6c IMPROVING THE ACCESSIBILITY OF FRONTLINE SERVICES… FOR DIGNIFIED, PERSON-CENTERED CARE AMIDST DEMOGRAPHIC CHANGE THE CHALLENGE Even in mature health systems, universal access to frontline health services remains largely aspirational. Most countries in the Organisation for Economic Co-operation and Development (OECD) have few general practitioners relative to specialists, and many systems suffer from long wait times for primary care or limited options outside standard office hours. Those living in disadvantaged communities or on the margins of society—including rural, poor, minority, mobility constrained, and immigrant patients—can also face entrenched physical, social, and financial barriers to accessing health services, even in countries with universal health coverage. Universal coverage of accessible frontline services will require creative solutions to encourage physician entry into primary care (see Brief 15c); task shifting to emerging cadres of workers (see Brief 7c); creating flexible, nontraditional care models that make it easier to access care; and reaching populations excluded under the status quo. FRONTLINE SERVICES ARE INCONVENIENT OR UNAVAILABLE Although general practitioners (GPs) should be the gatekeepers into the health system, they are outnumbered by specialists in most high-income countries. With the exceptions of Ireland, Norway, Denmark, and Australia, specialist doctors comprise over half of the physician workforce in all OECD countries, and over 75% of the physician workforce in countries such as the United States (88%), Italy (77%), and Germany (77%).i The relative shortage of general practitioners drives long wait times for frontline services, with up to a third of patients with chronic diseases reporting wait times of a week or longer to see a primary care doctor.ii Besides costly emergency rooms (ERs), patients also have few options for accessing care outside normal office hours. Survey evidence from Canada, for example, shows that 62% of patients with chronic diseases find it somewhat or very difficult to get weekend or evening care outside the emergency room, and up to 23% have visited the emergency room in the past 2 years for “a condition that could have been treated by [a] regular doctor if available.”iii Findings from other wealthy countries (Austria and the United States) are similar, though the Netherlands and New Zealand get better marks for accessibility, demonstrating the feasibility of strengthened frontline care networks.iv Japan Trust Fund for OCTOBER 2018 Scaling Up Nutrition IMPROVING THE ACCESSIBILITY OF FRONTLINE SERVICES… FOR DIGNIFIED, PERSON-CENTERED CARE AMIDST DEMOGRAPHIC CHANGE Inequities Prevent Poor and Marginalized Communities from Poor and Accessing Health Services marginalized Even within the world’s wealthiest societies, poor and marginalized communities, including communities immigrants and ethnic, racial, and religious minorities, can struggle physically, socially, and typically face worse financially to access care. In the United States, which lacks universal health coverage, families outcomes and under the poverty line were more than three times as likely the wealthiest families to delay or access to care. For forego care for their children due to cost or lack of insurance coverage.v (See Brief 8a for example, 27% of more on payment and financing models to address financial barriers to care.) Racial and ethnic minorities, including indigenous populations, typically face persistently worse Hispanic Americans outcomes and worse access to care, sometimes intermediated by racial disparities in wealth, were uninsured, education, or geographic community.vi In 2014, for example, only 73% of Hispanic Americans compared to 11% of had a usual source of care (compared to 86% of white Americans); 24% of Native Americans, white Americans. 