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Objective: To examine the impact of 'cross-market' hospital mergers on prices and quality and the extent to which serial acquisitions contribute to any measured effects. Data Sources: 2009-2017 commercial claims from the Health Care Cost Institute (HCCI) and quality measures from Hospital Compare. Study Design: Event study models in which the treated group consisted of hospitals that acquired hospitals further than 50 miles, and the control group was hospitals that were not part of any merger activity (as a target or acquirer) during the study period. Data Extraction Methods: We extracted data for 214 treated hospitals and 955 control hospitals. Principal Findings: Six years after acquisition, cross-market hospital mergers had increased acquirer prices by 12.9% (CI: 0.6%-26.6%) relative to control hospitals, but had no discernible impact on mortality and readmission rates for heart failure, heart attacks and pneumonia. For serial acquirers, the price effect increased to 16.3% (CI: 4.8%-29.1%). For all acquisitions, the price effect was 21.8% (CI: 4.6%-41.7%) when the target's market share was greater than the acquirer's market share versus 9.7% (CI: -0.5% to 20.9%) when the opposite was true. The magnitude of the price effect was similar for out-of-state and in-state cross-market mergers. Conclusions: Additional evidence on the price and quality effects of cross-market mergers is needed at a time when over half of recent hospital mergers have been cross-market. To date, no hospital mergers have been challenged by the Federal Trade Commission on cross-market grounds. Our study is the third to find a positive price effect associated with cross-market mergers and the first to show no quality effect and how serial acquisitions contribute to the price effect. More research is needed to identify the mechanism behind the price effects we observe and analyze price effect heterogeneity. KEYWORDS cross-market, health care competition, hospitals, price, quality, serial acquisitions, 1 | INTRODUCTION U.S. hospitals have been consolidating for decades. Between 1998 and 2017 there were 1577 hospital mergers with 456 occurring from 2013 to 2017. (1) By 2016, 90% [...]

This document contains the four issues of volume 21 of the newsletter, "Linkages." The first issue discusses business partnerships, collaboration, community outreach, grants and contributions at the following community colleges: Salt Lake (UT), Monroe (NY), Niagara County (NY), Elgin (IL), Westmoreland (PA), Wayne (NC), Redlands (OK), Burlington (NJ), Del Mar (TX), and Santa Monica (CA). Issue 2 celebrates 20 years of service to community colleges, with highlights on what's "new for '98," conference features, program strands, business partnerships and community outreach at the following community colleges: Monroe (NY), Allan Hancock (CA), Colorado Mountain, Skagit Valley (WA) and Ivy Tech State (IA). The third issue covers grants, collaboration and community outreach at Long Beach City College (CA), Forsyth Technical Community College (NC), Santa Monica College (CA), Baltimore City Community College (MD), Cambrian College (Canada), Schoolcraft College (MI), Cossatot Technical College (AR), Anson College (NC) and Westmoreland College (PA). Finally, issue 4 discusses grants, business partnerships, technology, collaboration, and community outreach at the following community colleges: Salt Lake (UT), Garden City (KS), Burlington (NJ) Kirkwood (IA), Redlands (OK), Washtenaw (MI), DuPage (IL), Mountain View (TX) and Metropolitan (KS). (AS)

The Elusiveness of HTCs The issue of using a reliable value for the heat transfer coefficient (HTC) at the mold-casting interface for the purpose of modeling the temperature history inside [...]

Objective: The objective of this analysis was to evaluate the effect of resident program training size on clinician productivity and turnover in the Veterans Health Administration (VHA), the largest education and training platform for medical professionals in the United States. Data Sources: We retrieved administrative data on training programs and training facilities from the VA Office of Academic Affiliations and the VHA Corporate Data Warehouse. Data on primary care physician shortage areas were retrieved from the Health Resources and Services Administration. Study Design: We used a quasi-experimental instrumental variables 2SLS design and constructed an exogenous predicted training allocation treatment variable as a function of the total national training program allocation. The outcome was clinical staff productivity and turnover. Secondary analyses stratified results using Health Professional Shortage Areas data (HPSA). Data Collection/Extraction Methods: Data were obtained for a national dataset of 141 VHA medical facilities and 26 specialties that hosted training programs across 11 years from 2011 to 2021 (N = 132,177). Principal Findings: Instrumental variables results showed that on average, an increase of one training slot in a specialty leads to a decrease of 0.039 visits per standardized clinic day (p < 0.001) and a 0.02 percentage point increase in turnover (p < 0.001). The direction of this association varied by specialty: while psychiatry and psychology specialties saw a decline in productivity, fields such as primary care and cardiology experienced an increase in productivity. HPSA stratified results indicate that negative effects on productivity and turnover are driven by areas with little to no primary care physician shortage, whereas shortage areas experienced a small increase in productivity and no effect on turnover. Conclusions: This quasi-experimental evaluation indicates that resident training program size is associated with reduced productivity and increased turnover in specialties such as psychiatry and in facilities with high baseline productivity. However, in specialties like primary care and cardiology, as well as areas with shortages of primary care, larger training programs are associated with increased productivity. KEYWORDS graduate medical education, productivity, residents, turnover, Veterans Health Administration, workforce, 1 | INTRODUCTION Limited availability of physicians has been identified as one of the top barriers to meeting the growing healthcare demands of individuals in the United States. (1) Studies [...]

