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By 2030 more people in the United States will be older than age sixty-five than younger than age five. Our health care system is unprepared for the complexity of caring for a heterogenous population of older adults-a problem that has been magnified by the coronavirus disease 2019 (COVID-19) pandemic. Here, as part of the National Academy of Medicine's Vital Directions for Health and Health Care: Priorities for 2021 initiative, we identify six vital directions to improve the care and quality of life for all older Americans. The next administration must create an adequately prepared workforce; strengthen the role of public health; remediate disparities and inequities; develop, evaluate, and implement new approaches to care delivery; allocate resources to achieve patient-centered care and outcomes, including palliative and end-of-life care; and redesign the structure and financing of long-term services and supports. If these priorities are addressed proactively, an infrastructure can be created that promotes better health and equitable, goal-directed care that recognizes the preferences and needs of older adults.

In 2016, in anticipation of the US presidential election and forthcoming new administration, the National Academy of Medicine launched a strategic initiative to marshal expert guidance on pressing health and health care priorities. Published as Vital Directions for Health and Health Care, the products of the initiative provide trusted, nonpartisan, evidence-based analysis of critical issues in health, health care, and biomedical science. The current collection of articles published in Health Affairs builds on the initial Vital Directions series by addressing a set of issues that have a particularly compelling need for attention from the next administration: health costs and financing, early childhood and maternal health, mental health and addiction, better health and health care for older adults, and infectious disease threats. The articles also reflect the current experience with both the coronavirus disease 2019 (COVID-19) pandemic and the health inequities that have been drawn out sharply by COVID-19, as well as the implications going forward for action.

Worldwide, leaders are implementing nonpharmaceutical interventions to slow transmission of the novel coronavirus while pursuing vaccines that confer immunity to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. In this article we describe lessons learned from past pandemics and vaccine campaigns about the path to successful vaccine delivery. The historical record suggests that to have a widely immunized population, leaders must invest in evidence-based vaccine delivery strategies that generate demand, allocate and distribute vaccines, and verify coverage. To generate demand, there must be an understanding of the roots of vaccine hesitancy, involvement of trusted sources of authority in advocacy for vaccination, and commitment to longitudinal engagement with communities. To allocate vaccines, qualified organizations and expert coalitions must be allowed to determine evidence-based vaccination approaches and generate the political will to ensure the cooperation of local and national governments. To distribute vaccines, the people and organizations with expertise in manufacturing, supply chains, and last-mile distribution must be positioned to direct efforts. To verify vaccine coverage, vaccination tracking systems that are portable, interoperable, and secure must be identified. Lessons of past pandemics suggest that nations should invest in evidence-informed strategies to ensure that coronavirus disease 2019 (COVID-19) vaccines protect individuals, suppress transmission, and minimize disruption to health services and livelihoods.

As the coronavirus disease 2019 (COVID-19) pandemic surged in New York City, the city's public hospital system, New York City Health + Hospitals, recognized that innovative technological solutions were needed to respond to the crisis. Our health system recently transitioned to a unified enterprisewide electronic medical record across all of our hospitals. This accelerated our ability to implement a series of technological solutions to the crisis. We engaged in focused efforts to improve staff efficiency, including rapid medical screening exams for low-acuity patients, use of "SmartNotes," and improved vital sign monitoring. We standardized patient workup using specialty-specific order sets, created dashboards to give insight into enterprisewide bed availability and facilitate transfers from the hardest-hit hospitals, and improved the patient experience by using tablets to connect patients with loved ones. The technology bridged divides between different hospital systems across New York City to encourage the sharing of data and improve patient care. By rapidly expanding its use of information technology, NYC Health + Hospitals was able to respond to the COVID-19 surge and is now better positioned to work in a more integrated fashion in the future.

Addressing patients' social needs is key to helping them heal from coronavirus disease 2019 (COVID-19), preventing the spread of the virus, and reducing its disproportionate burden on low-income communities and communities of color. New York City Health + Hospitals is the city's single largest health care provider to Medicaid and uninsured patients. In response to the COVID-19 pandemic, NYC Health + Hospitals staff developed and executed a strategy to meet patients' intensified social needs during the COVID-19 pandemic. NYC Health + Hospitals identified food, housing, and income support as patients' most pressing needs and built programming to quickly connect patients to these resources. Although NYC Health + Hospitals was able to build on its existing foundation of strong social work support of patients, all health systems must prioritize the social needs of patients and their families to mitigate the damage of COVID-19. National and local leaders should accelerate change by developing robust policy approaches to redesign the social and economic system that reinforces structural inequity and exacerbates crises such as COVID-19.

