Exploring the feasibility and acceptability of community paramedicine programs in achieving vaccination equity: a qualitative study.

BACKGROUND: Mobile Integrated Health-Community Paramedicine (MIH-CP) is a novel approach that may reduce the rural-urban disparity in vaccination uptake in the United States. MIH-CP providers, as physician extenders, offer clinical follow-up and wrap-around services in homes and communities, uniquely positioning them as trusted messengers and vaccine providers. This study explores stakeholder perspectives on feasibility and acceptability of community paramedicine vaccination programs. METHODS: We conducted semi-structured qualitative interviews with leaders of paramedicine agencies with MIH-CP, without MIH-CP, and state/regional leaders in Indiana. Interviews were audio recorded, transcribed verbatim, and analyzed using content analysis. RESULTS: We interviewed 24 individuals who represented EMS organizations with MIH-CP programs (MIH-CP; n = 10), EMS organizations without MIH-CP programs (non-MIH-CP; n = 9), and state/regional administrators (SRA; n = 5). Overall, the sample included professionals with an average of 19.6 years in the field (range: 1-42 years). Approximately 75% (n = 14) were male, and all identified as non-Hispanic white. MIH-CPs reported they initiated a vaccine program to reach underserved areas, operating as a health department extension. Some MIH-CPs integrated existing services, such as food banks, with vaccine clinics, while other MIH-CPs focused on providing vaccinations as standalone initiatives. Key barriers to vaccination program initiation included funding and vaccinations being a low priority for MIH-CP programs. However, participants reported support for vaccine programs, particularly as they provided an opportunity to alleviate health disparities and improve community health. MIH-CPs reported low vaccine hesitancy in the community when community paramedics administered vaccines. Non-CP agencies expressed interest in launching vaccine programs if there is clear guidance, sustainable funding, and adequate personnel. CONCLUSIONS: Our study provides important context on the feasibility and acceptability of implementing an MIH-CP program. Findings offer valuable insights into reducing health disparities seen in vaccine uptake through community paramedics, a novel and innovative approach to reduce health disparities in rural communities.

Clinician Willingness to Prescribe Medications for Opioid Use Disorder to Adolescents in Indiana.

Importance: Prescribing medications for opioid use disorders (MOUD), including buprenorphine, naltrexone, and methadone, to adolescents remains an underused evidence-based strategy for reducing harms associated with opioid use. Objective: To identify potential associations between clinician- and community-level characteristics regarding clinicians' self-reported willingness to prescribe MOUD to adolescents. Design, Setting, and Participants: This cross-sectional study included a phone survey of Indiana clinicians and spatial analysis of community-level characteristics. Clinicians were eligible for inclusion in analyses if actively providing health care and listed on the Buprenorphine Practitioner Locator website, a publicly available national registry of clinicians possessing a waiver to legally prescribe buprenorphine (ie, waivered clinicians). Exposures: Community-level characteristics, including total population, rurality or urbanicity, percentage with incomes below the federal poverty line, and racial or ethnic makeup. Main Outcomes and Measures: Clinicians were asked about their willingness to prescribe MOUD to adolescents younger than 18 years if clinically indicated. Responses were recorded as no, yes, or yes with conditions. Results: Among the 871 clinicians listed on the website as of July 2022, 832 were eligible for inclusion and contacted by phone. Among waivered clinicians, 759 (91.2%) reported being unwilling to prescribe MOUD to adolescents, 73 clinicians (8.8%) reported willingness to prescribe MOUD to adolescents, and only 24 (2.9%) would do so without conditions. A multivariable logistic regression model including spatially lagged community-level variables showed that, among areas with waivered clinicians, clinicians practicing in more populated areas were significantly less likely to prescribe to adolescents (ß = 0.65; 95% CI, 0.49-0.87; P = .003). Similarly, those in more rural areas were significantly more likely to prescribe to adolescents (ß = 1.27; 95% CI, 1.02-1.58; P = .03). Variation in clinician willingness to prescribe was not explained by other community-level characteristics. Among all waivered clinicians, advanced practice clinicians were less likely than physicians to report willingness to prescribe (ß = 0.58; 95% CI, 0.35-0.97; P = .04), as were physicians without any specialty training relevant to MOUD prescribing when compared with family medicine clinicians (ß = 0.40; 95% CI, 0.18-0.89; P = .03). A small subgroup of waivered clinicians had training in pediatrics (13 clinicians [1.6%]), and none were willing to prescribe MOUD to adolescents. Conclusions and Relevance: From this cross-sectional study, it appears that Indiana adolescents continued to face gaps in access to MOUD treatment, despite its well-established efficacy. Programs that support primary care practitioners, including family medicine clinicians and pediatricians, in safe and appropriate use of MOUD in adolescents may bridge these gaps.

