Recruiting and Retaining a Diverse and Skilled Addiction Treatment Workforce.

National drug overdose deaths have been rising for decades, with particularly significant increases in recent years among populations of color. There is an urgent need for timely, accessible substance use disorder treatment, but workforce shortages across roles and settings impede the ability of the treatment system to meet the rising and evolving demand. In this Commentary, the authors discuss reasons for workforce shortages across roles, and offer recommendations for 8 areas of investment to grow and sustain a substance use and addiction care workforce prepared to address the overdose crisis in a racially equitable manner.

Perspectives and recommendations of opioid overdose survivors experiencing unsheltered homelessness on housing, overdose, and substance use treatment in Boston, MA.

INTRODUCTION: Opioid overdose causes one in four deaths among people experiencing homelessness in Boston, MA. To reduce overdose risks, the experience and perspectives of people experiencing homelessness should be incorporated into housing, overdose prevention, and substance use treatment efforts. METHODS: In 2021, we conducted qualitative interviews with 59 opioid overdose survivors to inform equitable access to treatment services. In response to policy debate surrounding a public drug scene near a key recruitment site, we conducted a targeted thematic analysis of transcribed interview data from a subset of participants experiencing unsheltered homelessness (n=29) to explore their perspectives and recommendations on housing, overdose prevention, and substance use treatment. RESULTS: Among 29 participants who identified as non-Hispanic Black (n=10), Hispanic/Latinx (n=10), or as non-Hispanic White (n=9), the median number of self-reported opioid overdoses in the past three months was 2.0 (SD 3.7). Three themes emerged from this targeted analysis: (1) Participants described inadequate housing resources and unwelcoming shelter environments. (2) Participants near a large public drug scene explained how unsheltered homelessness was chaotic, dangerous, and disruptive to recovery goals. (3) Participants provided recommendations for improving housing and addiction treatment systems and including their perspectives in the development of solutions to the intersecting housing and opioid overdose crises. CONCLUSIONS: The overdose prevention, housing and substance use treatment systems must address the needs of opioid overdose survivors experiencing unsheltered homelessness. Overdose survivors experiencing unsheltered homelessness described a chaotic public drug scene but resorted to residing in nearby encampments because the existing shelter, housing, and addiction treatment systems were unwelcoming, difficult to navigate, or unaffordable. Despite efforts to provide low-threshold housing in Boston, additional low-barrier housing services (i.e., including harm reduction resources and without "sobriety" requirements) could promote the health and safety of people who use drugs and are experiencing homelessness.

The Harvard Macy Institute Art Museum-based Health Professions Education Fellowship: Transformational faculty development through the arts.

Museum-based education for health professionals can lead to a variety of important learning outcomes within the domain of skills development, personal insight, perspective-taking and social advocacy. The Harvard Macy Institute's Art Museum-based Health Professions Education Fellowship was designed to develop faculty expertise in art museum-based practices, encourage scholarship, and cultivate a cohesive and supportive community of educators. The Fellowship was piloted from January to May 2019 with twelve interprofessional Fellows. Two in-person experiential sessions were held at Boston-area museums with intervening virtual learning. Fellows were introduced to a variety of approaches used in art museum-based education and developed a project for implementation at their home institution. A qualitative formative evaluation assessed immediate and 6-month post-Fellowship outcomes. Outcomes are reported in four categories: (1) Fellows' personal and professional development; (2) Institutional projects and curriculum development; (3) Community of practice and scholarly advancement of the field; and (4) Development of Fellowship model. A follow-up survey was performed four years after the conclusion of the pilot year, documenting Fellows' significant accomplishments in museum-based education, reflections on the Fellowship and thoughts on the future of the field.

Primary Care Behavioral Health Integration for Anxiety Management in a Safety-Net Health Care System.

This report describes the implementation of a primary care behavioral health integration program for anxiety management at Cambridge Health Alliance (CHA), a safety-net health care system. Using a staged implementation process, CHA built upon existing capacities to create a comprehensive infrastructure for managing behavioral health conditions in primary care.

Incorporating patient input into the design of a disease management program for COPD.

