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A variety of microbial communities and their genes (the microbiome) exist throughout the human body, with fundamental roles in human health and disease. The National Institutes of Health (NIH)-funded Human Microbiome Project Consortium has established a population-scale framework to develop metagenomic protocols, resulting in a broad range of quality-controlled resources and data including standardized methods for creating, processing and interpreting distinct types of high-throughput metagenomic data available to the scientific community. Here we present resources from a population of 242 healthy adults sampled at 15 or 18 body sites up to three times, which have generated 5,177 microbial taxonomic profiles from 16S ribosomal RNA genes and over 3.5 terabases of metagenomic sequence so far. In parallel, approximately 800 reference strains isolated from the human body have been sequenced. Collectively, these data represent the largest resource describing the abundance and variety of the human microbiome, while providing a framework for current and future studies.

PURPOSE: How accurately physicians perceive patient suffering remains unclear. The authors sought to quantitatively compare physicians' estimates of their patients' suffering with the patients' ratings of their own suffering, using a paired survey. METHOD: Six major domains of suffering (DOSs) were derived from narrative descriptions of suffering by physicians and patients in a preliminary multicenter pilot study. From September 2005 through July 2006 at two teaching hospitals in Washington, DC, and Bethesda, Maryland, before a clinical encounter between a patient and physician, patients rated the impact of each of these DOSs on their overall suffering. After the same encounter, physicians rated the same DOSs according to their perception of suffering experienced by that patient. Patient responses were compared with physician responses using the Wilcoxon signed ranks and Spearman correlation tests. RESULTS: Two hundred twenty-seven adult patients and their treating physicians completed the survey. Cooperation rates among patients and physicians were 94% and 97%, respectively. For two of the six DOSs (pain and physically nonpainful symptoms), there was no significant difference between the physicians' estimates of suffering and the patients' ratings of the DOS. For the remaining four DOSs (communication, emotional factors, loss, and systems factors), there was significant disagreement between the physicians' estimates and the actual suffering of the patients (P < .01). When all six DOSs were combined to ascertain how well perceptions of overall suffering correlated, significant discordance was also observed between physicians' perceptions and patients' descriptions (P < .001). CONCLUSIONS: This study suggests that the physicians who participated might need more training in the recognition of patient suffering. Because these physicians were trained in medical schools across the country, the deficiencies noted here may not be limited to only the physicians in this study. More studies of physicians' ability to detect and manage suffering are needed, especially at nonteaching hospitals.

Young children who are enrolled in Medicaid or the Children’s Health Insurance Program (CHIP) can be at risk for developing early childhood caries (ECC). ECC is a chronic bacterial infection that causes severe tooth decay and can begin to develop before baby teeth erupt. Children with ECC may experience pain, difficulty eating, developmental complications, and loss of days in day care or preschool. ECC is expensive to treat and untreated ECC can lead to other serious infections.

Young children who are enrolled in Medicaid or the Children’s Health Insurance Program (CHIP) can be at risk for developing early childhood caries (ECC). ECC is a chronic bacterial infection that causes severe tooth decay and can begin to develop before baby teeth erupt.

States across the nation are redesigning their health care systems to promote higher quality health care services, healthier populations, and lower per capita costs. Medicaid and the Children’s Health Insurance Program (CHIP) are playing key roles in health system redesign for the 31 million children enrolled in these programs.

Objective. To study the short- and long-term effects of botulinum neurotoxin A (BoNT-A, Botox®, Allergan Inc.) on refractory chronic low back pain. Design. The effect of botulinum neurotoxin A on chronic low back pain was prospectively studied in 75 patients with repeated treatments over a period of 14 months. Pain intensity (visual analog scale [VAS]), pain frequency (pain days), and perceived functional status (Oswestry scale) were assessed at baseline, 3 weeks, and at 2, 4, 6, 8, 10, 12, and 14 months. BoNT-A was injected into para-spinal muscles at 4–5 levels (between L1 and S1) unilaterally or bilaterally. The dose per site varied from 40 to 50 units. The total dose per session ranged from 200 to 500 units. Reinjections were performed at 4 months only when pain returned. Results. At 3 weeks, 40 patients (53%) and at 2 months, 39 patients (52%) reported significant pain relief. The change in VAS, Oswestry score, and pain days was significant compared with baseline at 2 months after each injection period ( P < 0.005) and remained so over subsequent treatments. Among initial responders, 91% continued responsiveness over the length of the study. Three patients (4%), after the first treatment, had a mild flulike reaction that lasted 2–5 days. Conclusion. Botulinum neurotoxin A may be beneficial in patients with chronic low back pain. A favorable initial response predicts subsequent responsiveness. The treatment is well tolerated, and side effects are mild and transient.