Objective: To determine the barriers transgender and gender nonconforming (TGNC) adults face when accessing or receiving healthcare in the United States. Data Sources and Study Setting: Primary data were collected between September 2022 and March 2023 from a purposive sample of TGNC adults (N = 116 participants) using an online survey with a series of open-ended and closed-ended questions. Study Design: Thematic analysis was employed to extract and analyze participants' responses to an open-ended question about challenges they experienced when accessing or receiving healthcare. Two members of the research team conducted qualitative data analyses using Dedoose. The quality of each analysis was subsequently reviewed by a third research team member. Data Collection/Extraction Methods: Data were collected from responses to one open-ended question that asked about participants' healthcare barriers as a TGNC individual. Principal Findings: Five main themes surrounding healthcare barriers emerged from the content analysis: (1) acceptability, (2) accommodation, (3) affordability, (4) availability, and (5) accessibility. First, participants who noted acceptability issues reported explicit discriminatory treatment from providers, providers not using their chosen names and pronouns (e.g., misgendering), and provider refusal to provide gender-affirming care. Second, participants who experienced accommodation challenges identified provider medical training gaps on TGNC patient needs and administrative barriers to care. Third, participants explained affordability issues due to a lack of adequate health insurance coverage. Fourth, participants described availability challenges with accessing hormone therapy prescriptions. Finally, participants noted accessibility issues with obtaining TGNC-specific care at LGBTQ+-affirming clinics. Conclusions: There is a growing interest in the needs of TGNC adults within healthcare settings. This requires that health policies are enacted to ensure that TGNC adults have access to healthcare that is accommodating and accepting/affirming. Study findings may provide insight into the potential impact of current legislation on transgender access and availability. KEYWORDS gender nonconforming, gender-affirming care, healthcare, nonbinary, transgender, 1 | INTRODUCTION An estimated 1.3 million adults identify as transgender in the United States, and approximately 26% of this population identify as gender nonconforming. (1) Transgender is an umbrella [...]

Objective: To determine how the rise of telehealth during the COVID-19 pandemic impacted Medicaid enrollees' access to opioid use disorder (OUD) treatment. Data Sources and Study Setting: Electronic health records from Northwestern Medicine, a large midwestern academic health system, from January 1, 2019 to December 31, 2021. Study Design: The exposure was the expansion of telehealth services during the COVID-19 pandemic. A difference-in-differences design was used to determine the impact of telehealth on the probability of receiving any OUD care, any in-person OUD care, and any telehealth OUD care in a month. Data Collection/Extraction Methods: The study included Medicaid and privately insured patients older than 18 years of age, diagnosed with OUD, who had any encounter with the Northwestern Medicine system. All outpatient visits with OUD as the primary diagnosis were included in the analysis. There were 486 individuals in the sample and 17,496 person-month observations. Principal Findings: After the onset of the COVID-19 pandemic, Medicaid enrollees are 4.5 percentage points (percentage change, 43.7%; 95% confidence interval [CI] 8.7 to 0.3 percentage points; p = 0.035) less likely to receive any OUD care in a month, relative to privately insured patients. While no statistically significant differences in the likehood of receiving in-person OUD care were detected between the groups after exposure, we did observe that Medicaid enrollees are 3.6 percentage points (percentage change 64.2%; 95% CI 6.0 to 1.1 percentage points; p = 0.004) less likely to receive any telehealth OUD care in a month relative to privately insured patients. Conclusions: While those with private insurance were able to maintain OUD treatment during the pandemic by supplementing in-person care with telehealth, Medicaid enrollees experienced a drop in overall OUD treatment rates due to lower telehealth use. The rise of telehealth for OUD treatment might contribute to widening care gaps for Medicaid enrollees. KEYWORDS disparities, Medicaid policy, opioid use disorder, substance use, telehealth, 1 | INTRODUCTION Opioid-related overdose deaths in the United States reached an all-time high of 80,000 in 2021. (1) Although medication for opioid use disorder (MOUD) reduces one's risk for [...]

