Experts Matter. Find Yours.

COVID-19 Pandemic Increasing Substance Use Among Veterans with PTSD

Nine months into the pandemic, everyone has been affected by COVID-19 in some way. However, one group that needs special attention and support is U.S. veterans who were already struggling with symptoms of posttraumatic stress disorder (PTSD). A recently conducted survey by Jordan Davis, assistant professor at the USC Suzanne Dworak-Peck School of Social Work, and Eric Pedersen, associate professor at Keck School of Medicine of USC, found evidence that veterans with PTSD prior to the pandemic were now managing their symptoms with more frequent alcohol and cannabis use. “The pandemic has not been easy on folks, especially for those that have PTSD or an alcohol use disorder (AUD),” said Davis, who also is associate director of the USC Center for Artificial Intelligence in Society (CAIS). “Some of the stories I’ve heard [from study participants] have been heart-wrenching.” An extraordinary resource of veterans not affiliated with VA services Davis and Pedersen lead several efforts examining substance use among veterans. They have assembled a survey group of about 1,200 military veterans, a percentage of whom struggle with PTSD symptoms but have not yet sought professional help via the Department of Veterans Affairs (VA) to improve their wellbeing. “We’ve decided to focus on the population of veterans who, for one reason or another, say they don’t need mental health care,” Davis said. Attitudes about care, transportation barriers or perceived stigma from others may deter them from seeking care for PTSD symptoms, and some self-medicate with alcohol, cannabis, cigarettes, or more rarely, methamphetamine or cocaine. Davis cited larger studies 1,2 that found only about half of the veterans who need some sort of mental health care receive it. Many studies of veterans recruit subjects from the VA who are likely already receiving care. The unique sample group that Davis and Pedersen have created may offer fresh insights into how to motivate these veterans outside the VA system to seek care and how best to deliver it. Tracking pandemic effects on mental health It all began with a one-time survey of young adult veterans to measure drinking habits and willingness to seek help. Pedersen and others had developed a brief intervention that had yielded some success reducing drinking in the short-term, but he knew that sustaining those reductions would be difficult unless the veterans agreed to more formal care. The one-off survey, conducted in February 2020, would set a baseline that could be used to inform the brief intervention content. Then COVID-19 cases began multiplying. Affected cities and states began to impose restrictions on public gatherings and more. Pedersen and Davis soon obtained additional funding from the Keck School of Medicine of USC COVID-19 Funding Program and the National Institute of Alcohol and Abuse to follow up with their sample group and see how these veterans were coping with the unprecedented health crisis. “The result is that we can follow up with these veterans from a pre-COVID-19 time period for the next several years, tracking their depression, anxiety and PTSD symptoms and substance use,” Pedersen said. The researchers aim to understand how the veterans are sleeping, what their stress levels are like, and how things have changed as the pandemic wears on. They hope to gain new insights about what motivates some to seek care and how that can be replicated. So far, the results point to some unfortunate, but not unexpected, news. “We’re finding that those veterans who were struggling with PTSD prior to the pandemic are actually doing worse in terms of their substance use behaviors, drinking and cannabis use, as well as their stressful reactions to the pandemic,” Pedersen said. Pedersen and Davis will continue to follow up with these veterans through at least February 2022, surveying them every three months to see how they are progressing. In addition to the survey, they also conduct in-depth qualitative interviews with a subset of the group to enrich their understanding of what their lives are like now and how things have changed for them. The interviews last about an hour, sometimes more. “We talk about the positive and negative things that have happened and what their expectations are for the future,” Davis said. The details are confidential, of course, but it is clear that the pandemic has upended people’s lives and livelihoods across the United States. The toll on those who were already experiencing mental health issues and addiction has been heavy, but Davis and Pedersen are hopeful that their insights and findings will lead to better treatment and outreach in the future. Reducing barriers to care One bright spot over the past nine months has been the quick embrace of telehealth. The VA was already leading the way to telehealth as a way to improve access to its services, and following the stay-at-home orders of the pandemic, telehealth has grown in acceptance and use. Now, online counseling sessions, Alcoholics Anonymous meetings, and medical visits are commonplace. Pedersen and Davis don’t see that changing even when face-to-face gatherings become the norm once again. It has been a promising start to the research, and Pedersen and Davis are even more excited about what the future may hold. They plan on submitting for more grants to continue to track the mental health and substance use of this group of hundreds of veterans with the goal of understanding what factors lead individuals to seek care. Down the road, they hope to use this longitudinal data to help identify profiles of people more or less likely to seek care. “Then we can tailor interventions to increase their willingness to seek care for a problem like a substance use disorder or PTSD,” Davis said. Recognizing patterns in substance use and when to seek care is very important in helping that part of the veteran population that is trying to deal with symptoms of depression, anxiety, PTSD, or substance abuse on their own. “We know that things are bad now and we can expect that there will be lingering effects for years to come,” said Pedersen. “What we hope is that these findings and our future work will help the VA and others create more effective programs and outreach to address the unique needs of veterans.” 1 Veterans Health Administration Office of Patient Care Services, Analysis of VA Health Care Utilization Among Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn Veterans. Washington, DC: U.S. Department of Veterans Affairs, 2017. www.publichealth.va.gov/epidemiology/reports/oefoifond/health-care-utilization/. 2 Tanielian, Terri and Lisa H. Jaycox, eds., Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Santa Monica, CA: RAND Corporation, 2008. www.rand.org/pubs/monographs/MG720.html.

