We Rely on Relationships: Homeless Service Providers' Experiences in Coordinating Care Transitions During COVID-19.

PURPOSE OF STUDY: Care coordination occurring across multiple sectors of care, such as when professionals in health or social service organizations collaborate to transition patients from hospitals to community-based settings like homeless shelters, happens regularly in practice. While health services research is full of studies on the experiences of case management and care coordination professionals within health care settings, few studies highlight the perspective of nonclinical homeless service providers (HSPs) in coordinating care transitions. PRIMARY PRACTICE SETTING: This study explores the experience of nonclinical HSPs, employed in a large homeless service agency in New York, United States, responsible for coordinating care transitions of patients presenting to a homeless shelter after hospitalization, with attention to COVID-19 impact. METHODOLOGY AND SAMPLE: Semi-structured interviews were conducted with providers at three hierarchical levels (frontline, managerial, and executive). The data were analyzed using qualitative content analysis. The implementation science framework Normalization Process Theory was used to structure semi-deductive coding categories. RESULTS: The findings included three major themes that highlight promoting and inhibiting factors in care coordination, including a reliance on informal relationships, the impact of strong hierarchical structures, and a lack of collaborative cross-sector information exchange pathways. Altogether, findings offer insights from an infrequently studied professional group engaging in cross-sector care coordination for a high-risk population. Operational insights can inform future research to ensure that the implementation of interventions to improve cross-sector care coordination is evidence-based. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: This study of nonclinical HSPs facilitating care transitions demonstrates the importance of understanding this critical provider population. Opportunities for acute care case managers and administrators include the importance of relationships, reciprocal education on the differences in work settings, and the need for administrative structure to ensure complex clinical information is effectively translated.

Heart failure symptom burden in outpatient cardiology: observational cohort study.

OBJECTIVES: To assess the self-reported symptom burden in patients with a diagnosis of heart failure attending an outpatient cardiology clinic through the utilisation of validated patient-reported outcome measures. METHODS: Eligible patients were invited to partake in this observational cohort study. Participant demographics and comorbidities were recorded, followed by participants recording their symptoms using the Integrated Palliative care Outcome Scale (IPOS) and Brief Pain Inventory (BPI) outcome measure tools. RESULTS: A total of 22 patients were included in the study. The majority were male (n=15). The median age was 74.5 (range 55-94) years. Atrial fibrillation and hypertension were the most common comorbidities (n=10). Dyspnoea, weakness and poor mobility were the most prevalent symptoms, affecting 15 (68%) of the 22 patients. Dyspnoea was reported as being the most troublesome symptom. The BPI was completed by 68% (n=15) of the study participants. Median average pain score was 5/10; median worst pain score in the preceding 24 hours was 6/10 and median pain score at time of BPI completion was 3/10. The impact of pain on daily living during the preceding 24 hours ranged from impacting on all activities (n=7) to not impacting on activities (n=1). CONCLUSIONS: Patients with heart failure experience a range of symptoms that vary in severity. Introduction of a symptom assessment tool in the cardiology outpatient setting could help identify patients with a high symptom burden and prompt timely referral to specialist palliative care services.

Exosomes from Von Hippel-Lindau-Null Cancer Cells Promote Metastasis in Renal Cell Carcinoma.

Exosomes are extracellular vesicles that modulate essential physiological and pathological signals. Communication between cancer cells that express the von Hippel-Lindau (VHL) tumor suppressor gene and those that do not is instrumental to distant metastasis in renal cell carcinoma (RCC). In a novel metastasis model, VHL(-) cancer cells are the metastatic driver, while VHL(+) cells receive metastatic signals from VHL(-) cells and undergo aggressive transformation. This study investigates whether exosomes could be mediating metastatic crosstalk. Exosomes isolated from paired VHL(+) and VHL(-) cancer cell lines were assessed for physical, biochemical, and biological characteristics. Compared to the VHL(+) cells, VHL(-) cells produce significantly more exosomes that augment epithelial-to-mesenchymal transition (EMT) and migration of VHL(+) cells. Using a Cre-loxP exosome reporter system, the fluorescent color conversion and migration were correlated with dose-dependent delivery of VHL(-) exosomes. VHL(-) exosomes even induced a complete cascade of distant metastasis when added to VHL(+) tumor xenografts in a duck chorioallantoic membrane (dCAM) model, while VHL(+) exosomes did not. Therefore, this study supports that exosomes from VHL(-) cells could mediate critical cell-to-cell crosstalk to promote metastasis in RCC.