16% of black Americans, and 27% of Hispanic Americans were uninsured (compared with just Discrimination can 11% of white Americans); 17% of black children suffered from asthma (compared to 10% of also taint patients’ white children); and African American HIV diagnosis rates are over eight times as high among experiences in black teens and adults than among their white counterparts.vii Direct discrimination or insensitive care can also taint patients’ experiences within health servicesviii and in some health services; settings deter care,ix although systematic review evidence does not find a consistent however, systematic relationship between experiences of racism and lower use of health services.x review evidence does not find a Mobility Constraints Can Limit Access to Care consistent Within OECD countries, population ageing and high prevalence from chronic diseases are relationship driving high rates of mobility-limiting disability. In 2016, 12.8% of the U.S. population (and half of the population aged 75 and up) experienced at least one disability; more than half of this between group had difficulty walking,xi potentially creating a physical constraint to health care access. experiences of Rural populations may likewise struggle to physically reach frontline services, resulting in racism and lower delayed or deferred care. Studies from the U.S. suggest that emergency transport times can use of health be twice as high in rural areas compared to urban areas, potentially leading to higher risk of services.. death,xii and rural residents are significantly more likely than their urban counterparts to receive a late HIV diagnosis.xiii THE PATH FORWARD: TOWARD ACCESSIBLE CARE FOR ALL New Care Models Can Increase the Convenience and Accessibility of Frontline Services Intermediate care centers—including walk-in centers, retail clinics, urgent care centers, and nurse practitioner-led practices—can help fill gaps when a patient lacks a designated general practitioner or when GP services are temporarily unavailable (see Brief 7c). These services enhance patient convenience by extending care accessibility; allowing care without first scheduling an appointment; offering easy intake for tourists and travelers who otherwise may struggle to find available health providers; and providing greater price transparency, particularly in the U.S. context.xiv Such models are expanding quickly, driven by consumer demand for increased convenience and payer optimism about the potential for cost savings (as these centers can theoretically substitute for more expansive ER visits).xv In practice, OCTOBER 2018 2 IMPROVING THE ACCESSIBILITY OF FRONTLINE SERVICES… FOR DIGNIFIED, PERSON-CENTERED CARE AMIDST DEMOGRAPHIC CHANGE evidence suggests that expansion of intermediate care models can increase accessibility and Evidence suggests use of frontline health services, but the evidence on cost-savings is mixed.xvi While some that expanding evidence suggests that retail clinics can reduce unnecessary ER visits (and costs),xvii increased intermediate care convenience can also drive overutilization of health services for minor health concerns, models can increase potentially increasing health spending.xviii Direct comparisons based on claims data show that urgent care centers provide comparably (though somewhat lower) priced services to use of frontline traditional office visits, but retail clinics offer care that is substantially more affordable.xix health services. However, evidence Top Interventions on cost savings for Intervention Evidence Strength Research Findings these models is Intermediate care centers Strong Mixed mixed, with Telephone-based triage and advice Moderate Mixed increased Find & treat outreach services Low Mixed convenience Patient navigators Moderate Positive potentially driving Telemedicine Strong Positive overuse for minor Drone deliveries Feasibility Positive health concerns. Home visits Strong Mixed/Null Telephone-based triage and advice services—wherein a patient can contact a health provider for basic diagnostic services, counselling, and medical advice—is also increasingly used as a substitute for face-to-face consultations, with call services now available in countries such as the United Kingdom, Australia, and Denmark.xx Systematic review evidence suggests that about half of calls received by such hotlines