Homelessness And Health: Factors, Evidence, Innovations That Work, And Policy Recommendations

On a single night in 2023, more than 653,000 people experienced homelessness in the United States. In this overview, we highlight structural and individual risk factors that can lead to homelessness, explore evidence on the relationship between homelessness and health, discuss programmatic and policy innovations, and provide policy recommendations. Health system efforts to address homelessness and improve the health of homeless populations have included interventions such as screening for social needs and medical respite programs. Initiatives using the Housing First approach to permanent supportive housing have a strong track record of success. Health care financing innovations using Medicaid Section 1115 waivers offer promising new approaches to improving health and housing for people experiencing homelessness. To substantially reduce homelessness and its many adverse health impacts, changes are needed to increase the supply of affordable housing for households with very low incomes. Health care providers and systems should leverage their political power to advocate for policies that scale durable, evidence-based solutions to reduce homelessness, including increased funding to expand housing choice vouchers and greater investment in the creation and preservation of affordable housing.

Gauging the stress of long-term care nursing assistants using ecological momentary assessment, wearable sensors and end of day reconstruction

BACKGROUND

Nursing assistants working in long-term care (LTC) often report that their job is stressful. To reduce their work stress, a better understanding of their stress profile is needed.

OBJECTIVE

We aimed to pilot test methods to identify and understand stressors that LTC nursing assistants experience.

METHODS

We asked each participant to provide wearable sensor/watch data, ecological momentary assessment (EMA) surveys and end of day review data over two eight-hour working shifts.

RESULTS

Eight nursing assistants participated. All participants worked in a common continuing care retirement community in Maryland, United States of America. Our stress assessment method revealed 83 stressful events that were classified under 10 categories. Most of the reported events were rated as having a mild to low-moderate intensity. The three most common causes of stress were work demands and pressure (28.35%), heavy workload and staffing (19.69%), and safety issues and COVID-19 concerns (17.32%). We also explored the difference between stress events and intensity among different shifts. Disrespect from residents (22.73%) was the most commonly reported stressor during day shifts. Feeling rushed was the most commonly reported stressor during the evening (22.47%) and the night (38.46%) shifts.

CONCLUSIONS

We found stress was commonly reported. Stress intensity conflicted with prior literature, and we explored possible explanations.

IMPLICATIONS FOR PRACTICE

We discuss potential implications for these findings, modification of our methods to increase feasibility, the utility of these data collection methods for future work and suggest next steps.

Peer Activate: A Feasibility Trial of a Peer-Delivered Intervention to Decrease Disparities in Substance Use, Depression, and Linkage to Substance Use Treatment

Although effective evidence-based interventions (EBIs) exist, racial/ethnic minority individuals with lower income are less likely to have access to these interventions and may experience greater stigma in the health care system, resulting in disproportionate rates of morbidity and mortality. Peer recovery specialists (PRSs) may be uniquely suited to address barriers faced by those from impoverished areas; however, peers have not traditionally been trained in implementing EBIs. The current open-label trial (N = 8) was performed to evaluate implementation and preliminary effectiveness of an adapted EBI supporting recovery, linkage to treatment, and reduced depression. Results suggest the intervention was feasible, acceptable, and appropriate for linking individuals from a community setting to substance use treatment and could be delivered with fidelity by a peer interventionist. Participants who completed the intervention demonstrated clinically reliable decreases in substance use and depressive symptoms. Findings provide initial support for PRS dissemination of EBIs to increase linkage to care and support recovery in traditionally underserved populations. [Journal of Psychosocial Nursing and Mental Health Services, 61(11), 23-31.].

2021 SAEM Consensus Conference Proceedings: Research Priorities for Developing Emergency Department Screening Tools for Social Risks and Needs

Introduction: The Emergency Department (ED) acts as a safety net for our healthcare system. While studies have shown increased prevalence of social risks and needs among ED patients, there are many outstanding questions about the validity and use of social risks and needs screening tools in the ED setting. Methods: In this paper, we present research gaps and priorities pertaining to social risks and needs screening tools used in the ED, identified through a consensus approach informed by literature review and external expert feedback as part of the 2021 SAEM Consensus Conference -- From Bedside to Policy: Advancing Social Emergency Medicine and Population Health. Results: Four overarching research gaps were identified: (1) Defining the purpose and ethical implications of ED-based screening; (2) Identifying domains of social risks and needs; (3) Developing and validating screening tools; and (4) Defining the patient population and type of screening performed. Furthermore, the following research questions were determined to be of highest priority: (1) What screening tools should be used to identify social risks and needs? (2) Should individual EDs use a national standard screening tools or customized screening tools? (3) What are the most prevalent social risks and needs in the ED? and (4) Which social risks and needs are most amenable to intervention in the ED setting? Conclusion: Answering these research questions will facilitate the use of evidence-based social risks and needs screening tools that address knowledge gaps and improve the health of our communities by better understanding the underlying determinants contributing to their presentation and health outcomes.

