Behavioral Crisis and First Response: Qualitative Interviews with Chicago Stakeholders.

Improving interactions between first responders and individuals experiencing behavioral crisis is a critical public health challenge. To gain insight into these interactions, key informant qualitative interviews were conducted with 25 Chicago stakeholders. Stakeholders included directors and staff of community organizations and shelters that frequently engage first responders. Interviews included granular depictions related to the expectations and outcomes of 911 behavioral crisis calls, and noted areas requiring improved response. Stakeholders called 911 an average of 2 to 3 times per month, most often for assistance related to involuntary hospitalization. Engagements with first responders included unnecessary escalation or coercive tactics, or conversely, refusal of service. While stakeholders lauded the value of police trained through the city's Crisis Intervention Team program, they emphasized the need for additional response strategies that reduce the role of armed police, and underscored the need for broader social and behavioral health services for individuals at-risk of such crises.

Social relationships, homelessness, and substance use among emergency department patients.

Background: Emergency department (ED) patients commonly experience both substance use and homelessness, and social relationships impact each in varied ways not fully captured by existing quantitative research. This qualitative study examines how social relationships can precipitate or ameliorate homelessness and the connection (if any) between substance use and social relationships among ED patients experiencing homelessness. Methods: As part of a broader study to develop ED-based homelessness prevention interventions, we conducted in-depth interviews with 25 ED patients who used alcohol or drugs and had recently become homeless. We asked patients about the relationship between their substance use and homelessness. Interviews were recorded, transcribed, and coded line-by-line by investigators. Final codes formed the basis for thematic analysis through consensus discussions. Results: Social relationships emerged as focal points for understanding the four major themes related to the intersection of homelessness and substance use: (1) Substance use can create strain in relationships; (2) Help is there until it's not; (3) Social relationships can create challenges contributing to substance use; and (4) Reciprocal relationship of substance use and isolation. Sub-themes were also identified and described. Conclusions: The association between substance use and homelessness is multifaceted and social relationships are a complex factor linking the two. Social relationships are often critical for homelessness prevention, but they are impacted by and reciprocally affect substance use. ED-based substance use interventions should consider the high prevalence of homelessness and the impact of social relationships on the interaction between homelessness and substance use.

Strategies for Sustaining Fidelity: A Multi-state Qualitative Analysis in Housing First Programs.

Little is known about long-term fidelity of evidence-based interventions (EBIs) under changing conditions. This study examines how staff at 'mature' (eight or more years in operation) Housing First (HF) programs strategize to sustain EBI fit in different geographic areas in the Mid-Atlantic/Northeastern United States. Six focus groups (FGs) at three purposively selected HF programs were conducted with separate FGs for case managers and supervisors at each site. FG discussions elicited participants' service approaches and strategies in addressing fidelity amidst ongoing changes affecting each program. Thematic content analysis of FG transcripts was conducted using the five HF fidelity domains (housing choice/structure, separation of housing and services, service philosophy, service array, and program structure) as a priori themes with inductive content analyses conducted on data in each theme. Strategies for rigor were employed. Case managers (N = 17) and supervisors (N = 16) were predominantly white (76%) and female (60%). Across the themes, challenges included lack of affordable housing and choice, funders' restrictions and practice 'drift.' Strategies included community engagement and hiring, strong leadership and 'bending the rules.' There were no differences across sites. Later-stage implementation challenges show the need for continued vigilance in fidelity to EBIs. Among the strategies used to address fidelity in this study, the pursuit of pro-active community engagement to attract knowledgeable staff as well as increase local buy-in was considered pivotal at all three sites. These findings underscore the need to attend to the external setting as well as to internal program operations.

How Practice Facilitation Strategies Differ by Practice Context.

