US Nonprofit Hospitals' Community Health Needs Assessments and Implementation Strategies in the Era of the Patient Protection and Affordable Care Act

This cross-sectional study examines the proportion of US nonprofit hospitals with community health needs assessments and implementation strategies as required by the Patient Protection and Affordable Care Act.

Generating Global Priority for Addressing Rheumatic Heart Disease: A Qualitative Policy Analysis

Background Rheumatic heart disease (RHD) poses a high burden in low-income countries, as well as among indigenous and other socioeconomically disadvantaged populations in high-income countries. Despite its severity and preventability, RHD receives insufficient global attention and resources. We conducted a qualitative policy analysis to investigate the reasons for recent growth but ongoing inadequacy in global priority for addressing RHD. Methods and Results Drawing on social science scholarship, we conducted a thematic analysis, triangulating among peer-reviewed literature, organizational documents, and 20 semistructured interviews with individuals involved in RHD research, clinical practice, and advocacy. The analysis indicates that RHD proponents face 3 linked challenges, all shaped by the nature of the issue. With respect to leadership and governance, the fact that RHD affects mostly poor populations in dispersed regions complicates efforts to coordinate activities among RHD proponents and to engage international organizations and donors. With respect to solution definition, the dearth of data on aspects of clinical management in low-income settings, difficulties preventing and addressing the disease, and the fact that RHD intersects with several disease specialties have fueled proponent disagreements about how best to address the disease. With respect to positioning, a perception that RHD is largely a problem for low-income countries and the ambiguity on its status as a noncommunicable disease have complicated efforts to convince policy makers to act. Conclusions To augment RHD global priority, proponents will need to establish more effective governance mechanisms to facilitate collective action, manage differences surrounding solutions, and identify positionings that resonate with policy makers and funders.

Treading a tightrope: Professional perspectives on balancing the rights of patient's and relative's under the Mental Health Act in England

Involuntary detention is used internationally to detain and treat people who are deemed to have a mental disorder. In England and Wales, approved mental health professionals (AMHPs) co-ordinate Mental Health Act assessments which allow for patients to be detained. AMHPs have legal duties to identify, inform and consult with a patient's nearest relative (NR), who are, in turn, given powers to initiate or challenge detention. Our study takes an original approach through examining how AMHPs interpret their duties towards nearest relatives. We adopted a two-stage design, which involved an online questionnaire with 55 AMHPs and focus group discussions with 33 AMHPs. The research was conducted in England between 2017 and 2018. Our questionnaire found that a high proportion of AMHPs reported that they had spoken to NRs for background information when assessing patients under the Mental Health Act. However, AMHPs were less likely to ask patients about their views of involving the NR prior to assessment. Focus group findings showed that AMHPs saw the NR role as offering an important 'safeguard' on the basis that NRs could provide information about the patient and advocate on their behalf. AMHPs identified practical difficulties in balancing their legal obligation towards NRs and patients; particularly where issues of potential abuse were raised or where patients had identified that they did not want NR involvement. While AMHPs stated that they sought to prioritise patient wishes regarding confidentiality, their accounts identified that patient consent about information sharing was sometimes implied rather than sought explicitly. Our findings reinforce conclusions by the recent Independent Review of the MHA, which states that current NR provisions are 'outdated, variable and insufficient'. We identify that current practice could be improved using advanced choice documents and outline implications for AMHP practice.

The use of 'tie down' in New Zealand prisons​-what is the role of the health sector?

We draw upon two recent reports from the Chief Ombudsman that describe the prison management of people assessed at risk of self-harm or suicide, as cruel, inhuman or degrading treatment or punishment. People were mechanically restrained on 'tie-down' beds by their legs, arms and chest or placed in waist restraints with their hands cuffed behind their backs over prolonged periods. These practices occurred at the direction of, or were approved by, health professionals. We highlight ethical issues for health professionals party to 'tie down' and examine the current guidance and regulatory framework for health professionals working in coercive environments. This article is timely in the context of current Government Inquiries into the criminal justice system and mental health and addictions, the review of the health and disability system, the Correction's Amendment Bill before parliament, and Government plans to expand Waikeria prison to include a 100-bed mental health facility. We call for the use of 'tie down' to be abolished in New Zealand prisons, and for all health professionals to refuse to participate in this practice. Government must make provision for sufficient forensic mental health capacity and capability in the health sector, and ensure timely, equitable access to high-quality, trauma-informed and culturally safe services.

