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Teens browse this list for services in your area. Don’t run away, call for help.NEW YORK AMERICAN CIVIL LIBERTIES UNION (ACLU) : YRights As a Pregnant Or Parenting Teen (2007)]Pregnant or Parenting? Title IX Protects You From Discrimination At SchoolGuttmacher Data: Minors’ Rights as ParentsIf you are facing abuse or threats because of your pregnancy here is a crisis line. http://www.thursdayschild.org/html/about.htm 800-USA-KIDSRESOURCES STATE BY STATE:ALABAMA: Babies First: United Methodist Children's HomeFor teen mothers in foster care.If you are a pregnant teen in Alabama in foster care, ask your case manager, counselor or CASA worker if this program could be right for you.ALASKA Passage House: Passage House907-272-1255 (Call to get help now.)Ages 17–21ARIZONA: Girls Ranch Scottsdale: Girls Ranch - Florence Crittenton.Ask a school counselor, case manager, or CASA Advocate about Girls Ranch Scottsdale.An adult needs to help arrange admission if this program is right for you.Most but not all pregnant teens at Girls Ranch Scottsdale are in Arizona state custody.ARIZONA:The House of El-Elyon:HousingParenting ClassesAges 12–18ARIZONA: Starting Out Right: Starting Out Right | Free Pregnancy Test | Arizona Youth PartnershipCall 520–719–2014 or email [email protected] suppliesARIZONA: Tempe. TeenAge Pregnancy Program (TAPP) / APPP👩‍🎓Educational support.Case management.Counseling.Parenting preparation.ARKANSAS: Compassion House: Get Help - Compassion House479-419-9100 (Call for help.)HousingChristian orientation.Ages: 19 and underARKANSAS: Hanna House: Hannah House of Fort Smith Arkansas479–782–5683 phone or email: [email protected] 13–29CALIFORNIA: (Alameda County) Bay Area Youth Center: Real AlternativesEmail: [email protected] SkillsAges 16–25CALIFORNIA: El Nido Programs - El Nido Family Centers: Teen Family ServicesHome Visits help teens connect to healthcare, education, counseling, financial help employment and childcare.Several locations in Los Angles areaAntelope Valley: Pacoima office at: 818.896.7776CALIFORNIA:Maternity Shelter Program - Home [email protected] Diego AreaAges 18–24CALIFORNIA : (Lake County) Lake Family Resource Center. Teen Parenting/Adolescent Family Life ProgramServices for Pregnant and Parenting teensMust enroll before 19th birthdaCalifornia: Welcome to Mary's Pregnant Teen Shelter .Housing.CALIFORNIA: (Sacramento) Waking the VillageHome Infograph — Waking the VillageContact us about our housing programs: 916-601-2979HousingEducational SupportIntensive MentoringCase ManagementArt, Friendship, Community, CreativityChild Development CenterTravel, Recreation, CampingAges 18–24CALIFORNIA (HOUSING) (North Hollywood.) Youth Volunteers of America Los Angeles. (VOALA) Women’s Care Cottage. Women’s Care Cottage is an Independent/Transitional living program assisting homeless young women coming out of emergency shelters, foster care and probation. Admits women with one infant up to the age of 1 year. Provides up to 18 months – 3 years of housing, case management, counseling, social and cultural activities. Ages 18–21.COLORADO: options for Pregnant or Parenting Teens. Jefferson County Adolescent Pregnancy and Parenting Program (JCAPPP) Jeffco Public Schools. Non-residential. Specialized curricula, job-training, social support. Onsite childcare for teen parents.COLORADO: ttp://ttps://obgyn.coloradowomenshealth.com/health-info/teens/teen-pregnancy-programs Non-residential. University of Colorado/Colorado Adolescent Maternity Program. (CAMP) Specialized obstetrical care for teens. Emotional and social support.COLORADO: (HOUSING) Hope House of Colorado Quote from the website: “Hope House is metro-Denver's only resource providing free self-sufficiency programs to parenting teen moms, including Residential, GED, and College & Career Support programs. Additional supportive services include parenting and life skills classes, healthy relationship classes, and certified counseling, all designed to prepare them for long-term independence.” (ages 16 to 24)COLORADO: Yampah Mountain High School Non-residential, public School-based support for pregnant and parenting teens. High quality Infant and toddler childcare onsite.CONNECTICUT: Noank Community Support Services Clift House. Shelter care for ages infant to 18, either gender. Pregnant and Parenting teens.CONNECTICUT: Young Parents Program Public school-based services for pregnant and parenting teens. High School completion support and ONSITE childcare at High Schools for teen parents. Districts offering the Young Parents Program: Bridgeport, Griswold, New Britain, Torrington, Waterbury, Windham. Contact: Shelby Pons, MSW, [email protected] (860) 807-2126DISTRICT OF COLUMBIA: (Non-Residential) Teen Alliance for Prepared Parenting Specialized Pre-natal care. Education support. Counseling. Teen fathers also served. Ages Served: Adolescents who are pregnant and aged 21 or younger are eligible to enroll at any time during their pregnancy. Young fathers may enroll if they are expecting a child, or if they have a child under the age of five years. Once enrolled, youth may continue to participate in the program until 23 years of age.DISTRICT OF COLUMBIA: http://tps://dcps.dc.gov/page/expectant-and-parenting-students (Non-residential). Expectant and Parenting Students. New Heights. “Supportive case management and assistance with securing services, such as a childcare voucher, WIC, housing, TANF, employment, job training opportunities, college/university admissions and more.” Public High School Programs: The following schools have the New Heights program in their buildings, and can be reached at the following phone numbers:Anacostia, (202) 645-4040Ballou, (202) 645-3400Ballou STAY, (202) 727-5344Cardozo, (202) 671-1995CHEC, (202) 939-7700 ext. 5063Coolidge, (202) 282-0081Dunbar, (202) 698-3762Luke C. Moore, (202) 678-7890Roosevelt, (202) 576-8899Roosevelt STAY, (202) 576-8399Washington MET, (202)727-4985Wilson, (202) 282-0120Woodson, (202) 939-20324. DISTRICT OF COLUMBIA (HOUSING) Perennial Transitional House for Teen Parent23.DISTRICT OF COLuMBIA: HBP Teens Non-residential. Support services and structured classes for pregnant and parenting teens. Case Management and Home Visiting. Centered particularly on the needs of young African-American parents. Multi-phase program. Ages Served:12–2124.DISTRICT OF COLUMBIA: DC Social Innovation Project Non-residential. Teens to Doulas: This innovative program trains teens who are already parenting to serve as doulas for women in the community. The goal is for successful teen mothers to share their skills to reduce the risk factors in the community for other mothers.25. DISTRICT OF COLUMBIA: Teen Parent Assessment Program (TPAP)(Non-residential) Financial Issues: This is an assessment program that evaluates teens for independent living in the D.C. area. Usually, teens can apply for TANF (Temporary Assistance for Needy Families) in D.C. , but must be living with their parents to receive this aid. The Teen Assessment program determines on a case by case if the pregnant/parenting teen in an independent or other living situation qualifies for the aid. Service Contact: Teen Parent Assessment Program Contact Phone: (202) 698-6671Contact TTY: 711. If you are unable to get an appointment for the Teen Parent Assessment Program, you may need to get a referral from your school guidance counselor or other social services.26.DELAWARE: Diocese of Wilmington Bayard House27.FLORIDA: (HOUSING) Group Home, Bellview FL, Hands of Mercy Everywhere Hands of Mercy Everywhere. Christian-oriented residence that also offers diverse practical, educational, and therapeutic services to teen mothers. Ages served not specified28.FLORIDA: Hannah's Transitional Living || ANCHORAGE CHILDREN'S HOME || (850) 763-7102 Transitional living apartments for pregnant and parenting young women. Ages 16–2229.FLORIDA: Home Our Mother’s Home. Keeps teen mothers who are in foster care with their children.30.FLORIDA: (Pinellas County) Transitional Living Programs - Family Resources SafePlace2BTOO-Young Moms. (Scroll down the page for maternity services. The first program listed on the page has the same name but is for LGBT youth.) Housing and support. 18 month program. Ages 16–21.31.FLORIDA: Woman to Woman - Children & Family Services Gulf CoasJewish Children & Family Services. Non-residential mentoring and goal-setting for pregnant and parenting teens. No age range specified.GEORGIA: House of Dawn: Changing Lives, Changing Generations770–477–2385Housing👩‍🎓Educational SupportCareer and Life skillsCounselingAges 13–23GEORGIA: Home | The Living Vine Christian Maternity Home.HousingProgram emphasizes strict Christian environment, so possibly suitable only for committed Christians.Hawaii: Hale Kipa: Independent Living Program808.754.9844Emergency ShelterAges 12–17HAWAII: Neighborhood Helping Pregnant and Parenting Teens Neighborhood Place of Puna. Non-residential. Practical, material and emotional support.37.HAWAII: (HOUSING) Mary Jane Home | Catholic Charities Hawaii The Mary Jane Home. Ages Served: 18 and over.38. IDAHO: (and Eastern Washington) Alexandria's House | Volunteers of America Ages Served: 16–20.39.IDAHO: (Burley) Cassia High School Alternative Public High School. Serves teens who would benefit from an alternative school, including pregnant and parenting teens. Childcare for teen parents provided.40.IDAHO: Marian Pritchett School Marian Pritchett School. (Serving pregnant teens since 1964) Public High School for pregnant and parenting teens. Includes Giraffe Laugh Childcare for students attending Marian Pritchett School. Marian Pritchett - Giraffe Laugh.41.ILLINOS: (HOUSING) (Chicago) response-Ability Pregnant and Parenting Program (RAPPP) The Night Ministry operates 120-day housing programs for youth and for pregnant and parenting young mothers and their children. Call toll-free 877-286-2523. Ages 14–19.42.ILLINOIS: http://theharbour.org/successful-teenseffective-parents.html The Harbour. STEPS Program. Individual subsidized apartments for teens and their children. Parenting classes, counseling and case management. Age range served: not specified.43.INDIANA: Maternity Home With A Heart Hannah’s House. (HOUSING.) Faith-based/Christian. Parenting classes, counseling, referrals to community resources, emotional support. Serves ages 13 up. (Website states youngest resident they have served was 13 and the oldest was 43.)44. Indiana: Project Home IndyResidency for Teenage Mothers (Link leads to application page)HousingMedical CareEducational SupportParenting ClassesLife Skills ClassesAges 15 -19 at admission.45.INDIANA: Young Families of Indiana Network Future Promises. Non-residential school-based support for pregnant and parenting teens.46.INDIANA: (South Bend) Youth Service Bureau of St. Joseph County Young Mom’s Self-Sufficiency Program. (YMSSP) Non-residential support services.47. IOWA: Ruth Harbor - Pregnant? Christian orientation. Counseling, midwife care, doula services, recreation, outings. Ages ?