Abstract
Objective
To compare the likelihood of intellectually and developmentally disabled (ID/DD) adults receiving a dental cleaning across places of residence.
Data Sources
Medicaid and Minnesota's Medicaid Management Information System (MMIS) databases.
Study Design
All adults with DD assessments in MMIS in 2001–2002.
Data Extraction Methods
All completed DD assessments in 2001–2002 linked to Medicaid utilization data for same recipients for same years.
Conclusions
The most disabled individuals are generally least likely to receive a dental cleaning. Individuals living in their own or a family home are less likely to receive the procedure than those living in ICF/MRs or a group home, even after controlling for disability, with those living in a group home falling in between ICF/MR and own/family home residents. The level of preventive dental care that ID/DD adults receive in community settings may be inadequate, particularly for persons living in own homes or with family.
Keywords: Mentally retarded, developmentally disabled, residence, dental care, disability
BACKGROUND
Increased importance is being placed on the quality of health care received by people with intellectual and developmental disabilities (ID/DD). Dental care is especially important for persons with ID/DD, many of whom for various reasons (e.g., use of antiseizure meds, poor oral hygiene) are more susceptible to oral diseases (Krahn, Hammond, and Turner 2006). Oral ailments may lead to other diseases, such as pulmonary infection and bacterial endocarditis (Fenton et al. 2003). Basic dental services are an effective preventive tool.
The importance of dental care for this population, however, is not matched by the quality of the care it receives. For example, Havercamp, Scandlin, and Roth (2004) found that 14.4 percent of adults with ID in North Carolina have not had a dental cleaning for at least 5 years (compared with 8 percent in the general population). According to the Shriver Center for Developmental Disabilities at the University of Massachusetts Medical School, oral disease is one of the conditions most likely to go undetected in people with ID/DD (as described in Voelker 2002). There are several contributing factors, such as a lack of trained and/or willing dental practitioners, inadequate insurance coverage and/or low reimbursements, and transportation (e.g., Hayden and Kim 2002; Reichard and Turnbull 2004;).
It has been found that people with ID/DD living in community are less likely to receive preventive services and may be in worse health than those living in institutions (e.g., Rimmer, Braddock, and Marks 1995; Lewis et al. 2002;). For example, Freedman and Chassler (2004) found that people living in a parent's/relative's home or in a group home are significantly less likely to have had a dental exam in the past 6 months than people who lived in an institutional facility (72.4 percent for relative's home residents, 82.1 percent for group homes, 87.9 percent for residents of institutions).
Living in community-based residences improves outcomes such as consumer choice, contacts with family and community integration, as well as service costs (Stancliffe and Lakin 1998). However, one of the advantages of institutions, which usually have a medical professional and perform many preventive medical services on-site, is the centralization of health care and oversight. Health care services for people with ID/DD have not advanced at the same rate as residential services.
If the problem of inadequate dental care is indeed more prevalent in certain residential settings (i.e., family homes and own homes), efforts to improve utilization and access should be focused on community-based residential options. However, existing studies exploring this issue have several persistent weaknesses: generally small sample size, convenience samples, and lack of adjustment for differential levels of disability likely to be found among people living in different residential settings. A person's level of disability can affect the likelihood of receiving dental services, as was found in one study of mothers of adults with DD (Pruchno and McMullen 2004).
Our study creates disability scales from available data and is thus able to control for it. It also uses a large sample consisting of all persons receiving ID/DD services in the state of Minnesota in a 2-year period.
