Improving post-hospital care for people who are homeless: Community-based participatory research to community-based action.

This article discusses how community-based participatory research (CBPR) on hospital care transitions in New Haven, Connecticut led to the development of a new medical respite program to better serve patients who are homeless. Key insights include: • Homelessness is an important driver of hospital utilization and must be addressed in efforts to decrease hospital readmissions. • Hospitals and community organizations often serve a shared patient/client base and can work together to develop innovative programs that are beneficial to all parties. • Community-based participatory research methods are particularly conducive to producing research that is translatable to policy and new programs. • Targeted dissemination of research results played a pivotal role in securing resources and funding for the new program.

Building community capacity: sustaining the effects of multiple, two-year community-based participatory research projects.

BACKGROUND: The time-limited nature of health and public health research fellowships poses a challenge to trainees' and community partners' efforts to sustain effective, collaborative, community-based participatory research (CBPR) relationships. OBJECTIVES: This paper presents CBPR case studies of partnerships between health services research trainees and community organization leaders in a medium-sized city to describe how participation in the partnership altered community partners' understanding and willingness to conduct research and to engage with research-derived data. METHODS: Trainees and faculty used participatory methods with community leaders to identify research questions, and conduct and disseminate research. Throughout the process, trainees and faculty included research capacity building of community partners as a targeted outcome. Community partners were asked to reflect retrospectively on community research capacity building in the context of CBPR projects. Reflections were discussed and categorized by the authorship team, who grouped observations into topics that may serve as a foundation for development of future prospective analyses. RESULTS: Important ideas shared include that trainee participation in CBPR may have an enduring impact on the community by increasing the capacity of community partners and agencies to engage in research beyond that which they are conducting with the current trainee. CONCLUSION: We posit that CBPR with research trainees may have an additive effect on community research capacity when it is conducted in collaboration with community leaders and focuses on a single region. More research is needed to characterize this potential outcome.

Improving the quality of discharge care for the homeless: a patient-centered approach.

Homeless patients are at risk for low-quality discharge care, yet there are limited patient-centered data to guide improvement. We explored relationships between assessment of housing status by hospital staff and quality of discharge care using quantitative and qualitative data from interviews and chart reviews with 98 homeless patients: 80% male, mean homelessness 2.8 years, mean age 44. Patient-reported performance of discharge care varied substantially across seven domains from 16-75% and chart review documented lower performance than patient report. Over half (56%) were not asked about their housing status and multivariable logistic regression showed assessment of housing status was independently associated with higher performance in five domains: discussions about cost of medications, physical activity levels, diet, transportation, and mental health follow-up. Qualitative data revealed patient concerns about stigmatization from disclosure of housing status. Our findings suggest that addressing housing status in acute care settings while avoiding stigmatization may improve discharge care for homeless patients.

Understanding transitions in care from hospital to homeless shelter: a mixed-methods, community-based participatory approach.

BACKGROUND: Coordinated transitions from hospital to shelter for homeless patients may improve outcomes, yet patient-centered data to guide interventions are lacking. OBJECTIVES: To understand patients' experiences of transitions from hospital to a homeless shelter, and determine aspects of these experiences associated with perceived quality of these transitions. DESIGNS: Mixed methods with a community-based participatory research approach, in partnership with personnel and clients from a homeless shelter. PARTICIPANTS: Ninety-eight homeless individuals at a shelter who reported at least one acute care visit to an area hospital in the last year. APPROACH: Using semi-structured interviews, we collected quantitative and qualitative data about transitions in care from the hospital to the shelter. We analyzed qualitative data using the constant comparative method to determine patients' perspectives on the discharge experience, and we analyzed quantitative data using frequency analysis to determine factors associated with poor outcomes from patients' perspective. KEY RESULTS: Using qualitative analysis, we found homeless participants with a recent acute care visit perceived an overall lack of coordination between the hospital and shelter at the time of discharge. They also described how expectations of suboptimal coordination exacerbate delays in seeking care, and made three recommendations for improvement: 1) Hospital providers should consider housing a health concern; 2) Hospital and shelter providers should communicate during discharge planning; 3) Discharge planning should include safe transportation. In quantitative analysis of recent hospital experiences, 44 % of participants reported that housing status was assessed and 42 % reported that transportation was discussed. Twenty-seven percent reported discharge occurred after dark; 11 % reported staying on the streets with no shelter on the first night after discharge. CONCLUSIONS: Homeless patients in our community perceived suboptimal coordination in transitions of care from the hospital to the shelter. These patients recommended improved assessment of housing status, communication between hospital and shelter providers, and arrangement of safe transportation to improve discharge safety and avoid discharge to the streets without shelter.

