Post-acute care for children with special health care needs

Background

Almost all studies of post-acute care (PAC) focus on older persons, frequently those suffering from chronic health problems. Some research is available on PAC for the pediatric population in general. However, very few studies focus on PAC services for children with special health care needs (SHCN).

Suppression of racial disparities for children with special health care needs among families receiving Medicaid

This study examines whether the US public health insurance program Medicaid suppresses racial disparities in parental identification of service needs of their children with special health care needs (CSHCN). We analyze data from the 2001 US National Survey of CSHCN (n = 14,167 children). We examine three outcomes which were parental identification of (a) the child's need for professional care coordination, (b) the child's need for mental health services, and (c) the family's need for mental health services. A suppression analysis, which is a form of mediation analysis, was conducted. Our results show a disparity, reflected in a negative direct effect of race for all three outcomes: Black parents of CSHCN are less likely to report a need for services than White parents of CSHCN and Medicaid coverage was associated with reduced racial disparities in reporting the need for services. These analyses suggest receipt of Medicaid is associated with a suppression of racial disparities in reported need for services.     

Modeling the determinants of Medicaid home care payments for children with special health care needs: A structural equation model approach

BackgroundThe management of children with special needs can be very challenging and expensive.ObjectiveTo examine direct and indirect cost drivers of home care expenditures for this vulnerable and expensive population.MethodsWe retrospectively assessed secondary data on children, ages 4–20, receiving Medicaid Personal Care Services (PCS) (n = 2760). A structural equation model assessed direct and indirect effects of several child characteristics, clinical conditions and functional measures on Medicaid home care payments.ResultsThe mean age of children was 12.1 years and approximately 60% were female. Almost half of all subjects reported mild, moderate or severe ID diagnosis. The mean ADL score was 5.27 and about 60% of subjects received some type of rehabilitation services. Caseworkers authorized an average of 25.5 h of PCS support per week. The SEM revealed three groups of costs drivers: indirect, direct and direct + indirect. Cognitive problems, health impairments, and age affect expenditures, but they operate completely through other variables. Other elements accumulate effects (externalizing behaviors, PCS hours, and rehabilitation) and send them on a single path to the dependent variable. A few elements exhibit a relatively complex position in the model by having both significant direct and indirect effects on home care expenditures – medical conditions, intellectual disability, region, and ADL function.ConclusionsThe most important drivers of home care expenditures are variables that have both meaningful direct and indirect effects. The only one of these factors that may be within the sphere of policy change is the difference among costs in different regions.     

Employment change and the role of the medical home for married and single-mother families with children with special health care needs

One in five U.S. households with children has at least one child with a special health care need (USDHHS, 2004). Like most parents, those with children with special health care needs struggle to balance child-rearing responsibilities with employment demands. This research examines factors affecting married parents' and single-mother's employment change decisions focusing specifically on whether having a medical home influences these decisions. This study includes 38,569 children with special health care needs from birth through age 17 surveyed in the 2005–2006 National Survey of Children with Special Health Care Needs. The employment model is estimated using multinomial logistic regression with the choice of a parent to maintain their current level of employment, reduce work hours, or stop working as the dependent variable. Independent variables are those characterizing the needs of the child, the resources of the family, and the socio-demographic characteristics of the family. Components of the medical home variable include: 1) having a usual source of care; 2) care provided is “family centered”; 3) receipt of care coordination services; and 4) receipt of needed referrals. Half of the children in our sample met criteria in all four facets. If the child has a medical home, the relative risk of a parent choosing to cut hours rather than not change hours decreases by 51%. The relative risk of choosing to stop working rather than not change hours decreases by an estimated 64%. Care coordination services significantly reduce the odds of changing employment status. Our results suggest that the medical home is a moderating factor in parental decisions concerning change in employment status.     

