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In the United States, public opinion on environmental issues is characterized by high levels of political polarization. This was not always the case. For example, the Environmental Protection Agency was formed in 1970, and most environmental legislation like the Clean Water Act (1972) and the Clean Air Act (1963) was established during the “environmental decade” in the Nixon administration. Since that time, however, environmental issues have become increasingly polarized. Both the science of and policy solutions to global climate change have been especially polarized. A huge interdisciplinary body of work in public opinion, political communication, political psychology, environmental and social psychology, science communication, sociology, anthropology, and behavioral economics has all sought to understand people’s attitudes toward environmental issues, how they prioritize different issues, support toward public and private initiatives to address environmental problems, how to change such attitudes, and the impact of environmental attitudes on public and private behavior. This article reviews some of the main trends in this literature, theoretical foundations of these phenomena, and empirical evidence. It then briefly reviewing the evidence of the impact of such attitudes on public and private behavior, and concludes with a list of resources and journals.

This paper reports the results of a field experiment to assess the collaborative effects of community participation in the Ugandan oil and gas sector. Our research design assesses collaborative impacts as relational between community members and different decision-makers in the sector and measures these impacts from the point of view of local people. Local people often face power imbalances in collaborative governance. Decision-makers are increasingly attempting to mitigate such imbalances to improve outcomes for communities, but little experimental evidence exists showing the impact of such efforts. Using multilevel ordered logit models, we estimate positive treatment effects, finding that encouraging the equitable participation of communities improves collaboration with other actors. Next, we use machine-learning techniques to demonstrate a method for targeting communities most likely to benefit from the intervention. We estimate that purposefully targeting communities that would benefit most yields a treatment effect about twice as large, relative to pure random assignment. Our results provide evidence that interventions mindful of community needs can improve collaborative governance and shows how such communities can be most effectively targeted. The experiment took place across 107 villages (53 treatment and 54 control) and the unit of statistical analysis is the household, where we report outcomes measured from 6,062 household surveys (approximately half at baseline and half at endline).

Many countries have adopted large-scale tree planting programmes as a climate mitigation strategy and to support local livelihoods. We evaluate a series of large-scale tree planting programmes using data collected from historical Landsat imagery in the state of Himachal Pradesh in Northern India. Using this panel dataset, we use an event study design to estimate the socioeconomic and biophysical impacts over decades of these programmes. We find that tree plantings have not, on average, increased the proportion of forest canopy cover and have modestly shifted forest composition away from the broadleaf varieties valued by local people. Further cross-sectional analysis, from a household livelihood survey, shows that tree planting supports little direct use by local people. We conclude that decades of expensive tree planting programmes in this region have not proved effective. This result suggests that large-scale tree planting may sometimes fail to achieve its climate mitigation and livelihood goals. Large-scale tree planting programmes have been implemented or planned for areas around the world suffering from deforestation, but this study presents evidence that such efforts may not necessarily deliver the desired environmental and economic outcomes.

This study evaluates the effectiveness of a Stakeholder Engagement (SE) intervention in improving outcomes for communities affected by oil and gas extraction in Western Uganda. The study design is a randomized controlled trial where villages are randomly assigned to a treatment group (participating in SE) or a control group (not participating). Data are collected via household surveys at baseline and end line in 107 villages in the Albertine Graben. We find that SE improves transparency, civic activity, and satisfaction with issues that most concern the people under study. While satisfaction has improved, it is too early to ascertain whether these interventions improve long-term outcomes. These results are robust when controlling for spillover effects and other subregional fixed effects.

Background Patients discharged from the hospital with skilled home healthcare (HHC) services have multiple comorbidities, high readmission rates, and multiple care needs. In prior work, HHC nurses described that patients often express expectations for services beyond the scope of skilled HHC. Objective The objective of this study is to evaluate and compare expectations for HHC from the patient, caregiver, and HHC perspectives after hospital discharge. Design/participants This was a descriptive qualitative case study including HHC patients, caregivers, and clinicians. Patients were discharged from an academic medical center between July 2017 and February 2018. Results The sample (N = 27) included 11 HHC patients, eight caregivers, and eight HHC clinicians (five nurses and three physical therapists). Patient mean age was 66 years and the majority were female, white, and had Medicare. We observed main themes of clear and unclear expectations for HHC after discharge. Clear expectations occur when the patient and/or caregiver have expectations for HHC aligned with the services received. Unclear expectations occur when the patient and/or caregiver expectations are uncertain or misaligned with the services received. Patients and caregivers with clear expectations for HHC frequently described prior experiences with skilled HHC or work experience within the healthcare field. In most cases with unclear expectations, the patient and caregiver did not have prior experience with HHC. Conclusions To improve HHC transitions, we recommend actively engaging both patients and caregivers in the hospital and HHC settings to provide education about HHC services, and assess and address additional care needs.