Comparing the effectiveness of environmental DNA and camera traps for surveying American mink (Neogale vison) in northeastern Indiana.

While camera traps can effectively detect semi-aquatic mammal species, they are also often temporally and monetarily inefficient and have a difficult time detecting smaller bodied, elusive mammals. Recent studies have shown that extracting DNA from environmental samples can be a non-invasive, alternative method of detecting elusive species. Environmental DNA (eDNA) has not yet been used to survey American mink (Neogale vison), a cryptic and understudied North American mustelid. To help determine best survey practices for the species, we compared the effectiveness and efficiency of eDNA and camera traps in surveys for American mink. We used both methods to monitor the shoreline of seven bodies of water in northeastern Indiana from March to May 2021. We extracted DNA from filtered environmental water samples and used quantitative real-time PCR to determine the presence of mink at each site. We used Akaike's Information Criterion to rank probability of detection models with and without survey method as a covariate. We detected mink at four of the seven sites and seven of the 21 total survey weeks using camera traps (probability of detection (ρ) = 0.36). We detected mink at five sites and during five survey weeks using eDNA (ρ = 0.25). However, the highest probability of detection was obtained when both methods were combined, and data were pooled (ρ = 0.47). Survey method did not influence model fit, suggesting no difference in detectability between camera traps and eDNA. Environmental DNA was twice as expensive, but only required a little over half (58%) of the time when compared to camera trapping. We recommend ways in which an improved eDNA methodology may be more cost effective for future studies. For this study, a combination of both methods yielded the highest probability for detecting mink presence.

Real-world data to support post-market safety and performance of embolization coils: evidence generation from a medical device manufacturer and data institute partnership.

BACKGROUND: Recognizing the limitations of pre-market clinical data, regulatory authorities have embraced total product lifecycle management with post-market surveillance (PMS) data to assess medical device safety and performance. One method of proactive PMS involves the analysis of real-world data (RWD) through retrospective review of electronic health records (EHR). Because EHRs are patient-centered and focused on providing tools that clinicians use to determine care rather than collecting information on individual medical products, the process of transforming RWD into real-world evidence (RWE) can be laborious, particularly for medical devices with broad clinical use and extended clinical follow-up. This study describes a method to extract RWD from EHR to generate RWE on the safety and performance of embolization coils. METHODS: Through a partnership between a non-profit data institute and a medical device manufacturer, information on implantable embolization coils' use was extracted, linked, and analyzed from clinical data housed in an electronic data warehouse from the state of Indiana's largest health system. To evaluate the performance and safety of the embolization coils, technical success and safety were defined as per the Society of Interventional Radiology guidelines. A multi-prong strategy including electronic and manual review of unstructured (clinical chart notes) and structured data (International Classification of Disease codes), was developed to identify patients with relevant devices and extract data related to the endpoints. RESULTS: A total of 323 patients were identified as treated using Cook Medical Tornado, Nester, or MReye embolization coils between 1 January 2014 and 31 December 2018. Available clinical follow-up for these patients was 1127 ± 719 days. Indications for use, adverse events, and procedural success rates were identified via automated extraction of structured data along with review of available unstructured data. The overall technical success rate was 96.7%, and the safety events rate was 5.3% with 18 major adverse events in 17 patients. The calculated technical success and safety rates met pre-established performance goals (≥ 85% for technical success and ≤ 12% for safety), highlighting the relevance of this surveillance method. CONCLUSIONS: Generating RWE from RWD requires careful planning and execution. The process described herein provided valuable longitudinal data for PMS of real-world device safety and performance. This cost-effective approach can be translated to other medical devices and similar RWD database systems.

