TITLE: Outcomes from a procedural abortion training program for providers in underserved areas: findings from a four-year evaluation. BACKGROUND: In 2019, the Clinical Abortion Training Centers (CATC) program was initiated in collaboration with the National Abortion Federation to address gaps in abortion training for a diverse array of clinicians, not limited to ob-gyn specialists. The program aimed to increase the number of clinicians providing procedural abortion care, especially in underserved areas. Five abortion clinics, including independent and Planned Parenthood affiliates, trained physicians. The training was tailored to individual goals around proficiency with specific gestational ages. We aimed to evaluate whether trainees in this program provided abortion after training. METHODS: An evaluation team assessed the program’s impact on the ability of physicians to provide abortion care, particularly to later gestational ages, over a period of four years from 2020 to 2024. Data sources included application data, semi-structured interviews, and surveys. The study followed trainees annually up to four times post-training to evaluate their job trajectories and abortion care provision. RESULTS: Sixty-nine physician trainees completed the program, with 44 completing at least two surveys. Post-training, 57% of trainees who completed at least two surveys were providing abortion care regularly, with increased proficiency over time. Trainees expanded access by working in underserved areas, increasing clinic hours, and raising gestational age limits for procedures. However, some trainees faced barriers such as institutional policies and state restrictions, and some needed or wanted additional training to provide independently. CONCLUSIONS: The CATC program demonstrated potential for expanding abortion access but highlighted the need for additional training to ensure independent provision, especially for higher gestational ages. Despite challenges, the program contributed to comprehensive reproductive health care by enhancing procedural skills and advocacy. The study’s limitations include potential selection bias, small sample size, and external influences like the COVID-19 pandemic and the Dobbs decision.

This study presents an evaluation of the University of Minnesota's BOLD Public Health Center of Excellence on Dementia Caregiving, which supports public health agencies in implementing dementia caregiving initiatives. The evaluation covers the Center's activities from 2021 to 2025, focusing on resources provided, usage by public health agencies, partnerships, equitable access, and agency capacity improvements.

The patchwork of laws and regulations that affect abortion access in the United States has become increasingly complex since the 2022 Dobbs v. Jackson Women's Health Organization U.S. Supreme Court decision that gave states the right to enact and enforce policies facilitating or restricting abortion access. The authors examined state, local, and institutional policies in Virginia-which is one of the only remaining states in the South post-Dobbs with legal access to abortion care past 13 weeks gestational age-to better understand how the policy landscape is influencing provision of care in the state. The authors reviewed existing legislation, bills, and sources detailing the policy landscape in Virginia and interviewed a sample of clinicians and nonclinicians working at organizations providing or supporting abortion care. The study principally focused on state laws, local policies and actions, institutional policies, and reported implementation experiences affecting access to abortion care.

The implementation and enforcement of state and local abortion policy can vary significantly between medical clinics and depend on the context and the individual decisionmakers involved. Research conducted prior to the U.S. Supreme Court decision in Dobbs v. Jackson Women's Health Organization showed that, when providers are unclear about potentially conflicting or changing local and state policies (formal and informal) or enforcement, many err on the side of caution and become more restrictive in their practices. However, it is unknown whether and to what extent state and local policies and practices adapted in the wake of Dobbs have influenced providers' practices. The authors conducted an initial study of laws and policies post-Dobbs in one state, North Carolina, to better understand the policy landscape and gather perspectives from staff in facilities or organizations that provide or support abortion care. This study served as a unique opportunity to explore laws and policies, as well as implementation experiences, given North Carolina's Senate Bill 20, which instituted a gestational limit of 12 weeks and 6 days, as well as other provisions, including a 72-hour in-person consent requirement. The findings highlight the reported impacts of Senate Bill 20 on facilities, providers, and patients, as well as other local and institutional policies on abortion care access. This work highlights the importance of understanding legislation and its underlying provisions to ensure a complete picture of implementation factors and potential impacts.

