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Mara Bensson-Ravunniarath,1 Joanna Bryan Ringel,2 Ariel Avgar,3 Faith Wiggins,4 Ann Lee,4 Margaret V McDonald,5 Lourdes R Guerrero,6 John Kallas,3 Geoffrey Gusoff,7 Megan Shen,8 Emily Tseng,9 Nicola Dell,9 Sara Czaja,2 Lee A Lindquist,10 Madeline R Sterling2 1Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; 2Department of Medicine, Weill Cornell Medicine, New York, NY, USA; 3Cornell University, School of Industrial Labor Relations, Ithaca, NY, USA; 4 1199SEIU Training and Employment Fund, New York, NY, USA; 5Center for Home Care Policy & Research, VNS Health, New York, NY, USA; 6Department of Neurosciences, UC San Diego, San Diego, CA, USA; 7Department of Family Medicine, UCLA, Los Angeles, CA, USA; 8Clinical Research Division, Fred Hutch Cancer Center, Seattle, WA, USA; 9Cornell Tech, Cornell University, New York, NY, USA; 10Division of Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USACorrespondence: Madeline R Sterling, Department of Medicine, Division of General Internal Medicine, Weill Cornell Medicine, 420 East 70th Street, Room LH-357, New York, NY, 10021, USA, Tel +1646-962-5029, Email mrs9012@med.cornell.eduPurpose: Despite a rapidly growing need for home health aides (HHAs), turnover rates are high. While this is driven in large part by the demanding nature of their work and low wages, another factor may be that HHAs are often not considered part of the medical team which can leave them feeling unheard by other healthcare professionals. We sought to determine whether this concept, or HHAs’ perceived voice, was associated with job satisfaction.Methods and Design: This cross-sectional survey of English- and Spanish-speaking HHAs caring for adults with heart failure (HF) was conducted from June 2020 to July 2021 in New York, NY in partnership with a labor management fund of a large healthcare union that provides benefits and training to HHAs. Voice was assessed with a validated 5-item scale (total score range 5 to 25). Job Satisfaction was assessed with the 5-item Work Domain Satisfaction Scale (total score range 5 to 35). Multivariable linear regression analysis was used to examine the association between voice and job satisfaction.Results: A total of 413 HHAs employed by 56 unique home care agencies completed the survey; they had a mean age of 48 years, 97.6% were female, 60.2% were Hispanic, and they worked as HHAs for a median of 10 years (IQR, 5, 17). They had a median Voice score of 18 (IQR 15– 20) and mean job satisfaction score of 26.4 (SD 5.6). Higher levels of voice (1.75 [0.46– 3.04]) were associated with greater job satisfaction (p=0.008). When adjusting for Race/Ethnicity, HF training, and HF knowledge, the association between Voice and job satisfaction remained significant ((1.77 [0.40– 3.13])Conclusion: HHAs with a voice in the care of their patients experienced greater job satisfaction. Voice may be an important target for interventions aiming to improve HHAs’ retention in the field.Keywords: long-term care, home health aide, communication, healthcare team

The article presents a response by the authors regarding a suggestion made by the editor of the periodical in connection with an author's letter, concerning the listing of rejected manuscripts. The approval of the listing of rejected manuscripts by the authors has been highlighted, and their trouble at the potential loss of valuable insights and contributions by fellow authors has also been presented. The reason for the rejection has been supplied as the falling of the results below the .05 level of significance, which is quite an arguable discussion.