-24. Does not specify minimum age.48.IOWA: Transitional Living for Teen Parents United Action for Youth. (UAC) Housing and other supports. Ages 17–21.49. IOWA: Transitional Living Services - Youth & Shelter Services, Inc. - Iowa50..KANSAS: About Us | Wichita Children's Home 1. Bridges. Housing for pregnant and parenting teen mothers 2. Moving on to Motherhood (MOM-Non-residential case management and support.)52. KENTUCKY: (HOUSING)Mother & Baby Home All God’s Children Mother & Baby Home. Faith-based. Nationally Accredited Childcare program onsite provides care for resident’s babies so they can attend school. Support, therapy, classes. Ages 13–21.53.KENTUCKY: (Louisville) Teenage Parent Program Georgia Chaffee Teenage Parent Program (TAPP). Non-residential. Provides support and services to help pregnant and parenting teens complete their high school educations.54. KENTUCKY: 👩‍⚕️ Young Parents Program (YPP.) Non-residential. Specialized obstetrical care, support and counseling. Ages served: Under age 18.55. LOUISIANA: I'm Pregnant. Now What?Phone : (318) 925-4663Crisis Line : (318) 277-9506Email : [email protected] Sanctuary for Women. Faith-based/Christian. Counseling, goal-setting, career planning, parenting classes, life skills and recreation. Participation in religious activities may be required. Onsite accredited education/certified teacher for High School completion or GED. Ages served: 13–23.56. LOUISIANA: Parenting Jus4me. Non-residential. Support and parenting classes for pregnant and parenting teens. No age range specified.57. LOUISIANA: http://ttp://www.lighthouseministriesinc.org/ The Lighthouse Child Residential Center. Faith-based. Cares for pregnant and parenting teens and their children. Licensed to care for children from birth through age 18.MAINE: FINANCIAL HELP: TANF and Teen Parents58. MAINE: rgh Rumford Group Homes Teens are housed in several different apartments supervised by the program and are provided with various services. Ages 16–21.59. MAINE: Crisis Center | Bangor, ME Shepherd’s Godparent Home. Ages served: teens to thirties.60. MARYLAND: Programp=s for Pregnant Teens and Teen Mothers | Hearts & Homes for Youth Damamli. This program is for pregnant and parenting teens in the foster care or juvenile justice system. The program starts the teen in a specialized foster home and later she lives independently with her child, with support from the program in her own apartment. Age range: 16–20.61. MARYLAND: Housing & Support Saint Ann’s: Grace House, Hope House and Faith House. Residence with onsite High School. Ages 13–21.62. MASSACHUSETTS: Programs Bridge Over Troubled Waters. Single Parent Housing. Transitional Housing for teen parents. Does not specify age range served.63. MASSACHUSETTS: (Boston) St. Mary’s Home Faith-based history but apparently no religious requirements or programming for participants. Housing. Case management, onsite high school completion, parenting classes, therapy. Ages 13–21.64. MICHIGAN: Shelter - Alternatives For Girls Provides emergency shelter for homeless teens and their children. Transitional housing program also available. Website did not mention specific maternity care programs offered. Ages 15—MICHIGAN: Eastpointe. Gianna House now open, but the website isn’t up currently. RESIDENTIAL. Ages 13–17. Contact information will be posted here ASAP>65. MICHIGAN: MI Health Family - MOASH Websites provide information on help for pregnant and parenting teens in Michigan. Michigan Organization on Adolescent Sexual Health. (MOASH) PREGNANT & PARENTING TEENS Ages served not specified.66. MICHIGAN: Michigan Adolescent Pregnancy and Parenting Program (MI-APPP) Case Management for pregnant and parenting teens. No are range specified.MINNESOTA: LEGAL RIGHTS OF TEENS: The Rights of Teen ParentsMINNESOTA: A School for Pregnant and Parenting Teens Longfellow High School. Non-residential public high school.MINNESOTA: The Nest: A Maternity Home The Nest. Focuses on ages 18–25 but may accept minors placed by parents. More information soon.MISSISSIPPI: http://mchms.org/pdfs/MCH_Two_of_Us_Brochure_032314_RGB.pdf Two of Us Therapeutic Maternity Home. Full-time licensed nursing staff. Highly specialized intensive care and education for mothers and infants. Ages 10–18.MISSOURI: 👩‍⚕️ https://www.barnesjewish.org/Medical-Services/Obstetrics-Gynecology/Women-Infants/Childbirth-at-Barnes-Jewish/Teen- Pregnancy-Center Barnes Jewish Hospital. Non-residential services, including specialized obstetrical care, classes and support. Ages 17 and under.MISSOURI: Mother's Refuge - Supporting Young Mother (HOUSING). Ages 12-21. Does not appear to focus on excessive religious pressureMISSOURI: Nativity House KC Faith-based. Roman Catholic.MISSOURI: Youth Services - reStart reStart Youth Services. Four transitional housing units for pregnant and parenting teens. Ages 16–21.MISSOURI: Home The Sparrow's Nest. (HOUSING) Ages 19 and under.MONTANA: Blackfeet Teen Pregnancy/Parenting Coalition Teen Pregnancy Parenting Coalition. Non-residential. GED tutoring. Case Management. Peer support. Nutritional Counseling. Childcare. Ages Served not specified.MONTANA: Mountain Home Montana Non-religious, comprehensive program. Housing. Bonnie Hamilton Home. (Group living) Mountain Home Apartments. (Individuals living with child.) Licensed Therapy. 24–7 mental health crisis line. Other resources. Ages 16–29.MONTANA: Nurtured baby, Healthy adult, Strong community Florence Crittenton . (Needs updating)NEBRASKA: CARES. ( info needs updating-program may be closed.)NEBRASKA: Center for Healthy Families Nebraska Mental Health/Project Harmony. Non-residential. Support services for pregnant and parenting teens. No age range specified. (Omaha residents only).NEBRASKA:Teen & Young Parent Program - Nebraska Early Childhood CollaborativeNNEVADA: “Living Grace” website is not available as of 8/15/2019. Will update as I get more information.NEVADA: Pregnant and Parenting Teen Saint Jude’s Ranch. Most residents are youth placed here by state social service and juvenile justice agencies.NEVADA: Contact Casa De Vida. (HOUSING) —More information available soon.NEW HAMPSHIRE: (Littleton)TRANSITIONAL LIVING PROGRAM (HOUSING). Case management, GED/Highschool completion, parenting classes and other services for pregnant and parenting teens and young adults. Ages served 18–21.NEW HAMPSHIRE: Our Place | Catholic Charities New Hampshire Our Place. Non-residential Faith-based. (Roman Catholic) Prenatal, breastfeeding, parenting and other classes and resources for parents of all ages.NEW JERSEY: http://ttps://www.cge-nj.org/program-offerings/adolescent-program/ The Center for Great Expectations (Adolescent Program) (HOUSING) AOther programs for women also available. Licensed Clinical Staff. Ages served: 13–18,NEW JERSEY: Capable Adolescent Mothers Crossroads Programs. (HOUSING) Intensive Long-term program. For General Program Information regarding Crossroads’ programs and services, please contact Michelle Wright at 609 880 0210, ext 109. Ages: 16–21.NEW JERSEY:services and Programs that help young homeless mothers and pregnant women Raphael’s Life House, Inc. Housing, licensed counseling, parenting classes, GED completion and career development. Ages served: Not specified.NEW MEXICO: Catholic Charities of Gallup NM (HOUSING)Casa San Jose. Residential care for pregnant and parenting teens. Ages Served: Not specified.NEW MEXICO: 14 to 17 Information Page Information from Pegasus Legal Services for Children about legal rights of minors in New Mexico, including teen pregnancy and parenting.NEW YORK: Residential Services Catholic Charities Community Maternity Services. Multiple programs: Heery Center-Ages 12–21, focuses on pregnant and parenting girls placed by juvenile and state agencies. Joyce Center is the transitional living maternity home.NEW YORK: Pregnant/Parenting Teens Children’s Village-Inwood House. Age range served not specified.NEW YORK: (Rochester) http://ttp://centerforyouth.net/index.php?cID=89 The Center For Youth. Chrysalis Program. 18 month program. Residential setting for pregnant or parenting young women. Ages 16–21.NEW YORK: Supportive Housing (Brooklyn) Diaspora Community Services/ “Mother’s Gaining Hope”. Federally funded “Maternity Group Home”. (MGH) I have not further details on ages served or its programs at this writing.NEW YORK: SERVICES SUSPENDED DUE TO BUDGET. (Concerned readers please consider donating. )(Niagara region) https://hannahhouse.ca/ Ages: through age 24. No lower age limit stated.NEW YORK: Regina Maternity Services Catholic Charities of Rockville Centre. Housing For pregnant teens and their children. Regina Residence is a structured program with case management. Mary Residence is supported independent living for graduates of Regina Residence. Ages 11–24.NORTH CAROLINA: http://www.angelhousematernityhome.org/admission_information0.aspx Angel House Maternity Home. Minimum Age: 17NORTH CAROLINA: Services for single, pregnant, & non-pregnant teens, women and their families | Florence Crittenton Services | Charlotte, NC Multiple residential programs. Ages 10 and up.NORTH DAKOTA: St. Gianna Maternity Home (HOUSING) Residents required to participate in prayers and attend Mass. Ages Served: Serves minors but does not specify age range.NORTH DAKOTA: Home | The Perry Center Serves minors placed by parents, but does not give age-range. Christian oriented services, apparently placing emphasis on evangelism but also offering life-skills and other practical services.OHIO: (Franklin County) The Center for Healthy Families The Center for Healthy Families. Non-residential. School and Community based services for pregnant and parenting teens offered at four high schools. Services for teen fathers also included. Ages: 13–19.OHIO: (Mentor, Ohio) Pregnancy - Hannah’s Home. Minimum age 18. More information available soon.OHIO: The Highlands - Shelter Care (HOUSING) Residential care for pregnant and parenting teens and their children. Ages 14–20.OHIO: (Columbus) 👩‍⚕️Teen and Pregnant Program Nationwide Children’s (Hospital). TaP. Non-residential. Comprehensive medical care, classes, counseling, referrals for pregnant girls and women ages 21.5 and under.OHIO: WIC (Supplemental food for Women, Infant Children) WIC - American Pregnancy Association\http://file:///C:/Users/17074/AppData/Local/Pa/TempState/Downloads/158843%20(1).pdfOKLAHOMA: Broken Arrow Public Schools Mentoring Healthy Parents (Formerly Margaret Hudson Program). Non-residential. Support for pregnant and parenting teens. Age range not specified.OKLAHOMA: J.A.M.E.S., INC. WEBSITE