Risk Factors and Clinical Outcomes of Nonhome Discharge in Patients With Acute Decompensated Heart Failure: An Observational Study.

Background No clinical studies have focused on the factors associated with discharge destination in patients with acute decompensated heart failure. Methods and Results Of 4056 consecutive patients hospitalized for acute decompensated heart failure in the KCHF (Kyoto Congestive Heart Failure) registry, we analyzed 3460 patients hospitalized from their homes and discharged alive. There were 3009 and 451 patients who were discharged to home and nonhome, respectively. We investigated the factors associated with nonhome discharge and compared the outcomes between home discharge and nonhome discharge. Factors independently and positively associated with nonhome discharge were age ≥80 years (odds ratio [OR],1.76; 95% CI,1.28-2.42), body mass index ≤22 kg/m2 (OR,1.49; 95% CI,1.12-1.97), poor medication adherence (OR, 2.08; 95% CI,1.49-2.88), worsening heart failure (OR, 2.02; 95% CI, 1.46-2.82), stroke during hospitalization (OR, 3.74; 95% CI, 1.75-8.00), functional decline (OR, 12.24; 95% CI, 8.74-17.14), and length of hospital stay >16 days (OR, 4.14; 95% CI, 3.01-5.69), while those negatively associated were diabetes mellitus (OR, 0.69; 95% CI, 0.51-0.94), cohabitants (OR, 0.62; 95% CI, 0.46-0.85), and ambulatory state before admission (OR, 0.25; 95% CI, 0.18-0.36). The cumulative 1-year incidence of all-cause death was significantly higher in the nonhome discharge group than in the home discharge group. The nonhome discharge group compared with the nonhome discharge group was associated with a higher adjusted risk for all-cause death (hazard ratio, 1.66; P<0.001). Conclusions The discharge destination of patients with acute decompensated heart failure is influenced by factors such as prehospital social background, age, body mass index, low self-care ability, events during hospitalization (worsening heart failure, stroke, etc), functional decline, and length of hospital stay; moreover, the prognosis of nonhome discharge patients is worse than that of home discharge patients. Registration Information clinicaltrials.gov. Identifier: NCT02334891.

Sober living house characteristics: A multilevel analyses of factors associated with improved outcomes.

Safe and stable housing is integral to addiction recovery. Across numerous studies, recovery housing has been found to be associated with improvements in a variety of domains. Although procedures for operating some types of recovery housing have been manualized and national standards established, there are few empirical findings identifying which recovery residence characteristics may lead to improved outcomes. Using data from 330 newly admitted residents recruited from 49 sober living houses in California and re-contacted for 6- and 12-month follow-up interviews, this study examines the effects of organizational, operational, and programming characteristics on substance use, criminal justice, and employment outcomes. Results from multilevel analyses adjusting for resident demographics and length of stay indicate that organizational characteristics were associated with outcomes. Residents recruited from houses that were part of a larger organization or group of houses had increased odds of total abstinence (aOR = 3.98, p < 0.001) and drug abstinence (aOR = 3.19, p < 0.001). Residents recruited from houses that were affiliated with a treatment program had increased odds of employment (aOR = 2.92, p = 0.003). Operational characteristics such as where the house was located and whether the house required incoming residents to be sober for at least 30 days prior to entry were also related to improved outcomes, but additional work is needed to develop tools to assess and measure recovery housing characteristics and to better understand how these factors contribute to improved outcomes.

Substance Abuse Treatment Patients in Housing Programs Respond to Contingency Management Interventions.

