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Coastal communities in South Louisiana and worldwide are increasingly impacted by climate-related events such as hurricanes, floods, and rising sea levels. In addition, they have recently faced the...

Although climate change poses a threat to health and well-being globally, a regional approach to addressing climate-related health equity may be more suitable, appropriate, and appealing to under-resourced communities and countries. In support of this argument, this commentary describes an approach by a network of researchers, practitioners, and policymakers dedicated to promoting climate-related health equity in Small Island Developing States and low- and middle-income countries in the Pacific. We identify three primary sets of needs related to developing a regional capacity to address physical and mental health disparities through research, training, and assistance in policy and practice implementation: (1) limited healthcare facilities and qualified medical and mental health providers; (2) addressing the social impacts related to the cooccurrence of natural hazards, disease outbreaks, and complex emergencies; and (3) building the response capacity and resilience to climate-related extreme weather events and natural hazards.

Community Partnered Participatory Research (CPPR) is grounded in the ethical principle of respect for persons participating in the research enterprise. The critical importance of respect for person...

Background The Resilience Against Depression Disparities (RADD), a community partnered, randomized comparative effectiveness study, aimed to address mental health in Lesbian, Gay, Bisexual, Transgender, and Queer/Questioning (LGBTQ) racial/ethnic populations in New Orleans and Los Angeles. Objectives To describe engagement methods, lessons learned, and recommendations in engaging LGBTQ individuals and agencies throughout the RADD study. Methods RADD used a community partnered participatory research framework to engage LGBTQ community members and agencies. Observational and quantitative data were collected to describe engagement activities and study adaptations from October 2016 to May 2019. Results Our partnered approach resulted in multiple study adaptations. The principles of cultural humility, coleadership, and addressing health determinants were important to successful engagement with LGBTQ community members and study participants. We recommend maintaining cultural humility as the tenant of all research activities. Conclusions This project's engagement plan demonstrates that community-academic partnerships can be forged to create and modify existing study models for LGBTQ communities.

BACKGROUND: Evidence of the effectiveness of treatment for obesity delivered in primary care settings in underserved populations is lacking. METHODS: We conducted a cluster-randomized trial to test the effectiveness of a high-intensity, lifestyle-based program for obesity treatment delivered in primary care clinics in which a high percentage of the patients were from low-income populations. We randomly assigned 18 clinics to provide patients with either an intensive lifestyle intervention, which focused on reduced caloric intake and increased physical activity, or usual care. Patients in the intensive-lifestyle group participated in a high-intensity program delivered by health coaches embedded in the clinics. The program consisted of weekly sessions for the first 6 months, followed by monthly sessions for the remaining 18 months. Patients in the usual-care group received standard care from their primary care team. The primary outcome was the percent change from baseline in body weight at 24 months. RESULTS: All 18 clinics (9 assigned to the intensive program and 9 assigned to usual care) completed 24 months of participation; a median of 40.5 patients were enrolled at each clinic. A total of 803 adults with obesity were enrolled: 452 were assigned to the intensive-lifestyle group, and 351 were assigned to the usual-care group; 67.2% of the patients were Black, and 65.5% had an annual household income of less than $40,000. Of the enrolled patients, 83.4% completed the 24-month trial. The percent weight loss at 24 months was significantly greater in the intensive-lifestyle group (change in body weight, −4.99%; 95% confidence interval [CI], −6.02 to −3.96) than in the usual-care group (−0.48%; 95% CI, −1.57 to 0.61), with a mean between-group difference of −4.51 percentage points (95% CI, −5.93 to −3.10) (P

Significance: Prior research suggests that Community Engagement and Planning (CEP) for coalition support compared with Re­sources for Services (RS) for program techni­cal assistance to implement depression quality improvement programs improves 6- and 12-month client mental-health related quality of life (MHRQL); however, effects for clients with multiple chronic medical condi­tions (MCC) are unknown. Objective: To explore effectiveness of CEP vs RS in MCC and non-MCC subgroups. Design: Secondary analyses of a cluster-randomized trial. Setting: 93 health care and community-based programs in two neighborhoods. Participants: Of 4,440 clients screened, 1,322 depressed (Patient Health Question­naire, PHQ8) provided contact information, 1,246 enrolled and 1,018 (548 with ≥3 MCC) completed baseline, 6- or 12-month surveys. Intervention: CEP or RS for implementing depression quality improvement programs. Outcomes and Analyses: Primary: depres­sion (PHQ9 ≥10), poor MHRQL (Short Form Health Survey, SF-12