A generalized knowledge of social-ecological relationships is needed to address current environmental challenges. Broadly comparative and synthetic research is a key method for establishing this type of knowledge. To date, however, most work on social-ecological systems has applied idiosyncratic methods to specific systems. Several projects, each based on the frameworks developed by Elinor Ostrom and colleagues, stand out for their application of consistent methods across a broad range of cases. In this paper we compare seven of these projects and draw conclusions regarding their potential benefits and the challenges that scholars can expect in conducting this type of research. The two main challenges that we identified are (1) the collective-action dilemmas that collaborators face in producing and maintaining the social and technical infrastructure that is needed for such projects; and (2) balancing complexity and comparability in the structure of the databases used and the associated methods for characterizing complex social-ecological cases. We discuss approaches for meeting these challenges, and present a guiding checklist of questions for project design and implementation to provide guidance for future broadly comparative research.

Scientists, corporations, mystics, and movie stars have convinced policymakers around the world that a massive campaign to plant trees should be an essential element of global climate policy. Public dialogue has emphasized potential benefits of tree planting while downplaying pitfalls and limitations that are well established by social and ecological research. We argue that if natural climate solutions are to succeed while economies decarbonize (Griscom et al. 2017), policymakers must recognize and avoid the expense, risk, and damage that poorly designed and hastily implemented tree plantings impose on ecosystems and people.

Objectives To describe a novel model of care that uses community‐based paramedics to deliver a modified version of the evidence‐based hospital‐to‐home Care Transitions Intervention (CTI) to a new context: the emergency department (ED)‐to‐home transition. Design Single‐blind randomized controlled trial. Setting Three EDs in 2 cities. Participants Through June 2017, 422 individuals discharged home from the EDs who provided consent and were randomized to receive the modified CTI. Intervention We modified the hospital‐to‐home CTI, applying it to the ED‐to‐home transition and delivering services through community paramedics, allowing the program to benefit from the unique attributes of paramedics to deliver care. Measurements Through surveys of participants, medical record review, and documentation of activities by CTI coaches, we characterize the participants and program, including feasibility and acceptability. Results Median age of participants was 70.7, 241 (57.1%) were female, and 385 (91.2%) were white. Coaches successfully completed 354 (83.9%) home visits and 92.7% of planned telephone follow‐up for call 1, 90.9% for call 2, and 85.8% for call 3. We found high levels of acceptability among participants, with most participants (76.2%) and their caregivers (83.1%) reporting themselves likely or extremely likely to choose an ED featuring the CTI program in the future. Coaches reported delivering expected services during contact at least 88% of the time. Conclusion Although final conclusions about program effectiveness must await the results of the randomized controlled trial, the findings reported here are promising and provide preliminary support for an ED‐to‐home CTI Program's ability to improve outcomes. The coaches' identity as community paramedics is particularly noteworthy, because this is a unique role for this provider type. J Am Geriatr Soc 66:2213–2220, 2018.

Increased community cooperation is an important objective of Community-Driven Reconstruction (CDR) programs in post-conflict settings. While these programs typically work with a limited group of beneficiaries, little is known about the potential community impact beyond these beneficiaries. To investigate this, we empirically analyze how cooperative behavior develops in a lab-in-the-field experiment with mixed groups of CDR program beneficiaries and non-beneficiaries, organized in 42 municipalities in Colombia with active CDR programs. In the experiment, we use two rounds of a binary public goods game with a communication stage between both rounds. The experimental data are complemented with information on pre-existing social proximity among the participants and whether they have participated in a CDR program. We find that cooperation increases after communication, and that it correlates positively with the proportion of cooperators before communication. This peer effect is mainly driven by the cooperative behavior of CDR program beneficiaries while the influence of non-beneficiaries is limited.

Hospitals and health care systems face increasing accountability for postdischarge outcomes of patients, but it is unclear how frequently hospital readmissions in particular occur at a different hospital than the index hospitalization and whether this is associated with worse outcomes.Describe the prevalence of nonindex 30-day readmissions in a nationally representative sample of all payers and associations with outcomes.Secondary retrospective analysis of the 2013 Nationwide Readmissions Database.Nonfederal hospitals from 21 states representing half of hospitalizations in the United States annually.Our overall sample included all adults discharged alive from an inpatient stay with 30 days of follow-up; we also created 3 additional cohorts: patients with Medicare as the payer (Medicare cohort), patients discharged to home health or skilled nursing facilities after discharge (postacute care cohort), and Medicare patients with any of the current Hospital Readmission Reduction Program's penalized conditions (readmission penalty cohort).Readmission within 30 days to "index" hospital (where index stay occurred) or "nonindex" hospital.In-hospital mortality and length of stay during the readmission.The weighted overall sample included 22,884,505 hospital discharges from 2004 unique hospitals. The overall 30-day readmission rate was 11.9%, of these, 22.5% occurred at a nonindex hospital. Readmissions to nonindex facilities were associated with increased odds of in-hospital mortality (odds ratio, 1.21; 95% confidence interval, 1.17-1.25) and longer hospital length of stay (hazard ratio for hospital discharge, 0.87; 95% confidence interval, 0.86-0.88) in the overall sample and in the 3 cohorts.Nonindex readmissions are common and associated with worse outcomes; the common findings across cohorts highlight the importance for hospitals and care systems participating in value-based payment models. Hospitals and care systems should invest in improved methods for real-time identification and intervention for these patients.

