Accountability, Cost-Effectiveness, and Program Performance: Progress Since 1998

The authors summarize the progress made in the past decade toward making homeless assistance programs more accountable to funders, consumers, and the public. They observe that research on the costs of homelessness and cost offsets associated with intervention programs has been limited to people who are homeless with severe mental illness. But this research has raised awareness of the value of this approach, such that dozens of new studies in this area are underway, mostly focused on chronic homelessness. Less progress has been made in using cost and performance data to systematically assess interventions for families, youth, and transitionally homeless adults. The authors present case studies of promising practices from the State of Arizona and Columbus, Ohio, demonstrating innovative uses of client and program data to measure performance and improve program management toward state policy goals, such as increased housing placement rates, reduced lengths of homelessness, and improved housing stability

Generating hypotheses about care needs of high utilizers: lessons from patient interviews.

Informed by a largely secondary and quantitative literature, efforts to improve care and outcomes for complex patients with high levels of emergency and hospital-based health care utilization have offered mixed results. This qualitative study identifies psychosocial factors and life experiences described by these patients that may be important to their care needs. Semi-structured interviews were conducted with 19 patients of the Camden Coalition of Healthcare Providers\u27 Care Management Team. Investigators coded transcripts using a priori and inductively-derived codes, then identified 3 key themes: (1) Early-life instability and traumas, including parental loss, unstable or violent relationships, and transiency, informed many participants\u27 health and health care experiences; (2) Many high utilizers described a history of difficult interactions with health care providers during adulthood; (3) Over half of the participants described the importance to their well-being of positive and caring relationships with primary health care providers and the outreach team. Additionally, the transient and vulnerable nature of this complex population posed challenges to follow-up, both for research and care delivery. These themes illuminate potentially important hypotheses to be explored in more generalizable samples using robust and longitudinal methods. Future work should explore the prevalence and impact of adverse childhood experiences among high utilizers, and the different types of relationships they have with providers. Investigators should test new modes of care delivery that attend to patients\u27 trauma histories. This qualitative study was well suited to provide insight into the life stories of these complex, vulnerable patients, informing research questions for further investigation

Measuring allostatic load in children: Exploring the pathway between biomarkers and educational outcomes

Allostatic load is hypothesized to be the physiological costs of chronic exposure to the neuroendocrine stress response. It refers specifically to a composite index of indicators of cumulative strain on multiple organs and tissues which accumulates via the wear and tear associated with shifts in physiologic activity in response to chronic exposure to negative stimuli. There has been very little research exploring the valid measurement of the allostatic load or the relationship between allostatic load and child developmental outcomes. In this study, cross-sectional National Health and Nutrition Examination Survey III biomarker data for children ages 8 to 16 years old and structural equation modeling were used to investigate the measurement of allostatic load and its impact on educational outcomes. Three alternative allostatic load measurement models were investigated, and one provided an adequate fit to the study data. The causal relationship between the allostatic load model, socioeconomic status and education outcomes was then investigated. Results indicated construct differences by sex and by race for females. Allostatic load in the male causal model was a small but significant predictor of absences and suspensions, but did not significantly predict reading and math scores. This work lays the foundation for future allostatic load measurement and outcome studies in children and adolescent populations. Recommendations for future research are discussed