A care coordinator screening strategy to address health harming legal needs.

BACKGROUND: Medical legal partnerships provide an opportunity to help address various social determinants of health; however, the traditional practice of screening patients during clinical encounters is limited by the capacity of busy clinicians. Our medical legal partnership utilized care coordinators trained by the legal service attorneys to screen patients outside of clinical encounters for health harming legal needs. The goal of our study was to demonstrate that our novel model could successfully identify and refer patients of a safety-net healthcare system to appropriate legal services. METHODS: We conducted a mixed methods evaluation of the program. Data was collected during the implementation period of the program from March 2017 to August 2018. Operational data collected included number of patients screened, number of referrals to the legal partner, source and reason for referrals. Return on investment was calculated by subtracting program costs from the total reimbursement to the health system from clients' insurance benefits secured through legal services. RESULTS: During the 18-month study, 29,268 patients were screened by care coordinators for health harming legal needs, with 492 patients (1.7%) referred for legal assistance. Of the 133 cases closed in 2017, all clients were invited to participate in a telephone interview; 63 pre-consented to contact, 33 were successfully contacted and 23 completed the interview. The majority (57%) reported a satisfactory resolution of their legal barrier to health. This was accompanied by an improvement in self-reported health with a decrease of patients reporting less than optimal health from 16 (89%) prior to intervention to 8 (44%) after intervention [risk ratio (95% confidence interval): 0.20 (0.04, 0.91)]. Patients also reported improvements in general well-being for themselves and their family. The healthcare system recorded a 263% return on investment. CONCLUSIONS: In our medical legal partnership, screening for health harming legal needs by care coordinators outside of a clinical encounter allowed for efficient screening in a high risk population. The legal services intervention was associated with improvements in self-reported health and family well-being when compared to previous models. The return on investment was substantial.

Rapid Creation of a Multiagency Alternate Care Site for COVID-19- Positive Individuals Experiencing Homelessness.

Cook County Health partnered with the Chicago Departments of Public Health and Family & Support Services and several dozen community-based organizations to rapidly establish a temporary medical respite shelter during the spring 2020 COVID-19 peak for individuals experiencing homelessness in Chicago and Cook County, Illinois. This program provided low-barrier isolation housing to medically complex adults until their safe return to congregate settings. We describe strategies used by the health care agency, which is not a Health Resource and Services Administration Health Care for the Homeless grantee, to provide medical services and care coordination.

Variability in comorbidites and health services use across homeless typologies: multicenter data linkage between healthcare and homeless systems.

BACKGROUND: Homelessness is associated with substantial morbidity. Data linkages between homeless and health systems are important to understand unique needs across homeless populations, identify homeless individuals not registered in homeless databases, quantify the impact of housing services on health-system use, and motivate health systems and payers to contribute to housing solutions. METHODS: We performed a cross-sectional survey including six health systems and two Homeless Management Information Systems (HMIS) in Cook County, Illinois. We performed privacy-preserving record linkage to identify homelessness through HMIS or ICD-10 codes captured in electronic medical records. We measured the prevalence of health conditions and health-services use across the following typologies: housing-service utilizers stratified by service provided (stable, stable plus unstable, unstable) and non-utilizers (i.e., homelessness identified through diagnosis codes-without receipt of housing services). RESULTS: Among 11,447 homeless recipients of healthcare, nearly 1 in 5 were identified by ICD10 code alone without recorded homeless services (n = 2177; 19%). Almost half received homeless services that did not include stable housing (n = 5444; 48%), followed by stable housing (n = 3017; 26%), then receipt of both stable and unstable services (n = 809; 7%). Setting stable housing recipients as the referent group, we found a stepwise increase in behavioral-health conditions from stable housing to those known as homeless solely by health systems. Compared to those in stable housing, prevalence rate ratios (PRR) for those without homeless services were as follows: depression (PRR = 2.2; 95% CI 1.9 to 2.5), anxiety (PRR = 2.5; 95% CI 2.1 to 3.0), schizophrenia (PRR = 3.3; 95% CI 2.7 to 4.0), and alcohol-use disorder (PRR = 4.4; 95% CI 3.6 to 5.3). Homeless individuals who had not received housing services relied on emergency departments for healthcare-nearly 3 of 4 visited at least one and many (24%) visited multiple. CONCLUSIONS: Differences in behavioral-health conditions and health-system use across homeless typologies highlight the particularly high burden among homeless who are disconnected from homeless services. Fragmented and high use of emergency departments for care should motivate health systems and payers to promote housing solutions, especially those that incorporate substance use and mental health treatment.

