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The aftermath of Hurricane Katrina has placed a national spotlight on the shameful state of healthcare for America's poor. In the face of this highly publicized disaster, public health experts are more concerned than ever about persistent disparities that result from income and race.This book tells the story of one groundbreaking approach to medicine that attacks the problem by focusing on the wellness of whole neighborhoods. Since their creation during the 1960s, community health centers have served the needs of the poor in the tenements of New York, the colonias of Texas, the working class neighborhoods of Boston, and the dirt farms of the South. As products of the civil rights movement, the early centers provided not only primary and preventive care, but also social and environmental services, economic development, and empowerment.Bonnie Lefkowitz-herself a veteran of community health administration-explores the program's unlikely transformation from a small and beleaguered demonstration effort to a network of close to a thousand modern health care organizations serving nearly 15 million people. In a series of personal accounts and interviews with national leaders and dozens of health care workers, patients, and activists in five communities across the United States, she shows how health centers have endured despite cynicism and inertia, the vagaries of politics, and ongoing discrimination.

Objectives. To test the effect of CommunityRx, a scalable, low-intensity intervention that matches patients to community resources, on mental health-related quality of life (HRQOL) (primary outcome), physical HRQOL, and confidence in finding resources. Methods. A real-world trial assigned publicly insured residents of Chicago, Illinois, aged 45 to 74 years to an intervention (n = 209) or control (n = 202) group by alternating calendar week, December 2015 to August 2016. Intervention group participants received usual care and an electronic medical record–generated, personalized list of community resources. Surveys (baseline, 1-week, 1- and 3-months) measured HRQOL and confidence in finding community resources to manage health. Results. At 3 months, there was no difference between groups in mental (–1.03; 95% confidence interval [CI] = −3.02, 0.96) or physical HRQOL (0.59; 95% CI = −0.98, 2.16). Confidence in finding resources was higher in the intervention group (odds ratio = 2.08; 95% CI = 1.18, 3.63); the effect increased at each successive time point. Among intervention group participants, 65% recalled receiving the intervention; 48% shared community resource information with others. Conclusions. CommunityRx did not increase HRQOL, but its positive effect on confidence in finding resources for self-care suggests that this low-intensity intervention may have a role in population health promotion. Trial Registration. ClinicalTrials.gov Identifier: NCT02435511.

Current treatment options for chronic pain and depression are largely medication-based, which may cause adverse side effects. Integrative Medical Group Visits (IMGV) combines mindfulness techniques, evidence based integrative medicine, and medical group visits, and is a promising adjunct to medications, especially for diverse underserved patients who have limited access to non-pharmacological therapies. Determine the effectiveness of IMGV compared to a Primary Care Provider (PCP) visit in patients with chronic pain and depression. 9-week single-blind randomized control trial with a 12-week maintenance phase (intervention-medical groups; control-primary care provider visit). Academic tertiary safety-net hospital and 2 affiliated federally-qualified community health centers. 159 predominantly low income racially diverse adults with nonspecific chronic pain and depressive symptoms. IMGV intervention- 9 weekly 2.5 hour in person IMGV sessions, 12 weeks on-line platform access followed by a final IMGV at 21 weeks. Data collected at baseline, 9, and 21 weeks included primary outcomes depressive symptoms (Patient Health Questionnaire 9), pain (Brief Pain Inventory). Secondary outcomes included pain medication use and utilization. There were no differences in pain or depression at any time point. At 9 weeks, the IMGV group had fewer emergency department visits (RR 0.32, 95% CI: 0.12, 0.83) compared to controls. At 21 weeks, the IMGV group reported reduction in pain medication use (Odds Ratio: 0.42, CI: 0.18-0.98) compared to controls. Absence of treatment assignment concealment for patients and disproportionate group attendance in IMGV. Results demonstrate that low-income racially diverse patients will attend medical group visits that focus on non-pharmacological techniques, however, in the attention to treat analysis there was no difference in average pain levels between the intervention and the control group. clinicaltrials.gov NCT02262377.

