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Transitions to health a cost savings impact new pilot prototype dual acute hospital homeless response team social healthcare through housing...

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Content Dual Acute Social Healthcare

1

Transitions to Health a Cost Savings Impact New Pilot Prototype Dual Acute Hospital Homeless
Response Team Social Healthcare Through Housing Chronic Homeless Patients with Mental
Illnesses and Chronic Diseases
The Grand Challenge for Social Workers: Ending Homelessness

Edgar Alfredo Manriquez, DSW, MSW, BSW, ACSW

University of Southern California
Suzanne Dworak-Peck School of Social Work
Doctor of Social Work Program
SOWK 722 Implementing Your Capstone and Re-Envisioning Your Career
Professor Dr. Annalisa Enrile
Assignment 3 Capstone Project Final Paper & Final Prototype
December 18, 2020

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Area I. Executive Summary
The “Transitions to Health” pilot program shall be a nonprofit program. This innovation
addresses the problem of chronic homeless patients that are mentally ill and have chronic
diseases. These populations visit hospitals for medical treatment and an overnight stay, costing
the hospitals and taxpayers millions of dollars (Wadhera, et al, 2019). Transitions to Health is
designed for implementation at hospitals in Fresno, California. The innovation intervention
implementation are for hospitals to have safe discharge plans with an new healthcare hospital
homeless response team.
Every year in the United States, more than one million people experience homelessness.
People become homeless from varying complex life circumstances such as; poverty, family
violence, disabilities, mental illnesses, post-traumatic stress disorders, depression, anxieties, loss
of a job, chronic diseases, intergenerational family trauma as it relates to their homeless situation
(Sharp, 2018). Other common factors include: lack of shelters, homeless services or affordable
housing by the policies that have govern to fail the chronic homeless people. Further, there are
stigmas surrounding the chronic homelessness that costs the state and local agencies a financial
burden. For example, the cost for the chronic homeless people to visit hospitals annually is
approximate $35,000.00 to $135,000.00 or more (Padgett & Henwood, 2018). Furthermore,
other stigmas are that hospitals have a reputations of discharging homeless patients to the streets.
The end results, taxpayers are paying for the homeless to continue to be homeless. The cycle
continues as community agencies (such as hospitals) are impacted with chronically homeless
patients, some of which have mental illnesses and chronic diseases, that use the hospitals for
overnight shelters and inevitably maximize the domicile hospital beds. The homeless patients use
the hospital emergency department for primary healthcare and seek for help in solving their high
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risk social problems. The hospitals are not financially equipped to solve all of the social
problems homeless people are facing on a daily basis. The continuous monthly readmissions are
costing hospitals a financial burden. The hospital waiting rooms and emergency departments can
take significant number of hours waiting for an acute medical treatment intervention. The grand
challenge will be to focus on the chronically homeless patients – one with mental illness and
chronic diseases who use the hospitals in Fresno, frequently.
The hospital systems theory approach to healthcare organizations have been found
ineffective. Historically designed for acute inpatient care, these organizations lack follow up care
after a chronic homeless patient is discharged (Pitts et al, 2018). Hospitals are designed to treat
medically homeless patients inside the hospital settings and are not designed to follow up after a
hospital discharge. Under the California SB 1152 Hospital Homeless Discharge Process enforced
as of July 2019 (California Legislative Information, 2019) the regulations are holding hospitals
and healthcare professionals accountable by setting them up for an un-realistic approach in
solving the hardships of the chronic homeless communities. Therefore, ending homelessness is a
Grand Challenge of Social Work (Fong et al, 2018).
The proposed capstone project, called Transitions to Health, will develop a five-year pilot
dual hospital homeless response team, social healthcare program in the Fresno, CA hospitals.
The focus is an inpatient and outpatient follow up to pathways bridge line transitional housing
within the hospitals and the community. The innovation will be to target the top 50 chronically
homeless patients with mental illnesses and chronic diseases that have the highest significant
number of hospital visits within the last 12 months and are the highest costs.
The Transitions to Health response team will consist of a Nurse Practitioner
(NP)/Physician Assistant (PA), Licensed Clinical Social Worker (LCSW) and Bachelor of Social
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Work (BSW). This response team will specialize in critical time intervention to the chronic
homeless patients with mental illnesses and chronic diseases services. The team has a passion for
the healthcare for the homeless.