Pilot Testing of the Promoting Positive Care Interactions Intervention in Assisted Living

The current study aimed to test the feasibility and preliminary efficacy of the Promoting Positive Care Interactions (PPCI) intervention designed to establish positive care interactions between staff and residents in assisted living (AL) using an online approach. PPCI was implemented in one AL community using a single group pre-/posttest design; 17 care staff were recruited from the memory care unit. Delivery, receipt, and enactment of the PPCI were assessed for feasibility. Change in staff outcomes and facility outcomes were examined for preliminary efficacy. The four steps of the PPCI were implemented as intended with 100% staff exposure to education and considerable staff engagement in weekly mentoring sessions. Although there was an improvement in AL environment and policy, no significant changes were observed in staff outcomes. Future testing of the PPCI should include a longer timeline and explore a hybrid model that includes online education and in-person mentoring and coaching of staff to improve care interactions. [Journal of Gerontological Nursing, 48(8), 17-25.].

Nursing Students' Perceptions of a Community Health Street Outreach Experience: Thematic Analysis

BACKGROUND

There has been increased focus within nursing to address social determinants of health (SDOH), and nurse educators are urged to integrate SDOH into the curriculum, strengthen community and public health (CPH) clinical experiences, and provide service-learning opportunities. Therefore, student feedback was sought for a CPH clinical experience involving street outreach.

METHOD

Two groups of nursing students conducted street outreach with unstably housed individuals in an urban area in the eastern United States. Focus groups and thematic analysis were conducted.

RESULTS

Students expressed high levels of satisfaction with the experience. The following themes were identified: Influence of Prior Experiences, Transformational Experience, and Making a Difference. Following the CPH experience, the majority of students reported they were considering working in CPH nursing.

CONCLUSION

Engaging in street outreach and similar experiences has the potential to improve nursing students' perceptions of CPH clinical experiences and prepare them for careers in CPH nursing. [J Nurs Educ. 2022;61(7):394-397.].

Working Memory Training Reduces Cigarette Smoking Among Low-Income Individuals With Elevated Delay Discounting

INTRODUCTION

The competing neurobehavioral decision systems theory conceptualizes addictive behavior, such as cigarette smoking, as arising from the imbalance between stronger impulsive relative to weaker executive decision processes. Working memory trainings may enhance executive decision processes, yet few studies have evaluated its efficacy on substance misuse, with mixed evidence. The current study is the first to evaluate the efficacy of a working memory training on cigarette smoking. We consider the moderating role of delay discounting (DD), or the preference for smaller, immediately available rewards relative to larger, delayed rewards, which has been associated with smoking onset, progression, and resumption. The investigation focuses on individuals living in high-poverty, low-resource environments due high burden of tobacco-related disease they experience.

AIMS AND METHODS

The study utilized a subset of data (N = 177 individuals who smoke) generated from a randomized clinical trial that is evaluating the efficacy of working memory training for improving health-related outcomes. Participants were randomized to complete up to 15 sessions of the active, working memory training or a control training.

RESULTS

Findings showed that among participants who were randomized to the working memory condition, those with higher rates of baseline DD demonstrated decreases in cigarette smoking (p = .05). Conversely, individuals randomized to the control condition, who had higher rates of baseline DD exhibited increases in cigarette smoking (p = .025).

CONCLUSIONS

Results suggest that DD may be an important indicator of working memory training outcomes and a possible approach for effectively targeting treatments in the future.

IMPLICATIONS

DD is important indicator of working memory training outcomes on cigarette smoking. The findings suggest the possibility to effectively target treatments considering the impact of DD. Given that rates of DD tend to be higher among individuals from low-resource communities, and that computer-based working memory training programs are relatively low-cost and scalable, these findings suggest this approach may have specific utility for adults at heightened risk for cigarette use.This study was registered with ClinicalTrials.gov (Identifier NCT03501706).

Factors Associated With the Quality of Staff-Resident Interactions in Assisted Living

BACKGROUND

Care interactions are verbal or nonverbal interactions between staff and residents during social or physical care activities. The quality of care interactions could be positive, negative, or neutral.

PURPOSE

The purpose of this study was to examine the resident- and facility-level factors associated with the care interactions in assisted living (AL).

METHODS

Regression analysis was performed using a stepwise method utilizing baseline data of 379 residents from 59 AL facilities recruited in a randomized trial.

RESULTS

Accounting for 8.2% of variance, increased resident agitation was associated with negative or neutral quality interactions while for-profit ownership was associated with positive quality interactions.

CONCLUSIONS

To promote positive care interactions, findings suggest the need to educate staff about strategies to minimize resident agitation (eg, calm posture and respectful listening) and work toward optimizing care interactions in nonprofit settings. Future research could further explore the influence of staff-level factors on care interactions.