Wood density is used for genetic selection because of its association with wood quality. Traditional assessments of wood density, such as volumetric measurement and X-ray densitometry, are labor intensive and time consuming. Drill resistance (measured with a Resistograph) is faster and gives an indirect assessment of wood density. The Resistograph generates thousands of data points for each tree that must be summarized. The data include bark and air as the drill enters and exits the bole, as well as friction that builds on the drill shaft. This study evaluated data processing methods for drill resistance to improve correlation with wood density, with a focus on practical implementation by breeding programs. We compared methods that thoroughly removed bark, air, and friction, as well as simple methods based on expected bark thickness and depth to the pith. The most thorough method produced the highest phenotypic correlation with density ([r.sub.p] = 0.81). All methods that excluded data after the drill exits the tree had very strong genetic correlations ([r.sub.g] > 0.92), although avoiding bark gave a noticeable increase in genetic correlation. Unprocessed drill resistance had unacceptably low phenotypic correlations ([r.sub.p] = 0.38) and the lowest genetic correlation observed, although it was still very high ([r.sub.g] = 0.91). For tree breeding programs, we recommend developing reasonable bark and pith depth thresholds and using simple rules to avoid bark and friction., Wood density is a widely used property for genetic selection because of its association with the quality of solid wood products and its strong genetic control (Zobel and van Buijtenen [...]

The pandemic and Red Sea crisis have once again revealed how disruptions in one part of the world can ripple through the entire system, exposing significant vulnerabilities within the global [...]

Objective: To examine the relationship between site-level adaptation and early adoption of Caregivers Finding Important Resources, Support, and Training (FIRST) training during national implementation across diverse Veteran Health Administration (VA) medical centers. Data Sources and Study Setting: We enrolled and evaluated 25 VA medical centers (VAMCs). Along with administrative data on site characteristics, we examined site-reported data on adaptations and intervention adoption, defined as [greater than or equal to]4 training classes delivered to [greater than or equal to]5 caregivers at 6 months from April through October 2022. Study Design: A type III hybrid implementation-effectiveness cluster randomized controlled trial, randomized VAMCs 1:1 to receive foundational (low-touch) implementation support (n = 12) or the addition of enhanced (high-touch) implementation support (n = 13). Data Collection/Extraction Methods: At key implementation phases, VAMCs were asked to report adaptations including content, contextual modifications (format, setting, personnel, and population), and training of providers. We describe site-level adaptations by arm and by organizational characteristics that included VAMC complexity level, staffing, rurality, and organizational readiness to change. We used qualitative comparative analysis to identify unique adaptations that contributed to intervention adoption at 6 months. Principal Findings: VAMCs randomized to receive enhanced support reported slightly more adaptations than those randomized to foundational support. At 6 months, VAMCs with two or more adaptations adopted Caregivers FIRST at a higher rate than those with fewer adaptations (90% vs. 44%). Staffing adaptations (e.g., who delivered the intervention), format and content (e.g., modified delivery pace), and referring provider training were unique adaptations to adopting sites. Conclusions: Site-level adaptations were diverse and occurred more frequently in sites with early adoption of Caregivers FIRST. Future research should identify best practices of supporting and monitoring intervention adaptation. Understanding the role of adaptation in early adoption success could assist other healthcare systems in implementing interventions for caregivers. KEYWORDS adaptation, contextual analysis, implementation science, Veterans What is known on this topic * Interventions developed and tested in research settings are rarely adopted in real-world settings. * Adaptation is often required to facilitate intervention implementation and scale; however, little is known on the nature of these adaptations and how they contribute to adoption and other implementation outcomes. What this study adds * This study uses novel survey methodologies for reporting intervention adaptations in real-world practice settings in a proactive, theoretically sound, and streamlined manner. * Overall, site-level adaptations were diverse and occurred more frequently in sites with early adoption. * Understanding the role of adaptation in adoption success could assist other healthcare systems to implement interventions supporting caregivers. Future research should identify best practices of supporting and monitoring intervention adaptation., 1 | INTRODUCTION In a fractured long-term service and support system in the United States, 53 million family caregivers fill an essential role and provide unpaid annual economic contributions of [...]