can be addressed by telephone advice alone, but there is still mixed evidence and many outstanding questions about their safety, cost- effectiveness, and overall impact on health service utilization and outcomes.xxi As with Telephone-based intermediate care centers, the extreme ease of use for telephone consultations also presents advice service is an opportunity for overuse, with recent evidence showing that telephone consultations result another area of in more frequent GP-patient contacts than face-to-face consultations.xxii exploration and faces similar Helping Disadvantaged Groups Enter and Navigate the Health questions System A range of community-based models seek to engage poor and marginalized groups in care concerning cost- through proactive outreach and case management. “Find & treat” models actively seek out effectiveness. secluded, hidden or otherwise disadvantaged populations. They have been widely used, for example to identify latent tuberculosis among immigrant populations in the United States;xxiii detect and treat tuberculosis among the homeless, alcohol and drug users, former inmates, and recent migrants in London;xxiv and to extend child health and chronic disease care services to Aboriginal communities in Australia.xxv The British National Health Service evaluated the approach as a cost-effective strategy to reach vulnerable populations with tuberculosis;xxvi elsewhere, however, street outreach has fallen short vis-à-vis effective linkage to follow-on care,xxvii highlighting the importance of strong referral and case management practices. Safety net facilities, which deliver health care and other health-related services to patients who cannot pay, can also play an important role as the provider of last resort, particularly where insurance coverage is incomplete. Patient navigators, who assist patients in entering care and maneuvering through the maze of health services, are intended to provide end-to-end support, particularly to groups that OCTOBER 2018 3 IMPROVING THE ACCESSIBILITY OF FRONTLINE SERVICES… FOR DIGNIFIED, PERSON-CENTERED CARE AMIDST DEMOGRAPHIC CHANGE otherwise might struggle with access. Patient navigation has been used extensively in the “Find & treat” United States, particularly for cancer care, and to a lesser extent for chronic diseases and in programs, which general primary care. The practice is associated with improved processes of care and increases in screening, but there is still limited evidence evaluating their effect on health actively seek out outcomes or costsxxviii (See further discussion in Brief 11c.). those in need, have been widely used to Bridging Geographic and Physical Access Divides engage the poor When distance or mobility constraints prevent individuals from accessing frontline facilities, and marginalized: emerging technology-based solutions offer a potential path to receive remote care. for example, Telemedicine solutions have been widely applied to a range of health care problems, programs to detect including diabetes care, psychiatry dementia management, post-stroke rehabilitation, and even for remote assistance to intensive care; it is particularly widely used for elderly care, and treat where a higher portion of patients have mobility constraints.xxix There is overwhelming tuberculosis in evidence that appropriate use of telemedicine can bring care closer to mobility-constrained selected populations patients and reduce hospital admissions and re-admissions, emergency department visits, in London, and to and even mortality among individuals with chronic disease,xxx but regulation is needed to extend child health prevent exploitation of patients and unnecessary cost escalations. (See Brief 1c for a broader and chronic disease discussion of telehealth.) Drone deliveries represent another promising hi-tech solution to care services in mobility constraints of rural residents, particularly when poor weather conditions temporarily cut off traditional transport routes; they have already been used to delivery health supplies to Aboriginal remote areas of high-income countries such as