To investigate the effect of botulinum toxin A on associated pain and functional impairment of refractory plantar fasciitis.This is a randomized, double-blind, placebo-controlled study of 27 patients (43 feet) with plantar fasciitis. Block randomization was performed using computer software. In patients with bilateral symptoms of comparable severity, botulinum toxin A was injected in one foot and saline in the other foot. The treatment group received a total of 70 units of botulinum toxin A divided into two sites per foot. One of the two sites was the tender area in the medial aspect of the heel close to the calcaneal tuberosity (40 units), and the other was in the arch of the foot between an inch anterior to the heel and middle of the foot (30 units). The placebo group received the same volume of normal saline. Main outcome measures included: Pain Visual Analog Scale, Maryland Foot Score, Pain Relief Visual Analog Scale, and pressure algometry response. Patients were assessed before injection, at 3 wks, and at 8 wks.The study revealed statistically significant changes in the treatment group. Compared with placebo injections, the botulinum toxin A group improved in all measures: Pain Visual Analog Scale (P0.005), Maryland Foot Score (P = 0.001), Pain Relief Visual Analog Scale (P0.0005), and pressure algometry response (P = 0.003). No side effects were noted.Botulinum toxin A injection for plantar fasciitis yields significant improvements in pain relief and overall foot function at both 3 and 8 wks after treatment.

The objective was to report the results of electrodiagnostic testing performed on 56 U.S. Persian Gulf War (GW) veterans versus 120 U.S. non-Persian Gulf War (N-GW) patients referred to a physical medicine and rehabilitation clinic.A retrospective review of medical records was conducted.Patient medical records of U.S. GW and N-GW patients were reviewed. Patient demographics, reason for consultation, and results of electrodiagnostic testing were extracted from both groups. Results were recorded as positive (abnormal) or negative (normal) occurrence of radiculopathy, generalized peripheral polyneuropathy, and mononeuropathy. The results were then compared using Fisher's exact test.Of the patients referred to rule out a radiculopathy, one of the GW patients (1 of 73) had a positive study, whereas 9 of 38 N-GW patients had positive studies (p = 0.000). There was no statistically significant difference between the two groups with respect to the presence of generalized peripheral polyneuropathy or mononeuropathy.This retrospective review of medical records reveals no objective evidence from electrodiagnostic testing of an increased incidence of neuromuscular disease in GW veteran patients compared with N-GW patients. On the contrary, our results reveal a statistically lower incidence of positive electrodiagnostic testing within the GW veteran group, suggesting a lower threshold for referral of GW veteran patients for electrodiagnostic testing than N-GW patients.

As states seek to improve home and community-based services for people with disabilities, many are incorporating consumer-directed supportive services into their Medicaid programs. The national Cash and Counseling Demonstration uses a randomized design to compare an innovative model of consumer direction with the traditional agency-directed approach. This paper presents findings from the first demonstration program to be implemented, in Arkansas. Our survey of 1,739 elderly and nonelderly adults showed that relative to agency-directed services, Cash and Counseling greatly improved satisfaction and reduced most unmet needs. Moreover, contrary to some concerns, it did not adversely affect participants' health and safety.

This issue brief highlights the communications strategies that the David and Lucile Packard Foundation’s state-based Finish Line grantees in Colorado, Ohio, and Wisconsin are using to keep children’s health coverage on their state’s policy agendas.

This implementation guide helps states implement or improve care management entities (CMEs), which are designed to coordinate services provided by the many state agencies that serve youth with complex behavioral health needs.

Objectives: To investigate the efficacy of botulinum toxin A in chronic low back pain and associated disabilities. Methods: Thirty-one consecutive patients with chronic low back pain who met the inclusion criteria were studied: 15 received 200 units of botulinum toxin type A, 40 units/site at five lumbar paravertebral levels on the side of maximum discomfort, and 16 received normal saline. Each patient’s baseline level of pain and degree of disability was documented using the visual analogue scale (VAS) and the Oswestry Low Back Pain Questionnaire (OLBPQ). The authors reevaluated the patients at 3 and 8 weeks (visual analogue scale) and at 8 weeks (OLBPQ). Results: At 3 weeks, 11 of 15 patients who received botulinum toxin (73.3%) had >50% pain relief vs four of 16 (25%) in the saline group ( p = 0.012). At 8 weeks, nine of 15 (60%) in the botulinum toxin group and two of 16 (12.5%) in the saline group had relief ( p = 0.009). Repeat OLBPQ at 8 weeks showed improvement in 10 of 15 (66.7%) in the botulinum toxin group vs three of 16 (18.8%) in the saline group ( p = 0.011). No patient experienced side effects. Conclusion: Paravertebral administration of botulinum toxin A in patients with chronic low back pain relieved pain and improved function at 3 and 8 weeks after treatment.