State-Level Community Benefit Regulation and Nonprofit Hospitals' Provision of Community Benefits

Do nonprofit hospitals provide enough community benefits to justify their tax exemptions? States have sought to enhance nonprofit hospitals' accountability and oversight through regulation, including requirements to report community benefits, conduct community health needs assessments, provide minimum levels of community benefits, and adhere to minimum income eligibility standards for charity care. However, little research has assessed these regulations' impact on community benefits. Using 2009-11 Internal Revenue Service data on community benefit spending for more than eighteen hundred hospitals and the Hilltop Institute's data on community benefit regulation, we investigated the relationship between these four types of regulation and the level and types of hospital-provided community benefits. Our multivariate regression analyses showed that only community health needs assessments were consistently associated with greater community benefit spending. The results for reporting and minimum spending requirements were mixed, while minimum income eligibility standards for charity care were unrelated to community benefit spending. State adoption of multiple types of regulation was consistently associated with higher levels of hospital-provided community benefits, possibly because regulatory intensity conveys a strong signal to the hospital community that more spending is expected. This study can inform efforts to design regulations that will encourage hospitals to provide community benefits consistent with policy makers' goals.

[Complete and detailed critiques of medical criteria for assessing the degree of dependence for the care allowance]

In 2012 it was applied to medical practice assessor new criteria for assessing the degree of dependence for the care allowance. After four years by the Ministry of Labour and Social Affairs proposed expansion of the existing activities and at the other activities, it is proposed to refine the text. New activities refine or complement the existing framework defining the basic needs of life and should lead to a more objective and personally assessment of the degree of dependence. With the change in legislation expected a growth in the number of applicants for assessment General assessment principles and policies remain unchanged.Key words: medical assessment service, dependence degree, basic living needs.

Health and Taxes: Hospitals, Community Health and the IRS

The Affordable Care Act created new conditions of federal tax exemption for nonprofit hospitals, including a requirement that hospitals conduct a community health needs assessment (CHNA) every three years to identify significant health needs in their communities and then develop and implement a strategy responding to those needs. As a result, hospitals must now do more than provide charity care to their patients in exchange for the benefits of tax exemption. The CHNA requirement has the potential both to prompt a radical change in hospitals' relationship to their communities and to enlist hospitals as meaningful contributors to community health improvement initiatives. Final regulations issued in December 2014 clarify hospitals' obligations under the CHNA requirement, but could do more to facilitate hospitals' engagement in collaborative community health projects. The Internal Revenue Service (IRS) has a rich opportunity, while hospitals are still learning to conduct CHNAs, to develop guidance establishing clear but flexible expectations for how providers should assess and address community needs. This Article urges the IRS to seize that opportunity by refining its regulatory framework for the CHNA requirement. Specifically, the IRS should more robustly promote transparency, accountability, community engagement, and collaboration while simultaneously leaving hospitals a good degree of flexibility. By promoting alignment between hospitals' regulatory compliance activities and broader community health improvement initiatives, the IRS could play a meaningful role in efforts to reorient our system towards promoting health and not simply treating illness.