Use of homeless and transitional housing (e.g., recovery homes) programs can be associated with success in substance abuse treatment, perhaps because many of these programs encourage or mandate sobriety. In this study, we examined whether contingency management (CM) protocols that use tangible incentives for submission of drug-free specimens or other specific behaviors are effective for treatment-seeking substance abusers whose behavior may also be shaped by housing programs. Of 355 participants in randomized trials of CM, 56 (16%) reported using transitional housing during the 12-week treatment period. Main and interaction effects of housing status and treatment condition were evaluated for the primary substance abuse treatment outcomes: a) longest duration of abstinence from alcohol, cocaine, and opioids, b) percentage of samples submitted that were negative for these substances, and c) treatment retention. After controlling for demographic and clinical characteristics, those who accessed housing programs submitted a higher percentage of negative samples (75%) compared to those who did not access housing programs (67%). Housing status groups did not differ in terms of longest duration of abstinence (accessed housing: M=3.1 weeks, SE=0.6; did not access housing: M=3.9 weeks, SE=0.3) or retention in substance abuse treatment (accessed housing: M=6.4 weeks, SE=0.6; did not access housing: M=6.6 weeks, SE=0.3). Regardless of housing status, CM was associated with longer durations of abstinence and treatment retention. No interactive effects of housing and treatment condition were observed (p>.05). Results suggest that those who accessed housing programs during substance abuse treatment benefit from CM to a comparable degree as their peers who did not use such programs. These effects suggest that CM remains appropriate for those accessing housing in community-based programs.

Proceso de recuperación en las personas mayores intervenidas por fractura de cadera / Recovery process in elderly patients after hip fracture surgery

OBJETIVO: identificar las principales características clínicas, funcionales y cognitivas de los pacientes mayores hospitalizados con fractura de cadera en el Hospital Universitario de León y analizar la influencia del tipo de domicilio tras el alta hospitalaria en el proceso de recuperación. MÉTODOS: estudio preliminar descriptivo transversal en el que se analizaron las características fisiológicas de personas mayores que fueron hospitalizadas por diagnóstico de fractura de cadera en el Hospital de León. Para ello se seleccionó a personas mayores de 75 años hospitalizadas por fractura de cadera. Se evaluó el estado de salud del paciente en el momento de ingreso y tras seis semanas después del alta hospitalaria. RESULTADOS: se incluyeron 38 personas mayores. Todos los pacientes intervenidos perdieron de manera significativa funcionalidad con respecto a su situación basal (domicilio propio p< 0,009; domicilio de familiares p< 0,024; residencia geriátrica p< 0,018). El número de comorbilidades presentadas por los pacientes fue de 3,7, siendo esto un agravante más que complica el proceso de recuperación. Los pacientes que peor deambulación adquirieron a las seis semanas tras el alta hospitalaria fueron aquellos que se trasladaron a una residencia, siendo estas diferencias significativas al compararlas con los que se trasladaron a casa de un familiar (p< 0,023). CONCLUSIONES: los pacientes que se trasladaron a una residencia geriátrica tras una intervención de fractura de cadera presentan peor deambulación a las seis semanas tras el alta hospitalaria

OBJECTIVE: to identify the main clinical, functional and cognitive characteristics of elderly patients admitted at the Hospital Universitario de León with hip fracture, and to analyze the influence on the recovery process of their type of living environment after discharge from hospital. METHODS: a preliminary transversal descriptive study that analyzed the physiological characteristics of elderly patients who were hospitalized due to hip fracture diagnosis in the Hospital de León. To this aim, >75-year-old patients were selected, who had been hospitalized due to hip fracture. The health status of patients was assessed at admission and six weeks after hospital discharge. RESULTS: thirty-eight (38) elderly persons were included. All patients who underwent surgery experienced a significant loss of functionality regarding their basal situation (own home p< 0.009; the home of relatives p< 0.024; geriatric institution p< 0.018). The number of comorbidities presented by patients was 3.7, and this was an additional problem that complicated further the recovery process. The patients with a worse walking ability six weeks after hospital discharge were those transferred to a geriatric institution, with a significant difference in comparison with those transferred to the home of a relative (p< 0.023). CONCLUSIONS: those patients transferred to a geriatric institution after hip fracture surgery presented worse walking abilities at six weeks after hospital discharge

[Investigation of community support measures for patients with comorbid substance use disorder and psychotic disorder: nationwide survey of drug addiction rehabilitation centers].

