Changing the Game? Increasing the Impact of Peer-Run Organizations.

Employment and deployment of peer support specialists in both clinical and non-clinical mental health settings has increased substantially since the 1990's. Peer-run organizations are defined as those led and managed by individuals with self-disclosed lived experience of mental health conditions. Many peer-run organizations promoting advocacy and offering services have been established during the past 30 years. Some adherents assert the effectiveness of peer-run organizations over hybrid mental health service providers in which peer support workers are integrated or partnered with existing community mental health agency multidisciplinary clinical and treatment teams. Although research has indicated the positive contributions of peer-run organizations to service user recovery, the impact of peer-run organizations on system transformation is not well documented. This concept paper explores benefits, accomplishments, and challenges faced by a peer-run organization during its 30-year evolution in offering self-help groups, supported housing, peer support services, peer specialist training, and systems change projects in Los Angeles County, California. Future research topics and policy options are suggested, along with recommendations for the SAMHSA Office of Recovery.

More than Just Bread and Wine: Using Yeast to Understand Inherited Cytochrome Oxidase Deficiencies in Humans.

Inherited defects in cytochrome c oxidase (COX) are associated with a substantial subset of diseases adversely affecting the structure and function of the mitochondrial respiratory chain. This multi-subunit enzyme consists of 14 subunits and numerous cofactors, and it requires the function of some 30 proteins to assemble. COX assembly was first shown to be the primary defect in the majority of COX deficiencies 36 years ago. Over the last three decades, most COX assembly genes have been identified in the yeast Saccharomyces cerevisiae, and studies in yeast have proven instrumental in testing the impact of mutations identified in patients with a specific COX deficiency. The advent of accessible genome-wide sequencing capabilities has led to more patient mutations being identified, with the subsequent identification of several new COX assembly factors. However, the lack of genotype-phenotype correlations and the large number of genes involved in generating a functional COX mean that functional studies must be undertaken to assign a genetic variant as being causal. In this review, we provide a brief overview of the use of yeast as a model system and briefly compare the COX assembly process in yeast and humans. We focus primarily on the studies in yeast that have allowed us to both identify new COX assembly factors and to demonstrate the pathogenicity of a subset of the mutations that have been identified in patients with inherited defects in COX. We conclude with an overview of the areas in which studies in yeast are likely to continue to contribute to progress in understanding disease arising from inherited COX deficiencies.

Supporting Peer Support Workers and Their Supervisors: Cluster-Randomized Trial Evaluating a Systems-Level Intervention.

OBJECTIVE: Peer support workers are a substantial and growing part of the mental health workforce. Because little research has investigated how to effectively support and supervise peer support workers, the authors evaluated the efficacy of a training program to strengthen the peer support workforce and the supervision of its workers. METHODS: Mental health services sites with peer support workers and supervisors in Los Angeles County were recruited for this cluster-randomized trial and 10-month follow-up. Of 348 peer support workers and 143 supervisors at 85 sites, 251 (72%) peer support workers and 115 (80%) supervisors completed baseline surveys. SHARE! the Self-Help And Recovery Exchange, a peer-run organization, delivered four training sessions on strategies to reduce stigma and to build an effective peer workforce, cultural competence, and a trauma-informed developmental model of supervision. Primary outcomes were peer-supportive organizational climate, mental health stigma, and peer support worker recovery. RESULTS: Intention-to-treat analyses indicated that sites receiving the training had significantly higher scores on peer-supportive organizational climate (Cohen's d=0.35, 95% CI=0.02-0.68, p=0.04) relative to sites not receiving the training. No significant differences were found between the two conditions for mental health stigma (Cohen's d=0.04) or peer support worker recovery (Cohen's d=0.14). CONCLUSIONS: The training had no impact on mental health stigma or peer support worker recovery. However, the findings suggest that the training increased the value organizations gave to peer support work, which may help improve peer support worker retention and outcomes among those served. Efforts to incorporate principles of the training into practice may strengthen outcomes.

Pulmonary Specialist-Supported Health Coaching Delivered by Lay Personnel Improves Receipt of Quality Care for Chronic Obstructive Pulmonary Disease: A Randomized Controlled Trial.

