Community Treatment Research Articles

RREACT: A mobile multidisciplinary response to overdose.

Opioid overdose is a leading cause of death in the United States, and engaging with patients following overdose to provide harm reduction and recovery resources can prove difficult. Quick response models use mobile, multidisciplinary teams to establish a time-sensitive connection between individuals who overdosed and harm reduction and recovery resources that improve outcomes. These quick response models are consistent with the broader field of mobile-integrated health programs that are growing in number and acceptability, though the literature base is sparse and programs vary. We describe the 5-year reach, effectiveness, adoption, implementation and maintenance (RE-AIM) framework of the Rapid Response Emergency Addiction and Crisis Team (RREACT), a fire/emergency medical services-led, multidisciplinary (firefighter/paramedic, law enforcement officer, social worker) mobile outreach team. RREACT provides harm reduction, linkage/transportation to care and wrap-around services to individuals following a nonfatal opioid overdose that resulted in an emergency response in Columbus, Franklin County, Ohio, United States. Between 2018 and 2022, RREACT made 22,157 outreach attempts to 11,739 unique patients. RREACT recorded 3,194 direct patient contacts during this time, resulting in 1,200 linkages to care: 799 direct transports to opioid use disorder treatment and 401 warm handoffs to community treatment agencies. Furthermore, RREACT's staffing increased from 4 full-time equivalent staff in 2018 to 15.5 in 2022 and was supported by the surrounding community through 287 community outreach events and the development of an alumni program. These preliminary results further support the deployment of multidisciplinary mobile outreach teams to increase access to harm reduction and recovery resources following opioid overdose.

Tackling social inequalities in health: Assessing contexts for implementing integrated health access for people with severe mental illness.

Social inequalities in health are a complex problem that often emerge at the interfaces between different sectors, such as health and social care, and the corresponding transitions between different provider organisations. Vulnerable people are typically in greater need of accessing different sectors of the health system and therefore often experience lack of coherence in their treatment pathway. We aimed to examine the contexts of health systems that influence initiatives concerned with integrated health access. We used the theory of Organizational Fields to study the contexts for implementing Flexible Assertive Community Treatment (FACT) in Central Denmark Region and three municipalities in the region. We collected 33 documents and conducted six qualitative interviews with professionals involved in FACT to understand the contexts of implementing integrated health access. We found that contexts for implementing FACT are highly complex, as they are divided between health and social care (horizontal complexity) and between national and the sub-national levels of the region and the municipalities (vertical complexity). This leads to conflicting demands on implementation. Local contexts of collaboration may offer a lever to handle these demands, but these are likely to vary. Analysis of how complex health system contexts influence implementation is important to understand how changes might become sustainable and help to tackle social inequalities in health.

Innovative porous mortar filters: wastewater purification for clean water.

Water scarcity is a major global challenge that affects both developed and developing countries, with Indonesia serving as a prime example. Indonesia's archipelagic nature, combined with its dense population, exacerbates the severity of water scarcity. The increased population density in these areas raises the demand for water resources, putting a strain on the available supply. The purpose of this research was to create porous mortar filters (PMFs) with different ratios (1:4, 1:5, and 1:6) by incorporating 10, 15, and 20% adsorbent material by weight of fine aggregate. The research was carried out in three stages: determining PMF properties, preparing synthetic wastewater, and assessing treatment effectiveness. Various PMF compositions consistently achieved notable success, with reductions in total dissolved solids and turbidity exceeding 25 and 75%, respectively. The PMF performed admirably in eliminating bacterial concentrations, achieving a 100% removal rate, and was critical in efficiently reducing metals, with compositions achieving over 80% reduction for manganese (Mn) and 38% reduction for iron (Fe). PMF emerges as a practical solution as a cost-effective and simple water treatment technology, particularly suitable for areas with limited technological infrastructure and resources, providing accessible water treatment for communities facing challenges in this regard.