CURRENTLY DOWN> CHECK BACK SOON> Educational support and college scholarships for pregnant and parenting teens. High School seniors and college students.OKLAHOMA: http://s://www.choctawnation.com/tribal-services/member-services/choctaw-support-expectant-and-parenting-teens-sept Choctaw Support for Expectant and Parenting Teens. (SEPT) Services for teens pregnant with or parenting a Native American child under the age of one year. Must live within the 10.5 county service area of Choctaw Nation. Ages 13–21.OKLAHOMA: (Owassa) Oklahoma Baptist Homes for Children . (HOUSING) (Owassa) Maternity Cottage and transitional living apartments for Mother and Child Program. Participants must attend Southern Baptist church while in residence. Age range served not specified.OKLAHOMA: Transitional Living Program (HOUSING) Housing offered to youth, including pregnant and parenting teens and their children. Ages 16–21.OREGON: Safe Haven Maternity Home Safe Haven Maternity Home.OREGON: Dedicated to helping young mothers Saint Child. Housing for pregnant girls and women and their infants. May stay for up to a year after birth of baby. Faith-based (Christian). Counseling, education, job training, life skills and other supports. Participants are offered bible study and other Christian activities but are apparently not coerced. Ages 14–24.Pennsylvania: (Lansdale) (HOUSING) Home Morning Star Maternity Home. Ages 13–25.Pennsylvania: Maternity & Pregnancy Services - Catholic Charities of Harrisburg PAPENNSYLVANIA: http://ttps://www.valleyyouthhouse.org/programs/transitional-housing/maternity-group-home-mgh/RHODE ISLAND: (HOUSING) (may be for 18 and above only) Little Flower Home - Serving RI & Southern MA - Housing for 'Pregnant Homeless' WomenRHODE ISLAND: About Nowell Leadership Academy (Public Charter High School) For Pregnant and Parenting teens.SOUTH CAROLINA: Help for pregnant and parenting young women in South CarolinTENNESSEE: Comprehensive Resource Center The Hagar Center. Non-residential. Classes, support and material assistance.102. TENNESSEE: http://ttps://mercymultiplied.com/about-us/ Mercy Multiplied. Faith-based/Non-denominational Christian. Residential programs are located in four states for girls including a facility in Nashville, Tennessee. The programs are designed to work with on many issues, including pregnancy. The website states that the program does not demand that the pregnant mother relinquish her child to adoption, however, neither is there any indication of housing or services offered for the mother/child family. Adoption services prominently noted on website. Counseling is strongly centered on Christian teachings, although Mercy Multiplied states that its counselors are Master’s Level or graduate student interns. Counseling process includes/demands “commitment to Christ”. This program might be appropriate for young women who of their own free will wish to pursue Christianity. Ages Served: Unknown at this writing.107. TEXAS: Annunciation House: Apply for Services108. TEXAS: Apply | LifeHouse Houston. Housing and other support. Strong focus on Christian evangelizing. Ages 12 and up. (Other services for non-residential clients also available.)109. TEXAS: Teen Parenting Help - Jane's Due Process Information and support for pregnant teenagers concerning Texas legal rights.110.TEXAS: Viola's House111. UTAH: 👩‍🎓Horizonte Instruction and Training Center. Young Parent Program. Programs Non-residential. High School completion and vocational education with onsite childcare provided by Head Start. Parenting and other skills. Flexible scheduling. Contact Person: Kathy Williams (801) 578-8574 ext. 233.112. UTAH: Teen Mother & Child Program Non-residential. University of Utah/Teen Mother and Child Program. Obstetrical care/Nurse-Midwives. Social and psychological support and referrals for other needed services. Ages served: 19 and younger.113. UTAH: YWCA Of Salt Lake City. Referrals to Transitional Housing. No other details as of this writing.114. VERMONT: Family Literacy Center (Non-residential) Educational center for pregnant and parenting teens and young adults. Infants may attend classes with parents until they are four months old and after that Onsite Nationally Accredited childcare is available full-time. Onsite licensed therapy, parenting and nutrition classes and other social supports. Ages served: High school freshmen age through age 25.115. VIRGINIA: Grace Home Ministries. (HOUSING) Program is long-term and residents encouraged to stay for as long as two years with their babies. Faith based/Christian. Program includes participation in Christian experiences. However, Grace Home states: “We believe religion is a matter of personal conviction; therefore, we don’t put any pressure on program participants in matters of personal faith or beliefs. Mentoring, childcare classes, case management. Ages 1–20.116. VIRGINIA: (Lynchburg) ADOPTION-ORIENTED! Liberty Godparent Maternity Home. Services | Liberty Godparent Home If you have decided for adoption AND you are a Baptist or of a similar faith, you might consider this facility, as its emphasis is on adoption. The program does offer “Mommy and Me” support if you decide on raising your baby yourself, however, the emphasis is clearly adoption. Faith-based. (Baptist) Residents attend Thomas Road Baptist church. Other services from their website: All residents are required to attend school, pursue a GED, or participate in vocational training. Classes are offered off site at Liberty Christian Academy through Liberty University Online Academy (grades 6-12). Tutoring services for GED and SAT exams are available as needed. To help each young lady build a positive future, the LGH staff is committed to educating the residents on Life Skills and other topics such as Decision-Making, Parenting, Adoption, and Nutrition. About Us Overview | Liberty Godparent Home Ages Served: Not specified.VIRGINIA: (Fairfax County) Second Story for Young Mothers - assistance for mothersSecond Story for Young Mothers. (HOUSING) Residential services offered through independent living in townhouses for young mothers between the ages of 18–21. Pregnant and parenting teens between the ages of 16 and 18 receive non-residential community based support, education and services. Follow-up support and case management also offered. 24/7 Crisis Hotline - Call 1-800-SAY-TEEN or text “TEENHELP” to 855-11 TTY 711VIRGINIA: (Alexandria) Keep it 360 | The Alexandria Campaign on Adolescent Pregnancy (ACAP) T.C. Futures. (Non-residential.) From website: The T.C. Futures Group provides parenting meetings and developmental playgroups specifically for Alexandria’s teenage parents and their children. Parents learn about positive parenting skills, child development, and local resources. The group meets every other week after school at T.C. Williams High School. Participation is not limited to T.C. Williams students; all teenage parents in Alexandria are invited to attend. Participation is free, and Spanish translation is available. For more information, contact David Wynne, TC Williams Social Worker, at 703.824.6800.VIRGINIA (Fredricksburg) Mary's Shelter Mary’s Shelter. (HOUSING) Faith-based. Provides residential care for up to three years. Minimum Age: 18.VIRGINIA: Mommy and Me Program. ( A program component of “Youth For Tomorrow”.). (RESIDENTIAL/HOUSING) Faith based/Christian. Intensive program for pregnant teens and their infants. Education for teens at accredited school on campus, health care, parenting classes, in-house therapy and nursing staff. ) Admissions are either by court placement or social service agency referral. Teens may stay until their child is four-years-old. Ages: 12–18.VIRGINIA: (Winchester.) About | New Eve Maternity Home New Eve Maternity Home. (HOUSING). Faith-based/Roman Catholic. Help with education, employment, life skills. Ages served: 18 and above. (?)VIRGINIA: (Norfolk) THIS LISTING NOT ACTIVE CURRENTLY. WILL UPDATE ASAP. Eastern Virginia Medical School. Non-residential. Specialized obstetrical care. Classes, parenting skills, emotional support, transportation to prenatal appointments.WASHINGTON: (Seattle area.) Housing Cocoon House. (HOUSING) Housing for pregnant and parenting teens and their children. (Short -term and long-term.) Support for education, life skills and employment. Ages 12–17.WASHINGTON: (Spokane) Alexandria's House | Volunteers of America (HOUSING). “Spacious historic home”. Mentoring, support, doulas, other services. Ages: 16–20.WASHINGTON: (Spokane)http://ttp://gracesonhousingfoundation.org/ Hope and Housing for Teen Moms and their Children Graceson Housing Foundation. (Housing.) Faith-based/Christian but spiritual activities are left up to choice. This program is strong on community and nurturing. Classes, life skills, and employments skills also offered. Ages 13-18.WASHINGTON (Seattle) 👩‍⚕️ "Family Medicine Residency Teen Pregnancy and Parenting Clinic. (A program of Kaiser Permanente but you DO NOT have to be a Kaiser Permanente member to receive services.) Non-residential. Accepts Medicaid and other insurance. Prenatal care with delivery at Swedish First Hill Hospital. Offers help getting medical care coverage, nutritious food, childbirth classes, parenting classes and well-child care for the baby until two years of age. (Well-child care is only for the babies whose mothers used the Teen Pregnancy and Parenting Clinic for their prenatal care and delivery.) Open Tuesdays and Thursdays. Drop by or call: Kaiser Permanente Capitol Hill Campus, West Building 206-326-2656. On the bus line. Ages served: Not specified.WEST VIRGINIA: Crittenton Services, Inc. A Florence Crittenton program. (More information to follow)WISCONSIN: (Milwaukee) Pregnant and Parenting Youth Program (PPYP). Non-residential public school-based support.WISCONSIN: (Sheboygan) 👩‍🎓 Sheboygan Area School District Non-residential. TAPP/Parenting Lab. School-based support for pregnant and parenting teens. Guidance counselor assists pregnant students with educational plan/ONSITE childcare/parenting lab for teen parents. Classes designed/flexible to accommodate pregnancy related issues. Pregnant or parenting students in Sheboygan contact your school guidance counselor to access these services.