In psychiatric care practice, patients are often seen who have difficulty with their social lives due to protracted psychiatric symptoms despite years without drug abuse. The difficulty of dealing with such cases and the lack of preparedness of the legal system leave circumstantial care as the only option. Western.countries have recently begun using the name 'concurrent disorder' as a diagnosis for patients deemed unable to recover solely through such treatment for drug addiction, signifying the presence of both a substance use disorder (SUD) and a mental health disorder. Various assessment and intervention methods are being investigated, and many studies have been reported. Based on the hypothesis that Drug Addiction Rehabilitation Center (DARC) are partly involved in supporting those with psychotic concurrent disorders (PSCD) in Japan, we conducted a survey to clarify the actual support for PSCD patients at DARC and the challenges they face. Surveys were administered to DARC-related institutions all over Japan (44 governing organizations and 66 institutions). Complete responses from 86 full-time employees and 445 DARC users were analyzed. DARC users were divided into two groups: psychiatric concurrent disorders (PSCD group, n = 178) and those without such symptoms (SUD group, n = 267), with the PSCD group accounting for 40% of the DARC users surveyed. Compared to the SUD group, the PSCD group was significantly less satisfied with their lifestyle and interpersonal relations at the DARC and a significantly higher proportion of the PSCD group requested assistance in communicating with others. When employees were presented with a hypothetical PSCD case and asked what was needed to deal with it, some responses were, "an institution that can treat both drug addiction and other mental health disorders," "a psychiatric care institution that provides 24-hour care," and "sufficient manpower and training." In the future, a treatment system must be established based on public medical institutions with a dedicated PSCD program that can provide medical care under legal observation.

A pilot study of the impact of housing first-supported housing for intensive users of medical hospitalization and sobering services.

OBJECTIVES: We examined changes in service use in a Housing First (HF) pilot program for adults who were homeless with medical illnesses and high prior acute-care use relative to a similar comparison group. METHODS: We used a 1-year pre-post comparison group design. The 29 participants and 31 comparison group members were adults who were homeless with inpatient claims of at least $10 000 or at least 60 sobering "sleep off" center contacts in the prior year. RESULTS: Participants showed a significantly greater reduction in emergency department and sobering center use relative to the comparison group. At a trend level, participants had greater reductions in hospital admissions and jail bookings. Reductions in estimated costs for participants and comparison group members were $62 504 and $25 925 per person per year-a difference of $36 579, far outweighing program costs of $18 600 per person per year. CONCLUSIONS: HF participants showed striking reductions in acute-care use relative to the comparison group, demonstrating that HF can be a successful model for people with complex medical conditions and high prior acute-care use. Despite notable methodological limitations, these findings could be used to inform a larger multisite study that would establish greater generalizability.

Abstinence-contingent recovery housing and reinforcement-based treatment following opioid detoxification.

AIMS: To conduct a randomized, controlled trial of abstinence-contingent recovery housing delivered with or without intensive day treatment among individuals exiting residential opioid detoxification. DESIGN: Random assignment to one of three conditions: recovery housing alone (RH), abstinence-contingent recovery housing with reinforcement-based treatment RBT (RH + RBT) or usual care (UC). RH and RH + RBT participants received 12 weeks of paid recovery housing contingent upon drug abstinence. RH + RBT participants also received 26 weeks of RBT, initiated concurrently with recovery housing. Assessments were conducted at 1, 3 and 6 months after treatment enrollment. SETTING: Out-patient drug-free substance abuse treatment program in Baltimore, Maryland. PARTICIPANTS: Patients (n = 243) who completed medication-assisted opioid detoxification. MEASUREMENTS: Primary outcome was drug abstinence (opioid- and cocaine-negative urine and no self-reported opioid or cocaine use in the previous 30 days). Secondary outcomes included abstinence at all time-points (1, 3 and 6 months), days in recovery housing and employment. FINDINGS: Overall rates of drug abstinence were 50% for RH + RBT, 37% for RH and 13% for UC (P < 0.001). At 6 months, RH + RBT participants remained more likely to meet abstinence criteria than UC participants (37% versus 20%, P = 0.016). Length of stay in recovery housing mediated abstinence outcomes and was longer in RH + RBT (49.5 days) than in RH (32.2 days; P < 0.002). CONCLUSIONS: Abstinence-contingent recovery housing improves abstinence in opioid-dependent adults following medication-assisted detoxification. The addition of intensive 'reinforcement-based treatment' behavioural counseling further improves treatment outcomes, in part by promoting longer recovery house stays.