The Physical Medicine and Rehabilitation Service provides a critical role in the assessment, management, and disposition of the newly injured combatant. This role has been well demonstrated during Operation Enduring Freedom and Operation Iraqi Freedom. Military physiatrists are uniquely suited to support military service members as they maximize their function and either return to duty or transition to civilian life.

This evaluation highlight illustrates how six grantees use multistate partnerships to improve the quality of children's health care. It describes the strategies that states use to create and maintain cross-state relationships, as well as the benefits and challenges of partnering.

California's Health-e-App Public Access (HeA PA) system enables low-income families to apply online for publicly funded children's health insurance. Findings from a study funded by the California Healthcare Foundation and the David and Lucile Packard Foundation have implications for Affordable Care Act implementation in California and other states. HeA PA contributed to growth in program applications, was used and well received by a segment of Internet-connected applicants, and complemented the system of assisted-online applications that many applicants used.

This brief presents the views of certified application assistants on barriers to the use of California's Health-e-App Public Access, a self-service online enrollment system for Healthy Families and Medicaid, and the potential role they could play in raising awareness of the system.

Critical thinking is not a subject that needs to be taught separately, but is a skill that can easily be included in any educational activity. As a skill it may be more important than the subject matter being taught because it is a skill that never goes out of date. English education, like any other form of education, should equip students with thinking skills that will enable them to evaluate and analyze constantly changing issues. As Indonesia prepares a cadre of English—speaking students whose role will be to interface with the influx of English information before it is translated into Indonesian, these students need analytical and critical thinking skills to evaluate what is important and what is not. The question this research attempted to analyze is as follows: are critical thinking skills presently part of the tool chest of third year Indonesian English language students. By using the Cornell Critical Thinking Test Level Z, students were analyzed in a series of subscales in order to provide data for improving educational instruction. Research showed that critical thinking skills among third year university English students in Indonesia lag far behind American secondary and university students.

This is the second brief in a series about the first year of California’s Health-e-App Public Access (HeA PA) self-service, public health benefits enrollment system, following its introduction in December 2010. It describes HeA PA applicants and their experiences with the tool. Findings suggest that tools like HeA PA are a good option for people who have convenient access to high-speed internet service and do not need extensive in-person help when applying for coverage.

This Evaluation Highlight discusses the early accomplishments, challenges, and lessons learned from the following four states pursuing practice-level quality measurement: Maine, Massachusetts, North Carolina, and Pennsylvania. It describes the states’ efforts to select meaningful measures, adapt health plan and state-level measures for practice-level reporting, and use technology to collect measurement data. The analysis draws on semi-structured interviews with demonstration staff, providers, and stakeholders and semi-annual reports the states submitted to the Centers for Medicare & Medicaid Services.

Error estimates for the cell discretization algorithm are obtained for polynomial bases used to approximate both H k ( Ω ) {H^k}(\Omega ) and analytic solutions to selfadjoint elliptic problems. The polynomial implementation of this algorithm can be viewed as a nonconforming version of the h-p finite element method that also can produce the continuous approximations of the h-p method. The examples provided by our experiments provide discontinuous approximations that have errors similar to the finite element results.

Health-e-App Public Access (HeA PA) is a self-service, online application for California's Healthy Families Program. This research brief describes the potential benefits of HeA PA for applicants and the state enrollment system, as well as use of the tool during its first year. The study found that in 2011 about 50,000 applicants used HeA PA (about 19 percent of all applications).