A cross-sectional analysis of fentanyl analog exposures among living patients.

Background: Synthetic opioids, including fentanyl analogs, contribute to an increasing proportion of opioid-related deaths. Highly potent analogs pose an increased risk for fatal overdose. The prevalence of fentanyl analog exposures in patients with known opioid exposure is unknown.Objective: The purpose of this study was to determine the exposure prevalence for fentanyl analogs in living patients with positive urine screens for opiates or fentanyl.Methods: This was a cross-sectional analysis of urine high performance liquid chromatography/tandem mass spectroscopy (HPLC-MS/MS) results from patients with a positive urine screen for opiates or fentanyl at a large public healthcare system in Chicago, Illinois. Samples with positive screens were non-continuously tested by HPLC-MS/MS for 5 selected months in 2018 and 2019.Results: A total of 219 urine samples which screened positive for fentanyl or opiates underwent HPLC-MS/MS testing. At least one fentanyl analog was detected in 65.3% (n = 143) of samples with 26.0% (n = 57) testing positive for multiple analogs. The most common analogs, intermediates, or metabolites were: 4-ANPP (n = 131); 2-furanylfentanyl (n = 22); acryl fentanyl (n = 21); butyrylfentanyl (n = 15); cyclopropylfentanyl (n = 15); and carfentanil (n = 13). Of samples which screened positive for fentanyl (n = 188), 70.2% (132) tested positive for at least one fentanyl analog. Of samples which screened negative for fentanyl but positive for opiates (n = 31), 35.5% (n = 11) tested positive for fentanyl analogsConclusion: Fentanyl analog exposure is common in patients with positive urine screens for fentanyl or opiates. Screening living patient samples for synthetic opioids has future toxicosurveillance implications and these data underscore the increased risks from illicit opioid use.

Prescribing Associated with High-Risk Opioid Exposures Among Non-cancer Chronic Users of Opioid Analgesics: a Social Network Analysis.

BACKGROUND: The continued rise in fatalities from opioid analgesics despite a steady decline in the number of individual prescriptions directing ≥ 90 morphine milligram equivalents (MME)/day may be explained by patient exposures to redundant prescriptions from multiple prescribers. OBJECTIVES: We evaluated prescribers' specialty and social network characteristics associated with high-risk opioid exposures resulting from single-prescriber high-daily dose prescriptions or multi-prescriber discoordination. DESIGN: Retrospective cohort study. PARTICIPANTS: A cohort of prescribers with opioid analgesic prescription claims for non-cancer chronic opioid users in an Illinois Medicaid managed care program in 2015-2016. MAIN MEASURES: Per prescriber rates of single-prescriber high-daily-dose prescriptions or multi-prescriber discoordination. KEY RESULTS: For 2280 beneficiaries, 36,798 opioid prescription claims were submitted by 3532 prescribers. Compared to 3% of prescriptions (involving 6% of prescribers and 7% of beneficiaries) that directed ≥ 90 MME/day, discoordination accounted for a greater share of high-risk exposures-13% of prescriptions (involving 23% of prescribers and 24% of beneficiaries). The following specialties were at highest risk of discoordinated prescribing compared to internal medicine: dental (incident rate ratio (95% confidence interval) 5.9 (4.6, 7.5)), emergency medicine (4.7 (3.8, 5.8)), and surgical subspecialties (4.2 (3.0, 5.8)). Social network analysis identified 2 small interconnected prescriber communities of high-volume pain management specialists, and 3 sparsely connected groups of predominantly low-volume primary care or emergency medicine clinicians. Using multivariate models, we found that the sparsely connected sociometric positions were a risk factor for high-risk exposures. CONCLUSION: Low-volume prescribers in the social network's periphery were at greater risk of intended or discoordinated prescribing than interconnected high-volume prescribers. Interventions addressing discoordination among low-volume opioid prescribers in non-integrated practices should be a priority. Demands for enhanced functionality and integration of Prescription Drug Monitoring Programs or referrals to specialized multidisciplinary pain management centers are potential policy implications.