Objective: The objective of this study was to identify place features associated with increased risk of drug-involved fatalities and generate a composite score measuring risk based on the combined effects of features of the built environment., Methods: We conducted a geospatial analysis of overdose data from 2022 to 2023 provided by the St. Louis County Medical Examiner's Office to test whether drug-involved deaths were more likely to occur near 54 different place features using Risk Terrain Modeling (RTM). RTM was used to identify features of the built environment that create settings of heightened overdose risk. Risk was estimated using Relative Risk Values (RRVs) and a composite score measuring Relative Risk Scores (RRS) across the county was produced for drugs, opioids, and stimulants, as well as by Black and White decedents., Results: In the model including all drugs, deaths were more likely to occur in close proximity to hotels/motels (RRV=39.65, SE=0.34, t-value=10.81 p<.001), foreclosures (RRV=4.42, SE=0.12, t-value = 12.80, p<.001), police departments (RRV=3.13, SE=0.24, t-score=4.86, p<.001), and restaurants (RRV=2.33, SE=0.12, t-value=7.16, p<.001). For Black decedents, deaths were more likely to occur near foreclosures (RRV=9.01, SE=0.18, t-value =11.92, p<.001), and places of worship (RRV= 2.51, SE=0.18, t-value = 11.92, p<.001). For White decedents, deaths were more likely to occur in close proximity to hotels/motels (RRV=38.97, SE=0.39, t-value=9.30, p<.001) foreclosures (RRV=2.57, SE=0.16, t-value =5.84, p<.001), restaurants (RRV=2.52, SE=0.17, t-value=5.33, p<.001) and, auto painting/repair shops (RRV=0.04, SE=0.18, t-value =3.39, p<.001)., Conclusion: These findings suggest that places of worship, the hospitality industry, and housing authorities may be physical features of the environment that reflect social conditions that are conducive to overdose. The scaling up of harm reduction strategies could be enhanced by targeting places where features are co-located., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier B.V.)

Heart failure (HF) affects six million people in the U.S., is associated with high morbidity, mortality, and healthcare utilization. (1, 2) Despite a decade of innovation, the majority of interventions aimed at reducing hospitalization and readmissions in HF have not been successful. (3-7) One reason may be that most have overlooked the role of home health aides and attendants (HHAs), who are often highly involved in HF care. (8-13) Despite their contributions, studies have found that HHAs lack specific HF training and have difficulty reaching their nursing supervisors when they need urgent help with their patients. Here we describe the protocol for a pilot randomized control trial (pRCT) assessing a novel stakeholder-engaged intervention that provides HHAs with a) HF training (enhanced usual care arm) and b) HF training plus a mobile health application that allows them to chat with a nurse in real-time (intervention arm). In collaboration with the VNS Health of New York, NY, we will conduct a single-site parallel arm pRCT with 104 participants (HHAs) to evaluate the feasibility, acceptability, and effectiveness (primary outcomes: HF knowledge; HF caregiving self-efficacy) of the intervention among HHAs caring for HF patients. We hypothesize that educating and better integrating HHAs into the care team can improve their ability to provide support for patients and outcomes for HF patients as well (exploratory outcomes include hospitalization, emergency department visits, and readmission). This study offers a novel and potentially scalable way to leverage the HHA workforce and improve the outcomes of the patients for whom they care. Clinical trial.gov registration: NCT04239911., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Previous research has focused on factors influencing turnover of employees in the mental health workforce, yet little research has explored reasons why employees stay. To facilitate retaining a diverse mental health workforce, the current study aimed to elucidate factors that contributed to employees' tenure at a community mental health center (CHMC) as well as compare these perceptions between Black and White employees. Long-term employees (7 years or more) from one urban CMHC (n = 22) completed semi-structured stayer interviews. Using emergent thematic analysis, stayer interviews revealed four major themes for why they have stayed at the organization for 7 years or more: (1) work as a calling, (2) supportive relationships, (3) opportunities for growth or meaningful contribution, and (4) organization mission's alignment with personal attributes or values. Comparison between Black and White stayer narratives revealed differences in their perceptions with work as a calling and opportunities for growth and meaningful contribution. Guided by themes derived from stayer interviews, the current study discusses theoretical (e.g., job embeddedness theory, theory of racialized organizations, self-determination theory) and practical implications (e.g., supporting job autonomy, Black voices in leadership) in an effort to improve employee retention and address structural racism within a mental health organization., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Importance: Home health aides and attendants (HHAs) provide essential care to older adults and those with chronic conditions in the home. However, some HHAs struggle with poor mood and stress, which may have been exacerbated by the COVID-19 pandemic., Objective: To elicit HHAs' perspectives toward mental health