Additional requirements for charitable hospitals; community health needs assessments for charitable hospitals; requirement of a section 4959 excise tax return and time for filing the return. Final regulations and removal of temporary regulations

This document contains final regulations that provide guidance regarding the requirements for charitable hospital organizations added by the Patient Protection and Affordable Care Act of 2010. The regulations will affect charitable hospital organizations

Examining the links between therapeutic jurisprudence and mental health court completion

Research demonstrates that mental health courts (MHCs) lead to improved outcomes compared to traditional criminal court processes. An underlying premise of MHCs is therapeutic jurisprudence (TJ). However, no research, to our knowledge, has examined whether MHC outcomes are predicted by TJ principles as theorized. In the present study, we examined whether principles measured at the onset of MHC enrollment (knowledge, perceived voluntariness, and procedural justice) predicted MHC completion (graduation). Using structural equation modeling with MHC participants from four courts, a significant, direct relationship between TJ and MHC completion was found, such that higher levels of TJ were associated with higher rates of success. Although this direct effect became nonsignificant when mediator variables were included, a significant indirect path remained, such that increased levels of initial perceived voluntariness and procedural justice, and MHC knowledge, led to decreased rates of new arrests, prison, MHC bench warrants, and increased court compliance, which, in turn, led to a higher likelihood of MHC graduation.

Department of Veterans Affairs. Technical revisions to update reference to the required assessment tool for state nursing homes receiving per diem payments from VA. Final rule

This rule updates the reference to the required resident assessment tool for State homes that receive per diem from VA for providing nursing home care to veterans. It requires State nursing homes receiving per diem from VA to use the most recent version of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument/Minimum Data Set (MDS), which is version 3.0. This will ensure that the standard used to assess veterans is the same as the standard applicable to Medicare and Medicaid beneficiaries.

[Development of targeted indicators of quality in postmortem examination]

The indicators of quality for impartial quantitative assessment of postmortem examination have been suggested. These indicators were based on ratio of achievement and target indexes of pathologicoanatomic activity. The indicators are necessary for decision making for enhancement of pathologicoanatomic service quality in the health-care agencies.

Findings from a national needs assessment of American Indian/Alaska native child welfare programs

The National Child Welfare Resource Center for Tribes, a member of the Children's Bureau Child Welfare Training and Technical Assistance Network, conducted a national needs assessment of tribal child welfare. This assessment explored current practices in tribal child welfare to identify unique systemic strengths and challenges. A culturally based, multi-method design yielded findings in five areas: tribal child welfare practice, foster care and adoption, the Indian Child Welfare Act, legal and judicial, and program operations.

Needs, rights, and the human family: the practicality of the Convention on the Rights of the Child

The United Nations Convention on the Rights of the Child (CRC) is an important document that has both policy and practice implications. Its practicality as a working document hinges on its implementation. This article proposes that the CRC be viewed from a child rights perspective that has five building blocks. These building blocks relate to specific articles in the CRC. They also each allow for the CRC to be realistically interpreted and to be actively promoted.

The mental and physical health difficulties of children held within a British immigration detention center: a pilot study

OBJECTIVE

The present study aimed to assess the mental and physical health of children held within a British immigration detention center.

METHOD

A total of 24 detained children (aged 3 months to 17 years) were assessed with their parents or carer after being referred by a registered legal charity. Thirteen were seen by a pediatrician alone, 4 by a psychologist alone, and 7 by both professions using semi-structured clinical interviews. The psychologist also used standardized self-report questionnaires to measure psychopathology.

RESULTS

During the psychological assessment of 11 children, 8 met criteria for psychiatric "caseness" on the Strengths and Difficulties Questionnaire. All 11 reported symptoms of depression and anxiety. Sleep problems, somatic complaints, poor appetite, emotional symptoms, and behavioral difficulties were common. Symptoms of global distress were also reported by all 9 parents. According to pediatric assessment 8 out of 20 children had lost weight. Six had missed health appointments and 2 were taken to hospital. Nutritional, developmental, educational, and child protection concerns were raised.

CONCLUSIONS

Detained children were found to be experiencing mental and physical health difficulties of recent onset, which appeared to be related to the detention experience. These findings support previous Australian studies demonstrating that detention is not in the best interest of the child. It suggests that current UK policies regarding the detention of children for purposes of immigration control should be re-examined. Further research in the area is required.

