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RESEARCH OBJECTIVE: Socioeconomic disparities in mental health care use can be mitigated by interventions to systematically improve disease diagnosis and treatment. Beginning 2010, Los Angeles County Departments of Health Services (DHS) and Mental Health (DMH) collaborated to increase access to effective mental health treatment. Implemented in staggered fashion among select safety‐net clinics, the Mental Health Integration Program (MHIP) embedded behavioral health specialists to co‐manage primary care patients (e.g., psychiatric consultation support for medication prescription, brief problem‐focused psychotherapy). This study examined whether clinic MHIP implementation was associated with higher treatment initiation (medication receipt and/or specialist follow‐up [for psychotherapy]) in safety‐net clinic sites. STUDY DESIGN: This retrospectively cohort study examined 33,537 primary care patients who were newly diagnosed with depression from June 30, 2009 to July 1, 2014 (n = 39,066 person‐years), using merged medical and pharmacy records from DHS and DMH. Patients were seen in one of 19 clinics that were either: (1) before, (2) after, or (3) had never implemented MHIP. We followed patients for 90 days after a new diagnosis, defined as having no diagnoses in the prior year. Then, we determined whether patients received antidepressant medication (prescription filled per pharmacy records) and/or mental health specialist follow‐up (completed referral documented in medical records). In multilevel regression models, we used MHIP implementation status to predict odds of treatment initiation, controlling for time and patient demographic and clinical characteristics (e.g., comorbidity). POPULATION STUDIED: 255,840 safety‐net patients seen in LA County. PRINCIPAL FINDINGS: In 30.1% of episodes, primary care patients received any treatment within 90 days of a new depression diagnosis (38.7% [after] vs 36.2% [before] vs 25.0% [never implemented MHIP in clinic]). 27.9% received medication within 90 days, while only 3% reached specialists. In multivariate analyses (n = 30,347 person‐years), we found that there was 2.35‐times odds of treatment initiation among patients in clinics after MHIP implementation (odds ratio [OR] = 2.35; 95% confidence interval [CI] = 2.18–2.55; p Latino > Black) than White patients, Spanish‐ than English‐speaking patients, and uninsured than insured patients in the study sample. CONCLUSIONS: Collaboration between two large, distinct health systems and its resulting integrated care programs were associated with greater odds of treatment initiation among patients newly diagnosed with depression, compared to patients in clinics before implementation or in clinics that did not implement. Findings suggest potential positive effects of targeted outreach (to minority and Spanish‐speaking patients) and possible leakage of insured patients to private sectors for depression treatment. IMPLICATIONS FOR POLICY OR PRACTICE: This evaluation is one of few to document effects from widescale implementation of integrated mental health care, in particular within the country's second largest public health system. Observed mental health integration programs may need further innovation to address current access gaps in mental health specialty care, such that evidence‐based psychotherapy options are also available to safety‐net primary care patients. PRIMARY FUNDING SOURCE: Department of Veterans Affairs.

BackgroundBeginning in 2010, Los Angeles County Departments of Health Services and Mental Health collaborated to increase access to effective mental health care. The Mental Health Integration Program (MHIP) embedded behavioral health specialists in primary care clinics to deliver brief, problem-focused treatments, and psychiatric consultation support for primary care-prescribed psychotropic medications.ObjectiveThe aim was to compare primary care visits associated with psychiatric diagnoses before and after MHIP implementation.MethodsThis retrospective cohort study (2009-2014) examined 62,945 patients from 8 safety-net clinics that implemented MHIP in a staggered manner in Los Angeles. Patients' primary care visits (n=695,354) were either associated or not with a previously identified or "new" (defined as having no diagnosis within the prior year) psychiatric diagnosis. Multilevel regression models used MHIP implementation to predict odds of visits being associated with psychiatric diagnoses, controlling for time, clinic, and patient characteristics.Results9.4% of visits were associated with psychiatric diagnoses (6.4% depression, 3.1% anxiety

