Community-based Care

San Mateo County is one of a small number of innovative local jurisdictions that is expanding coverage for uninsured adults and at the same time undertaking a reform of its safety net primary care system. We evaluated the impact of the systems redesign by comparing outcomes for a group of people served at the largest county safety net clinic prior to systems redesign (2006) to those served at the clinic after systems redesign (2009). Use of any preventive care services in a year climbed from 25.9 percent to 33.3 percent. Continuity of care also rose significantly, and emergency room use declined. The county's experience provides an example for other communities to follow as they improve the efficiency of health care services for the most vulnerable members of society.

In 2008 San Mateo County, California launched its Adult Coverage Expansion and Systems Redesign Initiative. The initiative expanded coverage for all uninsured adults below 200 percent of the poverty level and redesigned care in county safety net clinics. The program substantially improved access to care for uninsured adults, as well as improved continuity and quality of care for those served by county safety net clinics. However, access remains a problem for new enrollees, due to restrained provider supply and the economic recession. The report provides lessons for other counties as they expand coverage under national health reform.

This paper, from The Commonwealth Fund’s international program, examines the origins, content, and potential impact of England's evidence-based End-of-Life Care Strategy. Challenges addressed include moving such care beyond the province of hospice and palliative-care specialists and initiating palliative services before the patient's final days. Aspects of the English approach that may be useful in the U.S include helping physicians recognize when patients are entering a trajectory that may end in death, the use of "death at home" as a metric for measuring progress, improving the skills of clinical and caregiving personnel through Web-based training, and developing a national improvement pathway.

The Affordable Care Act (ACA) presents opportunities to support what has often been called the “new public health.” This analysis of the ACA provisions suggests five interrelated issues of importance for the future of public health-defining a new paradigm, identifying reliable funding streams, developing the evidence base, establishing effective relationships with other actors, and communicating the value proposition of public health. The brief concludes by noting that much work must still be done to assure that the ACA becomes a wellspring of appreciation for public health’s value, rather than the high water mark for public health advocacy.

Best Start LA is a place-based community investment in Los Angeles County designed to improve the well-being, development, and care experienced in children ages five and under. Focus groups with parents, home visitors, and community members -reveal that the investment is off to a good start. Mothers receiving "Welcome Baby!" home visiting were very satisfied with the education and support the service provides. Home visitors described the close bonds they form with their clients, but also feel that the program's model doesn't always meet families' extensive needs. Stakeholders involved in community mobilization efforts were excited about their early progress and shared vision for parents as the leaders.

A case study of the initial implementation of Best Start LA-a place-based community investment in Los Angeles County designed to improve the well-being, development, and care experienced by children ages five and under-finds mostly positive results, thus far. At the family level, home visiting for pregnant and parenting mothers is off to a strong start, rendering services to nearly 750 families by the end of 2010. Community-level efforts to mobilize community members and develop family-support strategies have been slower to develop. Systems-level investments to develop family-friendly policies and services across the county are proceeding on schedule.

The economic downturn has been milder in Little Rock than elsewhere, but increased unemployment and an almost 15 percent uninsurance rate have strained the area's fragmented health care safety net. This is the lead finding from a new Community Report released by the Center for Studying Health System Change (HSC). The Urban Institute's Ian Hill was one of three team leaders who conducted a site visit to the Little Rock metropolitan area in May 2010 to interview over 40 health leaders to examine how health care is organized, financed, and delivered in the community. The report was developed as part of HSC's Community Tracking Study, a project that has monitored health system evolution in 12 communities (including Little Rock) since 1996.

This guide offers practical insights about how home visiting programs can better serve depressed mothers and their young children. Results reveal no single source of help, formal or informal, is universally trusted by mothers, who look for someone with whom they have a trusting relationship over time. Home visiting programs have great potential to help these families. However, programs need strong mental health connections, staff training, and capacity to transition depressed mothers to follow-up treatment, among other enhancements. The Doris Duke Charitable Foundation funded this research as part of an Urban Institute project identifying effective service approaches for depressed mothers.