As a result of the coronavirus disease 2019 (COVID-19) pandemic, virtually all in-person outpatient visits were canceled in many parts of the country between March and May 2020. We sought to estimate the potential impact of COVID-19 on the operating expenses and revenues of primary care practices. Using a microsimulation model incorporating national data on primary care use, staffing, expenditures, and reimbursements, including telemedicine visits, we estimated that over the course of calendar year 2020, primary care practices would be expected to lose 67,774 in gross revenue per full-time-equivalent physician (the difference between 2020 gross revenue with COVID-19 and the anticipated gross revenue if COVID-19 had not occurred). We further estimated that the cost at a national level to neutralize the revenue losses caused by COVID-19 among primary care practices would be $15.1 billion. This could more than double if COVID-19 telemedicine payment policies are not sustained.

The coronavirus disease 2019 (COVID-19) pandemic presented unprecedented challenges to the New York City Health + Hospitals system. In addition to ramping up capacity and adapting operations quickly to handle the patient surge, NYC Health + Hospitals had to find new ways to provide emotional and psychological support for patients, families, and staff. To help families keep in touch, dedicated staff members provided daily updates by telephone and used tablets for virtual visits. An expanded palliative care team held virtual consultations with families to discuss advance care planning and end-of-life decisions. Bereavement hotlines were set up for families who lost loved ones. Enhanced staff support included one-on-one and group sessions with behavioral health specialists, a behavioral health hotline, a webinar series, and respite rooms, as well as complimentary lodging and child care. NYC Health + Hospitals created new rituals to celebrate recoveries and mourn losses. As regular operations resume, NYC Health + Hospitals plans to sustain and build on emotional and psychological support initiatives developed during the surge.

Clinical care in the United States has been transformed during the coronavirus disease 2019 (COVID-19) pandemic. To support these changes, regulators and payers have temporarily modified long-standing policies, recognizing the need for a trade-off between the costs and benefits of oversight during times of crisis. Specifically, there has been a heightened receptivity to the importance of preserving physicians' and other health care professionals' time, cognitive bandwidth, and emotional reserve for the direct care of patients, instead of squandering these resources on low-value tasks and frustrating technology. Instead of reflexively reverting to past practices and policies, there is now an opportunity to take advantage of the lessons of COVID-19 for the further transformation of health care to achieve Quadruple Aim outcomes (better care for individuals, better health for the population, better experience for clinicians, and lower costs). We outline some of the policy and practice changes that we believe should endure after the crisis has passed, and we recommend using similar logic during noncrisis times to make additional changes to further reduce administrative burden, and thus improve patient care.

New York City Health + Hospitals is the largest safety-net health care delivery system in the United States. Before the coronavirus disease 2019 (COVID-19) pandemic, NYC Health + Hospitals served more than one million patients annually, including the most vulnerable New Yorkers, while billing fewer than five hundred telehealth visits monthly. Once the pandemic struck, we established a strategy to allow us to continue to serve our existing patients while treating the surge of new patients. Starting in March 2020, we were able to transform the system using virtual care platforms through which we conducted almost eighty-three thousand billable televisits in one month, as well as more than thirty thousand behavioral health encounters via telephone and video. Telehealth also enabled us to support patient-family communication, postdischarge follow-up, and palliative care for patients with COVID-19. Expanded Medicaid coverage and insurance reimbursement for telehealth played a pivotal role in this transformation. As we move to a new blend of virtual and in-person care, it is vital that the major regulatory and insurance changes undergirding our COVID-19 telehealth response be sustained to protect access for our most vulnerable patients.

Despite the increase in awareness of chronic disease, little is known about whether multimorbidity-defined as two or more coexisting chronic conditions-has had a diminished impact on health in Europe in the past decade. We used multiple cross-sectional data from the Survey of Health, Ageing and Retirement in Europe to estimate changes in the prevalence of multimorbidity and in its association with health outcomes in ten European countries between 2006-07 and 2015. We found that the prevalence of multimorbidity rose from 38.2 percent in 2006-07 to 41.5 percent in 2015. Over the ten-year study period we also found a marginal reduction of the impact of multimorbidity on primary care visits and functional capacity. We did not find a reduction of its impact on hospital admissions and quality of life. Austria, the Czech Republic, Germany, and Spain were the countries that showed the largest reduction in the impact of multimorbidity on health outcomes. Multimorbidity continues to pose challenges for European health care systems, with only marginal improvement on health care use and health outcomes since 2006-07.