As President Biden Lays Out Infrastructure Plan, Experts Available to Discuss Proposals

As President Joe Biden lays out his plan for improving the nation's infrastructure, experts from Rensselaer Polytechnic Institute are available to discuss the ways in which proposed projects could affect shipping and delivery of goods, congestion in cities, and emissions in the environment, among other topics. José Holguín-Veras, the director of the Center for Infrastructure, Transportation, and the Environment at Rensselaer, and Cara Wang, an associate professor of civil and environmental engineering at Rensselaer, are leading experts in the role of infrastructure on freight and transportation systems, and the environmental impacts of both. Their research focuses on improving transportation and freight systems in order to increase efficiency, reduce traffic congestion and, in turn, reduce vehicle emissions. Holguín-Veras and Wang can also discuss what their research has uncovered that could guide policy makers as new projects are planned.

MEDIA RELEASE: After a one-year hiatus, the annual CAA Worst Roads campaign returns

With a renewed focus on education and safety, CAA South Central Ontario (CAA SCO) is proud to announce that following a one-year hiatus due to COVID-19, the annual CAA Worst Roads Campaign is back, and voting is now open. “The campaign is a platform for all road users to highlight which roadway improvements should be prioritized by our different levels of government,” says Raymond Chan, government relations manager CAA SCO. “The campaign gives decision-makers a snapshot of what roads the public perceives are not meeting their expectations.” Over the course of the last year people have changed their transportation habits. More people are cycling or driving their vehicles instead of carpooling and using public transit. CAA believes funding for roadway improvements needs to be consistent to ensure that quality and safety is maintained. “Our roads are essential, they are the arteries used every day to keep workers, goods and services flowing and should be maintained more than ever,” adds Chan. “As people are encouraged to stay home and telework during the pandemic, governments should continue to take advantage of lighter traffic patterns as an opportunity for road repair. These efforts can also be refocused on increasingly popular modes of transportation, such as cycling and walking.” Investing in infrastructure improvements, including the proper maintenance of roads and bridges, is important to the vitality and economic recovery of local communities. CAA continues to advocate for longer-term dedicated infrastructure funding to help municipalities prepare, plan, budget and execute on repair backlogs and capital projects. The success stories over the last 17 years are a result of governments prioritizing infrastructure through multi-year capital investments. Some examples include: 1. Riverdale Drive, Washago Despite appearing on the CAA Worst Roads list for the first time in 2019, the poor road conditions of Riverdale Drive was not new to residents of Severn. After 20 years since the street’s last resurfacing, Council approved $50,000 of prep work for Riverdale Drive led by Ward 5 Councillor Sarah Valiquette. 2. Dufferin Street, Toronto Appearing on the provincial top 10 list annually since 2015, Dufferin Street between Bloor Street and Dundas Street underwent resurfacing from September to November 2018. An estimated 35,000 vehicles travel Dufferin Street daily and the number of commuters is increasing. In response to community concerns, Toronto City Council adopted a motion to expedite studies relating to pedestrian and cyclist safety along Dufferin Street, among other improvements in December 2020. 3. College Road, Windsor The intersection of Campbell and College Avenue underwent sewer, road and water main rehabilitation in May 2019. College Avenue between South Street and Brock Street was repaired in November 2019. CAA is calling on all Ontarians to vote for their Worst Roads today and join the community of drivers, cyclists, transit riders and pedestrians committed to improving Ontario’s roads. Nominations for CAA’s Worst Roads can be cast at caaworstroads.com until April 18. To encourage participants to act on their concerns, they will be entered into a grand prize draw to win free gas for a year, or one of 5 secondary prizes. Once voting closes, CAA will compile a list of the 10 Worst Roads in Ontario, along with the Worst Roads in regions across the province. The regional top five lists will help shine further light on the state of local roads in municipalities across Ontario. CAA will present the list of 2021 Worst Roads to local and provincial officials to help inform future funding and planning decisions. Here is a roundup of Ontario's Top 10 Worst Roads in 2019: 1. Eglinton Avenue East, Toronto 2. Riverdale Drive, Washago 3. Dufferin Street, Toronto 4. County Road 49, Prince Edward 5. Barton Street East, Hamilton 6. Burlington Street East, Hamilton 7. Avondale Road, Belleville 8. Sheppard Avenue East, Toronto 9. Carnegie Beach Road, Scugog 10. Bathurst Street, Toronto