BACKGROUND: Practice facilitation is an implementation strategy used to build practice capacity and support practice changes to improve health care outcomes. Yet, few studies have investigated how practice facilitation strategies are tailored to different primary care contexts. OBJECTIVE: To identify contextual factors that drive facilitators' strategies to meet practice improvement goals, and how these strategies are tailored to practice context. DESIGN: Semi-structured, qualitative interviews analyzed using inductive (open coding) and deductive (thematic) approaches. This study was conducted as part of a larger study, HealthyHearts New York City, which evaluated the impact of practice facilitation on adoption of cardiovascular disease prevention and treatment guidelines. PARTICIPANTS: 15 facilitators working in two practice contexts: small independent practices (SIPs) and Federally Qualified Health Centers (FQHCs). MAIN MEASURES: Strategies facilitators use to support and promote practice changes and contextual factors that impact this approach. KEY RESULTS: Contextual factors were described similarly across settings and included the policy environment, patient needs, site characteristics, leadership engagement, and competing priorities. We identified four facilitation strategies used to tailor to contextual factors and support practice change: (a) remain flexible to align with practice and organizational priorities; (b) build relationships; (c) provide value through information technology expertise; and (d) build capacity and create efficiencies. Facilitators in SIPs and FQHCs described using the same strategies, often in combination, but tailored to their specific contexts. CONCLUSIONS: Despite significant infrastructure and resource differences between SIPs and FQHCs, the contextual factors that influenced the facilitator's change process and the strategies used to address those factors were remarkably similar. The findings emphasize that facilitators require multidisciplinary skills to support sustainable practice improvement in the context of varying complex health care delivery settings.

Unpacking Clinical Supervision in Transitional and Permanent Supportive Housing: Scrutiny or Support?

Behavioral health organizations use clinical supervision to ensure professional development and practice quality. This qualitative study examined 35 service coordinators' perspectives on supervision in two distinct supportive housing program types (permanent and transitional). Thematic analysis of in-depth interviews yielded three contrast themes: support versus scrutiny, planned versus impromptu time, and housing first versus treatment first. Supervisory content and format resulted in differential perceptions of supervision, thereby influencing opportunities for learning. These findings suggest that unpacking discrete elements of supervision enactment in usual care settings can inform implementation of recovery-oriented practice.

Maslow and mental health recovery: a comparative study of homeless programs for adults with serious mental illness.

This mixed-methods study uses Maslow's hierarchy as a theoretical lens to investigate the experiences of 63 newly enrolled clients of housing first and traditional programs for adults with serious mental illness who have experienced homelessness. Quantitative findings suggests that identifying self-actualization goals is associated with not having one's basic needs met rather than from the fulfillment of basic needs. Qualitative findings suggest a more complex relationship between basic needs, goal setting, and the meaning of self-actualization. Transforming mental health care into a recovery-oriented system will require further consideration of person-centered care planning as well as the impact of limited resources especially for those living in poverty.

Impact of Antecedent and Organizational Differences on Nurse-Social Worker Collaboration in a Retirement and Assisted Living Community with Skilled Nursing Care.

Nurse-social worker collaborative interactions in long-term care settings have received limited attention. This qualitative thematic study of 23 participants (11 social workers and 12 nurses) at an urban retirement and assisted living community explores experiences of collaborative work. Two themes of contrasts in responding to resident complexity and contrasts in peer-to-peer work highlight four subthemes reflecting: (a) social workers' orientation toward resident self-determination, requisite care, and advocacy; (b) nurses' orientation toward resident safety, tasks, and clinical outcomes; (c) social workers' devalued professional identity; and (d) nurses' attribution of collaborative challenges to individuals. Social workers showed greater openness toward working with nurses and viewed nurses as close partners. Nurses showed greater separation from social workers and non-clinical peers and maintained a greater intraprofessional focus. Whereas challenges may stem from antecedent disciplinary training nurses and social workers receive, organizational triggers related to residents' care and associated decision-making exacerbate them. Interprofessional education may strengthen collaboration.

Miracle friends and miracle money in California: a mixed-methods experiment of social support and guaranteed income for people experiencing homelessness.

BACKGROUND: This paper describes the protocols for a randomized controlled trial using a parallel-group trial design that includes an intervention designed to address social isolation and loneliness among people experiencing homelessness known as Miracle Friends and an intervention that combines Miracles Friends with an economic poverty-reduction intervention known as Miracle Money. Miracle Friends pairs an unhoused person with a volunteer "phone buddy." Miracle Money provides guaranteed basic income of $750 per month for 1 year to Miracle Friends participants. The study will examine whether either intervention reduces social isolation or homelessness compared to a waitlist control group. METHODS: Unhoused individuals who expressed interest in the Miracle Friends program were randomized to either receive the intervention or be placed on a waitlist for Miracle Friends. Among those randomized to receive the Miracle Friends intervention, randomization also determined whether they would be offered Miracle Money. The possibility of receiving basic income was only disclosed to study participants if they were randomly selected and participated in the Miracle Friends program. All study participants, regardless of assignment, were surveyed every 3 months for 15 months. RESULTS: Of 760 unhoused individuals enrolled in the study, 256 were randomized to receive Miracle Friends, 267 were randomized to receive Miracle Money, and 237 were randomized to the waitlist control group. In the two intervention groups, 360 of 523 unhoused individuals were initially matched to a phone buddy. Of the 191 study participants in the Miracle Money group who had been initially matched to a volunteer phone buddy, 103 were deemed to be participating in the program and began receiving monthly income. DISCUSSION: This randomized controlled trial will determine whether innovative interventions involving volunteer phone support and basic income reduce social isolation and improve housing outcomes for people experiencing homelessness. Although we enrolled unhoused individuals who initially expressed interest in the Miracle Friends program, the study team could not reach approximately 30% of individuals referred to the study. This may reflect the general lack of stability in the lives of people who are unhoused or limitations in the appeal of such a program to some portion of the unhoused population. TRIAL REGISTRATION: ClinicalTrials.gov NCT05408884 (first submitted on May 26, 2022).