Australia, Germany, the Netherlands, New communities in Zealand, Switzerland, and the United States.xxxi Evidence on their effectiveness and scalability Australia. in practice is still extremely limited, but early simulation studies suggest potential to reduce delivery times in emergencies.xxxii Scaling the use of drones for more systematic deployment will require resolution of thorny regulatory and safety issues, particularly with respect to use of airspace.xxxiii Low-tech home-based solutions, specifically home health care visits, can also provide personalized care to elderly, frail, or disabled individuals with limited mobility. Evidence concerning their impact on morbidity, mortality, hospitalization, and cost of healthcare is mixed; in general, they are associated with null to slightly positive effects, but benefits are quickly eroded among the frail and very elderly.xxxiv Nonetheless, home visits offer a convenient and sometimes inevitable course of action for patients with severe mobility constraints; the visits can also be used to extend preventive and curative health services that would otherwise be difficult for such patients to obtain, such as influenza vaccination.xxxv SPOTLIGHT Expanding Access to Mental Health Care Through Telepsychiatry ► Telepsychiatry offers a highly promising approach to address the enormous global burden of unmet need for mental health care, particularly among groups like rural residents, veterans, and the elderly, who might otherwise have difficulty accessing in-person services due to mobility constraints, geographic distance, or stigma. Telepsychiatry has now been widely studied and validated as an equally effective and cost- reducing alternative to in-person psychiatric care that helps expand the reach of care to vulnerable or underserved populations.xxxvi OCTOBER 2018 4 IMPROVING THE ACCESSIBILITY OF FRONTLINE SERVICES… FOR DIGNIFIED, PERSON-CENTERED CARE AMIDST DEMOGRAPHIC CHANGE One specific study, conducted among military veterans with post-traumatic stress disorder (PTSD) in rural Hawai’i, offers a concrete illustration of telepsychiatry’s value proposition. The small-scale program recruited 74 veterans with PTSD living on Maui and the Big Island of Hawaii, and randomly assigned study participants to either traditional in- person care or clinical video-teleconferencing (CVT) for anger management therapy. Clinical outcomes in the CVT group were significantly better than those from the traditional therapy group—and were achieved at a dramatically lower cost. In-person care under the traditional model required air travel to satellite Veterans Administration clinics, driving a total per-person cost of $792 over the course of the program; in contrast, CVT cost just $79 per study participant—a tenth the cost of in-person care. The cost structure of in-person care may be particularly high given Hawaii’s unique geography; nonetheless, the study shows the potential of telepsychiatry for expanding financial and geographic access to underserved groups and rural regions more broadly.xxxvii Walk-In Centers in the U.K.: A Partial Success Story ► The United Kingdom was an early adopter of intermediate care centers, opening 230 walk-in centers between 2000 and 2010 through the government’s National Health Service (NHS). The U.K. did not create a standardized national definition of a “walk-in center” and sites throughout the country varied greatly in terms of staffing mix and the services provided. However, such centers can be broadly characterized as nurse- or physician-led practices, open during expanded hours (including evenings and weekends), where individuals could access basic diagnosis and treatment services without a preexisting appointment. Walk-in centers were intended to expand access to care, particularly among disadvantaged groups, and were disproportionately located in relatively deprived communities. Indeed, in practice, the centers primarily served young people, individuals with lower socioeconomic status, and patients that perceived or experienced challenges accessing services through general