Intimate partner violence (IPV) is a persistent public health problem in the United States, with an estimated one in three women experiencing rape, physical violence, and/or stalking by an intimate partner within her lifetime. Non-Hispanic Black women disproportionately experience IPV, but there has been limited success in implementing culturally appropriate preven­tion programs and services for members of this population. Community health workers (CHWs) are trusted members of under-resourced communities who provide reliable health information and improve the cultural appropriateness of service delivery and may be a vital resource for developing new IPV interventions. Guided by the prin­ciples of community partnered participatory research, we developed the CHW-led Safe Spaces project, which aimed to establish a strong academic-community partnership to focus on issues related to experiences of IPV and the prevention of IPV in New Orleans. In this article, we describe the development of our partnership including the formation of an advisory board, creation of a broad-based stakeholder coalition, offering a community partnered participatory research training, conducting IPV education and out­reach, and establishing a research agenda. Our processes are replicable and lessons learned may be relevant to other groups seeking to address IPV by leveraging the strengths of community-academic collabora­tions and CHWs.Ethn Dis. 2018;28(Suppl 2):317-324; doi:10.18865/ed.28.S2.317.

Underserved and minority populations suffer from a disproportionately high prevalence of obesity and related comorbidities. Effective obesity treatment programs delivered in primary care that produce significant weight loss are currently lacking. The purpose of this trial is to test the effectiveness of a pragmatic, high intensity lifestyle-based obesity treatment program delivered within primary care among an underserved population. We hypothesize that, relative to patients who receive usual care, patients who receive a high-intensity, health literacy- and culturally-appropriate lifestyle intervention will have greater percent reductions in body weight over 24 months. Eighteen clinics (N = 803 patients) serving low income populations with a high proportion of African Americans in Louisiana were randomized to the intervention or usual car. Patients in the intervention participate in a high-intensity lifestyle program delivered by health coaches employed by an academic health center and embedded in the primary care clinics. The program consists of weekly (16 in-person/6 telephone) sessions in the first six months, followed by sessions held at least monthly for the remaining 18 months. Primary care practitioners in usual care receive information on weight management and the current Centers for Medicare and Medicaid Services reimbursement for obesity treatment. The primary outcome is percent weight loss at 24 months. Secondary outcomes include absolute 24-month changes in body weight, waist circumference, blood pressure, fasting glucose and lipids, health-related quality of life, and weight-related quality of life. The results will provide evidence on the effectiveness of implementing high-intensity lifestyle and obesity counseling in primary care settings among underserved populations. Trial Registration: ClinicalTrials.gov Identifier NCT02561221

IntroductionDepression is the leading cause of adult disability and common among sexual and gender minority (SGM) adults. The current study builds on findings showing the effectiveness of depression quality improvement (QI) and delivery of cognitive behavioural therapy (CBT) skills provided by community health workers in reducing depression. Depression QI approaches across healthcare and social/community services in safety-net settings have shown improvements in mental wellness, mental health quality of life and depression over 12 months. Further, a randomised study showed improved depression among low-income racial/ethnic minorities enrolled in a CBT-informed resiliency class (Building Resilience and Increasing Community Hope (B-RICH)). The current protocol describes a comparativeness effectiveness study to evaluate whether predominantly low-income, SGM racial/ethnic minority adults randomised to a CBT-informed resiliency class have improvements in depressive symptoms over and above community-engaged QI resources and training only.Methods and analysisThe study approached three clusters of four to five programs serving predominantly SGM and racial/ethnic minority communities in the USA: two clusters in Los Angeles, California, and one in New Orleans, Louisiana. Clusters are comprised of one primary care, one mental health and two to three community agencies (eg, faith-based, social services/support, advocacy). All programs received depression QI training. The current study employed a community-partnered participatory research model to adapt the CBT-informed resiliency class, B-RICH+, to SGM communities. Study participants were screened and recruited in person from participating programs, and will complete baseline, 6- and 12-month survey follow-ups. Participants were depressed adults (8-item Patient Health Questionnaire ≥10; ≥18 years of age) who provided contact information. Enrolled participants were individually randomised to B-RICH+ or depression QI alone. Primary outcomes are depressive symptoms; secondary outcomes are mental health quality of life, mental wellness and physical health quality of life. Data collection for this study is ongoing.Ethics and disseminationThe current study was approved by the UCLA Institutional Review Board. Study findings will be disseminated through scientific publications and community conferences.Trial registration numberhttps://clinicaltrials.gov/ct2/show/NCT02986126

