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IntroductionAlthough traditional patient-centered medical homes (PCMHs) are effective for patients with complex needs, it is unclear whether homeless-tailored PCMHs work better for homeless veterans. We examined the impact of enrollment in a Veterans Health Administration (VHA) homeless-tailored PCMH on health services use, cost, and satisfaction compared with enrollment in a traditional, nontailored PCMH.MethodsWe conducted a prospective, multicenter, quasi-experimental, single-blinded study at 2 VHA medical centers to assess health services use, cost, and satisfaction during 12 months among 2 groups of homeless veterans: 1) veterans receiving VHA homeless-tailored primary care (Homeless-Patient Aligned Care Team [H-PACT]) and 2) veterans receiving traditional primary care services (PACT). A cohort of 266 homeless veterans enrolled from June 2012 through January 2014.ResultsCompared with PACT patients, H-PACT patients had more social work visits (4.6 vs 2.7 visits) and fewer emergency department (ED) visits for ambulatory care-sensitive conditions (0 vs 0.2 visits); a significantly smaller percentage of veterans in H-PACT were hospitalized (23.1% vs 35.4%) or had mental health-related ED visits (34.1% vs 47.6%). We found significant differences in primary care provider-specific visits (H-PACT, 5.1 vs PACT, 3.6 visits), mental health care visits (H-PACT, 8.8 vs PACT, 13.4 visits), 30-day prescription drug fills (H-PACT, 40.5 vs PACT, 58.8 fills), and use of group therapy (H-PACT, 40.1% vs PACT, 53.7%). Annual costs per patient were significantly higher in the PACT group than the H-PACT group ($37,415 vs $28,036). In logistic regression model of acute care use, assignment to the H-PACT model was protective as was rating health "good" or better.ConclusionHomeless veterans enrolled in the population-tailored primary care approach used less acute care and costs were lower. Tailored-care models have implications for care coordination in the US Department of Veterans Affairs VA and community health systems.

This paper applies an action research (AR) design and action learning (AL) approach to network capability development in an entrepreneurial context. Recent research suggests that networks are a viable strategy for the entrepreneurial firm to overcome the liabilities associated with newness and smallness. However, a gap emerges as few, if any, studies have examined the process and challenges in developing and using network capability to generate advantage through collaboration with network actors. In recognising that capabilities are developed rather than acquired, this paper address this theoretical gap and contributes to literature by tracing the development of network capability in an entrepreneurial context. A further contribution of the paper is in applying an AR design and AL sets as a method for capability development for the entrepreneurial firm. Findings suggest that, although network capability is of use, to develop the ability to use it requires a change in the market making perceptions of the entrepreneur from an independence mind-set to a more collaborative, interdependent one. Our research also supports the applicability of AL as an intervention strategy to promote action and learning among entrepreneurs for capability development, fitting the learning preferences of the nascent venture. For practitioners, evolving towards an interdependent mind-set facilitates network capability use and has the potential to relieve some of the resource pressure on entrepreneurs by providing them with strategic routes through their existing and potential network ties. For the entrepreneurship literature, a benefit stemming from this study is in introducing AR in its design and AL sets as an invention strategy in addition to developing theory in relation to network capability development.

Purpose: The main aim of this paper is to develop guidelines on the critical issues to consider in research design in an action research (AR) environment for SME network capability development. Design/methodology/approach: The issues in research design for AR studies are developed from the authors' experience in running learning sets but, in particular, by an SME owner-manager learning set established to develop and test theory about network capability. Findings: The authors present a comprehensive set of research design issues for AR across seven areas--sampling; the facilitator; learning set interaction; set design; measurement; data collection decisions; and data analysis. Research limitations/implications: While action research is inherently situational in approach, for those researchers wishing to use it to develop or test theory, the authors' framework will provide a benchmark for research design decisions. Practical implications: The methodology is ideally suited to knowledge exchange settings and for collecting research data in such contexts and, if used in this way, could be an incentive to encourage more academic engagement with practice. Management and organisational development using AR is often reported on, but rarely in an SME context. The paper provides an example of a study conducted in this setting. Originality/value: The main contribution of this article is to present an implementation framework for research design using AR. In addition, given policy goals now often require firms to collaborate with each other and in partnership with training organisations and universities, it makes sense to develop a mechanism to enhance the understanding of research methodologies that can be used in these contexts. (Contains 2 tables.)

