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The world of welfare has changed radically. As the poor trade welfare checks for low-wage jobs, their low earnings qualify them for a hefty check come tax time—a combination of the earned income tax credit and other refunds. For many working parents this one check is like hitting the lottery, offering several months' wages as well as the hope of investing in a better future. Drawing on interviews with 115 families, the authors look at how parents plan to use this annual cash windfall to build up savings, go back to school, and send their kids to college. However, these dreams of upward mobility are often dashed by the difficulty of trying to get by on meager wages. In accessible and engaging prose, It's Not Like I'm Poor examines the costs and benefits of the new work-based safety net, suggesting ways to augment its strengths so that more of the working poor can realize the promise of a middle-class life.

Background Regulations put in place to protect the privacy of individuals receiving substance use disorder (SUD) treatment have resulted in an unintended consequence of siloed SUD treatment and referral information outside of the integrated electronic health record (EHR). Recent revisions to these regulations have opened the door to data integration, which creates opportunities for enhanced patient care and more efficient workflows. We report on the experience of one safety-net hospital system integrating SUD treatment data into the EHR. Methods SUD treatment and referral information was integrated from siloed systems into the EHR through the implementation of a referral order, treatment episode definition, and referral and episode-related tools for addiction therapists and other clinicians. Integration was evaluated by monitoring SUD treatment episode characteristics, patient characteristics, referral linkage, and treatment episode retention before and after integration. Satisfaction of end-users with the new tools was evaluated through a survey of addiction therapists. Results After integration, three more SUD treatment programs were represented in the EHR. This increased the number of patients that could be tracked as initiating SUD treatment by 250%, from 562 before to 1,411 after integration. After integration, overall referral linkage declined (74% vs. 48%) and treatment episode retention at 90-days was higher (45% vs. 74%). Addiction therapists appreciated the efficiency of having all SUD treatment information in the EHR but did not find that the tools provided a large time savings shortly after integration. Conclusions Integration of SUD treatment program data into the EHR facilitated both care coordination in patient treatment and quality improvement initiatives for treatment programs. Referral linkage and retention rates were likely modified by a broader capture of patients and changed outcome definition criteria. Greater preparatory workflow analysis may decrease initial end-user burden. Integration of siloed data, made possible given revised regulations, is essential to an efficient hub-and-spoke model of care, which must standardize and coordinate patient care across multiple clinics and departments.

Background Programs that aim to increase access to substance use disorder (SUD) treatment in hospital-based settings have proliferated in recent years. These efforts include transitional opioid programs (TOPs), which navigate patients to community-based SUD treatment programs post-discharge. Successful navigation from TOPs to outpatient treatment hinges on effective coordination between hospitals and post-discharge endpoints, yet it is unclear how hospitals can best develop effective partnerships with outpatient treatment organizations. The objective of this study is to synthesize the common themes underpinning the development of partnerships to facilitate care transitions between TOPs and ongoing SUD treatment. Methods Qualitative study with staff and providers from hospitals affiliated with four safety-net health systems ( n  = 21) and leaders from community-based organizations (CBOs) and treatment facilities that had established referral partnerships with one of the four health systems in our study ( n  = 4). Results Analysis of interview transcripts revealed seven common themes that underpinned the development of care transitions partnerships: (1) Active, intentional outreach; (2) Responding to a community need; (3) External Enabling Factors; (4) Leveraging reputations and community connections; (5) Focusing on operations; (6) Reciprocal relationships; and (7) Building Infrastructure and Processes to Ensure Collaboration. The seven identified themes were categorized into three groups corresponding to different partnership development stages. The first group revolves around the initial stage of meeting and developing a relationship (themes #1–4). The second set focuses on navigating and resolving challenges that arise in the partnership (themes #5–6). Lastly, the third group pertains to sustaining a partnership long-term (theme #7). Conclusions This study identifies seven core themes underlying the development of care transition partnerships for SUD patients within four safety net health systems and their CBO partners. These themes demonstrate how partner organizations can establish the trust, reciprocity, and commitment necessary to support patients through the critical transition period.

Precise real-time obstacle recognition is both vital to vehicle automation and extremely resource intensive. Current deep-learning based recognition techniques generally reach high recognition accuracy, but require extensive processing power. This study proposes a region of interest extraction method based on the maximum difference method and morphology, and a target recognition solution created with a deep convolutional neural network. In the proposed solution, the central processing unit and graphics processing unit work collaboratively. Compared with traditional deep learning solutions, the proposed solution decreases the complexity of algorithm, and improves both calculation efficiency and recognition accuracy. Overall it achieves a good balance between accuracy and computation.

