Planning a Better Future for Dual Eligible Elderly in Montgomery County

Older adults who are dual eligible (who qualify for both Medicare and Medicaid) face a daunting gauntlet of challenges in healthcare. Despite comprehensive coverage through Medicare and Medicaid, the lack of coordination between the two systems creates often insurmountable problems of access and delivery. Federally-funded Medicare lacks coordination and integration with federal-state funded Medicaid. Ironically, it is these dual eligible individuals who so desperately need healthcare since they have a higher incidence of cognitive impairment (including Alzheimer's Disease), mental disorders, diabetes, pulmonary disease and strokes. Further, they are more vulnerable and frail, have lower incomes, and are more isolated than are non-dual eligible elderly. These problems, in turn, contribute to significant challenges with housing, food and transportation. The challenges with access to care are tragic, expensive and avoidable.The high care needs of dual eligible individuals and the associated costs have driven states and the federalgovernment to seek ways to better integrate and coordinate their care. The Affordable Care Act (2010) is teemingwith initiatives, demonstrations, and new opportunities premised on finding a way to better meet dual eligibleindividuals' healthcare needs at a cost-effective rate. While little has yet been done at the state level, localproviders are starting to test innovative approaches to delivering better care to dual eligible individuals.This report summarizes state and federal initiatives and opportunities for delivering better care to dual eligible elderly. It also presents the efforts underway at the County level and by local providers. Following the informational section of the report, the Workgroup presents nine systems change recommendations to better improve the care provided to Montgomery County's dual eligible elderly. The recommendations may stand alone, each reflecting their own systems change, or may be combined in a more encompassing effort at service delivery system overhaul.There are numerous federal opportunities for delivering better care to frail populations. Some of them are specifically targeted towards the dual eligible population and others are targeted towards other populations, but include a considerable number of dual eligible individuals. In the report, we describe five different types ofapproaches and describe examples of each

Modeling building semantics: providing feedback and sustainability

Even minor changes in user activity can bring about significant energy savings within built space. Many building performance assessment methods have been developed, however these often disregard the impact of user behavior (i.e. the social, cultural and organizational aspects of the building). Building users currently have limited means of determining how sustainable they are, in context of the specific building structure and/or when compared to other users performing similar activities, it is therefore easy for users to dismiss their energy use. To support sustainability, buildings must be able to monitor energy use, identify areas of potential change in the context of user activity and provide contextually relevant information to facilitate persuasion management. If the building is able to provide users with detailed information about how specific user activity that is wasteful, this should provide considerable motivation to implement positive change. This paper proposes using a dynamic and temporal semantic model, to populate information within a model of persuasion, to manage user change. By semantically mapping a building, and linking this to persuasion management we suggest that: i) building energy use can be monitored and analyzed over time; ii) persuasive management can be facilitated to move user activity towards sustainability

Roadmap to Gridlock: The Failure of Long-Range Metropolitan Transportation Planning

Federal law requires metropolitan planning organizations in urban areas of more than 50,000 people to write long-range (20- to 30- year) metropolitan transportation plans and to revise or update those plans every 4 to 5 years. A review of plans for more than 75 of the nation's largest metropolitan areas reveals that virtually all of them fail to follow standard planning methods. As a result, taxpayers and travelers have little assurance that the plans make effective use of available resources to reduce congestion, maximize mobility, and provide safe transportation facilities. Nearly half the plans reviewed here are not cost effective in meeting transportation goals. These plans rely heavily on behavioral tools such as land-use regulation, subsidies to dense or mixed-use developments, and construction of expensive rail transit lines. Nearly 40 years of experience with such tools has shown that they are expensive but provide negligible transportation benefits. Long-range transportation planning necessarily depends on uncertain forecasts. Planners also set qualitative goals such as "vibrant communities" and quantifiable but incomparable goals such as "protecting historic resources." Such vagaries result in a politicized process that cannot hope to find the most effective transportation solutions. Thus, long-range planning has contributed to, rather than prevented, the hextupling of congestion American urban areas have suffered since 1982. Ideally, the federal government should not be in the business of funding local transportation and dictating local transportation policies. At the least, Congress should repeal long-range transportation planning requirements in the next reauthorization of federal surface transportation funding. Instead, metropolitan transportation organizations should focus planning on the short term (5 years), and concentrate on quantifiable factors that are directly related to transportation, including safety and congestion relief

A telehealth approach to improving clinical trial access for infants with tuberous sclerosis complex.