Identifying Competencies of the ACT Program Nurse Using the DACUM Method

The nurse role on an Assertive Community Treatment (ACT) team requires a specialized set of skills in psychiatric community-based care. While the ACT model has existed for fifty years, no nationally recognized standard curriculum to train ACT nurses has been developed. The ACT Nursing Project described in this paper aimed to create a competency-based on-board training program using the Developing a Curriculum (DACUM) method. Eight ACT nurses from three states served as the expert panel to create a DACUM chart detailing the full set of nine duties and 127 tasks required of ACT nurses. To verify the DACUM results, 57 ACT nurses from four states completed a survey and confirmed that 80% of the tasks identified by the expert panel were also performed by the validation sample of ACT nurses. This paper describes how the DACUM duties and tasks provided the framework to develop onboard training curriculum for ACT program nurses. The next step is to pilot the onboard training curriculum to newly hired ACT nurses to ensure they are equipped to meet the complex needs of people living with serious mental illness, and to increase their competency, job satisfaction and decrease the high annual turnover rate among ACT nurses.

Counterweight, Carrot, Crucible: Theorizing “Community” in Community Treatment Orders

The idea of community in community mental health has recently been criticized as problematic in that it has been ill defined, under-investigated and under-theorized. In this article we introduce actor-network theory as a useful framework for the analysis of everyday psychiatric and legal interventions and their effects. We focus on the community treatment order (CTO) in Alberta as one such intervention, showing how community positions people diagnosed with mental illness as risky subjects. In examining the CTO as an important actor in the construction of mental illness, we argue that the idea of community acts as a counterweight to balance rights, a carrot in a mechanism of consent, and as a crucible where interpretive work on a subject must be done in chains of examinations. Further, we propose a procedural and relational definition of community to inform scholarly work as well as professional practice.

Rehabilitation for adults with an intellectual disability and mental health and behavioural complexities: A scoping review

AbstractBackgroundThere has been significant focus in the past decade on reducing admissions to assessment and treatment units for people with intellectual disabilities experiencing mental health or behavioural concerns. This has included the development of intensive support functions of National Health Service Learning Disability services to bolster community support and treatment for people at risk of admission. However, in recent years, there has been increased consideration of service development to include rehabilitation functions which would aim to proactively provide medium‐term additional input to individuals with a complexity of need. This input would aim to improve future trajectories and support the individuals to remain living a good life in their own community. This review focuses on community and in‐patient approaches to meeting a complexity of need.MethodA scoping review was carried out according to established best practice guidelines. Papers returned from the search were screened by the following inclusion criteria (a) Models or Outcomes of Rehabilitation; (b) Intellectual Disability Population; (c) Sample being 18 or above and (d) longer than short‐term stay/treatment, defined as 6 months or longer; and (e) Mental health and/or behaviour complexities. The search was conducted in electronic databases CINAHL, PsycInfo, Medline, Embase and Social Policy & Practice. Here, 3790 articles were initially identified and 27 were ultimately included in the review.FindingsThere are few studies evaluating rehabilitation for people with intellectual disabilities and mental health or behavioural concerns. There was some evidence that accessing assessment and treatment inpatient provision resulted in clinical improvements. Some studies demonstrated initial evidence that longer term rehabilitation was beneficial as a step‐down from inpatient care. Some key principles were identified in terms of rehabilitation approaches: the need for person‐centred creative approaches, suitable staff training, focus on building skills, and a focus on increasing quality of life.ConclusionThere are some indicators of what good rehabilitation services might comprise for people with an intellectual disability, who have rehabilitation needs. However, far more research and guidance are required in this area. In particular, it is unclear whether rehabilitation is best provided within an inpatient or community model, and further detail is required about optimal components of such rehabilitation.

Assertive community treatment for high-utilizing alcohol misuse patients: a before-and-after cohort study protocol