practitioners—groups that would otherwise not necessarily receive care from traditional services. Walk-in centers have proven important in facilitating access for a range of underserved communities, including the homeless; drug and alcohol users; former inmates; and minority, immigrant, and refugee communities. By 2014, it was clear that demand for services at walk-in centers outstripped expectations, and patient surveys found that most users were satisfied with the services they received. (84% of visitors declined to seek further care from a second medical practitioner.) Nonetheless, the centers remained a source of controversy and local commissioning bodies had closed more than 50 such facilities. Critics alleged that the walk-in centers were duplicating care, generating unnecessary care-seeking for self-limiting ailments, and creating confusion about care pathways in a system otherwise built around designated primary care providers. (Importantly, evidence about service usage did not necessarily support these critiques, with most users coming from otherwise underserved communities). Integrating the walk-in centers within the NHS structure also proved challenging; general practitioners are paid through capitation in the NHS system, so local commissioning bodies perceived additional payment to walk-in centers as an unnecessary and duplicative expense. The experience highlights the importance of a comprehensive approach to accessible health services that proactively and simultaneously accounts for health financing and care pathways in addition to entry points alone.xxxviii OCTOBER 2018 5 IMPROVING THE ACCESSIBILITY OF FRONTLINE SERVICES… FOR DIGNIFIED, PERSON-CENTERED CARE AMIDST DEMOGRAPHIC CHANGE ENDNOTES i Organization for Economic Co-Operation and Development, “OECD Statistics,” OECD.Stat, accessed October 6, 2018, https://stats.oecd.org/. ii Cathy Schoen et al., “In Chronic Condition: Experiences of Patients with Complex Health Care Needs, in Eight Countries, 2008,” Health Affairs (Project Hope) 28, no. 1 (February 2009): w1-16, https://doi.org/10.1377/hlthaff.28.1.w1. iii Schoen et al. iv Schoen et al. v Lauren E. Wisk and Whitney P. Witt, “Predictors of Delayed or Forgone Needed Health Care for Families With Children,” Pediatrics 130, no. 6 (December 2012): 1027–37, https://doi.org/10.1542/peds.2012-0668. vi Sonia Marrone, “Understanding Barriers to Health Care: A Review of Disparities in Health Care Services among Indigenous Populations,” International Journal of Circumpolar Health 66, no. 3 (July 2007): 188–98, https://doi.org/10.3402/ijch.v66i3.18254; Mary Curry Narayan and Katherine N. Scafide, “Systematic Review of Racial/Ethnic Outcome Disparities in Home Health Care,” Journal of Transcultural Nursing: Official Journal of the Transcultural Nursing Society, March 1, 2017, 1043659617700710, https://doi.org/10.1177/1043659617700710; Samantha Artiga et al., “Key Facts on Health and Health Care by Race and Ethnicity - Section 2: Health Access and Utilization” (Kaiser Family Foundation, June 7, 2016), https://www.kff.org/report-section/key-facts-on-health- and-health-care-by-race-and-ethnicity-section-2-health-access-and-utilization/. vii Artiga et al., “Key Facts on Health and Health Care by Race and Ethnicity - Section 2”; Samantha Artiga et al., “Key Facts on Health and Health Care by Race and Ethnicity - Section 4: Health Coverage” (Kaiser Family Foundation, June 7, 2016), https://www.kff.org/report-section/key-facts- on-health-and-health-care-by-race-and-ethnicity-section-4-health-coverage/; Samantha Artiga et al., “Key Facts on Health and Health Care by Race and Ethnicity - Section 3: Health Status and Outcomes” (Kaiser Family Foundation, June 7, 2016), https://www.kff.org/report-section/key- facts-on-health-and-health-care-by-race-and-ethnicity-section-3-health-status-and-outcomes/. viii Jehonathan Ben et al., “Racism and Health Service Utilisation: A Systematic Review and Meta- Analysis,” PLOS ONE 12, no. 12 (December 18, 2017): e0189900, https://doi.org/10.1371/journal.pone.0189900. ix Clive Aspin et al., “Strategic Approaches to Enhanced