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Persistence of a Birth Cohort Effect in the US Among the Adult Homeless Population
Byrne, Thomas; Doran, Kelly M; Kuhn, Randall; Metraux, Stephen; Schretzman, Maryanne; Treglia, Dan; Culhane, Dennis P
PMID: 39724378
ISSN: 2574-3805
CID: 5767712
Implementation of a peer-delivered opioid overdose response initiative in New York City emergency departments: Insight from multi-stakeholder qualitative interviews
Goldberg, Leah A; Chang, Tingyee E; Freeman, Robin; Welch, Alice E; Jeffers, Angela; Kepler, Kelsey L; Chambless, Dominique; Wittman, Ian; Cowan, Ethan; Shelley, Donna; McNeely, Jennifer; Doran, Kelly M
BACKGROUND:Emergency departments (EDs) are critical touchpoints for overdose prevention efforts. In New York City (NYC), the Health Department's Relay initiative dispatches trained peer "Wellness Advocates" (WAs) to engage with patients in EDs after an overdose and for up to 90 days subsequently. Interest in peer-delivered interventions for patients at risk for overdose has grown nationally, but few studies have explored challenges and opportunities related to implementing such interventions in EDs. METHODS:We conducted in-depth interviews with Relay WAs, ED patients, and ED providers across 4 diverse NYC EDs. Sampling was purposeful and continued until theoretical saturation was reached. Interviews followed a semi-structured interview guide based on key domains from the Consolidated Framework for Implementation Research (CFIR). Interviews were conducted by telephone or web conferencing; audio recordings were professionally transcribed. The study utilized rapid qualitative analysis using template summaries and summary matrices followed by line-by-line coding conducted independently by 3 researchers, then discussed and harmonized at group coding meetings. Coding was both inductive (using an a priori code list based on CFIR domains and study goals) and deductive (new codes allowed to emerge from transcripts). Dedoose software was used for data organization. RESULTS:We conducted 32 in-depth interviews (10 WAs, 12 patients, 10 ED providers). Four overarching themes emerged: 1) EDs are characterized by multiple competing demands (e.g., related to provider time and physical space), underscoring the utility of Relay and leading to some practical challenges for its delivery; 2) There is a strong role distinction of WAs as peers with lived experience; 3) ED providers value Relay, even though they have a limited understanding of its full scope and outcomes; 4) While the role of structural factors (e.g., homelessness and unstable housing) is recognized, responsibility is often placed on patients for controlling their own success. CONCLUSIONS:We identified four themes that shed new light on the implementation of peer-based overdose prevention programs in EDs. Our findings highlight unique ED inner and outer setting factors that may impact program implementation and effectiveness. The findings provide actionable information to inform implementation of similar programs nationally.
PMID: 39442627
ISSN: 2949-8759
CID: 5738922
A community-academic partnership to develop an implementation support package for overdose prevention in permanent supportive housing
Gazzola, Marina Gaeta; Torsiglieri, Allison; Velez, Lauren; Blaufarb, Stephanie; Hernandez, Patricia; O'Grady, Megan A; Blackburn, Jamie; Florick, Jacqueline; Cleland, Charles M; Shelley, Donna; Doran, Kelly M
INTRODUCTION/BACKGROUND:The overdose crisis in the U.S. disproportionately impacts people experiencing homelessness. Permanent supportive housing (PSH) - permanent, affordable housing with voluntary support services - is an effective, evidence-based intervention to address homelessness. However, overdose risk remains high even after entering PSH for individual and structural reasons. In this study, we aimed to refine a set of evidence-based overdose prevention practices (EBPs) and an associated implementation support package for PSH settings using focus groups with PSH tenants, frontline staff, and leaders. METHODS:Our community-academic team identified an initial set of overdose EBPs applicable for PSH through research, public health guidance, and a needs assessment. We adapted these practices based on feedback from focus groups with PSH leaders, staff, and tenants. Focus groups followed semi-structured interview guides developed using the EPIS (Exploration, Preparation, Implementation, Sustainment) framework constructs of inner context, outer context, and bridging factors related to overdose prevention and response. RESULTS:We conducted 16 focus groups with 40 unique participants (14 PSH tenants, 15 PSH staff, 11 PSH leaders); focus groups were held in two iterative rounds and individuals could participate in one or both rounds. Participants were diverse in gender, race, and ethnicity. Focus group participants were enthusiastic about the proposed EBPs and implementation strategies, while contributing unique insights and concrete suggestions to improve upon them. The implementation support package contains an iteratively refined PSH Overdose Prevention (POP) Toolkit with 20 EBPs surrounding overdose prevention and response, harm reduction, and support for substance use treatment and additional core implementation strategies including practice facilitation, tenant-staff champion teams, and learning collaboratives. CONCLUSIONS:This manuscript describes how robust community-academic partnerships and input from people with lived experience as tenants and staff in PSH informed adaptation of evidence-based overdose prevention approaches and implementation strategies to improve their fit for PSH settings. This effort can inform similar efforts nationally in other settings serving highly marginalized populations. We are currently conducting a randomized trial of the refined overdose prevention implementation support package in PSH.