Background With the expansion of online patient portals linked to electronic health records in safety-net health care settings, we need more data on the use of these websites by patients with limited English proficiency (LEP) in order to guide their continued design, implementation, and evaluation as portals for the underserved. Methods Cross-sectional portal data for the Los Angeles County Department of Health Services, the second largest safety-net system in the nation. We examined differences in portal use across language (English vs. non-English/LEP), covering four years since implementation. Results Of 425,281 patients assigned to primary care as of March 2019, 55,190 (13%) unique portal enrollments were registered. Among 54,981 portal users, LEP users had lower adjusted odds of using an active portal function (e.g., medication refill) vs. English-speakers. Conclusions Even among those registered to access portals, these websites are underused, particularly by LEP patients. All systems must facilitate use for these populations, especially for time-saving active functions, which can improve outcomes. Health systems must prioritize design/usability as a factor to counter LEP underuse.

Despite the implementation of internet patient portals into the safety net after the introduction of the Affordable Care Act in the United States, little attention has been paid to the process of engaging vulnerable patients into these portals. The portal is a health technology tool that was developed with a mainstream, English-speaking audience in mind. Thus, there are valid concerns that such technologies will actually exacerbate health care disparities, conferring further advantages to the already advantaged. In this paper, we describe a framework for portal engagement (awareness, registration, and use) among safety net patients. We incorporate the experiences in the Los Angeles County Department of Health Services to illustrate important contextual factors for portal outreach in our safety net. Finally, we discuss considerations for moving forward with health technology in the safety net as the next version of patient portals are being developed.

Objectives Driven by beneficial patient-centered outcomes associated with patient portal use and the Affordable Care Act, portal implementation has expanded into safety nets—health systems that offer access to care to a large share of uninsured, Medicaid, and other vulnerable populations. However, little attention has been paid to the factors that affect portal accessibility by the vulnerable patients served by these health systems—including those who are limited English proficient (LEP). Materials and Methods The Los Angeles County Department of Health Services (LAC DHS), the second-largest safety net system in the nation, launched its first patient portal, and one of the few bilingual English-Spanish interfaces in existence, in March of 2015. To explore portal awareness and perceptions, we conducted focus groups with LAC DHS patients, in English and Spanish (LEP). The Technology Acceptance Model was used to guide thematic analysis of focus group data. Results Of the 46 participants, 37 were patients and 9 were caretakers; 23 were English-speaking and 23 Spanish-speaking LEP. All patients had diabetes or hypertension. Over half had an annual household income Conclusions Safety net participants identified concrete benefits to the portal and emphasized the need for portal engagement that offered accessible education, support, and resources in clinical and community settings. The portal offers an additional opportunity to engage the patient and family with trusted and validated health information, and should be further developed in this capacity. This study provides a better understanding of preferred improvements of patient portal engagement that guide broader health technology efforts to address electronic health disparities.

© 2015 Wiley Periodicals, Inc. Background and Importance: Challenges in healthcare policy and practice have stimulated interest in dissemination and implementation science. The Institute of Medicine Committee on the Clinical Translational Science Award (CTSA) program recommended expanding the CTSA program's investment and activity in this domain. Guidance is needed to facilitate successful growth of DII science infrastructure, activity and impacts. Objectives: Several CTSAs in Southern California collaborated to identify and respond to local challenges and opportunities to expand dissemination, implementation and improvement research by strengthening capacity and relationships between DII researchers and community, health system, and population health partners. Main outcomes: Planning and outreach by the Southern California CTSAs increased awareness and interest in DII research and generated recommendations for growth. Recommendations include: increasing strong partnerships with healthcare and population health systems to guide policy research agendas and collaborative DII science; promoting multi-sector partnerships that involve researchers and delivery systems throughout DII processes; bringing together multiple disciplines; and addressing national and international barriers as well as opportunities in DII science. Implications: CTSAs through regional collaboration can increase their contributions to improved community health via skill-building, partnership development and enhanced outreach to local healthcare and public health agencies and delivery systems.