Objectives. To determine how community-based organizations (CBOs) define priorities for bolstering community resilience, challenges in addressing these priorities, and strategies to address challenges. Methods. The Community Resilience Learning Collaborative and Research Network (C-LEARN) is a multiphase study examining opportunities to improve community resilience to the threats of disaster and climate change in South Louisiana. Phase I of C-LEARN involved using the National Health Security Strategy and Implementation Plan for directed content analysis of key informant interviews with CBO representatives from 47 agencies within South Louisiana between February and May 2018. Results. CBO interviewees highlighted the importance of forging relationships and building trust through diverse cross-sector collaborations and partnerships before disasters. Such collaborations and partnerships were shown to tailor disaster response to the needs of particular communities and populations as well as address key challenges such as gaps in information, services, and resources. Conclusions. Our results encourage a culture of community resilience and community preparedness through partnerships and community-engaged strategies. C-LEARN will utilize the results of our interviews in the design of phase II of our agency-level coalition-building intervention.

Background: This year has seen the emergence of two major crises, a significant increase in the frequency and severity of hurricanes and the COVID-19 pandemic. However, little is known as to how each of these two events have impacted the other. A rapid qualitative assessment was conducted to determine the impact of the pandemic on preparedness and response to natural disasters and the impact of past experiences with natural disasters in responding to the pandemic. Methods: Semi-structured interviews were conducted with 26 representatives of 24 different community-based programs in southern Louisiana. Data were analyzed using procedures embedded in the Rapid Assessment Procedure-Informed Community Ethnography methodology, using techniques of immersion and crystallization and focused thematic analysis. Results: The pandemic has impacted the form and function of disaster preparedness, making it harder to plan for evacuations in the event of a hurricane. Specific concerns included being able to see people in person, providing food and other resources to residents who shelter in place, finding volunteers to assist in food distribution and other forms of disaster response, competing for funds to support disaster-related activities, developing new support infrastructures, and focusing on equity in disaster preparedness. However, several strengths based on disaster preparedness experience and capabilities were identified, including providing a framework for how to respond and adapt to COVID and integration of COVID response with their normal disaster preparedness activities. Conclusions: Although prior experience has enabled community-based organizations to respond to the pandemic, the pandemic is also creating new challenges to preparing for and responding to natural disasters.

The Patient Centered Outcomes Research Institute (PCORI) supports patient-centered clinical comparative effectiveness research (CER) including health disparities and engagement portfolios. In 2013, PCORI launched the Pipeline to Proposal (P2P) mechanism to support development of nov­el patient- and stakeholder-centered part­nerships focused on designing clinical CER funding proposals. By providing a tiered structure of successive small contracts and technical assistance, the P2P mechanism encourages development of new research partnerships among diverse stakeholders. As a comparatively new field, patient-centered outcomes research (PCOR) has few well-delineated methods for engaging patients and other non-scientists in effective teams with academics or clinicians to develop and implement rigorous, scientific research pro­posals. Community partnered participatory research (CPPR) provides a useful frame­work for structuring new partnerships.In this article we highlight the origins, de­velopment, and prospects of three current examples of funded P2P initiatives based in New Orleans and Los Angeles. We outline how these projects – Prisoner to Patient, the NOLA Partnership, and Resilience Among African American Men – use CPPR principles. We also describe how they have collaborated with, and contributed to, a two-way learning and knowledge exchange among members of the PCORI-funded Community and Patient Partnered Research Network. Lessons learned may be ap­plicable to other groups planning to create new partnerships focused on implementing PCOR.Ethn Dis. 2018;28(Suppl 2):303- 310; doi:10.18865/ed.28.S2.303.