Patients' journeys across the care continuum can be improved with patient-centered technology integrated into the care process. Misaligned financial incentives, change management challenges, and privacy concerns are some of the hurdles that have prevented health systems from deploying technology that engages patients along the care continuum. Despite these sociotechnical challenges, some health care organizations have developed innovative approaches to engaging patients. We describe promising technology-enabled consumer engagement practices at two community-based delivery organizations and two academic medical centers to demonstrate the approaches, sociotechnical challenges, and outcomes associated with their implementation. Leadership commitment and payer policies that align with the quadruple aim-enhancing patient experience, improving population health, reducing costs, and improving the work life of health care providers-would encourage further deployment and lead to greater consumer engagement along the care continuum.

There are numerous calls for building health care delivery systems that are more patient centered. The focus on patient-centered care has increasingly begun to rely upon, and even merge with, the concept of patients as consumers. Early references to patients as consumers were made by patient advocates who were attempting to challenge professional and corporate dominance in health care. Today, "consumer-driven" health care has become associated with neoliberal efforts to emphasize market factors in health reform and deemphasize government regulation and financing. In our view, a narrow focus on consumerism is conceptually confused and potentially harmful. The consumer metaphor wrongly assumes that health care is a market in the usual understanding of that term, that the high cost of US health care is a function of excessive consumer demand, and that price transparency and competition can deliver on the promise of reducing costs or ensuring quality. Furthermore, a consumer metaphor places disproportionate burdens on patients to reduce health care costs, and it could erode professional obligations to provide appropriate and effective care.

In Maryland communities such as Annapolis, Health Enterprise Zones have spurred investment and experimentation in care delivery.

Despite progress on patient safety since the publication of the Institute of Medicine's 1999 report, To Err Is Human, significant problems remain. Human factors and systems engineering (HF/SE) has been increasingly recognized and advocated for its value in understanding, improving, and redesigning processes for safer care, especially for complex interacting sociotechnical systems. However, broad awareness of HF/SE and its adoption into safety improvement work have been frustratingly slow. We provide an overview of HF/SE, its demonstrated value to a wide range of patient safety problems (in particular, medication safety), and challenges to its broader implementation across health care. We make a variety of recommendations to maximize the spread of HF/SE, including formal and informal education programs, greater adoption of HF/SE by health care organizations, expanded funding to foster more clinician-engineer partnerships, and coordinated national efforts to design and operationalize a system for spreading HF/SE into health care nationally.

Health plans use selective physician networks to control costs while improving quality. However, narrow (limited) networks raise concerns about reduced access to and continuity of care. In the period 2010-15, the proportion of Medicaid managed care plans in fourteen states with narrow primary care physician networks-that is, the plans that employed 30 percent or less of those physicians in their market-declined from a peak of 42 percent in 2011 to 27 percent in 2015. On average, plans experienced a 12 percent annual turnover rate, with 34 percent of primary care physicians exiting within five years. Turnover was 3 percentage points higher in plans with narrow networks after one year, and 20 percentage points higher after five years, compared to turnover in plans with non-narrow networks. These findings suggest that efforts to maintain adequate physician networks must monitor not only the breadth of the networks, but also the continuity within them.

As federal efforts to stabilize the individual market foundered on abortion coverage, states adopted a variety of approaches. The 2019 payment notice broadened states' options in implementing the ACA.

Precision medicine is making an impact on patients, health care delivery systems, and research participants in ways that were only imagined fifteen years ago when the human genome was first sequenced. Discovery of disease-causing and drug-response genetic variants has accelerated, while adoption into clinical medicine has lagged. We define precision medicine and the stakeholder community required to enable its integration into research and health care. We explore the intersection of data science, analytics, and precision medicine in the formation of health systems that carry out research in the context of clinical care and that optimize the tools and information used to deliver improved patient outcomes. We provide examples of real-world impact and conclude with a policy and economic agenda necessary for the adoption of this new paradigm of health care both in the United States and globally.