GOAL:This article explores how broad, contextual factors may be influential in the retention of direct care workers (DCWs; i.e., entry-level caregivers) who provide vital support to patients in healthcare settings. We reflect on lessons learned from an evaluation of a multisite intervention to improve retention among DCWs employed primarily in hospital settings at three health systems. METHODS:We evaluated a multitiered program for entry-level caregivers that included a risk assessment, a 4-day curriculum, and follow-up sessions, as well as workforce coaching at the three health systems. As part of our evaluation, we collected data on roughly 3,000 DCWs from the three health systems; the information included hiring date, any transfer date, and any termination date for each new DCW, as well as demographic information, position characteristics, and termination status and reasons for any termination. In addition, we collected information about organizational characteristics, including staffing and number of employees. We also conducted interviews with 56 DCWs and 21 staff members who implemented a retention program across each of the three health systems and remotely conducted virtual observations of the curriculum sessions at each system. PRINCIPAL FINDINGS:Although the program we evaluated focused on individual-level factors that may affect retention, our findings revealed other broader, contextual challenges faced by DCWs that they said would have an impact on their willingness to stay in their positions. These challenges included (1) job-related factors including limited compensation, aspects of the job itself, and the inability to advance in one's position; (2) health system challenges including the mission, policies, staffing, and organizational culture; and (3) external factors including federal policies and the ongoing COVID-19 pandemic. PRACTICAL APPLICATIONS:As the direct care workforce continues to grow, interventions to improve retention should consider the interconnectedness of these multilevel factors rather than solely individual-level factors. In addition, further research is needed to rigorously evaluate any potential intervention and consider how such an approach can target DCWs in hospital-based settings who are most affected by the multilevel challenges identified. Finally, any intervention to improve retention must be also aligned to ensure equity, especially in this population of low-wage DCWs, many of whom are marginalized women and individuals of color.

Importance The Million Hearts Model paid health care organizations to assess and reduce cardiovascular disease (CVD) risk. Model effects on long-term outcomes are unknown. Objective To estimate model effects on first-time myocardial infarctions (MIs) and strokes and Medicare spending over a period up to 5 years. Design, Setting, and Participants This pragmatic cluster-randomized trial ran from 2017 to 2021, with organizations assigned to a model intervention group or standard care control group. Randomized organizations included 516 US-based primary care and specialty practices, health centers, and hospital-based outpatient clinics participating voluntarily. Of these organizations, 342 entered patients into the study population, which included Medicare fee-for-service beneficiaries aged 40 to 79 years with no previous MI or stroke and with high or medium CVD risk (a 10-year predicted probability of MI or stroke [ie, CVD risk score] ≥15%) in 2017-2018. Intervention Organizations agreed to perform guideline-concordant care, including routine CVD risk assessment and cardiovascular care management for high-risk patients. The Centers for Medicare & Medicaid Services paid organizations to calculate CVD risk scores for Medicare fee-for-service beneficiaries. CMS further rewarded organizations for reducing risk among high-risk beneficiaries (CVD risk score ≥30%). Main Outcomes and Measures Outcomes included first-time CVD events (MIs, strokes, and transient ischemic attacks) identified in Medicare claims, combined first-time CVD events from claims and CVD deaths (coronary heart disease or cerebrovascular disease deaths) identified using the National Death Index, and Medicare Parts A and B spending for CVD events and overall. Outcomes were measured through 2021. Results High- and medium-risk model intervention beneficiaries (n = 130 578) and standard care control beneficiaries (n = 88 286) were similar in age (median age, 72-73 y), sex (58%-59% men), race (7%-8% Black), and baseline CVD risk score (median, 24%). The probability of a first-time CVD event within 5 years was 0.3 percentage points lower for intervention beneficiaries than control beneficiaries (3.3% relative effect; adjusted hazard ratio [HR], 0.97 [90% CI, 0.93-1.00]; P = .09). The 5-year probability of combined first-time CVD events and CVD deaths was 0.4 percentage points lower in the intervention group (4.2% relative effect; HR, 0.96 [90% CI, 0.93-0.99]; P = .02). Medicare spending for CVD events was similar between the groups (effect estimate, -$1.83 per beneficiary per month [90% CI, -$3.97 to -$0.30]; P = .16), as was overall Medicare spending including model payments (effect estimate, $2.11 per beneficiary per month [90% CI, -$16.66 to $20.89]; P = .85). Conclusions and Relevance The Million Hearts Model, which encouraged and paid for CVD risk assessment and reduction, reduced first-time MIs and strokes. Results support guidelines to use risk scores for CVD primary prevention. Trial Registration ClinicalTrials.gov Identifier: NCT04047147.