BackgroundThe challenge posed by Alcohol-Related Frequent Attenders (ARFAs) in Emergency Departments (EDs) is growing in Singapore, marked by limited engagement with conventional addiction treatment pathways. Recognizing this gap, this study aims to explore the potential benefits of Assertive Community Treatment (ACT) - an innovative, community-centered, harm-reduction strategy—in mitigating the frequency of ED visits, curbing Emergency Medical Services (EMS) calls, and uplifting health outcomes across a quartet of Singaporean healthcare institutions.MethodsEmploying a prospective before-and-after cohort design, this investigation targeted ARFAs aged 21 years and above, fluent in English or Mandarin. Eligibility was determined by a history of at least five ED visits in the preceding year, with no fewer than two due to alcohol-related issues. The study contrasted health outcomes of patients integrated into the ACT care model versus their experiences under the exclusive provision of standard emergency care across Hospitals A, B, C and D. Following participants for half a year post-initial assessment, the evaluation metrics encompassed socio-demographic factors, ED, and EMS engagement frequencies, along with validated health assessment tools, namely Christo Inventory for Substance-misuse Services (CISS) scores, University of California, Los Angeles (UCLA) Loneliness scores, and Centre for Epidemiologic Studies Depression Scale Revised (CESD-R-10) scores.DiscussionConfronted with intricate socio-economic and medical challenges, the ARFA cohort often grapples with heightened vulnerabilities in relation to alcohol misuse. Pioneering the exploration of ACT’s efficacy with ARFAs in a Singaporean context, our research is anchored in a patient-centered approach, designed to comprehensively address these multifaceted clinical profiles. While challenges, like potential high attrition rates and sporadic data collection, are anticipated, the model’s prospective contribution towards enhancing patient well-being and driving healthcare efficiencies in Singapore is substantial. Our findings have the potential to reshape healthcare strategies and policy recommendations.Trial RegistrationClinicalTrials.gov, NCT 04447079. Initiated on 25 June 2020.

Community Support for Harm Reduction and Treatment of Opioid Use Disorder.

As the opioid epidemic continues, availability of evidence-based strategies for harm reduction and treatment in communities is critical to reduce overdose and other consequences of opioid use disorder. Community members' support of harm reduction and treatment services is needed for new programs and to maintain existent programs. This study sought to understand beliefs and attitudes associated with support for three community-based strategies to address opioid misuse and addiction: naloxone, needle exchange, and medication-assisted treatment. We conducted a cross-sectional online survey with 545 adults. Results of the survey showed that participants supported all three strategies, with the strongest support for medication-assisted treatment. Multiple regression showed that stigma and perceived stigma were significant predictors for all three strategies, with inverse relationships. Stigmatizing beliefs predicted less support while perceiving stigma among others was associated with greater support for the strategies. Normative beliefs also significantly predicted support for all three strategies, such that stronger belief that others were supportive of each strategy was associated with greater support for that strategy. Other predictors varied across the three strategies. Support for harm reduction and treatment programs in communities affected by the opioid epidemic may be bolstered by reducing stigma and increasing normative beliefs. Stronger support for medication-assisted treatment may be leveraged and extended to harm reduction strategies. Results of our study contribute insights for bolstering community support for harm reduction and treatment, which is vital for adoption and maintenance of these important programs.

Pathogens Causing Pediatric Community Acquired Urinary Tract Infections and Their Increasing Antimicrobial Resistance: A Nationwide Study.

Urinary tract infections (UTIs) in childhood are common and are associated with considerable acute morbidity and long-term complications. The need for updated data to optimize empiric antibiotic therapy is crucial. We aimed to investigate the pathogens causing pediatric community acquired UTIs, their correlation with demographic characteristics, and trends in their antimicrobial resistance. This nationwide cross-sectional study included all 53,203 children (<18 years) diagnosed with UTI in community outpatient clinics in the following selected years: 2007, 2011, 2015, 2019 and 2021. Escherichia coli (E. coli) (82.1%) was the most common uropathogen, followed by Enterobacter, Klebsiella, Proteus, Pseudomonas, and Enterococcus species. The bacterial distribution displayed statistically significant (p < 0.0001) gender- and sector-specific patterns with a higher relative prevalence of non-E. coli UTI in Jewish and males. The rate of extended-spectrum beta-lactamase-positive E. coli increased substantially and significantly (p < 0.001) from only 6.1% in 2007 to 25.4% in 2021. Most non-E. coli uropathogens exhibited resistance to commonly used empiric antibiotics for UTIs in children. These findings are significant in guiding optimal empiric antibiotic treatment for pediatric community acquired UTIs. The resistance of uropathogens to antimicrobials is region- and time-dependent. Therefore, the periodic and local assessment of antibiotic resistance trends is essential to update guidelines and provide the most appropriate antibacterial therapy for children with UTIs.

Reliability and validity of the dynamic risk outcome scales-short version for clients with mild intellectual disabilities or borderline intellectual functioning.