Factors Associated With the Quality of Staff-Resident Interactions in Assisted Living

Care interactions are essential to understand and respond to resident needs in assisted living (AL). The factors that influence care interactions in AL have not been directly examined. In this study, we explored the factors associated with the quality of care interactions in AL. It was hypothesized that resident functional status, agitation, depression, and resistiveness to care as well as facility size and ownership would be significantly associated with the quality of care interactions in AL after controlling for resident demographics (age, gender, marital status), comorbidities, and cognition. To test the hypothesis, we utilized baseline data including 379 residents from the second and third cohorts recruited in a randomized trial titled ‘Dissemination and Implementation of Function Focused Care for Assisted Living Using the Evidence Integration Triangle’. Regression analysis was performed using a stepwise method. The care interactions were mostly positive (mean=6.3; range = 0-7). Resident agitation and facility ownership were significantly associated with care interactions and accounted for 8.2% of the variance. Increased resident agitation was associated with negative or neutral interaction while for-profit ownership was associated with positive interactions. To promote positive care interactions, staff should be educated about strategies to minimize resident agitation (e.g., calm posture and respectful listening) and encouraged to engage with residents using resident-centered care and communication approach. Findings also suggest the need to work towards optimizing care interactions in nonprofit stings. Future research could further explore the impact of facility-level factors (e.g., staffing ratios, staff longevity, and job satisfaction) on care interactions.

Pilot Testing of the Promoting Positive Care Interactions (PPCI) in Assisted Living Study During a Pandemic

The purpose of this study was to test the feasibility and preliminary efficacy of Promoting Positive Care Interactions (PPCI)—a four step intervention designed to establish positive care interactions between staff and residents with cognitive impairment or dementia in Assisted Living (AL). Initially designed as a traditional on-site intervention, PPCI was later transformed to be conducted remotely through webinar and virtual meetings due to challenges related to onsite engagement in AL during the COVID-19 pandemic. Additionally, the study adopted shorter timeline, a single group pretest-posttest design, and limited recruitment to staff only; 17 care staff were recruited, and data was collected via online surveys and interviews. PPCI was successfully implemented as intended with considerable stakeholder engagement. Findings demonstrated feasibility and promising staff adoption of PPCI. Continued research is needed to optimize the quality of care interactions in AL and evaluate whether online approach to staff training can change staff behavior.

A Nurse-Run Public Health Clinic for Individuals Utilizing a Community Outreach Center

This article describes a nurse-run clinic for low-income individuals or individuals experiencing homelessness. We conducted a quality improvement project using data from 111 individuals over 194 visits. Thirty-seven percent of patients had difficulty managing their health and 22% reported being in an active health crisis. The visits resulted in patients leaving with their visit goal being met (86%), and 96% of nonemergent cases being diverted from the emergency room. The nurse-run clinic provided access to care and served as a safety net for a vulnerable population, providing support for this clinic model with this population.

A Description of Staff-resident Interactions in Assisted Living

Positive social and care interactions are vital to understand and successfully accomplish the daily care needs of the residents in assisted living (AL) and optimize their quality of life. The purpose of this study was to explore and describe the staff-resident interactions in AL. This descriptive analysis utilized baseline data in a randomized trial that included 379 residents from 59 AL facilities. The majority of the interactions observed were positive; almost 25% were neutral or negative. Most interactions were care-related (31.9%) or one-on-one (27.4%), occurred with nursing (40.2%) or support staff (e.g., dining aide; 24.6%), and involved close interpersonal distance (64.6%). Future research should focus on the transition of neutral or negative interactions to positive and explore the factors that might influence neutral and negative interactions. Additionally, innovative approaches are needed to optimize interactions amid physical distancing in the context of the COVID-19 pandemic.

A Virtual Leadership Program's Impact on Employee Leadership Development at a Healthcare Organization

In this study, we explored the effectiveness of the virtual organizational leadership development program at Mayo Clinic. The purpose of this study was to explain how a virtual leadership development program impacted employee leadership efficacy. The research questions addressed how the program affected participant promotions, how the program learning objectives were implemented by participants, and how the program impacted participants. Collection tools included satisfaction surveys, interviews, and data reflecting promotion rates. Participants appreciated the advantages of the virtual format of the program and the quality of the instructors. They completed the program with enhanced communication skills, the ability to influence positive change, and increased self-awareness. Opportunities for program improvement included incorporating real-world projects to give participants the ability to practice the leadership skills taught, the ability to be paired with a mentor, and a second part to the program to explore the leadership competencies at a more advanced level.

Methods to Optimize Recruitment, Participation, and Retention Among Vulnerable Individuals Participating in a Longitudinal Clinical Trial

Low-income and ethnic/racial minority adults do not often participate in research or may face unique barriers when participating in research, which delays and impedes medical advances for this vulnerable population. This article describes in detail the evidenced-based methods used to enhance recruitment, participation, and retention in a clinical trial at a center serving ethnic/racial minorities and low-income individuals. The article details the partnership with a community outreach center and describes the duties and impact of a community liaison to enhance recruitment, participation, and retention in a randomized controlled trial with a 6-month follow-up. Of the 246 individuals initially recruited for screening, 80 did not meet inclusion criteria with the most common reason for disqualification being meeting criteria for substance use disorder (n = 44). One hundred sixty-six participants qualified for participation. The majority of participants identified as African American (n = 127, 77.1%) and reported an annual individual income under $10,000 (n = 121 (74.2%). Forty-five percent of the sample completed the requested number of sessions (i.e., 12). Sixty-three percent of participants completed post intervention assessments and 42% completed 6-month follow-up data collection. The participation and retention numbers in this study appear higher than typical participation and retention rates in longitudinal studies with similar populations. The methods and lessons learned may be useful for other clinical trials that recruit vulnerable populations and wish to enhance participation, engagement, and retention.