Health Service Delivery for Aboriginal and Torres Strait Islander People with Chronic Illness: A Qualitative Study,” BMC Health Services Research 12 (June 8, 2012): 143, https://doi.org/10.1186/1472-6963-12-143. x Ben et al., “Racism and Health Service Utilisation.” xi U.S. Census Bureau, “Disability Characteristics: 2015 American Community Survey 1-Year Estimates,” American Fact Finder, accessed October 6, 2018, https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_15_1YR_ S1810&prodType=table. xii Institute of Medicine, “Quality Through Collaboration: The Future of Rural Health” (Washington, DC: The National Academies Press, November 1, 2004), https://doi.org/10.17226/11140. xiii Mary Jo Trepka et al., “Late HIV Diagnosis: Differences by Rural/Urban Residence, Florida, 2007– 2011,” AIDS Patient Care and STDs 28, no. 4 (April 1, 2014): 188–97, https://doi.org/10.1089/apc.2013.0362. xiv Amer Kaissi, “Health Care Retail Clinics: Current Perspectives,” Innovation and Entrepreneurship in Health 3 (March 31, 2016): 47–55, https://doi.org/10.2147/IEH.S88610. xv Tracy Yee, Amanda E. Lechner, and Ellyn R. Boukus, “The Surge in Urgent Care Centers: Emergency Department Alternative or Costly Convenience?,” Research Brief, no. 26 (July 2013): 1–6; Elizabeth Danielson, “Research Gaps in Health Care Delivery: Retail Clinics’ Expansion into Chronic Condition Care,” Academy Health (blog), September 13, 2017, https://www.academyhealth.org/blog/2017- 09/research-gaps-health-care-delivery-retail-clinics-expansion-chronic-condition-care. xvi Ateev Mehrotra et al., “A Comparison of Patient Visits to Retail Clinics, Primary Care Physicians, and Emergency Departments,” Health Affairs (Project Hope) 27, no. 5 (2008): 1272–82, https://doi.org/10.1377/hlthaff.27.5.1272; Diane Alexander, Janet Currie, and Molly Schnell, “Check Up Before You Check Out: Retail Clinics and Emergency Room Use,” Working Paper (National Bureau of Economic Research, July 2017), https://doi.org/10.3386/w23585; J. Scott OCTOBER 2018 6 IMPROVING THE ACCESSIBILITY OF FRONTLINE SERVICES… FOR DIGNIFIED, PERSON-CENTERED CARE AMIDST DEMOGRAPHIC CHANGE Ashwood et al., “Retail Clinic Visits For Low-Acuity Conditions Increase Utilization And Spending,” Health Affairs 35, no. 3 (March 1, 2016): 449–55, https://doi.org/10.1377/hlthaff.2015.0995. xvii Alexander, Currie, and Schnell, “Check Up Before You Check Out.” xviii Ashwood et al., “Retail Clinic Visits For Low-Acuity Conditions Increase Utilization And Spending.” xix FAIR Health, “FH Healthcare Indicators and FH Medical Practice Index: A New View of Place of Service Trends and Medical Pricing,” White Paper (FAIR Health, March 2018), https://s3.amazonaws.com/media2.fairhealth.org/whitepaper/asset/FH%20Medical%20Price%20I ndex%20and%20FH%20Healthcare%20Indicators--white%20paper.pdf. xx Rebecca Lake et al., “The Quality, Safety and Governance of Telephone Triage and Advice Services – an Overview of Evidence from Systematic Reviews,” BMC Health Services Research 17, no. 1 (August 30, 2017): 614, https://doi.org/10.1186/s12913-017-2564-x. xxi Lake et al. xxii Martin J. Downes et al., “Telephone Consultations for General Practice: A Systematic Review,” Systematic Reviews 6, no. 1 (July 3, 2017): 128, https://doi.org/10.1186/s13643-017-0529-0. xxiii Jamie P. Morano et al., “Latent Tuberculosis Infection Screening in Foreign-Born Populations: A Successful Mobile Clinic Outreach Model,” American Journal of Public Health 104, no. 8 (June 12, 2014): 1508–15, https://doi.org/10.2105/AJPH.2014.301897. xxiv NHS, “Find & Treat Service,” University College London Hospitals, accessed October 6, 2018, https://www.uclh.nhs.uk/OurServices/ServiceA-Z/HTD/Pages/MXU.aspx. xxv S. L. Thomas et al., “Improving Paediatric Outreach Services for Urban Aboriginal Children through Partnerships: Views of Community-Based Service Providers,” Child: Care, Health and Development 41, no. 6 (November 1, 2015): 836–42, https://doi.org/10.1111/cch.12246; Teresa Ballestas et al., “A Metropolitan Aboriginal Podiatry and Diabetes Outreach Clinic to Ameliorate Foot-Related Complications