Does supported accommodation improve the clinical and social outcomes for people with severe psychiatric disability? The Project 300 experience.

OBJECTIVE: The present study was designed to investigate the clinical and social outcomes for a group of individuals (n = 181) discharged into supported accommodation from three long-stay facilities in Queensland. METHOD: Data were collected prospectively using a battery of standardized measures and individual interviews at 6 weeks pre-discharge and again at 6, 18, 36, and 84 months post-discharge. RESULTS: While there was little functional gain at follow up, the clients, as a group, did not deteriorate. Sixty per cent of the clients were engaged in some form of structured community activity and the need for hospitalization decreased significantly in the follow-up period. The ongoing costs of the programme, while remaining high, were significantly less than inpatient alternatives. CONCLUSION: The provision of community accommodation with adequate clinical and non-clinical support is a suitable option for a large proportion of individuals with serious mental illness.

A model for sober housing during outpatient treatment.

Finding a living environment that supports recovery is a major challenge for many clients attending outpatient treatment. Yet it is important because family, friends, and roommates who encourage substance use or discourage recovery can undermine the progress made in treatment. Destructive living environments are most problematic for clients who have limited incomes and reside in urban areas where housing markets are tight. Individuals who are homeless face constant threats to their sobriety and often lack the stability necessary to attend treatment consistently. Options Recovery Services is an outpatient program in Berkeley, California that uses sober living houses (SLHs) to provide an alcohol- and drug-free living environment to clients while they attend the outpatient program. This article describes the structure and processes of the houses along with six month outcome data on 46 residents. Improvements were seen in the number of months using substances, maximum number of days of substance use per month, arrests, and employment. Seventy six percent of the residents remained in the house at least five months and 39% reported being employed at some point during the past 30 days. Outpatient programs should consider establishing SLHs for clients who lack a living environment supportive of sobriety.

Seven-year life outcomes of adolescent offenders in Los Angeles.

OBJECTIVES: We examined important life outcomes for adolescent offenders to describe how they were faring in young adulthood. METHODS: We assessed 449 adolescent offenders (aged 13-17 years) in Los Angeles, CA, whose cases had been adjudicated by the Los Angeles Superior Court and who had been referred to group homes between February 1999 and May 2000. We used the Global Appraisal of Individual Needs to interview respondents at baseline and at 3, 6, 12, 72, and 87 months after baseline. A total of 395 respondents (88%) were interviewed or confirmed as dead at the final interview. RESULTS: At final interview, 12 respondents had died, 7 of them from gunshot wounds. Thirty-six percent of respondents reported recent hard drug use, and 27% reported 5 or more symptoms of substance dependence. Sixty-six percent reported committing an illegal activity within the previous year, 37% reported being arrested within the previous year, and 25% reported being in jail or prison every day for the previous 90 days. Fifty-eight percent had completed high school or obtained a GED, and 63% reported working at a job in the previous year. CONCLUSIONS: The high rates of negative life outcomes presented here suggest the need for more effective rehabilitation programs for juvenile offenders.