Objective: We describe the rationale, de­velopment, and progress on the Community and Patient Partnered Research Network (CPPRN). The CPPRN builds on more than a decade of partnered work and is designed to promote health equity by developing partnered research on behavioral health and social risk factors in Los Angeles and New Orleans. Methods: Review of rationale, history, structure, activities and progress in applying community partnered participatory research (CPPR) to CPPRN. Setting: A community-academic partner­ship across Los Angeles County and New Orleans. Design: Descriptive report. Findings: Patient and community stakehold­ers participated in all phases of develop­ment, including local and national activities. Key developments include partnered plan­ning efforts, progress on aggregating a large, de-identified dataset across county agen­cies, and development of an information technology-supported screening approach for behavioral and social determinants in health care, social, and community-based settings. Conclusion: The CPPRN represents a promising approach for research data networks, balancing the potential benefit of information technology and data analytic approaches while addressing potential risks and priorities of relevant stakehold­ers. Ethn Dis. 2018;28(Suppl 2):295-302; doi:10.18865/ed.28.S2.295.

Despite the HIV “test-and-treat” strategy’s promise, questions about its clinical rationale, operational feasibility, and ethical appropriateness have led to vigorous debate in the global HIV community. We performed a systematic review of the literature published between January 2009 and May 2012 using PubMed, SCOPUS, Global Health, Web of Science, BIOSIS, Cochrane CENTRAL, EBSCO Africa-Wide Information, and EBSCO CINAHL Plus databases to summarize clinical uncertainties, health service challenges, and ethical complexities that may affect the test-and-treat strategy’s success. A thoughtful approach to research and implementation to address clinical and health service questions and meaningful community engagement regarding ethical complexities may bring us closer to safe, feasible, and effective test-and-treat implementation.

Objectives The high prevalence of coronary heart disease and dramatic growth of cardiac interventions in India motivate an evaluation of the appropriateness of coronary revascularisation procedures in India. Although, appropriate-use criteria (AUC) have been used to analyse the appropriateness of cardiovascular care in the USA, they are yet to be applied to care in India. In our study, we apply AUC to cardiac care in Karnataka, India, compare our results to international applications of AUC, and suggest ways to improve the appropriateness of care in India. Setting Data were collected from the Vajpayee Arogyashree Scheme, a government-sponsored health insurance scheme in Karnataka, India. These data were collected as part of the preauthorisation process for cardiac procedures. Participants The final data included a random sample of 600 patients from 28 hospitals in Karnataka, who obtained coronary artery bypass grafting or percutaneous coronary intervention between 1 October 2014 and 31 December 2014. Primary and secondary outcome measures We obtained our primary baseline results using a random imputation simulation to fill in missing data. Our secondary outcome measure was a best case–worst case scenario where missing data were filled to give the lowest or highest number of appropriate cases. Results Of the cases, 86.7% (CI 0.837% to 0.892%) were deemed appropriate, 3.65% (CI 0.023% to 0.055%) were inappropriate and 9.63% (CI 0.074% to 0.123%) were uncertain. Conclusions The vast majority of cardiac revascularisation procedures performed on beneficiaries of a government-sponsored insurance programme in India were found to be appropriate. These results meet or exceed levels of appropriate use of cardiac care in the USA.

Objectives: To understand the health care access issues faced by Los Angeles (LA) County’s uninsured and residually unin­sured after implementation of the Afford­able Care Act (ACA) and to identify poten­tial solutions using a community-partnered dialogue.Design: Qualitative study using a com­munity-partnered participatory research framework.Setting: Community forum breakout discus­sion.Discussants: Representatives from LA County health care agencies, community health care provider organizations, local community advocacy and service organiza­tions including uninsured individuals, and the county school district.Main Outcome Measures: Key structural and overarching value themes identified through community-partnered pile sort, c-coefficients measuring overlap between themes.Results: Five overarching value themes were identified – knowledge, trust, quality, partnership, and solutions. Lack of knowl­edge and misinformation were identified as barriers to successful enrollment of the eligible uninsured and providing health care to undocumented individuals. Discussants noted dissatisfaction with the quality of tra­ditional sources of health care and a broken cycle of trust and disengagement. They also described inherent trust by the uninsured in “outsider” community-based providers not related to quality.Conclusions: Improving health care for the residually uninsured after ACA implementa­tion will require addressing dissatisfaction in safety-net providers, disseminating knowl­edge and providing health care through trusted nontraditional sources, and using effective and trusted partnerships between community and health care agencies with mutual respect. Community-academic part­nerships can be a trusted conduit to discuss issues related to the health care of vulner­able populations. Ethn Dis. 2015; 25(4)487- 494; doi:10.18865/ed.25.4.487