In the era of value-based payment contracts, there is increasing emphasis on disease management as a strategy for improving care quality and reducing costs. To design effective disease management programs, healthcare systems should understand the day-to-day experience of living with particular health conditions, and ensure that evidence-based services and interventions are adapted to align with the realities of patients' lives and their priorities. For healthcare systems operating with limited resources, there is a need for practical and small-scale approaches for collecting and using patient input as part of program design and operations. This case study describes a targeted interview process that Cambridge Health Alliance (CHA) used to gather patient input during the design of a disease management program for chronic obstructive pulmonary disease. The patient perspectives gathered through the interviews influenced several aspects of the program design. The key lessons from CHA's experience are: 1) A small-scale approach with cycles of 5-10 interviews can produce valuable insights for program design; 2) Short patient vignettes can be used to summarize patient data in a simple and compelling format; and 3) Clinicians' perspectives are critical for interpreting patient input and extracting information that is most likely to be useful for program design. CHA's approach provides an example of a systematic and practical process for gathering patient input that other healthcare systems can adapt to their local contexts.

Reducing the Use of Ad Hoc Interpreters at a Safety-Net Health Care System.

BACKGROUND: Providing effective communication assistance is critical to ensuring that patients with limited English proficiency (LEP) receive safe and high-quality health care services. Health care providers often use ad hoc interpreters such as patients' family members or friends to communicate with LEP patients; however, this practice presents risks to communication accuracy, patient safety, quality of care, and privacy. METHODS: Cambridge Health Alliance (CHA) undertook a quality improvement (QI) initiative to reduce the use of patients' family members and friends as interpreters during clinical encounters. A centralized QI team monitored data across clinics and implemented several improvement activities, including systemwide informational campaigns and policy changes, operational improvements within interpreter services, and site-specific outreach. In addition, individual clinics identified and tested improvement strategies with support from the QI team. RESULTS: The number of clinics with high (> 10%) utilization of family/friends as interpreters decreased from 16 to 11 between 2012 and 2018. Trends over time varied across sites, and two clinics had particularly striking and sustained improvement. At these clinics, there were several factors that facilitated improvement, including having trusted leadership champions, using clear and consistent messaging reinforcing CHA's policy, and implementing workflows promoting use of professional interpreters. CONCLUSION: Changing practice to reduce the use of ad hoc interpreters in a large multisite organization is challenging and takes sustained and prolonged effort. Strong institutional policies and site-specific outreach can help stimulate change, and partnership with leadership champions is critical to success. CHA's experience provides strategies and lessons that can be leveraged by other institutions seeking to improve care for LEP patients.

Directional cell migration in an extracellular pH gradient: a model study with an engineered cell line and primary microvascular endothelial cells.

Extracellular pH (pH(e)) gradients are characteristic of tumor and wound environments. Cell migration in these environments is critical to tumor progression and wound healing. While it has been shown previously that cell migration can be modulated in conditions of spatially invariant acidic pH(e) due to acid-induced activation of cell surface integrin receptors, the effects of pH(e) gradients on cell migration remain unknown. Here, we investigate cell migration in an extracellular pH(e) gradient, using both model α(v)ß(3) CHO-B2 cells and primary microvascular endothelial cells. For both cell types, we find that the mean cell position shifts toward the acidic end of the gradient over time, and that cells preferentially polarize toward the acidic end of the gradient during migration. We further demonstrate that cell membrane protrusion stability and actin-integrin adhesion complex formation are increased in acidic pH(e), which could contribute to the preferential polarization toward acidic pH(e) that we observed for cells in pH(e) gradients. These results provide the first demonstration of preferential cell migration toward acid in a pH(e) gradient, with intriguing implications for directed cell migration in the tumor and wound healing environments.

Acidic extracellular pH promotes activation of integrin α(v)ß(3).

Acidic extracellular pH is characteristic of the cell microenvironment in several important physiological and pathological contexts. Although it is well established that acidic extracellular pH can have profound effects on processes such as cell adhesion and migration, the underlying molecular mechanisms are largely unknown. Integrin receptors physically connect cells to the extracellular matrix, and are thus likely to modulate cell responses to extracellular conditions. Here, we examine the role of acidic extracellular pH in regulating activation of integrin α(v)ß(3). Through computational molecular dynamics simulations, we find that acidic extracellular pH promotes opening of the α(v)ß(3) headpiece, indicating that acidic pH can thereby facilitate integrin activation. This prediction is consistent with our flow cytometry and atomic force microscope-mediated force spectroscopy assays of integrin α(v)ß(3) on live cells, which both demonstrate that acidic pH promotes activation at the intact cell surface. Finally, quantification of cell morphology and migration measurements shows that acidic extracellular pH affects cell behavior in a manner that is consistent with increased integrin activation. Taken together, these computational and experimental results suggest a new and complementary mechanism of integrin activation regulation, with associated implications for cell adhesion and migration in regions of altered pH that are relevant to wound healing and cancer.