METHODS
Two administrative databases were utilized for the analysis. Medicaid records for years 2001–2002 provided utilization data. Minnesota's Medicaid Management Information System database containing DD Screening Documents (form DHS-3067) for persons with ID/DD receiving Waiver or regular Medicaid (called Medical Assistance in Minnesota) services was used to create measures for the level of disability as well as place of residence. The DD Screening Document is completed to determine the level of care required for a person with a diagnosis of mental retardation or a related condition. It makes no distinction between people with a diagnosis of ID and people with a diagnosis of a DD (two related but different terms)—we thus use the terms interchangeably throughout the text. The document is filled out when a person is entering services; there are also mandatory periodic (e.g., annual) screenings, as well as screenings when service needs of the persons have changed or are anticipated to change in the near future. The DD Screening Document contains information on the person's diagnoses, functional strengths and needs, and current and planned services and residential arrangements.
There were 15,352 persons with DD Screening Documents in 2001–2002 who were at least 18 years old. For each recipient, the latest available DD screening document was selected. Based on that assessment, each recipient was assigned one of the residential options: family home, foster/group home, own home, or ICF/MR. Seven hundred and sixty-two people could not be assigned to one of these residences.
Next, Medicaid Analytic Extract (MAX) data for the years 2001–2002 were obtained for the above individuals. Medicaid files were searched for the following CPT procedure codes signifying routine dental cleaning: D1110, D1120, and D1205.
In order to control for the length of observation period, MAX Personal Summary Record data were used to extract the number of Medicaid eligibility months in the 12 months before the date of the DD Screening Document. Fourteen thousand nine hundred and seventy-six people were eligible for Medicaid for at least 1 month before their latest screening.
Other control variables included age, gender (from DD Screening Document), and race (white/nonwhite) (from MAX Person Summary file).
ANALYSIS
Disability Scales
The DD Screening Document is a service-oriented assessment and is designed to assess the level of services a recipient needs. It does not include any conventional disability instruments (e.g., such as Activities of Daily Living). Nonetheless, the items on the document can be used to create useful scales that differentiate between, for example, physical disability and communication disability. We hypothesized several a priori disability domains and candidate assessment items (Table 1). All candidate items were rescaled to a common continuous scale, and factor analysis was performed using the selected assessments. Promax rotation was used, allowing the domains to correlate.
Table 1.
A Priori Disability Domains and Candidate DD Screening Items
| A Priori Disability of Interest | DD Screening Item |
|---|---|
| Physical Disability | Vision |
| Seizures | |
| Mobility | |
| Fine motor skills | |
| Functional Disability | Self-preservation |
| Independent living skills items | |
| Self-care | |
| Daily living skills/house management | |
| Money management | |
| Community living | |
| Leisure and recreation | |
| Behavioral Disability | Challenging (excess) behavior scales |
| Eating nonnutritive substances (pica) | |
| Injurious to self | |
| Physically aggressive | |
| Verbally/gesturally aggressive | |
| Inappropriate sexual behavior | |
| Property destruction | |
| Runs away | |
| Breaks law | |
| Temper outbursts | |
| Communication Disability | Hearing |
| Receptive communication | |
| Expressive communication | |
| Cognitive Disability | ICD-9 codes for level of mental retardation: 317—mild mental retardation, 318.0—moderate, 318.1—severe, 318.2—profound |
Factor analysis confirmed the a priori domains to a great extent, although it did suggest some adjustments. The resulting disability domains and the component DD Screening items were (1) Functional Disability, measured by the independent living skills items and self-preservation; (2) Physical Disability, measured by mobility, fine motor skills, and seizures items; (3) Communication Disability, measured by receptive and expressive communication items and hearing; (4) two subsets of Behavioral Disability—one consisting of behavior items that represent activities having legal repercussions (called Illegal Behavioral Disability) and the other consisting of challenging behavior items not having legal ramifications (called Legal Behavioral Disability).
We then formed simple additive disability scales by summing the domains' items. Cronbach α is a statistic commonly used as a measure of internal consistency (reliability) of a measurement instrument or a scale. It measures how well a set of variables or items measures a single unidimensional latent construct. αs were calculated for each disability scale and ranged from 0.60 to 0.89. α of 0.7 or higher is usually desired for a set of items to be considered a good scale, but a value of 0.6 is also often sited as sufficient for an exploratory study such as this one. In addition, we performed sensitivity analyses using all available DD Screening Documents. The factor structure was confirmed and the composition of domains followed the same pattern.