An exploratory multilevel analysis of income,income inequality and self-rated health of the elderly in China

In the last three decades, China has experienced rapid economic development and growing economic inequality, such that economic disparities between rural and urban areas, as well as coastal and interior areas have deepened. Since the late 1990s China has also experienced an ageing population which has attracted attention to the wellbeing of the rapidly growing number of elderly. This research aims to characterise province differences in health and to explore the effects of individual income and economic disparity in the form of income inequality on health outcomes of the elderly. The study is based on the Chinese Longitudinal Healthy Longevity Survey data collected in 2008 for 23 provinces. Multilevel logistic models are employed to investigate the relationship between income, income inequality and self-rated health for the elderly using both individual and province-level variables. Results are presented as relative odds ratios, and for province differentials as Median Odds Ratios. The analysis is deliberately exploratory so as to find evidence of income effects if they exist and particular attention is placed on how province-level inequality (contemporaneous and lagged) may moderate individual relationships. The results show that the health of the elderly is not only affected by individual income (the odds of poor health are 3 times greater for the elderly with the lowest income compared to those at the upper quartile) but also by a small main effect for province-level income inequality (odds ratio of 1.019). There are significant cross-level interactions such that where inequality is high there are greater differences between those with and without formal education, and between men and women with the latter experiencing poorer health.     

Prevalence of physical activity,screen time,and obesity among US children by the service type of special health care needs

BackgroundChildren with special health care needs (SHCN) may be at greater risk of obesity than children without SHCN. A new classification system categorizes SHCN among children by service type using the following categories: No-SHCN, medication use only, services use only, medication + service use, and functional limitations. Research is needed to examine obesity and obesity-related behaviors among children using the new classification system.ObjectiveTo determine the prevalence of inadequate vigorous physical activity (VPA), high screen time and obesity by SHCN category using the new classification system.MethodsMultivariate regression models were fitted for inadequate VPA, high screen time, and obesity to determine if there were differences in these outcomes by SHCN category, adjusting for multistage-sampling and survey-design effects using a nationally representative sample of children in the National Survey of Children's Health 2007.Results22.9% of the sample was classified as having SHCN: 9% medication use only, 5% medication + service use, 4% service use only, and 5% functional limitations. Children in the medication use only and medication + service use groups were not at increased risk for inadequate VPA, high screen time, or obesity. Children in the service use only and functional limitation groups had increased odds of high screen time and obesity, which disappeared after controlling for confounders. However, the higher odds of inadequate VPA remained significant in the service use only [OR (95% CI) = 2.00 (1.34–3.00)] and the functional limitations groups with 2.21 (1.55–3.15).ConclusionsPhysical activity promotion programs are needed for children with SHCN, especially children with functional limitations and those who require service use only and do not use prescribed medication.     

Protecting the health of employees caring for family members with special health care needs

Over half of American workers are holding a paid job while also providing unpaid assistance and support to a family member. Research shows that family members who provide care to children or adults with special health care needs are themselves at risk of physical and mental health problems. Yet, little research has explored how the work environment mediates the effects of caregiving on caregivers' mental and physical health. With a sample of 2455 currently employed U.S. adults from the Work, Family, Community Nexus (WFCN) survey, a random-digit dial, nationally representative survey of Americans aged 18-69, we examine whether paid leave and flexibility policies mediate the relationship between caregiving and health. In Ordinary Least Squares regression models, we find that paid leave to address family members' health was associated with better mental health status as measured by the 5-item Mental Health Inventory and paid sick leave with better physical health status as measured by self-rated overall health status. A supportive supervisor was also associated with improvements in mental and physical health. For both men and women, paid leave and a supervisor's support offset some or all of the negative effects of caregiving, but for women, the buffering effects of working conditions are slightly larger. Enhancing the unpaid leave guaranteed in the U.S. Family and Medical Leave Act so that it is paid and passing national paid sick days legislation will help ensure that employed caregivers can retain their jobs, receive needed income, and meet their own mental and physical health needs.     