Hospital to Housing (H2H) is a Department of Veteran Affairs (VA) program providing medical respite care to veteran's experiencing homelessness. The program partners community organizations providing transitional housing with local VA facilities delivering medical care for post-hospitalization veterans for clinical stabilization and ultimately, permanent housing. The program was launched October 2017 at 43 sites. Using mixed methods, we aim to assess participant health services utilization and community partner perceptions and experiences with the implementation of the program. We collected 90-day pre/post-enrollment health care utilization data for the first 200 H2H enrollees and conducted semi-structured interviews with six community organizations. Veterans enrolled in H2H had a significant decline in utilization of emergency department and inpatient care (67.0% vs. 39.5%, p < 0.01) and a significant increase in primary care utilization (47.5% vs. 78.0%, p < 0.01). The greatest barrier to implementation was concern of patient complexity while the greatest enabler was the perceived value/benefit of the program. Our findings suggest a community-partnered low intensity medical respite model for select lower acuity populations is feasible to operate and can substantially redirect care away from acute care settings and increase primary care and social services engagement. [ABSTRACT FROM AUTHOR]

A four-level framework illustrates the contributions of human resource development (HRD) to management of organizational boundaries: (1) leadership development; (2) HRD strategy, policy, and structure as boundary shapers; (3) HRD interventions as creators and innovators; and (4) HRD as boundary spanner outside the organization. A table summarizes contributions of articles in this special issue. (Contains 47 references.) (SK)

Responds to a critique by Susan S. Goldsmith of the Massachusetts Comprehensive Assessment System (MCAS) English Language Arts tests, focusing on Goldsmith's critique of test development, uniform topic focus, use of open-response items, and lack of explicit testing in vocabulary and grammar. Goldsmith replies to the response, highlighting needed refinements of testing tasks. (SM)

This article considers the role of the speech-language pathologist in providing services to children with swallowing disorders in the public school setting. Topics addressed include requirements (or aspects) under various federal laws and regulations, as well as ethical, liability, and funding issues. (Contains references.) (Author/CR)

Objectives. We compared a population-tailored approach to primary care for homeless veterans with a usual care approach. Methods. We conducted a retrospective prolective cohort study of homeless veterans enrolled in a population-tailored primary care clinic matched to a historical sample in general internal medicine clinics. Overall, 177 patients were enrolled: 79 in the Homeless-Oriented Primary Care Clinic and 98 in general internal medicine primary care. Results. Homeless-oriented primary care-enrolled patients had greater improvements in hypertension, diabetes, and lipid control, and primary care use was higher during the first 6 months (5.96 visits per person vs 1.63 for general internal medicine) but stabilized to comparable rates during the second 6 months (2.01 vs 1.31, respectively). Emergency department (ED) use was also higher (2.59 vs 1.89 visits), although with 40% lower odds for nonacute ED visits than for the general internal medicine group (95% confidence interval=0.2, 0.8). Excluding substance abuse and mental health admissions, hospitalizations were reduced among the homeless veterans between the 2 periods (28.6% vs 10.8%; P Conclusions. Tailoring primary care to homeless veterans can decrease unnecessary ED use and medical admissions and improve chronic disease management. (Am J Public Health. 2010;100:2493-2499. doi: 10.2105/AJPH.2009.179416)

