Barriers to accessing treatment for substance use after inpatient managed withdrawal (Detox): A qualitative study

Community Mental Health Services for Frequent Emergency Department Users: A Qualitative Study of Outcomes Perceived by Program Clients and Case Managers

PURPOSE OF STUDY

This study aimed to investigate the perceived outcomes and mechanisms of change of a community mental health service combining system navigation and intensive case management supports for frequent emergency department users presenting with mental illness or addiction.

PRIMARY PRACTICE SETTING

The study setting was a community mental health agency receiving automated referrals directly from hospitals in a midsize Canadian city for all individuals attending an emergency department two or more times within 30 days for mental illness or addiction.

METHODOLOGY AND SAMPLE

Qualitative interviews with 15 program clients. Focus groups with six program case managers. Data were analyzed using pragmatic qualitative thematic analysis.

RESULTS

Participants generally reported perceiving that the program contributed to reduced emergency department use, reduced mental illness symptom severity, and improved quality of life. Perceived outcomes were more mixed for outcomes related to addiction. Reported mechanisms of change emphasized the importance of positive working relationships between program clients and case managers, as well as focused efforts to develop practical skills.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

Community mental health services including intensive case management for frequent emergency department users presenting with mental illness or addiction were perceived to effectively address client needs while reducing emergency department resource burden. Similar programs should emphasize the development of consistent and warm working relationships between program clients and case managers, as well as practical skills development to support client health and well-being.

Pathways to professional mental care in the Swiss young adult community: a case-control study

Treatment success for mental health (MH) problems depends, among others, on the timeliness of help-seeking. Therefore, we studied the effect of symptoms and reasons for help-seeking on the point-of-contact and the most intensive professional treatment in a community sample. Participants were recruited as part of the 'Bern Epidemiological At-Risk' (BEAR) study on 16-40-year-old community persons of the Swiss canton Bern. Of the 2,683 participants, 615 (22.9%) reported at least one instance of help-seeking for MH problems and were selected for the presented analyses. Help-seeking behavior was assessed by a modified version of the 'WHO pathway-to-care questionnaire', from which the outcome 'most intensive MH professional contact' was generated. The effect of symptoms and reasons for help-seeking were analyzed in separate models using path analyses. Most help-seeking persons sought MH professional help (n = 405; 65.9%) with a high number of medical pre-contacts (n = 233; 37.9%). The 'most intensive MH professional contact' was provided after an average of 1.47 contacts. Both models showed negative associations between non-MH professional pre-contacts and the most intensive, likely most adequate MH treatment. In the symptom model, 'substance misuse' and 'central-vegetative problems' increased the general likelihood of MH professional contact. Our findings highlight the importance of the first point-of-contact in pathways to adequate MH care and, when seeking help from non-MH professional, of quick referrals to MH professionals. Awareness campaigns or training of health professionals, such as general practitioners, may support timely contact with MH professionals to improve diagnosis, prognosis, and outcome.

Encampment Clearings And Transitional Housing: A Qualitative Analysis Of Resident Perspectives

The number of people experiencing homelessness in tent encampments in the US has increased significantly. Citing concerns over health and safety, many cities have pursued highly visible encampment removals. In January 2022, a major tent encampment in Boston, Massachusetts, was cleared using a unique approach: Most encampment residents were placed in transitional harm reduction housing. We conducted interviews between July 2022 and February 2023 with thirty former encampment residents to explore how the encampment clearing affected their health and sense of safety. We also explored participants' perspectives on harm reduction housing. Of those interviewed, fourteen people had been placed in such housing. Among those not placed, the encampment clearing tended to exacerbate health and safety concerns, especially those related to mental health conditions and risk for violence. Among people successfully placed, harm reduction housing improved health and safety and allowed participants to make meaningful progress toward long-term goals such as addiction recovery, management of chronic health conditions, and permanent housing. Our findings suggest that encampments can have safety-promoting characteristics, but if encampment removal is pursued, offering harm reduction housing after removal can be beneficial.

Access challenges to opioid use disorder treatment among individuals experiencing homelessness: Voices from the streets

BACKGROUND

Achieving equitable access to medications for opioid use disorder (MOUD) such as buprenorphine is a pressing issue. Evidence suggests disparities in MOUD access based on race and socioeconomic status, further exacerbated by the COVID-19 pandemic. However, the drivers behind this access gap remain poorly understood. This study explores barriers to treatment access among individuals with opioid use disorder (OUD) experiencing homelessness.

METHODS

We interviewed 28 individuals in and around the Boston Public Health Commission (BPHC) Engagement Center, an area known for its high density of active substance use and homelessness. We asked about people's experiences, perceptions, and attitudes toward OUD treatment. We conducted a thematic analysis of our interview data.

RESULTS

Fifty-four percent of participants sampled were not prescribed MOUD. None of the participants reported having an active prescription of sublingual buprenorphine or buprenorphine/naloxone. White participants were more likely to have been prescribed buprenorphine in the past compared to participants of other races even in this socioeconomically homogeneous sample. Themes that emerged in our data included challenges to accessing MOUD due to reduced services during the COVID-19 pandemic, lost or stolen medications, fewer inpatient withdrawal management beds for women, transportation challenges, fear of adverse effects of MOUD, the perception that taking MOUD replaces one addiction for another, and community disapproval of MOUD. Participants also reported stigma and discrimination based on race, gender, and socioeconomic status.

CONCLUSION

Systems and individual-level factors contribute to the MOUD treatment gap across race and socioeconomic status. The COVID-19 pandemic posed additional access challenges. This study provides important, actionable insights about the barriers faced by a particularly vulnerable population of individuals with OUD experiencing homelessness.