The Transitions to Health team will provide critical time interventions and intensive
homeless case management services. These services include: establishing primary care
physicians, medication management, non-emergency medical transportation services, facilitate
telehealth and offer social, emotional supportive services. Upon receiving a referral by the
hospital case management services of a homeless patient that meets the criteria. Transitions to
Health will conduct an initial hospital bedside visit and homeless patient must consent for
services. Upon release from the hospital, the homeless patient will be provided with placement
into a home where the owners rent out a private room with board. Renter’s history will not be
required. The plan is to network and contract with 20 local room and boards available to house
50 patients with individual bedrooms. The room and boards will have additional supportive
services arranged by In-Home Supportive Services (IHSS) workers for those who have Medi-Cal
insurance to start independent living skills. Additional services would include iPads for mobile
Zoom telehealth psychiatry services, drug Medi-Cal for telehealth drug counseling. The
proposed funding source for the Transitions to Health will be funded by the Fresno/Madera
Continuum of Care source new grant funding of $900,000 per year for up to five years. This new
grant also includes 50 vouchers for Permanent Support Housing (PSH) from the Department of
Housing and Urban Development (HUD) for long term affordable housing.
Transitions to Health will demonstrate pre and post homeless patients cost saving
statistics by publishing annual journals for five consecutive years in the Journal of Medicine
and/or Journal of the National Association of Social Workers (NASW). The publications will
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provide social healthcare changes by evidence base practice (EBP) pre-homeless and post-
homeless hospital reduction of visits, taxpayers cost savings, healthcare stabilized post-homeless
patients, and educating the community on the awareness that the homeless are a social
determinant of health. The methodology for the Transitions to Health pilot project with the
implementation plan includes a timeline, logic model and line-item budget. These tools provide
the foundation for proposed project evaluation alignment with a mission, vision and tasks
outcomes. The pilot project plan will provide an overview plan of its functions designed to
create the momentum for community hospitals, comply with SB 1152 Hospital Homeless
Discharge Process. The proposed plan is to present a pitch deck marketing proposal prototype to
the San Joaquin Valley hospitals leadership departments and program developments. Their
feedback would continue ongoing modifications and refining the Transitions to Health pilot
project.

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Area II Conceptual Framework
Problem Statement
Ending homelessness is one of the 12 grand challenges of social work (Fong, et al, 2018).
Chronic homelessness is a common problem in society at the national, state and local levels.
Over one million individuals in the United States experience homelessness annually (Tobey,
2017). The United States of America (USA) has the reputation of the world’s wealthiest country,
but has not solved the homeless problems due to unrealistic govern policies that have created
these critical homeless numbers by the increase of cost of living and economic poverty..
According to the HUD Federal Register (2015) defines chronic homelessness, “McKinney-Vento
Homeless Assistance Act, 42 U.S.C. 11360 as an individual or family that is homeless and
resides in a place not meant for human habitation, a safe haven, or in an emergency shelter, and
has been homeless and residing in such a place for at least 1 year or at least four separate
occasions in the last 3 years.” (http://www.files.hudexchange.info, p.2) Since then, the term
chronic homelessness is used for public social services and other programs.
Stigmas associated with homelessness have resulted in negative attitudes such as homeless
people are viewed as lazy, do not want work, or are alcoholics and drug users. Societal stigmas
have created misconceptions in relation to having a mental illnesses. Acute hospital use among
homeless patients with mental illnesses, drug addictions and chronic diseases is on the rise and
homelessness is a social determinant of health (Wadhera, et al, 2019). Historically, specific
people with mental illnesses used to live in psychiatric hospitals, however, during the
Community Mental Health Act of 1963 Deinstitutionalized Movement they were released into
community mental health clinics and group homes which caused a dramatic change to the nature
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of modern psychiatric care (Martinez-Leal, et al, 2011). From that point, some people with
mental illness have had to reside in family’s homes and for some families the care has become a
daily burden to provide their special needs. In addition, some underfunded mental health
programs have inadequately provided services to the mentally ill people as results of
incarcerations and frequent hospitalizations usage of these public systems (Prins, 2011). The
National Alliance for the Mentally Ill was founded in 1979 to provide supportive services,
education, advocacy and research for people with serious psychiatric illnesses. Other
governmental interventions and programs have worked to improve mental health care access
such as Social Welfare programs. The challenges are that homeless people have barriers such as
uncontrolled mental illnesses, lack of shelters, not enough affordable housing, increases on the
cost of living and the end results they develop chronic diseases.