Genomics-based carrier screening is one of many opportunities to use genomic information to inform medical decision making, but clinicians, health care delivery systems, and payers need to determine whether to offer screening and how to do so in an efficient, ethical way. To shed light on this issue, we conducted a study in the period 2014-17 to inform the design of clinical screening programs and guide further health services research. Many of our results have been published elsewhere; this article summarizes the lessons we learned from that study and offers policy insights. Our experience can inform understanding of the potential impact of expanded carrier screening services on health system workflows and workforces-impacts that depend on the details of the screening approach. We found limited patient or health system harms from expanded screening. We also found that some patients valued the information they learned from the process. Future policy discussions should consider the value of offering such expanded carrier screening in health delivery systems with limited resources.

Aspects of the research and practice paradigm known as the diffusion of innovations are applicable to the complex context of health care, for both explanatory and interventionist purposes. This article answers the question, "What is diffusion?" by identifying the parameters of diffusion processes: what they are, how they operate, and why worthy innovations in health care do not spread more rapidly. We clarify how the diffusion of innovations is related to processes of dissemination and implementation, sustainability, improvement activity, and scale-up, and we suggest the diffusion principles that can be readily used in the design of interventions.

The movement to promote a culture of health bears many similarities to another large-scale and ambitious effort from more than fifty years ago: President Lyndon Johnson's War on Poverty. Long a target of critics of all ideological persuasions, the War on Poverty, through its heritage, offers an instructive precedent for champions of the culture of health movement. This essay examines two regional-level War on Poverty health endeavors, one each in New York City and Los Angeles. They show the influence the War on Poverty had on the ground in widening the health care safety net, implementing holistic models of care, and facilitating community involvement in the leadership of larger health care institutions.

In the face of growing competition, traditional practices have begun trying to guarantee same-day appointments.

Achieving an interoperable health care system remains a top US policy priority. Despite substantial efforts to encourage interoperability, the first set of national data in 2014 suggested that hospitals' engagement levels were low. With 2015 data now available, we examined the first national trends in engagement in four domains of interoperability: finding, sending, receiving, and integrating electronic patient information from outside providers. We found small gains, with 29.7 percent of hospitals engaging in all four domains in 2015 compared to 24.5 percent in 2014. The two domains with the most progress were sending (with an increase of 8.1 percentage points) and receiving (an increase of 8.4 percentage points) information, while there was no change in integrating systems. Hospitals' use for patient care of data from outside providers was low, with only 18.7 percent of hospitals reporting that they "often" used these data. Our results reveal that hospitals' progress toward interoperability is slow and that progress is focused on moving information between hospitals, not on ensuring usability of information in clinical decisions., (Project HOPE—The People-to-People Health Foundation, Inc.)

Physicians' willingness to change how care is delivered is a key component of the ability of accountable care organizations (ACOs) to transform patient care. Yet physicians participating in Medicare ACOs are only moderately convinced that ACOs are an effective model for delivering cost-effective care., (Project HOPE—The People-to-People Health Foundation, Inc.)

Long considered a paragon among low- and middle-income countries in its provision of primary health care, Costa Rica reformed its primary health care system in 1994 using a model that, despite its success, has been generally understudied: basic integrated health care teams. This case study provides a detailed description of Costa Rica's innovative implementation of four critical service delivery reforms and explains how those reforms supported the provision of the four essential functions of primary health care: first-contact access, coordination, continuity, and comprehensiveness. As countries around the world pursue high-quality universal health coverage to attain the Sustainable Development Goals, Costa Rica's experiences provide valuable lessons about both the types of primary health care reforms needed and potential mechanisms through which these reforms can be successfully implemented., (Project HOPE—The People-to-People Health Foundation, Inc.)

Organizations seeking to create innovative environments in health care need to pay attention to a number of factors. These include making available sufficient resources, notably money and physical space, but also coordination and consultation regarding intellectual property and licensing; enabling access to engineers, software developers, and behavioral scientists; making providers and patients available to innovators; having a sufficiently long-term view; and insulating the innovation group from operational demands. If there is a single essential key to success, it is making innovation a strategic priority. Academic health systems are enormous generators of innovation in the form of generalizable research in biomedical sciences. Typically, much of that innovation is externally supported, and little is directed to improving care processes internally. In industries other than health care, organizations invest their own funds in research and development to promote innovation, and this investment is seen as a metric for a firm's commitment to its future. Increased investment in care-process innovation is long overdue., (Project HOPE—The People-to-People Health Foundation, Inc.)