It's time to address our nation's health care price crisis.

High health care prices cause significant harm to individuals, businesses, communities, and society at large. These harms include reduced access to care, rising medical debt, lower wages, more inequity, and a growing burden on businesses and governments. Despite widespread recognition of the issue, there has been insufficient action to address it effectively. Catalyst for Payment Reform and the Employers' Forum of Indiana's new campaign, Price Crisis, will mobilize individuals, employers, and policy makers with evidence, guidance, and resources to take meaningful actions through marketplace initiatives, policy advocacy, and antitrust enforcement. The following article is written from the perspective of Catalyst for Payment Reform.

Factors Influencing Older People's Intentions to Vaccinate.

Vaccination is crucial in reducing the spread of disease and improving overall patient mortality. Limited information exists regarding pharmacist accessibility outside traditional medical settings or impact on older patients' intention to vaccinate. This study aimed to examine patient perceptions regarding pharmacist accessibility and vaccination intention. Researchers used a quantitative research method of older people from Ohio, Kentucky, and Indiana. A survey was given to community-dwelling older people who attended different vaccine clinics. The survey included 10 questions describing reasons for not receiving vaccines in the past, how likely they are to receive vaccines if administered at community events, and the importance of having easy access to vaccines. For Likert-type items, a 5-point scale was used. The surveys were collected electronically and anonymously from several community events. Aggregate data were analyzed with descriptive and inferential statistics. One hundred seventy-eight responses were collected. The average age of participants was 75 years, and 70.8% were females. Of the respondents, 44.9% preferred to receive vaccines at a community center, 17.4% at the doctor's office, 4.5% at a clinic, and 9.6% at a sporting event like a boxing match. Men were more likely to receive a vaccine at a sporting event, while women were more likely to be interested in receiving a vaccine at a community center (P < 0.05). Respondents somewhat agreed (median = 4, interquartile range = 3-5) that they do not have transportation to places with vaccines. Age was significantly and negatively correlated with educational attainment (P < 0.001). However, as participants' ages increased, they were significantly more likely to have a belief that vaccines do not work (P = 0.011). The study addressed how pharmacists should consider more community outreach events in convenient locations, like community centers, for older people to improve vaccination rates.

Development of a Multifaceted Program for Pharmacogenetics Adoption at an Academic Medical Center: Practical Considerations and Lessons Learned.

In 2019, Indiana University launched the Precision Health Initiative to enhance the institutional adoption of precision medicine, including pharmacogenetics (PGx) implementation, at university-affiliated practice sites across Indiana. The overarching goal of this PGx implementation program was to facilitate the sustainable adoption of genotype-guided prescribing into routine clinical care. To accomplish this goal, we pursued the following specific objectives: (i) to integrate PGx testing into existing healthcare system processes; (ii) to implement drug-gene pairs with high-level evidence and educate providers and pharmacists on established clinical management recommendations; (iii) to engage key stakeholders, including patients to optimize the return of results for PGx testing; (iv) to reduce health disparities through the targeted inclusion of underrepresented populations; (v) and to track third-party reimbursement. This tutorial details our multifaceted PGx implementation program, including descriptions of our interventions, the critical challenges faced, and the major program successes. By describing our experience, we aim to assist other clinical teams in achieving sustainable PGx implementation in their health systems.

Insights from a COVID-era health needs assessment of rural Midwestern Latinos.

Latino health and well-being are crucial to the growth and vibrancy of rural areas across the United States, particularly at a time when the demographics of many rural communities are transitioning from minority Latino to majority Latino populations. This manuscript details the findings of a study that explored the health and healthcare benefit status of 524 Latino households in rural Indiana during the COVID-19 pandemic. Via 20-minute, door-to-door interviews conducted by bilingual researchers, survey participants answered questions about access to healthcare services and benefits, dietary and safety habits, medical issues, and vaccination status. The study found that slightly more than half of those surveyed were enrolled in healthcare benefit plans; approximately a third were unsatisfied with their health/health status; almost two-thirds had not received a flu shot and were eating fast food/processed food on a daily basis. Top health concerns reported included: stress (52%), vision problems (34%), neck and back pain (30%), headaches/migraines (28%), anxiety and depression (28%) and weight problems (26%). The study also discovered that half of the respondents could not identify a primary healthcare provider (PCP) by name and that pregnant women faced a lack of resources for maternal health in the county where the study was conducted. The results indicate that Latinos in rural communities continue to endure significant health issues and barriers to healthcare. The study provides an excellent model of how a rural community can monitor the health of its residents, which can inform health interventions for underserved populations.

