Grassroots and Digital Outreach Strategies Raise Awareness of COVID-19 Information and Research in Baltimore City.

We aimed to disseminate reliable COVID-19 information to the Black and Latino communities of Baltimore City, Maryland, between July 2020 and December 2022. With community partners, we disseminated evidence-based COVID-19 information via grassroots and digital strategies, including Hopkins Opportunity for Participant Engagement, and connected volunteers to COVID-19 research. Using a multimodal approach facilitated dissemination of reliable information and raised awareness of research; evaluation of trust is ongoing. Robust, multimodal strategies are needed to foster trust and equity among diverse communities. (Am J Public Health. 2024;114(S1):S69-S73. https://doi.org/10.2105/AJPH.2023.307492).

Integrating community voices in the research continuum: Perspectives on a consultation service.

The Community Research Advisory Council (C-RAC) of the Johns Hopkins Institute for Clinical and Translational Research was established in 2009 to provide community-engaged research consultation services. In 2016-2017, C-RAC members and researchers were surveyed on their consultation experiences. Survey results and a 2019 stakeholder meeting proceeding helped redesign the consultation services. Transitioning to virtual consultations during COVID-19, the redesigning involved increasing visibility, providing consultation materials in advance, expanding member training, and effective communications. An increase in consultations from 28 (2009-2017) to 114 (2020-2022) was observed. Implementing stakeholder-researcher inputs is critical to holistic and sustained community-engaged research.

The Volume and Cost of Quality Metric Reporting.

Importance: US hospitals report data on many health care quality metrics to government and independent health care rating organizations, but the annual cost to acute care hospitals of measuring and reporting quality metric data, independent of resources spent on quality interventions, is not well known. Objective: To evaluate externally reported inpatient quality metrics for adult patients and estimate the cost of data collection and reporting, independent of quality-improvement efforts. Design, Setting, and Participants: Retrospective time-driven activity-based costing study at the Johns Hopkins Hospital (Baltimore, Maryland) with hospital personnel involved in quality metric reporting processes interviewed between January 1, 2019, and June 30, 2019, about quality reporting activities in the 2018 calendar year. Main Outcomes and Measures: Outcomes included the number of metrics, annual person-hours per metric type, and annual personnel cost per metric type. Results: A total of 162 unique metrics were identified, of which 96 (59.3%) were claims-based, 107 (66.0%) were outcome metrics, and 101 (62.3%) were related to patient safety. Preparing and reporting data for these metrics required an estimated 108 478 person-hours, with an estimated personnel cost of $5 038 218.28 (2022 USD) plus an additional $602 730.66 in vendor fees. Claims-based (96 metrics; $37 553.58 per metric per year) and chart-abstracted (26 metrics; $33 871.30 per metric per year) metrics used the most resources per metric, while electronic metrics consumed far less (4 metrics; $1901.58 per metric per year). Conclusions and Relevance: Significant resources are expended exclusively for quality reporting, and some methods of quality assessment are far more expensive than others. Claims-based metrics were unexpectedly found to be the most resource intensive of all metric types. Policy makers should consider reducing the number of metrics and shifting to electronic metrics, when possible, to optimize resources spent in the overall pursuit of higher quality.

Digital and virtual strategies to advance community stakeholder engagement in research during COVID-19 pandemic.

Despite the adversity presented by COVID-19 pandemic, it also pushed for experimenting with innovative strategies for community engagement. The Community Research Advisory Council (C-RAC) at Johns Hopkins University (JHU), is an initiative to promote community engagement in research. COVID-19 rendered it impossible for C-RAC to conduct its meetings all of which have historically been in person. We describe the experience of advancing the work of the C-RAC during COVID-19 using digital and virtual strategies. Since March 2020, C-RAC transitioned from in person to virtual meetings. The needs assessment was conducted among C-RAC members, and individualized solutions provided for a successful virtual engagement. The usual working schedule was altered to respond to COVID-19 and promote community engaged research. Attendance to C-RAC meetings before and after the transition to virtual operation increased from 69% to 76% among C-RAC members from the community. In addition, the C-RAC launched new initiatives and in eighteen months since January 2020, it conducted 50 highly rated research reviews for 20 research teams. The experience of the C-RAC demonstrates that when community needs are assessed and addressed, and technical support is provided, digital strategies can lead to greater community collaborations.