and well-being, including how their job influences both and how to better support the workforce in the future., Design, Setting, and Participants: For this qualitative study, focus groups and interviews with HHAs were facilitated in English and Spanish from August 17, 2022, to February 9, 2023, in partnership with the 1199SEIU Training and Employment Fund, a benefit fund of the 1199SEIU United Healthcare Workers East and the largest health care union in the US. Included were HHAs at risk for poor mental health and well-being, which were defined as having at least mild or more symptoms on either the 8-item Personal Health Questionnaire depression scale, the 4-item Cohen Perceived Stress Scale, or the University of California, Los Angeles Loneliness Scale., Exposure: Mental health and well-being of HHAs., Main Outcomes and Measures: Focus groups and interviews were audio recorded, professionally transcribed, and translated. A thematic analysis was performed that was informed by Pender's Health Promotion Model and the National Institute for Occupational Safety and Health's Total Worker Health model., Results: A total of 28 HHAs from 14 different agencies participated (mean [SD] age, 54.3 [10.8] years; 26 female [93%]). Seventeen participants (61%) spoke Spanish at home. Five key themes emerged: (1) HHAs' attitudes toward mental health and well-being were influenced by a variety of personal and cultural factors; (2) HHAs' relationships with their patients impacted their mood in both positive and negative ways; (3) structural and organizational aspects of the job, alongside the COVID-19 pandemic, impacted HHAs' mood and stress levels; (4) HHAs used a variety of strategies to cope with their emotions; and (5) HHAs were eager for interventions that can improve their mood, particularly those that bring them closer to their colleagues., Conclusions and Relevance: These findings suggest that HHAs' mental health and well-being may be influenced by both personal and occupational factors. Interventions and policies to better support their emotional well-being on the job are warranted.

Background: Although family caregivers play a critical role in care delivery, research has shown that they face significant physical, emotional, and informational challenges. One promising avenue to address some of caregivers' unmet needs is via the design of digital technologies that support caregivers' complex portfolio of responsibilities. Augmented reality (AR) applications, specifically, offer new affordances to aid caregivers as they perform care tasks in the home., Objective: This study explored how AR might assist family caregivers with the delivery of home-based cancer care. The specific objectives were to shed light on challenges caregivers face where AR might help, investigate opportunities for AR to support caregivers, and understand the risks of AR exacerbating caregiver burdens., Methods: We conducted a qualitative video elicitation study with clinicians and caregivers. We created 3 video elicitations that offer ways in which AR might support caregivers as they perform often high-stakes, unfamiliar, and anxiety-inducing tasks in postsurgical cancer care: wound care, drain care, and rehabilitative exercise. The elicitations show functional AR applications built using Unity Technologies software and Microsoft Hololens2. Using elicitations enabled us to avoid rediscovering known usability issues with current AR technologies, allowing us to focus on high-level, substantive feedback on potential future roles for AR in caregiving. Moreover, it enabled nonintrusive exploration of the inherently sensitive in-home cancer care context., Results: We recruited 22 participants for our study: 15 clinicians (eg, oncologists and nurses) and 7 family caregivers. Our findings shed light on clinicians' and caregivers' perceptions of current information and communication challenges caregivers face as they perform important physical care tasks as part of cancer treatment plans. Most significant was the need to provide better and ongoing support for execution of caregiving tasks in situ, when and where the tasks need to be performed. Such support needs to be tailored to the specific needs of the patient, to the stress-impaired capacities of the caregiver, and to the time-constrained communication availability of clinicians. We uncover opportunities for AR technologies to potentially increase caregiver confidence and reduce anxiety by supporting the capture and review of images and videos and by improving communication with clinicians. However, our findings also suggest ways in which, if not deployed carefully, AR technologies might exacerbate caregivers' already significant burdens., Conclusions: These findings can inform both the design of future AR devices, software, and applications and the design of caregiver support interventions based on already available technology and processes. Our study suggests that AR technologies and the affordances they provide (eg, tailored support, enhanced monitoring and task accuracy, and improved communications) should be considered as a part of an integrated care journey involving multiple stakeholders, changing information needs, and different communication channels that blend in-person and internet-based synchronous and asynchronous care, illness, and recovery., (©Liam Albright, Woojin Ko, Meyhaa Buvanesh, Harald Haraldsson, Fernanda Polubriaginof, Gilad J Kuperman, Michelle Levy, Madeline R Sterling, Nicola Dell, Deborah Estrin. Originally published in JMIR Formative Research (https://formative.jmir.org), 30.05.2024.)