Purpose: Half of people living with chronic obstructive pulmonary disease (COPD) do not receive high-quality, evidenced-based care as described in international guidelines. We conducted secondary data analysis of a previously published study to assess the ability of a model of lay health coaching to improve provision of guideline-based care in a primary care setting. Methods: As part of a randomized controlled trial, we recruited English- and Spanish-speaking patients with moderate to severe COPD from primary care clinics serving a low-income, predominantly African American population. Participants were randomized to receive usual care or 9 months of health coaching from primary care personnel informed by a pulmonary specialist practitioner. Outcome measures included prescription of appropriate inhaler therapy, participation in COPD-related education, engagement with specialty care, prescription of smoking cessation medications, and patient ratings of the quality of care. Results: Baseline quality measures did not differ between study arms. At 9 months, coached patients were more likely (increase of 9.3% over usual care; P=0.014) to have received guideline-based inhalers compared to those in usual care. Coached patients were more likely to engage with pulmonary specialty care (increase of 8.3% over usual care with at least 1 visit; P=0.04) and educational classes (increase of 5.3% over usual care; P=0.03). Receipt of smoking cessation medications among patients smoking at baseline in the health coaching group increased 21.1 percentage points more than in usual care, a difference near statistical significance (P=0.06). Conclusions: Health coaching may improve the provision of quality chronic illness care for conditions such as COPD.

Examining Care Planning Efficiency and Clinical Decision Support Adoption in a System Tailoring to Nurses' Graph Literacy: National, Web-Based Randomized Controlled Trial.

BACKGROUND: The proliferation of health care data in electronic health records (EHRs) is fueling the need for clinical decision support (CDS) that ensures accuracy and reduces cognitive processing and documentation burden. The CDS format can play a key role in achieving the desired outcomes. Building on our laboratory-based pilot study with 60 registered nurses (RNs) from 1 Midwest US metropolitan area indicating the importance of graph literacy (GL), we conducted a fully powered, innovative, national, and web-based randomized controlled trial with 203 RNs. OBJECTIVE: This study aimed to compare care planning time (CPT) and the adoption of evidence-based CDS recommendations by RNs randomly assigned to 1 of 4 CDS format groups: text only (TO), text+table (TT), text+graph (TG), and tailored (based on the RN's GL score). We hypothesized that the tailored CDS group will have faster CPT (primary) and higher adoption rates (secondary) than the 3 nontailored CDS groups. METHODS: Eligible RNs employed in an adult hospital unit within the past 2 years were recruited randomly from 10 State Board of Nursing lists representing the 5 regions of the United States (Northeast, Southeast, Midwest, Southwest, and West) to participate in a randomized controlled trial. RNs were randomly assigned to 1 of 4 CDS format groups-TO, TT, TG, and tailored (based on the RN's GL score)-and interacted with the intervention on their PCs. Regression analysis was performed to estimate the effect of tailoring and the association between CPT and RN characteristics. RESULTS: The differences between the tailored (n=46) and nontailored (TO, n=55; TT, n=54; and TG, n=48) CDS groups were not significant for either the CPT or the CDS adoption rate. RNs with low GL had longer CPT interacting with the TG CDS format than the TO CDS format (P=.01). The CPT in the TG CDS format was associated with age (P=.02), GL (P=.02), and comfort with EHRs (P=.047). Comfort with EHRs was also associated with CPT in the TT CDS format (P<.001). CONCLUSIONS: Although tailoring based on GL did not improve CPT or adoption, the study reinforced previous pilot findings that low GL is associated with longer CPT when graphs were included in care planning CDS. Higher GL, younger age, and comfort with EHRs were associated with shorter CPT. These findings are robust based on our new innovative testing strategy in which a diverse national sample of RN participants (randomly derived from 10 State Board of Nursing lists) interacted on the web with the intervention on their PCs. Future studies applying our innovative methodology are recommended to cost-effectively enhance the understanding of how the RN's GL, combined with additional factors, can inform the development of efficient CDS for care planning and other EHR components before use in practice.

A clinical tool to predict severe pain during wound dressing changes.