PMID: 39389548
ISSN: 2949-8759
CID: 5706252
Food insecurity in high-risk rural communities before and during the COVID-19 pandemic
Quintero Arias, Carolina; Rony, Melissa; Jensen, Erica; Patel, Rahi; O'Callaghan, Stasha; Koziatek, Christian A; Doran, Kelly M; Anthopolos, Rebecca; Thorpe, Lorna E; Elbel, Brian; Lee, David C
OBJECTIVE/UNASSIGNED:To perform a geospatial analysis of food insecurity in a rural county known to have poor health outcomes and assess the effect of the COVID-19 pandemic. METHODS/UNASSIGNED:In 2020, we mailed a comprehensive cross-sectional survey to all households in Sullivan County, a rural county with the second-worst health outcomes among all counties in New York State. Surveys of households included validated food insecurity screening questions. Questions were asked in reference to 2019, prior to the pandemic, and for 2020, in the first year of the pandemic. Respondents also responded to demographic questions. Raking adjustments were performed using age, sex, race/ethnicity, and health insurance strata to mitigate non-response bias. To identify significant hotspots of food insecurity within the county, we also performed geospatial analysis. FINDINGS/UNASSIGNED:From the 28,284 households surveyed, 20% of households responded. Of 4725 survey respondents, 26% of households reported experiencing food insecurity in 2019, and in 2020, this proportion increased to 35%. In 2020, 58% of Black and Hispanic households reported experiencing food insecurity. Food insecurity in 2020 was also present in 58% of unmarried households with children and in 64% of households insured by Medicaid. The geospatial analyses revealed that hotspots of food insecurity were primarily located in or near more urban areas of the rural county. CONCLUSIONS/UNASSIGNED:Our countywide health survey in a high-risk rural county identified significant increases of food insecurity in the first year of the COVID-19 pandemic, despite national statistics reporting a stable rate. Responses to future crises should include targeted interventions to bolster food security among vulnerable rural populations.
PMCID:11130676
PMID: 38807877
ISSN: 2405-8440
CID: 5663492
Homelessness And Health: Factors, Evidence, Innovations That Work, And Policy Recommendations
Garcia, Cheyenne; Doran, Kelly; Kushel, Margot
On a single night in 2023, more than 653,000 people experienced homelessness in the United States. In this overview, we highlight structural and individual risk factors that can lead to homelessness, explore evidence on the relationship between homelessness and health, discuss programmatic and policy innovations, and provide policy recommendations. Health system efforts to address homelessness and improve the health of homeless populations have included interventions such as screening for social needs and medical respite programs. Initiatives using the Housing First approach to permanent supportive housing have a strong track record of success. Health care financing innovations using Medicaid Section 1115 waivers offer promising new approaches to improving health and housing for people experiencing homelessness. To substantially reduce homelessness and its many adverse health impacts, changes are needed to increase the supply of affordable housing for households with very low incomes. Health care providers and systems should leverage their political power to advocate for policies that scale durable, evidence-based solutions to reduce homelessness, including increased funding to expand housing choice vouchers and greater investment in the creation and preservation of affordable housing.
PMID: 38315930
ISSN: 2694-233x
CID: 5738382
Associations Between Different Types of Housing Insecurity and Future Emergency Department Use Among a Cohort of Emergency Department Patients
Routhier, Giselle; Mijanovich, Tod; Schretzman, Maryanne; Sell, Jessica; Gelberg, Lillian; Doran, Kelly M.