Background Unhealthy alcohol use, a spectrum of use inclusive of risky consumption and alcohol use disorder (AUD), is a leading cause of preventable death in the United States. Most people with unhealthy alcohol use do not receive evidence-based treatment. This four-arm factorial design randomized trial will assess whether population health management (PHM) and clinical care management (CCM) support for primary care providers (PCPs) are associated with improved AUD treatment engagement among their patients, beyond electronic health record (EHR) prompting and decision support alone. Methods PCPs from an urban safety-net hospital-based primary care clinic are randomized to one of four groups (1) EHR best practice advisory (BPA) and clinical decision support tools for unhealthy alcohol use (BPA), (2) BPA plus population health manager support, (3) BPA plus clinical care manager support, and (4) all three. All PCPs will have access to the EHR BPA and decision support tools which provide chart-based advisories and order set navigation. PCPs assigned to receive PHM support will receive quarterly panel-level feedback on AUD treatment metrics for their patients. PCPs assigned to receive CCM support will receive CCM facilitation of AUD treatment processes including medication counseling, referrals, and support through direct patient interactions. The primary outcome will be the percent of patients engaged in AUD treatment among those with a new AUD diagnosis on a PCP’s panel. Secondary outcomes include the percent of patients with a new diagnosis of AUD who (1) initiated AUD treatment, (2) were prescribed AUD medications within 90 days, and (3) numerical counts of a range of AUD health services (outpatient encounters, specialty AUD care encounters, referrals, and acute healthcare utilization) in this sample. We will assess the primary outcome and the acute healthcare utilization secondary outcomes using Medicaid claims; the remaining secondary outcomes will be assessed using EHR data. Discussion The study will evaluate how a targeted EHR innovation alone, compared with population health and care management enhancements alone or in combination, impact engagement in AUD treatment, a national quality of care measure. Findings will advance understanding of supports needed to improve systems of care for AUD in general settings. Trial registration ClinicalTrials.gov identifier/registration number (NCT number): NCT05492942

This study examines organizational factors relating to climate and culture that might facilitate or impede the implementation of evidence-based practices (EBP) targeting behavioral health in federally qualified health centers (FQHCs). Employees at six FQHCs participating in an evidence-based quality improvement (EBQI) initiative for mood disorders and alcohol abuse were interviewed (N=32) or surveyed using the Organizational Context Survey (OCS) assessing culture and climate (N=64). The FQHCs scored relatively well on proficiency, a previously established predictor of successful EBP implementation, but also logged high scores on scales assessing rigidity and resistance, which may hinder implementation. Qualitative data contextualized scores on FQHC culture and climate dimensions. Results suggest that the unique culture of FQHCs may influence implementation of evidence-based behavioral health interventions.

Unit-based teams (UBTs), initially developed by Kaiser Permanente and affiliated unions, are natural work groups of clinicians, managers, and frontline staff who work collaboratively to identify areas for improvement and implement solutions. We evaluated the UBT model implemented by the Los Angeles County Department of Health Services in partnership with its union to engage frontline staff in improving patient care. We conducted a quasi-experimental study, comparing surveys at baseline and 6 months, among personnel in 10 clinics who received UBT training to personnel in 5 control clinics. We also interviewed staff from 5 clinics that received UBT training and 3 control clinics. We conducted 330 surveys and 38 individual, semi-structured interviews with staff at an outpatient facility in South Los Angeles. Each UBT leader received an 8-hour training in basic performance improvement methods, and each UBT was assigned a team \"coach.\" Our outcome measure was 6-month change in the \"adaptive reserve\" score, the units' self-reported ability to make and sustain change. We analyzed transcripts of the interviews to find common themes regarding the UBT intervention. The survey response rate was 63% (158/252) at baseline and 75% (172/231) at 6 months. There was a significant difference-in-change in adaptive reserve between UBTs and non-UBTs at 6 months (+0.11 vs -0.13; P = .02). Nine of the 10 UBTs reported increases in adaptive reserve and 8 UBTs reported decreased no-show rates or patient length of stay in clinic. Staff overwhelmingly felt the UBTs were a positive intervention because it allowed all levels of staff to have a voice in improvement. Our results indicate that partnership between management and unions to engage frontline staff in teams may be a useful tool to improve delivery of health care in a safety-net setting.