Objective: To estimate a causal relationship between mental health staffing and time to initiation of mental health care for new patients. Data Sources and Study Setting: As the largest integrated health care delivery system in the United States, the Veterans Health Administration (VHA) provides a unique setting for isolating the effects of staffing on initiation of mental health care where demand is high and out-of-pocket costs are not a relevant confounder. We use data from the Department of Defense and VHA to obtain patient and facility characteristics and health care use. Study Design: To isolate exogenous variation in mental health staffing, we used an instrumental variables approach--two-stage residual inclusion with a discrete time hazard model. Our outcome is time to initiation of mental health care after separation from active duty (first appointment) and our exposure is mental health staffing (standardized clinic time per 1000 VHA enrollees per pay period). Data Collection/Extraction Methods: Our cohort consists of all Veterans separating from active duty between July 2014 and September 2017, who were enrolled in the VHA, and had at least one diagnosis of post-traumatic stress disorder, major depressive disorder, and/or substance use disorder in the year prior to separation from active duty (N = 54,209). Principal Findings: An increase of 1 standard deviation in mental health staffing results in a higher likelihood of initiating mental health care (adjusted hazard ratio: 3.17, 95% confidence interval: 2.62, 3.84, p < 0.001). Models stratified by tertile of mental health staffing exhibit decreasing returns to scale. Conclusions: Increases in mental health staffing led to faster initiation of care and are especially beneficial in facilities where staffing is lower, although initiation of care appears capacity-limited everywhere. KEYWORDS access to care, mental health, staffing, Veterans, workforce What is known on this topic * Veterans have high need for mental health care, yet access issues can delay initiation of care. * Increased mental health staffing has been shown to reduce suicide-related events in the Veterans Health Administration. What this study adds * We demonstrate a causal relationship between staffing and initiation of mental health care. * Increases in mental health staffing are especially beneficial when staffing is lower, although initiation of care appears capacity-limited everywhere within VHA., 1 | INTRODUCTION Mental health and suicide prevention are prominent concerns for the approximately 19 million living Veterans of the United States' armed forces, with more than 9 million enrolled [...]

Objective: To conduct a business case analysis for Department of Veterans Affairs (VA) program STRIDE (ASsisTed EaRly Mobilization for hospitalizeD older VEterans), which was designed to address immobility for hospitalized older adults. Data Sources and Study Setting: This was a secondary analysis of primary data from a VA8-hospital implementation trial conducted by the Function and Independence Quality Enhancement Research Initiative (QUERI). In partnership with VA operational partners, we estimated resources needed for program delivery in and out of the VA as well as national implementation facilitation in the VA. A scenario analysis using wage data from the Bureau of Labor Statistics informs implementation decisions outside the VA. Study Design: This budget impact analysis compared delivery and implementation costs for two implementation strategies (Replicating Effective Programs [REP]+CONNECT and REP-only). To simulate national budget scenarios for implementation, we estimated the number of eligible hospitalizations nationally and varied key parameters (e.g., enrollment rates) to evaluate the impact of uncertainty. Data Collection: Personnel time and implementation outcomes were collected from hospitals (2017-2019). Hospital average daily census and wage data were estimated as of 2022 to improve relevance to future implementation. Principal Findings: Average implementation costs were $9450 for REP+CONNECT and $5622 for REP-only; average program delivery costs were less than $30 per participant in both VA and non-VA hospital settings. Number of walks had the most impact on delivery costs and ranged from 1 to 5 walks per participant. In sensitivity analyses, cost increased to $35 per participant if a physical therapist assistant conducts the walks. Among study hospitals, mean enrollment rates were higher among the REP+CONNECT hospitals (12%) than the REP-only hospitals (4%) and VA implementation costs ranged from $66 to $100 per enrolled. Conclusions: STRIDE is a low-cost intervention, and program participation has the biggest impact on the resources needed for delivering STRIDE. Trial Registration: ClinicalsTrials.gov NCT03300336. Prospectively registered on 3 October 2017. KEYWORDS cost of care, geriatrics, implementation science, veterans What is known on this topic * Hospital mobility programs can reduce rates of hospital-associated disability, but they are not widely available. * A Department of Veterans Affairs (VA) program called STRIDE (ASsisTed EaRly MobIlization for hospitalizeD older VEterans) was designed to address immobility using supervised walks for hospitalized older adults. * In prior evaluations, STRIDE was found to reduce odds of discharge to a Skilled Nursing Facility (SNF). What this study adds * This budget impact analysis informs the business case for disseminating STRIDE in and out of the VA. * STRIDE is a low-cost intervention to deliver, and program participation among eligible veterans has the biggest impact on the resources needed for delivering STRIDE. * Achieving improved veteran outcomes through national STRIDE dissemination may require substantial investment of VA resources to facilitate successful implementation., 1 | INTRODUCTION Acute medical illness that requires hospitalization is common among older adults with chronic conditions, and disability is common following hospitalization in and out of the U.S. Veterans [...]