HIV/AIDS-related stigma is a key factor impeding patient utilization of HIV testing services. To destigmatize HIV testing, the Centers for Disease Control and Prevention recommended an 'opt-out' screening strategy aimed at all patients in all clinical settings, regardless of HIV risk. This study assessed whether opt-out screening as compared to opt-in screening was associated with increased uptake of HIV testing among patients with HIV/AIDS-related stigma concerns. This study included 374 patients attending two Los Angeles ambulatory care clinics. Stigma items were grouped into three constructs: Blame/isolation, abandonment, and contagion. Individuals endorsing the blame/isolation subscale (AOR = 0.52; 95 % CI 0.29-0.92; p\0.05) and abandonment subscale (AOR = 0.27; 95 % CI 0.13-0.59; p\0.01) were significantly less likely to accept an HIV test. Additionally, the opt-out model did not counter the negative effects of stigma on HIV test acceptance. These findings indicate that stigma remains a barrier to HIV testing, regardless of the opt-out screening approach.

Background: A major obstacle to the administration of highly active antiretroviral therapy (HAART) in resource-limited settings is the high cost of CD4 count testing. The total lymphocyte count (TLC) has been proposed as a surrogate marker to monitor immune response to therapy. Objective: To assess, in a developed country setting, the capability and clinical utility of TLC change as a surrogate marker for CD4 count change in monitoring patients on HAART. Methods: Longitudinal co-variation between changes in TLC and concomitant changes in CD4 count following the initiation of HAART was examined using a retrospective cohort study of 126 HIV-positive patients attending The Miriam Hospital, Brown University, Providence, Rl. Analyses included evaluation of the direction of TLC change as a marker for direction of CD4 change, using sensitivity and specificity; evaluation of absolute change in TLC as a marker for benchmark changes in CD4 (≥50 over 6 months, ≥100 over 12 months), using receiver-operator characteristic (ROC) curves; and a regression model of change in TLC as a function of change in CD4, to understand within-individual variation of longitudinal TLC measures. Results: In the first 24 months of HAART, the sensitivity of a TLC increase as a marker for CD4 count increase over the same time period ranged from 86-94%, and the specificity ranged from 80-85%. The median change in TLC among patients with a CD4 count rise of ≥100 cells/mm 3 at 1 year of HAART was +766 cells/mm 3 while that of patients with a CD4 count rise of

Dried blood spots (DBS) on filter paper have been used as a practical method of sample collection in sero-surveillance studies of numerous diseases. DBS may be particularly useful for HIV screening in remote areas, in which unrefrigerated transfer time to a laboratory may take a number of days. In this study, we evaluate the ability to detect human immunodeficiency virus (HIV) type-1 antibodies from DBS that have been subjected to a tropical climate in southern India for 6 days. DBS were prepared from blood samples of 59 known HIV-positive individuals and 30 known HIV-negative individuals. ELISA and Western blot results from DBS that were subjected to a mean temperature of 35.8°C and humidity of 73% for 6 days had a sensitivity of 100% and 92%, respectively, and a specificity of 100% and 100%, respectively. Based on these findings, we conclude that DBS sampling could serve as a cost-effective and convenient tool for widespread HIV sero-surveillance in remote areas within tropical countries.