Storytelling training to promote stakeholder engagement in research dissemination.

Storytelling is increasingly recognized as a culturally relevant, human-centered strategy and has been linked to improvements in health knowledge, behavior, and outcomes. The Community Engagement Program of the Johns Hopkins Institute for Clinical and Translational Research designed and implemented a storytelling training program as a potentially versatile approach to promote stakeholder engagement. Data collected from multiple sources, including participant ratings, responses to open-ended questions, and field notes, consistently pointed to high-level satisfaction and acceptability of the program. As a next step, the storytelling training process and its impact need to be further investigated.

Approaches to Measuring Trends in Interdisciplinary Research Publications at One Academic Medical Center.

PURPOSE: To determine if interdisciplinary research has increased between 2005 and 2015, based on an analysis of journal articles containing at least 1 author from Johns Hopkins University, and to compare different methods for determining the disciplinarity of research articles. METHOD: In 2017-2018, 100 peer-reviewed biomedical science articles were randomly selected from years 2005, 2010, and 2015 and classified as unidisciplinary or interdisciplinary based on Scopus author affiliation data (method 1). The corresponding authors of the 2010 and 2015 articles were sent a survey asking them to describe the disciplines involved in their research (method 2) and to define their research as unidisciplinary or interdisciplinary based on provided definitions (method 3). RESULTS: There was a statistically significant increase in the proportion of interdisciplinary articles in 2015 compared with both 2005 and 2010 (P = .02). Comparison of the 3 methods indicated that 45% of the articles were classified as interdisciplinary based on author affiliation data (method 1), 40% based on the corresponding author's description of the disciplines involved in their research (method 2), and 71% based on the corresponding author's definition of their article's disciplinarity (method 3). There was a statistically significant difference in the proportion of articles classified as interdisciplinary between methods 1 and 3 (P < .001) and between methods 2 and 3 (P < .001). CONCLUSIONS: This study found that interdisciplinary research increased at Johns Hopkins University over the past decade and highlights the difference between corresponding authors' views of their own research and other methods for determining interdisciplinarity.

The Baltimore Community-Based Organizations Neighborhood Network: Enhancing Capacity Together (CONNECT) Cluster RCT.

INTRODUCTION: This cluster RCT aimed to reduce healthcare utilization and increase the referral of patients between an academic health center and local community-based organizations (CBOs) that address social determinants of health. STUDY DESIGN: Cluster RCT. SETTINGS/PARTICIPANTS: Twenty-two CBOs located in Baltimore, Maryland, were randomly assigned to the intervention or control group, and 5,255 patients were allocated to the intervention or control group based on whether they lived closer to an intervention or control CBO. Data were collected in 2014-2016; the analysis was conducted in 2016. INTERVENTION: A multicomponent intervention included an online tool to help refer clients to community resources, meet-and-greet sessions between CBO staff and healthcare staff, and research assistants. MAIN OUTCOME MEASURES: The primary outcomes were patient emergency department visits and days spent in the hospital. Additional outcomes for CBO clients included knowledge of other CBOs, number of referrals to CBOs by the healthcare system, and number of referrals to healthcare system by CBOs. Outcomes for CBO staff included the number of referrals made to and received from the healthcare system and the number of referrals made to and received from other CBOs. RESULTS: There was no significant effect of the intervention on healthcare utilization outcomes, CBO client outcomes, or CBO staff outcomes. Ancillary analyses demonstrated a 2.9% increase in referrals by inpatient staff to intervention CBOs (p=0.051) and a 6.6% increase in referrals by outpatient staff to intervention CBOs between baseline and follow-up (p=0.027). Outpatient staff reported a significant reduction in barriers related to the lack of information about CBO services (-18.3%, p=0.004) and an increase in confidence in community resources (+14.4%, p=0.023) from baseline to follow-up. CONCLUSIONS: The intervention did not improve healthcare utilization outcomes but was associated with increased healthcare staff knowledge of, and confidence in, local CBOs. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT02222909.

Baltimore CONNECT: A Randomized Trial to Build Partnership Between Community Organizations and a Local Health System.