Development and psychometric properties of the Multidimensional Inventory of Recovery Capital (MIRC).

BACKGROUND: Researchers have developed several instruments to measure recovery capital-the social, physical, human, and cultural resources that help people resolve alcohol and other drug problems. However, existing measures are hampered by theoretical and psychometric weaknesses. The current study reports on process and psychometric outcomes for the Multidimensional Inventory of Recovery Capital (MIRC), a novel measure of recovery capital. METHODS: We used a three-phase, mixed methods approach to develop the MIRC. Individuals who identified as having resolved alcohol problems were recruited in each phase. Phase one focused on item development, with participants providing qualitative feedback on potential items. In phase two (pilot testing) and phase three (final psychometric evaluation), participants completed revised versions of the MIRC to assess its psychometric strength and item performance. RESULTS: Phase one (n=44) resulted in significant item alteration, culminating in a 48-item pilot measure. Pilot testing analyses (n=497) resulted in the deletion or replacement of 17 items. In the final psychometric evaluation (n=482), four additional items were deleted, resulting in a 28-item MIRC comprising four subscales measuring social, physical, human, and cultural capital. The psychometric properties of the final MIRC and its subscales ranged from sound to strong, with high response variability suggesting appropriate item discrimination. CONCLUSION: Results confirm the psychometric strength of the MIRC and underscore the importance of incorporating the insights of diverse samples of people in recovery. The MIRC holds promise as an assessment tool in future research and is available for use at no cost in treatment and community-based settings.

Trauma and principles of trauma-informed care in the U.S. federal legislative response to the opioid epidemic: A policy mapping analysis.

OBJECTIVE: The U.S. declared the opioid epidemic as a national public health emergency in 2017. Given the strong and bidirectional relationship between trauma and substance misuse, policy responses to this crisis that reflect principles of trauma-informed care are especially salient. This study is the first to use trauma-informed policy analysis to systematically assess the U.S. Congressional response to the opioid epidemic. METHOD: We used policy mapping methods to build and analyze a dataset of all opioid-related bills and resolutions proposed in Congress between 2009 and 2017 (N = 188). Following an established trauma-informed policy analysis framework, 2 researchers reviewed these policies and coded their incorporation of trauma-specific language and the principles of safety; choice; trust and transparency; collaboration and peer support; empowerment; and intersectionality. We calculated coding frequencies in these categories and rates of intercoder agreement. RESULTS: A minority of policies (10.6%) directly mentioned trauma and 55% of policies incorporated at least 1 trauma-informed principle. Safety was the most commonly coded principle (38.3%), while intersectionality was the least (6.9%). CONCLUSIONS: Our analysis found limited attention to trauma in opioid-related federal legislation. Based on these findings and following the example of coalitions such as the Campaign for Trauma-Informed Policy and Practice, advocates can mobilize for better inclusion of trauma-informed principles in opioid policy. Further, this study demonstrates the feasibility of applying the trauma-informed policy analysis framework to code Congressional policies using publicly available data, a replicable methodology with potential application at federal and state levels. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Qualitative insights in item development for a comprehensive and inclusive measure of recovery capital.

Background: Item specification is foundational to measurement development but rarely reported in depth. We address this gap by explicating our use of qualitative methods to ground and develop items for a new recovery capital measure, the Multidimensional Inventory of Recovery Capital. Method: We recruited a diverse sample of service providers (n = 9) and people in recovery from alcohol problems (n = 23) to provide feedback on an item pool assessing social, human, physical, community, and cultural capital. Using applied qualitative analysis, we coded findings from interviews and focus groups and made final decisions by consensus regarding item elimination, retention, or revision. This process yielded a 49-item draft measure. Results: Only nine items from an initial 90-item list were retained in their original form. Participant feedback guided item elimination, addition, and revision for linguistic or conceptual clarity. We detected little systematic variation in feedback based on income or race; however, there were stark divergences on particular items based on recovery pathway (i.e. 12-step versus other approaches). Conclusions: The high degree of alteration to the item pool highlights the importance of establishing validity with respondents. Response variation based on recovery pathway suggests the need for broad heterogeneity in respondents. Measures that are sensitive, psychometrically sound, and aligned with theory are critical for advancing research on recovery capital and related disparities for diverse populations.