BackgroundAlcohol use is an important issue among problem drug users. Although screening and brief intervention (SBI) are effective in reducing problem alcohol use in primary care, no research has examined this issue among problem drug users. ObjectiveThe objective of this study is to determine if a complex intervention including SBI for problem alcohol use among problem drug users is feasible and acceptable in practice. This study also aims to evaluate the effectiveness of the intervention in reducing the proportion of patients with problem alcohol use. MethodsPsychosocial intervention for alcohol use among problem drug users (PINTA) is a pilot feasibility study of a complex intervention comprising SBI for problem alcohol use among problem drug users with cluster randomization at the level of general practice, integrated qualitative process evaluation, and involving general practices in two socioeconomically deprived regions. Practices (N=16) will be eligible to participate if they are registered to prescribe methadone and/or at least 10 patients of the practice are currently receiving addiction treatment. Patient must meet the following inclusion criteria to participate in this study: 18 years of age or older, receiving addiction treatment/care (eg, methadone), or known to be a problem drug user. This study is based on a complex intervention supporting SBI for problem alcohol use among problem drug users (experimental group) compared to an “assessment-only” control group. Control practices will be provided with a delayed intervention after follow-up. Primary outcomes of the study are feasibility and acceptability of the intervention to patients and practitioners. Secondary outcome includes the effectiveness of the intervention on care process (documented rates of SBI) and outcome (proportion of patients with problem alcohol use at the follow-up). A stratified random sampling method will be used to select general practices based on the level of training for providing addiction-related care and geographical area. In this study, general practitioners and practice staff, researchers, and trainers will not be blinded to treatment, but patients and remote randomizers will be unaware of the treatment. ResultsThis study is ongoing and a protocol system is being developed for the study. This study may inform future research among the high-risk population of problem drug users by providing initial indications as to whether psychosocial interventions for problem alcohol use are feasible, acceptable, and also effective among problem drug users attending primary care. ConclusionsThis is the first study to examine the feasibility and acceptability of complex intervention in primary care to enhance alcohol SBI among problem drug users. Results of this study will inform future research among this high-risk population and guide policy and service development locally and internationally.

Introduction: Housing insecure veterans are aging, but the prevalence of Alzheimer's disease and related dementias (AD/ADRD) in the population is unknown. Methods: We calculated the prevalence of AD/ADRD diagnoses in 2018 among veterans that experienced homelessness, were at‐risk for homelessness, or were stably housed. We determined acute care (emergency department, hospitalizations, psychiatric hospitalizations), and any long‐term care (nursing home, and community‐based) use by housing status among veterans with an AD/ADRD diagnosis. Results: The overall prevalence of AD/ADRD diagnoses for homeless, at‐risk, and stably housed veterans was 3.66%, 13.48%, and 3.04%, respectively. Housing insecure veterans with AD/ADRD used more acute care, and were more likely to have a nursing home admission compared to stably housed veterans. At risk, but not homeless veterans, were more likely to use US Department of Veterans Affairs–paid home and community‐based care than stably housed veterans. Discussion: The prevalence of AD/ADRD diagnoses is greater among housing insecure veterans than stably housed veterans. [ABSTRACT FROM AUTHOR]

Understanding why substance-using patients seek care at emergency departments (EDs) and who utilizes such service at high rates is important in tailoring and targeting interventions. We conducted a retrospective/prospective cohort study of 326 medically ill substance-using adults to identify factors associated with 12-month high-frequency utilization of ambulatory care, ED, and inpatient medical care. The majority were actively using heroin (74.6%), cocaine (62.4%), and alcohol (54.4%); 94.8% had a chronic medical condition; and 53.8% reported a chronic mental health condition. High-frequency use of ED ([greater than or equal to] 3 visits) was independently associated with being female (adjusted odds ratio [AOR] = 1.88; 95% confidence interval [95% CI] = 1.12, 3.17), being African American (AOR = 2.36; 95% CI = 1.30, 4.29), being homeless (AOR = 2.07; 95% CI = 1.08, 3.96), a history of > 1 substance abuse treatment episode (AOR = 4.10; 95% CI = 3.28, 10.87), and [greater than or equal to] 1 ambulatory care visit (AOR = 8.94; 95% CI = 3.28, 24.41). However, the combination of having certain chronic conditions (seizure disorder, hepatitis B, and hepatitis C) and accessing ambulatory care was protective against high-frequency use of ED. In contrast, high-frequency use of ambulatory care ([greater than or equal to] 3 visits) was independently associated with having insurance (Medicare/Medicaid: AOR = 2.39; 95% CI = 1.31, 4.69), having HIV/AIDS (AOR = 3.15; 95% CI = 1.70, 5.85), and receiving substance abuse treatment during the study period (AOR = 3.58; 95% CI = 1.61, 7.98) Efforts to redirect medical care to more subacute settings will likely require both capacity building and addressing a client's underlying needs, including homelessness, access to substance abuse treatment, and chronic disease management. Keywords: Substance abuse; Health services utilization; Emergency department care; Ambulatory care; Integrated treatment

