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

Pain conditions are the leading cause of disability among active-duty service members. Given the significant implications for force readiness and service member well-being, the Military Health System (MHS) has made it a strategic priority to provide service members with the highest-quality treatment for pain conditions. RAND researchers assessed MHS outpatient care for acute and chronic pain, including opioid prescribing. The assessment involved developing a set of 14 quality measures designed to assess aspects of outpatient care for pain, including care associated with dental and ambulatory procedures, acute low back pain, chronic pain, opioid prescribing, and medication treatment for opioid use disorder. This research offers the most comprehensive examination to date of the quality and safety of pain care in the MHS and its alignment with evidence-based clinical practice guidelines. It identifies several areas of strength in pain care delivery, along with some areas for improvement, and provides recommendations to support the MHS in continuing to improve pain care for service members.

Medicare payments for most surgical procedures cover both procedures and post-operative visits occurring within a global period of either 10 or 90 days following procedures. There have been concerns that fewer post-operative visits are provided than the number of post-operative visits considered when the procedure was valued. To help inform accurate valuation of procedures with global periods, the Centers for Medicare & Medicaid Services (CMS) required select practitioners to report on post-operative visits after select procedures with 10- or 90-day global periods. The authors of this article summarize patterns of post-operative visits for procedures furnished during calendar year 2019, building on prior research that analyzed data for procedures furnished from July 1, 2017, through June 30, 2018, and for the entire 2018 calendar year. During calendar year 2019, 96.5 percent of procedures with 10-day global periods did not have an associated post-operative visit. Approximately two-thirds of procedures with 90-day global periods had an associated post-operative visit; however, the ratio of observed to expected post-operative visits provided for 90-day global period procedures was only 0.38. Underreporting of post-operative visits might be driving these low rates. However, in sensitivity analyses limited to practitioners who were actively reporting their post-operative visits, post-operative patterns were largely similar to the main analysis. Collectively, these findings suggest that many expected post-operative visits are not delivered and that underreporting is unlikely to fully explain the low ratio of expected post-operative visits provided.

Since 2001, more than 3 million service members have deployed in support of multiple combat operations in Afghanistan, Iraq, and other theaters. Many have been diagnosed with the ""signature wounds"" of these conflicts: posttraumatic stress disorder (PTSD) and/or traumatic brain injury (TBI). During the intervening years, the process by which service members are evaluated for disability has evolved significantly, including a complete overhaul of the Disability Evaluation System (DES) beginning in 2007. Meanwhile, the Department of Defense (DoD) and the services made policy changes and initiated other efforts to improve screening for PTSD and TBI, encourage service members to seek treatment, improve quality of care, and reduce the stigma associated with treatment for these conditions. To explore these changes, as well as their potential effects on the numbers and characteristics of service members who are evaluated through DES, the authors identify and assess trends in DES outcomes for PTSD and TBI between 2002 and 2017.

Medicare payment for many health care procedures covers not only the procedure itself but also most post-operative care over a fixed period of time (the “”global period””). The Centers for Medicare & Medicaid Services (CMS) sets payment rates assuming that a certain number and type of post-operative visits specific to each procedure typically occur. This article describes how CMS might use claims-based data on the number of post-operative visits to adjust valuation for procedures with 10- and 90-day global periods. There are links between the number of bundled post-operative visits and the components of valuation addressed in this study: work, practice expense (PE), and malpractice relative value units (RVUs). There is some ambiguity regarding how a reduction in post-operative visits translates into changes in work RVUs. In contrast, a reduction in post-operative visits has clear implications on physician time and direct PE. Changes in physician work, physician time, and direct PE will, in turn, affect the allocation of pools of PE and malpractice RVUs to individual services. The idiosyncrasies of the resource-based relative value scale system used to determine payment for Medicare services result in some ambiguity about how procedures should be revalued to reflect reductions in post-operative visits. These results may inform further policy development around revaluation for global procedures.

A large part of this study is based on data collected in 2011 in five focus countries of the MENA region. In addition, other existing data sources were used as well, as documented in the various chapters that follow, but this need not be discussed in this chapter. This chapter documents the process followed and some of the choices made for new data collection, both quantitative and qualitative, for the study on climate change and migration in the MENA region. After a brief introduction, we explain the nature of the household survey questionnaire, what it enables us to document, as well as some of its limits. Next, we explain how the household survey sites were selected and how the samples were constructed in each of the five focus countries. We also provide a few comments on the challenges encountered during survey implementation. The chapter finally explains the process used for the focus group discussions and in-depth interview, as well as for the interviews with key informants conducted in each country.

As the United States continues deployments of service members to support operations in Iraq and Afghanistan, it is increasingly important to understand the effects of this military involvement, not only on service members but also on the health and well-being of their spouses and youth. This article shares highlights from a study that examined the functioning of a sample of youth in military families who applied to a free camp for children of military personnel and to specifically assess how these youth are coping with parental deployment. It addresses the general well-being of military youth during and after parental deployment, with attention to their emotional, social, and academic functioning. It also examines the challenges that their nondeployed caregivers face. The study included quantitative and qualitative components: three waves of phone surveys with youth and nondeployed caregivers, and in-depth interviews with a subsample of caregivers. The researchers found that children and caregivers who had applied to attend the camp confronted significant challenges to their emotional well-being and functioning. Four factors in particular-(1) caregiver emotional well-being, (2) more cumulative months of deployment, (3) National Guard or Reserve status, and (4) quality of caregiver-youth communication-were strongly associated with greater youth or caregiver difficulties.

An estimated 36 percent of American adults have health literacy levels rated at "basic or below," indicating that they have difficulty obtaining, processing, and understanding basic health information and services. To help healthcare decisionmakers in Missouri identify neighborhood-level "hotspots" of suboptimal health or healthcare that may be due to low health literacy, RAND developed a prototype interactive web-based mapping tool. This builds on earlier RAND work to develop a predictive model of health literacy and estimate levels of health literacy in small geographic areas (e.g., census tracts). The interactive mapping tool allows stakeholders to select the level of geography (e.g., census tract, county), obtain information for and map specific regions of interest, select the characteristics to be mapped (i.e., estimates of community-level health literacy, health outcomes and care quality, neighborhood sociodemographic characteristics, and neighborhood health services data), and generate tables and reports on the regions and characteristics of interest. Housed on a dedicated RAND website (http://www.rand.org/health/projects/missouri-health-literacy.html), the mapping tool makes it possible for a range of stakeholders, from health plans to community organizations, to access and use the tool to help address healthcare disparities in their communities.