Improving Consumer Experiences in Permanent Supportive Housing Co-Located With Health Centers: A Case Study From the Department of Veterans Affairs.

BACKGROUND: Permanent Supportive Housing (PSH), which provides subsidies for independent housing and supportive services, is an evidence-based practice that improves health and housing for homeless experienced persons. Though most PSH is scattered-site, that is, housing dispersed throughout the mainstream rental market, project-based PSH offers housing and supportive services in dedicated facilities with on-site services. In 2013, the Veterans Health Administration (VA) at Greater Los Angeles opened a novel project-based PSH program located on a VA campus. To inform plans to expand project-based PSH at this VA, we examined participants' experiences in this program. We aimed to identify participant characteristics that suggested they were well suited for the planned PSH expansion; to characterize services that participants found valuable in this setting; and to highlight gaps between participants' needs and PSH services provided. METHODS: We performed semi-structured interviews with a convenience sample (n = 24) of participants who had engaged in this project-based PSH program. Interviews asked why participants selected housing on a VA campus and explored valued program characteristics, designs, and services. Using rapid analysis methods, we generated templated summaries of each participant's responses across the domains of our interview guide, then used matrix analyses to identify salient themes across the interviews. KEY FINDINGS: Participants appreciated the ease of access to medical and mental health services; however, as services were assumed to be optimized by virtue of co-location with VA healthcare, their PSH providers often did not link them with non-VA social services as assertively as desired. Many participants raised concerns about building safety and on-site substance use. A lack of participant engagement in program oversight, often leading to conflicts with staff and building management, was also highlighted in our interviews. DISCUSSION: Given the value placed on ease of access to healthcare, these data suggest the value of this PSH model for persons with healthcare vulnerabilities. Specific recommendations for the planned PSH expansion include: (1) continuation of proximate, open-access healthcare; (2) clear tenant policies; (3) tenant councils for each development; (4) staff knowledgeable of non-VA resources and social services; (5) Veteran-preferred hiring practices by Property/Service management; (6) gender-specific accommodations; and (7) robust 24/7 security on-site.

Clinicians' Beliefs and Practices Regarding Drug Use Care of Their Community Health Center Patients.

OBJECTIVES: Integration of behavioral health including substance use problems into primary care is an essential benefit that federally qualified health centers (FQHCs) will offer as part of the Affordable Care Act. This study explores FQHC primary care clinicians' beliefs and practices regarding illicit drug use assessment and treatment. METHODS: We administered a 10-minute questionnaire to 68 primary care clinicians of 5 FQHCs in Los Angeles. RESULTS: Clinicians expressed limited confidence in their ability to address patients' illicit drug use, scoring on average 3.31 on a 5-point Likert scale. Two thirds reported that they assess for drug use routinely "at every visit" and/or "at annual visits." When asked how often they counsel regarding drug use (on a 5-point Likert scale from "never" to "always"), the median response was 4 ("usually"). Regarding their perspectives on the best practical resource for addressing drug use in their clinics, 45.6% named primary care clinicians. A minority (29.4%) of clinicians had completed a clinical rotation dealing with substance use, and 27.2% reported receiving more than 10  hours of training regarding substance use problems. Having a substance use rotation was associated with greater confidence in drug use assessment and treatment (P < 0.01). More hours of substance use training was associated with greater confidence (P = 0.01) and routinely addressing substance use in their patients (P = 0.04). CONCLUSIONS: Although two thirds of the surveyed clinicians assess for drug use routinely, and on average, report that they usually address drug use, clinicians' confidence in substance use care seems to be suboptimal, but both confidence and routinely addressing substance use are associated with increased substance use education. Improving clinicians' training and integrating drug use care in FQHCs may improve confidence in substance use care and facilitate the Affordable Care Act's mandate to integrate behavioral health into routine FQHC primary care.

Toward defining and measuring social accountability in graduate medical education: a stakeholder study.

BACKGROUND: Since 1965, Medicare has publically financed graduate medical education (GME) in the United States. Given public financing, various advisory groups have argued that GME should be more socially accountable. Several efforts are underway to develop accountability measures for GME that could be tied to Medicare payments, but it is not clear how to measure or even define social accountability. OBJECTIVE: We explored how GME stakeholders perceive, define, and measure social accountability. METHODS: Through purposive and snowball sampling, we completed semistructured interviews with 18 GME stakeholders from GME training sites, government agencies, and health care organizations. We analyzed interview field notes and audiorecordings using a flexible, iterative, qualitative group process to identify themes. RESULTS: THREE THEMES EMERGED IN REGARDS TO DEFINING SOCIAL ACCOUNTABILITY: (1) creating a diverse physician workforce to address regional needs and primary care and specialty shortages; (2) ensuring quality in training and care to best serve patients; and (3) providing service to surrounding communities and the general public. All but 1 stakeholder believed GME institutions have a responsibility to be socially accountable. Reported barriers to achieving social accountability included training time constraints, financial limitations, and institutional resistance. Suggestions for measuring social accountability included reviewing graduates' specialties and practice locations, evaluating curricular content, and reviewing program services to surrounding communities. CONCLUSIONS: Most stakeholders endorsed the concept of social accountability in GME, suggesting definitions and possible measures that could inform policy makers calls for increased accountability despite recognized barriers.