Racial/ethnic health disparities among children with special health care needs in Boston,Massachusetts

BackgroundLittle is known about the factors that contribute to racial/ethnic disparities among children with special health care needs (CSHCN).ObjectiveTo quantify the contributions of determinants of racial/ethnic disparities in health and health care among CSHCN in Boston, Massachusetts.MethodsA sample of 326 Black, Latino, and white CSHCN was drawn from the Boston Survey of Children's Health, a city-wide representative sample of children. The study implemented Oaxaca–Blinder-style decomposition techniques to examine the relative contributions of health resources and child-, family-, and neighborhood-level factors to disparities in four outcomes: health status, barriers to medical care, oral health status, and utilization of preventive dental care.ResultsWhite CSHCN had a greater likelihood of having very good/excellent health and oral health and were less likely to experience barriers to care than Black CSHCN. Compositional differences on predictors explained 63%, 98%, and 80% of these gradients, respectively. Group variation in household income, family structure, neighborhood support, and exposure to adverse childhood experiences accounted for significant portions of the Black–white gaps in health and access. White CSHCN were also more likely to have very good/excellent health and oral health compared to Latino CSHCN. Differences on predictors accounted for about 86% and 80% of these gaps, respectively. Household income, adverse childhood experiences, and household language emerged as significant determinants of Latino–white disparities.ConclusionsRacial/ethnic health disparities among CSHCN are explained by relatively few determinants. Several of the contributing factors that emerged from the analysis and could be targeted by public health and policy interventions.     

How families of children with complex care needs participate in everyday life

While we have some understanding of the impact caring for children with complex care needs has on families, little is known about how these families experience participation. This longitudinal qualitative study aimed to extend our limited understanding of how the changing geographies of care influence the ways that Canadian families with children with complex care needs participate in everyday life. The findings in this article focus on parents' conceptualizations of participation including their perspectives of participation involving themselves, their children, and their family unit. Sixty-eight parents from 40 families took part in the study. Conradson's (2005) conceptualization of therapeutic landscapes that focuses on the relational dimensions of the self-landscape encounter guided the study. Data collection methods included ethnographic methods of interviewing and photovoice. As a summary of their views, parents within this study described participation as a dynamic and reciprocal social process of involvement in being with others. For participation in everyday life to be meaningful, the attributes of choice, safety, acceptance, accessibility, and accommodation had to be present. Participation was valued by parents because it resulted in positive outcomes. Overall, meaningful participation contributed to them and their children having a life. Having a life referred to being involved in a place where families feel that they belong, are accepted, and are able to contribute to the landscape they participate in. The decision to choose to participate became contingent upon the availability of resources and the parents' ability to harness them. Harnessing resources referred to the work parents must do to get the necessary resources to make it possible for them and their children to have a life. Having a life for parents required significant physical, mental, psychological and spiritual work by parents. At times the personal resources of parents were so taxed that the possibility for meaningful participation was something less than what they desired. The families' stories raise questions of societal obligations to promote meaningful participation. This study lends support for further improvements that may enrich the lives of families with children with complex care needs.     

Medicaid managed care and the unmet need for mental health care among children with special health care needs

OBJECTIVE: To determine the association between Medicaid managed care pediatric behavioral health programs and unmet need for mental health care among children with special health care needs (CSHCN). DATA SOURCE: The National Survey of CSHCN (2000-2002), using subsets of 4,400 CSHCN with Medicaid and 1,856 CSHCN with Medicaid and emotional problems. Additional state-level sources were used. STUDY DESIGN: Multilevel models investigated the association between managed care program type (carve-out, integrated) or fee-for-service (FFS) and reported unmet mental health care need. DATA COLLECTION/EXTRACTION METHODS: The National Survey of CSHCN conducted telephone interviews with a sample representative at both the national and state levels. PRINCIPAL FINDINGS: In multivariable models, among CSHCN with only Medicaid, living in states with Medicaid managed care (odds ratio [OR]=1.81; 95 percent confidence interval: 1.04-3.15) or carve-out programs (OR=1.93; 1.01-3.69) were associated with greater reported unmet mental health care need compared with FFS programs. Among CSHCN on Medicaid with emotional problems, the association between managed care and unmet need was stronger (OR=2.48; 1.38-4.45). CONCLUSIONS: State Medicaid pediatric behavioral health managed care programs were associated with greater reported unmet mental health care need than FFS programs among CSHCN insured by Medicaid, particularly for those with emotional problems.     

Forces for reforming the U.S. health care system: a review of the cost and access issues.