Physical symptoms screening for cardiopulmonary complications of obesity using audio computer-assisted self-interviews.

PURPOSE: The main study objective was to assess the predictive value of selected physical symptoms for screening obstructive sleep apnea and major cardiac conditions in adults with obesity, thus providing the evidence for routine symptom screening of obesity complications endorsed by obesity management clinical practice guidelines. METHODS: We performed a retrospective cohort study using patient-reported outcomes data including the physical symptoms severity component of the Memorial Symptom Assessment Scale administered through Audio Computer-Assisted Self-Interviews combined with data from the electronic medical records of an urban safety-net primary care clinic. Non-underweight ambulatory patients completing the standardized survey assessment were included. The prevalence of pre-selected symptoms and the diagnostic characteristics at various severity cut-points were determined for obstructive sleep apnea or major cardiac conditions separately for patients with and without obesity. RESULTS: Of the 1399 patients included in this analysis, most (77%) were non-hispanic black or hispanic. Step-wise increases in positive likelihood ratios ranging between 1.2 and 4.6 with greater severity cough, dyspnea, fatigue, bloating, dizziness, and nausea were observed for both obstructive sleep apnea and major cardiac complications. Likelihood ratio estimates for both obese and non-obese patients were statistically significant. CONCLUSIONS: Our findings provide a basis to support current guideline recommendations for routine symptom screening to identify medical complications among patients with BMI 30 kg/m2 or greater.

Clinical significance of physical symptom severity in standardized assessments of patient reported outcomes.

PURPOSE: Standardized measures of physical symptoms predict mortality and healthcare utilization, but clinicians remain uncertain about how to apply them in routine clinical care. Recognizing the tendency for physician documentations to routinely underestimate symptom burden, we assessed whether or not severity was an important dimension of symptom assessments that may determine their usefulness in clinical encounters. METHODS: Retrospective cohort study using data from audio computer-assisted self-interviews augmented by chart review of patients from a primary care clinic of an urban health system. RESULTS: We sampled 145 patients who completed the Memorial Symptom Assessment Scale (MSAS) short form-physical symptom severity measurement-before their primary care visit. Most were women (60 %), and non-Hispanic black (59 %), and many responded in Spanish (19 %). All but three reported > 1 symptom. Overall, 79 % of elicited symptoms were not documented in physician notes from the same day. Severe symptoms were more likely to be documented [MSAS mean (95 % confidence interval): documented 2.2 (1.9, 2.4) vs. undocumented 1.8 (1.7, 1.9)]. CONCLUSION: Documentations reflect usual patient-clinician communications that prioritize severe symptoms, while standardized instruments target their comprehensive assessments. Among the many validated instruments, those eliciting the severity of physical symptoms may simultaneously help clinicians with prioritization and risk assessments.

Health perceptions and symptom burden in primary care: measuring health using audio computer-assisted self-interviews.

PURPOSE: To assess the relationships among somatic symptoms and health perception measures in data collected from the implementation of audio computer-assisted self-interview (ACASI) technology in a primary care clinic of a safety-net healthcare system. METHODS: We approached 2,848 English- or Spanish-speaking patients to complete an ACASI-administered survey before their clinic appointment between April 2011 and July 2012. We administered the National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health-10 assessing General Self-Rated Health (GSRH), Global Physical and Mental Health; Memorial Symptom Assessment Scale (MSAS) assessing symptom burden; and the Patient Health Questionnaire-2 (PHQ-2). We calculated population attributable fractions (PAF) of symptoms on poorly perceived health. RESULTS: Participation rate was 90 %, but 51 % of observations were analyzable. Mean age was 57 years; 53 % were non-Hispanic black; and 20 % completed the survey in Spanish. All but 2 % reported at least one symptom most commonly lack of energy (87 %) and pain (83 %). The MSAS was well correlated with PHQ-2 (r = 0.65) and Global Physical Health (r = -0.65), but less with GSRH (r = -0.49). All negative health perception measures were largely attributable to lack of energy and pain, while depression-range PHQ-2 was attributable also to less prevalent symptoms including decreased appetite and sexual disinterest. CONCLUSIONS: Symptom burden was less correlated with GSRH than with other measures of poor health perception. Fatigue and pain contributed the highest PAF to all measures of perceived poor health. Success with collecting PROMs in a resource-limited clinical setting demonstrates that the implementation of ACASI technology is feasible.