In degraded ecosystems, soil microbial communities (SMCs) may influence the outcomes of ecological restoration. Restoration practices can affect SMCs, though it is unclear how variation in the onset of restoration activities in woodlands affects SMCs, how those SMCs influence the performance of hard-to-establish woodland forbs, and how different woodland forbs shape SMCs. In this study, we quantified soil properties and species abundances in an oak woodland restoration chronosequence (young, intermediate, and old restorations). We measured the growth of three woodland forb species when inoculated with live whole-soil from young, intermediate, or old restorations. We used DNA metabarcoding to characterize SMCs of each inoculum treatment and the soil after conditioning by each plant species. Our goals were to (1) understand how time since the onset of restoration affected soil abiotic properties, plant communities, and SMCs in a restoration chronosequence, (2) test growth responses of three forb species to whole-soil inoculum from restoration sites, and (3) characterize changes in SMCs before and after conditioning by each forb species. Younger restored woodlands had greater fire-sensitive tree species and lower concentrations of soil phosphorous than intermediate or older restored woodlands. Bacterial and fungal soil communities varied significantly among sites. Forbs exhibited the greatest growth in soil from the young restoration. Each forb species developed a unique soil microbial community. Our results highlight how restoration practices affect SMCs, which can in turn affect the growth of hard-to-establish forb species. Our results also highlight that the choice of forb species can alter SMCs, which could have long-term potential consequences for restoration success., Competing Interests: Authors declare no conflict of interest., (© 2024 The Authors. Ecology and Evolution published by John Wiley & Sons Ltd.)

Objective: To understand the perspectives of home health aides (HHAs) toward their own health and health behaviors, and how their job impacts both., Data Sources and Study Setting: Interviews were conducted with 28 HHAs from 16 unique home care agencies from August 2021 to January 2022. The study was conducted in partnership with the 1199SEIU Training and Employment Fund, a labor-management fund of the largest health care union in the US., Study Design: A qualitative study with English and Spanish-speaking HHAs. Interviews were conducted using a semi-structured topic guide, informed by Pender's Health Promotion Model and the National Institute for Occupational Safety and Health's Total Worker Health Model. To be eligible, HHAs had to be currently employed by a home care agency in New York, NY., Data Collection/extraction Methods: Interviews were recorded, professionally transcribed, and analyzed thematically., Principal Findings: The 28 HHAs had a mean age of 47.6 years (SD 11.1), 39% were non-Hispanic Black, 43% were Hispanic, and they had a mean of 14.1 years (SD 7.8) of job experience. Five themes emerged; HHAs were: (1) Healthy enough to work, but were managing their own chronic conditions while working; (2) Motivated to be healthy, in part driven by their desire to care for others; (3) Worked closely with sick patients, which influenced their perceptions of health; (4) Experienced occupational and patient-level barriers to practicing healthy behaviors; (5) Sought support and resources to improve their health and wellbeing., Conclusions: HHAs have numerous health challenges, many of which are influenced by their job. Culturally and occupationally tailored interventions may mitigate the barriers that HHAs experience to achieve optimal health., (© 2023 Health Research and Educational Trust.)