Expanding the safety net of specialty care for the uninsured: a case study.

OBJECTIVE: To describe core principles and processes in the implementation of a navigated care program to improve specialty care access for the uninsured. STUDY SETTING: Academic researchers, safety-net providers, and specialty physicians, partnered with hospitals and advocates for the underserved to establish Project Access-New Haven (PA-NH). PA-NH expands access to specialty care for the uninsured and coordinates care through patient navigation. STUDY DESIGN: Case study to describe elements of implementation that may be relevant for other communities seeking to improve access for vulnerable populations. PRINCIPAL FINDINGS: Implementation relied on the application of core principles from community-based participatory research (CBPR). Effective partnerships were achieved by involving all stakeholders and by addressing barriers in each phase of development, including (1) assessment of the problem; (2) development of goals; (3) engagement of key stakeholders; (4) establishment of the research agenda; and (5) dissemination of research findings. CONCLUSIONS: Including safety-net providers, specialty physicians, hospitals, and community stakeholders in all steps of development allowed us to respond to potential barriers and implement a navigated care model for the uninsured. This process, whereby we integrated principles from CBPR, may be relevant for future capacity-building efforts to accommodate the specialty care needs of other vulnerable populations.

A physician team's experiences in community-based participatory research: insights into effective group collaborations.

BACKGROUND: Postdoctoral fellows from the Robert Wood Johnson Clinical Scholars Program are among a growing number of physician-researchers training in community-based participatory research (CBPR). These fellows are uniquely positioned to observe and evaluate CBPR training needs and the experience of collaboratively conducting a CBPR project. PURPOSE: To describe, from the perspective of physician-researchers, experiences in intragroup and intergroup collaborations while conducting CBPR. METHODS: During a 2-year fellowship, a group of seven fellows received 6 months of didactic training and then spent 18 months conducting a mentored CBPR project. The CBPR project was complemented by a 2-year facilitated leadership seminar, which allowed for reflection on intragroup (among fellows) and intergroup (fellows/community members) relationships throughout the CBPR process. RESULTS: Seven core principles of CBPR were found to apply to not only intergroup but also intragroup relationships: (1) building trust, (2) finding a shared interest, (3) power-sharing, (4) fostering co-learning and capacity building among partners, (5) building on existing strengths, (6) employing an iterative process, and (7) finding a balance between research and action for the mutual benefit of all partners. CONCLUSIONS: Establishing and maintaining relationships is at the core of CBPR. The development of intragroup relationships paralleled the development of intergroup relationships with community members. Applying the core principles of CBPR to the development of intragroup relationships provided experience that may have enhanced relationships with community partners. An a priori acknowledgement of the importance of relationships and the time needed to develop and manage those relationships may add to the CBPR training experience and assist in successfully executing collaborative projects.

Teaching community-based participatory research principles to physicians enrolled in a health services research fellowship.

To improve health and reduce inequities through health services research, investigators are increasingly actively involving individuals and institutions who would be affected by the research. In one such approach, community-based participatory research (CBPR), community members participate in every aspect of designing and implementing research with the expectation that this process will enhance the translation of research into practice in communities. Because few physician researchers have expertise in such community-based approaches to research, the Robert Wood Johnson Foundation leadership expanded the mission of the Robert Wood Johnson Clinical Scholars Program (RWJCSP), which historically focused on health services and clinical research, to include training and mentored experiences in CBPR.The authors discuss the three years of experience (2005-2008) implementing the new community research curricula at the four RWJCSP sites: University of California, Los Angeles; University of Pennsylvania in Philadelphia; University of Michigan in Ann Arbor; and Yale University in New Haven. Three common goals and objectives are identified across sites: teaching the principles of CBPR, providing opportunities for conducting CBPR, and making an impact on the health of the communities served. Each site's different approaches to teaching CBPR based on the nature of the existing community and academic environments are described. The authors use illustrative quotes to exemplify three key challenges that training programs face when integrating community-partnered approaches into traditional research training: relationship building, balancing goals of education/scholarship/relationships/product, and sustainability. Finally, the authors offer insights and implications for those who may wish to integrate CBPR training into their research training curricula.