Neurologic-Informed Care to Improve Health Equity Among Persons with Brain Injury Experiencing Homelessness: A Community-Engaged Implementation Approach

Ohio State University, Columbus OH

Investigators

Abstract

PROJECT SUMMARY Approximately half of individuals experiencing homelessness or housing instability have sustained at least one traumatic brain injury (TBI) in their lifetime, with up to 90% having sustained their first TBI prior to becoming homeless. Becoming unhoused is often precipitated by socioeconomic disadvantage resulting from job loss, inability to pay medical bills, and/or severing of family ties that provided financial and other supports. Furthermore, cognitive and behavioral impairments due to TBI can make it difficult to complete tasks of daily living and maintain key relationships at work and home. When left unidentified and unaddressed, these impairments can affect a person’s ability to fully benefit from existing homeless and housing service programs meant to facilitate housing access and housing retention, thus contributing to the chronicity of homelessness and housing instability. Neurologic-Informed Care (NIC) is a novel, integrated model of care that could enhance the equitability and effectiveness of services for this population. NIC consists of existing evidence-based interventions: 1) the Ohio State University TBI Identification Method to screen for lifetime exposure to TBI, 2) Adult Symptoms Questionnaire for Brain Injury to identify specific impairments, and 3) neurocognitive accommodations for overcoming these impairments. NIC is a scalable and potentially highly effective model that can be employed by front-line staff in these settings. NIC is now required by the American Society of Addiction Medicine when cognitive impairment is an issue, but it is not specific to substance use treatment. Increasing the uptake, effectiveness, and sustainment of NIC in homeless and housing service settings will take deliberate, implementation efforts to overcome multilevel barriers at the staff, organizational, and system levels. Our prior research has demonstrated the utility of implementation blueprints as an effective implementation strategy for overcoming barriers and scaling-out other interventions in complex treatment settings, but studies have yet to develop a blueprint for implementing NIC in homeless or housing service settings. Grounded in the NINDS Social Determinants of Health and Health Equity Implementation Frameworks, this R34 seeks to address several objectives necessary to prepare for a future hybrid effectiveness-implementation study aimed to increase the uptake, effectiveness, fidelity, and sustainment of NIC in homeless and housing service settings nationally. In Aim 1, we will determine client (n = 20) and staff (n = 15) acceptability of NIC and if adaptations are needed for persons with TBI experiencing homelessness or housing instability. In Aim 2, we will investigate multilevel determinants to NIC uptake using a convergent parallel mixed methods design through interviews (n = 25 staff) and surveys (n = 100 staff across 10 organizations in the United States). In Aim 3, we will co-develop an implementation blueprint with our Community Advisory Board members to address these determinants, connecting specific blueprint strategies to measurable implementation and effectiveness outcomes.