Victims of sexual assault and sexual harassment often experience a variety of psychological outcomes and mental health symptoms related to posttraumatic stress disorder (PTSD), depression, anxiety, substance abuse, suicidal ideation, and self-harm. Sexual trauma also might affect careers. Despite a need to address these harms, some service members have reported that connecting to health care or mental health services following sexual assault or sexual harassment can be difficult-in part because of a lack of leadership support. Given these persistent challenges, the Psychological Health Center of Excellence identified an urgent need to better understand research that is pertinent to sexual assault and sexual harassment during military service so that the U.S. Department of Defense and the military services can improve the health care response for service members. RAND researchers investigated and synthesized relevant research in three topic areas: (1) the effectiveness of psychotherapy treatments designed for adult victims of sexual assault or sexual harassment in military settings; (2) barriers faced by U.S. military members to accessing and remaining in mental health care settings; and (3) associations between sexual assault or sexual harassment and mental health conditions.

The U.S. direct care workforce employs nearly 4.6 million people and represents one of the fastest growing occupations in the United States. Direct care workers, or "caregivers," include nursing assistants, home care workers, and residential care aides, all of whom provide basic care to older adults and individuals with disabilities in various health care settings. Despite a growing need for caregivers, supply has not kept up with demand due to high turnover and low wages. In addition, caregivers often face high levels of workplace stress, limited training and growth opportunities, and personal stressors. Ranging from 35 to 90 percent, depending on the health care setting, the turnover rates of direct care workers pose a major challenge for health systems, as well as care recipients and workers themselves. In 2019, the Ralph C. Wilson Jr. Foundation funded three health systems to support the implementation of a new program: Transformational Healthcare Readiness through Innovative Vocational Education (THRIVE). This 12-month program was designed to help address barriers that entry-level caregivers experience and reduce turnover through a comprehensive risk assessment, training, and one-on-one coaching. Researchers from RAND conducted a process and outcome evaluation to determine whether THRIVE was meeting its goals of improving retention and achieving a positive return on investment (ROI). They also examined potential areas for program improvement.

Qualitative methods that capture individual lived experiences throughout rapidly changing circumstances are particularly important during public health emergencies. The COVID-19 pandemic has put home care workers at risk as they provide vital services in homes to individuals with chronic conditions or disabilities. Using a 6-week journaling process in which we enrolled participants at different points, we sought to examine experiences of home care workers ( n = 47) in the United States in New York and Michigan during April–July 2020 of the COVID-19 pandemic. Our methods for data collection and analysis were guided by a general qualitative approach as we aimed to examine the weekly perspectives and lived experiences of home care workers. We asked individuals to respond to our journaling prompts weekly to capture their reflections in “real time.” To better understand home care workers’ perspectives on journaling and the broader external context in which they provided care, we triangulated our data with interviews with home care workers ( n = 19) and home health agency representatives ( n = 9). We explored the feasibility of a rolling journaling process during an unprecedented public health emergency, characterized by rapid changes and uncertainty in day-to-day life, and reflect on lessons learned to guide future research on journaling for data collection, particularly for marginalized workers during public health crises, when events are evolving rapidly.

Background Enhanced recovery after surgery (ERAS) interventions aim to improve patient outcomes. Vascular surgery patients have unique requirements and it is unclear which ERAS interventions are supported by an evidence base. MethodsWe conducted a scoping review to identify ERAS randomized controlled trials (RCTs) published in the biomedical or nursing literature. We assessed interventions for applicability to vascular surgery and differentiated interventions given at preadmission, preoperative, intraoperative, and postoperative surgery stages. We documented the research in an evidence map. ResultsWe identified 76 relevant RCTs. Interventions were mostly administered in preoperative (23 RCTs; 30%) or intraoperative surgery stages (35 RCTs; 46%). The majority of studies reported mortality outcomes (44 RCTs; 58%), but hospital (27 RCTs; 35%) and intensive care unit (9 RCTs; 12%) length of stay outcomes were less consistently described. ConclusionThe ERAS evidence base is growing but contains gaps. Research on preadmission interventions and more consistent reporting of key outcomes is needed.

Home care aides are on the frontlines providing care to vulnerable individuals in their homes during the COVID-19 pandemic yet are often excluded from policies to protect health care workers. The goal of this study was to examine experiences of agency-employed home care aides during the COVID-19 pandemic and to identify ways to mitigate concerns. We used an innovative journaling approach with thirty-seven aides as well as in-depth interviews with fifteen aides and leadership representatives from nine home health agencies in New York and Michigan. Workers described a range of concerns around workplace safety including uncertainty around whether a client had COVID-19, inadequate access to personal protective equipment and safe transportation, as well as fundamental changes to interactions with clients. Agencies also faced challenges acquiring personal protective equipment for their aides. This research points to needed resources to support home care aides and home health agencies both during a public health crisis and in the future.