Author Manuscript date: 2013 February 05., Studies of the human microbiome have revealed that even healthy individuals differ remarkably in the microbes that occupy habitats such as the gut, skin and vagina. Much of this diversity remains unexplained, although diet, environment, host genetics and early microbial exposure have all been implicated. Accordingly, to characterize the ecology of human-associated microbial communities, the Human Microbiome Project has analysed the largest cohort and set of distinct, clinically relevant body habitats so far. We found the diversity and abundance of each habitat’s signature microbes to vary widely even among healthy subjects, with strong niche specialization both within and among individuals. The project encountered an estimated 81–99% of the genera, enzyme families and community configurations occupied by the healthy Western microbiome. Metagenomic carriage of metabolic pathways was stable among individuals despite variation in community structure, and ethnic/racial background proved to be one of the strongest associations of both pathways and microbes with clinical metadata. These results thus delineate the range of structural and functional configurations normal in the microbial communities of a healthy population, enabling future characterization of the epidemiology, ecology and translational applications of the human microbiome.

This brief, the fourth in a series that presents findings from the Administration on Aging's National Survey of Older Americans Act Program Participants, explores the prevalence of and challenges associated with multiple chronic conditions among program participants.

Background Back pain is the leading cause of disability in the world, but it is even more common in soldiers deployed for combat operations. Aside from battle injuries and psychiatric conditions, spine pain and other musculoskeletal conditions are associated with the lowest return-to-unit rate among service members medically evacuated out of Operations Iraqi and Enduring Freedom. Methods Demographic, military-specific, and outcome data were prospectively collected over a 2-week period at the Deployed Warrior Medical Management Center in Germany on 1410 consecutive soldiers medically evacuated out of theaters of combat operations for a primary diagnosis pertaining to back pain between 2004 and 2007. The 2-week period represents the maximal allowable time an evacuated soldier can spend in treatment before disposition (ie, return to theater or evacuate to United States) is rendered. Electronic medical records were then reviewed to examine the effect a host of demographic and clinical variables had on the categorical outcome measure, return to unit. Results The overall return-to-unit rate was 13%. Factors associated with a positive outcome included female sex, deployment to Afghanistan, being an officer, and a history of back pain. Trends toward not returning to duty were found for navy and marine service members, coexisting psychiatric morbidity, and not being seen in a pain clinic. Conclusions The likelihood of a service member medically evacuated out of theater with back pain returning to duty is low irrespective of any intervention(s) or characteristic(s). More research is needed to determine whether concomitant treatment of coexisting psychological factors and early treatment “in theater” can reduce attrition rates.

Objective To determine whether fluoroscopic guidance improves outcomes of injections for greater trochanteric pain syndrome. Design Multicentre double blind randomised controlled study. Setting Three academic and military treatment facilities in the United States and Germany. Participants 65 patients with a clinical diagnosis of greater trochanteric pain syndrome. Interventions Injections of corticosteroid and local anaesthetic into the trochanteric bursa, using fluoroscopy (n=32) or landmarks (that is, “blind” injections; n=33) for guidance. Main outcome measures Primary outcome measures: 0-10 numerical rating scale pain scores at rest and with activity at one month (positive categorical outcome predefined as ≥50% pain reduction either at rest or with activity, coupled with positive global perceived effect). Secondary outcome measures included Oswestry disability scores, SF-36 scores, reduction in drug use, and patients’ satisfaction. Results No differences in outcomes occurred favouring either the fluoroscopy or blind treatment groups. One month after injection the average pain scores were 2.7 at rest and 5.0 with activity in the fluoroscopy group compared with 2.2 and 4.0 in the blind injection group. Three months after the injection, 15 (47%) patients in the blind group and 13 (41%) in the fluoroscopy group continued to have a positive outcome. Conclusion Although using fluoroscopic guidance dramatically increases treatment costs for greater trochanteric pain syndrome, it does not necessarily improve outcomes. Trial registration Clinical trials NCT00480675

The IDEATel demonstration tested the effects of providing home-based telemedicine services to a large number of eligible Medicare beneficiaries who had diabetes and lived in medically underserved areas in New York City and upstate New York. This report updates two earlier reports to Congress and draws conclusions on demonstration impacts. The demonstration met the requirements set by Congress for implementation; however, as delivered, it was neither as intensive nor as technologically sophisticated as originally designed. The evaluation found IDEATel to be clinically effective in only one site and to have no effects on Medicare Total, Part A, and Part B expenditures or the use of expensive services, such as hospital care. The intervention’s costs were excessive (over $8,000 per person per year) compared to programs with similar-sized clinical impacts. Even if the intervention costs were halved and the program reduced hospitalizations by 50 percent (both unlikely scenarios), the program would still increase total costs to the government.