A Study Examining the Impact of County-Level Demographic, Socioeconomic, and Political Affiliation Characteristics on COVID-19 Vaccination Patterns in Indiana.

The COVID-19 vaccination campaign resulted in uneven vaccine uptake throughout the United States, particularly in rural areas, areas with socially and economically disadvantaged groups, and populations that exhibited vaccine hesitancy behaviors. This study examines how county-level sociodemographic and political affiliation characteristics differentially affected patterns of COVID-19 vaccinations in the state of Indiana every month in 2021. We linked county-level demographics from the 2016-2020 American Community Survey Five-Year Estimates and the Indiana Elections Results Database with county-level COVID-19 vaccination counts from the Indiana State Department of Health. We then created twelve monthly linear regression models to assess which variables were consistently being selected, based on the Akaike Information Criterion (AIC) and adjusted R-squared values. The vaccination models showed a positive association with proportions of Bachelor's degree-holding residents, of 40-59 year-old residents, proportions of Democratic-voting residents, and a negative association with uninsured and unemployed residents, persons living below the poverty line, residents without access to the Internet, and persons of Other Race. Overall, after April, the variables selected were consistent, with the model's high adjusted R2 values for COVID-19 cumulative vaccinations demonstrating that the county sociodemographic and political affiliation characteristics can explain most of the variation in vaccinations. Linking county-level sociodemographic and political affiliation characteristics with Indiana's COVID-19 vaccinations revealed inherent inequalities in vaccine coverage among different sociodemographic groups. Increased vaccine uptake could be improved in the future through targeted messaging, which provides culturally relevant advertising campaigns for groups less likely to receive a vaccine, and increasing access to vaccines for rural, under-resourced, and underserved populations.

Exploring the role of salon professionals in identifying sex trafficking and violence victims in Indiana.

BACKGROUND: Sex trafficking victims often have touchpoints with salons for waxing, styling, and other body modification services required by traffickers. Recently, some states have administered laws requiring salon professionals to receive intimate partner violence (IPV)-related training, with even fewer states mandating training on identifying sex trafficking. This study aimed to understand how salon professionals have witnessed evidence of violence, including IPV and sex trafficking, in the workplace and to explore the differences in their approach to each type of victim. METHODS: In-depth interviews were conducted with salon professionals (N = 10) and law enforcement professionals/policymakers (N = 5). Content and thematic analysis techniques were used. RESULTS: Salon professionals typically identified potential violence through signs such as bruises, odd behavior, and client disclosures, prompting them to engage in cautious conversations. Yet, few were trained to identify and intervene. Often, they responded to suspected violence by talking with the client, sharing concerns with salon leadership, directly intervening on the client's behalf, or contacting the police. Law enforcement and salon professionals had suggestions about improving salon professionals' recognition of and response to violence, including training on victim-focused resources, creating a safe environment, and building relationships with law enforcement. They also suggested strengthening community partnerships to increase resource advocacy and reporting. CONCLUSIONS: One-on-one salon services may provide a unique opportunity to intervene and identify victims of violence, especially when empowered through additional training and collaborative partnerships with community-oriented policing initiates. Implementing training and community-based initiatives could aid salon professionals in gaining greater confidence in knowing what to do when serving a client who is a victim of IPV or sex trafficking.

Pepea Pamoja:† Applying the Ecological Validity Framework to co-develop a wellbeing and behavioural training program for caregivers of young children with autism in low-resource settings of Kenya and the United States.