Public policy generally emerges from interactions among actors embedded within complex governance systems, composed of multiple actors and forums (issue-based arenas where stakeholders repeatedly interact to resolve collective action problems). Such systems allow actors multiple forums wherein they can influence policy decisions. But actors do not value the decisions made in each forum equally, and it remains unclear how actors allocate resources across forums. This article links actor strategy to their influence within the forums the actors identify as most important (their primary forum). There is theoretical ambiguity about how actors invest their limited resources across the forums that affect their interests to maximize primary forum influence. Do they concentrate all their effort within the primary forum or participate more broadly? To answer this question, we offer two competing theories. First, broad participation may allow actors to develop political capital necessary to influence other actors and thus influence primary forum policies. The second approach notes the opportunity costs of broad participation—actors have fewer resources to invest in their primary forum. An analysis of stakeholder participation in the Sacramento–San Joaquin River Delta and Tampa Bay Watershed governance systems demonstrates that broader participation is associated with greater primary forum influence.

In 2012, nearly one-third of adults 65 years or older with Medicare discharged to home after hospitalization were referred for home health care (HHC) services. Care coordination between the hospital and HHC is frequently inadequate and may contribute to medication errors and readmissions. Insights from HHC nurses could inform improvements to care coordination. To describe HHC nurse perspectives about challenges and solutions to coordinating care for recently discharged patients. We conducted a descriptive qualitative study with six focus groups of HHC nurses and staff (n = 56) recruited from six agencies in Colorado. Focus groups were recorded, transcribed, and analyzed using a mixed deductive/inductive approach to theme analysis with a team-based iterative method. HHC nurses described challenges and solutions within domains of Accountability, Communication, Assessing Needs & Goals, and Medication Management. One additional domain of Safety, for both patients and HHC nurses, emerged from the analysis. Within each domain, solutions for improving care coordination included the following: 1) Accountability—hospital physicians willing to manage HHC orders until primary care follow-up, potential legislation allowing physician assistants and nurse practitioners to write HHC orders; 2) Communication—enhanced access to hospital records and direct telephone lines for HHC; 3) Assessing Needs & Goals—liaisons from HHC agencies meeting with patients in hospital; 4) Medication Management—HHC coordinating directly with clinician or pharmacist to resolve discrepancies; and 5) Safety—HHC nurses contributing non-reimbursable services for patients, and ensuring that cognitive and behavioral health information is shared with HHC. In an era of shared accountability for patient outcomes across settings, solutions for improving care coordination with HHC are needed. Efforts to improve care coordination with HHC should focus on clearly defining accountability for orders, enhanced communication, improved alignment of expectations for HHC between clinicians and patients, a focus on reducing medication discrepancies, and prioritizing safety for both patients and HHC nurses.

Nearly all practicing hospitalists have firsthand experience discharging patients to post-acute care (PAC), which is provided by inpatient rehabilitation facilities, skilled nursing facilities, or home healthcare providers. Many may not know that PAC is poised to undergo transformative change, spurred by recent legislation resulting in a range of reforms. These reforms have the potential to fundamentally reshape the relationship between hospitals and PAC providers. They have important implications for hospitalists and will open up opportunities for hospitalists to improve healthcare value. In this article, the authors explore the reasons for PAC reform and the scope of the reforms. Then they describe the implications for hospitalists and hospitalists' opportunities to Choose Wisely and improve healthcare value for the rapidly growing number of vulnerable older adults transitioning to PAC after hospital discharge.

The use of Randomized Controlled Trials (RCTs) to evaluate development programs presents important challenges and opportunities for collaboration between academics and practitioners. Our team of experts measured the effectiveness of multi-stakeholder forums in 107 villages in Uganda over three years using an RCT approach. The focused technical demands of an RCT and the broad reality of practitioner worlds forced the team to tackle questions of: (a) how to manage the tensions of qualitative and quantitative data given the demand for evaluation procedures like power analysis estimation and hypothesis testing; (b) how to define measurable impact so it represents program realities and is amenable to the standardization required by an RCT; and (c) what compromises are required to maintain the spirit and practice of collaboration. We conclude that meaningful collaboration requires immense effort and compromise to leverage the significant benefits possible under this research paradigm.

Objectives To evaluate the quality of communication between hospitals and home health care (HHC) clinicians and patient preparedness to receive HHC in a statewide sample of HHC nurses and staff. Design A web-based 48-question cross-sectional survey of HHC nurses and staff in Colorado to describe the quality of communication after hospital discharge and patient preparedness to receive HHC from the perspective of HHC nurses and staff. Questions were on a Likert scale, with optional free-text questions. Setting and participants Between January and June 2017, we sent a web-based survey to individuals from the 56 HHC agencies in the Home Care Association of Colorado that indicated willingness to participate. Results We received responses from 50 of 122 individuals (41% individual response rate) representing 14 of 56 HHC agencies (25% agency response rate). Half of the respondents were HHC nurses, the remainder were managers, administrators, or quality assurance clinicians. Among respondents, 60% (n = 30) reported receiving insufficient information to guide patient management in HHC and 44% (n = 22) reported encountering problems related to inadequate patient information. Additional tests recommended by hospital clinicians was the communication domain most frequently identified as insufficient (58%). More than half of respondents (52%) indicated that patient preparation to receive HHC was inadequate, with patient expectations frequently including extended-hours caregiving, housekeeping, and transportation, which are beyond the scope of HHC. Respondents with electronic health record (EHR) access for referring providers were less likely to encounter problems related to a lack of information (27% vs 57% without EHR access, P = .04). Respondents with EHR access were also more likely to have sufficient information about medications and contact isolation. Conclusions/Implications Communication between hospitals and HHC is suboptimal, and patients are often not prepared to receive HHC. Providing EHR access for HHC clinicians is a promising solution to improve the quality of communication.