BACKGROUND: Community-based organizations (CBOs) are key partners in supporting care, but health systems and CBOs operate in silos. Baltimore Community-based Organizations Neighborhood Network: Enhancing Capacity Together (CONNECT) was a randomized, controlled trial based on the core tenets of the World Health Organization's (WHO) African Partnerships for Patient Safety Community Engagement (ACE) approach. OBJECTIVES: We describe a research protocol and lessons learned from a partnership between Johns Hopkins Health System and 11 CBOs. METHODS: Baltimore CONNECT involved 22 CBOs in East Baltimore randomized to a co-developed intervention bundle versus control. Data were from review of notes and minutes from meetings, and discussions with each CBO on value added by intervention elements and on impact of the project. LESSONS LEARNED: It is feasible to engage and maintain a network of CBOs linked with a local health system. CONCLUSIONS: The WHO ACE approach supported development and sustainment of a network of organizations linking health care and social services across East Baltimore.

Grappling With Complex Food Systems to Reduce Obesity: A US Public Health Challenge.

Despite 2 decades of effort by the public health community to combat obesity, obesity rates in the United States continue to rise. This lack of progress raises fundamental questions about the adequacy of our current approaches. Although the causes of population-wide obesity are multifactorial, attention to food systems as potential drivers of obesity has been prominent. However, the relationships between broader food systems and obesity are not always well understood. Our efforts to address obesity can be advanced and improved by the use of systems approaches that consider outcomes of the interconnected global food system, including undernutrition, climate change, the environmental sustainability of agriculture, and other social and economic concerns. By implementing innovative local and state programs, taking new approaches to overcome political obstacles to effect policy, and reconceptualizing research needs, we can improve obesity prevention efforts that target the food systems, maximize positive outcomes, and minimize adverse consequences. We recommend strengthening innovative local policies and programs, particularly those that involve community members in identifying problems and potential solutions and that embrace a broad set of goals beyond making eating patterns healthier. We also recommend undertaking interdisciplinary research projects that go beyond testing targeted interventions in specific populations and aim to build an understanding of the broader social, political, and economic context.

From Kisiizi to Baltimore: cultivating knowledge brokers to support global innovation for community engagement in healthcare.

BACKGROUND: Reverse Innovation has been endorsed as a vehicle for promoting bidirectional learning and information flow between low- and middle-income countries and high-income countries, with the aim of tackling common unmet needs. One such need, which traverses international boundaries, is the development of strategies to initiate and sustain community engagement in health care delivery systems. OBJECTIVE: In this commentary, we discuss the Baltimore "Community-based Organizations Neighborhood Network: Enhancing Capacity Together" Study. This randomized controlled trial evaluated whether or not a community engagement strategy, developed to address patient safety in low- and middle-income countries throughout sub-Saharan Africa, could be successfully applied to create and implement strategies that would link community-based organizations to a local health care system in Baltimore, a city in the United States. Specifically, we explore the trial's activation of community knowledge brokers as the conduit through which community engagement, and innovation production, was achieved. Cultivating community knowledge brokers holds promise as a vehicle for advancing global innovation in the context of health care delivery systems. As such, further efforts to discern the ways in which they may promote the development and dissemination of innovations in health care systems is warranted. TRIAL REGISTRATION: Trial Registration Number: NCT02222909 . Trial Register Name: Reverse Innovation and Patient Engagement to Improve Quality of Care and Patient Outcomes (CONNECT). Date of Trial's Registration: August 22, 2014.

A Concise Tool for Measuring Care Coordination from the Provider's Perspective in the Hospital Setting.

BACKGROUND: To support hospital efforts to improve coordination of care, a tool is needed to evaluate care coordination from the perspective of inpatient healthcare professionals. OBJECTIVES: To develop a concise tool for assessing care coordination in hospital units from the perspective of healthcare professionals, and to assess the performance of the tool in measuring dimensions of care coordination in 2 hospitals after implementation of a care coordination initiative. METHODS: We developed a survey consisting of 12 specific items and 1 global item to measure provider perceptions of care coordination across a variety of domains, including teamwork and communication, handoffs, transitions, and patient engagement. The questionnaire was distributed online between October 2015 and January 2016 to nurses, physicians, social workers, case managers, and other professionals in 2 tertiary care hospitals. RESULTS: A total of 841 inpatient care professionals completed the survey (response rate = 56.6%). Among respondents, 590 (75%) were nurses and 37 (4.7%) were physicians. Exploratory factor analysis revealed 4 subscales: (1) Teamwork, (2) Patient Engagement, (3) Handoffs, and (4) Transitions (Cronbach's alpha 0.84-0.90). Scores were fairly consistent for 3 subscales but were lower for patient engagement. There were minor differences in scores by profession, department, and hospital. CONCLUSIONS: The new tool measures 4 important aspects of inpatient care coordination with evidence for internal consistency and construct validity, indicating that the tool can be used in monitoring, evaluating, and planning care coordination activities in hospital settings.

