novel robotic exoskeleton gait training paradigm that focused on principles of motor learning to enhance the clinical outcomes. Taken together, these findings support the use of physical therapy treatments that incorporate key ingredients derived from neuroscience principles to promote beneficial neuroplastic and clinical changes for persons with CP
Effect of Praziquantel Treatment on the Nutritional Status of Children Infected with Schistosoma haematobium
Get PDFThis quasi-experimental trial examined the relationship between Schistosoma haematobium infection and nutritional status, and the impact of single dose praziquantel (PZQ) therapy on undernutrition. A total of 353 children were examined, 112 of which were infected with S. haematobium and treated with PZQ. Children\u27s heights, weights, and mid-upper arm circumferences (MUAC) were measured at baseline and one month post-treatment. Infected children had significantly smaller mean BMI-for-age z-scores (BAZ) (-1.16 vs. 0.11, p \u3c 0.01) and weight-for-age z-scores (WAZ) (-0.61 vs. -0.31, p = 0.03) than the uninfected ones at baseline. S. haematobium infection was associated with underweight (adjusted OR: 1.76, 95% CI: 1.63-1.90). One month after treatment, BAZ, WAZ, height for age z-scores (HAZ), and MUAC scores were comparable between treated and control children. However, there was a significant decrease in the prevalence of underweight among treated children, while no significant change was observed in the control group one month post-treatment. In conclusion, children infected with S. haematobium are likely to suffer from undernutrition; however, single dose PZQ therapy may not improve their nutritional status within one month of treatment. Future studies could have longer follow-up periods to better estimate the drug\u27s effect on nutritio
Immunoplasticity: A Key Determinant in the Outcome of Neurosurgical Biofilm Infection
No full textA craniotomy involves the temporary removal of a piece of the skull, providing access to the intracranial compartment for numerous indications including the excision of brain tumors, implantation of medical devices, or evacuation of hematomas. In a minority of cases (~1-5%), post-surgical infection develops, which is most commonly caused by Staphylococcus aureus, which forms a biofilm on the skull and resists antibiotic- and immune-mediated clearance. Current management of craniotomy infection involves additional surgical procedures to remove the biofilm nidus and chronic antibiotic therapy to prevent recurrence. Given this and rapidly expanding rates of antimicrobial resistance, there is renewed interest in the development of immune-based therapies to treat biofilm infections. This dissertation explores the role of immunoplasticity, the ability of the immune system to adapt to environmental cues present in the biofilm milieu, and chiefly during craniotomy infection. The work encompasses three main themes. First, the effects of tumor necrosis factor (TNF) and interferon-γ (IFN-γ) signaling on shaping immune responses and pathogen abundance during S. aureus craniotomy infection were explored, identifying key roles for each signaling pathway for both leukocyte recruitment and polarization in response to biofilm. Second, both patient samples and a mouse model of craniotomy infection were leveraged to explore immune polarization across the blood-to-tissue transition, tissue compartments, and distinct biofilm models and the kinetics of these specifications. Glycolysis, amino acid, fatty acid, and nucleotide metabolism were identified as key mediators of phenotypic differences in immune responses across time and tissue niche. Third, the role of epigenetics in modulating immune responses during craniotomy infection was explored. This work implicated histone acetylation as a key factor in controlling inflammatory mediator production, both in vitro and in vivo. Global histone deacetylase (HDAC) inhibition during S. aureus craniotomy infection resulted in significantly elevated bacterial burden, indicative of an ineffective immune response. Together, these findings support the existence of metabolic and epigenetic layers of control over the immune response to biofilm infection, aspects that may be leveraged for future immunomodulatory intervention
Universal Adolescent Depression Screening and Implications for Identification of Adolescent Depression and Mental Health Referrals
Get PDFBackground: Throughout the United States, mental health concerns have been steadily increasing, which has created a significant impact for caregivers, overburdened healthcare facilities, and patients. In fact, a large number of those experiencing mental health issues are unidentified and thus more likely to experience mental health crises, suicidal ideation, or suicide attempts. Rural adolescents are significantly more vulnerable than their urban counterparts related to disparities in both mental health services and preventative screening. Coordination with a critical access hospital (CAH) emergency department revealed that there was no universal adolescent depression screening in place, and patients were potentially going undiagnosed and untreated.
Objectives: Objectives of this quality improvement project included increasing staff knowledge and competence with administration of the PHQ-2/PHQ-9 through an educational in-service, providing universal adolescent depression screening in a CAH ED through administration of the PHQ-2/PHQ-9 to all presenting patients ages 12-18, and using depression screening results to increase the provision of mental health referrals in this setting.
Methods: This quality improvement project was a prospective cohort study design, which was initiated by a rural CAH in the ED setting. Retrospective chart review pre- and post- project implementation involving three months prior to implementation and three months after implementation was conducted. Additionally, staff education related to depression screening was provided prior to project implementation and its effectiveness was measured through pre- and post- test result comparisons. Universal depression screening using PHQ-2/PHQ-9 tools was then completed on patients presenting to the CAH who were within the designated 12-18 year old age range.
Results: There were 24 staff members that completed the educational training along with pre- and post- tests. Pre-test scores demonstrated a mean of 71.92 (SD=10.50), and post-test scores had an increased mean of 82.88 (SD=4.76). A paired t-test showed that the mean difference between pre- and post- test scores was -10.96 (CI: -15.22 to -6.70) with a significant t-value of -5.319 (p
Conclusion: Universal adolescent depression screening has the potential to increase identification and treatment rates as well as providing the opportunity for mental health referrals. Early intervention has been shown to prevent financially and emotionally costly mental health crises, and universal screening can aid in the identification that leads to early intervention. Although this study was limited by small sample sizes, staff knowledge and adolescent screening rates increased after education and project implementation. This demonstrated that further studies with larger sample sizes and more diverse settings are needed to demonstrate full practice implications
Acceptability of Self-Collected Pap Smears among Karen-speaking Patients in the Midwest
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