Browsing by Author "James, Sherman A"

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Open Access
An Assessment of Information & Assistance Services For Seniors Needing Long-term Care in North Carolina: What has changed and what comes next for the Aging Network?
(2011-04-22) Hayes, Ariel
Policy Question: How should North Carolina’s Aging Network provide information and assistance services so that all older adults (and their caregivers) looking for long-term care receive appropriate guidance? Introduction: Information and Assistance (I&A) programs inform, counsel and connect people seeking long-term care with services that could meet their needs. The Older Americans Act mandated that every Area Agency on Aging (of which there are 17 in North Carolina) establish I&A programs in their region. North Carolina has 42 I&A programs registered with the Division of Aging and Adult Services; more counties offer these services without OAA funds. As the population ages, more people will need a well-informed, local agency is critical to help them navigate the long-term care system and access services. Older adults and their families face such a complicated array of choices and decisions – about not only health care, but also housing, finances, and basic household tasks. Ten years ago, the North Carolina Institute of Medicine (NCIOM) delivered its report, “A Long-Term Care Plan for North Carolina: Final Report” to the North Carolina Department of Health and Human Services (DHHS). Early in its deliberations, the Task Force concluded “one of its goals would be to propose a system that would allow consumers to find their way into and through the system with ease.” Once the state was awarded a Real Choice Systems Grant, these recommendations became a roadmap for North Carolina, which launched two initiatives to improve seniors’ access to long-term care information and counseling: a web-based resource system called NCcareLink and the regional Community Resources Connections (CRC) program. My assessment focuses on how the Aging Network and its existing I&A programs have responded to these initiatives and worked to create a more accessible and understandable system. This report is especially relevant to counties that are beginning the transformation to a CRC and to state policymakers responsible for NCcareLink. s Methodology: I selected eight counties (Alamance, Beaufort, Forsyth, Henderson, Lenoir, Macon, Mecklenburg, and Surry) and contacted the primary agencies that serve older adults. The counties vary by geographic region, diversity, population density, and proportion of adults over 65. I conducted a total of 28 interviews. In each county, my goal was to identify and interview an organization that plays a central role in informing older adults about their options. In five counties, this was an agency that receives state or county-funding to provide information and assistance. In addition to the main I&A provider, I interviewed other organizations at the regional and local level that serve the same population. This allowed me to, first, gauge the “No Wrong Door” model by discussing the skills and tools each agency used to make accurate, effective referrals. Secondly, it spoke to a community’s recognition of the designated I&A provider (e.g. how many people are relying on the Senior Center instead of the Council on Aging, and for what reason). Lastly, to gain some understanding of how other states have addressed the issues, I interviewed employees at Departments of Aging in Oregon, Ohio, and Virginia, which have also established online databases. Key Findings: Many of the key findings from my interviews are fundamental and already known to providers and the state. 1. The role of the AAA and its staff is not clearly defined. The potential of AAAs are tremendous, but the history of AAAs in North Carolina has led to weakly defined roles that could impede easy entry into the system. In North Carolina, few people know even what the AAA does. A clearer definition and articulation of roles could help the staff members direct calls efficiently and reduce the number of inappropriate calls in the first place. The state can change its management strategy and level of supervision of the AAAs to promote certain roles and foster greater clarity. 2. Everyone in the Aging Network receives calls from older adults. Both in counties that have formal I&A programs and those that do not, every agency in the Aging Network is regularly contacted by older adults who do not know where to go for information and assistance. Seniors have diverse and often specific needs; when providers respond to these calls, it can be a time-intensive process and, if the provider is not experienced in I&A, may not lead to the best match for the consumer. 3. Older adults have trouble identifying their needs. Older adults recognize one need (e.g. help with light housekeeping) but they may not realize they also are struggling to walk and need to install grab bars in their home to prevent falls. The reason I&A is so valuable is that trained individuals can ascertain this information through phone conversations; it is much harder – but not impossible – to gather the same information online. 4. Older adults delay seeking help until they are in dire need. Information & Assistance programs usually receive calls from older adults only when their functioning has deteriorated to the point where they need immediate assistance. Culture plays an enormous role. It is very difficult for the Aging Network to convince people to call at the first sign of a need, rather than in a crisis. As the demands on the Aging Network increase, the AAA may have less time and resources to promote services at health fairs or reach out to pastors. Before the system is so strained that there is little or no time for community outreach, the Aging Network needs to find more effective ways to promote their services. 