This study investigated the reliability and validity of the dynamic risk outcome scales-short version (DROS-SV). This instrument is developed to monitor treatment progress using dynamic risk factors in clients with mild intellectual disabilities or borderline intellectual functioning and behavioural and/or mental health problems. Data were collected from 264 clients who received Flexible Assertive Community Treatment (FACT), a form of intensive outpatient treatment. A principal component analysis showed that there were six components explaining 73.9% of the variance. Furthermore, the DROS-SV showed good internal consistency of its subscales and total score (α > 0.78). Correlating the DROS-SV with the Historical and Clinical subscales of the Historical, Clinical and Future-30 indicated convergent and divergent validity. The DROS-SV has good psychometric properties for measuring dynamic risk factors in clients with mild intellectual disabilities or borderline intellectual functioning in FACT teams.

Barriers to opioid use disorder treatment among people who use drugs in the rural United States: A qualitative, multi-site study

BackgroundIn 2020, 2.8 million people required substance use disorder (SUD) treatment in nonmetropolitan or ‘rural’ areas in the U.S. Among this population, only 10% received SUD treatment from a specialty facility, and 1 in 500 received medication for opioid use disorder (MOUD). We explored the context surrounding barriers to SUD treatment in the rural United States. MethodsWe conducted semi-structured, in-depth interviews from 2018 to 2019 to assess barriers to SUD treatment among people who use drugs (PWUD) across seven rural U.S. study sites. Using the social-ecological model (SEM), we examined individual, interpersonal, organizational, community, and policy factors contributing to perceived barriers to SUD treatment. We employed deductive and inductive coding and analytical approaches to identify themes. We also calculated descriptive statistics for participant characteristics and salient themes. ResultsAmong 304 participants (55% male, mean age 36 years), we identified barriers to SUD treatment in rural areas across SEM levels. At the individual/interpersonal level, relevant themes included: fear of withdrawal, the need to “get things in order” before entering treatment, close-knit communities and limited confidentiality, networks and settings that perpetuated drug use, and stigma. Organizational-level barriers included: strict facility rules, treatment programs managed like corrections facilities, lack of gender-specific treatment programs, and concerns about jeopardizing employment. Community-level barriers included: limited availability of treatment in local rural communities, long distances and limited transportation, waitlists, and a lack of information about treatment options. Policy-level themes included insurance challenges and system-imposed barriers such as arrest and incarceration. ConclusionOur findings highlight multi-level barriers to SUD treatment in rural U.S. communities. Salient barriers included the need to travel long distances to treatment, challenges to confidentiality due to small, close-knit communities where people are highly familiar with one another, and high-threshold treatment program practices. Our findings point to the need to facilitate the elimination of treatment barriers at each level of the SEM in rural America.

Evaluation of a flexible assertive community treatment (FACT) program for patients with severe mental illness: an observational study in Salzburg, Austria

Abstract Background Inpatient treatment of severe mentally ill patients binds substantial resources and creates the dilemma of “revolving-door hospitalizations”. Evidence suggests that these patients benefit more from an assertive outreach community psychiatric treatment. This descriptive study evaluates the implementation of a new treatment program for severe mentally ill patients provided by a flexible assertive community treatment (FACT) team. Methods An uncontrolled design with routine data was used to measure the total length of stays, readmission rates and number of contacts one year prior to the implementation of the FACT program and the following first three years of treatment. Results A continuous decrease of hospitalization among patients with severe mental illness was observed with the implementation of the FACT program with declines in total length of stays and readmission rates and accompanied with a decreasing number of contacts per year. Conclusion Our findings indicate that this program may create effects in stabilizing patients with severe mental illness and may be highly relevant also for other patient groups.

Malignant mixed mullerian tumors: a SEER database review of rurality and treatment modalities on disease outcome.

Malignant Mixed Mullerian Tumors (MMMT) are rare and poorly understood sarcomas with limited research on risk factors, pathogenesis, and optimal treatments. This study aimed to address this knowledge gap and explore the impact of community size, patient characteristics, disease characteristics, and treatment modalities on MMMT outcomes. Using the Surveillance, Epidemiology, and End Results database (SEER), the largest SEER cohort to date of 3,352 MMMT patients was analyzed for demographic factors, treatment modalities, and histologic characteristics. Data was processed, including the removal of incomplete entries, and analyzed in Python 3.1 using packages scikit-learn, lifelines, and torch; log-rank analysis and Cox proportional hazards models were used to evaluate a number of demographic characteristics and disease characteristics for significance in regard to survival. Our study found adjuvant radiotherapy and chemotherapy significantly improved survival, with modest benefits from neoadjuvant chemotherapy. Our findings also suggest age at diagnosis, disease grade, and suburban versus rural geographic locations may play key roles in patient prognosis. On multivariable analysis both disease Grade and surgical treatment were significant factors. MMMTs remain challenging, but appropriate treatment appears to enhance survival. The present findings suggest opportunities for improved outcomes and treatment strategies for patients with MMMTs.