Additionally, the stigma associated with homeless people who have chronic diseases. Which
often prevent patients from seeking medical treatment and attempt to distance themselves from
medical exclusions. Chronic disease in the USA is the main cause of poor health, disability,
death and highest costs for healthcare expenditures (Bauer, et al, 2014). Chronic diseases are
defined as conditions that last 1 year or more and require ongoing medical attention or limit
activities of daily living or both. In the USA 90% of the annual $3.5 trillion health care
expenditures are for people with chronic and mental health conditions (DCD, 2019). According
the CDC the top eight chronic diseases are heart failure, cancer, pulmonary chronic lung, stroke,
Alzheimer’s, diabetes and kidney diseases. The top three chronic diseases in Fresno County are
heart failure, pulmonary chronic lung disease and diabetes (Hospital Council, 2019). There are
various healthcare disparities such as unhealthy air quality, poverty, and unhealthy lifestyle. The
specific populations who are at a higher risk of being diagnosed are those who are chronically
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homeless with mental illness. Due to lack of insurance healthcare, shelter and being exposed to
unhealthy environments and homelessness is a social determinants of health disparities.

Research
According, to the United States Interagency Council on Homelessness (USICH) the
Department of Housing and Urban Department (HUD) conducted the point in time count in 2018
and reported there was 553,742 homeless people in the United States, 369,081 individuals,
184,661 families with children, 40,799 youth, 40,056 veterans, 86,942 individuals with chronic
patterns of homelessness, 134,278 in California, and 1,814 in Fresno (USICH). In 2019 the
homeless have increased by 17% in Fresno and Madera counties. These complex problems affect
multiple public community agencies; hospitals, law enforcement and county jails, being the top
three. In addition, the annual cost for the chronic homeless people to visit hospitals cost
approximate $35,000.00 to $135,000.00 or more per person annually, where the cost of
permanently long-term housing is $13,000.00 to $25,000.00 per person annually (Padgett &
Henwood, 2018. p.127). The results indicate that hospitals and taxpayers are paying for the
ongoing cycle of chronic homeless patients with mental illnesses and chronic diseases to visit
hospitals for medical treatment and overnight stay. Homeless populations have a higher rate of
mortality and pre-mature death compared to the average life expectancy of the general USA
populations which are 77 years. The homeless men average pre-mature death at 47 years and
homeless woman are at 43 years (Ann Webb, et al 2018, p.1). There are several factors that
account for the high death rate of the homeless due to lack of shelter; inadequate food nutrition,
poverty, unemployment, disabilities, lack of insurance, no primary healthcare physician, post-
traumatic stress disorders, drug addiction, chronic diseases, depression, anxieties, uncontrolled
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mental health, no support system, intergenerational family trauma (as it relates to their homeless
situation) and hopelessness. These complex problems arise during acute hospital visits and
places hospital case managers under pressure to fix complex social care problems (Sorelle,
2019).
The grand challenge of ending homelessness for a specific homeless population reflected in
hospitals in the Fresno area. Homeless people in Fresno are at higher risk of being diagnosed
with a chronic disease due to being in the California’s San Joaquin Valley which has the highest
unhealthy air quality, uninsured, physician shortages and making frequent hospital visits for
medical care. The top three chronic diseases in Fresno County are; heart failure, pulmonary
chronic lung and diabetes (Hospital Council, 2019). Within these chronic health issues homeless
people use acute hospitals more often and have a higher rate of premature death (Health &
Medicine Week, 2018). Patients that are homeless with chronic diseases use the hospital
emergency department as their primary care, get admitted and can stay for multiple days until
their medical symptom conditions are temporary stable. Prevalence rates for mental disorders
which can be from 30% to more than 60%, and more that 50% of chronic homeless people have
concurrent substance addictions and mental disorders (Jego, et al, 2018). These numbers of
hospital homeless patients can take the hospital medical team more time to stabilize their
uncontrolled medical conditions.