Permanent supportive housing: addressing homelessness and health disparities?

Permanent supportive housing (PSH) is an intervention to address long-term homelessness. Evidence has resulted in a shift in US policy toward using PSH rather than shelters and transitional housing. Despite recognizing that individuals transitioning from homelessness to PSH experience a high burden of disease and health disparities, public health research has not considered whether and how PSH improves physical health outcomes. Based on diverse areas of research, we argue that in addition to improved access to quality health care, social determinants of health (including housing itself, neighborhood characteristics, and built environment) affect health outcomes. We identify implications for practice and research, and conclude that federal and local efforts to end long-term homelessness can interact with concurrent efforts to build healthy communities.

A picture is worth . . . ? Photo elicitation interviewing with formerly homeless adults.

We report on the use of photo elicitation interviewing (PEI) with 13 participants in a qualitative study of formerly homeless men and women with serious mental illness. Following a respondent-controlled approach, participants were asked to take up to 18 photographs visually portraying positive and negative aspects of their lives and to subsequently narrate the meaning of the photos in a one-on-one interview. Thematic analysis of the photos (N = 205) revealed two approaches to PEI: (a) a "slice of life" and (b) "then vs. now." Examples show how PEIs yielded deeper, more elaborate accounts of participants' lives compared to earlier verbal-only interviews. Participants spoke of the benefits of PEI and preferred taking positive as opposed to negative photographs depicting their lives. Implications of PEI as a means of complementing verbal-only data are discussed. By moving away from predetermined content and meaning, respondent-controlled PEIs enhance empowerment and enable creativity.

From the streets to a hotel: a qualitative study of the experiences of homeless persons in the pandemic era.

In the wake of COVID-19, programs for housing homeless individuals in hotels have emerged in the U.S., though research has yielded little information about the impact of these programs on participants expressed in their own words. In this qualitative study conducted in a major northeastern city, 13 previously street homeless individuals recount their experiences of hotel housing during the pandemic. Participants were recruited from an advocacy-initiated collaborative that operated with a housing first approach, providing private rooms without requirements or intrusive oversight typically found in shelter environments. Benefits of hotel housing reported include improvements in physical health, sleep, personal hygiene, privacy, safety, nutrition, and overall well-being. Inductive coding by consensus and thematic development yielded three themes. Participants described hotel living as (1) a platform for stability; (2) protection from COVID and other hazards; and (3) freeing mental space for future planning. As research shows hotel programs' success, an unprecedented opportunity has arisen from the pandemic to end homelessness for many. Given current federal budget increases, it is recommended that hotels become part of a larger effort to reduce shelter populations and increase access to independent housing.

Substance Abuse Recovery after Experiencing Homelessness and Mental Illness: Case Studies of Change Over Time.

OBJECTIVE: This paper addresses how consumers with dual diagnosis, who were formerly homeless but are now living in supportive housing, understand their recovery from substance abuse (i.e., substance abuse or dependence). Specifically, this study examined: What can be learned about substance abuse recovery from consumers considered to be doing well; how past substance abuse fits into their present-day narratives; and how (if at all) policies of harm reduction versus abstinence are regarded as affecting recovery efforts. METHODS: As part of a federally-funded qualitative study, 38 individuals who met criteria for having achieved a measure of success in mental health recovery were purposively sampled from two supportive housing agencies - one using a harm reduction and the other an abstinence model. Researchers conducted in-depth interviews and used case study analysis, the latter including the development of case summaries and data matrices, to focus on substance abuse recovery in the larger context of participants' lives. RESULTS: Recovery from substance abuse was depicted as occurring either through discrete decisions or gradual processes; achieving recovery was distinct from maintaining recovery. Emergent themes related to achievement included: (a) pivotal events and people (b) maturation, and (c) institutionalization. Central themes to maintaining recovery were: (a) housing, (b) self-help, and (c) the influence of significant others. CONCLUSIONS: These findings capture a complex picture of overcoming substance abuse that largely took place outside of formal treatment and was heavily dependent on broader contexts. Equally important is that consumers themselves did not necessarily view substance abuse recovery as a defining feature of their life story. Indeed, recovery from substance abuse was seen as overcoming one adversity among many others during their troubled life courses.