The need for innovations in care delivery is recognized by providers, payers, and patients alike. Hospitals, physicians, and other clinicians are experimenting with new models of care designed to better meet patients' needs, reduce administrative burdens, and lower costs. The Affordable Care Act placed the Medicare and Medicaid programs at the center of a national effort to experiment with delivery and payment models designed to improve care and contain costs. These public-sector efforts have often aligned with private initiatives, such as the use of reference pricing-in which an insurer will only pay for a service at the price available from the lowest-cost provider. Employers in the public and private sectors have adopted value-based insurance design, in which copayments and deductibles are calibrated to the clinical benefit obtained from different services. Patients have the most to gain-or lose-from delivery innovations. Better, more efficient care should translate into better health and lower costs, but payment models designed to encourage innovation may have the unintended effect of limiting access to care., (Project HOPE—The People-to-People Health Foundation, Inc.)

Strong health governance is key to universal health coverage. However, the relationship between governance and health system performance is underexplored. We investigated whether expansion of the Brazilian Estratégia de Saúde da Família (ESF; family health strategy), a community-based primary care program, reduced amenable mortality (mortality avoidable with timely and effective health care) and whether this association varied by municipal health governance. Fixed-effects longitudinal regression models were used to identify the relationship between ESF coverage and amenable mortality rates in 1,622 municipalities in Brazil over the period 2000-12. Municipal health governance was measured using indicators from a public administration survey, and the resulting scores were used in interactions. Overall, increasing ESF coverage from 0 percent to 100 percent was associated with a reduction of 6.8 percent in rates of amenable mortality, compared with no increase in ESF coverage. The reductions were 11.0 percent for municipalities with the highest governance scores and 4.3 percent for those with the lowest scores. These findings suggest that strengthening local health governance may be vital for improving health services effectiveness and health outcomes in decentralized health systems., (Project HOPE—The People-to-People Health Foundation, Inc.)

By 2050 an estimated 83.7 million Americans will be ages sixty-five and older, up from 40.3 million in 2010. The shock wave of aging Americans will have profound implications for older people, their families, health care providers, and the economy. Researchers, policy makers, health care leaders, and others are designing responses to the challenges these actuarial shifts will create. For example, delivering health care at home could help keep more older Americans out of costly emergency departments and nursing homes. But such steps require more health care providers, a broader distribution of providers than currently exists, and better use of the resources we have., (Project HOPE—The People-to-People Health Foundation, Inc.)

In-service training courses and supportive supervision of health workers are among the most common interventions to improve the quality of health care in low- and middle-income countries. Despite extensive investment from donors, evaluations of the long-term effect of these two interventions are scarce. We used nationally representative surveys of health systems in seven countries in sub-Saharan Africa to examine the association of in-service training and supervision with provider quality in antenatal and sick child care. The results of our analysis showed that observed quality of care was poor, with fewer than half of evidence-based actions completed by health workers, on average. In-service training and supervision were associated with quality of sick child care; they were associated with quality of antenatal care only when provided jointly. All associations were modest-at most, improvements related to interventions were equivalent to 2 additional provider actions out of the 18-40 actions expected per visit. In-service training and supportive supervision as delivered were not sufficient to meaningfully improve the quality of care in these countries. Greater attention to the quality of health professional education and national health system performance will be required to provide the standard of health care that patients deserve., (Project HOPE—The People-to-People Health Foundation, Inc.)

The rapid demographic and epidemiological transitions occurring in Latin America and the Caribbean have led to high levels of noncommunicable diseases in the region. In addition to reduced risk factors for chronic conditions, a strong health system for managing chronic conditions is vital. This study assessed the extent to which populations in six Latin American and Caribbean countries receive high-quality primary care, and it examined the relationship between experiences with care and perceptions of health system performance. We applied a validated survey on access, use, and satisfaction with health care services to nationally representative samples of the populations of Brazil, Colombia, El Salvador, Jamaica, Mexico, and Panama. Respondents reported considerable gaps in the ways in which primary care is organized, financed, and delivered. Nearly half reported using the emergency department for a condition they considered treatable in a primary care setting. Reports of more primary care problems were associated with worse perceptions of health system performance and quality and less receipt of preventive care. Urgent attention to primary care performance is required as the region's population continues to age at an unprecedented rate., (Project HOPE—The People-to-People Health Foundation, Inc.)