Social Significance and Market Analysis
Currently, Fresno’s hospitals do not have an ambulatory outpatient homeless team case
management providing intervention health for the homeless services to transitional housing. The
chronically homeless patients who visit the hospital are the highest hospital costs, however,
Sutter Health Hospital of Sacramento County started a campaign of 30 million project to house
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chronic homeless patients in hotels and build their own apartment complex (Bartolone, 2017).
Weingart Center in Los Angeles, CA is a comprehensive one-stop homeless center proving
residential housing, wraparound intervention services, employment mental health and long term
case management services located on a 11-story building.
In other hospitals across the country, there are also programs. For instance, in Chicago, the
University of Illinois Hospital and other hospitals started investing in permanent housing for the
chronically homeless patients to reduce the cost of emergency visits and better their health
(Elejalde-Ruiz, 2018). New York hospitals as well have contracted hotels and apartment
complex to housing the chronically homeless patients and provide outpatient supportive services.
In Portland, Oregon five hospitals and nonprofits health systems donating $21.5 million to build
400 housing units for the homeless (Flaccus, 2016). The key is by providing follow up ongoing
case management homeless services. These hospitals have acknowledged that thinking outside
the norms and on the long run its cost saving to house these homeless patients who are using the
hospitals for overnight shelters. There are some homeless patients who will refuse to be housed
and continue to reside in the homeless communities and continue using the hospital systems.
There are studies that show significant progress implementing the Housing First model. For
example, Wood (2019) explained in a study analysis called Housing First Program 50 Lives 50
house project a multi-agency collaboration found that hospitals and Housing First approach
shows evidence supports housing the homeless is a healthcare intervention (p. 27-39). That said
within the 12 month a reduction of hospital re-admitted visits was reduced and costs by 62.% to
71,1%. With an intervention team of 28 agencies collectively impacted housing programs,
mental health, outreach and social services (Wood, 2019). This is an example of the hospital
collaborating with community agencies working together and as results of cost savings.
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Framework Theory of Change
The Transitions to Health is modeled in DiClemente and Prochaska’s stages of change theory
and systems theory. Homeless people in general reach stages of long series of crisis, poor
decision making and missed opportunities. Other factors that influence people into ongoing
unsheltered situations and overcoming their moral psychological to overcome their obstacles of
drug addictions, deinstitutionalizations of the mentally ill, jobless, victims from violence,
reduced welfare benefits, lack of family/friend support systems, and lack of shelters (Ashford,
2013). The stages of change identifies five stages: precontemplation not planning to change,
contemplation considering change, preparation made a change, action changed occurred and
maintenance problem behavior absent (Littell & Girvin, 2002). The behaviors development
circle of stages that at any given time during an individual’s health recovery progress they can
reverse and relapse, go back into any of the five stages of change and return to context
successfully implementation in the change.
In social systems theory, people are affected by the human development of the people around
them and influence their behaviors in their communities. Systems theory are not able to solve
problems that are outside on their own system without realizing looking at all the components
that are not used function differently. Transitions to Health can eradicate the social norms of
hospital to have the greatest impact on the most homeless patients in their environmental circle
to support each individual for social good.

Area III. Problems of Practice and Solutions/Innovations
Innovative Solutions The Transitions to Health project is a five-year pilot program that is a
dual acute hospital homeless response team for social healthcare through hospitals and HUD
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housing programs. The program will be tested at the local hospitals in Fresno, CA for an acute
in-patient and out-patient pathways bridge line transitional housing within the hospital and
community supportive services hospital and HUD program. Historically, hospitals and HUD do
not communicate. The program will target 50 chronically homeless patients with mental illnesses
and chronic diseases that have the highest number of hospital visits in the last 12 months and are
the highest costs. The Transitions to Health hospitals homeless response team will be a
specialized team of a NP/PA, LCSW/MSW and BSW who specialize in working with the
healthcare system for the homeless patients. This team will provide critical time intervention
case management healthcare services.
The key metrics for success ongoing documentation in the patient’s health medical records
data of intensive case management outreach certified in critical time intervention (CTI) services
delivery. The Transitions to Health is a five-year pilot program will be initiated upon the initial
hospital discharged and placed in a room and board. The room and boards will be contracted in
advanced to accept homeless patient placements. Furthermore, document monthly stats on pre-
homeless and post-homeless hospitalizations visits, to demonstrate reduction stats, face to face
contacts, referrals provided, and document community homeless social work services delivery.