PRACTICE IMPLICATIONS

Although high levels of mental and physical health problems, as well as child protection concerns were detected, detained families had very limited access to appropriate assessment, support or treatment. The traumatic experience of detention itself also has implications for the sizeable proportion of psychologically distressed children who are eventually released from detention and expected to successfully reintegrate into British society; while those children who are deported are returned with increased vulnerability to future stressors.

The development of certificate of need legislation

This article examines the development of Certificate of Need (CON) legislation in the United States. Over time, CON legislation developed into efforts to contain rising health care costs, while maintaining quality of care. In recent years, numerous states have begun to reevaluate the current impact of CON regulations, and ask whether the programs should be discontinued. State regulators as well as academic researchers must address the costs vs. benefits of such legislation. Specific measures within such regulations must be addressed in order for health policy makers, administrators, and researchers to help meet the escalating demand for health services.

Preventive home visits to older people in Denmark--why, how, by whom, and when?

In Denmark, political decisions improved the implementation of 'preventative thinking' into every-day clinical work. The potential benefits of preventive efforts have been supported by legislative and administrative incentives, and an ongoing effort to remain focused on the benefits of these initiatives towards older people is politically formulated and underlined as part of the new structured municipality reform. Evidence of beneficial effects of health promotion and prevention of disease in old age is well documented. In-home visits with individualised assessments make it possible to reach older persons not normally seen in the health care system. In-home assessment is not just a health check, but also an opportunity to meet individual needs that may be of importance for older people to stay independent. Preventive home visits may be part of an overall culture and strategy to avoid or prevent functional decline. There is an urgent need of an interdisciplinary teamwork and management for such programmes, incorporating flexible cooperation between the primary and secondary health care sector. The value and importance of geriatric and gerontological education is evidence based.

[Diagnostic judgement and evaluation]

The present article provides an overview of principles and standards for diagnostic decisions and evaluation. Assessment aims to answer concrete questions. Clinical and statistical judgements represent two strategies for the integration of diagnostic information. It is illustrated that the hit-rate is closely linked to validity, base-rate, and selection-rate. Depending on the psychological question it might be necessary to either detect many "appropriate" or reject many "inappropriate" persons (sensitivity-specificity). In the case of multiple criteria three strategies are available, for which adequate practical applications are proposed. As far as the assessment process is concerned, recommendations are available for hypothesis-guided data collection and integration. As a special assessment problem simulation/aggravation is discussed. A listing of quality aspects shows how to identify good evaluations. Finally, procedures to maintain a high quality are recommended.

[Rehabilitation need in sociomedical assessment--development and evaluation of an algorithm of decision-making]

For sociomedical assessment on application for medical rehabilitation by the German Statutory Pension Insurance no valid diagnostic assessment tools exist. In the present study two expert surveys and current guidelines were used to develop an algorithm of decision-making which is based on 13 criteria for rehabilitation need. The algorithm was evaluated in a prospective, longitudinal survey in the sociomedical services of five Bavarian Statutory Pension Insurance agencies on a sample of applicants with primary musculoskeletal disease (n=243). The medical experts rated the criteria after they had made their decision on the applications. To examine validity of the algorithm, concordance with the medical expert decisions and individual need for rehabilitation was analyzed. Respectively results of the algorithm were compared with data in course of the measure (rating by the clinician, patient questionnaire). Analyzing data, there is evidence for problems in rating the criteria by assessment on medical records; on average 9.2 (s=2.4) of 13 criteria could be rated. There is statistically significant concordance between decisions by the algorithm and sociomedical decisions based on assessment of medical records (kappa=0.37, p<0.001) or examination (kappa=0.71, p<0.001). Applications with positive recommendation by the algorithm have a significantly higher degree of subjective rehabilitation need (d=0.38). The results illustrate the need for measures to improve the basis of information by medical records. By reason of heterogeneity in practical application of criteria for rehabilitation need, operationalisation and explicit diagnostic algorithms are necessary to improve objectivity of making decisions.