Housing insecurity can take multiple forms, such as unaffordability, crowding, forced moves, multiple moves, and homelessness. Existing research has linked homelessness to increased emergency department (ED) use, but gaps remain in understanding the relationship between different types of housing insecurity and ED use. In this study, we examined the association between different types of housing insecurity, including detailed measures of homelessness, and future ED use among a cohort of patients initially seen in an urban safety-net hospital ED in the United States between November 2016 and January 2018. We found that homelessness was associated with a higher mean number of ED visits in the year post-baseline. Other measures of housing insecurity (unaffordability, crowding, forced moves, and multiple moves) were not associated with greater ED use in the year post-baseline in multivariable models. We also found that only specific types of homelessness, primarily unsheltered homelessness, were associated with increased ED use.
SCOPUS:85167883140
ISSN: 1049-2089
CID: 5561152
Associations Between Different Types of Housing Insecurity and Future Emergency Department Use Among a Cohort of Emergency Department Patients
Routhier, Giselle; Mijanovich, Tod; Schretzman, Maryanne; Sell, Jessica; Gelberg, Lillian; Doran, Kelly M
Housing insecurity can take multiple forms, such as unaffordability, crowding, forced moves, multiple moves, and homelessness. Existing research has linked homelessness to increased emergency department (ED) use, but gaps remain in understanding the relationship between different types of housing insecurity and ED use. In this study, we examined the association between different types of housing insecurity, including detailed measures of homelessness, and future ED use among a cohort of patients initially seen in an urban safety-net hospital ED in the United States between November 2016 and January 2018. We found that homelessness was associated with a higher mean number of ED visits in the year post-baseline. Other measures of housing insecurity (unaffordability, crowding, forced moves, and multiple moves) were not associated with greater ED use in the year post-baseline in multivariable models. We also found that only specific types of homelessness, primarily unsheltered homelessness, were associated with increased ED use.
ORIGINAL:0017007
ISSN: 1548-6869
CID: 5553842
The POP (Permanent Supportive Housing Overdose Prevention) Study: protocol for a hybrid type 3 stepped-wedge cluster randomized controlled trial
Doran, Kelly M; Torsiglieri, Allison; Blaufarb, Stephanie; Hernandez, Patricia; Melnick, Emily; Velez, Lauren; Cleland, Charles M; Neighbors, Charles; O'Grady, Megan A; Shelley, Donna
BACKGROUND:Permanent supportive housing (PSH)-subsidized housing paired with support services such as case management-is a key part of national strategic plans to end homelessness. PSH tenants face high overdose risk due to a confluence of individual and environmental risk factors, yet little research has examined overdose prevention in PSH. METHODS:We describe the protocol for a hybrid type 3 stepped-wedge cluster randomized controlled trial (RCT) of overdose prevention practice implementation in PSH. We adapted evidence-based overdose prevention practices and implementation strategies for PSH using input from stakeholder focus groups. The trial will include 20 PSH buildings (with building size ranging from 20 to over 150 tenants) across New York City and New York's Capital Region. Buildings will be randomized to one of four 6-month intervention waves during which they will receive a package of implementation support including training in using a PSH Overdose Prevention (POP) Toolkit, time-limited practice facilitation, and learning collaboratives delivered to staff and tenant implementation champions appointed by each building. The primary outcome is building-level fidelity to a defined list of overdose prevention practices. Secondary and exploratory implementation and effectiveness outcomes will be examined using PSH staff and tenant survey questionnaires, and analysis of tenant Medicaid data. We will explore factors related to implementation success, including barriers and facilitators, using qualitative interviews with key stakeholders. The project is being conducted through an academic-community partnership, and an Advisory Board including PSH tenants and other key stakeholders will be engaged in all stages of the project. DISCUSSION:We describe the protocol for a hybrid type 3 stepped-wedge cluster RCT of overdose prevention practice implementation in PSH. This study will be the first controlled trial of overdose prevention implementation in PSH settings. The research will make a significant impact by testing and informing future implementation strategies to prevent overdose for a population at particularly high risk for overdose mortality. Findings from this PSH-focused research are expected to be broadly applicable to other housing settings and settings serving people experiencing homelessness. TRIAL REGISTRATION:ClinicalTrials.gov, NCT05786222 , registered 27 March 2023.