The United States Interagency Council on Homelessness has partnered with hospitals to
encourage to use the International Classification of Disease (ICD-10) diagnosis code for
homeless (Z59.0) patient medical records to be able to have statistics and patterns of homeless
patients visiting hospitals (Wilkins, 2016). The homeless patients, then, can be identified in a
longitudinal study and publish with evidence base research for five years. Another public
program to track homeless patients in communities are the Homeless Management Information
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System (HMIS) created by the USICH for the local, state and national data used in the annual
national point in time count of the number of homeless people.
Stakeholders Perspectives
The innovative target areas will be the Central California also known as the “San Joaquin
Valley” which has approximate 12 county hospitals; Adventist Health Hanford, Adventist Health
Reedley, Adventist Health Selma, Clovis Community Medical Center, Community Regional
Medical Center (includes Community Behavioral Health Center), Kaiser Permanente, Fresno
Service Area, Kaweah Delta Health Care District, Madera Community Hospital, San Joaquin
Valley Rehabilitation Hospital, Sierra View Medical Center, Saint Agnes Medical Center. These
hospitals listed do not provide acute social healthcare for the homeless patients after leaving the
hospital such as providing intervention on the homeless communities out-patient follow up
placements. These area hospitals also do not have an out-patient transitional housing program for
the chronic homeless patients in Fresno, CA. The aim is that there are no pathways to hospital
homeless out-patients collaborative initiative for ending homelessness and saving the taxpayers
money, saving homeless lives and reduce the cycle of social determinants of health. This
innovation supports the stakeholder’s hospitals healthcare social workers who specialize in acute
social, emotional and supportive services. The homeless response team can take a comprehensive
combination of these dual elements - inpatient hospital and out-patient, looking at both acute
healthcare systems approach. There is currently no collaboration for readiness of this state-of-
the-art healthcare homeless delivery program that will solve the homeless patients using the
hospital beds and costing tax payers..
The following analysis utilizes 14 stakeholders’ perspectives of barriers to services for
the homeless in Fresno, CA and what they envision as greater unmet needs and services. The
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common barriers to assist the homeless people are as follow; not enough shelters, specialized
shelters, more homeless people versus shelters, emergency housing, affordable housing, long
term housing, transitional housing, permanent supportive housing services, health for the
homeless, room and boards, not enough resources for shelters, hospitals do not provide housing
services, need more social workers to assist the homeless populations. The following are the
stakeholders solutions to change and reduce or end homelessness as follow: drug addiction
services, mental health and health services, end poverty, cycle of homelessness, wraparound
homeless services at one location, new homeless agency program, funding hosing homeless,
eligibility services to prevent homelessness, support from federal government at state and local
level, shelters for families, reconstructing outpatient homeless services is also a need to help
them become more accessible to the homeless population.
The analysis identified several patterns emerging from the stakeholders. First, a shortage
on available shelters to serve the higher numbers of homeless populations. Second, not enough
emergency housing services and long-term affordable housing with supportive services. Third,
not enough shelter services and social workers to provided services. Lastly, the stakeholders
have significant perspective to solutions for the homeless problem. Their visions to have new
innovative wraparound homeless services and a new department of homeless services. Others,
governmental support and reconstructing of outpatient homeless services. These are the issues
are and future visions to reduce and solve to change the cycle of homelessness.
Comparative Analysis
There is relevant history by hospital practices who are also working on ending
homelessness and reducing hospital visits for the homeless patients. This is an overview of the
relevant program solution by Jefferson Department of Family and Community Medicine
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partnership task force measuring evidence-based models such as assertive community treatment
models. The program focused on homeless patients with health needs by partnering with
community partnership solutions. The supportive treatment team included a nurse, psychiatrist,
medical social worker, peer specialist, vocational specialist and drug addiction counselor. These
chronic homeless populations with chronic health conditions need additional resources from
health clinics to focus on the medical needs. The medical social workers can also assist with
other social issues (Weinstein et al., 2013). This is an example of a medical home model-based
team-based approach with multiple experts intervening. To prevent the chronic homeless patients
with mental health illnesses and chronic diseases who use the hospital for medical shelters to
stabilize their medical regimen and pathways to homelessness collaboration community
initiatives and housed for long term care.