'A tax loophole is something that benefits the other guy. If it benefits you, it is tax reform.' --Russell B. Long I. Introduction With the impending 2024 Presidential election and [...]

* Human nature's perceived need for more persistently makes the concept of 'having it all' impossible. * Reconsider the balance between career ambitions and life contentment, and ask when it's time to take stock and reassess goals., Nov 01, 2024 I hate to lose. Some people are pretty competitive, and most Americans would say they hate losing. Hate is an incredibly strong word though; perhaps we simply [...]

In recent years, financial activity associated with digital assets has grown significantly, with periods of exponential growth and multiple precipitous crashes. Not only have digital asset prices experienced sharp increases [...]

Cross-border movements are surging as U.S.-based companies seek to shorten supply chains exposed for over-reliance on Far East manufacturing during and after the pandemic. Shippers are advised to plan early [...]

These are challenging times in the truckload (TL) market, as top carrier executives are predicting it will be the second half of 2025 before a rate recovery occurs in the [...]

It's now a race between environmentalists and government regulators on which technology to mandate on the ground freight transportation community to lower carbon emissions. But whatever happens, who occupies the [...]

ONE TRAGEDY OF LIFE is when children make promises they never fulfill as adults. We're all guilty. As a youngster in the late 1990s, my aspirations were simple. In order [...]

Objective: The study aims to examine maternal care among Hispanic birthing people by primary language and state policy environment. Data Sources and Study Setting: Pooled data from 2016 to 2020 Pregnancy Risk Assessment Monitoring System surveys from 44 states and two jurisdictions. Study Design: Using multivariable logistic regression, we calculated adjusted predicted probabilities of maternal care utilization (visit attendance, timeliness, adequacy) and quality (receipt of guideline-recommended care components). We examined outcomes by primary language (Spanish, English) and two binary measures of state policy environment: (1) expanded Medicaid eligibility to those Data Collection/Extraction Methods: Survey responses from 35,779 postpartum individuals with self-reported Hispanic ethnicity who gave birth during 2016-2020. Principal Findings: Compared to English-speaking Hispanic people, Spanish-speaking individuals reported lower preconception care attendance and worse timeliness and adequacy of prenatal care. In states without Medicaid expansion and immigrant Medicaid coverage, Hispanic birthing people had, respectively, 2.3 (95% CI:0.6, 3.9) and 3.1 (95% CI:1.6, 4.6) percentage-point lower postpartum care attendance and 4.2 (95% CI:2.1, 6.3) and 9.2 (95% CI:7.2, 11.2) percentage-point lower prenatal care quality than people in states with these policies. In states with these policies, Spanish-speaking Hispanic people had 3.3 (95% CI:1.3, 5.4) and 3.0 (95% CI:0.9, 5.1) percentage-point lower prenatal care adequacy, but 1.3 (95% CI:-1.1, 3.6) and 2.7 (95% CI:0.2, 5.1) percentage-point higher postpartum care quality than English-speaking Hispanic people. In states without these policies, those same comparisons were 7.3 (95% CI:3.8,10.8) and 7.9 (95% CI:4.6,11.1) percentage-points lower and 9.6 (95% CI:5.5, 13.7) and 5.3 (95% CI:1.8, 8.9) percentage-points higher. Conclusions: Perinatal care utilization and quality vary among Hispanic birthing people by primary language and state policy environment. States with Medicaid expansion and immigrant Medicaid coverage had greater equity between Spanish-speaking and English-speaking Hispanic people in adequate prenatal care and postpartum care quality among those who gave birth. KEYWORDS Hispanic, Latinx, maternal health care, perinatal, postpartum, PRAMS, primary language What is known on this topic * Hispanic birthing people face elevated risks of poor maternal outcomes compared to non-Hispanic White people, including preeclampsia, hypertension, and gestational diabetes. * Hispanic adults in the United States access prenatal care at lower rates than non-Hispanic White people. * Patients with limited English proficiency experience barriers to accessing high quality healthcare services, and frequently report healthcare discrimination. What this study adds * Spanish-speaking Hispanic individuals reported significantly lower preconception care utilization, and worse timeliness and adequacy of prenatal care, compared to English-speaking Hispanic individuals. * States with Medicaid expansion and immigrant Medicaid coverage policies had smaller disparities in perinatal care between Spanish- and English-speaking Hispanic people. * Policy efforts to increase access to and equity in perinatal care among Hispanic people could include changes in Medicaid eligibility based on income and immigration status., 1 | INTRODUCTION There are long-standing maternal health disparities by race and ethnicity, language, immigration status, and country of origin among people who give birth in the United States. A [...]