BACKGROUND/OBJECTIVE: Older adults frequently use the emergency department (ED) for care, but the ED-to-home transition often goes poorly, with up to 20% experiencing adverse outcomes, including return to the ED for further care. We describe a novel model of care that uses community-based paramedics to deliver a modified version of the evidence-based hospital-to-home Care Transitions Intervention (CTI) to a new context: the ED-to-home transition. DESIGN: Single blinded randomized controlled trial. SETTING: Three EDs in two cities. PARTICIPANTS: Through June 2017, 422 patients discharged home from the EDs who were consented and randomized to receive the modified CTI. INTERVENTION: We modified the hospital-to-home CTI, applying it to the ED-to-home transition and delivering services through community paramedics, thus allowing the program to benefit from the unique attributes of paramedics to deliver care. MEASUREMENTS: Through surveys of participants, medical record review, and documentation of activities by CTI coaches, we characterize the participants and program, including feasibility and acceptability. RESULTS: The median age of patient participants was 70.7 years; 241 (57.1%) subjects were female; and 385 (91.2%) were white. Coaches successfully completed 354 (83.9%) home visits and 92.7%, 90.9%, and 85.8% of planned telephone follow-up for call 1, 2, and 3, respectively. We found high levels of acceptability among participants, with most patients (76.2%) and caregivers (83.1%) reporting themselves likely or extremely likely to choose an ED featuring the CTI Program in the future. Coaches reported delivering expected services during patient contact at least 88% of the time. CONCLUSION: While finalized conclusions about program effectiveness must await the results of the randomized controlled trial, the findings reported here are promising and provide preliminary support for an ED-to-home CTI Program’s ability to improve patient outcomes. The coaches’ identity as community paramedics is particularly noteworthy, as this is a unique role for this provider type.

Advances in Pt-based oxygen reduction reaction (ORR) fuel cell catalysts will continue to lead to remarkably more efficient fuel cells. However, more efficient Pt-based cathode catalysts will be required to deliver higher currents at lower overpotential, which will result in them becoming oxidized over periods of prolonged use. In this manuscript, a comprehensive analysis of the ORR on Pt-oxide films of varying thickness is presented. Oxides were grown for various times with various oxidizing potentials in pH 1 and pH 13 media, and the ORR process was probed on these surfaces during a negative-going voltammetry sweep. The oxide layer was found to be stronger bound in alkaline media, but acidic conditions seem to favor growth of thicker oxides. Product selectivity is also altered by the oxide layer to favor undesirable peroxide formation. A novel analysis shows how chemisorbed oxide led to alterations in Tafel slope that could be mistaken for a changing rate-determining step. This study provides strong evi...

Article-at-a-Glance Background Family caregivers play an instrumental role in executing the care plan of patients during care transitions and yet may lack preparation and confidence to be effective. Yet there has been little attempt by health care professionals to identify and strengthen family caregivers' sense of preparation and confidence. The Family Caregiver Activation in Transitions™ (FCAT™) tool was developed to guide the care team in better understanding patient and family needs and deploying appropriate resources accordingly. Methods The development and psychometric testing of the FCAT tool was guided by a "partial credit" Rasch model. The validation was completed in three phases. In Phase 1, cognitive testing was conducted in convenience samples of family caregivers (N = 54) participating in support groups in two geographic locations. In Phase 2, pilot testing was conducted (N = 50) to determine item fit and item difficulty. In Phase 3, the tool's psychometric properties were examined in two waves of recruitment (N = 187; N = 247) from Web-based national samples. Results Participants recommended revising the script, reducing redundancy, and simplifying item structure and language. Analysis of item fit and difficulty guided subsequent item reduction. The estimated person-separation reliability was 0.84. Conclusions The FCAT tool was developed to foster more productive interactions between health care professionals and family caregivers. Because it was developed with direct input from family caregivers, the items are both relevant to actual experience and relatively easy to understand. Psychometric testing supports the hypothesis that the FCAT tool items function as a unidimensional construct with a high level of reliability. The FCAT tool has the potential to guide interventions intended to enhance family caregiver preparation and confidence, and thereby positively influence clinical practice during care transitions.

The aims of this study were to (a) describe the nature of patients' goals upon discharge from hospital, family caregivers' goals for their loved ones, and family caregivers' goals for themselves; (b) determine the degree of concordance with respect to the three elicited goals; (c) ascertain goal attainment across the three elicited goals; and (d) examine factors predictive of goal attainment. Our findings support the position that eliciting patient and family caregiver goals and promoting goal attainment may represent an important step toward promoting greater patient and family caregiver engagement in their care.