Psychometric Properties of the Assessment of Recovery Capital (ARC) Instrument in a Diverse Low-Income Sample.

Background: Recovery capital is a theoretical construct elucidating the resources that support recovery from addiction. The 50-item Assessment of Recovery Capital (ARC) instrument and related brief-format versions are the predominant measures of this construct. However, some of the ARC's psychometric properties are not well-established, particularly in racially and economically diverse populations. Objectives: We aimed to determine if the ARC is a valid and reliable measure of recovery capital in a diverse sample. Methods: Paper-and-pencil survey data were collected between March 2017 and May 2018 from a low-income, racially diverse sample of adults in recovery (N = 273). Participants were recruited from nontreatment community settings throughout a mid-sized northeastern U.S. city. They completed the ARC and sociodemographic questions. To determine the ARC's reliability and factor structure, we used item-level analyses and Cronbach's alpha, followed by confirmatory and exploratory factor analyses. Results: Several items performed poorly, having means close to response extremes and problematically small variances. Cronbach's alpha for the full measure was α = .92; however, alphas for the majority of subscales were below .70. The a priori 10-factor model solution failed, preventing interpretation of the confirmatory factor analysis results. Exploratory factor analysis revealed that although the 10-factor model marginally fit the data, items did not load together as proposed. Not once did all five subscale items load highly on the same factor. Conclusions/Importance: The ARC has substantial weaknesses in its theoretical alignment, item performance, and psychometric properties with diverse populations. We recommend the development of a new multidimensional, theory-aligned measure, following a rigorous measurement development protocol.

A policy mapping analysis of goals, target populations, and punitive notions in the U.S. congressional response to the opioid epidemic.

BACKGROUND: The U.S. Congress has proposed numerous bills and resolutions in response to the opioid epidemic unfolding over the past decade. Although this legislative response has been the subject of considerable media attention and commentary, very little research has systematically analyzed congressional opioid-related legislation in terms of primary goals, focal populations, and the extent to which it includes punitive mechanisms. METHODS: To address this gap in research, we conducted a policy mapping content analysis of all opioid-related bills and resolutions (N = 188) proposed in Congress between 2009-2017 (111th - 115th Congresses). Two researchers independently coded basic characteristics (e.g. type, status, sponsorship, funding); goals, using a taxonomy developed by the researchers; focal populations; and punitive intent. Researchers compared codes and addressed discrepancies through consensus. RESULTS: Legislation addressed a wide range of goals, but frequently did not advance beyond the introduction stage (80.3%). Goals most often centered on treatment (43.1% of legislation), research (36.7%), and supply reduction of licit (34.0%) and illicit opioids (21.3%). Relatively little legislation addressed long-term recovery, avenues of safer drug consumption, or stigma reduction. Youth (21.3%) and veterans (17.0%) were the most common population categories toward which legislation was directed. Explicit attention toward racial/ethnic minorities, low-income populations, and sexual minorities was rare to nonexistent. Legislation was largely coded as not directly punitive (91.0%). CONCLUSION: This study represents the first systematic analysis of key features of the U.S. congressional response to the opioid epidemic. Results indicate that the legislative response has largely focused on acute intervention, with limited attention to upstream social determinants and goal areas such as long-term recovery support. While the legislative response is primarily non-punitive, most opioid-specific policy does not explicitly address the intersection of opioid misuse and addiction with salient social factors such as economic disinvestment and social isolation.

Food Insecurity Among Formerly Homeless Individuals Living in Permanent Supportive Housing.