How Co-Developed Are Community and Academic Partnerships?

BACKGROUND: The world-renowned resources of Johns Hopkins Hospital (JHH) in Baltimore, Maryland, stand in marked contrast with the surrounding impoverished neighborhoods. Community-based organizations (CBOs) are critical frontline responders to residents' needs. Baltimore CONNECT, an academic-community partnership, co-developed an intervention to strengthen connections between CBOs and between CBOs and the health care system. OBJECTIVES: To understand how members of an academic- community partnership define the act of "co-development" and share perceptions of barriers, facilitators, and ways to measure it. METHODS: We conducted semistructured interviews with 15 community partners, academic partners, and external stakeholders. RESULTS: Partners conceptualized co-development as a fluid and evolving process that is the outcome of shared decision making. This exploration revealed nuances within partnership dynamics, including motivations for participation, underlying incentives, partnership equality, balance of power, and trust and relation building. CONCLUSIONS: We present insights that can be used by academic researchers and community leaders looking to co-develop interventions to improve health in urban communities domestically and internationally.JHH in Baltimore, Maryland, is one of the most highly regarded hospitals in the United States. However, its institutional resources stand in marked contrast with those available to the impoverished neighborhoods that surround it. Many have called for JHH to play a greater role in the surrounding community, where it serves as a leading source of health care.

Hospital Characteristics and the Agency for Healthcare Research and Quality Inpatient Quality Indicators: A Systematic Review.

BACKGROUND: The Agency for Healthcare Research and Quality Inpatient Quality Indicators (IQIs) include inpatient mortality for selected procedures and medical conditions. They have assumed an increasingly prominent role in hospital comparisons. Healthcare delivery and policy-related decisions need to be driven by reliable research that shows associations between hospital characteristics and quality of inpatient care delivered. OBJECTIVES: To systematically review the literature on associations between hospital characteristics and IQIs. METHODS: We systematically searched PubMed and gray literature (2000-2012) for studies relevant to 14 hospital characteristics and 17 IQIs. We extracted data for study characteristics, IQIs analyzed, and hospital characteristics (e.g., teaching status, bed size, patient volume, rural vs. urban location, and nurse staffing). RESULTS: We included 16 studies, which showed few significant associations. Four hospital characteristics (higher hospital volume, higher nurse staffing, urban vs. rural status, and higher hospital financial resources) had statistically significant associations with lower mortality and selected IQIs in approximately half of the studies. For example, there were no associations between nurse staffing and four IQIs; however, approximately 50% of studies showed a statistically significant relationship between nurse staffing and lower mortality for six IQIs. For two hospital characteristics-higher bed size and disproportionate share percentage-all statistically significant associations had higher mortality. Five hospital characteristics (teaching status, system affiliation, ownership, minority-serving hospitals, and electronic health record status) had some studies with significantly positive and some with significantly negative associations, and many studies with no association. CONCLUSIONS: We found few associations between hospital characteristics and mortality IQIs. Differences in study methodology, coding across hospitals, and hospital case-mix adjustment may partly explain these results. Ongoing research will evaluate potential mechanisms for the identified associations.

Home-based primary care practices in the United States: current state and quality improvement approaches.