Objective This article compares the effects of various climate change issue frames (deontological-moral, empirical-scientific, and economic) on support for climate change mitigation policies. Methods Using an issue-framing survey experiment conducted on Amazon Mechanical Turk, we assess framing effects on climate change policy support using ordinary least squares regression. Results We find mixed evidence regarding frame effectiveness. Religious moral frames and economic efficiency frames are ineffective, whereas scientific frames, secular moral frames, and economic equity frames are effective at increasing overall policy support. Additionally, the positive science frame and economic equity frame reduce the ideological divide in climate policy support. Conclusion The effects of issue framing on climate policy support are mixed. Frames that we expected conservatives to be responsive to (religious morality; economic efficiency) fail to change support for climate policy. Frames that emphasize science, secular morality, and economy equity have the potential to increase public support for climate change policies.

Rational choice scholarship posits two principal theories to explain why political institutions emerge and change: cooperation theory and conflict theory. We evaluate cooperation theory and conflict theory to explain the emergence of common property institutions among a group of Maasai pastoralists in southwestern Kenya. Our empirical results show that the change to common property is best explained by conflict theory

The extent of human cooperation depends on the institutional arenas wherein people interact. Scholars from the Ostrom school have been particularly interested in how behavior in common property institutions differs from private property. Using a model of reciprocal motivations, I hypothesize that common property institutions elicit less cooperation than private property institutions in post-Communist Bulgaria. To investigate this hypothesis, this article reports on a series of experiments that examine the effects of common and private property in the trust game. The results indicate that common property institutions in Bulgaria elicit less cooperation than private property.

A mechanistic electrochemical study of the oxygen reduction reaction (ORR) on a carbon-supported PtCu catalyst is presented. The catalyst was prepared by galvanic displacement of nanoporous copper with Pt. The electrochemistry of the catalyst was explored at pH 1 and pH 13. Hydrogen peroxide reduction and rotating ring–disk electrode (RRDE) studies showed that the PtCu/C catalyst facilitates a 4e– direct or series reduction to water in alkaline electrolyte. A Tafel study suggests that the ORR rate-limiting step for PtCu/C does not change when the catalyst is subject to pH extremes. The ORR activity of the PtCu/C catalyst was found to be 2–3 times higher than the ORR activity of commercially available Pt/C (Johnson Matthey). Adsorption of OH– was quantified for PtCu/C and Pt/C, and PtCu/C was observed to have a reduced affinity toward OHads in both acid and alkaline electrolyte, which was found to promote the rate of the ORR relative to Pt/C. On the basis of this study, we propose that (1) each Pt-based ca...

Background Family caregivers play a central yet under recognized role in ensuring quality and safety during a loved one's transition out of the hospital. Objective To explore facilitators and challenges family caregivers face in assuming postdischarge family caregiving roles and completing complex care tasks. Methods A qualitative study recruited 32 participants from 4 sites. Participants were unpaid family caregivers whose loved one was recently discharged from an acute care hospital. A modified Grounded Theory approach was used. Results Five central themes emerged from the analysis: (1) family caregivers' contributions to the care of their loved one unfold along on a spectrum where the readiness, willingness, and ability of both parties are often dynamic; (2) family caregivers have unique and potentially incongruent goals from those of the patient; (3) family caregivers feel unprepared for postdischarge medication management; (4) family caregivers encouragement to assert an identity; (5) family caregivers often assume the responsibility for the sequencing of posthospital care plan tasks and anticipating next steps. Conclusion Family caregivers provided valuable insights into the challenges they face facilitating their loved ones' transitions. These findings may directly inform the design and testing of an evidence-based intervention to enhance their roles.

BACKGROUND Family caregivers play a central role in ensuring the execution of the discharge care plan. OBJECTIVE To enhance an evidence-based model-the Care Transitions Intervention (CTI)-and to make it more responsive to the needs of family caregivers and determine its impact on a measure of activation. METHODS Prospective cohort of 83 patient-family caregiver partnerships discharged from hospital. The domains of the CTI were modified to incorporate those areas that family caregivers identified as wanting to feel better prepared and more confident. RESULTS Family caregivers experienced a mean improvement in activation of 6 points on a 0-10 scale (p < .0001). Sixty-four percent (95% confidence interval [CI], 52-75%) of family caregivers met or exceeded self-identified goals. Transitions Coaches identified 71% (95% CI, 60-80%) of patients as having medication discrepancies or errors after hospital discharge and coached family caregivers on how to respond. The mean 3-item Care Transitions Measure score on a 0-100 scale was 80.89 (95% CI, 76.62-85.16). Almost all (99%) (95% CI, 92-100%) participants would recommend the model to a friend of family member. DISCUSSION The enhanced family caregiver CTI significantly improved activation, quality, goal achievement, satisfaction, and medication safety. The enhanced family caregiver CTI may have application in improving the hospital discharge experience.