Additionally, in this study, program evaluations evidence-based practice when local
community partners worked together to better serve the chronic homeless people who suffer
from serious mental health illnesses and diseases. The study conducted a longitudinal evaluation
by the Jefferson Department of Family and Community Medicine and the Housing First model
called Pathways to Housing in Philadelphia, PA. They provided services to 259 homeless people
and they housed 183 people and reported 68% males (Weinstein et al. 2013). The data was
collected by program evaluations from a public health system performance assessment
instrument. A performance standard essential public health service.
The main findings and takeaways are the success of evidence-based models measured to
address a grand challenge of integrated community health services with multi community
partners to reduced homelessness. The local non-profits agencies applied the housing first
models and partnered by primary care, public health outreach, social workers as a unique system
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for community solutions united to solved individuals experiencing homelessness with serious
mental health illnesses.
Other research relates to the hospital homeless topic on the practices for intervention to
financial savings, time, tax dollars, reduce homeless patients, re-admissions to the hospitals and
house them permanently as a social determinant of health (Coleman, 2013).. According to
Coleman (2013) was based on the evaluations of multiple hospital emergency departments
process on discharging homeless patients with their effective homeless models. The evaluations
study was conducted at various hospitals in cities in the United States, and United Kingdom. The
study evaluated ten models by hospitals, three in the USA and seven in the United Kingdom.
Most hospitals reported started their models by pilot programs for hospital homeless discharge
process and the models had the common outcome and cost savings of the models during the
piloted and analysist of strategies ensue everyone homeless discharged safely from a hospital.
These models have an impact of multiple systems that include healthcare, housing and
non-profit programs (Coleman, 2013). Within the study eight of the ten models had both services
in place housing and or discharge coordinators, outreach workers, and social care coordinators
hired by the hospitals with provide service for patients experiencing homelessness. Most
outcomes the coordinators provided various outpatient services but also provided the hospital
staff educational protocols for discharging homeless patients (Coleman, 2013). One limitation on
the study found that one hospital using a model the hospital staff are not always trained on the
safe hospital discharge for patients experiencing homelessness. Other outcomes on the models
used it increased networking, care coordination, increased awareness and knowledge of
homelessness, decreased number in unsafe hospital discharges, decrease in re-admissions to
hospitals, and reduce the length of stay for the homeless patients, reduction in hospital care and
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ER visits. The study asked to assess each hospitals chart of effective models of hospital
discharge reviewed, by project partners, cross-sector partnerships, details/rationale, program
outline/process, outcomes and cost savings. The evaluations and sources of bias there was no
interviewed hospital coordinators teams, all was evaluated by the chart of effective models of
hospital discharge (Coleman, 2013).
Consideration of opportunities for innovation
Larkin et al. (2016) reports the overall homeless initiatives mission and vision for
universities of social work education departments to use strength base curriculum to further zero
in with policy advocacy, field placement opportunities for the social work students for best
practices. Therefore, the report indicated not enough social work education programs were
preparing social work students with the homelessness populations. Therefore, a logic model
called for the National Homelessness Social Work Initiative was generated. For example, an
input; University and Council of Social Work Education partnership, activities; innovation
exchange, outputs; homeless content in curriculum, effective evidence-information, policy
changes to support homelessness and to reduce homelessness at the local, national (Larkin et al.
2016). On its first launch in 2013, seven Universities were accepted to develop prototypes
homeless community services. Since then, more schools have partnered and implemented
prototypes for new homeless services .
In 2015, the National Center received support from the U.S. Department of Housing
Urban Development to end homelessness and engage social work programs nationally in
aligning with the American Academy Social Work and Social Welfare implementation of the
Grand Challenge to End Homelessness (Lark et al. 2016). Therefore, Transitions to Health will
include medical students and social work interns for case management practice experiences from
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various universities University of California Davis, University of California San Francisco,
University of Southern California, California State University of Fresno, and Fresno Pacific
University etc.
A systematic literature review by Pitt et al (2018), conducted a search of 28 studies
identifying hospitals homeless patients entering the emergency department and concluded
findings, homeless patients were underrecognized, distinct care disease needs patterns and more
evidence-based research was needed to determine the prevalence and caring for this vulnerable
population (p. 20). The barriers can be stigmas society has targeted the homeless people for
example, are all lazy and don’t want to work and are stereotype as social Darwinism.