OBJECTIVES: To assess the role of health-related factors, health care, nutrition, and socioeconomic factors in food insecurity prevalence in a sample of previously homeless adults living in permanent supportive housing. METHODS: In 2016 to 2017, we recruited and completed survey interviews with permanent supportive housing residents aged 45 years and older in Los Angeles, California (n = 237). We conducted univariable and multivariable analyses to determine the odds and covariates of low or very low food security, according to the US Department of Agriculture's definition and measure. RESULTS: Two thirds of residents (67%) reported low or very low food security. In the multivariable analyses, several variables were positively associated with this outcome, including accessing food aid or being late in paying bills. The odds of low or very low food security decreased by 8% for every $100 increase in monthly income. CONCLUSIONS: The prevalence of food insecurity in our sample exceeded rates among similarly aged low-income adults in the general population and adults who are currently homeless. This suggests that food insecurity, along with other indicators of socioeconomic disadvantage, remains a threat to health equity for formerly homeless individuals even after they transition to stable housing.

Socioeconomic determinants of pediatric asthma emergency department visits under regional economic development in western New York.

Although the links between asthma in children and physical environmental factors have been well established, the role of community-level socioeconomic status remains inconclusive. Consequently, little attention has been paid to the dynamic changes in the associations between socioeconomic status and asthma outcomes due to structural changes in the community, such as an influx of financial resources. This study examined the relationship between community-level socioeconomic status indicators and asthma-related emergency department utilization for school-aged children in 2011 and 2015, assessing the early impact of a large-scale regional economic development project in western New York, United States. Our analyses controlled for other community-level health risk factors, such as environmental exposure, and spatial correlation of the emergency department usage data. Results indicated that both median household income and health insurance coverage were key socioeconomic predictors of the children's asthma-related emergency department utilization over the study period. We also found that the risk of emergency department utilization for asthma decreased significantly in the area in which regional economic development projects were completed during the initial stage of the project. Through a comparison study we demonstrated that the spatial correlation present in asthma-related ED utilization improved model fit and corrected biases in the estimates. Although our findings suggest that improving the socioeconomic status of communities contributes to a reduction in emergency department utilization for pediatric asthma, more empirical studies are warranted for evaluating the comprehensive effects of regional economic development on public health.

'Hello, you're not supposed to be here': homeless emerging adults' experiences negotiating food access.

OBJECTIVE: We aimed to examine the food-seeking experiences of homeless emerging adults (age 18-24 years) in a US urban context. DESIGN: The study used a qualitative descriptive design, combining semi-structured interviews with a standardized quantitative measure of food insecurity. Interview data were coded using constant comparative methods to identify patterns across and within interviews. Emerging themes were confirmed and refined through member checking. SETTING: Buffalo, a mid-sized city in the Northeastern USA. SUBJECTS: A sample of thirty participants was recruited through community-based methods. Eligibility criteria specified that participants were aged 18-24 years and did not have a stable place to live. The sample was demographically diverse and included participants who were couch-surfing, staying on the streets and/or using shelters. RESULTS: Participants' food access strategies varied across their living circumstances. Common strategies included purchasing food with cash or benefits (reported by 77 %), using free meal programmes (70 %) and eating at friends' or relatives' homes (47 %). Although 70 % of participants received Supplemental Nutrition Assistance Program benefits, several reported access barriers, including initial denials of eligibility due to being listed on a parent's application even when the participant no longer resided in the household. Participants described a stigma associated with using food pantries and free meal programmes and expressed preference for less institutionalized programmes such as Food Not Bombs. CONCLUSIONS: Given endemic levels of food insecurity among homeless youth and young adults, policy modifications and service interventions are needed to improve food access for this population.

A Trauma-Informed Analysis of the Violence Against Women Act's Provisions for Undocumented Immigrant Women.

Immigrant women in the United States are among the groups disproportionately affected by intimate partner violence (IPV). Undocumented immigrants generally have fewer resources for coping with violence and may experience a range of personal, cultural, and immigration status-related barriers to reporting violence and accessing help. Thus, undocumented immigrant victims of IPV could benefit significantly from policies that promote access to trauma-informed services and legal options. This article applies a trauma-informed policy analysis framework to the Violence Against Women Act's immigration protections to demonstrate how the Act's U-Visa provisions and implementation practices could be improved by incorporating trauma-informed principles of trustworthiness and transparency, empowerment, choice, safety, collaboration, and intersectionality.