5. Caregivers are seeking out information online and being directed to many different sites. Adult children looking for information are likely to begin with a Google search. Even once NCcareLink is fully developed and being promoted by the Aging Network, policymakers need to be aware of the websites that appear at the top of a Google search query, such as private rehabilitation and home healthcare providers. Additionally, online information needs to be integrated with off-line service delivery. People who are searching for information online are often looking for phone numbers of service providers. They may want the phone number to a provider of specific services (e.g. transportation, personal care) or to a public office (e.g. DSS) that can screen for Medicaid eligibility. Either way, these websites will play an important role in directing people to services, so the way services are described and pathways are mapped online needs to match the offline system 6. Changes to the long-term care system need to allow for county differences, while also moving toward consistency. Every county has organized their services differently. The CRC pilot projects and expansions demonstrate that every county will interpret and implement programs in their own way. However, it would be unfortunate if these variations prevented counties from sharing insights about what works or created additional confusion for senior citizens and caregivers. Moving forward, the goal for the state is to ensure information is readily available to all aging adults, without prescribing a set of certain set of services that may be unrealistic for or incompatible with a particular county’s current organization. Recommendations In keeping with the NCIOM’s initial recommendation, any new alternatives must advance the three goals that information should be readily available and easily accessed, understandable, and uniform for all in need. Objective #1: Reduce the time it takes for older adults to find the services they need 1. Identify at least one I&A program in every county. 2. Expand and modify online presence of all Aging Network agencies to make them consistent and senior-friendly. 3. Prioritize good website design over expediency. 4. Work with Aging Network staff to collect and record data on caller demographics (age, race, location) and level of functioning 5. Allow providers the opportunity to see the same software interface that Aging Network agencies are using. Objective #2: Make it easier for older adults to identify if they need information or assistance 6. Learn from states that have implemented needs assessment tools. 7. Create a .pdf version of the state’s needs assessment tool that can be emailed to or downloaded by interested caregivers. Objective #3: Provide high-quality assistance services 8. Train I&A providers in options counseling. 9. Implement benefits or incentives that help recruit and retain exceptional staff at I&A agencies. Objective #4: Engage the private, for-profit sector to reduce the strain on the public and non-profit Aging Network 10. Provide training to I&A programs to promote services provided in the private, for-profit sector. 11. Expand or replicate the Forsyth Senior Services’ Elder Care Choices program, which provides consultation and referral services to employees as part of subscribing companies' employee benefits packages.
Open Access
Anticipated Negative Police-Youth Encounters and Depressive Symptoms among Pregnant African American Women: A Brief Report
(Journal of Urban Health, 2017-04) Jackson, Fleda Mask; James, Sherman A; Owens, Tracy Curry; Bryan, Alpha F
Open Access
Communicating About Costs: A qualitative analysis to understand the out-of-pocket financial burden associated with cancer care
(2012-04-20) Harris, Jessica R
EXECUTIVE SUMMARY Policy Question In the context of the Affordable Care Act, what factors create financial burden for female breast cancer patients eligible for Medicare? Specifically, how can LIVESTRONG, a leading cancer advocacy organization, minimize the individual burden from out-of-pocket costs? Recommendations The goal of this study was two-fold: 1) develop recommendations to target LIVESTRONG ‘s research about the practical concerns of survivorship, and 2) improve the effectiveness and impact of LIVESTRONG’s navigation services. Correspondingly, my recommendations are separated into these two categories. Past research on patient-provider communication, medical decision-making, and cost-effectiveness precede this work. All recommendations were evaluated using the criteria of minimizing implementation costs, and maximizing collaboration and buy-in among stakeholders, and maximizing applicability to clients of diverse backgrounds. Further Research 1. Conduct market research to develop a segmented approach to assist different client groups. OOP costs are a universal challenge. However, different types of individuals (age, gender, race, socio-economic position, insurance type, etc.) access information in different ways. These groups likely have different coping strategies and varying comfort levels in discussing costs. The Medicare population in this study, for example, had limited experience using the Internet. They also did not appear to be widely connected to the larger community of cancer survivors. 2. Build an infrastructure of partners, professional standards, and political support to advance the field of cancer navigation. Since payers do not yet recognize these services for reimbursement, it will be important to demonstrate value for money and any associated cost savings. Any overlap or points of collaboration with other medical providers, including nurse practitioners, social workers, and medical financial counselors, should be carefully studied. Clinical Practice 3. Improve tools that facilitate information sharing and increase ease of accessing financial assistance. There are two audiences for these tools: 1) direct access by patients and caregivers, or 2) professional use by the cancer care team that works with patients, including social workers, financial counselors, and cancer navigators. 4. Develop a curriculum to share information on the financial impacts of cancer treatment at the clinical level. Use LIVESTRONG Survivorship Centers of Excellence as a platform to develop targeted programs for physicians, medical professionals, and patient assistance organizations. 