BACKGROUND: Autism is a complex neurodevelopmental disability with global prevalence of one in 100 individuals. Poor access to interventions in both under-resourced regions of high-income countries and low- and middle-income countries has deleterious effects on the health and wellbeing of individuals with autism and their families. Our objective was to utilize a reciprocal innovation framework and participatory methods to adapt and co-develop a culturally grounded group-based wellbeing and naturalistic developmental behavioural intervention (NDBI) training program for caregivers of young children with autism to be implemented in Kenya and rural Indiana. METHODS: This study was conducted within the Academic Model Providing Access to Healthcare (AMPATH) program. An evidence-informed Naturalistic Developmental Behavioral Intervention (NDBI) previously utilized in Indiana was adapted and iteratively refined using the Ecological Validity Framework (EVF) by a team of US and Kenyan disability experts. Key adaptations to the program were made across the EVF domains of language, persons, metaphors/content, concepts, goals, methods, and context. RESULTS: Substantial cultural adaptations were made to the NDBI following the EVF model, including the addition of traditional Kenyan cultural practices, use of narrative principles, and focus on daily routines over play. Pepea, the adapted program, involves 10 group sessions covering content in basic education on autism, positive caregiver coping strategies, and behavioural skills training to promote child communication and reduce challenging behaviour. Key adaptations for Pepea were integrated back into a US NDBI caregiver training program. CONCLUSIONS: This study fills a critical gap by detailing the adaptation process of a caregiver wellbeing and naturalistic developmental behavioural training program for caregivers of children with autism in low-resource settings. Our next steps are to report on mixed-methods outcomes from pilot implementation. Our long-term goal is to apply these insights to advance sustainable and scalable autism intervention services across the globe.

A community-based participatory research approach to evaluating and improving hepatitis C risk, knowledge, and stigma associations among people who inject substances in Indiana.

OBJECTIVES: To explore hepatitis C risk, knowledge, and stigma among individuals who inject substances in South Central Indiana. DESIGN: A cross-sectional study design was employed using a community-based participatory research approach. The community partner was a grassroots harm reduction organization. SAMPLE: Participants in this study were at least 18 years of age, current residents of Indiana, and self-identified as injection substance users (n = 179). MEASUREMENTS: The survey measured hepatitis C risk, knowledge, and stigma, as well as differences in hepatitis C risk scores among key demographic characteristics. RESULTS: Most participants identified as male (n = 106, 59%), White (n = 139, 78%), and straight (n = 143, 80%). People of color reported lower hepatitis C knowledge than White participants. Women had significantly lower hepatitis C knowledge compared with men. LGBTQ participants reported increased hepatitis C risk compared with straight participants. Increased frequency of substance use was associated with decreased stigma. Unhoused participants demonstrated significantly lower hepatitis C knowledge compared with housing-secure participants. CONCLUSIONS: Our findings increase understanding that knowledge and risk around hepatitis C are associated with demographic characteristics. Results underscore the need for tailored public health interventions to increase hepatitis C knowledge, reduce stigma, and improve testing and treatment among vulnerable populations.

Evaluation of tetrachloroethylene (PCE) and its degradation products in human exhaled breath and indoor air in a community setting.

Tetrachloroethylene (PCE) is a widely utilized volatile chemical in industrial applications, including dry cleaning and metal degreasing. Exposure to PCE potentially presents a significant health risk to workers as well as communities near contamination sites. Adverse health effects arise not only from PCE, but also from PCE degradation products, such as trichloroethylene (TCE) and vinyl chloride (VC). PCE, TCE, and VC can contaminate water, soil, and air, leading to exposure through multiple pathways, including inhalation, ingestion, and dermal contact. This study focused on a community setting in Martinsville, Indiana, a working-class Midwestern community in the United States, where extensive PCE contamination has occurred due to multiple contamination sites (referring to 'plumes'), including a Superfund site. Utilizing proton transfer reaction time-of-flight mass spectrometry (PTR-TOF-MS), PCE, TCE, and VC concentrations were measured in the exhaled breath of 73 residents from both within and outside the plume areas. PCE was detected in 66 samples, TCE in 26 samples, and VC in 68 samples. Our results revealed a significant positive correlation between the concentrations of these compounds in exhaled breath and indoor air (Pearson correlation coefficients: PCE = 0.75, TCE = 0.71, and VC = 0.89). This study confirms the presence of PCE and its degradation products in exhaled breath in a community exposure investigation, demonstrating the potential of using exhaled breath analysis in monitoring exposure to environmental contaminants. This study showed the feasibility of utilizing PTR-TOF-MS in community investigations to assess exposure to PCE and its degradation products by measuring these compounds in exhaled breath and indoor air.