The objective of this Perspective was to provide guidance to hospitalists and hospital clinical leadership on how to implement the Caregiver Advise Record and Enable (CARE) Act, which has been passed into law in 30 US states and territories. Specifically, the objective is 3-fold: (1) increase awareness among hospitalists and encourage them to begin to prepare for implementation, (2) explore the impetus for this legislation, and (3) provide a list of suggested resources geared to both family caregivers and healthcare professionals that may be helpful in preparation for implementing the CARE Act. Journal of Hospital Medicine 2015;11:883-885. © 2015 Society of Hospital Medicine.

BACKGROUND: Care coordination between adult hospitalists and primary care providers (PCPs) is a critical component of successful transitions of care from hospital to home, yet one that is not well understood. OBJECTIVE: The purpose of this study was to understand the challenges in coordination of care, as well as potential solutions, from the perspective of hospitalists and PCPs in North Carolina. DESIGN AND PARTICIPANTS: We conducted an exploratory qualitative study with 58 clinicians in four hospitalist focus groups (n = 32), three PCP focus groups (n = 19), and one hybrid group with both hospitalists and PCPs (n = 7). APPROACH: Interview guides included questions about care coordination, information exchange, follow-up care, accountability, and medication management. Focus group sessions were recorded, transcribed verbatim, and analyzed in ATLAS.ti. The constant comparative method was used to evaluate differences between hospitalists and PCPs. KEY RESULTS: Hospitalists and PCPs were found to encounter similar care coordination challenges, including (1) lack of time, (2) difficulty reaching other clinicians, (3) lack of personal relationships with other clinicians, (4) lack of information feedback loops, (5) medication list discrepancies, and (6) lack of clarity regarding accountability for pending tests and home health. Hospitalists additionally noted difficulty obtaining timely follow-up appointments for after-hours or weekend discharges. PCPs additionally noted (1) not knowing when patients were hospitalized, (2) not having hospital records for post-hospitalization appointments, (3) difficulty locating important information in discharge summaries, and (4) feeling undervalued when hospitalists made medication changes without involving PCPs. Hospitalists and PCPs identified common themes of successful care coordination as (1) greater efforts to coordinate care for "high-risk" patients, (2) improved direct telephone access to each other, (3) improved information exchange through shared electronic medical records, (4) enhanced interpersonal relationships, and (5) clearly defined accountability. CONCLUSIONS: Hospitalists and PCPs encounter similar challenges in care coordination, yet have important experiential differences related to sending and receiving roles for hospital discharges. Efforts to improve coordination of care between hospitalists and PCPs should aim to understand perspectives of clinicians in each setting.

This article examines the robustness of citizen involvement in decentralized governance. It develops two behavioral theories of citizen involvement and examines their relative explanatory power with survey data collected from subsistence households in forest-dependent communities in Bolivia, Kenya, Mexico, and Uganda. Counterintuitively, the analysis finds that households that have been engaged with collective action the longest are the most likely to disengage from decentralized institutions once they confront crises. This result is interpreted in light of psychological self-licensing theory: people justify noninvolvement with decentralization precisely because of their past effort. This result implies that policies that rely on local involvement may be unsustainable insofar as they fail to address the underlying vulnerability of local users. In order to ensure that citizen involvement with decentralized governance is consistent and effective, policies need to address the structural factors that make users vulnerable to crises.

One of the key technical challenges for polymer electrolyte fuel-cell researchers is improving both the activity and stability of the oxygen reduction reaction (ORR) catalysts at the cathode. Pt-based alloys have shown great promise for achieving these targets. Herein, we report a new strategy for producing a highly active and stable class of PtCu catalysts with tunable compositions. Several unique nanoparticle catalysts were prepared by galvanically displacing a monolithic nanoporous Cu support with Pt, leading to a Pt-enriched PtCu shell over a PtCu core. It was observed that temperature during galvanic displacement is a key experimental parameter and a novel means to control catalyst particle size. This paper presents several modifications to the galvanic displacement process and describes the resulting enhancements in ORR activity (up to 2.1 mA/cm 2 Pt) and stability relative to pure Pt.

AimThis article presents a conceptual model to help facilitate the transition from primary care to specialty substance use disorder (SUD) care for appropriate patients.BackgroundSubstance misuse is a common health condition among patients presenting to primary care settings and may complicate the treatment of chronic health conditions such as diabetes and hypertension. It is therefore critical that primary care providers be prepared to identify and determine appropriate treatment options for patients presenting with substance misuse.MethodsWe conducted a narrative review that occurred in three stages: literature review of health care transition models, identification of conceptual domains common across care transition models, and identification of SUD-specific model elements.FindingsThe conceptual model presented describes patient, provider, and system-level facilitators and barriers to the transition process, and includes intervention strategies that can be utilized by primary care clinics to potentially improve the process of transitioning patients from primary care to SUD care. Recognizing that primary care clinics vary in available resources, we present three examples of care practices along an intensity continuum from low (counseling and referral) to moderate (telephone monitoring) to high (intensive case management) resource demands for adoption. We also provide a list of common outcomes clinics might consider when evaluating the impact of care transition practices in this patient population; these include process outcomes such as patients’ increased knowledge of available treatment resources, and health outcomes such as patients’ reduced substance use and better quality of life.