Background: Human resources (HR) departments collect extensive employee data that can be useful for predicting turnover. Yet, these data are not often used to address turnover due to the complex nature of recorded data forms., Aims of the Study: The goal of the current study was to predict community mental health center employees' turnover by applying machine learning (ML) methods to HR data and to evaluate the feasibility of the ML approaches., Methods: Historical HR data were obtained from two community mental health centers, and ML approaches with random forest and lasso regression as training models were applied., Results: The results suggested a good level of predictive accuracy for turnover, particularly with the random forest model (e.g., Area Under the Curve was above .8) compared to the lasso regression model overall. The study also found that the ML methods could identify several important predictors (e.g., past work years, wage, work hours, age, job position, training hours, and marital status) for turnover using historical HR data. The HR data extraction processes for ML applications were also evaluated as feasible., Discussion: The current study confirmed the feasibility of ML approaches for predicting individual employees' turnover probabilities by using HR data the organizations had already collected in their routine organizational management practice. The developed approaches can be used to identify employees who are at high risk for turnover. Because our primary purpose was to apply ML methods to estimate an individual employee's turnover probability given their available HR data (rather than determining generalizable predictors at the wider population level), our findings are limited or restricted to the specific organizations under the study. As ML applications are accumulated across organizations, it may be expected that some findings might be more generalizable across different organizations while others may be more organization-specific (idiographic)., Implications for Health Care Provision and Use: The organization-specific findings can be useful for the organization's HR and leadership to evaluate and address turnover in their specific organizational contexts. Preventing extensive turnover has been a significant priority for many mental health organizations to maintain the quality of services for clients., Implications for Health Policies: The generalizable findings may contribute to broader policy and workforce development efforts., Implications for Further Research: As our continuing research effort, it is important to study how the ML methods and outputs can be meaningfully utilized in routine management and leadership practice settings in mental health (including how to develop organization-tailored intervention strategies to support and retain employees) beyond identifying high turnover risk individuals. Such organization-based intervention strategies with ML applications can be accumulated and shared by organizations, which will facilitate the evidence-based learning communities to address turnover. This, in turn, may enhance the quality of care we can offer to clients. The continuing efforts will provide new insights and avenues to address data-driven, evidence-based turnover prediction and prevention strategies using HR data that are often under-utilized.

This study examines the unique challenges facing rural home care workers. Semi-structured interviews were undertaken between July 2021 and February 2022 with 23 participants that have experience in rural home care delivery. The major challenge confronting rural home care workers involved distance and transportation. This challenge emerged due to long distance between clients, unreliable vehicles, inadequate reimbursement, and inclement weather. In turn, this challenge exacerbated three other types of challenges facing rural home care workers: workforce challenges that consisted of a persistent labor shortage and shorter visits that forced workers to rush through tasks, client isolation due to the social and physical seclusion of households, and the poor working conditions of home care work more broadly. Without policy interventions that respond to these particular challenges, the care gap in rural areas can be expected to grow.