Likelihood of Success
A new policy in California was embedded for hospitals to identify homeless patients and
mandated for the hospitals and healthcare facilities. The Senate Bill 1152 Hospital patient
discharge process: homeless patients, which is in effect as of July 1, 2019. Hospitals must
document once a homeless patient is identified and upon a safe homeless discharge as follow;
establish a follow up appointment with a primary care physician, provided medication supplies,
clothes, food, shelter or location preference and transportation within 30 miles of the hospital.
There can be legal action toward the hospital and medical healthcare team. Therefore, the pilot
program can alleviate these chronically homeless patients with mental illnesses and chronic
diseases that use visit the hospital for social healthcare. This program can have success which
supports and applies to SB 1152.
The Transitions to Health is to open the hospital and community partnership service
providers to impact a new way of thinking and the visions is to end homeless patients using the
hospitals for shelters. There will be better outcomes for reducing the homeless populations and
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those who care about solving the homeless crisis. The data collected with demonstrate pre and
post reports of numbers reduced hospital homeless patient visits and overnight days. Identify at
the hospital for temporary housed into room and board and referred to the HUD for long term
affordable housing recipient. The outcomes are cost savings across service agencies at the local,
state and federal levels, and taxpayers. These reports will also be submitted every six months to
all stakeholders, funders and Homeless Management Information System to show an impact of
the success by the Transitions to Health. This is innovative because hospitals do not have a
healthcare care team pathways to inpatient and outpatient for the chronic homeless initiatives
unite hospitals and HUD..

Area IV. Project Structure, Methodology, and Action Components
Prototype/market analysis
Transitions to Health is designed for individual chronically homeless patients- both adult
men and women. The hospital case management and healthcare staff will make the referral. The
patient will be interviewed at bedside if receptive to consent for services. The patients will be
placed in a room and board upon discharge from the hospital. The response team will make
outpatient visits and provide iPads for ongoing telehealth appointments treatment. This way the
individuals can receive telehealth primacy care medical assessments and telehealth psychiatry
assessments for coping, therapy and ongoing medical treatment. The target populations are to
reduce the homelessness in Fresno, CA for the chronically homeless patients with mental
illnesses and chronic diseases who frequently visit the hospitals for medical shelter. Which are
costing taxpayers approximately million per year for 50 chronic homeless patients. However, a
permanent long-term government housing solution cost approximate $13,000 to $25,000 per year
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(Kertesz, et al. 2016) Hospital case management and medical teams are challenged with time
consuming and complex cases which are the chronically homeless patients who use the hospital
beds for medical shelter. The Transitions to Health team will conduct acute care to the homeless
patient in a hospital visits and street medicine. This is the combination of the broader of both
healthcare factors for taking the first step in treatment which homeless is a social determinant of
health.
For example, Fresno, CA Community Regional Medical Center (CRMC) hospitals case
management department discharge planning team are RN, MSW/LCSW and BSW/BHS. The
case management teams will identify the homeless patients. The role of the team is for the social
worker to assess a safe discharge plan. Homeless patients with no need for medical follow up
and no income can be referred to the overnight shelters in Fresno County. These include Fresno
Rescue Mission, Rescue The Children, Poverello House, and Naomi’s House. In addition, there
are three new shelters as of September 2019- Turning Point, Golden State Triage Center and The
Hacienda Hotel. The Fresno room and boards are private homes which usually can cost from
$550.00 per month or more depending on the services such as provide three meals and 24/7
supervision and minimal support.
CRMC and other local hospitals are contracted with the Fresno Rescue Mission medical
respite program for a safe homeless patient discharge program with short term medical needs.
The medical respite program also requires follow up by Home Health Services. There are about
ten medical respite beds male beds and 12 female beds. The homeless patients who are at a lower
level of medical needs can stay at the medical respite from one week to up to six weeks. CRMC
uses medical respite as a system for the homeless patients safe discharge process. Lastly, when
homeless patients are discharged from the hospital and if they do not meet the medical respite
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care criteria it is a highly probability these same homeless patients will return to the hospital
within one day or be readmitted within 30 days and the hospital pays for the hospital visit.