Peer Education as a Tool to Improve Health Knowledge for People Who Are Incarcerated: A Secondary Analysis of Data From the Indiana Peer Education Program ECHO.

Considerable health inequities occur among people who are incarcerated, with ripple effects into broader community health. The Indiana Peer Education Program uses the Extension for Community Health Outcomes (ECHO) model to train people who are incarcerated as peer health educators. This analysis sought to evaluate the effectiveness of this program and explore emergent themes not covered in survey instruments. Survey data for both peer educators and their students were assessed using multivariate regression. Qualitative data were used to triangulate survey findings and explore additional themes via thematic analysis. Students showed improvements in knowledge scores and postrelease behavior intentions; peer educators improved in knowledge, health attitudes, and self-efficacy. Qualitative data affirmed survey findings and pointed toward peer educators acquiring expertise in the content they teach, and how to teach it, and that positive results likely expand beyond participants to others in prison, their families, and the communities to which they return. Though preliminary, the results confirm an earlier analysis of the New Mexico Peer Education Program ECHO, adding to the evidence that training individuals who are incarcerated as peer educators on relevant public health topics increases health knowledge and behavior intentions and likely results in improvements in personal and public health outcomes.

Listening to the community: identifying obesity prevention strategies for rural preschool-aged children.

Multi-level interventions promoting healthy weight in rural preschool children aged 2-5 years are limited. With the goal of developing a community-informed obesity prevention intervention for rural preschool-aged children, the purpose of this descriptive study was to identify: (1) community settings and intervention strategies to prioritize for an intervention; (2) potential implementation challenges and solutions; and (3) immediate interventions the study team and community partners could collaboratively implement. Workshops occurred in two rural communities in Indiana (2 workshops) and North Carolina (2 workshops), with high obesity rates. A guide was developed to moderate discussions and participants voted to rank community settings and intervention strategies. There were 9-15 participants per workshop, including parents, childcare providers, and representatives of community organizations. Community settings identified as priorities for child obesity prevention included the home, educational settings (preschools), food outlets, recreational facilities, and social media. Priority intervention strategies included providing nutrition and physical activity education, increasing access to healthy foods and physical activity in the built environment, and enhancing food security. Potential intervention implementation challenges centered on poor parental engagement; using personalized invitations and providing transportation support to families were proffered solutions. Immediate interventions to collaboratively implement focused on making playgrounds esthetically pleasing for physical activity using game stencils, and nutrition education for families via quarterly newsletters. This participatory approach with community partners provided insight into two rural communities' needs for child obesity prevention, community assets (settings) to leverage, and potential intervention strategies to prioritize. Findings will guide the development of a multi-level community-based intervention.

Development of a Real-Time Dashboard for Overdose Touchpoints: User-Centered Design Approach.

BACKGROUND: Overdose Fatality Review (OFR) is an important public health tool for shaping overdose prevention strategies in communities. However, OFR teams review only a few cases at a time, which typically represent a small fraction of the total fatalities in their jurisdiction. Such limited review could result in a partial understanding of local overdose patterns, leading to policy recommendations that do not fully address the broader community needs. OBJECTIVE: This study explored the potential to enhance conventional OFRs with a data dashboard, incorporating visualizations of touchpoints-events that precede overdoses-to highlight prevention opportunities. METHODS: We conducted 2 focus groups and a survey of OFR experts to characterize their information needs and design a real-time dashboard that tracks and measures decedents' past interactions with services in Indiana. Experts (N=27) were engaged, yielding insights on essential data features to incorporate and providing feedback to guide the development of visualizations. RESULTS: The findings highlighted the importance of showing decedents' interactions with health services (emergency medical services) and the justice system (incarcerations). Emphasis was also placed on maintaining decedent anonymity, particularly in small communities, and the need for training OFR members in data interpretation. The developed dashboard summarizes key touchpoint metrics, including prevalence, interaction frequency, and time intervals between touchpoints and overdoses, with data viewable at the county and state levels. In an initial evaluation, the dashboard was well received for its comprehensive data coverage and its potential for enhancing OFR recommendations and case selection. CONCLUSIONS: The Indiana touchpoints dashboard is the first to display real-time visualizations that link administrative and overdose mortality data across the state. This resource equips local health officials and OFRs with timely, quantitative, and spatiotemporal insights into overdose risk factors in their communities, facilitating data-driven interventions and policy changes. However, fully integrating the dashboard into OFR practices will likely require training teams in data interpretation and decision-making.