Adverse drug events and the challenges of clarifying and adhering to complex medication regimens are central drivers of hospital readmissions. Medication reconciliation programs can reduce the incidence of adverse drug events after discharge, but evidence regarding the impact of medication reconciliation on readmission rates and health care costs is less clear. We studied an insurer-initiated care transition program based on medication reconciliation delivered by pharmacists via home visits and telephone and explored its effects on high-risk patients. We examined whether voluntary program participation was associated with improved medication use, reduced readmissions, and savings net of program costs. Program participants had a 50 percent reduced relative risk of readmission within thirty days of discharge and an absolute risk reduction of 11.1 percent. The program saved $2 for every $1 spent. These results represent real-world evidence that insurer-initiated, pharmacist-led care transition programs, focused on but not limited to medication reconciliation, have the potential to both improve clinical outcomes and reduce total costs of care., (Project HOPE—The People-to-People Health Foundation, Inc.)

Malaysia has made substantial progress in providing access to health care for its citizens and has been more successful than many other countries that are better known as models of universal health coverage. Malaysia's health care coverage and outcomes are now approaching levels achieved by member nations of the Organization for Economic Cooperation and Development. Malaysia's results are achieved through a mix of public services (funded by general revenues) and parallel private services (predominantly financed by out-of-pocket spending). We examined the distributional aspects of health financing and delivery and assessed financial protection in Malaysia's hybrid system. We found that this system has been effective for many decades in equalizing health care use and providing protection from financial risk, despite modest government spending. Our results also indicate that a high out-of-pocket share of total financing is not a consistent proxy for financial protection; greater attention is needed to the absolute level of out-of-pocket spending. Malaysia's hybrid health system presents continuing unresolved policy challenges, but the country's experience nonetheless provides lessons for other emerging economies that want to expand access to health care despite limited fiscal resources., (Project HOPE—The People-to-People Health Foundation, Inc.)

The growth of shared decision making has been driven largely by the understanding that patients need information and choices regarding their health care. But while these are important elements for patients who make decisions in partnership with their clinicians, our experience suggests that they are not enough to address the larger issue: the need for the patient and clinician to jointly create a course of action that is best for the individual patient and his or her family. The larger need in evidence-informed shared decision making is for a patient-clinician interaction that offers conversation, not just information, and care, not just choice., (Project HOPE—The People-to-People Health Foundation, Inc.)

Policy makers and practitioners increasingly believe that medical evidence plays a critical role in improving care and health outcomes and lowering costs. However, public understanding of the role of evidence-based care may be different. Public deliberation is a process that convenes diverse citizens and has them learn about and consider ethical or values-based dilemmas and weigh alternative views. The Community Forum Deliberative Methods Demonstration project, sponsored by the Agency for Healthcare Research and Quality, obtained informed public views on the role of evidence in health care decisions through seventy-six deliberative groups involving 907 people overall, in the period August-November 2012. Although participants perceived evidence as being essential to high-quality care, they also believed that personal choice or clinical judgment could trump evidence. They viewed doctors as central figures in discussing evidence with patients and key arbiters of whether to follow evidence in individual cases. They found evidence of harm to individuals or the community to be more compelling than evidence of effectiveness. These findings indicate that increased public understanding of evidence can play an important role in advancing evidence-based care by helping create policies that better reflect the needs and values of the public., (Project HOPE—The People-to-People Health Foundation, Inc.)

Every year around fourteen million people globally are infected with human papillomavirus (HPV), the sexually transmitted virus that is the cause of most cervical cancers. A number of vaccines have been developed to protect against HPV, but in many countries, HPV vaccination rates have been low compared with rates for other recommended vaccines. Parental concerns, cost, and lack of information and awareness among both health professionals and parents are cited as important barriers to HPV vaccination. In Argentina the HPV vaccine has been provided to all eleven-year-old girls since 2011 as part of a comprehensive national program to prevent cervical cancer. Coverage increased from negligible levels before 2011 to a national average of 87.9 percent for the first dose, 71.6 percent for the second dose, and 52.2 percent for the third dose in 2013. There was a large variance in HPV vaccine coverage across the country's provinces. This article describes key strategies to overcome barriers to implementation of HPV vaccination and provides recommendations for policy makers., (Project HOPE—The People-to-People Health Foundation, Inc.)