Using the interactive systems framework to support a quality improvement approach to dissemination of evidence-based strategies to promote early detection of breast cancer: planning a comprehensive dynamic trial.

Dissemination efforts must optimize interventions for new settings and populations. As such, dissemination research should incorporate principles of quality improvement. Comprehensive Dynamic Trial (CDT) designs examine how information gained during dissemination may be used to modify interventions and improve performance. Although CDT may offer distinct advantages over static designs, organizing the many necessary roles and activities is a significant challenge. In this article, we discuss use of the Interactive Systems Framework for Dissemination and Implementation to systematically implement a CDT. Specifically, we describe "Bronx ACCESS", a program designed to disseminate evidence-based strategies to promote adherence to mammography guidelines. In Bronx ACCESS, the Intervention Delivery System will elicit information needed to adapt strategies to specific settings and circumstances. The Intervention Synthesis and Translation System will use this information to test changes to strategies through "embedded experiments". The Intervention Support System will build local capacities found to be necessary for intervention institutionalization. Simulation modeling will be used to integrate findings across systems. Results will inform on-going policy debate about interventions needed to promote population-level screening. More generally, this project is intended to advance understanding of research paradigms necessary to study dissemination.

Substance use outcomes among homeless clients with serious mental illness: comparing Housing First with Treatment First programs.

The Housing First (HF) approach for homeless adults with serious mental illness has gained support as an alternative to the mainstream "Treatment First" (TF) approach. In this study, group differences were assessed using qualitative data from 27 HF and 48 TF clients. Dichotomous variables for substance use and substance abuse treatment utilization were created and examined using bivariate and logistic regression analyses. The HF group had significantly lower rates of substance use and substance abuse treatment utilization; they were also significantly less likely to leave their program. Housing First's positive impact is contrasted with the difficulties Treatment First programs have in retaining clients and helping them avoid substance use and possible relapse.

The role of housing: a comparison of front-line provider views in housing first and traditional programs.

PURPOSE: Within the mental health system, there are two distinct service models for adults who have severe mental illness and are homeless: one prioritizes treatment before accessing permanent housing (Treatment First) while the other provides permanent housing upfront followed by clinical support (Housing First). Investigating front-line providers working within these two models affords an opportunity to learn more about their implementation from an insider perspective, thus shedding light on whether actual practice is consistent with or contrary to these program models' contrasting philosophical values. METHODS: Forty-one providers were recruited from four agencies as part of a NIMH funded qualitative study. Multiple, in-depth interviews lasting 30-45 min were conducted with providers that explored working within these agencies. Thematic analysis was utilized to compare the views of 20 providers working in Housing First versus the 21 providers working in Treatment First programs. RESULTS: Providers viewed housing as a priority but differences emerged between Treatment First and Housing First providers along three major themes: the centrality of housing, engaging consumers through housing, and (limits to...) a right to housing. CONCLUSION: Ironically, this study revealed that providers working within Treatment First programs were consumed with the pursuit of housing, whereas Housing First providers focused more on clinical concerns since consumers already had housing. Clearly, how programs position permanent housing has very different implications for how providers understand their work, the pressures they encounter, and how they prioritize client goals.

"Home Is Where Your Root Is": Place Making, Belonging, and Community Building among Somalis in Chicago.

This qualitative study examines the notion of home as it relates to place making, belonging, and community building. Using a phenomenological method of inquiry, data were gathered through in-depth qualitative interviews with 15 Somali Americans and subjected to transcendental phenomenological analyses. Three major themes were found: (1) the meaning of community: being Somali and Muslim; (2) "We help each other. We are connected"; and (3) "Home is where your root is." The study findings highlight how Somali participants drew on their faith and culture as foundational to community building and drew on acts of mutual giving and receiving to bind them together even as subjective feelings of "home" could be place based or could transcend geography. Although sometimes disrupted by bias and discrimination, Somalis persevered in defining themselves and pursuing a sense of belonging both within their own community and in the city at large. This study offers an expansive and dynamic view of the meaning of place making, community building, and belonging (home) in the lives of displaced refugees. Both research and practice can benefit from special attention given to the "natural" formation of refugee communities and their role in enhancing adjustment to life in a new land.