Indiana's Public Health Investment Holds Insights For Other States.

Indiana has a business-friendly environment, but historical underinvestment in public health has yielded poor health outcomes. In 2023, when trust in governmental public health was strained nationwide, Indiana increased public health spending by 1,500 percent. In this article, we explain how Indiana achieved this unprecedented legislative victory for public health, describing the context, approach, and lessons learned. Specifically, an Indiana University report linking economic vitality and overall health sparked the creation of a governor's commission charged with exploring ways to address Indiana's shortcomings. Working with the Indiana Department of Health, the commission developed multisectoral coalitions and business and government partnerships, and it maintained consistent and coordinated communication with policy makers. Lessons learned included the value of uncoupling public health from partisan narratives, appointing diverse commission membership with strategically selected cochairs, involving local leaders, and ensuring local decision-making control. We believe that Indiana's approach holds insights for other states interested in strengthening public health funding in the current era.

Outcome Evaluation of a Health System Clinical Nurse Specialist Fellowship Program.

PURPOSE: Healthcare is a complex adaptive system, requiring agile, innovative leaders to transform care. Clinical nurse specialists (CNSs) are uniquely positioned to influence change and achieve high-quality outcomes. Nurse leaders need strategies to onboard and retain CNSs considering high demand across the nation. The purpose of this program evaluation was to describe the core components and outcomes of CNS fellowship programs. DESIGN: This program evaluation used the Kirkpatrick Model as a framework to assess learning and knowledge translation. METHODS: The study was conducted within 3 Indiana healthcare organizations. Clinical nurse specialist leaders from each organization identified fellowship core components and analyzed team composition (ie, percentage of CNS team that was current/past fellows). Current and past CNS fellows were invited to participate in a survey evaluating program effectiveness, impact on role transition, project leadership, and outcomes achieved. RESULTS: Overlap was identified among 85% (17/20) of the core components, team composition was 71% (25/35) past/current fellows, and retention was 100% (12/12). Of the 23 invited, 18 (78%) participated in the program evaluation. Program effectiveness was evaluated as very/extremely effective by 94% (17/18) of participants. Themes salient to independent practice transition were applying learning, achieving influence, and developing relationally, contributing to incremental gain of the CNS perspective (ie, CNS values and guiding principles influencing critical thinking and behavior). CONCLUSION: Nurse leaders should consider fellowship implementation to recruit and retain CNS talent within organizations.

Foreword to: Indiana University's Response to the Addictions Crisis: A Grand Challenge Initiative.

Use of heroin, prescription painkillers, methamphetamines, and fentanyl led to a national health crisis in 2017, resulting in 1852 overdose deaths in Indiana. Governor Eric J. Holcomb made tackling substance use in the state one of his highest priorities, calling on all Hoosiers to collaborate. In October 2017, Indiana University (IU) President Michael A. McRobbie responded, announcing that the University would be initiating the Responding to the Addictions Crisis Grand Challenge (AGC). Partners included Governor Holcomb, IU Health, and Eskenazi Health. Leveraging the university's research strengths and partnering with more than 160 community organizations across the state, the AGC sought to address substance use facing Indiana and beyond. Fifty interdisciplinary research projects were created through the AGC, focusing on IU's greatest strength in five areas: (1) education, training, and certification; (2) data science and analysis; (3) policy analysis, economics, and law; (4) basic, applied, and translational research; (5) community engagement and workforce development. Diversity, equity, and inclusion implications were often considered. This supplement describes the IU approach to address the health of the people of the State, investigator initiated projects and research conducted to inform practice, strategy and policy.