Promax rotation used in factor analysis allowed the domains to correlate, but the correlations were not high enough (highest was around 0.6) to present multicollinearity issues when more than one disability scale was included in analysis.
To address a possible “threshold” effect, we categorized disability scales using none/mild/moderate–severe categories for illegal behavior disabilities and using quartiles for other disabilities. In addition, cognitive disability was derived directly from the ICD-9 mental retardation diagnosis and was categorized as mild/moderate/severe/profound.
Logistic Analysis
All analyses were performed using SPSS. Series of logistic regressions were fitted, starting with regressions examining the relationship between individual disability scales and the probability of having a dental cleaning in the previous 12 months. The next model examined the probability in terms of place of residence. Finally, the last model combined disability scales and place of residence. All models also controlled for months of Medicaid eligibility, age, gender, and race.
RESULTS
Table 2 presents statistics describing living arrangements in terms of residents' disability levels, demographics, and proportion receiving dental cleaning in the previous 12 months.
Table 2.
Descriptive Statistics
| ICF/MR (n=2,271) | Foster/Group Home (n=6,998) | Family Home (n=4,067) | Own Home (n=1,254) | |
|---|---|---|---|---|
| Received dental cleaning in past 12 months | 69.7% (n=2,264) | 70.8% (n=6,983) | 37.8% (n=3,909) | 52.3% (n=1,194) |
| Age in years (mean [SD]) | 46.7 (14.1) | 41.8 (14.9) | 30.9 (13.0) | 40.6 (12.6) |
| Percent white | 95.6 | 93.9 | 83.6 | 86.3 |
| Percent nonwhite | 4.1 | 5.2 | 10.8 | 7.3 |
| Percent female | 45.7 | 43.3 | 44.4 | 53.8 |
| Months of Medicaid eligibility in last 12 months (mean [SD]) | 11.3 (2.1) | 11.8 (1.2) | 10.8 (2.8) | 10.0 (3.4) |
| Functional Disability (%) | ||||
| 1st quartile | 5.8 | 23.7 | 33.0 | 78.0 |
| 2nd quartile | 23.2 | 31.4 | 30.4 | 17.3 |
| 3rd quartile | 38.7 | 27.6 | 22.4 | 3.7 |
| 4th quartile | 32.2 | 17.0 | 14.0 | 1.0 |
| Physical Disability (%) | ||||
| 1st quartile | 19.1 | 29.7 | 32.6 | 51.0 |
| 2nd quartile | 17.7 | 23.6 | 24.9 | 25.5 |
| 3rd quartile | 24.0 | 22.0 | 20.1 | 15.9 |
| 4th quartile | 38.3 | 23.9 | 21.4 | 7.4 |
| Communication Disability (%) | ||||
| 1st quartile | 12.8 | 27.9 | 32.3 | 60.2 |
| 2nd quartile | 16.2 | 23.2 | 23.6 | 21.0 |
| 3rd quartile | 22.5 | 22.5 | 24.0 | 15.3 |
| 4th quartile | 45.5 | 25.2 | 17.8 | 2.8 |
| Legal Behavior Disability (%) | ||||
| 1st quartile | 18.0 | 18.8 | 37.7 | 42.5 |
| 2nd quartile | 28.5 | 29.0 | 31.6 | 35.7 |
| 3rd quartile | 24.6 | 21.8 | 15.0 | 15.2 |
| 4th quartile | 28.8 | 30.3 | 15.4 | 6.7 |
| Illegal Behavior Disability (%) | ||||
| None | 60.5 | 58.9 | 74.6 | 75.6 |
| Mild | 27.4 | 26.1 | 17.3 | 18.8 |
| Severe | 11.8 | 14.8 | 7.8 | 5.6 |
| Cognitive Disability (%) | ||||
| Mild | 17.2 | 36.0 | 41.7 | 79.3 |
| Moderate | 22.3 | 26.7 | 33.4 | 12.8 |
| Severe | 26.1 | 19.0 | 14.2 | 1.6 |
| Profound | 33.5 | 16.0 | 6.3 | 0.3 |
Residents of ICF/MRs are on average oldest and residents of family homes youngest. The percentage of females is highest in own homes. The percentage of nonwhites is highest in family homes.