A trauma-informed examination of the hardships experienced by abortion fund patients in the United States.

Researchers describe hardships experienced by abortion patients, examining administrative health cases from 2010 to 2015 in the United States. All patients received financial assistance from an abortion fund to help pay for abortion. Case data were analyzed to assess types and numbers of hardships experienced by age, race, and geographic origin. Hardships ranged from homelessness to parenting multiple children. Patients from the geographic South experienced the most hardships, followed by those from the Midwest. Hardships experienced by abortion fund patients are like those reported in other samples of abortion patients; hardships potentially cause or exacerbate trauma. Results are discussed in the context of a trauma-informed perspective.

Predictors of CD4 health and viral suppression outcomes for formerly homeless people living with HIV/AIDS in scattered site supportive housing.

Stable housing is key to improving health outcomes for people living with HIV/AIDS. Though many formerly homeless HIV positive individuals reside in supportive housing, little research has examined biometric HIV health outcomes for residents of these programs. Through a community-based research partnership, this study analyzed secondary data from a Shelter Plus Care supportive housing program in Cincinnati, Ohio to examine the likelihood of participants achieving a healthy CD4 count (>500 cells/mm3) and viral suppression (viral load <200 copies/mL) while in supportive housing and to identify participant characteristics associated with these outcomes. The study sample was 86 participants who entered the program between 2008 and 2016, including 50 current residents and 36 exited participants. Participants' average length of stay in Shelter Plus Care was 35.2 months (range 3.2-108.1 months) during the study period. Bivariate analysis indicated statistically significant improvements on both outcome variables, with 45% of participants achieving a healthy CD4 count and 79% achieving viral suppression by program exit or most recent time point. Participants who had health insurance at intake and who had never been incarcerated were more likely to achieve viral suppression, and longer length of stay in the program was also positively associated with viral suppression. These results add to the literature on the relationship between housing conditions and HIV health outcomes by demonstrating that residence in supportive housing is associated with improvements in CD4 count and viral load for a sample of formerly homeless persons living with HIV/AIDS, two-thirds of whom had co-occurring physical health, mental health, or substance abuse problems. Further research collaborations should expand on these findings to examine the service packages that are associated with optimal HIV health outcomes for supportive housing residents.

Descriptive and injunctive network norms associated with nonmedical use of prescription drugs among homeless youth.

BACKGROUND: Nonmedical use of prescription drugs (NMUPD) among youth and young adults is being increasingly recognized as a significant public health problem. Homeless youth in particular are more likely to engage in NMUPD compared to housed youth. Studies suggest that network norms are strongly associated with a range of substance use behaviors. However, evidence regarding the association between network norms and NMUPD is scarce. We sought to understand whether social network norms of NMUPD are associated with engagement in NMUPD among homeless youth. METHODS: 1046 homeless youth were recruited from three drop-in centers in Los Angeles, CA and were interviewed regarding their individual and social network characteristics. Multivariate logistic regression was employed to evaluate the significance of associations between social norms (descriptive and injunctive) and self-reported NMUPD. RESULTS: Approximately 25% of youth reported past 30-day NMUPD. However, more youth (32.28%) of youth believed that their network members engage in NMUPD, perhaps suggesting some pluralistic ignorance bias. Both descriptive and injunctive norms were associated with self-reported NMUPD among homeless youth. However, these varied by network type, with presence of NMUPD engaged street-based and home-based peers (descriptive norm) increasing the likelihood of NMUPD, while objections from family-members (injunctive norm) decreasing that likelihood. CONCLUSIONS: Our findings suggest that, like other substance use behaviors, NMUPD is also influenced by youths' perceptions of the behaviors of their social network members. Therefore, prevention and interventions programs designed to influence NMUPD might benefit from taking a social network norms approach.

Housing as a Social Determinant of Health: Exploring the Relationship between Rent Burden and Risk Behaviors for Single Room Occupancy Building Residents.