The impact of hospitalist discontinuity on hospital cost, readmissions, and patient satisfaction.

BACKGROUND: Achieving patient-physician continuity is difficult in the inpatient setting, where care must be provided continuously. Little is known about the impact of hospital physician discontinuity on outcomes. OBJECTIVE: To determine the association between hospital physician continuity and percentage change in median cost of hospitalization, 30-day readmission, and patient satisfaction with physician communication. DESIGN: Retrospective observational study using various multivariable models to adjust for patient characteristics. PARTICIPANTS: Patients admitted to a non-teaching hospitalist service in a large, academic, urban hospital between 6 July 2008 and 31 December 2011. MAIN MEASURES: We used two measures of continuity: the Number of Physicians Index (NPI), and the Usual Provider of Continuity (UPC) index. The NPI is the total number of unique physicians caring for a patient, while the UPC is calculated as the largest number of patient encounters with a single physician, divided by the total number of encounters. Outcome measures were percentage change in median cost of hospitalization, 30-day readmissions, and top box responses to satisfaction with physician communication. KEY RESULTS: Our analyses included data from 18,375 hospitalizations. Lower continuity was associated with modest increases in costs (range 0.9-12.6 % of median), with three of the four models used achieving statistical significance. Lower continuity was associated with lower odds of readmission (OR = 0.95-0.98 across models), although only one of the models achieved statistical significance. Satisfaction with physician communication was lower, with less continuity across all models, but results were not statistically significant. CONCLUSIONS: Hospital physician discontinuity appears to be associated with modestly increased hospital costs. Hospital physicians may revise plans as they take over patient care responsibility from their colleagues.

A qualitative investigation into the effectiveness of a housing navigator program linking justice-involved clients with recovery housing.

BACKGROUND: Roughly 24-36% of people who are incarcerated in the U.S. are formally diagnosed with opioid use disorder (OUD). Once released, individuals involved with the criminal legal system (CLS) face increased risks of return to use and fatality and are 129 times more likely to die from an overdose within the first two weeks of release compared to those without CLS involvement. People who are CLS-involved and who are seeking a recovery living environment can access temporary stable housing through recovery homes. However, entering a recovery home can be difficult due to fragmentation among recovery housing organizations and their non-uniform application and screening procedures. A navigation pilot program was implemented to provide clients with recovery home placement advice, pre-screening, and referrals in Cook County, IL. Existing research on recovery homes has rarely examined the importance of recovery housing navigation for enhancing service engagement among CLS-involved individuals receiving medications for OUD. METHODS: Semi-structured qualitative interviews were conducted with 22 clients and three recovery housing navigators as part of a program evaluation of the navigation program pilot. Qualitative software was used to organize and qualitatively analyze transcripts through several rounds of coding producing emergent themes, which were then triangulated, and expanded using navigator data. RESULTS: Clients seeking recovery home services reported multiple prior challenges securing safe and supportive recovery living environments. Despite low initial expectations, clients described their interactions with housing navigators in favorable terms and felt navigators worked with them effectively to identify and meet their housing and substance use needs in a timely manner. Clients also commented on their partnerships with the navigator throughout the process. Interactions with navigators also calmed fears of rejection many clients had previously experienced and still harbored about the process, which bolstered client-navigator relationships and client motivation to engage with additional services. CONCLUSION: Evidence from this study suggests recovery home navigation can improve the speed and efficiency with which clients are connected to appropriate services that are tailored to their specific needs as well as increase client motivation to engage with a myriad of recovery services.