Homelessness, housing instability and mental health: making the connections.

Research on the bi-directional relationship between mental health and homelessness is reviewed and extended to consider a broader global perspective, highlighting structural factors that contribute to housing instability and its mental ill health sequelae. Local, national and international initiatives to address housing and mental health include Housing First in Western countries and promising local programmes in India and Africa. Ways that psychiatrists and physicians can be agents of changes range from brief screening for housing stability to structural competence training. Narrow medico-scientific framing of these issues risks losing sight of the foundational importance of housing to mental health and well-being.

Eliciting Life Priorities of Older Adults Living in Permanent Supportive Housing.

BACKGROUND AND OBJECTIVES: Adults who have experienced chronic homelessness are considered to be "old" by age 50 due to accelerated aging. While permanent supportive housing (PSH) has been found effective for these individuals, there is limited focus on the needs of adults "aging in place" in PSH. This study examined (1) how older adults in PSH identify and rank their life priorities, (2) how they describe these priorities in their own words, and (3) how life course adversity deepens an understanding of these priorities. RESEARCH DESIGN AND METHODS: A convergent parallel mixed methods design was used in which qualitative case study analyses informed by a life course perspective provided a deeper understanding of how 14 older residents of PSH viewed their life priorities using quantitative card-sort rankings of 12 life domains. RESULTS: Housing, family, mental health, physical health, and partner were the most frequently endorsed life priorities. Four themes emerged from the cross-case analyses: "aging in, aging out," "carefully restoring relationships," "life goes on," and "housing is fundamental." Convergent findings indicated that life adversity-social losses and interrupted lives-influenced both the high- and low-ranked card-sort priorities. DISCUSSION AND IMPLICATIONS: This study demonstrated that participants were aware of their advancing years yet they sought to overcome adversity and losses through maintaining mental health and sobriety, improving physical health, and cautiously rebuilding relationships. As the numbers of older homeless rise, the inclusion of age-related services will be an important component of PSH services for residents as they age.

Employment experiences of formerly homeless adults with serious mental illness in Housing First versus treatment first supportive housing programs.

OBJECTIVE: This paper examines how formerly homeless adults with serious mental illness living in Housing First (HF) and "treatment first" (TF) supportive housing programs experience employment. Research questions include: How do these individuals experience employment in the context of their mental health recovery? What do they perceive as the benefits of and obstacles to attaining employment? Are there programmatic differences in their employment experiences? METHOD: Case study analyses of data from a federally funded qualitative study were conducted of 40 individuals purposively sampled from HF and TF programs. Data were independently analyzed and consensually discussed to develop cross-case themes. RESULTS: Three themes emerged: (a) the meaning of work, (b) working within the system, and (c) balancing treatment requirements and work. While none of the study participants had full-time jobs, more HF program clients had part-time employment than their TF counterparts. Of the 12 employed participants, all but 2 worked within their respective programs. Participants in both groups described similar benefits of obtaining employment, but TF program requirements inhibited job-seeking. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: These findings provide insight into the challenges of obtaining employment for formerly homeless individuals with serious mental illness residing in supportive housing. Despite the motivation to work, individual, structural, and organizational factors impeded employment. To address this problem, factors at each of these levels will need to be considered. Interventions such as supported employment offer promise to supportive housing programs committed to employment as a contributor to recovery. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Obtaining large-scale funding for empowerment-oriented qualitative research: a report from personal experience.

Obtaining funding for qualitative research remains a challenge despite greater openness to methodological pluralism. Such hurdles are presumably compounded when the proposed study employs empowerment theory, rendering it susceptible to charges of elevating ideology over rigor. This article draws on the authors' experience in securing large-scale funding for an empowerment-oriented qualitative study of homeless mentally ill adults. Lessons learned include the importance of weaving empowerment theory into the proposal's "argument," and infusing empowerment values into study protocols while simultaneously paying close attention to rigorous and transparent methods. Additional benefits accrue from having prior relationships with study sites and being willing to revise and resubmit proposals whenever possible. Though representing a fraction of all externally funded projects in the United States, qualitative research has tremendous untapped potential for success in this competitive arena-success that need not entail surrendering a commitment to empowerment values.