Introduction: People who experience human trafficking (HT) visit emergency departments (ED). The International Classification of Diseases, Clinical Modification (ICD-10-CM) introduced codes to document HT in June 2018. The aim of this study is to identify characteristics of ED patients who experienced forced labor or sexual exploitation as a documented external cause of morbidity in US visits., Methods: Nationally representative surveillance based on patient visits to 989 hospital-owned EDs in the Nationwide Emergency Department Sample in 2019 became available in 2021. Eight ICD-10-CM codes to classify HT as an external cause of morbidity were combined into one HT variable for analysis in 2021-2022., Results: A weighted count of 517 of 33.1 million ED visits (0.0016%) documented HT as an external cause of morbidity. Of them, sexual exploitation (71.6%) was documented more frequently than labor exploitation (28.4%). Most HT-related codes were visits by females (87.3%) from large metropolitan areas, and identified as white. Approximately 40% of visits were from ZIP codes with a median household income less than $48,000 annually. Relative to all other ED visits, patients with HT as an external cause of morbidity had higher odds of being female (OR = 6.54, 95% CI:3.59, 11.92) and being a minor (OR = 1.76, 95% CI:1.02, 3.04)., Conclusion: HT was rarely documented as an external cause of morbidity in 989 hospitals' ED visits from a nationally representative sample in 2019. Documentation of recently added HT ICD-10-CM codes does not appear to have been implemented sufficiently to yield an unbiased representation of those who experienced HT and presented in the ED. Efforts to enhance the utility of ICD-10-CM HT codes for surveillance and documentation must first address ED personnel training on identification and response to HT. In doing so, ED personnel also need to address ethical concerns (e.g. stigma, confidentiality, risk of patient harm) and allow for informed consent among trafficked patients in order to be scaled up responsibly., Competing Interests: Declaration of Competing Interest None of the authors have personal, commercial, or financial conflicts of interests to disclose., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The Centers for Disease Control and Prevention reported a sharp increase in overdose deaths from illicitly manufactured fentanyls (IMFs) occurring between 2020 and 2021 in the United States. Approximately 4 in 10 drug overdose deaths involved opioids and stimulants. Fentanyl test strips (FTS), used to test drug product before use, can be a powerful harm reduction tool to promote safer use behaviors., Objectives: This pilot study assessed treatment-seeking service users' knowledge and understanding of IMFs and motivation to use FTS to prevent overdose., Methods: Clients receiving residential-based or office-based substance use treatment services were recruited from a community mental health center in the midwestern United States to complete a harm reduction-focused survey. Eligibility criteria included clients aged 18-89 years with self-reported drug use in the past year. A 20-question survey was administered verbally, both in person and via phone to assess knowledge of IMFs and FTS., Results: Of respondents (N = 30), 80% agreed that IMFs cause more overdoses than heroin. Most (73%) indicated concern about a friend overdosing owing to IMFs, and half (53%) expressed concern about personal risk of overdose. Most (73%) would like to be able to detect whether there is fentanyl in their drug before use, but only 17% indicated that they feel confident in their ability to use FTS., Conclusion: Many respondents who were receiving services for past-year substance use lacked understanding of how to use FTS for harm reduction. Clients who primarily use nonopioid (stimulant) drug products are at even greater risk of IMF overdose and would benefit the most from increased access and education surrounding the use of FTS. Our health care system must rapidly continue to explore and expand on overdose prevention efforts, including access to FTS, given that urgent action is needed to reduce the continued rise in overdose deaths in the United States., (Copyright © 2022 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Background: Home health aides (HHAs) provide necessary hands-on care to older adults and those with chronic conditions in their homes. Despite their integral role, HHAs experience numerous challenges in their work, including their ability to communicate with other health care professionals about patient care while caring for patients and access to educational resources. Although technological interventions have the potential to address these challenges, little is known about the technological landscape and existing technology-based interventions designed for and used by this workforce., Objective: We conducted a scoping review of the scientific literature to identify existing studies that have described, designed, deployed, or tested technology-based tools and apps intended for use by HHAs to care for patients at home. To complement our literature review, we conducted a landscape analysis of existing mobile apps intended for HHAs providing in-home care., Methods: We searched the following databases from their inception to October 2020: Ovid MEDLINE, Ovid Embase, Cochrane Library, and CINAHL (EBSCO). A total of 3 researchers screened the yield using prespecified inclusion and exclusion criteria. In addition, 4 researchers independently reviewed these articles, and a fifth researcher arbitrated when needed. Among studies that met the inclusion criteria, data were extracted and summarized narratively. An analysis of mobile health