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.

Incarceration poses significant health risks for people involved in the criminal justice system. As the world's leader in incarceration, the United States incarcerated population is at higher risk for infectious diseases, mental illness, and substance use disorder. Previous studies indicate that the mortality rate for people coming out of prison is almost 13 times higher than that of the general population; opioids contribute to nearly 1 in 8 post-release fatalities overall, and almost half of all overdose deaths. Given the hazardous intersection of incarceration, opioid use disorder, and social determinants of health, we systematically reviewed recent evidence on interventions for opioid use disorder (OUD) implemented as part of United States criminal justice system involvement, with an emphasis on social determinants of health (SDOH). We searched academic literature to identify eligible studies of an intervention for OUD that was implemented in the context of criminal justice system involvement (e.g., incarceration or parole/probation) for adults ages 19 and older. From 6,604 citations, 13 publications were included in final synthesis. Most interventions were implemented in prisons (n = 6 interventions), used medication interventions (n = 10), and did not include SDOH as part of the study design (n = 8). Interventions that initiated medication treatment early and throughout incarceration had significant, positive effects on opioid use outcomes. Evidence supports medication treatment administered throughout the period of criminal justice involvement as an effective method of improving post-release outcomes in individuals with criminal justice involvement. While few studies included SDOH components, many investigators recognized SDOH needs as competing priorities among justice-involved individuals. This review suggests an evidence gap; evidence-based interventions that address OUD and SDOH in the context of criminal justice involvement are urgently needed.

Awareness of the impact of disasters globally on mental health is increasing. Known difficulties in preparing communities for disasters and a lack of focus on relationship building and organizational capacity in preparedness and response have led to a greater policy focus on community resiliency as a key public health approach to disaster response. In this article, the authors describe how an approach to community engagement for improving mental health services, disaster recovery, and preparedness from a community resiliency perspective emerged from their work in applying a partnered, participatory research framework, iteratively, in Los Angeles County and the City of New Orleans.

The “Health Care for the Urban Underserved” course was developed to prepare students to provide services to underserved populations. Student knowledge, attitudes, and perceptions were assessed. This graduate-level course improved knowledge about the problems of the underserved and improved self-efficacy with respect to working with the underserved.

A lack of insurance and underinsurance in the United States constitutes a significant national public health problem.1 In the United States, 50.7 million individuals, 16.7% of the population, are uninsured and many more experience barriers to obtaining health care.2,3 Certain population subgroups have a low amount of health insurance coverage, including ethnic minorities, residents of southern and urban locations, and low-income households.3 In Louisiana, 17.4% of the population is uninsured and the highest uninsured rate for the state is in Orleans Parish (24.3%).3 There is a substantial need for safety-net services to provide care for uninsured individuals in the United States and Louisiana in particular. Many medical students are exposed to the safety-net healthcare environment for underserved populations, either on a volunteer basis or as part of their education. Approximately half of US medical schools have at least one student-run clinic, with most serving poor and uninsured patients.4 In addition to providing a needed service to patients, these clinics have the potential to teach students clinical skills, medical humanism, systems-based practice, collaborative and multidisciplinary approaches to medicine, and leadership skills.4–6 Participating in community-based, student-run clinics has the added advantage of potentially influencing students’ choice to practice in primary care.7 The purpose of this article is to describe the clinic models, patient demographics, and services provided by four student-run clinicsVBridge House Wednesday Clinic, Ozanam Inn Weekend Clinic, Fleur de Vie at Covenant House, and Fleur de Vie in New Orleans East—and to examine the relevance of these clinics for medical education and healthcare service delivery for underserved populations in New Orleans.