in Aboriginal People,” Australian and New Zealand Journal of Public Health 38, no. 5 (October 2014): 492–93, https://doi.org/10.1111/1753-6405.12268. xxvi ICF Consulting Services, “Find & Treat (Loacating and Treating Tuberculosis)” (European Union, 2017), https://webgate.ec.europa.eu/dyna/bp-portal/getfile.cfm?fileid=74. xxvii Stephanie H. Factor et al., “Street-Outreach Improves Detection but Not Referral for Drug Users with Latent Tuberculosis, New York City,” Substance Use & Misuse 46, no. 14 (2011): 1711–15, https://doi.org/10.3109/10826084.2011.615562. xxviii Margaux C. Genoff et al., “Navigating Language Barriers: A Systematic Review of Patient Navigators’ Impact on Cancer Screening for Limited English Proficient Patients,” Journal of General Internal Medicine 31, no. 4 (April 2016): 426–34, https://doi.org/10.1007/s11606-015-3572-3; Annette Peart et al., “Patient Navigators Facilitating Access to Primary Care: A Scoping Review,” BMJ Open 8, no. 3 (March 1, 2018): e019252, https://doi.org/10.1136/bmjopen-2017-019252; Kerry A. McBrien et al., “Patient Navigators for People with Chronic Disease: A Systematic Review,” PLOS ONE 13, no. 2 (February 20, 2018): e0191980, https://doi.org/10.1371/journal.pone.0191980. xxix Jun-Feng Hao et al., “Tele-ICU: The Way Forward in Geriatric Care?,” Aging Clinical and Experimental Research 26, no. 6 (December 2014): 575–82, https://doi.org/10.1007/s40520-014- 0217-z; Leonard E. Egede et al., “Psychotherapy for Depression in Older Veterans via Telemedicine: A Randomised, Open-Label, Non-Inferiority Trial,” The Lancet. Psychiatry 2, no. 8 (August 2015): 693–701, https://doi.org/10.1016/S2215-0366(15)00122-4; Ronald C. Merrell, “Geriatric Telemedicine: Background and Evidence for Telemedicine as a Way to Address the Challenges of Geriatrics,” Healthcare Informatics Research 21, no. 4 (October 2015): 223–29, https://doi.org/10.4258/hir.2015.21.4.223. xxx Neeltje van den Berg et al., “Telemedicine and Telecare for Older Patients--a Systematic Review,” Maturitas 73, no. 2 (October 2012): 94–114, https://doi.org/10.1016/j.maturitas.2012.06.010; Rashid L. Bashshur et al., “The Empirical Foundations of Telemedicine Interventions for Chronic Disease Management,” Telemedicine Journal and E-Health: The Official Journal of the American Telemedicine Association 20, no. 9 (September 2014): 769–800, https://doi.org/10.1089/tmj.2014.9981. xxxi Judy E. Scott and Carlton H. Scott, “Drone Delivery Models for Healthcare” (50th Hawaii International Conference on System Sciences, 2017), https://aisel.aisnet.org/cgi/viewcontent.cgi?referer=&httpsredir=1&article=1442&context=hicss- 50. OCTOBER 2018 7 IMPROVING THE ACCESSIBILITY OF FRONTLINE SERVICES… FOR DIGNIFIED, PERSON-CENTERED CARE AMIDST DEMOGRAPHIC CHANGE xxxii R. M. Carrillo-Larco et al., “The Use of Unmanned Aerial Vehicles for Health Purposes: A Systematic Review of Experimental Studies,” Global Health, Epidemiology and Genomics 3 (2018), https://doi.org/10.1017/gheg.2018.11. xxxiii Grantmakers In Aging, “Mobility & Aging in Rural America: The Role for Innovation” (Berkeley, California: Grantmakers In Aging, May 2018), https://www.giaging.org/documents/180424_GIA_Rural_Mobility_Funding_Guide_F.pdf; Carrillo- Larco et al., “The Use of Unmanned Aerial Vehicles for Health Purposes.” xxxiv Maureen Markle-Reid et al., “The Effectiveness and Efficiency of Home-Based Nursing Health Promotion for Older People: A Review of the Literature,” Medical Care Research and Review: MCRR 63, no. 5 (October 2006): 531–69, https://doi.org/10.1177/1077558706290941; Ans Bouman et al., “Effects of Intensive Home Visiting Programs for Older People with Poor Health Status: A Systematic Review,” BMC Health Services Research 8 (April 3, 2008): 74, https://doi.org/10.1186/1472-6963-8-74; Evan Mayo-Wilson et al., “Preventive Home Visits for Mortality, Morbidity, and Institutionalization in Older Adults: A Systematic Review and Meta- Analysis,” PLOS ONE 9, no. 3 (March 12, 2014): e89257, https://doi.org/10.1371/journal.pone.0089257. xxxv Roger E. 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