CONTEXT:Despite rapid growth in outpatient palliative care, we lack an understanding of patient and caregiver experiences of care received in this context.OBJECTIVES:As part of a national effort to develop palliative care quality metrics for use in accountability programs, we sought to develop survey items assessing patients' experiences of outpatient palliative care, incorporating the patient's voice.METHODS:We conducted 25 one-hour telephone cognitive interviews using a convenience sample of outpatient palliative care patients and caregivers to cognitively test survey items. Guided by a semi-structured protocol, we assessed the comprehensibility, ambiguity, and adaptability of survey instructions and specific items/response options.RESULTS:Participants generally understood the intended meaning of the question content. Some participants struggled with the stated time period of three months as a reference period for reporting their experiences. While some expressed preferences for question wording, no clear patterns emerged across participants.CONCLUSION:In general, question wording and response options did not present challenges to understanding content. Respondents ascribed a variety of meanings to the concepts, validating that the measures capture a range of experiences. However, the referenced timeframe of three months was more difficult to answer for some questions than others. Implications for research, policy or practice: Based on the findings from the cognitive testing, the survey items are being tested as part of a national study to understand the quality of care for patients. These measures may be used in the future by Medicare to help outpatient palliative care programs improve their care.

Epilepsy prevalence is high among infants, but treatment guidelines are not clear. We conducted a scoping review of interventions to manage epilepsy in infants, and identified 37 studies. Most studies reported that interventions were effective (22 studies; 76 %), but randomized controlled trials were uncommon (7 studies; 19 %) and sample sizes were small (range: 2 to 284 participants; mean: 69.4; 95 % confidence interval: 49.5, 89.2). Additional high quality research and systematic reviews on interventions for infantile epilepsy are needed to establish better treatment guidelines for the disease.

In this Perspective, the authors provide a brief background on (1) the important role that home care workers play in the United States, particularly during the coronavirus disease 2019 pandemic; (2) how they gathered these workers' perspectives through journaling; and (3) how journaling can serve as a valuable source of support and a flexible data collection method, especially when circumstances are changing rapidly, as in a public health crisis.

•Summarize challenging constructs for patients and caregivers related to feeling heard and understood and symptom management.•Identify circumstances or constructs that may be challenging for patients to reflect on within a specified time period.•Describe the complexity of item wording to assess critical care components in the context of palliative care. There are significant gaps in symptom management and meaningful communication measures, despite the noted importance of these domains to seriously ill patients and their families. In partnership with AAHPM and the National Coalition for Hospice and Palliative Care, RAND Health is testing measurement items for a short survey about the care patients receive from their palliative care doctors, nurses, and other team members. Survey questions focus on concepts related to communication (e.g., feeling heard and understood) and symptom management (e.g., receiving help wanted for pain). The interviews were designed to assess comprehensibility, ambiguity, and adaptability to context-specific circumstances for patients and caregivers as well as gather suggestions for language refinement for both symptom and communication measure concepts. The team conducted 22 one-hour telephone cognitive interviews using a convenience sample of patients and caregivers drawn from partner networks. Participants were mailed interview materials in advance of each call. Across four different interview rounds, the team adjusted item wording and question ordering to assess the items under different conditions. Participants generally understood the intended meaning of the question content although there was ambiguity for some terms, like “whole person.” For some constructs, such as trust, participants struggled with restricting their responses to the stated three-month reference period. While there were expressed preferences for format and question wording, no clear patterns emerged across participants although some responses varied slightly depending on item wording. In general, question wording and response options did not present challenges to understanding content, but certain constructs had different interpretations depending on the respondent. Further, the context setting, such as the lookback period and referenced provider team, were more difficult to answer for some questions than others.