"A lot of moving parts": Recovery home challenges linking and housing individuals with criminal legal system involvement.

INTRODUCTION: There are high rates of substance use disorder (SUD) among people released from carceral settings and, upon release, many of these people also face unstable housing situations, posing challenges to connecting with resources to facilitate SUD recovery. Recovery homes provide a temporary sober living environment for those seeking both SUD recovery and transition back to the community after carceral release. However, successful recovery home placement for this population can prove difficult, and there is a need for research to identify ways to overcome them. METHODS: The current qualitative study seeks to understand barriers to recovery home access for people leaving carceral settings and identify potential best practices for overcoming these barriers from the perspective of recovery home directors. The study conducted semi-structured interviews at two data collection points with eight recovery home directors from sites participating in a housing linkage and placement intervention pilot. The research team used qualitative software to identify and organize directors' experiences and practices in housing and supporting this population. RESULTS: Recovery home directors identified significant barriers to linkage from carceral settings, including difficulties communicating and coordinating placement with potential residents while still incarcerated. Interviews also revealed approaches recovery home directors take to improve recovery home placement, such as sharing information and resources with carceral settings prior to release and helping residents avoid reincarceration by managing relationships with court agents and parole. CONCLUSION: Recovery resident directors have considerable insight into the most significant placement challenges faced by recovery homes upon carceral release as well as experience with potential solutions for overcoming them. Directors can be the key to direct seamless support and continuity of care for criminal legal system involved individuals through coordination with jails, prisons, and other community resources. Directors can also play a significant role in the successful completion of probation and parole by helping residents avoid further issues with the legal system. These directors view working cooperatively with residents as an effective approach to ensuring clients adhere to court orders and are successful in recovery and reentry.

Worklife and satisfaction of hospitalists: toward flourishing careers.

BACKGROUND: The number of hospitalists in the US is growing rapidly, yet little is known about their worklife to inform whether hospital medicine is a viable long-term career for physicians. OBJECTIVE: Determine current satisfaction levels among hospitalists. DESIGN: Survey study. METHODS: A national random stratified sample of 3,105 potential hospitalists plus 662 hospitalist employees of three multi-state hospitalist companies were administered the Hospital Medicine Physician Worklife Survey. Using 5-point Likert scales, the survey assessed demographic information, global job and specialty satisfaction, and 11 satisfaction domains: workload, compensation, care quality, organizational fairness, autonomy, personal time, organizational climate, and relationships with colleagues, staff, patients, and leader. Relationships between global satisfaction and satisfaction domains, and burnout symptoms and career longevity were explored. RESULTS: There were 816 hospitalist responses (adjusted response rate, 25.6%). Correcting for oversampling of pediatricians, 33.5% of respondents were women, and 7.4% were pediatricians. Overall, 62.6% of respondents reported high satisfaction (≥4 on a 5-point scale) with their job, and 69.0% with their specialty. Hospitalists were most satisfied with the quality of care they provided and relationships with staff and colleagues. They were least satisfied with organizational climate, autonomy, compensation, and availability of personal time. In adjusted analysis, satisfaction with organizational climate, quality of care provided, organizational fairness, personal time, relationship with leader, compensation, and relationship with patients predicted job satisfaction. Satisfaction with personal time, care quality, patient relationships, staff relationships, and compensation predicted specialty satisfaction. Job burnout symptoms were reported by 29.9% of respondents who were more likely to leave and reduce work effort. CONCLUSIONS: Hospitalists rate their job and specialty satisfaction highly, but burnout symptoms are common. Hospitalist programs should focus on organizational climate, organizational fairness, personal time, and compensation to improve satisfaction and minimize attrition.

Interventions to reduce 30-day rehospitalization: a systematic review.