Housing First for long-term shelter dwellers with psychiatric disabilities in a suburban county: a four-year study of housing access and retention.

Housing First is an effective intervention that ends and prevents homelessness for individuals with severe mental illness and co-occurring addictions. By providing permanent, independent housing without prerequisites for sobriety and treatment, and by offering support services through consumer-driven Assertive Community Treatment teams, Housing First removes some of the major obstacles to obtaining and maintaining housing for consumers who are chronically homeless. In this study, consumers diagnosed with severe mental illness and who had the longest histories of shelter use in a suburban county were randomly assigned to either one of two Housing First programs or to a treatment-as-usual control group. Participants assigned to Housing First were placed in permanent housing at higher rates than the treatment-as-usual group and, over the course of four years, the majority of consumers placed by both Housing First agencies were able to maintain permanent, independent housing. Results also highlight that providers new to Housing First must be aware of ways in which their practices may deviate from the essential features of Housing First, particularly with respect to enrolling eligible consumers on a first-come, first-served basis and separating clinical issues from tenant or housing responsibilities. Finally, other aspects of successfully implementing a Housing First program are discussed.

Substance abuse treatment and receipt of liver specialty care among persons coinfected with HIV/HCV who have alcohol problems.

We examined the association of substance abuse treatment with access to liver specialty care among 231 persons coinfected with HIV and hepatitis C virus (HCV) with a history of alcohol problems who were recruited and followed up in the HIV-Longitudinal Interrelationships of Viruses and Ethanol cohort study from 2001 to 2004. Variables regarding demographics, substance use, health service use, clinical variables, and substance abuse treatment were from a standardized research questionnaire administered biannually. We defined substance abuse treatment services as any of the following in the previous 6 months: 12 weeks in a halfway house or residential facility, 12 visits to a substance abuse counselor or mental health professional, day treatment for at least 30 days, or any participation in a methadone maintenance program. Liver specialty care was defined as a visit to a liver doctor, a hepatologist, or a specialist in treating hepatitis C in the past 6 months. At study entry, most of the 231 subjects (89%, n = 205) had seen a primary care physician, 50% had been exposed to substance abuse treatment, and 50 subjects (22%) had received liver specialty care. An additional 33 subjects (14%) reported receiving liver specialty care during the follow-up period. In the multivariable model, we observed a clinically important although not statistically significant association between having been in substance abuse treatment and receiving liver specialty care (adjusted odds ratio = 1.38; 95% confidence interval = 0.9-2.11). Substance abuse treatment systems should give attention to the need of patients to receive care for prevalent treatable diseases such as HIV/HCV coinfection and facilitate its medical care to improve the quality of care for individuals with substance use disorders. The data illustrate the need for clinical care models that give explicit attention to the coordination of primary health care with addiction and hepatitis C specialty care while providing ongoing support to engage and retain these patients with complex health needs.

A six-month outcome of long-stay inpatients resettled in a hostel.

This prospective study evaluated a 6-month outcome of resettlement of long-term psychiatric inpatients to a hostel-based residence. Participants included 92 patients with DSM-IV chronic psychotic disorders, aged 18 to 65 years, hospitalized for 16.7 +/- 10.6 years. Evaluations performed at 2 weeks before their resettlement and following 6 months of hostel residence included the Positive and Negative Syndromes Scale, Montgomery and Asberg Depression Scale, Clinical Global Impression, Global Assessment of Functioning, Social Adaptive Functioning Evaluation and Social Behavior Schedule. The Nurses' Observation Scale for Inpatient Evaluation was completed regularly. Psychopathological symptoms declined and social interaction increased. Hostel-based deinstitutionalization programs are a promising alternative for long-term psychiatric inpatients.

The effects of respite care for homeless patients: a cohort study.