This study describes a videovoice project implemented in post-Katrina New Orleans during a pivotal time in city rebuilding and revitalization. Videovoice is a health advocacy, promotion, and research method through which people get behind video cameras to research issues of concern, communicate their knowledge, and advocate for change. Using videovoice method, a community–academic–filmmaker partnership engaged 10 Central City neighbors, who took part in an 18-week training and community assessment. The resulting 22-min film premiered before more than 200 city leaders and residents, reached more than 4,000 YouTube viewers during its first 2 months online, and was shared through the distribution of 1,000 DVDs. Viewing further helped mobilize the community for action on three priority issues: affordable housing, education, and economic development. Challenges in using videovoice, including privacy issues and cost considerations in a resource-poor community, are discussed. Despite such challenges, this method may provide community–academic partnerships with the opportunity to equitably engage in research, produce independent media, and mobilize for action.

The floods and devastation of Hurricanes Katrina and Rita contributed to socioeconomic instability and psychosocial trauma for the affected communities and populations, significantly for people of limited economic means and persons of color. Though more than 1/3 of the adult population from impacted areas experienced significant psychological distress, few people had access to or received appropriate health or mental health services in the months and years that followed. Community health workers (CHWs)—defined as lay community members whose backgrounds are similar to those for whom they provide such services as culturally relevant health education, individual- and community-level advocacy, and links to the health care system— may represent a particularly promising workforce strategy to increase access to quality mental health services and overcome racial and ethnic disparities in care. In this paper, we briefly review a post-disaster mental health training program for CHWs from the greater New Orleans area. We present preliminary evidence that CHWs remain engaged in addressing post-disaster concerns, and that there is community support for further CHW education. We discuss implications for CHW participation in recovery from future disasters and we highlight the work of Cynthia Carriere, a CHW from the Lower 9th Ward in New Orleans.

This manuscript presents the protocol and participatory planning process for implementing the Community Resilience Learning Collaborative and Research Network (C-LEARN) study. C-LEARN is designed to determine how to build a service program and individual client capacity to improve mental health-related quality of life among individuals at risk for depression, with exposure to social risk factors or concerns about environmental hazards in areas of Southern Louisiana at risk for events such as hurricanes and storms. The study uses a Community Partnered Participatory Research (CPPR) framework to incorporate community priorities into study design and implementation. The first phase of C-LEARN is assessment of community priorities, assets, and opportunities for building resilience through key informant interviews and community agency outreach. Findings from this phase will inform the implementation of a two-level (program-level and individual client level) randomized study in up to four South Louisiana communities. Within communities, health and social-community service programs will be randomized to Community Engagement and Planning (CEP) for multi-sector coalition support or Technical Assistance (TA) for individual program support to implement evidence-based and community-prioritized intervention toolkits, including an expanded version of depression collaborative care and resources (referrals, manuals) to address social risk factors such as financial or housing instability and for a community resilience approach to disaster preparedness and response. Within each arm, the study will randomize individual adult clients to one of two mobile applications that provide informational resources on services for depression, social risk factors, and disaster response or also provide psychoeducation on Cognitive Behavioral Therapy to enhance coping with stress and mood. Planned data collection includes baseline, six-month and brief monthly surveys for clients, and baseline and 12-month surveys for administrators and staff.

Background: Hurricane Katrina and levee failures disrupted healthcare access for hundreds of thousands of New Orleans residents. Few models exist to explain community stakeholders’ priorities for post-disaster recovery while building capacity for response. This project engaged community stakeholders in a rapid, participatory assessment of health priorities 1 year post-disaster, to inform the policy process and build capacity for recovery planning among community members. Methods: This project combined community-based participatory research methods and rapid assessment procedures to engage diverse community members in design, conduct, data interpretation, and dissemination of results. Thirty stakeholders in the health and healthcare fields were interviewed in Summer 2006, and four grassroots community discussion groups were held in New Orleans neighborhoods to assess perceptions of the disaster’s impacts on healthcare access. Interview transcripts were reviewed in Summer 2006, and themes were elicited using methods rooted in grounded theory. Findings were shared at a public community feedback conference, and recovery-relevant community action steps were set in motion. Results: Three main themes emerged from the data: (1) healthcare access challenges; (2) unmet needs of specific vulnerable populations; (3) opportunities, resources, and community adaptations to improve healthcare access. Conclusions: This rapid, community-based participatory assessment provided new information on diverse community members’ concerns and priorities, and it produced a sustainable community–academic partnership dedicated to improving both access to care and the public’s health following this major disaster. (Am J Prev Med 2009;37(6S1):S237–S243) © 2009 American Journal of Preventive Medicine

Those who survived Hurricanes Katrina and Rita faced homelessness and physical and mental health problems that created ethical dilemmas for physicians. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.

