OBJECTIVES To determine the effect of integrating informal caregivers into discharge planning on post-discharge cost and resource utilization in the older adult population. DESIGN A systematic review and meta-analysis of randomized controlled trials that examine the effect of discharge planning with caregiver integration begun prior to patient discharge on healthcare cost and resource utilization outcomes. MEDLINE, EMBASE and the Cochrane Library databases were searched for all English language articles published between 1990 and April 2016. SETTING Hospital or skilled nursing facility. PARTICIPANTS Older adults with informal caregivers discharged to a community setting. MEASUREMENTS Readmission rates, length of and time to post-discharge rehospitalizations, costs of post-discharge care. RESULTS Of 10,715 abstracts identified, fifteen studies met the inclusion criteria. Eleven studies provided sufficient detail to calculate readmission rates for treatment and control. Compared to usual care, discharge planning interventions with caregiver integration were associated with a 25 percent reduction in readmissions at 90 days (Relative Risk [RR], .75 [95% CI, .62-.91]) and a 24 percent reduction in readmissions at 180 days (Relative Risk [RR], .76 [95% CI, .64–.90]). The majority of studies reported statistically significant reductions in time to readmission, length of rehospitalization, and costs of post-discharge care. CONCLUSION For older adult patients discharged to a community setting, the integration of caregivers into the discharge planning process, compared to non-systematic inclusion of caregivers, reduces the risk of hospital readmission.

Scholarship on social policy has recently emphasised the importance of gradual processes of institutional change. However, conceptual work on the identification of processes such as drift, conversion and layering has not produced clear empirical indicators that distinguish these processes from one another, posing major problems for empirical research. We argue that, in order to improve the validity of its empirical findings, scholarship on gradual change should – and can – pay more attention to issues of measurement and detection. We then contribute to this goal by clearly articulating observable indicators for several mechanisms of gradual institutional change and validating them against extant empirical work on political economy.

Canada and the United States are often grouped together as liberal welfare‐state regimes, with broadly similar levels of social spending. Yet, as the COVID‐19 pandemic reveals, the two countries engage in highly divergent approaches to social policymaking during a massive public health emergency. Drawing on evidence from the first 5 months of the pandemic, this article compares social policy measures taken by the United States and Canadian governments in response to COVID‐19. In general, we show that Canadian responses were both more rapid and comprehensive than those of the United States. This variation, we argue, can be explained by analysing the divergent political institutions, pre‐existing policy legacies, and variations in cross‐partisan consensus, which have all shaped national decision‐making in the middle of the crisis.

Implementing e-government in the contemporary American state is challenging. E-government places high technical demands on agencies and citizens in an environment of budget austerity and political polarization. Governments developing e-government policies often mobilize frontline workers-also termed "street-level bureaucrats"-to help citizens gain access to services. However, we know little about how frontline workers cope in these challenging circumstances. Th is article fi lls this gap by examining frontline workers implementing the Patient Protection and Aff ordable Care Act. Based on a qualitative analysis, the authors fi nd that frontline workers "move toward clients" when coping with stress: they bend the rules, work overtime, and collaborate in order to help clients. Th ey are less inclined to "move away" or "move against" clients, for instance, through rigid rule following and rationing. In other words, frontline workers try to serve clients, even "when the server crashes." Frontline workers, then, can play a vital role in the successful implementation of e-government policies. Practitioner Points• Frontline workers cope with e-government service delivery in ways that are benefi cial for clients, even in diffi cult circumstances. Hence, they can play a vital role in successfully delivering e-government. • Frontline workers have a wealth of knowledge about implementation challenges, such as technical problems, impossible caseloads, and unclear rules. Th eir knowledge can improve implementation and should be gathered systematically. • Despite extensive coping skills, frontline workers may also experience considerable strain when implementing e-government reforms. Th is can lead to burnout and/or turnover. Th erefore, governments should pay particular attention to the challenges that frontline workers face in their daily work and try to address them.

Federalism plays a foundational role in structuring public expectations about how the United States will respond to the COVID-19 pandemic, as both an unprecedented public-health crisis and an economic recession. As in prior crises, state governments are expected to be primary sites of governing authority, especially when it comes to immediate public-health needs, while it is assumed that the federal government will supply critical countercyclical measures to stabilize the economy and make up for major revenue shortfalls in the states. Yet there are reasons to believe that these expectations will not be fulfilled, especially when it comes to the critical juncture of the COVID-19 pandemic. Though the federal government has the capacity to engage in counter-cyclical spending to stabilize the economy, existing policy instruments vary in the extent to which they leverage that capacity. This leverage, we argue, depends on how decentralized policy arrangements affect the implementation of both discretionary emergency policies as well as automatic stabilization programs such as Unemployment Insurance, Medicaid, and the Supplemental Nutrition Assistance Program. Evidence on the US response to COVID-19 to date suggests the need for major revisions in the architecture of intergovernmental fiscal policy.