What Careers Are Most In-Demand Right Now?If you are planning your career path and want to cultivate sustainable skills that employers need and want, it is important to know the current trends in the job market. When you become aware of the current trends in the job market, you can prepare yourself to obtain a position in one of the most in-demand careers. These in-demand careers have the most anticipated growth rates for the next five years. In this article, we will list the 15 most in-demand careers with job duties, national average pay and education requirements.Explore your next job opportunity on IndeedView Data Entry Clerk jobsFind Jobs15 most in-demand careersCareers that qualify as in-demand are options that offer long-term growth and contain a large number of open positions. Industries with in-demand careers seek to fill positions with qualified candidates who possess a specific set of skills and abilities and many of these in-demand jobs are willing to offer certain benefits to encourage longevity. Here is a list of the 15 careers in high demand ranked from lowest to highest paid:1. Home health aideNational average salary: $11.98 per hourPrimary duties: A home health aide works in clients’ homes to assist them with the activities of daily life. Most home health aides work with geriatric patients or patients who are unable to care for themselves. Their responsibilities include:Helping patients with dressing, bathing and other personal hygienePerforming basic health care for patients such as checking vital signs or administering medicationAssisting with light housecleaningWorking with nurses, CNA’s, nursing aides and other in-home care professionals to provide patient careReporting the health status of clients they observeRequirements: No formal education is required, though many employers may prefer National Association for Home Care and Hospice (NAHC) certification. Additional requirements include:Reliable transportationAbility to work with minimal to no direct supervisionAbility to follow instructions, verbal and written2. Nursing assistantNational average salary: $28,454 per yearPrimary duties: A nursing assistant, also known as a certified nursing assistant (CNA), helps patients with healthcare and other needs under the supervision of a Registered Nurse in hospitals, clinics, nursing homes or other medical treatment facilities. Their responsibilities include:Taking patient vital signsServing food to patients or feeding themChange and cleaning bed linens on a routine basisBathing and dressing patientsMoving or lifting bedridden patientsRecording the observations of patient healthRequirements: A high school diploma or GED is typically required. These healthcare professionals must also complete state nursing assistant training and earn certification. Other requirements may include:PatienceAbility to remain calm under stressful situationsExceptional interpersonal skillsDecent physical strength3. Construction workerNational average salary: $31,616 per yearPrimary duties: Construction workers operate and maintain equipment to build different structures, including buildings, homes, bridges and others. They are often responsible for:Loading and unloading tools, materials and other necessary equipmentRemoving garbage and debris from sitesAssembling barricades and temporary structuresHelping contractors as requiredAssisting with the operation of large machinery and equipmentRegulating traffic with traffic signsRequirements: These professionals can find employment with a high school diploma or GED and the completion of trade school or apprenticeships. Other requirements may include:Licensure to work with hazardous materials may be requiredWillingness to undergo additional training, as necessary4. Physical therapy aideNational average salary: $33,238 per yearPrimary duties: Physical therapy (PT) aides are responsible for setting up equipment and maintaining a clean area for patient treatments and exercises. PT aides are also responsible for:Motivating and assisting patients under the direction of medical staff when performing exercises and functional activitiesTransporting patients using wheelchairs or providing standing support to and from treatmentRecording treatment administered and the equipment that was usedPerforming clerical duties. For instance, taking inventory, ordering supplies, answering the telephone and patient intakeRequirements: High school diploma or GED. Other requirements may include:Basic Life Support for Healthcare Providers certification5. Truck driverNational average salary: $57,616‬ per yearPrimary duties: Truck drivers are responsible for moving goods from one location, usually from a warehouse or supplier, to another location, typically a store or vendor on a strict deadline. Some additional responsibilities of a truck driver may include:Driving long distances to deliver good to businesses or customersLoading and unloading truck cargoRecording deliveriesRefueling and cleaning the truckFollowing applicable traffic lawsInspecting trucks and reporting mechanical issues to maintenanceLogging work activities and work hours.Requirements: High school diploma. The other requirements for becoming a truck driver are:Commercial driver license (CDL)Passing alcohol and drug testClean driving record6. Medical technologistNational average salary: $56,368 per yearPrimary duties: Medical technologists are responsible for maintaining and operating medical equipment used to analyze complex scientific tests on blood and other bodily fluids. A medical technologist’s detailed responsibilities include:Collecting and preparing urine, blood and tissue samples for analysisIdentifying any cell abnormalities in the collected samplesPreparing detailed reports about any possible test resultsDocumenting and reviewing data that has been testedCollaborating with other medical specialists to determine the possible diagnosisMaintaining a clean working environment according to safety procedures and regulationsRequirements: Bachelor’s Degree in Medical Technology or Clinical Laboratory Science. Other requirements may include:Advanced biology and chemistry knowledgeDemonstrated experience working with a variety of medical tools and equipment7. Operations research analystNational average salary: $61,457 per yearPrimary duties: Operations research analysts advise managers and other leaders about the proper course of action when making decisions using high-level analytical methods and advanced mathematics. Additional operations research analyst responsibilities include:Collecting and analyzing data from operational systems to develop software for decision reportsGathering specialized knowledge from workers about operations to assist with solving problemsUsing statistical simulations to analyze and define operational issuesDeveloping mathematical models of potential operational issuesAdvising upper level management on decision making for operationsRequirements: Bachelor of Science in Operations Research, Statistics, Mathematics or a related field. Some other requirements of this in-demand career may include:A high level of computer literacy and expertise with advanced statistical software and databasesAnalytical, problem-solving, mathematical and critical-thinking skills.8. Financial advisorNational average salary: $66,083 per yearPrimary duties: A financial advisor provides financial advice to clients based on current market trends and may invest money for clients. Some detailed responsibilities of a financial advisor may include:Talking to clients to determine their financial objectives and expenses to develop a financial planAnswering client finance questionsAdvising clients based on investment strategiesAnalyzing financial data received from clients to develop strategies for meeting clients’ financial goals.Interpreting client’s financial summaries and investment performance reportsContinuously communicating with clients to update their financial status as neededRequirements: Bachelor of Arts in Finance or related major. Additional requirements for this career may include:Knowledge of various financial industries and insurance industriesSales experienceUp to date FINRA Series 7 and 63 Securities Registration9. Registered nurseNational average salary: $70,366 per yearPrimary duties: Registered nurses have been in high demand for a few years, and this profession allows room for advancement opportunities. Some responsibilities an RN may have are:Administering medicationsPerforming diagnostic testingCollaborating with other healthcare providers for efficient patient careRequirements: Bachelor of Science in Nursing (BSN) degree. Some additional requirements for this career may include:National Council Licensure Examination or NCLEX-RN.Current state licensure as a registered nurse10. Web developerNational average salary: $72,040 per yearPrimary duties: Web developers use programming languages such as HTML, CSS and JavaScript to create easy-to-navigate sites for clients in addition to performing maintenance on existing pages. Some detailed responsibilities of a web developer are:Performing website updatesDeveloping web testing schedules to test all browser and device types.Designing, writing or editing website contentMaintaining an accurate knowledge of new Web applications and programmingIdentifying any website issues with testing and customer feedbackRequirements: Associate Degree in Web Development, Web Design, Programming or another relevant field. Some other requirements may include:Proficiency in JavaScript, HTML, CSS and MySQL11. Health services administratorNational average salary: $70,147 per yearPrimary duties: A health services administrator provides direction to the operation of hospitals, health systems and other healthcare-related organizations. They deal with regulatory affairs and overall health management policies. Some detailed responsibilities of a health services administrator include:Keeping detailed records of the stock of medical and office suppliesInforming employees of department changes and other new policy updatesCreating work schedules for employeesCoordinating with healthcare professionals to identify needs and resolve issuesRequirements: Bachelor’s Degree in Health Care Administration, Business Administration or related field. Other requirements for this position include:A comprehensive knowledge of medical terminology and healthcare regulations12. Physical therapistNational average salary: $74,672 per yearPrimary duties: Physical therapists provide therapy services to people of all ages who are injured or have other medical conditions that limit their ability to move around and perform basic daily tasks. A few detailed responsibilities a PT may have are:Developing treatment plans for each individual patientAdministering physical therapy treatments to assist with pain management and improve mobility, as medically prescribedProviding information about in-home treatment options to patients and their familiesRequirements: Doctorate or professional degree, typically a Doctor of Physical Therapy degree. Additional requirements for this position may include:Passing the National Physical Therapist Examination (NPTE)State licensure to practice physical therapy13. Information security analystNational average salary: $81,555 per yearPrimary duties: The responsibilities of an information security