Using Implementation Mapping to develop protocols supporting the implementation of a state policy on screening children for Adverse Childhood Experiences in a system of health centers in inland Southern California.

Adverse Childhood Experiences (ACEs) are defined as traumatic events occurring before age 18, such as maltreatment, life-threatening accidents, harsh migration experiences, or violence. Screening for ACEs includes asking questions about an individual's early exposure to these types of events. ACEs screenings have potential value in identifying children exposed to chronic and significant stress that produces elevated cortisol levels (i.e., toxic stress), and its associated physical and mental health conditions, such as heart disease, diabetes, depression, asthma, ADHD, anxiety, and substance dependence. However, ACEs screenings are seldom used in primary care settings. The Surgeon General of California has addressed this care gap by introducing ACEs Aware, an ACEs screening fee-for-service healthcare policy signed into law by Gov. Gavin Newsom. Since January 2020, Medi-Cal, California's Medicaid health care program, has reimbursed primary care providers for using the Pediatric ACEs and Related Life-events Screener (PEARLS) tool to screen children and adults for ACEs during wellness visits. To achieve the goals set by the ACEs Aware state policy, it is essential to develop and test implementation strategies that are informed by the values, priorities, and resources of clinical settings, healthcare professionals, and end-users. To address this need, we partnered with a system of federally qualified health centers in Southern California on a pilot study to facilitate the implementation of ACEs screenings in five community-based clinics. The health centers had broad ideas for an implementation strategy, as well as best practices to improve adoption of screenings, such as focusing on staff training to improve clinic workflow. This knowledge was incorporated into the development of an implementation strategy template, used at the outset of this study. We used the Exploration, Preparation, Implementation and Sustainment (EPIS) framework to guide the study and inform a participatory planning process called Implementation Mapping. In this paper, we describe how Implementation Mapping was used to engage diverse stakeholders and guide them through a systematic process that resulted in the development of the implementation strategy. We also detail how the EPIS framework informed each Implementation Mapping Task and provide recommendations for developing implementation strategies using EPIS and Implementation Mapping in health-care settings.

Views on health activation and support services among formerly homeless adults living in Permanent Supportive Housing in the United States.

Individuals who have experienced chronic homelessness often have unmet physical and mental health needs and experiences of trauma and stigma. This study aimed to measure, for the first time, health activation (self-advocacy and empowerment) levels among formerly homeless adults living in Permanent Supportive Housing or PSH (referred to hereafter as residents). In addition, residents' experiences accessing health services, and their sense of health activation and efforts to manage their health within PSH settings, were explored. A mixed-methods study was conducted in Southern California (October 2018-June 2019) using a validated survey and interviews with a randomly selected group of residents (n = 61) from three PSH agencies. Activation levels were measured using the Patient Activation Measure. Descriptive and univariate survey analyses were conducted. Interview data was analysed using NVivo. Two coders coded all transcripts, and team meetings were held to reach consensus. Results showed most residents were female (64%), racial and ethnic minorities (66%), on average 54-year-olds, with 37 months of PSH residency, and 43% were taking some action to manage their health (intermediate activation level). Challenges accessing care were due to breakdowns in care, unpleasant experiences with providers, low health literacy and feeling overwhelmed by co-occurring chronic conditions. Health activation related to knowing when to take care of their health on their own and when to seek care. Unique challenges emerged related to PSH, such as lack of resident control within the housing setting and limited personnel responding to health emergencies. These challenges were magnified because residents live alone, per PSH requirements.

Empowering Psychiatric Mental Health Nurse Practitioners to Expand Treatment Opportunities for Veterans With Opioid Use Disorder.

BACKGROUND: Few veterans with opioid use disorder receive effective treatment despite the Veterans Health Administration's efforts to expand treatment by offering buprenorphine, a medication to treat opioid use disorder (MOUD). An insufficient prescribing workforce contributes to the underutilization of buprenorphine; however, nurse practitioners (NPs) can now obtain a waiver to prescribe this medication. This quality improvement project aimed to expand the prescribing workforce by educating psychiatric mental health NPs (PMHNPs) working in an emergency setting at a Veterans Affairs Health Care System about free MOUD training and empowering them to utilize buprenorphine treatment. METHODS: Eleven PMHNPs were asked for their perception of prescribing buprenorphine. They were asked if they had an MOUD waiver and/or were aware of the free waiver training. The PMHNPs were educated on the importance and process of obtaining the DEA-X waiver, and then a post-intervention discussion was completed to determine if they completed the waiver training. RESULTS: At baseline, all 11 PMHNPs believed offering MOUD was important, but only three had the waiver to prescribe buprenorphine. After the education, three additional PMHNPs obtained the waiver and 10 planned to have the waiver in the next year. The department is planning to trial offering buprenorphine treatment, and PMHNPs at this facility are privileged to prescribe buprenorphine. In addition, five new PMHNP residents started or completed the training. CONCLUSIONS: This project shows the potential to increase veteran access to MOUD by emphasizing education and empowering PMHNPs to initiate treatment. Providing education regarding the importance of buprenorphine treatment in the emergency setting and delivering information about the free waiver training facilitated workforce preparedness.