OBJECTIVES: In academic medical centers, resident physicians are most involved in the care of patients, yet many have little training in the proper use of interpreters in the care of patients with limited English-language proficiency. Residents have cited lack of time and lack of access to trained medical interpreters as barriers to the use of professional interpreter services. The purpose of this study was to examine the usage patterns of interpreters and perceived barriers to using interpreters in New Orleans. METHODS: Subjects included resident physicians training in internal medicine, pediatrics, and combined internal medicine and pediatrics at Tulane University and Louisiana State University in New Orleans. A survey that consisted of demographics, short-answer, and Likert-scale questions regarding attitudes related to the use of interpreters was used as the metric. RESULTS: The overall response rate was 55.5%. A total of 92.4% of subjects surveyed stated that they had used an interpreter during their residency. Telephone services and family members were the most commonly used types of interpreters (41.3% and 30.5%, respectively). Resident physicians were most likely to use interpreter services during their initial history taking as well as at discharge, but use declined throughout patients' hospitalization (P < 0.001). Residents cited lack of availability, lack of time, and lack of knowledge about accessing interpreter services as the major barriers to using interpreters. CONCLUSIONS: Resident physicians training in New Orleans have experience using interpreter services; however, they continue to use untrained interpreters and use varies during the hospital encounter. Targeted training for residents, including interpreter logistics, may help increase the use of interpreters.

Academic institutions and community organizations engaged community health workers (CHWs) in creating a community-appropriate CHW workforce capacity-building program in an area without a previously established CHW professional group. From 2009 to 2010, we solicited New Orleans-based CHWs’ opinions about CHW professional development through a survey, a community conference, and workgroup meetings. Throughout 2011 and 2012, we created and implemented a responsive 80-h workforce development program that used popular education techniques. We interviewed CHWs 6 months post-training to assess impressions of the course and application of skills and knowledge to practice. CHWs requested training to develop nationally-recognized core competencies including community advocacy, addresses issues unique to New Orleans, and mitigate common professional challenges. Thirty-five people completed the course. Among 25 interviewees, common themes included positive impressions of the course, application of skills and community-specific information to practice, understanding of CHWs’ historical roles as community advocates, and ongoing professional challenges. Engaging CHW participation in workforce development programs is possible in areas lacking organized CHW groups. CHW insight supports development of training that addresses unique local concerns. Trained CHWs require ongoing professional support.

Argues that destruction of the training environment by Katrina opened an opportunity for rapid innovation and improvement of the physician training environment for the internal medicine residency at Tulane School of Medicine.