analyst are to monitor for security issues in computer systems. Some detailed responsibilities an information security analyst might possess are:Investigating and document security breaches and other incidentsOperating software and installing security measure to protect information infrastructure and systemsRequirements: Bachelor’s Degree in Computer Science, Programming or a related field. Other requirements for this job may include:Knowledge of firewalls, antivirus, proxies and SIEMAbility to notice and fix network issues and explain how they can be avoided14. StatisticianNational average salary: $83,291 per yearPrimary duties: A statistician develops and applies statistical theories to obtain useful data that helps solve real-world problems. A few detailed responsibilities of a statistician may be:Creating statistically accurate experiments, questionnaires, surveys and pollsUsing statistical software to identify trends and relationships within a set of dataReporting conclusions to their analysesRequirements: Master’s Degree in Mathematics, Statistics or Survey Methodology. Additional requirements may include:An expert understanding of statistics, calculus and linear algebra15. Software developerNational average salary: $105,090 per yearPrimary duties: The responsibilities of a software developer are to research, design, implement and manage software programs. Some detailed responsibilities of a software developer include:Preparing reports on programming project activitiesModifying software to adapt it to updated hardware, fix errors, or improve software performanceConsulting with software engineering personnel to assess software/hardware interfacesRequirements: Bachelor’s Degree in Computer Science, Software Engineering or other related technical programs. Some additional requirements of this position may include:Knowledge of deep programming languageDemonstrated experience with several software development projects

The six major government health care programs—Medicare, Medicaid, the State Children’s Health Insurance Program (SCHIP), the Department of Defense TRICARE and TRICARE for Life programs (DOD TRICARE), the Veterans Health Administration (VHA) program, and the Indian Health Service (IHS) program—provide health care services to about one-third of Americans. The federal government has a responsibility to ensure that the more than $500 billion invested annually in these programs is used wisely to reduce the burden of illness, injury, and disability and to improve the health and functioning of the population. It is imperative that the federal government exercise strong leadership in addressing serious shortcomings in the safety and quality of health care in the United States.RECOMMENDATION 1: The federal government should assume a strong leadership position in driving the health care sector to improve the safety and quality of health care services provided to the approximately 100 million beneficiaries of the six major government health care programs. Given the leverage of the federal government, this leadership will result in improvements in the safety and quality of health care provided to all Americans.Suggested Citation:"2 Overview of the Government Health Care Programs." Institute of Medicine. 2003. Leadership by Example: Coordinating Government Roles in Improving Health Care Quality. Washington, DC: The National Academies Press. doi: 10.17226/10537.The six major government health care programs serve older persons, persons with disabilities, low-income mothers and children, veterans, active-duty military personnel and their dependents, and Native Americans. Three of these programs—Medicare, Medicaid, and the State Children’s Health Insurance Program (SCHIP)—were devised for groups for whom the health care market has historically failed to work because of their high health care needs and low socioeconomic status. The remaining three programs—DOD TRICARE, VHA, and IHS—serve particular populations with whom the federal government has a special relationship, respectively, military personnel and their dependents, veterans, and Native Americans.Many millions of Americans receive services through multiple government programs simultaneously. Low-income Medicare beneficiaries who qualify for both Medicare and Medicaid account for 17 percent of the Medicare population and 19 percent of the Medicaid population (Gluck and Hanson, 2001; Health Care Financing Administration, 2000). These “dual eligibles” account for a total of 28 percent of Medicare expenditures and 35 percent of Medicaid expenditures. Native Americans eligible to receive services through IHS may also qualify for Medicaid if they satisfy income and other eligibility requirements, and those aged 65 and older may qualify for Medicare. Nearly 45 percent of veterans are 65 years and older and also qualify for Medicare (Van Diepen, 2001b). In addition, many Americans eligible for these programs have private supplemental insurance as well. Thus, patients and clinicians would surely benefit from greater consistency in quality enhancement requirements, measures, and processes across public and private insurance programs.Table 2-1 provides a capsule summary of the six government health care programs. A more detailed description of the programs is provided in the following section. The broad trends affecting the needs and expectations of the programs’ beneficiaries are then reviewed. The final section examines some key features of the programs beyond their quality enhancement processes.MEDICARE1Medicare provides health insurance to all individuals eligible for social security who are aged 65 and over, those eligible for social security because of a disability, and those suffering from end-stage renal disease (ESRD)—a total of about 40 million beneficiaries and growing. While chronic condition and 63 percent have two or more (Anderson, 2002). The over 30 percent of the Medicare population that has a physical and/or cognitive impairment accounts for about 60 percent of expenditures (see Figure 2-1). Medicare beneficiaries with three or more chronic conditions account for the bulk of program expenditures (see Figure 2-2). The most prevalent diagnoses in persons aged 65 and over—high blood pressure, osteoporosis, chronic obstructive pulmonary disease, asthma, diabetes, heart disease, and stroke—are all chronic illnesses requiring medical management over extended time periods and multiple settings (Medical Ex-Suggested Citation:"2 Overview of the Government Health Care Programs." Institute of Medicine. 2003. Leadership by Example: Coordinating Government Roles in Improving Health Care Quality. Washington, DC: The National Academies Press. doi: 10.17226/10537.FIGURE 2-1 Medicare beneficiaries with cognitive and/or physical limitations as a percentage of beneficiary population and total Medicare expenditures, 1997. NOTE: A person with cognitive impairment has difficulty using the telephone or paying bills, or has Alzheimer’s disease, mental retardation, or various other mental disorders. A person with physical impairment is someone reporting difficulty performing three or more activities of daily living.SOURCE: Reprinted with permission from Moon and Storeygard, 2001.penditure Panel Survey, 1998). The fastest-growing sectors in Medicare in terms of spending (though not the largest proportion of total program spending) have been home health, skilled nursing facilities, and hospice care, reflecting a shift in demand toward more chronic care.MEDICAID2Medicaid serves about 42 million people who are poor and who require health care services to achieve healthy growth and development goals or meet special health care needs. The program covers low-income people who meet its eligibility criteria, such as children, pregnant women, certain low-income parents, disabled adults, federal Supplemental Security Income (SSI) recipients (low-income children and adults with severe disability), and the medically needy (non-poor individuals with extraordinary medical expenditures who meet spend-down requirements generally for long-term care). There is a good deal of variability across states in the maximum income for eligibility.Unless otherwise indicated, data in this section are based on Centers for Medicare and Medicaid Services, 2000a.Suggested Citation:"2 Overview of the Government Health Care Programs." Institute of Medicine. 2003. Leadership by Example: Coordinating Government Roles in Improving Health Care Quality. Washington, DC: The National Academies Press. doi: 10.17226/10537.FIGURE 2-2 Medicare beneficiaries with five or more chronic conditions account for two-thirds of Medicare spending.SOURCE: Centers for Medicare and Medicaid Services, 1999.Medicaid is administered and financed jointly by the federal government and the states, although the federal government pays for over 50 percent of aggregate program expenditures (U.S. Government Printing Office, 2002). There is a good deal of variability in methods of health care delivery and financing across states. Medicaid programs rely extensively on private-sector health care providers, managed care plans, and community health centers to deliver services and, to a lesser degree, state, county, or other publicly owned facilities or programs. Nationwide, over half of the total Medicaid population is enrolled in Medicaid managed care arrangements. Institutionalized, disabled, dually eligible, and elderly beneficiaries are most likely to receive services through FFS payment arrangements.The majority of Medicaid beneficiaries are children (54 percent), most under the age of 6 (see Figure 2-3). Each year, over one-third of all births in the United States are covered by Medicaid. While a minority of the program in terms of population (26 percent), the aged/blind/disabled account for 71 percent of program expenditures. Over half of Medicaid expenditures are for long-term care services, with the majority going to institutional long-term care providers (Centers for Medicare and Medicaid Services, 2000a).While coordinated collection of Medicaid data from the states is lacking, other data sources indicate a substantial prevalence of chronic condi-Suggested Citation:"2 Overview of the Government Health Care Programs." Institute of Medicine. 