5. Lobby for more accountability and transparency about the cost of care, and consumer protection from prohibitive cost sharing, high interest health payment plans, or “wallet biopsy” software that might evade patient privacy laws. Overview Although much is known about the rising economic cost of cancer care compared to other diseases in the United States, there is little research to date on effective strategies to reduce patient financial burden. A first step is to better understand what type of challenges patients face and the events leading up to these challenges. This project uses a qualitative study design to explore the patient experience surrounding OOP costs, specifically for female breast cancer survivors on Medicare. My study hypothesizes that there is little communication about costs early in treatment, and that increased communication could help alleviate individual burden. A literature review suggests that more timely communication could improve the patient experience, and in some cases, reduce financial hardship. More cost information, coupled with support services, may improve medical decision-making and in the long term, health outcomes. Although provider-patient communication is of specific interest, social workers and financial counselors contribute to this conversation. The study design also assumes that caregivers, friends, and family play an essential role in facilitating information about costs and devising strategies to cope with financial burden. Research and Methods In-depth, semi-structured telephone interviews were conducted until the criterion of thematic saturation was met. Interviews were conducted with a total of 22 participants selected from a prospective, nationwide survey completed by the Duke Cancer Care Research Program in 2011. I selected female breast cancer survivors, 65-75 years old and eligible for Medicare at the time of completion of the baseline survey for my study. Eligible participants must have received anti-cancer therapy for breast cancer (chemotherapy or hormonal treatment) within the past year. Participants were required to be English-speaking, literate, and with full capacity to be interviewed independently. When the original survey respondents were sorted based on these criteria, there were 70 participants eligible for phone interviews. I interviewed patients who both a) did talk to their doctor about costs of care and b) patients who did not speak to their doctor about cost of care. Survey respondents reported significant/catastrophic, moderate, or minimal financial burden. Participants were not equally distributed in all categories, but efforts were made to speak to similar numbers of each type among the 70 eligible participants. Data Transcripts were analyzed using a thematic analysis approach, where major themes were coded, followed by minor themes. The major themes identified in this study represent different stages of communicating about costs. First, many survivors discussed the cost of their care only when the burden became unmanageable. Second, a number of participants discussed the process of identifying resources and determining eligibility. Third, several participants expressly stated that there is an associated need for self-advocacy in applying for assistance. Finally, several participants described significant emotional impacts of their financial concerns, including feelings of shame. They also showed immense gratitude for the assistance, and a desire to pay it forward to other survivors. Interviews were also conducted with two LIVESTRONG patient navigators, a HealthWell Foundation Board Member, and the Oncology Services Revenue Manager for the Duke University Medical Center. These stakeholders reflected on the complexity of the current system in which cancer care is administered, with multiple providers and varying resources available. Conclusions In this detailed qualitative study, I gained insight into the varied situations in which older women with breast cancer experience OOP costs related to their cancer care. Through their narratives, participants described a fragmented continuum of care, without programs in place to safeguard financial health as well as physical health in a sustainable, reliable manner. Many participants only considered discussing costs with their care team only once they were in financial distress – when it was too late. There were psychological and behavioral barriers to addressing this practical concern; many participants indicated that as long as insurance was paying, they were indifferent to the cost of their cancer care. However, once OOP costs became a significant factor, often as a result of the Medicare coverage gap, they were then willing to seek assistance. Additionally, when branded drugs became generic, participants became less concerned with the cost of their care. Many of the hormone therapies for breast cancer went off patent during the course of the study and significantly cheaper generic options became available for study participants. These findings provide additional, nuanced understanding of the factors that impact the financial burden of cancer care for individual patients. My hypothesis was that early communication did not occur between patients and physicians about the cost of care – specifically, the individual burden related to OOP costs. These results suggest that communication may be happening, but that it is currently not helpful for patients. First, there is still too little communication overall, and it is mainly initiated by the patient. Only the most proactive patients appear to be seeking out this type of information. Second, communication is often too late. Patients will wait until they lose coverage or have other financial complications before trying to understand cost details relating to their treatment. Third, there are not sustainable solutions in terms of assistance – although help is available, it is highly variable and difficult to access. These conclusions suggest that larger policy changes on a national scale are required – validating the need for comprehensive health care reform but also highlighting the systemic, rooted nature of these challenges.
Open Access
Family Structure and Child Malnutrition in China: Three Essays
(2013) He, Wei
Over the past three decades, the phenomenon of children's health in China has been marked by a co-existence of overweight and underweight. As the primary institution for a child, family is an opportune place for child malnutrition intervention. By advancing a framework that addresses the contextual factors which shape the heterogeneity of socioeconomic gradients of child overweight/obesity, this dissertation has sought to understand the channels through which access to family resources influences child overweight/obesity in China. Based on these developed understandings, I identified the mechanisms by which having any younger siblings and three generation living together or proximately affect child malnutrition in China. Using data drawn from China Health and Nutrition Survey, this dissertation uncovered remarkable differences in multiple levels of contextual factors that shape a child's risk of overweight/obesity and underweight in China as compared to Western society. China's stage of economic development together with the drastically increasing income inequality has created an ever-increasing socioeconomic gap in child overweight/obesity, especially after 1997. This finding confirmed the position of the Ecological System framework that access to obesogenic environment is much more important than willpower based on knowledge in shaping one's obesity-related risk behavior. Although the fertility level has been lowered by One Child Policy, resource dilution effect still affects girls' nutrition status, especially for those exposed to poverty and food insecurity. Children in the care of grandparents are healthier, probably due to the generally low degree of access to obesogenic foods and a closer intergenerational relationship that facilitates effective communication and promotes healthy lifestyle formation.
Open Access
Invited Commentary: Cassel's "The Contribution of the Social Environment to Host Resistance"-A Modern Classic.
(Am J Epidemiol, 2017-06-01) James, Sherman A
John Cassel's 1976 paper "The Contribution of the Social Environment to Host Resistance" (Am J Epidemiol. 1976;104(2):107-123) is widely regarded as a classic in epidemiology. He makes the compelling argument that the quality of a person's social relationships, that is, the degree to which her relationships are more stressful than supportive (or vice versa) influences her susceptibility to disease independent of genetic endowment, diet, physical activity, etc. Cassel's provocative thesis was anchored in a cogent synthesis of findings from animal experiments and observational studies on diverse human populations. Beginning in the late 1970s, the paper stimulated an explosion of epidemiologic research on social support and human health. Beyond advancing epidemiologic theory, Cassel showed how findings from various epidemiologic study designs could be marshalled to build a persuasive causal argument that impaired social bonds increase the risk of premature disease and death. The paper also foreshadowed core ideas of later theoretical constructs, such as weathering and allostatic load, regarding the power of chronic environmental stressors to accelerate biological aging across multiple organ systems. Cassel's assessment of the research and practice implications of his conclusions has remarkable contemporary resonance for the field of epidemiology.
Open Access
Receipt of public assistance during childhood and hypertension risk in adulthood
(Annals of Epidemiology, 2017-02) Barrington, Debbie S; James, Sherman A
Open Access
Social and physical environments and disparities in risk for cardiovascular disease: the healthy environments partnership conceptual model.
(Environ Health Perspect, 2005-12) Schulz, Amy J; Kannan, Srimathi; Dvonch, J Timothy; Israel, Barbara A; Allen, Alex; James, Sherman A; House, James S; Lepkowski, James
The Healthy Environments Partnership (HEP) is a community-based participatory research effort investigating variations in cardiovascular disease risk, and the contributions of social and physical environments to those variations, among non-Hispanic black, non-Hispanic white, and Hispanic residents in three areas of Detroit, Michigan. Initiated in October 2000 as a part of the National Institute of Environmental Health Sciences' Health Disparities Initiative, HEP is affiliated with the Detroit Community-Academic Urban Research Center. The study is guided by a conceptual model that considers race-based residential segregation and associated concentrations of poverty and wealth to be fundamental factors influencing multiple, more proximate predictors of cardiovascular risk. Within this model, physical and social environments are identified as intermediate factors that mediate relationships between fundamental factors and more proximate factors such as physical activity and dietary practices that ultimately influence anthropomorphic and physiologic indicators of cardiovascular risk. The study design and data collection methods were jointly developed and implemented by a research team based in community-based organizations, health service organizations, and academic institutions. These efforts include collecting and analyzing airborne particulate matter over a 3-year period; census and administrative data; neighborhood observation checklist data to assess aspects of the physical and social environment; household survey data including information on perceived stressors, access to social support, and health-related behaviors; and anthropometric, biomarker, and self-report data as indicators of cardiovascular health. Through these collaborative efforts, HEP seeks to contribute to an understanding of factors that contribute to racial and socioeconomic health inequities, and develop a foundation for efforts to eliminate these disparities in Detroit.
Open Access
Socioeconomic position, John Henryism, and incidence of acute myocardial infarction in Finnish men
(Social Science & Medicine, 2017-01) Mujahid, Mahasin S; James, Sherman A; Kaplan, George A; Salonen, Jukka T
Open Access
Strategic Analysis of the TROSA Grocery Store in the Context of Durham’s Food Deserts
(2012-04-19) Ruatto, Maria
This research was commissioned by Triangle Residential Options for Substance Abusers (TROSA), a non-profit based in Durham, North Carolina that operates several small businesses as part of their integrated approach to supporting rehabilitation through vocational training, counseling, and education in a therapeutic community setting. In 2010, TROSA opened a grocery store in Northeast Central Durham, in response to a perceived need on the part of community leaders for increased access to fresh foods within the neighborhood. The primary objective of the original research was to examine the strategic value of the TROSA Grocery Store within TROSA’s overall mission. The profitability and strategic analysis conducted for TROSA contain confidential and proprietary data concerning costs, sales, and organizational priorities. As such, the original problem statement, strategic analysis and recommendations could not be included in this modified version of the thesis. Northeast Central Durham includes several neighborhoods that can be classified as “food deserts”, defined as areas with limited access to fresh food retail. Research indicates that living in a food desert may increase incidence of nutrition related diseases such as cardiovascular disease, diabetes, and hypertension. Food deserts are caused by private business decisions in reaction to market forces, specifically the economies of scale experienced in the grocery industry. The lack of grocery stores in low-income neighborhoods should not be interpreted as a lack of demand. In fact, there is latent demand for fresh foods in low-income neighborhoods, provided that these foods can be sold at a competitive price point. As such, public-private partnerships to reduce the costs of operating a fresh food retail business in a low-income neighborhood may be able to sufficiently incentivize grocery stores to locate in these neighborhoods. The opening of new stores in low-income neighborhoods will provide the additional benefit of creating new jobs and expanding the tax base. The following recommendations are not targeted to a single organization, but provide a high-level view of the types of programs and partnerships that would encourage increased retail of fresh foods in low-income neighborhoods in Durham. 1) Make available economic development funds specifically for fresh food retailers in underserved areas. 2) Develop a “patient capital” financing program to provide grants and loans to supermarkets, small grocery stores, and other fresh food retailers to enhance healthy food access in underserved areas. 3) Work with large grocery stores in the area to explore the financial viability of opening “satellite” stores, to take advantage of economies of scale.
Open Access
The strangest of all encounters: racial and ethnic discrimination in US health care
(Cadernos de Saúde Pública, 2017) James, Sherman A

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