A growing body of health determinants research recognizes that housing and health are intimately linked. This study explores the relationship between rent burden (the ratio of rent to income) and health risk behaviors among a sample of single room occupancy (SRO) building residents. Cross-sectional data were gathered from a sample of 162 residents living in privately owned, for-profit SROs in Chicago. Findings indicated that participants who had full rental subsidies and thus were designated in a no-rent-burden category were more likely to engage in risk behaviors including illicit drug use, having multiple sexual partners, and having sex without a condom, in comparison to participants with moderate or high-rent burdens. These findings suggest that interventions to increase housing stability and affordability and bolster reliable income sources (in addition to rental subsidies) may be key in reducing risk behaviors and improving health for vulnerably housed populations such as SRO residents.

A Multilevel Ecological Model of HIV Risk for People Who Are Homeless or Unstably Housed and Who Use Drugs in the Urban United States.

Elevated HIV prevalence has been observed among urban U.S. individuals who use drugs and who lack stable housing. This article synthesizes extant research on this population and situates it in a multilevel, ecologically based model of HIV risk. Based on a multidisciplinary review of the literature, the model applies social-ecological theory on human development to identify factors shaping the HIV risk context for individuals who use drugs and who are unstably housed at global, societal, neighborhood, household, and individual levels of influence. At the global level, the model includes neoliberal ideologies contributing to the social inequalities that frame the HIV epidemic. U.S. housing and drug policy, including urban renewal, HOPE VI, and the War on Drugs, is the focus of the societal level. At the neighborhood level, mechanisms of the built environment and psychosocial mechanisms are explored for their salience to HIV risk. Research on the association between housing instability and HIV risk is reviewed at the household level. At the last level, relevant individual differences in biology, psychology, and cognition are discussed. Modeling risk at multiple levels of the environment underscores the need to expand the focus of research, treatment, and prevention interventions for HIV/AIDS and addictions beyond individuals and their risk behaviors to address facets of structural violence and incorporate the broader social, political, and economic contexts of risk and health.

Prevalence and covariates of food insecurity among residents of single-room occupancy housing in Chicago, IL, USA.

OBJECTIVE: Emerging evidence suggests that food insecurity is a significant public health concern among people who are homeless or marginally housed. The present study assessed prevalence of food insecurity and its covariates among a group of marginally housed individuals living in single-room occupancy (SRO) dwellings, a population for which there is little extant health or nutrition research. DESIGN: Cross-sectional survey incorporating the Household Food Insecurity Access Scale. SETTING: Ten private SRO residences in the Uptown neighbourhood of Chicago, IL, USA, 2013. SUBJECTS: SRO residents over 18 years of age who were able to communicate verbally in English (n 153). RESULTS: Food insecurity was widespread among SRO residents, with 75 % of the sample considered food insecure and 52 % meeting criteria for severe food insecurity. Bivariate analyses indicated that female gender, eating most meals at a soup kitchen, having a mental health condition, problem drinking, having at least one chronic health condition, and diabetes were all significantly associated with food insecurity. In the multivariate ordered logistic regression model, eating most meals at a soup kitchen remained as the only significant correlate of food insecurity (OR=10·13). CONCLUSIONS: SRO residents and other marginally housed populations face unique food access challenges. Although targeted assistance in the form of food stamps and congregate meal programmes remains critical, efforts to prevent and address food insecurity among homeless and marginally housed individuals should include policy interventions that recognize poverty as the root cause of food insecurity and aim to increase overall income and improve housing conditions.

What the MAYSI-2 Can Tell Us About Anger-Irritability and Trauma.

The rate of experiencing trauma can be quite high for juvenile offenders and those experiences can lead to feelings of anger and irritability. This study uses Massachusetts Youth Screening Instrument-Version 2 (MAYSI-2) data to examine the relationship between the Traumatic Experiences (TE) and Angry-Irritable (AI) scales for juvenile offenders (N = 1,348) from a Midwest detention center. Chi-square analyses revealed statistically significant relationships between the AI scale and gender, race, and the TE scale. In addition, ordinal logistic regression results showed that as the number of traumatic experiences increased, so did the odds of scoring Caution or Warning on the AI scale. Recommendations are that juvenile justice systems utilize a trauma-informed process throughout the adjudicatory process and there be improved efforts to coordinate services across multiple systems, such as child welfare and special education, where juvenile offenders are often engaged.