People living in own homes are least disabled across all disability domains. Those living in ICF/MRs are generally most disabled, followed by residents of foster/group homes. Those living with family tend to be less disabled than residents of own home and residents of group homes.
People living with family are also least likely to have had a dental cleaning in the prior 12 months (37.8 percent). ICF/MR residents and residents of foster/group homes are about equally likely to have had a dental cleaning (69.7 and 70.8 percent), followed by those living in their own homes (52.3 percent).
Table 3 presents the results of logistic regressions. Models 1–6 examine the effect of disability. The largest effect is by the level of functional disability. The odds of having had a dental cleaning are 80–90 percent higher for a person in the two lower quartiles than they are for a person in the highest quartile. Odds of having the procedure are 1.6 for those in lowest physical disability quartile as compared with the most physically disabled. Being in the most disabled communication disability quartile also lowers the odds (1.4–1.5 times for those in the two lower quartiles as compared with the highest quartile). Most cognitively disabled recipients are also least likely to have had a dental cleaning—the odds are about 1.3 for those with mild or moderate disability as compared with those with profound cognitive disability. Being most disabled in terms of both behavior disabilities, however, raises the probability. Age does not seem to be a significant predictor, and gender only marginally so. Race, however, is a significant predictor, with whites being more than twice as likely to have received the service than nonwhites.
Table 3.
Logistic Models: Dental Cleaning and Disability
| Odds Ratio (95% CI) | |
|---|---|
| Model 1: Functional Disability | |
| Functional disability quartile 1† | 1.77 (1.60–1.97)*** |
| Functional disability quartile 2 | 1.90 (1.72–2.10)*** |
| Functional disability quartile 3 | 1.49 (1.34–1.64)*** |
| Functional disability quartile 4 | Reference category |
| Months of Medicaid eligibility (per month) | 1.30 (1.28–1.33)*** |
| Age (per year) | 1.000 (0.997–1.002) |
| Female | 1.09 (1.01–1.16)* |
| White | 2.22 (1.94–2.54)*** |
| Model 2: Physical Disability | |
| Physical disability quartile 1 | 1.61 (1.47–1.77)*** |
| Physical disability quartile 2 | 1.25 (1.13–1.37)*** |
| Physical disability quartile 3 | 1.24 (1.12–1.37)*** |
| Physical disability quartile 4 | Reference category |
| Months of Medicaid eligibility (per month) | 1.31 (1.28–1.33)*** |
| Age (per year) | 0.998 (0.996–1.001) |
| Female | 1.09 (1.02–1.17)* |
| White | 2.21 (1.93–2.53)*** |
| Model 3: Communication Disability | |
| Communication disability quartile 1 | 1.48 (1.34–1.63)*** |
| Communication disability quartile 2 | 1.37 (1.24–1.52)*** |
| Communication disability quartile 3 | 1.14 (1.03–1.25)* |
| Communication disability quartile 4 | Reference category |
| Months of Medicaid eligibility (per month) | 1.31 (1.28–1.33)*** |
| Age (per year) | 0.999 (0.997–1.002) |
| Female | 1.07 (0.998–1.148) |
| White | 2.19 (1.91–2.51)*** |
| Model 4: Legal Behavior Disability | |