OBJECTIVES: To describe the characteristics of home-based primary care practices: staffing, administrative, population served, care practices, and quality of care challenges. DESIGN: Survey of home-based primary care practices. SETTING: Home-based primary care practices in the United States. PARTICIPANTS: Members of the American Academy of Home Care Medicine and nonmember providers identified by surveyed members. MEASUREMENTS: A 58-item questionnaire that assessed practice characteristics, care provided by the practice, and how the quality of care that the practice provided was assessed. RESULTS: Survey response rate was 47.9%, representing 272 medical house calls practices. Mean average daily census was 457 patients (median 100 patients, range 1-30,972 patients). Eighty-eight percent of practices offered around-the-clock coverage for urgent concerns, 60% held regularly scheduled team meetings, 89% used an electronic medical record, and one-third used a defined quality improvement process. The following factors were associated with practices that used a defined quality improvement process: practice holds regularly scheduled team meetings to discuss specific patients (odds ratio (OR)=2.07, 95% confidence interval (CI)=1.02-4.21), practice conducts surveys of patients (OR=8.53, 95% CI=4.07-17.88), and practice is involved in National Committee for Quality Assurance patient-centered medical home (OR=3.27, 95% CI=1.18-9.07). Ninety percent of practices would or might participate in quality improvement activities that would provide them timely feedback on patient and setting-appropriate quality indicators. CONCLUSIONS: There is a substantial heterogeneity of home-based primary care practice types. Most practices perform activities that lend themselves to robust quality improvement efforts, and nearly all indicated interest in a national registry to inform quality improvement.

Performance measurement for people with multiple chronic conditions: conceptual model.

BACKGROUND: Improving quality of care for people with multiple chronic conditions (MCCs) requires performance measures reflecting the heterogeneity and scope of their care. Since most existing measures are disease specific, performance measures must be refined and new measures must be developed to address the complexity of care for those with MCCs. OBJECTIVES: To describe development of the Performance Measurement for People with Multiple Chronic Conditions (PM-MCC) conceptual model. STUDY DESIGN: Framework development and a national stakeholder panel. METHODS: We used reviews of existing conceptual frameworks of performance measurement, review of the literature on MCCs, input from experts in the multistakeholder Steering Committee, and public comment. RESULTS: The resulting model centers on the patient and family goals and preferences for care in the context of multiple care sites and providers, the type of care they are receiving, and the national priority domains for healthcare quality measurement. CONCLUSIONS: This model organizes measures into a comprehensive framework and identifies areas where measures are lacking. In this context, performance measures can be prioritized and implemented at different levels, in the context of patients' overall healthcare needs.

Transfusion medicine in American undergraduate medical education.

BACKGROUND: Blood transfusion is the most common procedure performed in American hospitals, and transfusions are commonly ordered by physicians without formal training in transfusion medicine. Several transfusion medicine curricula have been proposed, including those developed through the Transfusion Medicine Academic Awards (TMAA). To our knowledge, no comprehensive study has assessed how transfusion medicine is incorporated into undergraduate medical education. STUDY DESIGN AND METHODS: We conducted an online survey to determine the manner in which transfusion medicine is incorporated into American undergraduate medical education. The survey was e-mailed to administrators of medical education at all of the 129 American medical schools accredited by the Association of American Medical Colleges. RESULTS: Eighty-six (67%) of the 129 identified medical school administrators responded. Seventy-one (83%) of the 86 administrators reported that their undergraduate medical education curriculum provides didactic lectures in transfusion medicine, with 48% of medical schools providing 1 or 2 hours of lecture-based instruction. A minority reported small group sessions devoted to transfusion medicine topics. While a slim majority reported the availability of transfusion medicine electives, only one of 84 administrators reported that such a rotation is required. Seventy-six of 83 (92%) administrators were unfamiliar with either the 1989 or the 1995 TMAA transfusion medicine curricula. CONCLUSION: Transfusion medicine content in American undergraduate medical education is variable and the influence of the TMAA program on contemporary medical school curricula is questionable. Future efforts in this area should focus on standardizing and improving undergraduate medical education in transfusion medicine.

Faculty involvement in translational research and interdisciplinary collaboration at a US academic medical center.