Purpose The purpose of this paper is to determine the experience participating in a health promotion program for refugee and asylum seekers and torture survivors in a safety net clinical setting. Design/methodology/approach Refugee and asylum seeker torture survivors participated in a seven-week health promotion program at a safety-net clinic. Participants interviewed before, during and after the program was designed to improve and maintain health promotion program quality. Findings Six major themes emerged: social networks; tools/techniques/skills; wellness planning; spiritualism; health maintenance; and social/group interaction. Preliminary results suggest that this multi-pronged approach is feasible and acceptable to foreign-born torture survivors. Research limitations/implications Torture impacts many facets of one’s life. A program which addresses health from a multidisciplinary perspective has promise to facilitate healing. Practical implications The impact of torture and human rights violations significantly affects many facets of peoples’ lives including emotional, social, physical and spiritual dimensions. Therefore a program which utilizes a multidisciplinary integrated bio-psychosocial and spiritual approach has the potential to simultaneously address many domains facilitating healing. Originality/value BeWell, a bio-psychosocio-spiritual health promotion strategy aimed at improving health service quality and increasing patient satisfaction to support positive health outcomes by implementing in-classroom/person modules for patients, to the authors’ knowledge is unique in its efforts to encompass multiple domains simultaneously and fully integrate an approach to wellbeing.

Background Medicare hospital Value-based purchasing (VBP) program that links Medicare payments to quality of care will become effective from 2013. It is unclear whether specific hospital characteristics are associated with a hospital’s VBP score, and consequently incentive payments. The objective of the study was to assess the association of hospital characteristics with (i) the mean VBP score, and (ii) specific percentiles of the VBP score distribution. The secondary objective was to quantify the associations of hospital characteristics with the VBP score components: clinical process of care (CPC) score and patient satisfaction score. Methods Observational analysis that used data from three sources: Medicare Hospital Compare Database, American Hospital Association 2010 Annual Survey and Medicare Impact File. The final study sample included 2,491 U.S. acute care hospitals eligible for the VBP program. The association of hospital characteristics with the mean VBP score and specific VBP score percentiles were assessed by ordinary least square (OLS) regression and quantile regression (QR), respectively. Results VBP score had substantial variations, with mean score of 30 and 60 in the first and fourth quartiles of the VBP score distribution. For-profit status (vs. non-profit), smaller bed size (vs. 100–199 beds), East South Central region (vs. New England region) and the report of specific CPC measures (discharge instructions, timely provision of antibiotics and beta blockers, and serum glucose controls in cardiac surgery patients) were positively associated with mean VBP scores (p<0.01 in all). Total number of CPC measures reported, bed size of 400–499 (vs. 100–199 beds), a few geographic regions (Mid-Atlantic, West North Central, Mountain and Pacific) compared to the New England region were negatively associated with mean VBP score (p<0.01 in all). Disproportionate share index, proportion of Medicare and Medicaid days to total inpatient days had significant (p<0.01) but small effects. QR results indicate evidence of differential effects of some of the hospital characteristics across low-, medium- and high-quality providers. Conclusions Although hospitals serving the poor and the elderly are more likely to score lower under the VBP program, the correlation appears small. Profit status, geographic regions, number and type of CPC measures reported explain the most variation among scores.

Background: Academic centers and community programs are too often separated by institutional and cultural chasms. Such divides weaken our capacity to develop a diverse public health-oriented, community-based workforce. This article describes one bridge designed to connect the academy to local safety net systems and the lessons learned during its construction. Program Description: \"Health & Illness in Context\" is an interdisciplinary program developed in 2008 by students at Oregon Health & Science University and staff at Portland's Central City Concern. Over a 7-week period, small cohorts of medical, nursing, and public health students gain an intimate, street-level understanding of the local safety net and the structural forces that shape it. Guided by program faculty, they traverse the maze of urban social services—following clients' pathways from homelessness and addiction to treatment, recovery, and social reintegration. In each 4-hour session, students: (1) apply key concepts from public health to challenging real-world contexts, (2) explore effective, innovative approaches to addressing complex health and social issues, and (3) directly engage members of underserved communities and the diverse professionals that serve them. Outcomes: Although too early to formally assess its impact on career choice, Health & Illness in Context is already serving as an incubator for novel public health-oriented experiences, curricula, and activism that are further narrowing the community-university divide. Citing Health & Illness in Context as a primary inspiration, students have developed complementary elective courses, community-outreach activities, and long-term community collaborations. Meanwhile, program faculty members, now formally advise student initiatives, serve as mentors/preceptors, and have expanded their involvement at the university.