Charrow A, DiFazio M, Foster L, Pasquina PF, Tsao JW. Intradermal botulinum toxin type A injection effectively reduces residual limb hyperhidrosis in amputees: a case series. Objective To study the effectiveness of botulinum toxin type A (BTX-A) therapy for residual limb hyperhidrosis, prosthesis fit and function, and residual and phantom limb pain in patients with limb amputation. Design Consecutive case series. Setting Outpatient physical medicine and rehabilitation clinic. Participants Walter Reed Army Medical Center patients (N=8) with unilateral traumatic upper- or lower-limb amputation. Intervention BTX-A was injected transdermally in a circumferential pattern around the residual limb by using a 1-cm matrix grid. Main Outcome Measure A 10-cm continuous Likert visual analog scale was used to assess residual limb sweating and pain and prosthesis fit and function before and 3 weeks after BTX-A injections. Results Patients reported a significant reduction in sweating and improvement in prosthesis fit and function after treatment. However, residual limb and phantom pain were unaffected by treatment. Conclusions BTX-A may be an effective treatment for residual limb hyperhidrosis, resulting in subjective improvement in prosthesis fit and functioning. BTX-A should be considered as a method to manage excessive sweating in the residual limb of traumatic amputees.

To examine how a new model of consumer-directed care changes the way that consumers with disabilities meet their personal care needs and, in turn, affects their well-being.Eligible Medicaid beneficiaries in Arkansas, Florida, and New Jersey volunteered to participate in the demonstration and were randomly assigned to receive an allowance and direct their own Medicaid supportive services as Cash and Counseling consumers (the treatment group) or to rely on Medicaid services as usual (the control group). The demonstration included elderly and non-elderly adults in all three states and children in Florida.Telephone interviews administered 9 months after random assignment.Outcomes for the treatment and control group were compared, using regression analysis to control for consumers' baseline characteristics.Treatment group members were more likely to receive paid care, had greater satisfaction with their care, and had fewer unmet needs than control group members in nearly every state and age group. However, among the elderly in Florida, Cash and Counseling had little effect on these outcomes because so few treatment group members actually received the allowance. Within each state and age group, consumers were not more susceptible to adverse health outcomes or injuries under Cash and Counseling.Cash and Counseling substantially improves the lives of Medicaid beneficiaries of all ages if consumers actually receive the allowance that the program offers.

Consumer direction of Medicaid supportive services raises concerns about who should be permitted to self-direct, whether consumers should be allowed to pay family members, whether a self-directed option increases demand for services, and how to ensure quality. The Cash and Counseling programs contained features designed to address these concerns. DEMONSTRATION ENROLLMENT: Many consumers used representatives to manage the allowance on their behalf and others chose to disenroll, suggesting that beneficiaries were capable of deciding for themselves whether the programs were suitable for them. Participation among eligible beneficiaries during the demonstration was modest, suggesting that consumer direction did not itself substantially increase the demand for services. CONSUMER EXPERIENCES: Most consumers were able to assume the role of employer without difficulty, many hiring relatives or acquaintances as workers. In each state, more than 85 percent reported they would recommend the program to others seeking more control over their care, and more than half said the program had "improved their lives a great deal."

In light of evidence that Cash and Counseling improved beneficiary satisfaction and quality of life, this paper examines how the model worked for two other important groups: (1) the family and friends providing the most unpaid assistance to beneficiaries when those beneficiaries enrolled in the demonstration; and (2) the workers hired directly by beneficiaries who were randomly assigned to the demonstration treatment group. There are good reasons to study these groups. Most Medicaid beneficiaries who have disabilities rely on informal (unpaid) caregivers for most of their assistance with personal care, and society relies on unpaid caregivers to help beneficiaries live in the home or community as long as possible. Medicaid supplements informal assistance with paid supportive services. However, if paid services are unsatisfactory or too inflexible to meet beneficiaries' needs, the burden to compensate usually falls on informal caregivers, potentially causing them emotional, financial, and physical strain. Furthermore, although beneficiaries in the demonstration treatment group continued to receive informal care while enrolled in Cash and Counseling, a key feature of program participation was being able to hire workers of one's choosing, train and supervise them, and determine their wages, schedule, and tasks. Although consumer empowerment is the primary objective of Cash and Counseling, the viability of the model hinges on the willingness of family, friends, and others to work for self-directing consumers. Thus, understanding the rewards and hardships of consumers' directly hired workers is also important. We used telephone survey data to (1) estimate the impacts of Cash and Counseling on the well-being of caregivers who were beneficiaries' primary informal caregivers at baseline, and (2) describe the experiences and job conditions of the workers who were hired by treatment group consumers and were their primary paid workers at follow-up. Both groups of caregivers were interviewed about 10 months after beneficiaries enrolled in the demonstration.