Objective: To examine rural--urban disparities in substance use disorder treatment access and continuation. Data Sources and Study Setting: We analyzed a 2016-2018 U.S. national secondary dataset of commercial insurance claims. Study Design: This cross-sectional study examined individuals with a new episode of opioid, alcohol, or other drug use disorders. Treatment initiation and engagement rates, and rates of using out-of-network providers for these services, were compared between rural and urban patients. Data Collection: We included individuals 18-64 years old with continuous employer-sponsored insurance. Principal Findings: Patients in rural settings experienced lower treatment initiation rates for alcohol (36.6% vs. 38.0%, p < 0.001), opioid (41.2% vs. 44.2%, p < 0.001), and other drug (37.7% vs. 40.1%, p < 0.001) use disorders, relative to those in urban areas. Similarly, rural patients had lower treatment engagement rates for alcohol (15.1% vs. 17.3%, p < 0.001), opioid (21.0% vs. 22.6%, p < 0.001), and other drug (15.5% vs. 17.5%, p < 0.001) use disorders. Rural patients had higher out-of-network rates for treatment initiation for other drug use disorders (20.4% vs. 17.2%, p < 0.001), and for treatment engagement for alcohol (27.6% vs. 25.2%, p = 0.006) and other drug (36.1% vs. 31.1%, p < 0.001) use disorders. Conclusions: These findings indicate that individuals with substance use disorders in rural areas have lower rates of initial and ongoing treatment, and are more likely to seek care out-of-network. KEYWORDS alcohol-related disorders, managed care programs, opioid-related disorders, provider networks, rural health services, substance-related disorders What is known on this topic * Treatment for substance use disorders is underutilized, even for those with commercial health insurance. * Rural areas have additional barriers to accessing care, including limited networks of healthcare providers who contract with commercial insurance. What this study adds * Individuals with substance use disorders in rural areas receive initial and ongoing treatment less often than their urban counterparts. * For patients that do receive treatment, those in rural areas are more likely to go outside their insurance network for treatment of alcohol and other (non-opioid) use disorders., 1 | INTRODUCTION Nearly 35 million working-age Americans report having a substance use disorder (SUD) involving alcohol, opioids, or other drugs. (1,2) Nationwide, drug overdose deaths nearly doubled from 2015 [...]