Implementing a peer recovery coach model to reach low-income, minority individuals not engaged in substance use treatment

Background: Low-income, racial/ethnic minority individuals face significant barriers in access to substance use (SU) treatment. Peer recovery coaches (PRCs), individuals with lived experience with substance use disorder (SUD), may be uniquely well suited to assist those encountering barriers to treatment. PRCs can also help reach those not engaged in treatment to promote harm reduction and support linkage-to-care when embedded in community rather than clinical settings. This study evaluated a community-based program in which a PRC facilitated linkage to and supported retention in SU treatment. Methods: Guided by the RE-AIM framework, we evaluated implementation of the intervention in a community resource center (CRC) serving homeless and low-income residents of Baltimore City. We examined the reach, effectiveness, adoption, and implementation of this PRC model. Results: Of 199 clients approached by or referred to the PRC, 39 were interested in addressing their SU. Of those interested in addressing SU, the PRC linked 64.1% (n = 25) to treatment and was able to follow up with 59.0% (n = 23) at prespecified time points after linkage (24-48 hours, 2 weeks, and 1 month). Fifty-two percent (n = 13) of clients linked to SU treatment remained in treatment at 30 days post-linkage. Of clients who did not remain in treatment, 77% (n = 10) continued contact with the PRC. Conclusions: Results indicate the utility of the CRC's approach in linking people to treatment for SU and addressing barriers to care through work with a PRC. Findings also highlight important barriers and facilitators to implementation of this model, including the need for adaptation based on individual goals and fluctuations in readiness for treatment.

An interdisciplinary street outreach program to engage vulnerable neighbors in care

Those experiencing poverty, homelessness, or behavioral health disorders are difficult to engage and maintain in health care services. These vulnerable populations experience unique barriers to engagement in health care services, which fuel health inequity. We need innovative approaches to address this need. This paper discusses the reciprocal relationship between a community center and a local university, which led to a street outreach program that provides a dynamic interprofessional experience for nursing, medical, and social work students and helps connect vulnerable populations to care. Over 12 weeks, students interacted with 127 neighbors. The most common interventions used were as follows: support and encouragement, health teaching, providing medical supplies, and/or referrals to the community center to meet with case management and/or attend the nurse-run public health clinic. The encounters often resulted in neighbors' goals being met, neighbors' planning to use the community outreach center (COC) in the future, and neighbors leaving the encounter with a plan to manage their health.

Students' perceptions of interprofessional education in geriatrics: A qualitative analysis

Interprofessional education (IPE) is critical for ensuring that students are prepared to collaborate with team members across disciplines once they enter clinical practice; particularly, in the complex care of the geriatric population. This qualitative study explored the experiences of interdisciplinary students in a clinical based IPE experience at a senior housing residence. Reflective journals were examined from students (n = 23) in nursing, social work, pharmacy, and medicine participating in an IPE program. Four core themes emerged in the analysis: exposure to geriatrics, IPE advantages for students, IPE advantages for older adults, and IPE challenges. Findings from this study confirmed advantages of IPE in a real-world clinical setting in terms of students learning the value and scope of practice of interdisciplinary team members. The exposure to geriatrics helped students to gain an in-depth understanding of issues affecting older adults in the community and increase professional confidence in their future clinical practice.

Improvement of Working Memory is a Mechanism for Reductions in Delay Discounting Among Mid-Age Individuals in an Urban Medically Underserved Area

BACKGROUND

Delay discounting, or the tendency to devalue rewards as a function of their delayed receipt, is associated with myriad negative health behaviors. Individuals from medically underserved areas are disproportionately at risk for chronic health problems. The higher rates of delay discounting and consequent adverse outcomes evidenced among low-resource and unstable environments suggest this may be an important pathway to explain health disparities among this population.

PURPOSE

The current study examined the effectiveness of a computerized working memory training program to decrease rates of delay discounting among residents of a traditionally underserved region.

METHODS

Participants (N = 123) were recruited from a community center serving low income and homeless individuals. Subjects completed measures of delay discounting and working memory and then took part in either an active or control working memory training.

RESULTS

Analyses indicated that participants in the active condition demonstrated significant improvement in working memory and that this improvement mediated the relation between treatment condition and reductions in delay discounting.

CONCLUSIONS

Results suggest that a computerized intervention targeting working memory may be effective in decreasing rates of delay discounting in adults from medically underserved areas (ClinicalTrials.gov number NCT03501706).