Fewer cars, but more fatalities - What's happening on America's pandemic roadways

Fewer vehicles are traveling on America's roadways during the ongoing coronavirus pandemic, but the number of fatal car crashes in 2020 increased exponentially compared to the same time period in 2019. UConn expert Eric Jackson, a research professor and director of the Connecticut Transportation Safety Research Center, and behavioral research assistant Marisa Auguste examined the increase in a recent essay published by The Conversation:  Curious about traffic crashes during the pandemic, we decided to use our skills as a social scientist and a research engineer who study vehicle crash data to see what we could learn about Connecticut’s traffic deaths when the stay-at-home orders first went into place last March. A partnership between the Department of Transportation, local hospitals and the University of Connecticut discovered what many people intuitively knew: Traffic volume and multivehicle crashes fell significantly during the stay-at-home order. Statewide, daily vehicle traffic fell by 43% during the stay-at-home order compared to earlier in the year, while mean daily counts of multivehicle crashes decreased from 209 before the stay-at-home order to 80 during lockdown. What was unexpected, however, was the significant increase in single-vehicle crashes, especially fatal ones. During the stay-at-home period, the incidence rate of fatal single-vehicle crashes increased 4.1 times, while the rate of total single-vehicle crashes was also up significantly. Data about all crash types in the state, whether single- or multivehicle, tell a similar story. Although preliminary, police reports have placed the 2020 year-end total for traffic deaths at 308, a 24% increase from 2019. While the researchers said that it's unclear why this counterintuitive increase in fatalities on the roads has occurred, their advice to drivers? "Check your speed" and "don't drive angry." If you are a journalist looking to know more about this topic, let us help. Simply click on Eric Jackson’s icon to arrange an interview today.