| Legal behavior disability quartile 1 | 0.78 (0.71–0.86)*** |
| Legal behavior disability quartile 2 | 0.84 (0.77–0.93)*** |
| Legal behavior disability quartile 3 | 1.08 (0.97–1.20) |
| Legal behavior disability quartile 4 | Reference category |
| Months of Medicaid eligibility (per month) | 1.29 (1.27–1.32)*** |
| Age (per year) | 0.998 (0.995–1.000)* |
| Female | 1.10 (1.03–1.18)** |
| White | 2.20 (1.93–2.52)*** |
| Model 5: Illegal Behavior Disability | |
| Illegal behavior disability—none | 0.83 (0.74–0.93)*** |
| Illegal behavior disability—mild | 1.04 (0.92–1.18) |
| Illegal behavior disability—moderate/severe | Reference category |
| Months of Medicaid eligibility | 1.29 (1.27–1.32)*** |
| Age (per year) | 0.998 (0.996–1.001) |
| Female | 1.11 (1.04–1.20)** |
| White | 2.19 (1.92–2.51)*** |
| Model 6: Cognitive Disability | |
| Cognitive disability—mild | 1.26 (1.14–1.40)*** |
| Cognitive disability—moderate | 1.30 (1.17–1.45)*** |
| Cognitive disability—severe | 1.13 (1.01–1.28)* |
| Cognitive disability—profound | Reference category |
| Months of Medicaid eligibility (per month) | 1.30 (1.28–1.33)*** |
| Age (per year) | 0.998 (0.995–1.000)* |
| Female | 1.07 (1.00–1.15) |
| White | 2.26 (1.97–2.59)*** |
| Model 7: Residence | |
| Own home | 0.64 (0.54–0.74)*** |
| Foster/group home | 0.89 (0.80–0.99)* |
| Family home | 0.24 (0.21–0.27)*** |
| ICF/MR | Reference category |
| Months of Medicaid eligibility (per month) | 1.26 (1.24–1.29)*** |
| Age (per year) | 0.987 (0.985–0.990)*** |
| Female | 1.12 (1.05–1.21)** |
| White | 2.01 (1.75–2.32)*** |
| Model 8: Disability and Residence | |
| Own home | 0.42 (0.35–0.50)*** |
| Foster/group home | 0.76 (0.68–0.85)*** |
| Family home | 0.19 (0.17–0.22)*** |
| ICF/MR | Reference category |
| ADL disability quartile 1† | 1.75 (1.47–2.07)*** |
| ADL disability quartile 2 | 1.75 (1.51–2.03)*** |
| ADL disability quartile 3 | 1.37 (1.20–1.55)*** |
| ADL disability quartile 4 | Reference |
| Physical disability quartile 1 | 1.16 (1.03–1.32)* |
| Physical disability quartile 2 | 0.95 (0.84–1.07) |
| Physical disability quartile 3 | 1.00 (0.89–1.13) |
| Physical disability quartile 4 | Reference |
| Communication disability quartile 1 | 1.38 (1.20–1.60)*** |
| Communication disability quartile 2 | 1.25 (1.09–1.43)*** |
| Communication disability quartile 3 | 1.09 (0.96–1.24) |
| Communication disability quartile 4 | Reference |
| Legal behavior disability quartile 1 | 1.00 (0.88–1.13) |
| Legal behavior disability quartile 2 | 0.96 (0.86–1.07) |
| Legal behavior disability quartile 3 | 1.11 (0.97–1.25) |
| Legal behavior disability quartile 4 | Reference |
| Illegal behavior disability—none | 1.07 (0.93–1.22) |
| Illegal behavior disability—mild | 1.10 (0.96–1.26) |
| Illegal behavior disability—moderate/severe | Reference |
| Cognitive disability—mild | 0.96 (0.82–1.13) |
| Cognitive disability—moderate | 1.11 (0.95–1.30) |
| Cognitive disability—severe | 1.04 (0.91–1.20) |
| Cognitive disability—profound | Reference |
| Months of Medicaid eligibility (per month) | 1.27 (1.24–1.30)*** |
| Age (per year) | 0.988 (0.986–0.991)*** |
| Female | 1.11 (1.03–1.19)** |
| White | 2.09 (1.80–2.43)*** |
Lower quartile signifies lower level of disability.