Background: In a previously reported study, 21 women (propositi) who reported changes in body habitus during highly active antiretroviral therapy (HAART) were evaluated and compared with 21 women (comparison group) on HAART who did not report body habitus changes. Mean durations of HAART at baseline evaluation were 12.5 and 15.2 months for the propositi and comparison group, respectively. Objective: Follow-up of the propositi and comparison group was conducted to determine whether body habitus changes and lipid abnormalities are progressive. stable, or improved with time and alteration of the HAART regimen. Methods: Patients were evaluated by standardized interview, physical examination, body weight, body mass index, CD4 cell count, plasma HIV RNA levels, and lipid profiles. Results: Fourteen of 21 propositi were available for follow-up. The mean duration of HAART was 42.7 months; body habitus changes were stable in 10 of the 14 women. Thirteen of 21 women in the comparison group were available for follow-up after a mean duration of HAART of 38.5 months; 2 of the 13 women had developed body habitus changes at follow-up. In both groups, mean serum lipid values at follow-up remained elevated to levels associated with increased cardiovascular risk. Conclusions: Body habitus changes in women most often developed within I year of initiation of HAART. Changes were largely stable after 2.5 additional years of HAART. Only modest and inconsistent improvement was achieved with alteration in the HAART regimen. Serum lipid abnormalities evident within the first year of HAART were also stable with 2.5 additional years of therapy.

Provider-initiated opt-out HIV screening suggests that providers should routinely order HIV tests unless a patient declines. However, data on how providers will respond to this new screening model are scarce. Documented concerns from the providers' perspectives have included time constraints of a typical patient encounter, and discomfort with discussing sexual history and risk behavior with patients. To address these potential barriers, nurse-initiated screening has been proposed as an approach to increasing screening rates in general medical and urgent care settings. This study compares patient acceptability of provider-initiated opt-out HIV screening with nurse-initiated opt-out HIV screening among 220 patients between the ages of 18-64 from two publically funded "safety-net" outpatient clinics in Los Angeles County. Our study found that 77% of patients agreed to HIV testing using opt-out screening, and that HIV test acceptance was higher with the physician-initiated opt-out model compared with the nurse-initiated opt-out model (adjusted odds ratios = 2.92; 95% CI = 1.37-6.22). These findings indicate that adding opt-out screening to primary care providers responsibilities may be an acceptable and effective strategy for addressing the perennially low HIV testing rates, particularly among low income, traditionally underserved patient populations among whom the epidemic is expanding most rapidly.

In September 2006, the Centers for Disease Control and Prevention (CDC) released the "Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-care Settings" to improve screening and diagnosis. The CDC now recommends that all patients in all health care settings be offered opt-out HIV screening without separate written consent and prevention counseling. State law on HIV testing is widely assumed to be a barrier to implementing the recommendations. To help policymakers and providers better understand their own legal context and to correct possible misunderstandings about statutory compatibility, a state-by-state review (including Washington, DC) of all statutes pertaining to HIV testing was performed and the consistency of these laws with the new recommendations was systematically assessed. Criteria were developed for classifying state statutory frameworks as consistent, neutral, or inconsistent with the new recommendations, and the implications for implementation of the CDC recommendations in these various legal contexts were examined. The statutory frameworks of 34 states and Washington, DC, were found to be either consistent with or neutral to the new CDC recommendations, which would enable full implementation. Statutory frameworks of 16 states were inconsistent with the new CDC recommendations, which would preclude implementation of 1 or more of the novel provisions without legislative change. In the 2 years since release of the recommendations, 9 states have passed new legislation to move from being inconsistent to consistent with the guidelines. State statutory laws are evolving toward greater compliance with the CDC recommendations. Policymakers, provider groups, consumer advocates, and other stakeholders should ensure that HIV screening practices comply with existing state law and work to amend inconsistent laws if they are interested in implementing the CDC recommendations.

Although stigma is considered a major barrier to effective responses to the HIV/AIDS epidemic, stigma reduction efforts are relegated to the bottom of AIDS programme priorities. The complexity of HIV/AIDS-related stigma is often cited as a primary reason for the limited response to this pervasive phenomenon. In this paper, we systematically review the scientific literature on HIV/AIDS-related stigma to document the current state of research, identify gaps in the available evidence and highlight promising strategies to address stigma. We focus on the following key challenges: defining, measuring and reducing HIV/AIDS-related stigma as well as assessing the impact of stigma on the effectiveness of HIV prevention and treatment programmes. Based on the literature, we conclude by offering a set of recommendations that may represent important next steps in a multifaceted response to stigma in the HIV/AIDS epidemic.

High-deductible health plans provide insurance coverage only after the patient has paid all expenses below a predefined cumulative outlay. They are designed to encourage prudent use of health care,...