Objectives The aim of this study was to evaluate the effects of two successive neurotoxin treatments for chronic low back pain using multiple pain rating scales in an open-label, prospective study. Methods Adult patients with chronic low back pain received multiple paraspinal muscle injections with a maximum dosing of 500 units of botulinum A toxin per session. Those with a beneficial clinical response received a second treatment at 4 months. Pain was assessed by visual analog scale (VAS), modified low back pain questionnaire (OLBPQ), and a clinical low back pain questionnaire (CLBPQ) at baseline, 3 weeks, 2 months, 4 months, and 6 months after the first treatment. Results Eighteen women and 42 men, ages 21 to 79 years (mean 46.6 years), with low back pain of a mean duration of 9.1 years were included. Significant improvement in back and radicular pain occurred at 3 weeks in 60% and at 2 months in 58% of the cohort. Beneficial clinical response to the first injection predicted response to reinjection in 94%. A significant minority of patients had a sustained beneficial effect from the first injection at 4 (16.6%) and 6 months (8.3%). Two patients had a transient flu-like reaction after the initial treatment. Conclusions Botulinum toxin A improves refractory chronic low back pain with a low incidence of side effects. The beneficial clinical response is sustained with a second treatment.

The new Medicare Part D benefit, which began on January 1, 2006, expanded Medicare to include prescription drugs, and it required beneficiaries to change how they interact with the program. Past experience with low enrollment in a variety of programs designed to aid low-income Medicare beneficiaries suggests that there will be significant barriers to enrolling them into the Low-Income Subsidy (LIS) and Part D plans and getting them to make choices among different plan options. This report presents the evaluation framework, methods of data collection, and analytic strategies for identifying best practices–and the factors that contribute to their effectiveness–for the successful enrollment of all types of low-income Medicare beneficiaries into the LIS and Part D programs.

Purpose: We assess the effect of consumer-directed care on the emotional, physical, and financial well-being of the primary informal caregivers of the Medicaid beneficiaries who voluntarily joined Arkansas's Cash and Counseling demonstration. Design and Methods: The demonstration randomly assigned beneficiaries to a program in which they could direct their own disability-related supportive services (the treatment group) or rely on traditional agency services (the control group). We constructed outcome measures from telephone interviews with 1,433 caregivers who provided beneficiaries with the most unpaid assistance at baseline, and we used multivariate regression models to estimate program effects. Interviews occurred between February 2000 and April 2002, 10 months after beneficiaries' random assignment. Results: At follow-up, treatment group caregivers provided fewer hours of assistance than did their control group counterparts, on average, and they reported better emotional, physical, and financial well-being. Implications: Permitting interested Medicaid beneficiaries to direct their own in-home supportive services reduces burden on informal caregivers, which may help reduce beneficiaries' nursing home use.

Promoting the well-being of parents and other relatives who serve as informal caregivers to provide vital, unpaid personal care to children with developmental disabilities is an important policy objective. Furthermore, paid supportive services that children receive in addition to unpaid care could profoundly affect the informal caregivers who help them most. Treatment group caregivers provided as much overall assistance as did control group caregivers, yet they reported greater satisfaction with the child’s care and less physical strain on themselves. Treatment group caregivers were more likely to be working and less likely to say that caregiving caused great financial strain. They were also more likely to be very satisfied with how they were spending their own lives.

As states seek to improve home and community-based services for people with disabilities, many are incorporating consumer-directed supportive services into their Medicaid programs. The national Cash and Counseling Demonstration uses a randomized design to compare an innovative model of consumer direction with the traditional agency-directed approach. This paper presents findings from the first demonstration program to be implemented, in Arkansas. Our survey of 1,739 elderly and nonelderly adults showed that relative to agency-directed services, Cash and Counseling greatly improved satisfaction and reduced most unmet needs. Moreover, contrary to some concerns, it did not adversely affect participants' health and safety.

This report presents the first impact analysis results from a three-state demonstration in which disabled Medicaid enrollees eligible for personal assistance services get a cash allowance so they can hire whom they please or use the money to buy equipment or supplies, instead of obtaining services through a home health agency. The results show that the Arkansas program greatly increases consumers' satisfaction with the quality and reliability of care. The program also reduces unmet needs for assistance, preserves health and safety, and improves outlook on life. The findings from this random assignment design provide strong support for the many states considering Medicaid program modifications that promote increased consumer direction.