2003. Leadership by Example: Coordinating Government Roles in Improving Health Care Quality. Washington, DC: The National Academies Press. doi: 10.17226/10537.FIGURE 2-3 Distribution of persons served through Medicaid and payments by basis of eligibility, fiscal year 1998.NOTE: Disabled children are included in the aged, blind and disabled category.SOURCE: Centers for Medicare and Medicaid Services, 2000a.tions in the program. These conditions include asthma, diabetes, neurological disorders, high blood pressure, mental illness, substance abuse, and HIV/AIDS (Centers for Medicare and Medicaid Services, 2001c; Medical Expenditure Panel Survey, 1996; Westmoreland, 1999).STATE CHILDREN’S HEALTH INSURANCE PROGRAM3Designed as a joint federal-state program, SCHIP was created in 1997 to provide health insurance to poor and near-poor children through age 18 without another source of insurance. Approximately 4.6 million children were enrolled in SCHIP as of fiscal year 2001 (Centers for Medicare and Medicaid Services, 2000b). SCHIP is targeted to children with incomes that exceed Medicaid eligibility requirements but remain under 200 percent of the federal poverty level (FPL) (Rosenbach et al., 2001). Some states recognized American Indian and Alaska Native tribes. IHS currently provides health services to approximately 1.4 million American Indians and Alaska Natives belonging to more than 557 federally recognized tribes in 35 states.The provision of these health services is based on treaties, judicial determinations, and acts of Congress that result in a unique government-to-government relationship between the tribes and the federal government. IHS, the principal health care provider, is organized as 12 area offices located throughout the United States. These 12 areas contain 550 health care delivery facilities operated by IHS and tribes, including: 49 hospitals; 214 health centers; and 280 health stations, satellite clinics, and Alaska village clinics. Almost 44 percent of the $2.6 billion IHS budget is transferred to the tribes to manage their own health care programs.Poverty and low education levels strongly affect the health status of the Indian people. Approximately 26 percent of American Indians and Alaska Natives live below the poverty level, and more than one-third of Indians over age 25 who reside in reservation areas have not graduated from high school. Common inpatient diagnoses include diabetes, unintentional injuries, alcoholism, and substance abuse.BROAD TRENDS AFFECTING THE NEEDS AND EXPECTATIONS OF BENEFICIARIESIn identifying ways to improve the quality enhancement processes of government health care programs, it is important to understand both the needs and expectations of today’s beneficiaries and the trends likely to affect these needs and expectations in the future. As beneficiaries’ needs and expectations evolve over time, so, too, must the government health care programs. This section highlights two important trends: the increase in chronic care needs and expectations for patient-centered care.Chronic Care NeedsTrends in the epidemiology of health and disease and in medical science and technology have profound implications for health care delivery. Chronic conditions (defined as never resolved conditions, with continuing impairments that reduce the functioning of individuals) are now the leading cause of illness, disability, and death in the United States and affect almost half the U.S. population (Hoffman et al., 1996). Most older people have at least one chronic condition, and many have more than one (Administration on Aging, 2001). Fully 30 percent of those aged 65–74, and over 50 percent of those aged 75 and older report a limitation caused by a chronic condition (Administration on Aging, 2001). The proportion of children and adolescents with limitation of activity due to a chronic health condition more than tripled from 2 percent in 1960 to over 7 percent in the late 1990s (Newacheck and Halfon, 1998).Thus, the majority of U.S. health care resources is now devoted to the treatment of chronic disease (Anderson and Knickman, 2001). This trend is strongly reflected in the government health care programs. In the Medicare and VHA programs, most of the beneficiaries have multiple chronic conditions. Diseases such as asthma, diabetes, hypertension, cancer, congestive heart failure, and mental health and cognitive disorders are important clinical concerns for all or nearly all of the programs.The increasing prevalence of chronic illness challenges systems of care designed for episodic contact on an acute basis (Wagner et al., 1996). Hospitals and ambulatory settings are generally designed to provide acute care services, with limited communication among providers, and communication between providers and patients is often limited to periodic visits or hospitalizations for acute episodes. Serious chronic conditions, however, require ongoing and active medical management, with emphasis on secondary and tertiary prevention. The same patient may receive care in multiple settings, so that there is frequently a need to coordinate services across a variety of venues, including home, outpatient office or clinic setting, hospital, skilled nursing facility, and when appropriate, hospice.There is mounting evidence that care for chronic conditions is seriously deficient. Fewer than half of U.S. patients with hypertension, depression, diabetes, and asthma are receiving appropriate preventive, acute, and chronic disease management services (Clark, 2000; Joint National Committee on Prevention, 1997; Legorreta et al., 2000; Wagner et al., 2001; Young et al., 2001). Health care is typically delivered by a mix of providers having separate, unrelated management systems, information systems, payment structures, financial incentives, and quality oversight for each segment of care, with disincentives for proactive, continuous care interventions (Bringewatt, 2001). For individuals with multiple chronic conditions, coordination of care and communication among providers are major problems that require immediate attention.There are many efforts under way to develop new models of care capable of meeting the needs of the chronically ill. For example, Healthy Future Partnership for Quality, an initiative in Maine now in its fifth year, enrolls insured individuals (from leading health plans and the state Medicaid program) and uninsured individuals (covered by a 10 percent surcharge on the fee for each insured participant and paid by insurance companies) with chronic illness in an intensive care management program that provides patient education, improved access to primary care and preventive services, and disease management (Healthy Futures Partnership for Quality Project, 2002). The diabetes telemedicine collaborative in New York State (IDEATel, 2002) is a randomized controlled trial supported by CMS and others. It involves 1,500 patients, half of whom participate in home monitoring (using devices that read blood sugar, take pictures of skin and feet, and check blood pressure), intensive education on diabetes, and reminders and instructions on how to manage their disease.The changing clinical needs of patients have important implications for government quality enhancement processes. These processes and the health care providers they monitor should be capable of assessing how well patients with chronic conditions are being managed across settings and time. This capability necessitates consolidation of all clinical and service use information for a patient across providers and sites, a most challenging task in a health care system that is highly decentralized and relies largely on paper medical records.Patient-Centered CarePatient-centered care is respectful of and responsive to individual patient preferences, needs, and values and ensures that patient values and circumstances guide all clinical decisions (Institute of Medicine, 2001). Informed patients participating actively in decisions about their own care appear to have better outcomes, lower costs, and higher functional status than those who take more passive roles (Gifford et al., 1998; Lorig et al., 1993, 1999; Stewert, 1995; Superio-Cabuslay et al., 1996; Van Korff et al., 1998). Most patients want to be involved in treatment decisions and to know about available alternatives (Guadagnoli and Ward, 1998); (Deber et al., 1996; Degner and Russell, 1988; Mazur and Hickam, 1997). Yet many physicians underestimate the extent to which patients want information about their care (Strull et al., 1984), and patients rarely receive adequate information for informed decision making (Braddock et al., 1999).Patient-centered care is not a new concept, rather one that has been shaping the clinician and patient relationship for several decades. Authoritarian models of care have gradually been replaced by approaches that encourage greater patient access to information and input into decision making (Emanuel and Emanuel, 1992), though only to the extent that the patient desires such a role. Some patients may choose to delegate decision making to clinicians, while patients with cognitive impairments may not be capable of participating in decision making and may be without a close family member to serve as a proxy. Patients may also confront serious constraints in terms of covered benefits, copayments, and ability to pay (discussed below under benefits and copayments)American Society of Internal Medicine (ACP-ASIM) Foundation, and the European Federation of Internal Medicine embodies three fundamental principles to guide the medical profession, including:Principle of Patient Autonomy. Physicians must have respect for patient autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment. Patients’ decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demand for inappropriate care (American Board of Internal Medicine et al., 2002, p. 244).The current focus on making the health care system more patient-centered stems at least in part from the growth in chronic care needs discussed above. Effective care of a person with a chronic condition is a collaborative process, involving extensive communication between the patient and the multidisciplinary team (Wagner et al., 2001). Patients and their families or other lay caregivers deliver much if not most of the care. Patients must have the confidence and skills to manage their condition, and they must understand their care plan (e.g., drug regimens and test schedules) to ensure proper and safe implementation. For many chronic diseases, such as asthma, diabetes, obesity, heart disease, and arthritis, effective ongoing management involves changes in diet, increased exercise, stress reduction, smoking cessation, and other aspects of lifestyle (Fox and Gruman, 1999; Lorig et al., 1999; Von Korff et al., 1997).Pressures to make the care system more respectful of and responsive to the needs, preferences, and values of individual patients also stem from the increasing ethnic and cultural diversity that characterizes much of the United States. Although minority populations constitute less than 30 percent of the national population, in some states, such as California, they already constitute about 50 percent of the population (Institute for the Future, 2000). A culturally diverse population poses challenges that go beyond simple language competency