To improve health care quality within communities, increasing numbers of multistakeholder alliances-groups of payers, purchasers, providers, and consumers-have been created. We used data from two rounds (conducted in July 2007-March 2009 and January 2012-November 2013) of a large nationally representative survey of small and medium-size physician practices. We examined whether the adoption of patient-centered medical home processes spread more rapidly in fourteen Robert Wood Johnson Foundation Aligning Forces for Quality communities, where multistakeholder health care alliances promoted their use, than in other communities. We found no difference in the overall growth of adoption of the processes between the two types of communities. However, improvement on a care coordination subindex was 7.17 percentage points higher in Aligning Forces for Quality communities than in others. Despite the enthusiasm for quality improvement led by multistakeholder alliances, such alliances may not be a panacea for spreading patient-centered medical home processes across a community., (Project HOPE—The People-to-People Health Foundation, Inc.)

In 2009 HealthCare Partners Affiliates Medical Group, based in Southern California, launched House Calls, an in-home program that provides, coordinates, and manages care primarily for recently discharged high-risk, frail, and psychosocially compromised patients. Its purpose is to reduce preventable emergency department visits and hospital readmissions. We present data over time from this well-established program to provide an example for other new programs that are being established across the United States to serve this population with complex needs. The findings show that the initial House Calls structure, staffing patterns, and processes differed across the geographic areas that it served, and that they also evolved over time in different ways. In the same time period, all areas experienced a reduction in operating costs per patient and showed substantial reductions in monthly per patient health care spending and hospital utilization after enrollment in the House Calls program, compared to the period before enrollment. Despite more than five years of experience, the program structure continues to evolve and adjust staffing and other features to accommodate the dynamic nature of this complex patient population., (Project HOPE—The People-to-People Health Foundation, Inc.)

There is a widely acknowledged time lag in health care between an invention or innovation and its widespread use across a health system. Much is known about the factors that can aid the uptake of innovations within discrete organizations. Less is known about what needs to be done to enable innovations to transform large systems of health care. This article describes the results of in-depth case studies aimed at assessing the role of key agents and agencies that facilitate the rapid adoption of innovations. The case studies-from Argentina, England, Nepal, Singapore, Sweden, the United States, and Zambia-represent widely varying health systems and economies. The implications of the findings for policy makers are discussed in terms of key factors within a phased approach for creating a climate for change, engaging and enabling the whole organization, and implementing and sustaining change. Purposeful and directed change management is needed to drive system transformation., (Project HOPE—The People-to-People Health Foundation, Inc.)

The prevalence of noncommunicable diseases in East Africa is rising rapidly. Although the epidemiologic, demographic, and nutritional transitions are well under way in low-income countries, investment and attention in these countries remain focused largely on communicable diseases. We discuss existing infrastructure in communicable disease management as well as linkages between noncommunicable and communicable diseases in East Africa. We describe gaps in noncommunicable disease management within the health systems in this region. We also discuss deficiencies in addressing noncommunicable diseases from basic science research and medical training to health services delivery, public health initiatives, and access to essential medications in East Africa. Finally, we highlight the role of collaboration among East African governments and civil society in addressing noncommunicable diseases, and we advocate for a robust primary health care system that focuses on the social determinants of health., (Project HOPE—The People-to-People Health Foundation, Inc.)

Health systems in low- and middle-income countries were designed to provide episodic care for acute conditions. However, the burden of disease has shifted to be overwhelmingly dominated by chronic conditions and illnesses that require health systems to function in an integrated manner across a spectrum of disease stages from prevention to palliation. Low- and middle-income countries are also aiming to ensure health care access for all through universal health coverage. This article proposes a framework of effective universal health coverage intended to meet the challenge of chronic illnesses. It outlines strategies to strengthen health systems through a "diagonal approach." We argue that the core challenge to health systems is chronicity of illness that requires ongoing and long-term health care. The example of breast cancer within the broader context of health system reform in Mexico is presented to illustrate effective universal health coverage along the chronic disease continuum and across health systems functions. The article concludes with recommendations to strengthen health systems in order to achieve effective universal health coverage., (Project HOPE—The People-to-People Health Foundation, Inc.)