ABSTRACT: Dressing changes cause severe pain (ie, 8-10 on a 10-point scale) for approximately one-third (36%) of patients with open skin wounds. No tool exists that allows nurses to predict which patients are likely to experience severe pain during dressing changes. The aim of this study was to develop a clinical tool to predict severe pain during dressing changes using clinically accessible wound and pain predictors and to evaluate the diagnostic validity of this model. Using a cross-sectional design, a one-time study dressing change was conducted by the same wound care nurse on 445 subjects while concurrently measuring patient and wound predictors and pain intensity during the dressing change. Three predictors came out of the study as most useful for a clinical prediction tool: type of dressing, resting wound pain, and expected pain. Algorithms based on these predictors are presented, which can be applied in other settings to predict patients likely to experience severe pain during a dressing change. This is the first study to systematically examine a comprehensive set of wound and patient predictors for their individual and collective associations with pain during dressing changes using precisely defined and rigorously measured study variables. The ability to predict which patients are likely to have severe pain during dressing changes is critically needed so that they can be targeted for preventive pain control strategies.

Conducting a representative national randomized control trial of tailored clinical decision support for nurses remotely: Methods and implications.

Clinical Decision Support (CDS) systems, patient specific evidence delivered to clinicians via the electronic health record (EHR) at the right time and in the right format, has the potential to improve patient outcomes. Unfortunately, outcomes of CDS research are mixed. A potential cause lies in its testing. Many CDS are implemented in practice without sufficient testing, potentially leading to patient harm. When testing is conducted, most research has focused on "what" evidence to provide with little attention to the impact of the CDS display format (e.g., textual, graphical) on the user. In an adequately powered randomized control trial with 220 hospital based registered nurses, we will compare 4 randomly assigned CDS format groups (text, text table, text graphs, tailored to subject's graph literacy score) for effects on decision time and simulated patient outcomes. We recruit using state based professional registries, which allows access to participants from multiple institutions across the nation. We use online survey software (REDCap) for efficient study workflow including screening, informed consent documentation, pre-experiment demographic data collection including a graph literacy questionnaire used in randomization. The CDS prototype is accessed via a web app and the simulation-based experiment is conducted remotely at a subject's local computer using video-conferencing software. Also included are 6 post intervention surveys to assess cognitive workload, usability, numeracy, format preference, CDS utilization rationale, and CDS interpretation. Our methods are replicable and scalable for testing of health information technologies and have the potential to improve the safety and effectiveness of these technologies across disciplines.

Effective Peer Employment Within Multidisciplinary Organizations: Model for Best Practice.

This study sought a clearer understanding of organizational mechanisms reinforcing effective peer employment and organizational change from the perspectives of peer workers, non-peer staff and management in multidisciplinary mental health and substance use recovery services. Findings were used to develop a model for organizational best practice for peer employment and associated organizational change to promote recovery-oriented and person-directed services. Qualitative research was undertaken, involving 132 people participating in 14 focus groups and eight individual interviews. These people were employed across five U.S. multidisciplinary organizations providing mental health and substance use recovery services and deemed by a panel of experts to provide effective employment of peer workers. Study findings include the articulation of an interactive working model of best practice, comprising organizational commitment, organizational culture and effective organizational strategies necessary for a "whole-of-organization" approach to support authentic peer work and enable organizational transformation, to actualize recovery-oriented values and person-driven services. Strategies include Human Resources engagement, peers in positions of senior organizational authority, recurring whole of workforce training, along with peer training and peer-led supervision. Findings suggest whole-of-organization commitment, culture and practice are essential for the organizational transformation needed to support effective employment of peers in multidisciplinary environments.

National Practice Guidelines for Peer Support Specialists and Supervisors.

In 2017, the National Association of Peer Supporters (N.A.P.S.) leadership became aware of growing member concerns about supervision contradicting or conflicting with core peer support values. In response, N.A.P.S. established a work group that revised the association's 2013 National Practice Guidelines for Peer Supporters to include specific guidance to supervisors (i.e., the National Practice Guidelines for Peer Specialists and Supervisors). The new guidelines are not intended to address administrative or other basic functions of supervision; instead, they offer expertise and practical guidance to supervisors of peer support workers in understanding the core values of mutual support and managing the complexities of the nonclinical role in settings that may have different values and priorities.

Implementation and Impact of the Pulmonary Specialist Health Coach Consultation Model to Improve Care for Patients with COPD.