and include the need to understand the effects of lifestyle and cultural differences on health status and health-related behaviors; the need to adapt treatment plans and modes of delivery to different lifestyles and familial patterns; the implications of a diverse genetic endowment among the population; and the prominence of nontraditional providers as well as family caregivers.Although there has been a virtual explosion in Web-based health and health care information that might help patients and clinicians make more informed decisions, the information provided is of highly variable quality (Berland et al., 2001; Biermann et al., 1999; Landro, 2001). Some sites provide valid and reliable information. These include the National Library of Medicine’s Medline Plus sites (Lindberg and Humphreys, 1999); the National Diabetes Education Program, launched by the Centers for Disease Control and Prevention and the National Institutes of Health (U.S. Government Printing Office, 2001); and the National Health Council’s public education campaign. There are also notable efforts to provide consumers with comparative quality information on providers and health plans. Examples are the health plan report cards produced by the National Committee for Quality Assurance and by the Consumers Union/California HealthCare Foundation Partnership and nursing home quality reports produced by CMS (Centers for Medicare and Medicaid Services, 2001a; Consumers Union/California Healthcare Foundation Partnership, 2002; National Committee for Quality Assurance, 2002). These efforts are discussed further in Chapter 5. There is little doubt, however, that we are embarking on a long journey to determine how best to make valid and reliable information available to diverse audiences with different cultural and linguistic capabilities (Foote and Etheredge, 2002).In general, communication with consumers is enhanced through the use of common terminology, standardized performance measures, and reporting formats that follow common conventions. At the program level, the predilection of each government program to design and operate its health care quality enhancement processes independently is a serious problem.KEY PROGRAM FEATURESAlthough the focus of this report is on quality enhancement processes, the committee believes it important to acknowledge other important program features—such as benefits, payment approaches, and program design and administration—that influence quality. Just as the quality enhancement processes of the government programs are being assessed in this report, these other aspects of program design must be evaluated in the future for alignment with the objectives of those processes.Benefits and CopaymentsHealth insurance was established in the United States in the 1930s and 1940s as a way to help the average person cope with the high costs of hospital care (Stevens, 1989). Today hospital care, although still very expensive, consumes about one-third of the health care dollar, and other facets of health care, such as prescription medications (9 percent with a growth rate of 13.8 percent) have grown in importance (Centers for Medicare and Medicaid Services, 2002c; Strunk et al., 2002). Increased demand for these other facets of care reflects the growth in chronic care needs discussed earlier as well as new treatment options stemming from the extraordinary advances made in medical knowledge and technology, including minimally invasive surgery.The benefit package of an insurance program has a direct effect on the likelihood of patients receiving needed health care services (Federman et al., 2001). Although there are frequent changes in the benefit packages of the various government health care programs, these modifications have not always kept pace with the needs, especially the chronic care needs, of the populations being served (Bringewatt, 2001).When one assesses the extent to which the government health care programs provide coverage for benefits important to persons with chronic conditions, the results are mixed (see Table 2-2). The basic Medicare package, for example, generally does not cover outpatient prescription drugs or personal care, and coverage is very limited for preventive services, nursing home services, family counseling, and dietitian–nutritionist services. Medicare payment mechanisms are designed for acute care, often by a single provider; there is no Medicare payment mechanism that recognizes care delivered by a team of providers to an individual with multiple chronic conditions or that rewards prevention efforts such as extensive patient education for self-care.Other government programs offer important benefits in specific areas. VHA provides extensive mental health outpatient and inpatient services, especially for veterans with service-related disabilities. Medicaid provides residential care to the disabled and mentally retarded and long-term care for the elderly as a major part of program spending. Its benefit package is very comprehensive, including complex therapies for chronic conditions and congenital neurological disorders, such as cerebral palsy and Down syndrome, although states vary substantially in the scope of such benefits. Both Medicaid and SCHIP programs cover outpatient prescription medications. Note that IHS is not included in Table 2-2 because it is not an entitlement program or an insurance plan; therefore, it has no established benefit package (Indian Health Service, 2001). It is estimatedCost-sharing provisions are also important. Persons with chronic conditions are the heaviest users of health care services. Deductibles and especially copayments can be sizable for these individuals. Some government health care programs, such as VHA, have minimal cost-sharing provisions, while others, especially Medicare, make more extensive use of such provisions.Also important is how the different programs interpret “medical necessity.” Even when a service is covered, payment for that service to a particular patient can be denied because of failure to meet a medical necessity criterion. In some instances, the quantity and duration of certain repetitive services may be limited unless the person shows functional improvement, not just stability or a slowing of decline (Anderson et al., 1998).The committee believes that each of the six government health care programs should review its benefit package and medical necessity criteria to identify enhancements in coverage or cost sharing that would facilitate the provision of more appropriate care to today’s beneficiaries. Such analyses should be conducted under alternative financial scenarios, including budget neutrality and varying levels of growth in expenditures. Efforts should also be made to understand how well the benefit packages of various government health care programs meet the needs of vulnerable populations and how well these packages fit together for those who are dual- or triple-eligible.Payment ApproachesEfforts to improve quality of care will be far more effective if implemented in an environment that encourages and rewards excellence. Unfortunately, current methods of payment to health plans and providers have the unintended consequence of working against quality objectives. This is true for both capitated and FFS payment methods.Capitation is a payment arrangement in which health plans are paid a fixed amount for each enrollee under their care, regardless of the level of services needed by and actually provided to the person. Some health plans also pay physicians on a capitated basis for certain outpatient care, putting them at some degree of financial risk.Capitated payment rates are usually based on the average cost per enrollee of the enrolled group, often with adjustments for demographic characteristics (e.g., age and sex). Capitation rates are usually not adjusted for the health status of the enrolled population. Therefore, health plans and providers receive the same payment for someone who is less healthy and more likely to use a large number of services, such as a person with a chronic condition, as they do for someone who is healthier and likely to use no or fewer services during the year.Health plans or clinicians that develop exemplary care programs for persons with chronic conditions may, as a result, attract a disproportionate share of these individuals. Under capitated payment systems, this situation has a highly negative financial impact on the health plan and providers (Luft, 1995; Maguire et al., 1998). Persons with chronic conditions are more likely both to use services and to use a greater number of services during the year than those without chronic conditions. In 1996, for example, mean health care expenditures for a person with one or more chronic conditions were nearly 4 times the overall average ($3,546 versus $821) (Partnerships for Solutions, forthcoming). The average number of inpatient days per year is 0.2 for persons with no chronic conditions compared to 4.6 for those with five or more such conditions.Risk adjustment is a mechanism designed to ensure that payments to health plans and other capitated providers more accurately reflect the expected cost of providing health care services to the population enrolled. Capitated plans and providers caring for a population that includes less healthy, higher-cost enrollees should receive higher payments. As more states require their entire Medicaid populations, including those who are disabled and have high health care needs, to enroll in managed care, adjustment of payments becomes even more necessary to ensure quality of care for enrollees (Maguire et al., 1998). Some states have addressed this issue. Michigan, for example, has created a separately funded capitated option for children with special health care needs (Department of Health and Human Services, 2000).Numerous options exist for risk-adjusting payments, but their application in government health care programs has been limited (Ellis et al., 1996; Hornbrook and Goodman, 1996; Newhouse et al., 1997; Starfield et al., 1991). The Medicare+Choice program has initiated demonstration projects to pilot the application of capitated payments adjusted for health status (Centers for Medicare and Medicaid Services, 2000d).Regardless of whether the beneficiary is enrolled in an indemnity or capitated plan, the physicians on the front line of care delivery in the private sector are generally compensated under FFS payment methods (Center for Studying Health System Change, 2001; Institute of Medicine, 2001). FFS is the most common method of payment to physicians under Medicare, Medicaid, and SCHIP.Under FFS payment, physicians have strong financial incentives to increase their volume of billable services (e.g., visits and office-based procedures and tests). Sometimes the incentives