Determinants of intergenerational sexual relationships and HIV risk among South African women outpatients in Gauteng

Age-discrepant sexual relationships may place women at risk for HIV infection in South Africa. Results are based on medical records and case-control interview data of 889 sexually experienced women outpatients aged 15-29 in a Gauteng township. Women with partners at least ten years older (intergenerational) show an elevated chance of having an early sexual debut, concurrent and transactional partners, and intimate partner violence. Hardship during childhood including parental loss, food insecurity and abuse are related to age asymmetric relationships. HIV is two times more likely (aOR=1.96) with an intergenerational partner. Transactional sex increases the odds of HIV independently (aOR=1.76) as does intimate partner violence (aOR=1.6). To the extent that transactional and intergenerational sex overlap the chance of contracting HIV increases more than two-fold (uOR=4.57). Girls (15-19) with intergenerational partners face the highest chance of HIV (uOR=8.55) compared to other age groups. They are also five times more likely than controls to have lived with a cross-age partner. Our findings indicate there are multiple pathways emanating from childhood leading to women's choice of intergenerational partners, and the link to HIV is strongest among the youngest women.

T cell response during Group B Streptococcus vaginal colonization and ascending infection

Pre-term birth, miscarriage, and other adverse pregnancy outcomes remain the primary cause of neonatal death and are associated with bacterial ascending infections within the female reproductive tract. Group B Streptococcus (GBS), a vaginal tract colonizer, is a leading contributor to adverse pregnancy outcomes and neonatal invasive disease. We have developed a mouse model of GBS vaginal colonization and ascending infection and have observed increased IL-17 production in mice that cleared GBS colonization compared to those still colonized. Thus, we hypothesize that IL-17 and IL-17-producing cells may be important for host defense; yet, the immune dynamics during GBS vaginal persistence and ascending infection/adverse pregnancy outcomes remain unknown.

T cells are a major source of IL-17 in the mucosa. To assess the role of adaptive immunity during GBS colonization, we colonized RAG1+/+ and RAG1−/− mice with GBS and observed increased persistence of GBS in the vaginal tract of the RAG1−/− mice. To determine the cellular source of IL-17 within the reproductive tract of GBS-colonized mice, we isolated immune cells from vaginal, cervical, and uterine tissues at the time of GBS clearance and performed flow cytometry. TCRɣδ+ cells comprised the highest percentage of RORɣT+ immune cells in the vagina, cervix, and uterus. We further observed an increased percentage of TCRɣδ+ cells in the uterus of GBS-colonized mice compared to naïve mice at day 9 post-inoculation, at which point half the mice had cleared. We hypothesize that IL-17-producing TCRɣδ+ cells contribute to GBS clearance in the murine reproductive tract. Future studies will assess GBS vaginal persistence and ascending infection in IL-17- and TCRɣδ-deficient mouse lines.

The Indirect Effects of Trait Anxiety on Drug Use Via Emotion Dysregulation in a Low-Income Sample

Background: Research has demonstrated consistent associations between anxiety and illicit drug use. However, few studies to date have examined the shared risk factors that may contribute to this common comorbidity. Therefore, the current investigation tested the indirect effect of trait anxiety on drug use disorder symptoms via emotion dysregulation, a widely recognized transdiagnostic risk factor found to be relevant across both anxiety and illicit drug use. Method: The sample was comprised of 241 adults (Mage = 50.56, SDage = 5.90; 76.8% Black) recruited from a community center serving low-income and homeless individuals. Results: Consistent with our hypothesis, structural equation modeling demonstrated an indirect effect of trait anxiety on drug use disorder symptoms through emotion dysregulation. Conclusions: The current findings show initial support for emotion dysregulation as an explanatory vulnerability factor indirectly underlying the relationship between anxiety and drug use.

Adapting a peer recovery coach-delivered behavioral activation intervention for problematic substance use in a medically underserved community in Baltimore City

Low-income, racial/ethnic minority groups have disproportionately high rates of problematic substance use yet face barriers in accessing evidence-based interventions (EBIs). Peer recovery coaches (PRCs), individuals with lived experience with problematic substance use, may provide an effective approach to reaching these individuals. Traditionally PRCs have focused on bridging to other types of care rather than delivering EBIs themselves. The aim of this study was to assess perceptions of the appropriateness of a PRC-delivered adapted behavioral activation (BA) intervention to reduce problematic substance use for individuals not engaged in care. This study was conducted at a community resource center in Baltimore, Maryland serving low-income and homeless clients who have high rates of problematic substance use yet also face barriers to accessing care. Guided by the ADAPT-ITT framework, we conducted semi-structured key informant interviews with clients (n = 30) with past or present problematic substance use, and a focus group with community providers, including staff at the community resource center (n = 5) and PRCs (n = 6) from the community. Thirty percent (n = 9) of clients interviewed reported past problematic substance use and 70% (n = 21) met criteria for current use, most commonly cocaine and opioids. Clients, center staff, and PRCs shared that PRC-delivered BA could be acceptable and appropriate with suggested adaptations, including adding peer-delivered case-management and linkage to care alongside BA, and tailoring BA to include activities that are accessible and feasible in the community. These findings will inform the adaptation of PRC-delivered BA to address problematic substance use in this setting.