BACKGROUND: About 1 in 5 Medicare fee-for-service patients discharged from the hospital is rehospitalized within 30 days. Beginning in 2013, hospitals with high risk-standardized readmission rates will be subject to a Medicare reimbursement penalty. PURPOSE: To describe interventions evaluated in studies aimed at reducing rehospitalization within 30 days of discharge. DATA SOURCES: MEDLINE, EMBASE, Web of Science, and the Cochrane Library were searched for reports published between January 1975 and January 2011. STUDY SELECTION: English-language randomized, controlled trials; cohort studies; or noncontrolled before-after studies of interventions to reduce rehospitalization that reported rehospitalization rates within 30 days. DATA EXTRACTION: 2 reviewers independently identified candidate articles from the results of the initial search on the basis of title and abstract. Two 2-physician reviewer teams reviewed the full text of candidate articles to identify interventions and assess study quality. DATA SYNTHESIS: 43 articles were identified, and a taxonomy was developed to categorize interventions into 3 domains that encompassed 12 distinct activities. Predischarge interventions included patient education, medication reconciliation, discharge planning, and scheduling of a follow-up appointment before discharge. Postdischarge interventions included follow-up telephone calls, patient-activated hotlines, timely communication with ambulatory providers, timely ambulatory provider follow-up, and postdischarge home visits. Bridging interventions included transition coaches, physician continuity across the inpatient and outpatient setting, and patient-centered discharge instruction. LIMITATIONS: Inadequate description of individual studies' interventions precluded meta-analysis of effects. Many studies identified in the review were single-institution assessments of quality improvement activities rather than those with experimental designs. Several common interventions have not been studied outside of multicomponent "discharge bundles." CONCLUSION: No single intervention implemented alone was regularly associated with reduced risk for 30-day rehospitalization. PRIMARY FUNDING SOURCE: None.

Prevalence and risk factors for opioid related mortality among probation clients in an American city.

INTRODUCTION: Substance use disorder researchers and treatment professionals have long recognized that risk of opioid-related mortality (ORM) is elevated after release from jail and prison. However, there are gaps in knowledge around ORM among people on probation and the relationship of ORM to drug testing and treatment referral while under supervision. Understanding this relationship is critical for probation officers who are often tasked with referring clients to treatment and monitoring compliance with treatment, without having a clinical background. In this cross-sectional study we estimate the prevalence and risk factors for ORM in a large, urban probation department. METHODS: We joined mortality records and probation records for 2018 and 2019 to determine the rate of ORM for the probation population. We stratified ORM rates by risk factors, including demographics, drug testing results, and treatment placements. RESULTS: Individuals on probation were fifteen times more likely to die from ORM (361 per 100,000) than the general county population (23 per 100,000), largely driven by fentanyl (detected in 86.8% of deaths). Risk was elevated for clients over age 45 (838 per 100,000; 95% CI [655-1057]), clients with at least one positive drug test for opioids (1995 per 100,000; 95% CI [1419-2727]) or cocaine (1200 per 100,000; 95% CI [841-1661]), and clients with previous placements in drug treatment (692 per 100,000; 95% CI [503-929]). Positive urine tests for opioids were associated with 80 times greater risk of ORM than the general population. Although Black clients experienced ORM in greater numbers, white clients had relatively greater ORM risk. CONCLUSIONS: Elevated risk for ORM among the probation population justifies urgent and data-driven partnerships between public health and community corrections to train probation staff; to identify high-risk clients for evidence-based treatment and overdose prevention strategies; and to institute policies to support and sustain these activities.

Does Bail Reform Decarcerate Mental Illness? Public Health Challenges for a Large County Jail System.

Although bail reform reduces jail census, whether or not its effects extend to incarcerated individuals with mental illness is unknown. Using a novel high-sensitivity measure of serious mental illness (SMI) from jail-based electronic health records, we conducted an interrupted time series analysis assessing the impact of Illinois bail reform on total jail registrations and the nested subset with SMI ± co-occurring substance use disorder (SUD). Compared with a decline in total jail registrations, admission of individuals with SMI ± SUD showed no decline. Consequently, the proportion of admissions involving SMI increased between 2015 and 2019 from 26% to 35%. Intentional efforts involving cooperation by the health, social services, and justice sectors are needed to translate the impact of bail reform onto the population experiencing SMI.

Declining health risk exposure among Chicago public high school students: Trends from the Youth Risk Behavior Survey 1997-2017.