Fungal symbiont diversity drives growth of Holcus lanatus depending on soil nutrient availability

Abstract Arbuscular mycorrhizal (AM) fungi frequently colonise plant roots and can affect plant morphology and physiology through their contribution to plant nutrition. However, the functional role of AM fungi in the presence of other microbial symbionts, including widespread Mucoromycotina ‘fine root endophytes’ (MFRE) fungi, remains largely unknown. While both AM fungi and MFRE transfer nutrients, including nitrogen, from inorganic and organic sources to host plants, their combined effects on co‐colonised plants have only been investigated in liverworts. Here, we compare the morphology and physiology of the grass Holcus lanatus grown with an AM fungal community versus a more diverse symbiotic fungal community containing both AM fungi and MFRE. Holcus lanatus plants were grown in the presence of either a diverse MFRE+AM fungi soil inoculum or a multi‐species AM fungal inoculum. Plant traits associated with growth were quantified, along with fungal transfer of 15N tracer to plants from a variety of sources (ammonium chloride, alanine, glycine and algal necromass). Holcus lanatus grown with the AM fungal community had greater root and shoot growth during early development and prior to the addition of 15N‐labelled sources, compared with plants grown with the more diverse symbiotic fungal community. When nitrogen sources were made available to the fungal symbionts in the pot microcosms, plants growing with the MFRE+AM fungi soil inoculum had a faster growth rate than plants growing with the AM fungal community. At harvest, H. lanatus grown with the AM fungal community had a larger biomass, and there were no differences in 15N tracer assimilation in plants across the two fungal community treatments. Our results demonstrate that the diversity of fungal inocula in conjunction with soil nutrient availability determine the benefits derived by plants from diverse fungal symbionts. Our research contributes to understanding host plant outcomes in diverse multi‐symbiont scenarios. Read the free Plain Language Summary for this article on the Journal blog.

Six-month post-release outcomes for inmates with traumatic brain injury in supported community programming

ABSTRACT Objective: The goal of this study is to examine the effectiveness of case management services for a population of justice-involved individuals with TBI history. Methods: Two thousand three hundred and eighty-nine records from statewide behavioral health and brain injury program databases were used in two studies. Results: Participants with a reported TBI history were more likely to have experienced trauma and to have a behavioral health diagnosis relative to incarcerated persons without TBI. Six months after release, 56.8% of participants with a history of TBI were still receiving community treatment, 27.8% were not in treatment, and 3.4% had completed treatment. There was a high attrition rate; 70% of people referred for case management failed to maintain contact. Conclusions: For those that did receive services, these data suggest that it prevented an escalation of psychosocial needs. There were no differences in community participation as measured by the Mayo Portland Adaptability Index’s Participation Index (M2PI) scores (t24 = .497, p = 0.624) at intake and after 6 months of case management. This study confirms that case management confers a benefit to persons with TBI who are released from the criminal justice system. Further, recidivism rates for this vulnerable group were no different from the larger population of returning citizens.

Abstract HUP5: Patient and Hospital Characteristics Associated With Disparities in Acute Stroke Treatment in Community and Academic Hospitals