PMCID:10246871
PMID: 37287026
ISSN: 1748-5908
CID: 5541642
Proceedings from the 2021 SAEM Consensus Conference: Research Priorities for Interventions to Address Social Risks and Needs Identified in Emergency Department Patients
Kraynov, Liliya; Quarles, Aaron; Kerrigan, Andrew; Mayes, Katherine Dickerson; Mahmoud-Werthmann, Sally; Fockele, Callan E; Duber, Herbert C; Doran, Kelly M; Lin, Michelle P; Cooper, Richelle J; Wang, Nancy Ewen
INTRODUCTION/BACKGROUND:Emergency departments (ED) function as a health and social safety net, regularly taking care of patients with high social risk and need. Few studies have examined ED-based interventions for social risk and need. METHODS:Focusing on ED-based interventions, we identified initial research gaps and priorities in the ED using a literature review, topic expert feedback, and consensus-building. Research gaps and priorities were further refined based on moderated, scripted discussions and survey feedback during the 2021 SAEM Consensus Conference. Using these methods, we derived six priorities based on three identified gaps in ED-based social risks and needs interventions: 1) assessment of ED-based interventions; 2) intervention implementation in the ED environment; and 3) intercommunication between patients, EDs, and medical and social systems. RESULTS:Using these methods, we derived six priorities based on three identified gaps in ED-based social risks and needs interventions: 1) assessment of ED-based interventions, 2) intervention implementation in the ED environment, and 3) intercommunication between patients, EDs, and medical and social systems. Assessing intervention effectiveness through patient-centered outcome and risk reduction measures should be high priorities in the future. Also noted was the need to study methods of integrating interventions into the ED environment and to increase collaboration between EDs and their larger health systems, community partners, social services, and local government. CONCLUSION/CONCLUSIONS:The identified research gaps and priorities offer guidance for future work to establish effective interventions and build relationships with community health and social systems to address social risks and needs, thereby improving the health of our patients.
PMCID:10047718
PMID: 36976612
ISSN: 1936-9018
CID: 5454092
2021 SAEM Consensus Conference Proceedings: Research Priorities for Implementing Emergency Department Screening for Social Risks and Needs
Yore, Mackensie; Fockele, Callan Elswick; Duber, Herbert C; Doran, Kelly M; Cooper, Richelle J; Lin, Michelle P; Campbell, Steffani; Eswaran, Vidya; Chang, Betty; Hong, Haeyeon; Gbenedio, Kessiena; Stanford, Kimberly A; Gavin, Nicholas
INTRODUCTION/BACKGROUND:Despite literature on a variety of social risks and needs screening interventions in emergency department (ED) settings, there is no universally accepted or evidence-based process for conducting such interventions. Many factors hamper or promote implementation of social risks and needs screening in the ED, but the relative impact of these factors and how best to mitigate/leverage them is unknown. METHODS:Drawing on an extensive literature review, expert assessment, and feedback from participants in the 2021 Society for Academic Emergency Medicine Consensus Conference through moderated discussions and follow-up surveys, we identified research gaps and rated research priorities for implementing screening for social risks and needs in the ED. We identified three main knowledge gaps: 1) screening implementation mechanics; 2) outreach and engagement with communities; and 3) addressing barriers and leveraging facilitators to screening. Within these gaps, we identified 12 high-priority research questions as well as research methods for future studies. RESULTS:Consensus Conference participants broadly agreed that social risks and needs screening is generally acceptable to patients and clinicians and feasible in an ED setting. Our literature review and conference discussion identified several research gaps in the specific mechanics of screening implementation, including screening and referral team composition, workflow, and use of technology. Discussions also highlighted a need for more collaboration with stakeholders in screening design and implementation. Additionally, discussions identified the need for studies using adaptive designs or hybrid effectiveness-implementation models to test multiple strategies for implementation and sustainability. CONCLUSION/CONCLUSIONS:Through a robust consensus process we developed an actionable research agenda for implementing social risks and needs screening in EDs. Future work in this area should use implementation science frameworks and research best practices to further develop and refine ED screening for social risks and needs and to address barriers as well as leverage facilitators to such screening.
PMCID:10047739
PMID: 36976611
ISSN: 1936-9018
CID: 5454082