The Emerging Crisis of Aged Homelessness in the US: Could Cost Avoidance in Health Care Fund Housing Solutions?

Background with rationale The US homeless population has had a fairly unique age structure for thirty years, with one-third concentrated among the 1955-1965 birth cohort. They are aging prematurely and are experiencing aging related morbidity and mortality in increasing numbers. This study uses demographic methods to project the growth in aged homelessness out to 2030. Using linked administrative data, historical patterns of health care, nursing home and shelter are used to estimate future costs. Potential offsets are estimated from anticipated reductions in excess services use associated with housing placement. Main Aim To determine if housing placement among future aged homeless adults could be offset by reduced health and social service costs. Methods/Approach Demographic methods are applied to historical shelter data in Los Angeles, New York and Boston to project the future growth in aged homelessness. Linked administrative data are used to estimate future age-related use of health and social services. Housing models are applied to meet population needs to estimate costs. Health and social service costs offsets are estimated from prior literature. The net cost is estimated based on the differential. Results Elderly homelessness will triple in the US over the next ten years. Average annual health and shelter costs will be $22-28,000 per person. Housing costs are estimated at $7-11,000 annually. Cost offsets yield a positive ROI of 1.13 in New York and Los Angeles; Boston results are closer to break-even. Conclusion Substantial public dollars will be spent on the aged homelessness problem as it triples over the next ten years. Some of those dollars could be shifted to housing solutions, reducing homelessness significantly, with little to no increase in public expenditures; positive returns on such investments are also possible.

Staff Self-Efficacy and Staff Outcome Expectations for Function-Focused Care: Rasch Testing

BACKGROUND AND PURPOSE

The purpose of this study was to test the reliability and validity for two new scales.

METHODS

We used baseline data from a worksite health promotion project with 98 long-term care staff and Pearson correlations and Rasch analysis testing.

RESULTS

For Staff Self-Efficacy for Function Focused Care and Staff Outcome Expectations for Function Focused Care item, reliability was .80 and .83, respectively. All items except one had acceptable INFIT and OUTFIT mean square statistics. Both new scales were significantly correlated (r = .342, p = .007), but neither of the scales were correlated with participants' baseline exercise levels (r = .014, p = .918; r = .092, p = .454, respectively).

CONCLUSIONS

There was some evidence of validity and internal consistency for both scales. Suggestions are provided to improve the measures for future use.

Parental And Clinician Views Of Consent In Neonatal Research

AIM

To determine parental and clinician views of the informed consent process in neonatal research.

METHODS

A questionnaire-based study on the informed consent process. Two questionnaires were developed and distributed to parents and clinicians over a four-month period.

RESULTS

Thirty-four parents (79%) surveyed had consented their baby to a research study. The majority of clinicians (72%) had a preference for antenatal provision of information. A desire to help future babies (97%, n=32) and a belief that their baby's healthcare would directly benefit (72%, n=28) were primary reasons for consenting. The majority (76% n=28) of parents were not in favour of a waiver of consent. However twenty clinicians (56%) agreed that a waiver of consent may be appropriate in neonatal research. Thirty-one (86%) clinicians rated GCP training as important.

DISCUSSION

Parents are generally supportive of neonatal research. Good clinical practice training is essential for clinicians involved in neonatal research.

2018 American Society of Consultant Pharmacists Annual Meeting & Exhibition

Poster abstracts are evaluated based on the following criteria: significance of the problem to healthy aging or medication management; innovativeness of ideas, methods, and/or approach; methodological rigor of methods and approach; presentation of finding; implications identified for future research, practice, and/or policy; and clarity of writing. Submissions are not evaluated through the peer-reviewed process used by The Consultant Pharmacist. Industry support is indicated, where applicable. Presenting author is in italics. The poster abstract presentation is supported by the ASCP Foundation.

Doctors' attitudes towards the introduction and clinical operation of do not resuscitate orders (DNRs) in Ireland

BACKGROUND

Do not resuscitate orders (DNRs) are documents which state that should a patient suffer from cardiopulmonary failure, resuscitation should not be attempted. Internationally, DNRs are often misunderstood and used inappropriately in a clinical setting.

AIMS

The aim of this paper was to determine the current understanding of DNRs and their clinical operation among hospital doctors in Ireland.

METHODS

A cross-sectional, questionnaire-based study was conducted involving doctors from the Cork teaching hospitals. The questionnaire sought information regarding understanding of DNRs and their clinical operation, as well as attitudes regarding the current absence of relevant Irish guidelines. The questionnaire also collected information regarding demographics, clinical specialty, and level of experience.

RESULTS

45.9% (47/103) of all doctors stated that their clinical knowledge was sufficient to draft a DNR, but 48.7% of this group (n = 23) chose the incorrect definition for a DNR when provided with three separate options. Thirty-five percent (n = 36) of all doctors surveyed demonstrated an incorrect understanding of a DNR. Neither specialty nor experience level had any effect on level of understanding of DNRs (p > 0.05). 93.2% (n = 96) agreed that there is a need for introduction of domestic guidelines regarding DNRs. 57.6% (n = 59) would draft more DNRs in the event that such domestic guidelines were in place.