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.addbeh.2006.01.003 Byline: Robin A. Pollini (a), Thomas P. O'Toole (b), Daniel Ford (c), George Bigelow (d) Keywords: Substance abuse; Medical co-morbidities; Hospitalization; Readiness for change; Motivation Abstract: Little is known about motivation for treatment and readiness for change during an acute medical event. We present data from a cohort of 353 actively substance abusing adults assessed at baseline and every three days during their hospital admission for readiness to change substance use behaviors (URICA), self-reported motivations for substance abuse treatment, and pain and withdrawal symptoms. Factors independently associated with being in a higher (i.e., contemplation or action) stage of change included female sex (AOR=2.33; 95% CI: 1.42, 3.81), being on probation or parole (AOR=2.55; 95% CI: 1.32, 4.93), bipolar disorder (AOR 2.60; 95% CI: 1.20, 5.63), believing they would get sick again if drug use continued (AOR=2.24; 95% CI: 1.36, 3.70), being 'tired of using' (AOR=2.91; 95% CI: 1.21, 6.96) and family concerns (AOR=1.78; 95% CI: 1.08, 2.96). During their hospitalization 43.6% increased from precontemplation or contemplation to a higher stage or remained in the action stage. Believing one would get sick again if substance use continued (AOR=2.42; 95% CI: 1.07, 5.48), physical health concerns (AOR=5.28; 95% CI: 1.36, 20.44) and citing 'tired of using' as a primary motivator (AOR=2.88; 95% CI: 1.10, 7.54) were independently associated with increased stage of change. Author Affiliation: (a) Johns Hopkins Bloomberg School of Public Health, Department of Epidemology, United States (b) Georgetown University School of Medicine, NE113 Med Dent Building, 3900 Reservoir Rd. NW, Washington, DC 20057, United States (c) Johns Hopkins Division of General Internal Medicine, United States (d) Johns Hopkins Department of Psychiatry, United States

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jsat.2006.03.014 Byline: Thomas P. O'Toole (a), Robin A. Pollini (b), Daniel Ford (c), George Bigelow (d) Keywords: Motivation; Readiness for change; Medically ill; Substance abuse; Opiate; Treatment retention Abstract: Substance-using adults often present at medical facilities for acute complications of their drug or alcohol use with transiently high motivation for addiction treatment. We studied a cohort of medically ill polysubstance-using adults admitted to a partial hospitalization/day-hospital program in an acute hospital, serially tracking their reasons for treatment motivation, pain and withdrawal scores, and readiness for change. Physical health concerns were the most frequently cited reason for wanting to enter substance abuse treatment at baseline (27.8%), yet individuals who cited this as their primary motivator were significantly less likely to complete the treatment program (14.8% vs. 40.7%, p = .03). However, 43% of respondents also recorded a shift in their motivation during treatment; 100% of those transitioning from an extrinsic motivator (e.g., physical health concerns) to an intrinsic motivator (e.g., wanting to do more with one's life) completed treatment, compared with only 38.4% of those whose extrinsic motivating factors were static. This suggests that medical illness represents a 'treatable moment' to engage individuals in substance abuse treatment. Author Affiliation: (a) Georgetown University School of Medicine, NE111 Med Dent Building, 3900 Reservoir Road NW, Washington, DC 20057, USA (b) Department of Epidemology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA (c) Division of General Internal Medicine, Johns Hopkins University, Baltimore, MD, USA (d) Department of Psychiatry, Johns Hopkins University, Baltimore, MD, USA Article History: Received 18 July 2005; Revised 15 March 2006; Accepted 22 March 2006 Article Note: (footnote) Dr. O'Toole is funded by a National Institute on Drug Abuse career development award (K23DA13988-01).

Objectives. We identified substance use patterns and factors associated with increased substance use after users become homeless. Methods. We carried out a 2-city, community-based survey that used population proportionate sampling of 91 sites with random selection at each site. Results. Five hundred thirty-one adults were interviewed; 78.3% of them met Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition criteria for substance abuse or dependence. Most of those who met the criteria reported using drugs and alcohol less since they became homeless, commonly be cause they were in recovery. Factors independently associated with increased use were no health insurance (odds ratio [OR] = 1.6; 95% confidence interval [CI] = 1.02, 2.58), alcohol abuse or dependence (OR = 3.5; 95% CI = 1.85, 6.78), and selling plasma (OR=2.6; 95% CI = 1.32, 5.14) or panhandling (OR = 3.0; 95% CI = 1.65, 5.55) to acquire drugs. Conclusions. Becoming homeless plays a role in self-reported substance use. Multiservice treatment programs and tailored interventions for homeless persons are needed. (Am J Public Health. 2004;94:830-835)