BACKGROUND: Forty-six academic health centers have been awarded Clinical and Translational Science Awards by the National Institutes of Health to enhance health by advancing translational research. OBJECTIVE: As a recipient of a Clinical and Translational Science Award, we aimed to determine the prevalence of translational and interdisciplinary collaboration at our institution. DESIGN, SETTING, AND PARTICIPANTS: We surveyed all full-time faculty and postdoctoral fellows (n = 3870) in the Johns Hopkins Schools of Medicine, Public Health, Nursing and Engineering, in late 2008. MAIN OUTCOME MEASURES: Outcomes included (1) the proportion of investigators involved in early (T1), late (T2), and reverse translational (RT) research; (2) barriers to translational research; (3) attitudes about translational research; (4) involvement in interdisciplinary collaboration; and (5) barriers to collaboration. RESULTS: With 1800 respondents, the response rate was 55% for faculty and 40% for postdoctoral fellows. Of the 1314 investigators with more than 30% of their time committed to research, 69% reported conducting 1 or more types of translational research (T1 = 79%, T2 = 36%, RT = 36%). Attitudes about translational research revealed both concern and uncertainty. Fifty-four percent of respondents described translational research as having complex regulatory requirements; 42% felt that an individual's contributions suffer from underrecognition, 39% described it as high risk, and 35% consider funding less secure for translational researchers. Collaboration across school and types of research was common. Forty-seven percent of basic scientists collaborated with a clinical investigator in the last year, and 56% of clinical investigators collaborated with a basic scientist. CONCLUSIONS: Overall, investigators who did translational research reported a greater number of collaborators than those who did not.

Evaluating online continuing medical education seminars: evidence for improving clinical practices.

The purpose of this study was to evaluate the potential for online continuing medical education (CME) seminars to improve quality of care. Primary care physicians (113) participated in a randomized controlled trial to evaluate an online CME series. Physicians were randomized to view either a seminar about type 2 diabetes or a seminar about systolic heart failure. Following the seminar, physicians were presented with 4 clinical vignettes and asked to describe what tests, treatments, counseling, or referrals they would recommend. Physicians who viewed the seminars were significantly more likely to recommend guideline-consistent care to patients in the vignettes. For example, physicians who viewed the diabetes seminar were significantly more likely to order an eye exam for diabetes patients (63%) compared with physicians in the control group (27%). For some guidelines there were no group differences. These results provide early evidence of the effectiveness of online CME programs to improve physician clinical practice.

Impact of chronic conditions on quality of life in patients with inflammatory bowel disease.

BACKGROUND: Although studies suggest that inflammatory bowel disease (IBD) has a significant impact on an individual's health-related quality of life, the added weight of other health conditions and comorbidities has not been investigated. The purpose of this study was to expand on prior research by taking into account the impact of other chronic health conditions on the health-related quality of life of individuals with IBD, and to develop a model to help clinicians understand the relative impact of various predictors of their patients' physical and mental health-related quality of life. METHODS: 615 patients from the gastroenterology outpatient practice of a large, urban university hospital received a self-administered survey including questions about their health conditions, the severity of their bowel symptoms, and their health-related quality of life (measured using the SF-36 instrument). RESULTS: 314 completed surveys were returned, resulting in a response rate of 51.1%. Two regression analyses were conducted to identify the role of patient demographic variables and other chronic conditions on the 2 primary outcomes of interest: the SF-36 Physical Component and Mental Component Summary scores. Statistically significant predictors of physical quality of life included IBD disease severity, arthritis, heart disease, age, anemia, back/shoulder pain, and hypertension; statistically significant predictors of mental health-related quality of life were IBD disease severity, depression/anxiety, age, and headaches. CONCLUSIONS: IBD disease severity is the most important predictor of both physical and mental health-related quality of life in patients with this condition despite the presence of other chronic conditions.

The NJ SEED project: evaluation of an innovative initiative for ethics training in nursing homes.

OBJECTIVES: This article reports the results of an evaluation of the New Jersey Stein Ethics Education and Development (NJ SEED) project--a statewide initiative to create, organize and educate a statewide network of regional long-term care ethics committees. The main focus of the evaluation was to measure utilization of the committees, describe how facilities have benefited from the project, and identify potential barriers to the use of this resource. METHODS: Based on administrative records from the NJ SEED project, 225 facilities were identified and asked to complete a facility survey. Ninety-three surveys were received, resulting in a 41% response rate. An additional survey of the regional ethics committees (RECs), as well as several focus groups and individual interviews were conducted to supplement the survey data. RESULTS: Fifty-eight percent of the facility respondents reported current participation in an NJ regional ethics committee. About one third (30%) of participating facilities had requested a formal case consultation (on at least one occasion) on behalf of a resident, but two thirds had consulted with their RECs on a more informal basis. Facilities that reported participating in the REC Network were more likely to have formally written policies than nonparticipants. CONCLUSIONS: Many NJ nursing homes find the statewide REC Network to be an important resource; however continued efforts need to be expended for recruiting and training facilities that are not taking full advantage of this important source of peer support and professional expertise.