BACKGROUND: Health coaching has emerged as an important tool for improving patient-centered care in primary care practice but has not specifically been evaluated for patients whose care is shared by a primary care provider (PCP) and specialist. METHODS: As part of a nine-month randomized controlled trial comparing health coaching to usual care for patients with chronic obstructive pulmonary disease (COPD), the authors developed the Pulmonary Specialist Health Coach Consultation (PuSHCon). In this novel model, health coaches facilitated pulmonary specialist consultations for patients with COPD without the need for an in-person visit. Observational data from the randomized controlled trial were analyzed to study the implementation, adoption, and impact of the PuSHCon model for 70 of 92 patients randomized to the health coaching arm and for 17 of 100 patients in the control arm (who received PuSHCon after the end of the study). Quality of care was measured using the Patient Assessment of Chronic Illness Care (PACIC). RESULTS: Of 87 patients who participated in PuSHCon, 74 (85.1%) received one or more specialist recommendations, of which 86.8% were implemented. Only 12 patients (13.8%) subsequently required an in-person visit with the PuSHCon specialist. The proportion of PuSHCon participants receiving guideline-concordant care increased from 64.7% to 94.1% (p < 0.001). The mean PACIC item score increased from 3.48 to 3.74 (p = 0.03). CONCLUSION: The PuSHCon model facilitated consultations that resulted in changes in care, which were implemented for a majority of patients. Guideline-concordant care and patient-reported quality of care increased over nine months. This model could potentially be expanded to help patients with other chronic conditions when PCPs and specialists share patient care.

Topiramate-chitosan nanoparticles prevent morphine reinstatement with no memory impairment: Dopaminergic and glutamatergic molecular aspects in rats.

Besides their clinical application, chronic misuse of opioids has often been associated to drug addiction due to their addictive properties, underlying neuroadaptations of AMPA glutamate-receptor-dependent synaptic plasticity. Topiramate (TPM), an AMPAR antagonist, has been used to treat psychostimulants addiction, despite its harmful effects on memory. This study aimed to evaluate the effects of a novel topiramate nanosystem on molecular changes related to morphine reinstatement. Rats were previously exposed to morphine in conditioned place preference (CPP) paradigm and treated with topiramate-chitosan nanoparticles (TPM-CS-NP) or non-encapsulated topiramate in solution (S-TPM) during CPP extinction; following memory performance evaluation, they were re-exposed to morphine reinstatement. While morphine-CPP extinction was comparable among all experimental groups, TPM-CS-NP treatment prevented morphine reinstatement, preserving memory performance, which was impaired by both morphine-conditioning and S-TPM treatment. In the NAc, morphine increased D1R, D2R, D3R, DAT, GluA1 and MOR immunoreactivity. It also increased D1R, DAT, GluA1 and MOR in the dorsal hippocampus. TPM-CS-NP treatment decreased D1R, D3R and GluA1 and increased DAT in the NAc, decreasing GluA1 and increasing D2 and DAT in the dorsal hippocampus. Taken together, we may infer that TPM-CS-NP treatment was able to prevent the morphine reinstatement without memory impairment. Therefore, TPM-CS-NP may be considered an innovative therapeutic tool due to its property to prevent opioid reinstatement because it acts modifying both dopaminergic and glutamatergic neurotransmission, which are commonly related to morphine addiction.

Effects of a robot-aided somatosensory training on proprioception and motor function in stroke survivors.