IMPLEMENTATION OF THE AFFORDABLE CARE ACT AND health care reform is under way. A central dimension of this process that has captured health sector interest is development and implementation of accountable care organizations (ACOs). ACOs are formal collaborations of health care professionals who agree to assume responsibility for providing a specific and potentially comprehensive set of health care services to a defined population of at least 5000 Medicare recipients. ACOs are considered to have the potential to reconfigure care-delivery systems to align incentives among physicians, other health professionals, hospitals, and payers (primarily the federal government through Medicare and the federal share of Medicaid) with the goal of increasing perceived value of care, improving clinical outcomes, and lowering health care costs (the triple aim). The Centers for Medicare & Medicaid Services has indicated that the secretary of the Department of Health and Human Services will share some portion of savings derived from lower costs of ACO care with ACO clinicians. Less apparent to the public during this period of historic change are the struggles occurring in US board rooms among hospital groups, specialty physicians, and primary care clinicians—debating quietly but intensely over how to form these ACOs, how to be accountable for care delivery, and how to divide anticipated savings derived from ACOs. However, in most of these settings, important constituencies—middle class and other working patients whose health and welfare are at stake—are not included in the discussions. This suggests a number of provocative speculations. Would the discussions be any different if this community of patients participated as equal principals in forming ACOs alongside their physicians and hospital representatives? In many ways, the ACOs proposed today were anticipated by the models of community-oriented primary care debated nearly 3 decades ago except that community-oriented primary care more explicitly expected “involvement of the community in the promotion of its health.” Group Health Cooperative, a Puget Sound health care system, well known for high quality of care, has for nearly as long ensured community involvement and leadership through its elected patient board and patient councils. If presented with the option, would communities of patients require specific benefits, roles, and responsibilities in exchange for participating in an ACO? Would the behaviors of community members resemble those of blocs of shareholders in a corporation, partners in a group venture, or patient-board members of neighborhood health centers? Would this kind of patient relationship with the formal care delivery system potentially change the social contract of health care delivery and increase the likelihood of achieving the triple aim, ie, improving the health of the population, enhancing the patient experience of care, and reducing or controlling the per capita cost of health care or some piece of it? Would communities of patientshareholders perceive each of these aims as equally relevant or valuable? Would they perceive the aims in the same way or differently from how they are perceived by provider groups? Might engaged and empowered communities be more motivated to work with clinicians to receive needed health care services or to engage in healthpromoting behaviors if granted an equitable voice in discussions about how the health care system to which they subscribe is configured and implemented? Would it make a difference if that opportunity came now, before the ACOs have been fully developed, as opposed to bringing in these communities as partners after the ACO was already functioning? Would this opportunity to participate in decision making—to argue, to vote, to express opinion freely about an individual’s own health care system in a forum with real power—have an effect on health and potentially represent a step toward more effective and more patient-centered care? The freedom of individuals to participate in decisions that have significant influence on their lives has been proposed as an important way to improve health and economic functioning. Similarly, patients are believed to benefit from playing active roles in health care choices and decision making. Patient-centered medical homes have been widely pro

Objective: Population-based demands for trauma services have accelerated interest in the rapid deployment of efficacious interventions to address the diverse mental health consequences of traumatic experiences. However, optimal strategies for supporting either implementation or dissemination of trauma-focused interventions within healthcare or mental healthcare systems are underdeveloped. Methods: This work offers suggestions for adapting treatment research parameters in order to advance the science on the implementable and practical use of trauma-focused interventions within a public health framework. To this end, we briefly examine the current status of research evidence in this area and discuss efficacy and effectiveness treatment research parameters with specific attention to the implications for developing the research base on the implementation and dissemination of effective trauma practices for children and adolescents. Results: Examples from current studies are used to identify approaches for developing, testing and enhancing strategies to roll out effective treatment practices in real-world settings. Conclusions: New approaches that reflect the contexts in which these practices are implemented may enhance the feasibility, acceptability, replicability and sustainability of trauma treatments and services, and thus improve outcomes for a broader population of youth and families.

Stakeholders in communities in which health care access was disrupted by Hurricane Katrina were engaged in an assessment of health priorities, as well as in data interpretation and plan design, to produce a sustainable community-academic partnership.

Discusses the potential of community-based participatory research (CBPR) to reduce the burden of chronic health problems on poor and minority neighborhoods and describes three successful CBPR programs.

Concerns about mental health recovery persist after the 2005 Gulf storms. We propose a recovery model and estimate costs and outcomes.To estimate the costs and outcomes of enhanced mental health response to large-scale disasters using the 2005 Gulf storms as a case study.Decision analysis using state-transition Markov models for 6-month periods from 7 to 30 months after disasters. Simulated movements between health states were based on probabilities drawn from the clinical literature and expert input.A total of 117 counties/parishes across Louisiana, Mississippi, Alabama, and Texas that the Federal Emergency Management Agency designated as eligible for individual relief following hurricanes Katrina and Rita.Hypothetical cohort, based on the size and characteristics of the population affected by the Gulf storms. Intervention Enhanced mental health care consisting of evidence-based screening, assessment, treatment, and care coordination.Morbidity in 6-month episodes of mild/moderate or severe mental health problems through 30 months after the disasters; units of service (eg, office visits, prescriptions, hospital nights); intervention costs; and use of human resources.Full implementation would cost $1133 per capita, or more than $12.5 billion for the affected population, and yield 94.8% to 96.1% recovered by 30 months, but exceed available provider capacity. Partial implementation would lower costs and recovery proportionately.Evidence-based mental health response is feasible, but requires targeted resources, increased provider capacity, and advanced planning.