Eliminating The Barriers To Telehealth & Patient Retention

During the ongoing national pandemic, healthcare is in a period of rapid evolution, bringing telehealth to the forefront of patient care. Telehealth is a proven strategy to improve health outcomes, but it’s gated behind socioeconomic privilege and leaves behind many of our community’s most vulnerable patients. One such disparity is the inability of many Americans to access digital health care. This silent epidemic affects lives daily. Many patients, especially those in rural communities, face obstacles when trying to get the care they need. From access to reliable transportation and affordable child care to financial instability and lack of culturally competent providers, there is no shortage of hurdles standing in the way of disadvantaged populations accessing quality care. Well-implemented telehealth services can offer a clear path through these common barriers to care while improving health outcomes and boosting patient retention. “We know that mobile health intervention is an effective tool for retaining patients in care, but it’s only as effective as it is accessible,” said Richard Walsh, our CEO. “It would be negligent to assume that every individual has access to the devices, internet, or knowledge necessary to engage in telemedicine.” Like other leaders in the industry, we know telehealth is a privilege, but at Continuud, we believe it should be a right.” As Nathan Walsh, our CXO, said, “During a public health crisis such as this, we have to be proactive in ensuring that underserved communities have access to the care that they need in every way possible.” Through our research and conversations with community health leaders, we have identified 4 common barriers to telehealth success: access to video-ready phones or tablets, access to a reliable & affordable internet connection, an understanding of how to use the device to access services, and trust in technology being used for health services. Our solution is to create a platform that not only solves these problems but also enhances the patient experience and drives the best possible outcome of telehealth intervention. Our platform, Access, provides 8-inch tablets with an unlimited data connection to patients. Each device ships with a secured environment and limited functionality customized by the health care provider to include the tools that patients need to access care. We have created a simple deployment and warehousing solution to make it easy for organizations to get started quickly. Our end-to-end deployment and recall services handle every aspect of the platform so organizations can remain focused on serving their patients. The platform supports patient-by-patient interface customizations, so each patient’s experience is tailored to their unique treatment plan. We have device insurance and same-day replacement built into the program to account for loss, theft, and damaged devices, so organizations will always have access to the inventory they need to serve their clients. At Continuud, we offer an integrated ecosystem designed from the ground up to enable health care providers to work more efficiently toward a common goal of driving positive health outcomes in their communities. Continuud is known throughout Indiana for our innovative approach to connecting high-risk populations to care and implementing strategic technology to help retain and learn from patients so providers can evolve with the needs of their patients. To learn more about our platform, click here to visit our homepage. If you would like to schedule a demo with our team to talk about the platform in greater detail, click here.

Consumer Behavior Has Shifted Significantly During Pandemic, Survey Reveals

The COVID-19 pandemic has brought about significant shifts in people’s behaviors, from a sharp increase in telework and online commerce, to a significant decrease in the number of personal trips people make. Understanding the effects of these rapid changes on the economy, supply chains, and the environment is essential, as some of these behaviors will continue even after the pandemic has ended. José Holguín-Veras, the director of the Center for Infrastructure, Transportation, and the Environment at Rensselaer Polytechnic Institute, is part of a research team conducting a series of surveys in an effort to quantify and understand these unprecedented shifts. For instance, according to the team’s surveys, the number of monthly work trips people made during the start of the pandemic decreased by 60%. Post-pandemic, respondents believe they will still be making fewer work trips than before, down by 8.2%. Monthly grocery store trips decreased by 41.6% when the pandemic happened, with some people shopping less frequently and others shifting to grocery purchases online. Post-pandemic, survey respondents expect to return to the grocery store more often, but still less than before the pandemic began, by about 8.2%. In contrast, monthly delivery of groceries increased by 132.2% during the pandemic, a trend that may not disappear once the pandemic is over. Respondents expect that post-pandemic, their monthly grocery deliveries will still be 63.8% higher than before COVID-19. While all package deliveries increased during this pandemic period, the grocery delivery increase was the largest. The researchers hope their findings help policymakers develop future policies to offset not just the effects of COVID-19, but also the lasting changes that may result even after the pandemic has ended. Holguín-Veras is available to talk about the research team’s findings, and the importance of understanding these significant shifts.

Cheap Energy Can Be a Bridging Fuel Needed to Get to the Endpoint of Renewable Energy Sooner

Far from banning fracking, the Biden/Harris ticket appears to be allowing it if not tacitly supporting it. This is not a contradictory stance to their aggressive renewable energy policy, according to Scott Jackson, a visiting professor of chemical and biological engineering at Villanova University's College of Engineering, who previously directed the microbial enhanced oil recovery program at DuPont Corporation. "Rather, it is recognition that cheap energy—especially natural gas produced as a result of fracking—can be a bridging fuel needed to get to the end point of renewable energy sooner," Jackson says. No one can dispute that the share of our energy coming from less efficient/more polluting coal has dropped dramatically despite the current administration’s attempts at supporting the coal industry. The reason is obvious—cleaner burning energy (less CO2 emissions) from gas fired turbine generators make more economic sense. Gas fired turbine generators are economical at a smaller scale and provides an energy source that can be rapidly turned on or off at any time. This helps to counterbalance the intermittency of renewable energy and, in some sense; this has allowed greater adoption of renewable energy. The cheapest energy source on the planet is land based wind power. The market has responded to this and now renewables make up 19 percent of our electricity. This percentage was thought to be impossible just a few years ago. Wind power energy payback time (time needed to recoup the energy invested) is measured in months and not years, and investors understand this. A much greater share of renewables (wind and solar) is very doable and makes economic sense. Jackson notes that development of cheap energy storage technology will help and must be implemented once economies of scale are achieved, however, a national power grid capable of moving energy from the wind- and sun-rich Midwest to the West Coast and East Coast will improve the reliability of renewables to the point where as much as 70% of our electricity can be sourced renewably—without new storage capacity (2018 study by the National Renewable Energy Laboratory). Improvements in battery technologies and economy of scale are starting to drive down the costs of electric transportation and storage. Eventually, natural gas sourced power generation will not be competitive to renewables," notes Jackson. "Despite the current low price of gasoline, in part as a result of fracking used in oil fields, electric cars are far more economical to operate. Companies like BP, Exxon-Mobile and Shell recognize that they are energy companies and are pivoting to more renewable sources of energy. "Ultimately, our government has a responsibility to invest in the technologies of the future that make economic sense—as renewables do—and not support the more costly and outdated fossil fuel industry," says Jackson.