apps designed for HHAs was performed using a predefined set of terms to search Google Play and Apple App stores. Overall, 2 researchers independently screened the resulting apps, and those that met the inclusion criteria were categorized according to their intended purpose and functionality., Results: Of the 8643 studies retrieved, 182 (2.11%) underwent full-text review, and 4.9% (9/182) met our inclusion criteria. Approximately half (4/9, 44%) of the studies were descriptive in nature, proposing technology-based systems (eg, web portals and dashboards) or prototypes without a technical or user-based evaluation of the technology. In most (7/9, 78%) papers, HHAs were just one of several users and not the sole or primary intended users of the technology. Our review of mobile apps yielded 166 Android and iOS apps, of which 48 (29%) met the inclusion criteria. These apps provided HHAs with one or more of the following functions: electronic visit verification (29/48, 60%), clocking in and out (23/48, 48%), documentation (22/48, 46%), task checklist (19/48, 40%), communication between HHA and agency (14/48, 29%), patient information (6/48, 13%), resources (5/48, 10%), and communication between HHA and patients (4/48, 8%). Of the 48 apps, 25 (52%) performed monitoring functions, 4 (8%) performed supporting functions, and 19 (40%) performed both., Conclusions: A limited number of studies and mobile apps have been designed to support HHAs in their work. Further research and rigorous evaluation of technology-based tools are needed to assess their impact on the work HHAs provide in patient's homes., (©Elizabeth Fong-Chy Kuo, Jacklyn Cho, Iredia Olaye, Diana Delgado, Nicola Dell, Madeline R Sterling. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 11.11.2022.)

Background : Relatively few community-based programs have been found to be helpful for homeless people with alcohol disorders, even though this group represents a high-risk, vulnerable population prone to poor outcomes. Aims : This study sought to implement and evaluate intensive community-based programs for homeless people with alcohol disorders. Method : The project worked closely with a homeless outreach team for referrals, and then provided two different, intensive substance abuse treatment approaches matched to the needs of two subgroups: homeless individuals with alcohol disorders without severe mental illness received community reinforcement approach (CRA) and case management services, while those with alcohol and severe mental illness were assigned to assertive community treatment and integrated dual disorders (ACT/IDDT) services. The study enrolled 322 homeless people with alcohol disorders and outcomes were assessed at six months and program discharge. Results : Participants improved significantly over the first six months in a number of outcome areas, including substance abuse, mental health, housing, employment and health; progress generally remained stable between six months and discharge. Conclusions : Community-based programs that coordinate with mobile outreach teams and then provide CRA and ACT/IDDT appear to be promising approaches for helping individuals with alcohol disorders out of homelessness and into recovery.

Importance: Home health care workers care for community-dwelling adults and play an important role in supporting patients with confirmed and suspected coronavirus disease 2019 (COVID-19) who remain at home. These workers are mostly middle-aged women and racial/ethnic minorities who typically earn low wages. Despite being integral to patient care, these workers are often neglected by the medical community and society at large; thus, developing a health care system capable of addressing the COVID-19 crisis and future pandemics requires a better understanding of the experiences of home health care workers., Objective: To understand the experiences of home health care workers caring for patients in New York City during the COVID-19 pandemic., Design, Setting, and Participants: From March to April 2020, a qualitative study with 1-to-1 semistructured interviews of 33 home health care workers in New York City was conducted in partnership with the 1199SEIU Home Care Industry Education Fund, a benefit fund of the 1199 Service Employees International Union United Healthcare Workers East, the largest health care union in the US. Purposeful sampling was used to identify and recruit home health care workers., Main Outcomes and Measures: Audio-recorded interviews were professionally transcribed and analyzed using grounded theory. Major themes and subthemes were identified., Results: In total, 33 home health care workers employed by 24 unique home care agencies across the 5 boroughs of New York City participated. Participants had a mean (SD) age of 47.6 (14.0) years, 32 (97%) were women, 21 (64%) were Black participants, and 6 (18%) were Hispanic participants. Five major themes emerged: home health care workers (1) were on the front lines of the COVID-19 pandemic but felt invisible; (2) reported a heightened risk for virus transmission; (3) received varying amounts of information, supplies, and training from their home care agencies; (4) relied on nonagency alternatives for support, including information and supplies; and (5) were forced to make difficult trade-offs in their work and personal lives., Conclusions and Relevance: In this qualitative analysis, home health care workers reported providing frontline essential care, often at personal risk, during the COVID-19 pandemic. They experienced challenges that exacerbated the inequities they face as a marginalized workforce. Interventions and policies to better support these frontline health care professionals are urgently needed.