BACKGROUND: Proprioceptive deficits after stroke are associated with poor upper limb function, slower motor recovery, and decreased self-care ability. Improving proprioception should enhance motor control in stroke survivors, but current evidence is inconclusive. Thus, this study examined whether a robot-aided somatosensory-based training requiring increasingly accurate active wrist movements improves proprioceptive acuity as well as motor performance in chronic stroke. METHODS: Twelve adults with chronic stroke completed a 2-day training (age range: 42-74 years; median time-after-stroke: 12 months; median Fugl-Meyer UE: 65). Retention was assessed at Day 5. Grasping the handle of a wrist-robotic exoskeleton, participants trained to roll a virtual ball to a target through continuous wrist adduction/abduction movements. During training vision was occluded, but participants received real-time, vibro-tactile feedback on their forearm about ball position and speed. Primary outcome was the just-noticeable-difference (JND) wrist position sense threshold as a measure of proprioceptive acuity. Secondary outcomes were spatial error in an untrained wrist tracing task and somatosensory-evoked potentials (SEP) as a neural correlate of proprioceptive function. Ten neurologically-intact adults were recruited to serve as non-stroke controls for matched age, gender and hand dominance (age range: 44 to 79 years; 6 women, 4 men). RESULTS: Participants significantly reduced JND thresholds at posttest and retention (Stroke group: pretest: mean: 1.77° [SD: 0.54°] to posttest mean: 1.38° [0.34°]; Control group: 1.50° [0.46°] to posttest mean: 1.45° [SD: 0.54°]; F[2,37] = 4.54, p = 0.017, ηp2 = 0.20) in both groups. A higher pretest JND threshold was associated with a higher threshold reduction at posttest and retention (r = - 0.86, - 0.90, p ≤ 0.001) among the stroke participants. Error in the untrained tracing task was reduced by 22 % at posttest, yielding an effect size of w = 0.13. Stroke participants exhibited significantly reduced P27-N30 peak-to-peak SEP amplitude at pretest (U = 11, p = 0.03) compared to the non-stroke group. SEP measures did not change systematically with training. CONCLUSIONS: This study provides proof-of-concept that non-visual, proprioceptive training can induce fast, measurable improvements in proprioceptive function in chronic stroke survivors. There is encouraging but inconclusive evidence that such somatosensory learning transfers to untrained motor tasks. Trial registration Clinicaltrials.gov; Registration ID: NCT02565407; Date of registration: 01/10/2015; URL: https://clinicaltrials.gov/ct2/show/NCT02565407 .

Pilot of Brief Health Coaching Intervention to Improve Adherence to Positive Airway Pressure Therapy.

BACKGROUND: Adherence to positive airway pressure (PAP) therapies is poor, particularly among low-income populations and racial minorities. This study tested a low-resource, brief telephonic health coaching intervention to improve PAP adherence. METHODS: Post hoc analysis of a quality improvement initiative in which English- and Spanish-speaking patients from a county-based public health system were randomly assigned to receive health coaching or usual care. An unlicensed, trained health coach called patients three times to resolve barriers to adherence. A per-protocol analysis was conducted for adherence measures collected by device modem at baseline and 30 days. RESULTS: Of 131 people for whom device data were available, 56 were randomized to health coaching and 75 to usual care. At baseline, 47.3% of patients had used their device at any time in the past 30 days, with a mean of 2 hours of use per night. At 30 days, adjusting for baseline, patients in the coaching arm were more likely than usual care patients to use their device (55.4% vs. 41.3%, p = 0.03), and they increased their use for 0.4 hours over usual care (p = 0.04). CONCLUSION: This pilot study suggests that a low-cost intervention could be effective at improving PAP adherence, even in a population known to have poor adherence and among long-term PAP users with poor adherence. Future research may examine whether a higher-touch intervention or one using videoconferencing yields greater improvements. This promising intervention warrants further study.

Lay Health Coaching to Increase Appropriate Inhaler Use in COPD: A Randomized Controlled Trial.

PURPOSE: Poor adherence to medications is more prevalent for chronic obstructive pulmonary disease (COPD) than for other chronic conditions and is associated with unfavorable health outcomes. Few interventions have successfully improved adherence for COPD medications; none of these use unlicensed health care personnel. We explored the efficacy of lay health coaches to improve inhaler adherence and technique. METHODS: Within a randomized controlled trial, we recruited English- and Spanish-speaking patients with moderate to severe COPD from urban, public primary care clinics serving a low-income, predominantly African American population. Participants were randomized to receive 9 months of health coaching or usual care. Outcome measures included self-reported adherence to inhaled controller medications in the past 7 days and observed technique for all inhalers. We used generalized linear models, controlling for baseline values and clustering by site. RESULTS: Baseline adherence and inhaler technique were uniformly poor and did not differ by study arm. At 9 months, health-coached patients reported a greater number of days of adherence compared with usual care patients (6.4 vs 5.5 days; adjusted P = .02) and were more likely to have used their controller inhalers as prescribed for 5 of the last 7 days (90% vs 69%; adjusted P = .008). They were more than 3 times as likely to demonstrate perfect technique for all inhaler devices (24% vs 7%; adjusted P = .01) and mastery of essential steps (40% vs 11%; adjusted P <.001). CONCLUSIONS: Health coaching may provide a scalable model that can improve care for people living with COPD.