There is a need for a psychometrically sound measure of the stigma experienced by diverse persons living with HIV/AIDS (PLHA). The goal of this study was to develop and evaluate a multidimentional measure of internalized HIV stigma that captures stigma related to treatment and other aspects of the disease among sociodemographically diverse PLHA. We developed a 28-item measure of internalized HIV stigma composed of four scales based on previous qualitative work. Internal consistency reliability estimates in a sample of 202 PLHA was 0.93 for the overall measure, and exceeded 0.85 for three of the four stigma scales. Items discriminated well across scales, and correlations of the scales with shame, social support, and mental health supported construct validity. This measure should prove useful to investigators examining in the role of stigma in HIV treatment and health outcomes, and evaluating interventions designed to mitigate the impacts of stigma on PLHA.

Background: Workplace programmes refer to a range of company-based interventions including the institution of an HIV/AIDS policy, voluntary counselling and testing (VCT), and antiretroviral therapy (ART) provision. Objective: To review the existing information on workplace policies and programmes in southern Africa, and ascertain the common accomplishments in and challenges to implementation and efficacy. Methods: Given the paucity of peer-reviewed academic publications, information for this review was also drawn from working papers, symposia proceedings, and case studies. A convenience sample of 17 key informants was identified, and semi-structured interviews were conducted. Results: Workplace policies and programmes of varying sophistication are proliferating in large companies and selected sectors. Accomplishments include the institution of a legal apparatus that safeguards against discriminatory practices, the high prevalence of HIV education programmes, the growing provision of VCT, and the development of supply-chain initiatives that may enable smaller companies to develop HIV programmes. Challenges include poor recognition and monitoring of legal violations by management and unions, lack of monitoring and evaluation (M&E) methodologies for workplace HIV prevention programmes, persistent stigma in the workplace resulting in poor uptake of HIV testing, and low enrollment into workplace ART programmes. Conclusion: The existing literature indicates a wide variation in workplace policies and programmes currently in place in southern Africa. The effectiveness of workplace interventions at the firm level, including prevention and treatment programmes is difficult to assess with currently available data. Further research on workplace programmes that addresses operational challenges to implementation and develops M&E strategies is urgently needed.

Latino adults between ages 50 and 60 yr are at high risk for developing chronic conditions that can lead to early disability. We conducted a qualitative pilot study with 11 Latinos in this demographic group to develop a foundational schema for the design of health promotion programs that could be implemented by occupational therapy practitioners in primary care settings for this population. One-on-one interviews addressing routines and activities, health management, and health care utilization were conducted, audiotaped, and transcribed. Results of a content analysis of the qualitative data revealed the following six domains of most concern: Weight Management; Disease Management; Mental Health and Well-Being; Personal Finances; Family, Friends, and Community; and Stress Management. A typology of perceived health-actualizing strategies was derived for each domain. This schema can be used by occupational therapy practitioners to inform the development of health-promotion lifestyle interventions designed specifically for late-middle-aged Latinos.

We investigated the safety, tolerability and effectiveness of locally produced generic highly active antiretroviral therapy (HAART) regimens with a chart review conducted at YRG CARE, a tertiary HIV referral centre in India. A total of 333 patients had been on Indian-manufactured generic HAART for at least 3 months. In this cohort, generic HAART was safe, well tolerated and effective at increasing CD4 T-lymphocyte counts in patients with advanced HIV, comparable to the experience with proprietary HAART.

Background: In most resource-constrained countries, CD4 cell count testing is prohibitively expensive for routine clinical use and is not widely available. As a result. physicians are often required to make decisions about opportunistic infection (OI) chemoprophylaxis without a laboratory evaluation of HIV stage and level of immunosuppression. Objectives: To evaluate the correlation of total lymphocyte count (TLC), an inexpensive and widely available parameter, to CD4 count. To determine a range of TLC cutoffs for the initiation of OI prophylaxis that is appropriate for resource-constrained settings. Methods: Spearman correlation between CD4 count and TLC was assessed in patients attending an HIV/AIDS clinic in South India. Positive predictive value (PPV), negative predictive value (NPV), and sensitivity and specificity of various TLC cutoffs were computed for CD4 count