In recent years, a spate of health care reform proposals have emerged on the American agenda. Although the elements of the reform proposals often vary substantially, most of the initiatives are fuelled by two common concerns: rising health care expenditures and a growing uninsured population. National health spending, for example, commands an increasing share of U.S. gross national product despite numerous cost-containment efforts initiated by public and private payers throughout the 1980s. And the uninsured population continues to grow--by an estimated 30 percent between 1978 and 1989. To facilitate understanding of the public policy options being considered to address these concerns, the article examines U.S. health care expenditure data and some of the causes of rising health care costs. The article also discusses the demographic characteristics of the uninsured population, the reasons why they lack health coverage, and the health consequences associated with being uninsured.     

The health care access and utilization of homeschooled children in the United States

Although the population of homeschooled children in the United States is large and growing, little is known about their access to and utilization of preventive health care services. This paper compares the health care access and utilization of homeschooled children and public school children in the United States using data from the nationally-representative 2007 National Survey of Children's Health. Using logistic regression models, this study finds that homeschooled children were significantly less likely than public school children to have access to a medical home, to visit a health care professional annually, and to receive the Human Papillomavirus vaccine. They were not statistically less likely to have health insurance, to receive annual dental care, or to receive Tetanus or Meningitis vaccinations. This research suggests that public health practitioners, medical providers, researchers, and educators should be attentive to the health care needs of homeschooled children.     

The embodied spaces of children with complex care needs: Effects on the social realities and power negotiations of families

This paper presents research findings that advance knowledge around the power and agency families with children with complex care needs (CCN). Our conceptual framework uses concepts from geography towards situating the experiences and social realities of family carers within the ‘embodied space of care’. The data originate from a longitudinal qualitative study of Canadian families with children with CCN. Findings reveal that interactions and decision-making processes relating to health and everyday life were complex and socially interconnected, and emphasize the need for provisions for family-based decision-making and enhanced social inclusion of families and the importance of the renegotiation of power.     

Early origins of health disparities: Burden of infection,health, and socioeconomic status in U.S. children

Recent work in biodemography has suggested that lifetime exposure to infection and inflammation may be an important determinant of later-life morbidity and mortality. Early exposure to infections during critical periods can predispose individuals to chronic disease, in part through the reallocation of energy away from development needed for immune and inflammatory responses. Furthermore, markers of inflammation are known to vary by socioeconomic status in adults and may contribute to overall socioeconomic health inequalities, but little is known about how the sources of this inflammation differ over the life course. This paper uses novel biomarker data from the Third National Health and Nutrition Examination Survey (NHANES III) to test the association of the burden of common chronic infections (Helicobacter pylori (H. pylori), cytomegalovirus (CMV), herpes simplex virus-1 (HSV-1), hepatitis A and hepatitis B) with height-for-age and asthma/chronic respiratory conditions in U.S. children ages 6 and older, and the association of these chronic infections to children's socioeconomic status. A higher burden of infection is found to be associated with lower height-for-age as well as an increased likelihood of asthma net of race/ethnicity, family income, and parental education. Children with lower family income, lower parental education, and non-white race/ethnicity have a higher likelihood of infection with several individual pathogens as well as the overall burden of infection. Differential exposure and/or susceptibility to infections may be one mechanism through which early social factors get embodied and shape later-life health outcomes.     

广州市流动人口儿童保健现况抽样调查分析

了解广州市流动人口中儿童卫生保健服务现状 ,存在的主要问题和原因 ,以加快实现流动儿童享有与户籍地儿童同等的卫生保健服务。采用《流动人口中妇女儿童享有与户籍地儿童同等卫生保健服务现状与对策研究》的调研方案。于 2 0 0 3年8～ 9月在广州市 4个区内进行分层整群随机抽样调查。结果显示 ,外来流动儿童与我市常住儿童相比较 ,其在建卡、建册和系统管理的体检方面有较大的差异。在计划免疫接种率和疾病正规医院就诊率方面较以前有了明显的提高。因此 ,为使流动儿童能够享有与户籍地儿童相同水平的卫生保健 ,医疗保健和政府部门应该采取相应的措施 ,改革现有的保健管理模式