Qualitative Study of Mental Health Recovery in Dual Diagnosed Homeless

描述（由申请人提供）：总统的新自由委员会提出了精神健康康复的愿景，预示着精神残疾人士服务的转变，但关于康复的实证研究并没有跟上它的修辞诉求。对于“双重诊断”的无家可归者来说，尽管他们承担了不成比例的高额医疗费用，生活在集中的不利条件中，但他们对康复之路的描述或理解甚至更少。与20世纪90年代的康复运动不约而同的是，“住房优先”的兴起，这是一种为患有精神疾病的无家可归的成年人提供的服务方式，与通常的护理或“治疗优先”形成鲜明对比。与心理健康康复一样，“住房优先”得到了联邦和各州的支持，但尚未普及，研究仍未充分。这个多阶段的定性纵向研究将利用相关的理论框架来检查进入纽约市住宅服务的“双重诊断无家可归者”成年人的心理健康恢复情况。具体目标是：1)通过“住房优先”（HF）和“治疗优先”（TF）项目，确定双重诊断的无家可归成年人（DDHAs）康复的共同要素和背景。这一目标将通过使用独立提名标准抽样来选择在进入TF项目（n=10）或HF项目（n=10）两年后表现出相对较高功能水平的个体来实现。另外10个长期（50 - 5年）HF和TF样本将被标准抽样和招募。这40个人将被深入访谈和案例研究分析，用于开发一个或多个恢复模型，为目标2提供信息；2)对进入HF和TF项目的双重诊断的无家可归成年人（DDHAs）进行前瞻性定性研究，以记录康复的障碍和动机及其“实时”序列和背景。在目标1中开发的模型将为目标2中对个人（目标2a）、供应商（目标2b）和组织（目标2c）因素的查询提供信息。目标2a将包括为期18个月的4次深度访谈，涉及50名新入选者（HF和TF项目各25名），3次与他们的附属人员的访谈，以及对10名入选者的子样本进行“影子”观察（每人6天）。目标2b将包括与他们的病例管理人员进行3次访谈，目标2c将包括对项目地点进行有针对性的人种学访问（n=24次访问）。以个案为中心的数据收集和分析将用于开发与寻求摆脱无家可归的双重诊断成年人相关的康复归纳模型。以提供者和组织为中心的数据收集和分析将用于确定从服务系统环境中产生的面向恢复的服务的障碍和激励。目标3：在与双重诊断的无家可归者一起工作时，提出有助于实施以康复为导向的实践（rop）的建议。这一目标将包括整合目标1和目标2的研究结果，以建议促进发展中保健机构之间恢复所需的与组织和提供者有关的变革。为了实现这一目标，我们将进行一项初步研究，探讨这些ROP建议在三个区域环境中是否“可接受、适当和可行”：纽约市、费城和华盛顿特区。这一目标旨在将研究结果“提出来”，以探索其在HF和TF项目（3个城市的6个项目）中的可翻译性。具体而言，我们将在每个HF和TF项目开展15个焦点小组，一个是一线工作人员，另一个是主管人员，每个城市一个消费者焦点小组。来自这些小组的数据分析将为考虑到不同设置和程序的rop提供一套建议。拟议的研究试图从消费者的角度出发，扩大到包括重要的其他人（抵押品，案例经理和组织），并纳入观察数据，以最大限度地提高分析能力和翻译和传播的潜力，以改善“现实世界”为严重弱势群体提供的服务。

DESCRIPTION (provided by applicant): The vision of mental health recovery promoted by the President's New Freedom Commission portends a transformation of services for psychiatrically disabled persons, yet empirical research on recovery has not kept pace with its rhetorical appeal. For 'dual diagnosed' homeless persons, paths to recovery are even less described or understood despite the fact that they incur disproportionately high medical costs and live amidst concentrated disadvantage. Coincidentally with the recovery movement in the 1990s was the rise of 'housing first', a service approach for mentally ill homeless adults that distinctly contrasts with usual care, or 'treatment first'. Like mental health recovery, 'housing first' has received Federal and state endorsements yet is not yet widespread and remains understudied. This multi-phase qualitative longitudinal study will draw on relevant theoretical frameworks to examine mental health recovery among 'dual diagnosed homeless' adults entering residential services in New York City. Specific Aims are: 1) To identify common elements and contexts of recovery among dual diagnosed homeless adults (DDHAs) served by 'housing first' (HF) and 'treatment first' (TF) programs. This aim will be accomplished by using independent nominations criterion sampling to select individuals who manifest relatively high levels of functioning two years after entering a TF program (n=10) or a HF program (n=10). An additional 10 long-term (>5 years) HF and TF samples will be criterion-sampled and recruited. These 40 individuals will be interviewed in-depth and case study analyses used to develop one or more models of recovery to inform Aim 2; 2) To conduct a prospective qualitative study of dual diagnosed homeless adults (DDHAs) entering HF and TF programs in order to document barriers and incentives for recovery and their 'real time' sequences and contexts. Model(s) developed in Aim 1 will inform Aim 2 inquiries into individual (Aim 2a), provider (Aim 2b) and organizational (Aim 2c) factors. Aim 2a will include 4 in-depth interviews over an 18-month period with 50 new enrollees (25 each at HF and TF programs), 3 interviews with their collateral persons, and 'shadowing' observation of a sub-sample of 10 enrollees (6 days per person). Aim 2b will include 3 interviews with their case managers and Aim 2c will involve targeted ethnographic visits to the program sites (n=24 visits). Individual case-centered data collection and analyses will be used to develop an inductive model of recovery relevant to dual diagnosed adults seeking to exit homelessness. Provider- and organization-centered data collection and analyses will be used to identify barriers and incentives to recovery-oriented services emanating from the service system context. Aim 3: To recommend changes that will facilitate implementation of recovery-oriented practices (ROPs) in working with the dual diagnosed homeless population. This aim will involve integrating findings from Aims 1 and 2 to recommend organizational and provider- related changes needed to foster recovery among DDHAs. To accomplish this aim, we will conduct a preliminary study to explore whether these ROP recommendations are "acceptable, appropriate and feasible" in three regional settings: New York City, Philadelphia, and Washington DC. This aim is intended to take the findings 'up and out' to explore their translatability in both HF and TF programs (6 programs in 3 cities). Specifically, we will conduct 15 focus groups, one with front-line staff and another with supervisory staff at each HF and TF program and one focus group of consumers per city. Data analyses from these groups will inform a set of recommendations for ROPs that take into account diverse settings and programs. The proposed study seeks to start broadly from the consumer's perspective, expand to include significant others (collaterals, case managers and organizations) and incorporate observational data to maximize analytic power and the potential for translation and dissemination to improve 'real world' services for a severely disadvantaged population. PUBLIC HEALTH RELEVANCE: This proposed qualitative study addresses mental health recovery among homeless mentally ill adults with co-occurring substance abuse. Such individuals, who live amidst concentrated disadvantage and incur high medical and other costs, challenge the 'recovery paradigm' that has become prominent in mental health services. Drawing upon the President's New Freedom Commission report valuing consumer perspectives, it will produce guidelines designed to improve recovery-oriented practices for one of society's most difficult-to-reach populations.