Bedarf an rehabilitativen Leistungen: Zur Theorie von Bedarfsermittlungen („needs assessment”)

Several projects of the North German Association for Rehabilitation Research had focused on needs assessment in the field of medical rehabilitation to be provided by statutory pension funds. Their results prompted a more differentiated understanding of the concepts of rehabilitation-neediness, -ability and -prognosis and lead to the development of the "Lübecker algorithm". It is based on (a) assessing the present health disorder and its consequences in terms of activity limitations and participation restrictions, (b) defining rehabilitation goals, and (c) selecting a rehabilitative intervention. The three components form the corners of a triangle. Its connecting sides can be described in terms of norms and expectations (disorder-goals), theoretical considerations (disorder-intervention), and empirical evidence from systematic research (intervention-goals). Needs assessment can thus be--partly--objectified, and "need" can be safely distinguished from related concepts such as "burden of illness", "wish", "demand", "supply", and "provision".

Selbstausfüllbogen zur Unterstützung der Begutachtung von Rehabedarf: Probleme und Lösungen

Rehabilitation in Germany is an important sector of the medical system. Rehabilitation need of insurees who claim rehabilitation benefits is assessed by the financially responsible agency (mostly pension funds). Legal regulations allow little time for this decision so insurers aim at making decisions from the records only. Information on the specific case often is however insufficient. Self-administered questionnaires have been employed in the past to remedy that problem. In this article typical problems are illustrated which arise when administering additional questionnaires to assist the assessment, and solutions for these problems are shown. Important questions concern the instruments that should be used, technical problems of computer-aided assessment and processing of the data, and possible legal objections. Also, general problems and limitations of the approach are discussed.

Legal aspects of continence

This article considers the law which applies to the supply of incontinence equipment. It considers the liability of the employee and the primary care trust and possible defences to an action for negligence and the right to acquire records relating to an incident which has arisen. It also looks at the health and safety laws which apply to the provision of safe equipment, and considers the patient's right to access health services and the issues which arise when resources are limited.

"Medical necessity" determinations--a continuing healthcare policy problem

To promote an understanding of the implications of current structures and processes for medical necessity determinations that affect everyone, directly or indirectly, the American Health Lawyers Association will devote its biannual Public Interest Colloquium (to be held in February 2005) to the topic. In preparation for the colloquium, the author summarizes the history and current importance of the topic, identifies stakeholders in the system and their interests, and sets forth a preliminary list of issues to be considered by the colloquium participants, focusing on potential elements of an ideal system for making medical necessity determinations.

Finance issue brief: medical necessity: year end report-2003

The information in this issue brief is based on a 50--state survey and a recent literature review. The Health Policy Tracking Service recognizes the complexity of this issue and discourages the use of this document as a sole resource on the issue.

Funktionale Kompetenz und Pflegebedürftigkeit nach SGB XI bei Hundertjährigen

The maintenance of autonomy and independence in the oldest old population is at high risk due to the inevitable aging process, which primarily affects functional and cognitive capacities. In this study, we investigate centenarians to assess the extent in which they have lost their ability to live independently. This is done with a classification system for dependency that considers both functional and cognitive limitations and determines the level of functional competence in this population. Based on this system, we evaluate the necessity for nursing care and investigate to which extent their actual needs are covered by the German Long-term Care Insurance. An important and relevant question is whether this system even addresses the evaluation of cognitive impairment. For this reason, 85 centenarians and their proxies were assessed with standardized instruments and the results show a severe loss of independence. The necessity for at least daily contact with nursing care was identified in 91 percent of the centenarians due to their dramatically limited capacities. Forty-four percent of the centenarians need more support than they actually receive from the German Long-term Care Insurance. Therefore, considering cognitive impairment is a crucial component in the evaluation, which would lead to more support by the official system in 20 percent of the centenarians. The considerable differences between the granted and the necessary nursing care demonstrate that co-operation from family members must be heavily relied upon.