Organizational Climate and Support Among Peer Specialists Working in Peer-Run, Hybrid and Conventional Mental Health Settings.

As the peer specialist workforce continues to expand, it is critical to better understand peer providers' working conditions and workplace experiences. The current study utilized a targeted non-probability sample of 801 peer specialists to explore whether key organizational climate and support variables would yield distinct multivariate groups, and to investigate the correlates of these groups. Analyses yielded a seven-group solution, with peer run organizations comprising a substantially greater proportion of the groups with high organizational climate and support scores. In direct comparisons, peer-run programs outranked all other groups in the areas of perceived organizational climate, supports for career development and perceived service quality.

Investigating the mobility of the peer specialist workforce in the United States: Findings from a national survey.

OBJECTIVE: The objectives of the current study were to characterize (a) peer specialist interest in enrolling in/returning to higher education and perceived barriers, (b) perceptions of the local availability of higher education/continuing education programming, and (c) perceived barriers to the advancement of the peer workforce. METHOD: We utilized both close-ended and open-ended items from a large, collaboratively developed national survey of peer specialists. Analytic methods included both descriptive and basic inferential statistics (N = 801) and qualitative coding and analysis (subsample N = 451). RESULTS: High levels of interest in higher education were found, with nearly 80% of participants reporting that they would enroll/return to college were it feasible. Analysis of open-ended responses regarding perceived barriers to career advancement revealed 5 major themes: financing and administrative policies; perceived public discrimination and devaluation of the peer specialist role by coworkers and agency leadership; lack of opportunities and mechanisms for advancement; the simultaneous need for advanced education and the inaccessibility of college or graduate degrees; and individual level barriers, including internalized stigma and derailed work histories due to disability. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: As the peer workforce continues to grow, it is critical that the field grapple with fundamental questions as to how to best support the development and advancement of the peer workforce. Our findings underscore persistent workplace challenges and perceived barriers to advancement, insights which may help the field develop strategies for improving development supports. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

A robot-assisted sensorimotor training program can improve proprioception and motor function in stroke survivors.

Proprioceptive deficits are common among stroke survivors and are associated with slower motor recovery, poorer upper limb motor function, and decreased self-care ability. Somatosensory feedback augmenting proprioception should enhance motor control after stroke, but available evidence is inconclusive. This study evaluated the effects of a robot-aided, somatosensory-focused training on proprioceptive acuity and motor performance in individuals with sub-acute and chronic stroke. Twelve stroke survivors completed two training sessions on two consecutive days. During training, participants used a haptic robotic wrist exoskeleton and made continuous, goal-directed wrist ab/adduction movements to a visual target while receiving vibro-tactile feedback. Proprioceptive acuity and active movement errors were assessed before, immediately after, and two days after intervention. Results showed significantly improved proprioceptive acuity at posttest and retention. Motor accuracy measures showed improvements, however these were not statistically significant. This study demonstrates the feasibility of robot-aided somatosensory rehabilitation training in stroke survivors.

Effects of Vocal Training on Students' Voices in a Professional Drama School.

OBJECTIVE: The purpose of this study was to investigate the effect of vocal training on acoustic and aerodynamic characteristics of student actors' voices. STUDY DESIGN: Prospective cohort study. SETTING: Tertiary medical facility speech and swallow center. SUBJECTS AND METHODS: Acoustic, aerodynamic, and Voice Handicap Index-10 measures were collected from 14 first-year graduate-level drama students before and after a standard vocal training program and analyzed for changes over time. RESULTS: Among the aerodynamic measures that were collected, mean expiratory airflow was significantly reduced after vocal training. Among the acoustic measures that were collected, mean fundamental frequency was significantly increased after vocal training. On average, Voice Handicap Index-10 scores were unchanged after vocal training. CONCLUSION: The cohort of drama students undergoing vocal training demonstrated improvements in voice aerodynamics, which indicate enhanced glottal efficiency after training. The present study also found an increased average fundamental frequency among the actors during sustained voicing and no changes in jitter and shimmer despite frequent performance.