BackgroundResearch in rare genetic syndromes associated with ASD is often hampered by the wide geographic distribution of families and the presence of medical comorbidities, such as epilepsy, that may preclude travel to clinical sites. These challenges can limit the sample size and generalizability of the cohorts included in both natural history studies and clinical trials. Tuberous sclerosis complex (TSC) is a rare genetic syndrome that confers an elevated risk for autism spectrum disorder (ASD), with social communication delays identified in this population as early as 12 months of age. Early identification of risk necessitates parallel testing of early intervention, prompting the first randomized controlled clinical trial of behavioral intervention for infants with TSC (NCT03422367). However, considerable early recruitment challenges have mandated the systematic identification of enrollment barriers followed by modification of the study design to address these barriers.MethodsCaregivers were interviewed regarding barriers to enrollment (phase 1). Adaptations to the intervention were made to address these barriers (phase 2). Outcomes based on this modification to the study design were defined by enrollment rate and participant demographics.ResultsQualitative reports from caregivers indicated that distance and time were the primary barriers to clinical trial enrollment. The intervention was then modified to a remote model, with at-home, parent-delivered intervention, and weekly video conferencing with interventionists at the study sites. Enrollment increased 10-fold (from 3 to 30 participants) within 1 year and included a more diverse and clinically representative cohort of infants.ConclusionThe design and implementation of more scalable methods to disseminate research remotely can substantially improve access to clinical trials in rare neurodevelopmental disorders. The lessons learned from this trial can serve as a model for future studies not only in rare conditions, but in other populations that lack adequate access, such as families with limited financial or clinical resources. Continued efforts will further refine delivery methods to enhance efficiency and ease of these delivery systems for families

Magnetoencephalography in Stroke Recovery and Rehabilitation

Magnetoencephalography (MEG) is a non-invasive neurophysiological technique used to study the cerebral cortex. Currently, MEG is mainly used clinically to localize epileptic foci and eloquent brain areas in order to avoid damage during neurosurgery. MEG might, however, also be of help in monitoring stroke recovery and rehabilitation. This review focuses on experimental use of MEG in neurorehabilitation. MEG has been employed to detect early modifications in neuroplasticity and connectivity, but there is insufficient evidence as to whether these methods are sensitive enough to be used as a clinical diagnostic test. MEG has also been exploited to derive the relationship between brain activity and movement kinematics for a motor-based brain-computer interface. In the current body of experimental research, MEG appears to be a powerful tool in neurorehabilitation, but it is necessary to produce new data to confirm its clinical utility

Feasibility of Measuring Tobacco Smoke Air Pollution in Homes: Report from a Pilot Study.

Tobacco smoke air pollution (TSAP) measurement may persuade parents to adopt smoke-free homes and thereby reduce harm to children from tobacco smoke in the home. In a pilot study involving 29 smoking families, a Sidepak was used to continuously monitor home PM(2.5) during an 8-h period, Sidepak and/or Dylos monitors provided real-time feedback, and passive nicotine monitors were used to measure home air nicotine for one week. Feedback was provided to participants in the context of motivational interviews. Home PM(2.5) levels recorded by continuous monitoring were not well-accepted by participants because of the noise level. Also, graphs from continuous monitoring showed unexplained peaks, often associated with sources unrelated to indoor smoking, such as cooking, construction, or outdoor sources. This hampered delivery of a persuasive message about the relationship between home smoking and TSAP. By contrast, immediate real-time PM(2.5) feedback (with Sidepak or Dylos monitor) was feasible and provided unambiguous information; the Dylos had the additional advantages of being more economical and quieter. Air nicotine sampling was complicated by the time-lag for feedback and questions regarding shelf-life. Improvement in the science of TSAP measurement in the home environment is needed to encourage and help maintain smoke-free homes and protect vulnerable children. Recent advances in the use of mobile devices for real-time feedback are promising and warrant further development, as do accurate methods for real-time air nicotine air monitoring