Significant at 0.05 level.
Significant at 0.01 level.
Significant at 0.001 level.
Model 7 shows the effect of place of residence. Residents of foster/group homes are only slightly less likely to have had a dental cleaning as residents of ICF/MRs (odds ratio of 0.9 only marginally statistically significant). Those living with families are markedly least likely to have received the service—odds of 0.2 as compared with ICF/MR residents. Those living in their own home are also less likely to have had the procedure—odds of 0.6 as compared with ICF/MR residents. Being older lowers the likelihood, as does being nonwhite. Being female slightly raises the likelihood.
Model 8 adds all the disability domains to the previous model. The patterns generally persist and gap between residents of ICF/MRs and other types of living arrangements widens. After controlling for disability, living in foster/group home lowered the odds of having received a dental cleaning to 0.8 as compared with those living in ICF/MRs. The odds of receiving the service for someone living in own home are 0.4 as compared with those living in an ICF/MR, after controlling for disability. The odds for those living in family home remained 0.2. As in previous model, being older lowers the likelihood, as does being nonwhite. Females are more likely to have received the service.
DISCUSSION
Several important results emerged from the analysis. With the exception of behavior disabilities, being more disabled generally lowers the recipient's likelihood of receiving a dental cleaning. The opposite effect that high behavior disability has is likely due to the fact that recipients with the most behaviors usually have more oversight and more people involved in their care.
The findings that living in community settings may decrease the likelihood of receiving preventive health care services are confirmed, even after controlling for levels of disability. The difference is particularly striking for those living with family and own homes. In fact, even those living in foster/group homes are slightly less likely to have received a dental cleaning than those who lived in an ICF/MR after their level of disability is controlled for.
These findings raise concerns. A severely disabled person should still be able to access dental services. A higher level of disability should not decrease a DD person's chances of getting a basic service such as dental cleaning. This discrepancy may be due to access barriers or value judgments.
Our study had limitations, but we do not believe them to be detrimental to our conclusions. We were able to capture only the procedures that were billed to Medicaid, so if a person had private insurance that paid for the dental cleaning or paid out of pocket, his/her dental cleaning was not captured in our data. However, as the vast majority of our sample had Medicaid coverage throughout the follow-up period and Medicaid is generally a more comprehensive plan than most other available plans, it is unlikely private insurance had a large role as a payer, especially for dental coverage. We looked at MAX data and found that about 15 percent of people living in a family home had private insurance during the follow-up period; the number of people who had private insurance coverage and lived in their own homes was small and did not differ from the number who lived in group homes. It is safe to conclude that while inability to capture private insurance utilization may skew our results, it cannot account for all of the differences we found.
There is also the issue of temporality. Utilization was measured over a period of time, whereas a person's living situation could be assigned at one point in time. An individual may not have remained in the same setting during the entire follow-up period. However, data indicated that “moving” occurred relatively infrequently (about 7 percent of cases) and is not likely to significantly affect the result. When consumers changed residences, the majority moved from a less staff-intensive residential option to a more staff-intensive one (e.g., from family home to group home). We performed sensitivity analyses by assigning residence at beginning of follow-up and also by creating an indicator variable for a person moving, and our conclusions were unaffected. In fact, assigning residence at the end of follow-up may lead to underestimating the gap between some of the residence types.
A basic limitation in any study looking at utilization of a particular service is the difficulty of linking the service with health outcomes. We do not attempt to draw definitive conclusions that people with ID/DD who received a dental cleaning have better dental or medical outcomes. However, if the level of care provided at institutions such as ICF/MRs is the standard, then the level received in community settings is inadequate. Resources should be provided to individuals with ID/DD and their families to insure that they are able to access community-based dental care, including transportation, education, appointments, staffing, etc. Community-based care improves quality of life and many outcomes; it should not come at a price of decreased quality of dental care.