of FFS or other physician payment methods are attenuated by incentives (e.g., bonuses) tied to performance (e.g., measures of safety, clinical quality, service), but this is not the norm. In a 1998–1999 survey of a nationally representative sample of physicians, fewer than 30 percent indicated that their compensation was affected by performance-based incentives, a result similar to findings from a survey conducted in 1996–1997 (Stoddard et al., 2002). When they are used, performance-based incentives are more likely to be tied to patient satisfaction (24 percent) and quality measures (19 percent) than to measures that may restrain care, such as profiling (14 percent).The principal “reimbursable event” under FFS is a face-to-face encounter between a physician and patient, which may or may not trigger other reimbursable events, such as diagnostic tests and minor office procedures. Services such as e-mail communications, telephone consultations, patient education classes, and care coordination are important for the ongoing management of chronic conditions, but they are not reimbursable events. Moreover, physicians who communicate with patients through e-mail or telephone to emphasize patient education, self-management of chronic conditions, and to coordinate care may experience a reduction in overall revenues if these uncompensated services have the effect of reducing patient demand for or time available to devote to reimbursable face-to-face encounters.There is no perfect payment method; all methods have advantages and disadvantages. FFS contributes to overuse of billable services (e.g., face-to-face encounters, ancillary tests, procedures) and underuse of preventive services, counseling, medications, and other services often not covered under indemnity insurance programs. Overuse, especially the provision of services that expose patients to more potential harm than good, is a serious quality-of-care and cost concern. On the other hand, capitated payments may contribute to underuse—the failure to provide services from which patients would likely benefit. This is especially true when there is a good deal of turnover among plan enrollees so that the long-term cost consequences of underuse tend to be borne by another insurer. Although particular payment methods may contain a bias towards underuse or overuse, it is important to note that the quality-of-care literature contains ample evidence of both phenomena occurring in both FFS and capitated payment systems, reinforcing the notion that payment is but one, albeit an important, factor influencing care (Chassin and Galvin, 1998).The committee believes enhancements can be made in both capitated and FFS payment approaches to encourage the provision of quality health care. It should also be noted that there are some promising efforts under way to design alternative payment approaches and evaluate their impact on quality. The National Health Care Purchasing Institute, a nonprofit research institute supported by The Robert Wood Johnson Foundation, has identified various incentive models that might be effective in motivation.The Buyers Health Care Action Group, an employer coalition in Minnesota, provides gold ($100,000) and silver ($50,000) awards to care systems for performance on quality improvement projects (Bailit Health Purchasing, 2002a)PacifiCare in California has developed a quality index that profiles providers on the basis of measures of clinical quality, patient safety, service quality, and efficiency. This information is used to reward providers on the basis of their performance, as well as to construct a tiered system of premiums, copayments, and coinsurance rates for enrollees that vary inversely with provider performance in terms of quality and efficiency (Ho, 2002)The Employers’ Coalition on Health in Rockford, Illinois, makes incentive payments to provider groups based on whether the group completes care flowsheets on 95 percent of its diabetic encounters and maintains hemoglobin A1c levels below 7.5 for the majority of patients. Incentive payments to medical groups have been approximately $28,000 per year ($3.60 per member per year) (Bailit Health Purchasing, 2002a)Blue Shield of California has introduced a variable cost-sharing model under which patients pay either an additional $200 copayment or 10 percent of the hospital’s fee each time they are admitted to a hospital that is not on Blue Shield’s preferred list. Blue Shield rates hospitals on the basis of measures of quality, safety, patient satisfaction, and efficiency (Freudenheim, 2002)General Motors’ value-based purchasing approach rates health plans according to their performance on various clinical quality measures, patient satisfaction measures, NCQA accreditation results, and cost-effectiveness measures, and adjusts employee out-of-pocket contributions so that those choosing the best-ranked plans have the lowest contributions (Salber and Bradley, 2001).It may be hoped that much more will be known about the impact of various financial and non-financial incentive models in the near future. The Robert Wood Johnson Foundation (National Health Care Purchasing Institute, 2002) has recently announced an initiative entitled “Rewarding Results,” which will provide support for payment demonstrations that reward improvements in quality. This initiative is being evaluated under an Agency for Healthcare Research and Quality contract.Program Design and AdministrationBenefits coverage and payment methods are among the most important design features of the six government health care programs reviewed in this report, but they are not the only ones that influence the likelihood of patients receiving high-quality care. Other important features include delivery system and provider choices, fluctuations in eligibility and delivery system options, and administrative efficiency.In some government health care programs, consumers have multiple options in terms of delivery system and choice of providers, while in others the options are more limited. Under Medicare, 87 percent of beneficiaries have chosen to enroll in FFS arrangements, which provide extensive choice of clinicians and hospitals. Most Medicare beneficiaries who live in metropolitan areas also have the option of enrolling in Medicare+Choice plans, enrollment that historically has been associated with enhanced benefits for little or no additional out-of-pocket expense. Enrollment in managed care is mandatory for the majority of the Medicaid population in most states, and in some instances, there is little or no choice of plan. DOD TRICARE, the VHA, and IHS programs are all structured to encourage, and in some cases require, use of their own health care delivery systems, which are similar to group or staff-model health plans.Studies of the clinical quality (in terms of both medical care processes and patient outcomes) in managed care and indemnity settings consistently find little or no difference between the two (Chassin and Galvin, 1998; Miller and Luft, 1993; Schuster et al., 1998). But it is clear that some consumers have strong preferences for one delivery system over another, and that most prefer to have choice (Gawande et al., 1998; Ullman et al., 1997). Limited choice of health plans may or may not seriously constrain the choice of clinicians and hospitals, since plan networks vary greatly in size and structure (Lake and Gold, 1999). In the private sector, there has been a pronounced trend in recent years toward larger networks of providers in response to consumer demand for more extensive choice (Draper et al., 2002; Lesser and Ginsburg, 2000). In the absence of comparative quality information on providers, consumers apparently equate choice with quality.The design and financing of some government health care programs result in frequent changes in eligibility and delivery system options that disrupt patterns of care delivery. Since the implementation of changes in Medicare payment policies stemming from enactment of the Balanced Budget Act of 1997, there has been a steady erosion of health plans participating in the Medicare+Choice program. Since 1998, 2.2 million Medicare beneficiaries have been involuntarily disenrolled from Medicare+Choice plans, affecting approximately 5 percent of beneficiaries in 2002. Of the health plans that remain, the proportion offering prescription drug coverage during the period 1999 through 2002 dropped from 73 to 66 percent, and the proportion charging zero premiums to beneficiaries from 62 to 39 percent (Gold and McCoy, 2002). Under Medicaid, beneficiaries move in and out of the program as their eligibility changes in accordance with minor fluctuations in income, causing beneficiaries to lose contact with providers and further complicating the tracking of care. For many eligible children and women, the re-enrollment process is initiated only when they present themselves at a hospital or physician’s office seeking service for an illness; this process results in adverse selection in capitated plans.Lastly, efforts must be made to reduce administrative burden. In recent years, there has been a steady growth in regulatory requirements in most if not all of the government health care programs. The Secretary’s Advisory Committee on Regulatory Reform estimates that about two regulations are published each week, resulting in the promulgation of more than 120 regulations in each of the last two years (Wood, 2002). The American Hospital Association (2002) has identified 100 new or revised regulations pertaining to hospitals that have been issued by federal agencies since 1997, of which 57 are significant. Some of these regulations relate to quality enhancement processes and data requirements, while others relate to such areas as payment, patient confidentiality and privacy, and fraud and abuse.The current practice of promulgating separate regulations for each type of provider (e.g., hospital, home health agency, nursing home, ambulatory care provider) has produced excessive burdens and barriers to the provision of coordinated care. Unnecessary regulations frustrate clinicians and reduce the time available to devote to patient care. They can also interfere with the movement of individuals across settings, thus hampering the transition from hospital to nursing home to home health agency, for example.Regulatory burden must also be fair. For example, the quality measurement and reporting requirements applied to Medicare+Choice plans should be applied to FFS Medicare institutional and individual providers. These issues are addressed further in Chapters 3 and 4.In summary, while technically comprising separate areas of analysis, the issues of benefits, payment, program design, and administration are inextricably linked to achieving consistent levels of high-quality care.