Racial and LGBT bias persists in ridesharing drivers despite mitigation efforts

Despite efforts by ridesharing companies to eliminate or reduce discrimination, research from the Indiana University Kelley School of Business finds that racial and LGBT bias persists among drivers. Platforms such as Uber, Lyft and Via responded to drivers' biased behavior by removing information that could indicate a rider's gender and race from initial ride requests. However, researchers still found that biases against underrepresented groups and those who indicate support for the LGBT community continued to exist after drivers accepted a ride request -- when the rider's picture would then be displayed. In other words, their efforts shifted some of the biased behavior until after the ride was confirmed, resulting in higher cancellation rates. Understanding whether bias has been removed also is important for ridesharing companies as they not only compete against each other but also with traditional transportation options. "Our results confirm that bias at the ride request stage has been removed. However, after ride acceptance, racial and LGBT biases are persistent, while we found no evidence of gender biases," said Jorge Mejia, assistant professor of operations and decision technologies. "We show that signaling support for a social cause -- in our case, the lesbian, gay, bisexual and transgender community -- can also impact service provision. Riders who show support for the LGBT community, regardless of race or gender, also experience significantly higher cancelation rates." Mejia and co-author Chris Parker, assistant professor in the information technology and analytics department at American University in Washington, believe they are the first to use support for social causes as a bias-enabling characteristic. Their article, "When Transparency Fails: Bias and Financial Incentives in Ridesharing Platforms," is published in Management Science. They performed a field experiment on a ridesharing platform in fall 2018 in Washington, D.C. They randomly manipulated rider names, using those traditionally perceived to be white or Black, as well as profile pictures to observe drivers' behavior patterns in accepting and canceling rides. To illustrate support for LGBT rights, the authors overlaid a rainbow filter on the rider's picture profile. "We found that underrepresented minorities are more than twice as likely to have a ride canceled than Caucasians; that's about 3 percent versus 8 percent," Mejia said. "There was no evidence of gender bias." Mejia and Parker also varied times of ride requests to study whether peak price periods affected bias. They found that higher prices associated with peak times alleviated some of the bias against riders from the underrepresented group, but not against those who signal support for the LGBT community. They believe that ridesharing companies should use other data-driven solutions to take note of rider characteristics when a driver cancels and penalize the driver for biased behavior. One possible way to punish drivers is to move them down the priority list when they exhibit biased cancellation behavior, so they have fewer ride requests. Alternatively, less-punitive measures may provide "badges" for drivers who exhibit especially low cancellation rates for minority riders. But, ultimately, policymakers may need to intervene, Mejia said. "Investments in reducing bias may not occur organically, as ridesharing platforms are trying to maximize the number of participants in the platform -- they want to attract both riders and drivers," he said. "As a result, it may be necessary for policymakers to mandate what information can be provided to a driver to ensure an unbiased experience, while maintaining the safety of everyone involved, or to create policies that require ridesharing platforms to monitor and remove drivers based on biased behavior. "Careful attention should be paid to these policies both before and after implementation, as unintended consequences are almost sure to follow any simple fix."