Patient safety and quality care remain major challenges to Ghana's healthcare system. Like many health systems in Africa, this is largely because demand for healthcare is outstripping available human and material resource capacity of healthcare facilities and new investment is insufficient. In the light of these demand and supply constraints, systematic community engagement (SCE) in healthcare quality assessment can be a feasible and cost effective option to augment existing quality improvement interventions. SCE entails structured use of existing community groups to assess healthcare quality in health facilities. Identified quality gaps are discussed with healthcare providers, improvements identified and rewards provided if the quality gaps are closed. This paper evaluates whether or not SCE, through the assessment of health service quality, improves patient safety and risk reduction efforts by staff in healthcare facilities. A randomized control trail was conducted in 64 primary healthcare facilities in the Greater Accra and Western regions of Ghana. Patient risk assessments were conducted in 32 randomly assigned intervention and control facilities. Multivariate multiple regression test was used to determine effect of the SCE interventions on staff efforts towards reducing patient risk. Spearman correlation test was used to ascertain associations between types of community groups engaged and risk assessment scores of healthcare facilities. Clinic staff efforts towards increasing patient safety and reducing risk improved significantly in intervention facilities especially in the areas of leadership/accountability (Coef. = 10.4, p<0.05) and staff competencies (Coef. = 7.1, p<0.05). Improvement in service utilization and health resources could not be attributed to the interventions because these were outside the control of the study and might have been influenced by institutional or national level developments between the baseline and follow-up period. Community groups that were gender balanced, religious/faith-based, and had structured leadership appeared to be better options for effective SCE in healthcare quality assessment. Community engagement in healthcare quality assessment is a feasible client-centered quality improvement option that should be discussed for possible scale-up in Ghana and other resource poor countries in Africa.

Although ample evidence exists that community health centers lower federal medical expenditures, it has been hypothesized that the eligibility assistance offered by staff at health centers could also increase insurance enrollment and federal costs. We analyzed the effects of eligibility assistance on insurance enrollment at both the health center and state levels. Using multivariate panel analysis with two-way fixed effects, we examined effects of eligibility assistance during the period 2016-23 to determine how insurance enrollment is affected at the health center and state levels. Data sources were administrative data from health centers and state-level enrollment data from Medicaid, the Children's Health Insurance Program (CHIP), and health insurance Marketplaces. Higher levels of eligibility assistance staffing are associated with modest increases in numbers of Medicaid and CHIP enrollees at health centers and modest reductions in numbers of uninsured patients. However, neither eligibility assistance nor overall health center size significantly affect state-level enrollment for any of the programs. Eligibility assistance modestly increases insurance coverage among health center patients, which improves health centers' financial status and patient care capacity. But this assistance does not significantly increase overall Medicaid, CHIP, or Marketplace enrollment, nor does it raise federal expenditures.

A cluster-randomized trial in 20 Ugandan health centers compared a multicomponent strategy (on-site molecular testing for TB, restructuring of clinic workflows, and feedback of quality metrics) with routine care (on-site sputum-smear microscopy and referral-based molecular testing). The intervention led to greater numbers of patients being tested for, receiving a diagnosis of, and being treated for confirmed TB.

Background Nurses in Ghana play a vital role in the delivery of primary health care at both the household and community level. However, there is lack of information on task shifting the management and control of hypertension to community health nurses in low- and middle-income countries including Ghana. The purpose of this study was to assess nurses’ knowledge and practice of hypertension management and control pre- and post-training utilizing task-shifting strategies for hypertension control in Ghana (TASSH). Methods A pre- and post- test survey was administered to 64 community health nurses (CHNs) and enrolled nurses (ENs) employed in community health centers and district hospitals before and after the TASSH training, followed by semi-structured qualitative interviews that assessed nurses’ satisfaction with the training, resultant changes in practice and barriers and facilitators to optimal hypertension management. Results A total of 64 CHNs and ENs participated in the TASSH training. The findings of the pre- and post-training assessments showed a marked improvement in nurses’ knowledge and practice related to hypertension detection and treatment. At pre-assessment 26.9% of the nurses scored 80% or more on the hypertension knowledge test, whereas this improved significantly to 95.7% post-training. Improvement of interpersonal skills and patient education were also mentioned by the nurses as positive outcomes of participation in the intervention. Conclusions Findings suggest that if all nurses receive even brief training in the management and control of hypertension, major public health benefits are likely to be achieved in low-income countries like Ghana. However, more research is needed to ascertain implementation fidelity and sustainability of interventions such as TASSH that highlight the potential role of nurses in mitigating barriers to optimal hypertension control in Ghana. Trial registration Trial registration for parent TASSH study: NCT01802372 . Registered February 27, 2013.