•Summarize challenging constructs for patients and caregivers related to feeling heard and understood and symptom management.•Identify circumstances or constructs that may be challenging for patients to reflect on within a specified time period.•Describe the complexity of item wording to assess critical care components in the context of palliative care. In partnership with AAHPM and the National Coalition for Hospice and Palliative Care, RAND Health is testing measurement items for a short survey about the care patients receive from their palliative care doctors, nurses, and other team members. Survey questions focus on concepts related to communication (e.g., feeling heard and understood) and symptom management (e.g., receiving help wanted for pain). The interviews were designed to assess comprehensibility, ambiguity, and adaptability to context-specific circumstances for patients and caregivers as well as gather suggestions for language refinement for both symptom and communication measure concepts. The team conducted 22 one-hour telephone cognitive interviews using a convenience sample of patients and caregivers drawn from partner networks. Participants were mailed interview materials in advance of each call. Across four different interview rounds, the team adjusted item wording and question ordering to assess the items under different conditions. Participants generally understood the intended meaning of the question content although there was ambiguity for some terms, like “whole person.” For some constructs, such as trust, participants struggled with restricting their responses to the stated three-month reference period. While there were expressed preferences for format and question wording, no clear patterns emerged across participants although some responses varied slightly depending on item wording. In general, question wording and response options did not present challenges to understanding content, but certain constructs had different interpretations depending on the respondent. Further, the context setting, such as the lookback period and referenced provider team, were more difficult to answer for some questions than others.

Context: Community education and engagement are important for informing family planning projects. The objective of this study was to update two prior systematic reviews assessing the impact of community education and engagement interventions on family planning outcomes. Evidence acquisition: Sixteen electronic databases were searched for studies relevant to a priori determined inclusion/exclusion criteria in high development settings, published from March 2011 through April 2016, updating two reviews that included studies from 1985 through February 2011. Evidence synthesis: Nine relevant studies were included in this updated review related to community education, in addition to 17 from the prior review. No new community engagement studies met inclusion criteria, as occurred in the prior review. Of new studies, community education modalities included mass media, print/mail, web-based, text messaging, and interpersonal interventions. One study on mass media intervention demonstrated a positive impact on reducing teen and unintended pregnancies. Three of four studies on interpersonal interventions demonstrated positive impacts on medium-term family planning outcomes, such as contraception and condom use. Three new studies demonstrated mostly positive, but inconsistent, results on short-term family planning outcomes. Conclusions: Findings from this systematic review update are in line with a previous review showing the positive impact of community education using traditional modalities on short-term family planning outcomes, identifying additional impacts on long-term outcomes, and highlighting new evidence for education using modern modalities, such as text messaging and web-based education. More research is necessary to provide a stronger evidence base for directing community education and engagement efforts in family planning contexts. Theme information: This article is part of a theme issue entitled Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Providing Quality Family Planning Services, which is sponsored by the Office of Population Affairs, U.S. Department of Health and Human Services. Am I Prey Med 2018;55(5):747-758. (C) 2018 Published by Elsevier Inc.

Context: The purpose of this paper is to synthesize and evaluate the evidence on the effectiveness of repeat teen pregnancy prevention programs offered in clinical settings. Evidence acquisition: Multiple databases were searched for peer-reviewed articles published from January 1985 to April 2016 that included key terms related to adolescent reproductive health services. Analysis of these studies occurred in 2017. Studies were excluded if they focused solely on sexually transmitted disease/HIV prevention services, or occurred outside of a clinic setting or the U.S., Canada, Europe, Australia, or New Zealand. Inclusion and exclusion criteria further narrowed the studies to those that included information on at least one short-term (e.g., increased knowledge); medium-term (e.g., increased contraceptive use); or long-term (e.g., decreased repeat teen pregnancy) outcome, or identified contextual barriers or facilitators for providing adolescent focused family planning services. Standardized abstraction methods and tools were used to synthesize the evidence and assess its quality. Only studies of clinic-based programs focused on repeat teen pregnancy prevention were included in this review. Evidence synthesis: The search strategy identified 27,104 citations, 940 underwent full-text review, and 120 met the adolescent-focused family planning services inclusion criteria. Only five papers described clinic-based programs focused on repeat teen pregnancy prevention. Four studies found positive (n=2) or null (n=2) effects on repeat teen pregnancy prevention; an additional study described facilitators for helping teen mothers remain linked to services. Conclusions: This review identified clinic-based repeat teen pregnancy prevention programs and few positively affect factors that may reduce repeat teen pregnancy. Access to immediate postpartum contraception or home visiting programs may be opportunities to meet adolescents where they are and reduce repeat teen pregnancy. (C) 2018 Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine.