Until recently, when anthrax triggered a concern about preparedness in the public health infrastructure, U.S. health policy and health spending had been dominated by a focus on payment for medical treatment. The fact that many of the conditions driving the need for treatment are preventable ought to draw attention to policy opportunities for promoting health. Following a brief review of the determinants of population health-genetic predispositions, social circumstances, environmental conditions, behavioral patterns, and medical care-this paper explores some of the factors inhibiting policy attention and resource commitment to the nonmedical determinants of population health and suggests approaches for sharpening the public policy focus to encourage disease prevention and health promotion.

To meet the long-term care needs of Baby Boomers, social and public policy changes must begin soon. Meeting the financial and social service burdens of growing numbers of elders will not be a daunting task if necessary changes are made now rather than when Baby Boomers actually need long-term care.

OBJECTIVES: This study examined predictors of entry into shelter and subsequent housing stability for a cohort of families receiving public assistance in New York City. METHODS: Interviews were conducted with 266 families as they requested shelter and with a comparison sample of 298 families selected at random from the welfare caseload. Respondents were reinterviewed 5 years later. Families with prior history of shelter use were excluded from the follow-up study. RESULTS: Demographic characteristics and housing conditions were the most important risk factors for shelter entry; enduring poverty and disruptive social experiences also contributed. Five years later, four fifths of sheltered families had their own apartment. Receipt of subsidized housing was the primary predictor of housing stability among formerly homeless families (odds ratio [OR] = 20.6, 95% confidence interval [CI] = 9.9, 42.9). CONCLUSIONS: Housing subsidies are critical to ending homelessness among families.

This study compares social relationships of 677 mothers in families requesting shelter with those of 495 mothers in housed families, randomly selected from the public assistance caseload in New York City. As hypothesized, women seeking shelter had experienced higher levels of a variety of childhood and adult events indicative of disruptions in social relationships. Contrary to our hypothesis, they were more likely than were housed mothers to have had recent contact with parents, other relatives, and friends, although they felt less able to draw on these resources for help with their current housing needs. More than three fourths of families seeking shelter had already stayed with members of their social network in the past year. The data suggest that they had used up potential sources of support before turning to public shelter.

The past decade has seen a growing recognition of the importance of social determinants of health for health outcomes. However, the degree to which US health systems are directly investing in community programs to address social determinants of health as opposed to screening and referral is uncertain. We searched for all public announcements of new programs involving direct financial investments in social determinants of health by US health systems from January 1, 2017, to November 30, 2019. We identified seventy-eight unique programs involving fifty-seven health systems that collectively included 917 hospitals. The programs involved at least $2.5 billion of health system funds, of which $1.6 billion in fifty-two programs was specifically committed to housing-focused interventions. Additional focus areas were employment (twenty-eight programs, $1.1 billion), education (fourteen programs, $476.4 million), food security (twenty-five programs, $294.2 million), social and community context (thirteen programs, $253.1 million), and transportation (six programs, $32 million). Health systems are making sizable investments in social determinants of health.

People with special medical and supportive care needs often have to navigate several disparate financing and delivery systems to obtain the services they need.by Gerard Anderson and James R. Knickman ABSTRACT: Persons who are likely to be the heaviest users of medical and supportive care services-those with chronic illnesses, disabilities, and functional limitations-are often forced to navigate a system that requires them to perform most of the coordination functions themselves and is generally not organized around their needs. In 1996 an estimated 128 million Americans had at least one of these three conditions, and 9.5 million had all three. This paper examines the current programs designed to assist these persons and suggests changes in eligibility rules, coverage policies, and educational programs to provide a system more oriented to people's chronic care needs.A n estimated 125 million americans had one or more chronic illnesses, fifty million had a disability, and fifteen million had a functional limitation in 2000.Unfortunately, the medical care system is not oriented around the needs of persons with chronic illnesses; many persons with disabilities have difficulties obtaining appropriate services; and the long-term supportive care system does not facilitate access to some of the services that people with functional limitations need. The challenges to obtaining appropriate care, however, are exacerbated when a person has two or all three of these problems. Such persons often have to navigate a system that requires them to coordinate several disparate financing and delivery systems themselves, making it more difficult to obtain the full range of appropriate services.In this paper we first estimate the number of persons who have chronic illnesses, disabilities, and functional limitations and then examine the number who fall into one, two, or all three categories.

The Patient Protection and Affordable Care Act (PPACA) affords opportunities to sustain the role of community health workers (CHWs). Among myriad strategies encouraged by PPACA are prevention and care coordination, particularly for chronic diseases, chief drivers of increased health care costs. Prevention and care coordination are functions that have been performed by CHWs for decades, particularly among underserved populations. The two key delivery models promoted in the PPACA are accountable care organizations and health homes. Both stress the importance of interdisciplinary, interprofessional health care teams, the ideal context for integrating CHWs. Equally important, the payment structures encouraged by PPACA to support these delivery models offer the vehicles to sustain the role of these valued workers.

Both the number of residents and the amount of time existing residents have in which to carry out their activities may soon be decreasing. To consider the potential for alternative ways of staffing teaching hospitals, it is necessary to know how residents spend their time. The authors sought to learn this by conducting a time-motion study of eight internal medicine residents at two urban hospitals in New York City in 1988. The residents' activities were observed and coded by premedical students, and the authors independently classified the possible activities into (1) those that had to be done by a physician, (2) those that were educational only, and (3) those that could be done by a non-physician. A total of 1,726 activities of 67 kinds were coded, averaging 7.75 minutes each. The authors analyze and project their data using two models--the traditional model of care in which the physician is the primary medical manager of the patient, and an alternative model in which a midlevel practitioner, such as a nurse practitioner, would perform the day-to-day monitoring of patients. For example, the data indicate that in the traditional model, almost half of a resident's time is spent in activities that must be done by a physician, meaning that another kind of physician would be needed to do those activities if the resident were unavailable; but in the midlevel practitioner model, only around 20% of the activities would require a physician. The authors give detailed breakdowns of their data, estimate the kinds and numbers of non-physician health care professionals necessary to substitute for residents in appropriate activities, and review possible difficulties in implementing such substitutions.