There have been improvements nationally in teenagers' self-reported health risk since the 1990s. This study provides an overview of trends in substance use, sexual health, violence and victimization, and suicide risk among Chicago Public High School (CPS) students over a 20-year period. We compared responses to 29 identically worded items from the 1997, 2007, and 2017 Chicago Youth Risk Behavior Survey (YRBS) in the four domains. We show changes in responses across individual items, mean changes across the four domains, and change in the proportion of students with highest risk exposure (≥10 affirmative responses). Analyses control for CPS students' grade, sex, and race/ethnicity. Reductions in substance use, sexual health risk, and violence and victimization (30, 40% and 40% in the mean number of affirmative responses, respectively) were observed. Suicide risk showed an initial improvement from 1997 to 2007, only to worsen by 2017 and show little difference from 1997. There was an approximate 70% decrease in the likelihood of being in the high multiple risk category (≥10 affirmative responses) in 2017 compared to 1997 (OR 0.33; CI 0.22-0.49). In alignment with national trends, our study documents significant improvement in Chicago public high school students' long-term health risk exposure over the 20-year study period, with the notable exception of suicide risk. This study emphasizes the need to invest in strategies both inside and outside of the classroom to mitigate the effect of adversity and promote protective factors, which are at the root of academic success and overall wellbeing.

Effect of positive urine fentanyl screen on attitudes toward heroin use.

BACKGROUND: It is unknown if targeted risk reduction counseling in the health care setting, after documented exposure to fentanyl, can affect behavior change to reduce risks and increase utilization of evidence-based overdose prevention strategies. METHODS: We conducted a retrospective analysis of results (7/2018-6/2019) from questionnaire-facilitated counseling by recovery coaches in the emergency department (ED) and primary care settings following disclosure of a urine toxicology positive for fentanyl. RESULTS: Seventy-five percent of N = 101 respondents were neither aware of nor expecting fentanyl in their substances of use. Fifty-three (70 %) of those initially unaware answered that learning about exposure to and the risks from fentanyl changed their thoughts about reducing or abstaining from use. A greater proportion of patients seen in the ED expressed desire to stop or reduce opioid use as compared to ambulatory clinic patients (91 % vs. 46 %, p < 0.001). Of those not already engaged in treatment, 18 % and 15 % were interested in medication and behavioural health treatment, respectively, and each of them indicated a change in thought based on the counseling. Forty-five percent of individuals not yet receiving naloxone endorsed interest in receiving it, and 22 % of all respondents were somewhat or very interested in access to safe consumption sites. CONCLUSION: This study suggests a novel clinical utility in toxicology screens to inform behavior in the setting of illicit fentanyl exposure. In addition to linkages to evidence-based treatment, linkages to harm-mitigating strategies associated with ongoing substance use may be critical to a comprehensive overdose prevention strategy in the clinical setting.

Accuracy of ICD-10 Diagnostic Codes for Identifying Housing Instability.

This cohort study assesses the performance of International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) Z59 codes for identifying housing instability during health care encounters.

Patient-level exclusions from mHealth in a safety-net health system.

Excitement about mobile health (mHealth) for improving care transitions is fueled by widespread adoption of smartphones across all social segments, but new disparities can emerge around nonadopters of technology-based communications. We conducted a cross-sectional survey of urban low-income adults to assess inadequate reading health literacy and limited English proficiency as factors affecting access to and engagement with mHealth. Although the proportion owning smartphones were comparable to national figures, adjusted analysis showed fewer patients with inadequate reading health literacy having Internet access (odds ratio [95% confidence interval]: 0.50 [0.26-0.95]), e-mail (0.43 [0.24-0.79]), and interest in using e-mail (0.34 [0.18-0.65]) for healthcare communications. Fewer patients with limited English proficiency were interested in using mobile apps (0.2 [0.09-0.46]). Inpatient status was independently associated with less interest in text messaging (0.46 [0.25-0.87]). mHealth exclusions around literacy and language proficiency threaten equity, and innovative solutions are needed to realize mHealth's potential for reducing disparities. Journal of Hospital Medicine 2017;12:90-93.