CONCLUSIONS

A substantial proportion of hospital doctors surveyed demonstrated an incomplete understanding of DNRs and their clinical operation. However, the overwhelming majority of the present sample believe that domestic guidelines are needed on the matter.

Cardiovascular Risk Factors of Long-Term Care Workers

Little is known about long-term care workers’ cardiovascular disease (CVD) risk. Thus, the authors used baseline objective and subjective data from 98 long-term care staff participating in a worksite health promotion study to provide a comprehensive CVD assessment. The median age of the sample was 32 years ( SD = 13.38). Nine (12.2%) participants smoked and 27 (37.0%) participants reported exposure to secondhand smoke. The average nightly hours of sleep was 6.5 ( SD = 1.18), with 24 (32%) participants reporting sleeping at least fairly bad. Sixty-eight participants (73.1%) were overweight or obese. The median aerobic activity was 0 ( SD = 18.56). Participants ate on average 27 ( SD = 17.34) servings of high fatty and/or salty foods per week. Although blood pressure and cholesterol levels were within normal limits, this population demonstrated poor behavioral CVD risk factors. Given this finding and the young age of the sample, these workers may be ideal candidates for health promotion efforts before health risk factors are present.

Applying the Social Ecological Model and Theory of Self-Efficacy in the Worksite Heart Health Improvement Project-PLUS

Background: Long-term care (LTC) employees are at high risk for cardiovascular disease. Despite the documented benefits of worksite health promotion (WHP) programs for employees and employers and the potential benefits to residents in LTC facilities, LTC employees are rarely offered WHP programs. Purpose: The purpose of the intervention described in this article is to reduce cardiovascular disease risk factors among LTC workers using a physical activity, nutrition, and stress management WHP implemented during paid work time with 98 LTC staff members. Methods: This article describes a 9-month physical activity, nutrition, and stress management WHP intervention delivered during paid work time to reduce the cardiovascular disease risk of employees working in LTC. The intervention is rooted in the social ecological model and social cognitive theory. The intervention is based on formative research and evidence-based practice recommendations and is specifically designed to reduce barriers to intervention participation (e.g., inconsistent break times and unpredictable resident care needs) and enhance motivators to program participation (e.g., enhanced social support). Results: The intervention is ongoing, but measures are described. Conclusion: As more employers offer WHP programs, it is important that programs are tailored to meet specific employee groups and work environments. This article operationalizes a WHP research protocol with LTC employees that can be applied to reduce cardiovascular disease risk in LTC employees or similar employee groups in similar work environments.

Characteristics of Medicaid-Covered Emergency Department Visits Made by Nonelderly Adults: A National Study

BACKGROUND

The Affordable Care Act has added millions of new Medicaid enrollees to the health care system. These patients account for a large proportion of emergency department (ED) utilization.

OBJECTIVE

Our aim was to characterize this population and their ED use at a national level.

METHODS

We used the 2010 National Hospital Ambulatory Medical Care Survey (NHAMCS) to describe demographics and clinical characteristics of nonelderly adults (≥18 years old and ≤64 years old) with Medicaid-covered ED visits. We defined frequent ED users as individuals who make ≥4 ED visits/year and business hours as 8 am to 5 pm. We used descriptive statistics to describe the epidemiology of Medicaid-covered ED visits.

RESULTS

NHAMCS included 21,800 ED visits by nonelderly adults in 2010, of which 5,659 (24.09%) were covered by Medicaid insurance. Most ED visits covered by Medicaid were made by patients who are young (25 and 44 years old) and female (67.95%; 95% confidence interval [CI] 66.00-69.89). A large proportion of the ED visits covered by Medicaid were revisits within 72 h (14.66%; 95% CI 9.13-20.19) and from frequent ED users (32.32%; 95% CI 24.29-40.35). Almost half of all ED visits covered by Medicaid occurred during business hours (45.44%; 95% CI 43.45-47.43).

CONCLUSIONS

The vast majority of Medicaid enrollees who used the ED were young females, with a large proportion of visits occurring during business hours. Almost one-third of all visits were from frequent ED users.

The at-risk medical student--what more can we do?

Securing a place in medical school is extremely difficult-students who are successful all have similar high levels of academic achievement. So why do some students, and not others, have difficulty with the course, and in some cases, leave the programme? Studies on medical school attrition offer valuable insight into why medical students under-perform. Identification of the 'at-risk' student can trigger additional support and early remediation, helping some students remain in their chosen profession.

Abstract 204: Emergency Department Visits for Heart Failure and Subsequent Hospitalization or Observation Unit Admission

Background: Although the majority of hospitalizations for heart failure (HF) originate in the emergency department (ED), many of these patients might be adequately treated and released in the ED or managed for a short period in an observation unit. Both ED and observation management have been shown to reduce costs and avoid the penalties related to rehospitalization. The purpose of this study was to examine trends in ED visits for HF and disposition following these visits. Because of increasing policy pressure to reduce rehospitalization for HF, we hypothesized that the number of HF patients hospitalized by ED providers decreased over time with a concurrent increase in admissions to the observation unit. We further hypothesized that the overall number of ED visits for HF decreased as a result of improved therapy for HF the last two decades.