Although property rights have been linked to a variety of positive social outcomes at the macro-level, less research focuses on how property rights affect the benefits that actors receive at the micro-level. This article examines property rights to a common-pool resource (CPR) that are asymmetrically allocated among users, and presents a theoretical argument that property rights affect the allocation of resource benefits in two important ways. First, users with extensive property rights receive more benefits than users with limited property rights. Second, users with the power to influence how community rules are enforced—for example, landholders and ethnic majorities—more effectively define and defend their property and thus receive disproportionate CPR benefits compared to users with similar levels of property rights, but with less power. Using household-level survey data in Bolivia, Kenya, Mexico, and Uganda, collected after a period of property rights decentralization, the empirical analysis finds support for these propositions. We conclude that power critically moderates the effects of property rights on the commons.

Poorly-executed transitions out of the hospital contribute significant costs to the healthcare system. Several evidence-based interventions can reduce post-discharge utilization.To evaluate the cost avoidance associated with implementation of the Care Transitions Intervention (CTI).A quasi-experimental cohort study using consecutive convenience sampling.Fee-for-service Medicare beneficiaries hospitalized from 1 January 2009 to 31 May 2011 in six Rhode Island hospitals.The CTI is a patient-centered coaching intervention to empower individuals to better manage their health. It begins in-hospital and continues for 30 days, including one home visit and one to two phone calls.We examined post-discharge total utilization and costs for patients who received coaching (intervention group), who declined or were lost to follow-up (internal control group), and who were eligible, but not approached (external control group), using propensity score matching to control for baseline differences.Compared to matched internal controls (N = 321), the intervention group had significantly lower utilization in the 6 months after discharge and lower mean total health care costs ($14,729 vs. $18,779, P = 0.03). The cost avoided per patient receiving the intervention was $3,752, compared to internal controls. Results for the external control group were similar. Shifting of costs to other utilization types was not observed.This analysis demonstrates that the CTI generates meaningful cost avoidance for at least 6 months post-hospitalization, and also provides useful metrics to evaluate the impact and cost avoidance of hospital readmission reduction programs.

Objective To describe parent perceptions of their child's hospital discharge and assess the relationship between these perceptions and hospital readmission. Design A prospective study of parents surveyed with questions adapted from the care transitions measure, an adult survey that assesses components of discharge care. Participant answers, scored on a 5-point Likert scale, were compared between children who did and did not experience a readmission using a Fisher's exact test and logistic regression that accounted for patient characteristics associated with increased readmission risk, including complex chronic condition and assistance with medical technology. Setting A tertiary-care children's hospital. Participants: A total of 348 parents surveyed following their child's hospital discharge between March and October 2010. Intervention None. Main Outcome Measure Unplanned readmission within 30 days of discharge. Results There were 28 children (8.1%) who experienced a readmission. Children had a lower readmission rate (4.4 vs. 11.3%, P = 0.004) and lower adjusted readmission likelihood [odds ratio 0.2 (95% confidence interval 0.1, 0.6)] when their parents strongly agreed ( n = 206) with the statement, ‘I felt that my child was healthy enough to leave the hospital’ from the index admission. Parent perceptions relating to care management responsibilities, medications, written discharge plan, warning signs and symptoms to watch for and primary care follow-up were not associated with readmission risk in multivariate analysis. Conclusions Parent perception of their child's health at discharge was associated with the risk of a subsequent, unplanned readmission. Addressing concerns with this perception prior to hospital discharge may help mitigate readmission risk in children.

The Centers for Medicare and Medicaid Services (CMS) has launched the Partnership for Patients initiative, promising a 20% reduction in readmissions nationally across all payers by December 31, 2013. To address this ambitious goal, CMS has awarded grants to Hospital Engagement Networks, Pioneer Accountable Care Organizations, and the Community-based Care Transitions Program, as well as instituted new penalties for excessive readmission that began in October 2012. National efforts aimed at realizing this goal are predicated, in part, on our effectiveness in disseminating evidence-based care models into practice to improve outcomes and reduce costs. The Care Transitions Intervention (CTI) has been developed, tested, and disseminated to over 750 health care organizations in 40 states nationwide. Four factors promote wide-scale CTI dissemination. The first factor focuses on model fidelity whereby adopters are given insight into which elements of the intervention can be adapted and customized. The second factor concerns the selection of Transitions Coaches and reinforcement of their role through training and participation in a national peer learning network. The third factor relates to model execution with attention to integrating the intervention into existing workflows and fostering relationships with community stakeholders. The fourth factor involves cultivating the support to sustain or expand the intervention through continually making the business case in a changing health care landscape. The lessons learned through the dissemination and implementation of the CTI may be generalizable to the spread of a variety of evidence-based care models.