Introduction: Expedited transportation, identification, and coordination of care are essential drivers of optimal outcomes in the management of acute ischemic stroke (AIS), but systemic biases and barriers may affect these processes. We assessed patient- and hospital-level factors that may be associated with differences in prehospital and emergency department care processes for patients with AIS at academic medical centers (AMC) and those at community hospitals (CH). Methods: We retrospectively collected data from the electronic health record at an academic medical center (Tufts Medical Center) for adults age ≥ 18 hospitalized with AIS between 1/1/2018-12/31/2020, including patients who presented directly to the AMC versus patients transferred from a CH for further care. We performed multivariate analyses to assess predictors of emergency medical service (EMS) use, stroke code activation, door-to-CT time, and door-to-needle time across all patients and in each group. Results: 542 patients were included. AMC patients identifying as Asian (OR 0.25, 95% CI 0.13-0.47) and Hispanic (OR 0.19, 95% CI 0.05-0.72) and CH patients identifying as Black (OR 0.17, 95% CI 0.17-0.62) were less likely to use EMS compared to white patients. Patients with non-English primary language were less likely to use EMS (OR 0.38, 95% CI 0.23-0.63) compared to English-speaking patients in all hospitals. CH patients identifying as Hispanic were less likely to have stroke code activation (OR 0.24, 95% CI 0.05-0.86) compared to white patients. There were no differences in median door-to-CT or door-to-needle times between CH and AMC patients. In analyses including all patients, Asian race was associated with longer door-to-CT time (OR 1.25, 95% CI 1.03-1.49), and female sex was associated with longer door-to-needle time (OR 1.23, 95% CI 1.03-1.43). Conclusion: There are multiple potential sources of disparity in prehospital and hospital-based hyperacute care for patients with AIS including sex, race, ethnicity, and non-English primary language. These may represent opportunities for community outreach on EMS use, interventions to address systemic racism among healthcare providers, and interventions to alleviate language barriers.

Influence of decreasing temperature on aerobic granular sludge - microbial community dynamics and treatment performance

Municipal wastewater in temperate climates is characterized by seasonal temperature changes. Temperature is a determining factor for biological processes, but the impact of gradually decreasing temperature on aerobic granular sludge (AGS) has been largely unexplored. In this study, the influence of decreasing temperature from 20 °C to 6 °C on AGS was investigated at rates of 0.5 and 1 °C per week. Temperature was a major driver for microbial community change, where the community response could be divided into three main subclusters. Strains within the guilds of ammonium- and nitrite-oxidising bacteria (AOB and NOB) as well as polyphosphate- and glycogen-accumulating organisms (PAOs and GAOs) grouped in different subclusters, indicating variable responses among and between the guilds. The phosphorous removal rate was sufficient for complete removal at all temperatures, presumably due to functional redundancy within the PAOs. The nitrification rate was, however, seriously impaired below 13 °C, despite diversity within AOB and NOB.

Medicine Constitution Intervention Combined with "Three-in-One" Treatment in Elderly Patients with Atherosclerotic Cardiovascular and Cerebrovascular Diseases

Objectives: The aim of this study was to evaluate the effectiveness of an intervention that combines Traditional Chinese Medicine (TCM) constitution identification and TCM health management with the "Three-in-One" community prevention and treatment model in managing atherosclerotic cardiovascular and cerebrovascular diseases in elderly patients. Methods: In this retrospective multicenter study, the medical records of 206 outpatient participants diagnosed with atherosclerotic cardiovascular and cerebrovascular diseases from June 2022 to June 2023 were reviewed. Participants were divided into 2 groups. Among participants, 104 (the control group) received instructions on adjusting medications and general health education. The other 102 (the intervention group) underwent TCM constitution identification and health management, which included psychological conditioning, dietary regulation, lifestyle adjustment, and physical exercise. Each intervention period lasted for 52 weeks, constituting one treatment course. Results: No notable improvements were identified in the changes to constitutional elements across both groups (p &gt; .05). Both the treatment and control rates demonstrated significant improvement in both the intervention and control groups (p &lt; .05). Conclusion: The combination of TCM constitution identification, TCM health management, and the Three-in-One treatment model showed promising results in managing atherosclerotic cardiovascular and cerebrovascular diseases in elderly patients.

Associations of length of stay with frailty status and COVID-19 disease severity among older adults at a community treatment facility in Singapore

Associations of length of stay with frailty status and COVID-19 disease severity among older adults at a community treatment facility in Singapore

SUPPORT Act: APF compares House and Senate bills

The Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act was signed into law in 2018 to combat the opioid epidemic. The Addiction Policy Forum issued a comparison of the two bills currently under consideration by Congress to reauthorize the SUPPORT Act (see below). Since the law's passage, the problem has become worse, with illicit fentanyl, xylazine and other adulterants compounding the substance use and overdose crisis.