OBJECTIVES: Homeless individuals experience high rates of physical and mental illness, increased mortality, and frequent hospitalizations. Respite care provides homeless individuals with housing and services allowing more complete recovery from illnesses and stabilization of chronic conditions. METHODS: We investigated respite care's impact on 225 hospitalized homeless adults consecutively referred from an urban public hospital during a 26-month period. The cohort was separated into 2 groups: (1) patients referred and accepted into the respite center and (2) patients referred but denied admission because beds were unavailable. All patients met the center's predefined eligibility criteria. Main outcome measures were inpatient days, emergency department visits, and outpatient clinic visits. RESULTS: The 2 groups had similar demographic characteristics, admitting diagnoses, and patterns of medical care use at baseline. During 12 months of follow-up, the respite care group required fewer hospital days than the usual care group (3.7 vs 8.3 days; P=.002), with no differences in emergency department or outpatient clinic visits. Individuals with HIV/AIDS experienced the greatest reduction in hospital days. CONCLUSIONS: Respite care after hospital discharge reduces homeless patients' future hospitalizations.

Youths living away from families in the US mental health system: opportunities for targeted intervention.

This study examines the clinical characteristics of youths who lived away from families at the time of admission to specialty mental health services, and investigates the association between type of nonfamily living situation and admission to residential versus outpatient programs. Of 3995 youths sampled from 1598 mental health programs in the United States, 14% lived away from their own families, either in foster care, group care settings, or correctional settings, or were emancipated. As a group, youths living away from families were more seriously emotionally disturbed and more likely to receive treatment in residential care programs. Youths who lived in foster care were more likely to be admitted to outpatient programs, while youths who lived in group care settings or correctional settings were more likely to be admitted to residential care programs, controlling on demographic and clinical characteristics. Targeting resources to enhance the availability and therapeutic capacity of foster care may facilitate community living, and decrease time spent in institutional settings.

Facility charter and quality of care for board and care residents.

In this investigation structure, process, and outcome measures of quality in for-profit and not-for-profit board and care homes are compared. We find one structural measure (providing nursing care), three process measures (food quality, staff treat residents with respect, and staff verbally abuse residents), and two outcomes measures (cleanliness of the facility and complaints to Ombudsman) to be significant. Moreover, the directions of these effects are all consistent, with for-profit facilities rated more poorly that not-for-profit facilities. These results are discussed emphasizing their implications for efficient and effective resident care.

Slowing the revolving door: stabilization programs reduce homeless persons' substance use after detoxification.

This study examined whether homelessness predicted earlier resumption of substance use after detoxification, and sought evidence concerning the impact of post-detoxification stabilization programs among homeless and nonhomeless individuals. Kaplan-Meier plots and proportional hazards models were used to determine the association between homelessness, stabilization program use, and recurrent substance use in a prospective cohort of persons entering inpatient detoxification (n=470). Among 254 persons available at 6 months, 76% reported recurrent substance use. Homeless persons not using stabilization programs experienced the highest hazard of return to substance use after detoxification, Hazard Ratio (HR) 1.26, 95% CI (0.88, 1.80). Homeless persons using these programs had the lowest rate of return to substance use: HR 0.61, 95% CI (0.40, 0.94). A similar impact of stabilization programs was not seen among nonhomeless subjects. Post-detoxification stabilization programs were associated with improved outcomes for homeless addicted persons. This treatment modality may slow the "revolving door" phenomenon of relapse after detoxification among homeless persons.

Current and preferred housing of psychiatric consumers/survivors.

As part of a participatory action research project, we surveyed 300 psychiatric consumers/survivors from southwestern Ontario regarding their housing preferences and housing satisfaction. We found that, while 79% of the sample preferred independent living, 76% were living in some other type of setting (e.g., temporary shelter, supportive housing, sheltered care). Those living in temporary shelters reported the lowest levels of housing satisfaction, and those who were living in the type of housing that they preferred had the highest levels of housing satisfaction. This information is being used by stakeholder groups involved in the project to help build the capacity of the community to provide the types of housing that are preferred by consumers/survivors.