Background: Readmission rates are high among heart failure (HF) patients who require home health care (HHC) after hospitalization. Although HF patients who require HHC are often sicker than those who do not, HHC delivery itself may also be suboptimal., Objective: We aimed to describe the workflow of HHC among adults discharged home after a HF hospitalization, including the roles of various stakeholders, and to determine where along these workflow challenges and opportunities for improvement exist., Design and Participants: In this qualitative study, we used purposeful sampling to approach and recruit a variety of key stakeholders including home health aides, nurses, HF patients, family caregivers, physicians, social workers, home care agency leaders, and policy experts. The study took place in New York, NY, from March to October 2018., Approach: Using a semi-structured topic guide, we elicited participants' experiences with HHC in HF through a combination of one-on-one interviews and focus groups. Data were recorded, transcribed, and analyzed thematically. We also asked selected participants to depict in a drawing their understanding of HHC workflow after hospitalization for HF patients. We synthesized the drawings into a final image., Key Results: Study participants (N = 80) described HHC for HF patients occurring in 6 steps, with home health aides playing a main role: (1) transitioning from hospital to home; (2) recognizing clinical changes; (3) making decisions; (4) managing symptoms; (5) asking for help; and (6) calling 911. Participants identified challenges and opportunities for improvement for each step., Conclusions: Our findings suggest that HHC for HF patients occurs in discrete steps, each with different challenges. Rather than a one-size-fits-all approach, various interventions may be required to optimize HHC delivery for HF patients in the post-discharge period.

Although highly involved in heart failure (HF) patients' care, home care workers (HCWs) lack HF training and are poorly integrated into the healthcare team. For its potential to address these challenges, we examined the role of technology among HCWs caring for HF patients. We conducted 38 interviews with key stakeholders. Overall, four themes emerged. Participants reported that technology is critical for HF care, but existing systems are outdated and ineffective. HCWs also have limited access to electronic resources. Technology, training, and principles of implementation science can be leveraged to improve HCWs' experience in caring for HF patients and home healthcare delivery., (© The Association for Clinical and Translational Science 2020.)

Nutrient-based meal recommendations have the potential to help individuals prevent or manage conditions such as diabetes and obesity. However, learning people's food preferences and making recommendations that simultaneously appeal to their palate and satisfy nutritional expectations are challenging. Existing approaches either only learn high-level preferences or require a prolonged learning period. We propose Yum-me , a personalized nutrient-based meal recommender system designed to meet individuals' nutritional expectations, dietary restrictions, and fine-grained food preferences. Yum-me enables a simple and accurate food preference profiling procedure via a visual quiz-based user interface and projects the learned profile into the domain of nutritionally appropriate food options to find ones that will appeal to the user. We present the design and implementation of Yum-me and further describe and evaluate two innovative contributions. The first contriution is an open source state-of-the-art food image analysis model, named FoodDist . We demonstrate FoodDist's superior performance through careful benchmarking and discuss its applicability across a wide array of dietary applications. The second contribution is a novel online learning framework that learns food preference from itemwise and pairwise image comparisons. We evaluate the framework in a field study of 227 anonymous users and demonstrate that it outperforms other baselines by a significant margin. We further conducted an end-to-end validation of the feasibility and effectiveness of Yum-me through a 60-person user study, in which Yum-me improves the recommendation acceptance rate by 42.63%.