Methods: We used the National Hospital Ambulatory Medical Care Survey (NHAMCS) to estimate rates and characteristics of ED visits for HF between 2002 and 2010. The primary outcome was the discharge disposition from the ED. Regression models were fit to estimate trends and predictors of hospitalization and admission to an observation unit.

Results: The number of ED visits for HF remained stable over the period, from 914,739 in 2002 to 848,634 in 2010 (annual change -0.7%; 95% CI -3.7% - +2.5%). Of these visits, 74.2% led to hospitalization while 3.1% led to observation unit admission (Figure). The likelihood of hospitalization did not change during the period (adjusted prevalence ratio (aPR) 1.00; 95% CI 0.99-1.01 for each additional year) while admission to observation increased annually (aPR 1.11; 95% CI 1.00-1.23). We observed significant regional differences: as compared to other regions, patients in the Northeast were more likely to be hospitalized (aPR 1.15; 95% CI 1.07-1.22) but less likely to be admitted to an observation unit (aPR 0.43; 95% CI 0.19-1.02).

Conclusions: The number of ED visits for HF has remained stable in the last decade. Although observation unit admissions increased during this period, they constituted a relatively small number of dispositions and did not appear to attenuate the substantial number of ED visits that resulted in hospitalization. Opportunities may exist to reduce hospitalizations by increasing short term management of HF in the observation unit.

Bacteriophage adhered to mucus provide a novel mucosal immune system (P3166)

Mucosal surfaces serve as a primary entry point for multiple pathogens and are therefore principal sites of immune defense. Here we demonstrate through in vitro and in silico studies that increased phage adherence to the host mucosal layer, provides a novel immune defense mechanism. We show that compared to the surrounding environment, phage-to-bacteria ratios were increased on all mucosal surfaces sampled ranging from cnidarians to humans. This increased phage abundance protects the underlying epithelium from bacterial infection. Enrichment of phage on mucus occurs via interactions between host mucin glycoproteins and phage immunoglobulin-like protein domains exposed on phage capsids. Metagenomic analysis found these immunoglobulin-like proteins present in many environments, particularly those adjacent to mucosal surfaces. Preliminary glycan microarrays and 2D gel electrophoresis show that phage adherence can rapidly adapt to hosts mucus glycan profiles, and in response, the host may regulate its mucus glycosylation to select for a beneficial phage community. This adaptation between phage and host provide a mechanism for the manipulation and selection of the mucosal microbiota. Based on these observations, we present the Bacteriophage Adherence to Mucus (BAM) model describing a phage-derived mucosal immunity with potential applicability to all mucosal surfaces, thus opening a novel field of immunological study.

Group B streptococcus induces trophoblast death

Group B streptococcus (GBS) is one of the leading causes of neonatal infection; however the molecular mechanisms involved are not clearly known. Here we used high and low hemolytic GBS isolates and mutant GBS that lacks beta-hemolysin expression and showed that GBS infection or exposure to GBS hemolysin extract induces primary human trophoblast, placental fibroblast and JEG3 trophoblast cell line death, and that GBS-induced trophoblast death was beta-hemolysin dependent. The fibroblasts and trophoblasts provide an innate immune barrier between fetal and maternal circulation in the placenta. These data suggest that GBS may disrupt this barrier to invade fetal circulation.

Controlled trial of pharmacist intervention in general practice: the effect on prescribing costs

BACKGROUND

It has been suggested that the employment of pharmacists in general practice might moderate the growth in prescribing costs. However, empirical evidence for this proposition has been lacking. We report the results of a controlled trial of pharmacist intervention in United Kingdom general practice.

AIM

To determine whether intervention practices made savings relative to controls.

METHOD

An evaluation of an initiative set up by Doncaster Health Authority. Eight practices agreed to take part and received intensive input from five pharmacists for one year (September 1996 to August 1997) at a cost of 163,000 Pounds. Changes in prescribing patterns were investigated by comparing these practices with eight individually matched controls for both the year of the intervention and the previous year. Prescribing data (PACTLINE) were used to assess these changes. The measures used to take account of differences in the populations of the practices included the ASTRO-PU for overall prescribing and the STAR-PU for prescribing in specific therapeutic areas. Differences between intervention and control practices were subjected to Wilcoxon matched-pairs, signed-ranks tests.

RESULTS

The median (minimum to maximum) rise in prescribing costs per ASTRO-PU was 0.85 Pound (-1.95 Pounds to 2.05 Pounds) in the intervention practices compared with 2.55 Pounds (1.74 Pounds to 4.65 Pounds) in controls (P = 0.025). Had the cost growth of the intervention group been as high as that of the controls, their total prescribing expenditure would have been around 347,000 Pounds higher.

CONCLUSION

This study suggests that the use of pharmacists did control prescribing expenditure sufficiently to offset their employment costs.