STORY: By the Numbers - CAA looks back on key initiatives from the pandemic

It’s been almost five months since COVID-19 started to dominate headlines in Canada and many people and businesses had to adapt to quickly changing circumstances.   As one of Canada’s largest membership organizations, with multiple areas of business, CAA had to navigate the changes in various industries in order to keep CAA members safe.   The initial response As a travel company, our agents helped to rebook hundreds of passenger travel itineraries as flights were cancelled and borders closed. CAA’s travel insurance company, Orion Travel Insurance, worked with thousands of insureds to extend their trip cancellation and interruption insurance policies while offering additional protection for travel suppliers’ vouchers and credits.   As the community spread of COVID-19 started to take hold, CAA had to make the difficult decision to implement contact-free service and ask members to seek alternative transportation from their breakdown location, all in the interest of keeping members and drivers safe.   To help do our part to curb the spread of the virus, a decision was made in early March to close all of CAA’s retail stores across south-central Ontario. While the state of emergency had not yet been implemented by the province, we felt it was the right thing to do. All CAA associates across the company quickly adapted to work from home.   Shortly after, a state of emergency went into effect in Ontario and CAA was established as an essential service both for roadside and insurance operations.   A Responsibility to do something good Once the safety of CAA operations was taken care of, we quickly started looking at how else we can make a difference during this difficult time.   First, we committed to supporting healthcare workers and first responders by offering free roadside assistance during this crisis.  We then leveraged our network of trucks to deliver vital food and supplies to those in need. CAA worked with several large organizations in need, such as food banks, Meals on Wheels, Mobilizing Masks for Healthcare Workers and other community service groups, to assist with delivering vital supplies where they were needed urgently.   CAA also felt that it was important to stay connected and check in on the vulnerable members of our community who are struggling most. We created Operation Outreach to proactively reach out to a group of CAA members who were over the age of 75. The initiative was overwhelmingly positive with members appreciating the call and opportunity to interact with someone. One member even offered to join our outbound-calling team and to help check in with others. As the pandemic continued, we noticed that another important way we could give back and help people in need was through our insurance coverage.   We saw that Canadians everywhere were feeling the profound social, emotional and financial effects of COVID-19, and so CAA Insurance looked at every possible way to help people save money. We are the only insurance company offering a 10% rate reduction on both home and auto policies, as well as a $100 Auto Insurance Relief Benefit. Unlike other insurers, we made sure that the rate reduction would be valid for the duration of the 12-month policy term.  By the numbers Everything that was accomplished throughout the pandemic was possible thanks to the hard work of dedicated Associates and the enduring support of our Members. While many Members may join CAA for roadside or to sign up for insurance, they are also contributing to the community.   The COVID-19 pandemic presented an opportunity for us to support our Members and the communities in which they live. We are pleased to share the impact that was made throughout this time.

Individuals With Intellectual and Developmental Disabilities More Likely to Contract COVID-19

Recent news coverage has indicated that individuals with intellectual and developmental disabilities (ID/DD) are more likely than those without ID/DD to contract COVID-19 and to die as a result of it. "Similar to other individuals with disability, those with ID/DD often have pre-existing health conditions that increase their risk," says Suzanne C. Smeltzer, EdD, RN, the Richard and Marianne Kreider Endowed Professor in Nursing for Vulnerable Populations at Villanova University's M. Louise Fitzpatrick College of Nursing. Some people with ID/DD live in group settings in which they come in contact with others who may be infected with COVID-19. The frequent turnover of personal assistants and contact of persons with ID/DD with multiple personal assistants may increase the risk of COVID-19 in part because of their exposure to multiple potential carriers and the need for many of their personal assistants to use public transportation. Dr. Smeltzer says, "There is also concern in the disability community, among family members of individuals with disability and among disability advocates that those with these disabilities will be viewed as less deserving of more aggressive therapies, such as ventilators. The quality of life of persons with ID/DD may be considered by others as low, even though quality of life can only be judged by the people themselves." Initial limitations put in place in many health care institutions included the exclusion of family members and other support persons because of risk for COVID-19 infection. However, a groundswell of advocacy resulted in changes in this policy because individuals with ID/DD hospitalized during the COVID-19 pandemic were being deprived of essential support. "These support persons are needed to help those with ID/DD understand what was happening in the hectic health care settings and to help with communication and decision making," says Dr. Smeltzer. "Individuals with ID/DD need the same care as others and must receive explanations about their care and must be allowed to participate in making decisions about their care."