Acknowledgments
Joint Acknowledgment/Disclosure Statement: We, the authors (Julie Bershadsky and Robert L. Kane), certify that we have no financial interests and no conflict of interest pertaining to the manuscript, and that the work has not been previously presented anywhere else.
Disclosures: None.
Disclaimers: None.
Supporting Information
Additional supporting information may be found in the online version of this article:
Appendix SA1: Author Matrix.
Please note: Wiley-Blackwell is not responsible for the content or functionality of any supporting materials supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author for the article.
REFERENCES
- Fenton SJ, Hood H, Holder M, May PB, Jr, Mouradian WE. The American Academy of Developmental Medicine and Dentistry: Eliminating Health Disparities for Individuals with Mental Retardation and Other Developmental Disabilities. Journal of Dental Education. 2003;67(12):1337–44. [PubMed] [Google Scholar]
- Freedman RI, Chassler D. Physical and Behavioral Health of Adults with Mental Retardation across Residential Settings. Public Health Reports. 2004;119:401–8. doi: 10.1016/j.phr.2004.05.004. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Havercamp SM, Scandlin D, Roth M. Health Disparities among Adults with Developmental Disabilities, Adults with Other Disabilities, and Adults Not Reporting Disability in North Carolina. Public Health Reports. 2004;119:418–26. doi: 10.1016/j.phr.2004.05.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Hayden MF, Kim SH. Health Status, Health Care Utilization Patterns, and Health Care Outcomes of Persons with Intellectual Disabilities: A Review of the Literature. Policy Research Brief. 2002;13:1–18. doi: 10.1352/0047-6765(2005)43[175:HSUPAO]2.0.CO;2. [DOI] [PubMed] [Google Scholar]
- Krahn GL, Hammond L, Turner A. A Cascade of Disparities: Health and Health Care Access for People with Intellectual Disabilities. MRDD Research Reviews. 2006;12:70–82. doi: 10.1002/mrdd.20098. [DOI] [PubMed] [Google Scholar]
- Lewis MA, Lewis CE, Leake B, King BH, Lindemann R. The Quality of Health Care for Adults with Developmental Disabilities. Public Health Reports. 2002;117:174–84. doi: 10.1016/S0033-3549(04)50124-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Pruchno RA, McMullen WF. Patterns of Service Utilization by Adults with a Developmental Disability: Type of Service Makes a Difference. American Journal on Mental Retardation. 2004;109(5):362–78. doi: 10.1352/0895-8017(2004)109<362:POSUBA>2.0.CO;2. [DOI] [PubMed] [Google Scholar]
- Reichard A, Turnbull HR., III Perspectives of Physicians, Families, and Case-Managers Concerning Access to Health Care by Individuals with Developmental Disabilities. Mental Retardation. 2004;42(3):181–94. doi: 10.1352/0047-6765(2004)42<181:POPFAC>2.0.CO;2. [DOI] [PubMed] [Google Scholar]
- Rimmer JH, Braddock D, Marks B. Health Characteristics and Behaviors of Adults with Mental Retardation Residing in Three Living Arrangements. Research in Developmental Disability. 1995;16(6):489–9. doi: 10.1016/0891-4222(95)00033-x. [DOI] [PubMed] [Google Scholar]
- Stancliffe RJ, Lakin KC. Analysis of Expenditures and Outcomes of Residential Alternatives for Persons with Developmental Disabilities. American Journal on Mental Retardation. 1998;102(6):552–68. doi: 10.1352/0895-8017(1998)102<0552:aoeaoo>2.0.co;2. [DOI] [PubMed] [Google Scholar]
- Voelker R. Improved Care for Neglected Population Must Be ‘Rule Rather Than Exception. Journal of American Medical Association. 2002;288(3):299–301. doi: 10.1001/jama.288.3.299. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.