BACKGROUND Rehospitalization is a prominent target for healthcare quality improvement and performance-based reimbursement. The generalizability of existing evidence on best practices is unknown. OBJECTIVE To determine the effect of Project BOOST (Better Outcomes for Older adults through Safe Transitions) on rehospitalization rates and length of stay. DESIGN Semicontrolled pre–post study. SETTING/PARTICIPANTS Volunteer sample of 11 hospitals varying in geography, size, and academic affiliation. INTERVENTION Hospitals implemented Project BOOST-recommended tools supported by an external quality improvement physician mentor. METHODS Pre–post changes in readmission rates and length of stay within BOOST units, and between BOOST units and site-designated control units. RESULTS The average rate of 30-day rehospitalization in BOOST units was 14.7% prior to implementation and 12.7% 12 months later (P = 0.010), reflecting an absolute reduction of 2% and a relative reduction of 13.6%. Rehospitalization rates for matched control units were 14.0% in the preintervention period and 14.1% in the postintervention period (P = 0.831). The mean absolute reduction in readmission rates in BOOST units compared to control units was 2.0% (P = 0.054 for signed rank test comparing differences in readmission rate reduction in BOOST units compared to site-matched control units). CONCLUSIONS Participation in Project BOOST appeared to be associated with a decrease in readmission rates. Journal of Hospital Medicine 2013;8:421–427. © 2013 Society of Hospital Medicine

The role of women's participation in community forestry has recently been investigated in a number of theoretical and empirical papers. This paper takes an existing theoretical framework developed by Agarwal (2001) and applies it to examine two questions: (1) What determines women's participation in forestry institutions? and (2) What effect does women's participation have on institutional outcomes (such as levels of conflict and rule fairness)? To answer these questions data is used from two sources: (1) a detailed household survey conducted with 1.433 households in Bolivia, Kenya, Mexico, and Uganda and (2) a more aggregated dataset from forest associations investigated by the International Forestry Resources and Institutions (IFRI) program in 10 countries. The analyses suggest that women's participation is likely when institutions exist that are less exclusionary, when households have more education, and when there is small economic inequality in general and across genders in particular. A history of women's participation, especially when women are seated on forest councils or attain leadership positions, is highly correlated with less disruptive conflict.

Objective To assess patient- and hospital-level factors associated with home health care (HHC) referrals following nonelective U.S. patient hospitalizations in 2012. Data Source The 2012 National Inpatient Sample (NIS). Study Design Retrospective, cross-sectional multivariable logistic regression modeling to assess patient- and hospital-level variables in patient discharges with versus without HHC referrals. Data Collection Analysis included 1,109,905 discharges in patients ≥65 years with Medicare. Principal Findings About 29.2 percent of discharges were referred to HHC, which were more likely with older age, female sex, urban location, low income, longer length of stay, higher severity of illness scores, diagnoses of heart failure or sepsis, and hospital location in New England (referent: Pacific). Conclusions As health policy changes influence postacute HHC, defining specific diagnoses and regional patterns associated with HHC is a first step to optimize postacute HHC services.

Summary In this paper we assess the institutional and environmental impacts of forest decentralization in Bolivia, Kenya, Mexico, and Uganda. We develop theories of institutional impacts based upon the specific content of decentralization reforms. We classify each country’s reforms in terms of the creation/change in local user group empowerment and accountability mechanisms. Using data from the International Forestry Resources and Institutions Program, we estimate the effects of forest decentralization on local forest investments, rulemaking, wealth inequality, and forest conditions in the four countries. Some results support our theory, but the theory is insufficient to explain the full range of outcomes.

This paper presents the results of a modified dictator game where donors are tourists in the island of Majorca, Spain, and the recipient is an environmental foundation. In this experiment we explore if the level of voluntary donations varies under different treatments that include taxes (high and low levels) and voting treatments on choosing and obligatory imposition of taxes (high vs. low and low vs. no tax). Our results show that participants only self-impose mandatory contributions when they must choose between a high or low tax, and rarely passing the high tax. In addition, we find that those individuals who voted for a high tax and are in a group where the majority votes for the low tax conform to their earlier vote by contributing more. Further, our data supports an incomplete crowding-out of voluntary donations by the application of tourism taxes ear-marked for environmental purposes. From a policy perspective, this result supports the potential for a complementary use of taxes and voluntary donations for fundraising environmental projects in tourism destinations.

Policy analysts have struggled to find methods that allow meaningful evaluation of forest management institutions, such as forest-sector decentralization, in terms of the resulting forest conditions. This article demonstrates how to use stocking indices to measure forest conditions when comparing forests across time or space. These measures are especially useful for comparative institutional and policy analysis because they are constructed with a common scale, thus providing a meaningful metric by which to compare conditions. As an example of the application of the method, evidence from Uganda is presented to show a reduction in stocking in many types of Ugandan forests during a time period of forest sector decentralization.

This paper reports the results of a statistical analysis which measures the effects of adaptive capacity on forest conditions in response to a prior disturbance. Particular emphasis is placed on common property rights as a form of institutional adaptive capacity. Common property rights are delineated in terms of rights of access, withdrawal, management, exclusion, and alienation. Using statistical analysis of 326 forest user groups from 13 countries in the database of the International Forestry Resources and Institutions (IFRI) program, the effects on user group rankings of forest conditions are estimated with a probability model. Overall, the results indicate that user groups with more complete property rights are more likely to rank forest conditions favorably. However, the effects of property rights also depend on the level of other forms of adaptive capacity such as the organizational capacity of the group and the number of rival user groups.