Objective: To examine changes in hospitalization trends and healthcare utilization among Veterans following Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act implementation. Data Sources and Study Setting: VA Corporate Data Warehouse and Centers for Medicare and Medicaid Services datasets. Study Design: Retrospective cohort study to compare 7- and 30-day rates for unplanned readmission and emergency department visits following index hospital stays based on payor type (VHA facility stay, VA-funded stay in community facility [CC], or Medicare-funded community stay [CMS]). Segmented regression models were used to compare payors and estimate changes in outcome levels and slopes following MISSION Act implementation. Data Collection/Extraction Methods: Veterans with active VA primary care utilization and [greater than or equal to]1 acute hospitalization between January 1, 2016 and December 31, 2021. Principal Findings: Monthly index stays increased for all payors until MISSION Act implementation, when VHA and CMS admissions declined while CC admissions accelerated and overtook VHA admissions. In December 2021, CC admissions accounted for 54% of index admissions, up from 25% in January 2016. From adjusted models, just prior to implementation (May 2019), Veterans with CC admissions had 47% greater risk of 7-day readmission (risk ratio [RR]: 1.47, 95% confidence interval [CI]: 1.43,1.51) and 20% greater risk of 30-day readmission (RR: 1.20, 95% CI: 1.19,1.22) compared with those with VHA admissions; both effects persisted postimplementation. Pre-implementation CC admissions were also associated with higher 7- and 30-day ED visits, but both risks were substantially lower by study termination (RR: 0.90, 95% CI: 0.88, 0.91) and (RR: 0.89, 95% CI: 0.87, 0.90), respectively. Conclusions: MISSION Act implementation was associated with substantial shifts in treatment site and federal payor for Veteran hospitalizations. Post-implementation readmission risk was estimated to be higher for those with CC and CMS index admissions, while post-implementation risk of ED utilization following CC admissions was estimated to be lower compared with VHA index admissions. Reasons for this divergence require further investigation. KEYWORDS care coordination, Department of Veterans Affairs, hospitalizations, VA MISSION Act, Veterans health What is known on this topic * Recent federal legislation increased Veterans' access to care in community hospital settings, including the VA Choice Act of 2014 and the MISSION Act of 2018. * Since MISSION Act implementation, little is known about post-hospitalization outcomes for care received in the community versus care received at the Veterans Health Administration (VHA) facilities. What this study adds * Veterans with VA-funded community care were estimated to have higher risk of readmission, but lower risk of post-discharge ED utilization compared with those with VA admissions. * MISSION Act implementation was associated with substantial shifts for Veteran hospitalizations toward VA-funded community care and away from VHA facilities and Medicare-funded admissions., 1 | INTRODUCTION The Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018 contained measures to expand Veterans' access to timely care, including increased outsourcing of services [...]

Objective: To investigate Covid-19 vaccination as a potential secondary public health benefit of case management for Medicaid beneficiaries with health and social needs. Data Sources and Study Setting: The CommunityConnect case management program for Medicaid beneficiaries is run by Contra Costa Health, a county safety net health system in California. Program enrollment data were merged with comprehensive county vaccination records. Study Design: Individuals with elevated risk of hospital and emergency department use were randomized each month to a case management intervention or usual care. Interdisciplinary case managers offered coaching, community referrals, healthcare connections, and other support based on enrollee interest and need. Using survival analysis with intent-to-treat assignment, we assessed rates of first-dose Covid-19 vaccination from December 2020 to September 2021. In exploratory sub-analyses we also examined effect heterogeneity by gender, race/ethnicity, age, and primary language. Data Collection and Extraction Methods: Data were extracted from county and program records as of September 2021, totaling 12,866 interventions and 25,761 control enrollments. Principal Findings: Approximately 58% of enrollees were female and 41% were under age 35. Enrollees were 23% White, 12% Asian/Pacific Islander, 20% Black/African American, and 36% Hispanic/Latino, and 10% other/unknown. Approximately 35% of the intervention group engaged with their case manager. Approximately 56% of all intervention and control enrollees were vaccinated after 9 months of analysis time. Intervention enrollees had a higher vaccination rate compared to control enrollees (adjusted hazard ratio [aHR]: 1.06; 95% confidence interval [CI]: 1.02-1.10). In subanalyses, the intervention was associated with stronger likelihood of vaccination among males and individuals under age 35. Conclusions: Case management infrastructure modestly improved Covid-19 vaccine uptake in a population of Medicaid beneficiaries that over-represents social groups with barriers to early Covid-19 vaccination. Amidst mixed evidence on vaccination-specific incentives, leveraging trusted case managers and existing case management programs may be a valuable prevention strategy. KEYWORDS case management, complex care, Covid-19 vaccination, Medicaid, social needs, survival analysis, vaccine uptake What is known on this topic * There is increasing evidence that case management for health and social risks may decrease use of high-cost healthcare services like hospitalization. * There is little evidence on other case management outcomes including vaccination as a spillover public health benefit. * Studies of vaccine-specific incentives like lotteries and small monetary payments yield inconsistent results. What this study adds * Enrollees offered case management had a 5% greater hazard of vaccination compared to a randomly selected control group. * The preexisting case management infrastructure may have enabled enrollees to uptake vaccination sooner, supported by trusting relationships and navigation assistance., 1 | INTRODUCTION Health systems are increasingly deploying new case management programs to address health and social risks among patients with complex care needs. (1,2) While it is well established [...]