Project Methods for Implementation
Transitions to Health will use the framework as it relates to implementation focusing on
services system, organization, research and stakeholders. Implementation strategies refers to
procedures used to in the implementations, adoptions, sustaining and scaling during the
intervention. These strategies to have importance impact for to make change. The Exploration
Preparation Implementation and Sustainment (EPIS) model has four inner and outer contexts
defined and analyzed with anticipated barriers and facilitators as well as a systematic table
summary.
To incorporate a framework with evidence base model to this innovative hospital
homeless response program, it will introduce the EPIS model of implementation framework. The
EPIS model incorporate to barriers and facilitator of implementation from an outer context and
inner context. According to Aarons, et al (2018) stated, “In the Exploration phase, a service
system, organization, research group, or other stakeholder(s) consider the emergent or existing
health needs of the patients, clients, or communities and work to identify the best EBP(s) to
address those needs, and subsequently describes whether to adopt the identified EBP” (p.5).
Therefore, the outer context the hospital services line system and organization do not have a plan
of the awareness of the social issues of chronic homeless patients using up hospital beds and
who’s funding for their overnight stays. A systematically sociopolitical they are concerned
because the hospital medical doctors, nurses, social workers and hospital management complain
of the difficulty to safely discharge chronic homeless patients who ill. Therefore, the exploration
phase is overlooked because at this time hospitals are not solving the homeless issues.
Dual Acute Social Healthcare

22
The EPIS framework has also had the contextual levels of outer context systems within
the organizations context. EPIS model has further illustrated the outer context describes the
external environmental factors of implementation of an organization such as sociopolitical policy
and funding (Aaron’s, 2018). An external factor affected California hospital healthcare facilities
new law SB 1152 homeless patient discharge process will be in effect June 2019. The
documentations of services provide to the homeless patients’ medical records will be enforced
before they are safely discharged from the hospital. California hospitals can now start tracking
the homeless patient discharge process as of July 2019. The inner context can be characterized
by the organization leadership to assess additional resources practices for staff protocols to focus
on the safe discharge plan for the homeless (Aarons et al, 2018). The innovation is for the
internal individual adopter to diffuse the hospital by piloting a new program for intervention and
prevention to housing chronically homeless patients who visit the hospital frequently and the
long run saving taxpayer’s money, more available hospital beds for the domicile patients and
save lives. The facilitators will be an individual adopter who will guide the awareness and start a
plan for intervention and to solve the hospital homeless issues such as if the CEO request of his
homeless program to be created.
The next stages of EPIS model is the preparation phase to target the goal and objectives
and identify potential barriers and facilitators. Preparation on the inner context the hospitals
organizational culture and climate to accept the homeless patient’s needs affordable housing and
access to care (Aarons, 2018). The hospital historically focuses on medical treatment symptoms
management but not focus on follow up social issues to healthcare homeless after discharged
from a hospital. Hospitals don’t diagnose homelessness to medical follow up on their social
determinant of health. The outer context could have funding barriers if those in the political
Dual Acute Social Healthcare

23
spectrum refuse to grant the funding source homeless patients in Room and Boards, until the
Housing Authority of Fresno can provide the vouchers for long term affordable housing. Lastly,
a networking facilitator will be required to network with stakeholders such as the City of Fresno,
Mayor, Fresno/Madera Continuum of Care and the government homeless funding sources and
fundraising.
The next stage in EPIS is the implementation phase, which implies to a solution of best
practices and monitoring. Therefore, the outer contact will apply to an intervention developer
engagement such as the quasi-experimental tool to track the homeless patients for five years, pre
and post hospital visits since housed with intervention community services such as mental health
and drug addiction services. The barriers could be confidentiality and HIPPA regulations for care
and or access to medical records.
The inner context is the fiscal viability such as to run reports within the organizations,
monthly, and full reports every six months, for five years annually and provide stats on the fiscal
viability to audit findings cost savings pre and post hospital visits. Since the homeless patient
was housed in the homeless pilot program their hospital visits reduced and quality of health care
life has improved. These implementations factors will demonstrate savings revenue for the
hospitals and taxpayers.
By housing the homeless patients in a transitional living housing program for two years
until the Fresno Housing Authority grants the vouchers for long term affordable housing for
these 50 homeless patients. The barriers could be if no housing contracts are established by the
Fresno Housing Authority and do not provide the 50 vouchers in two years. The end results,
more funding will be needed to continue funding for the room and boards living arrangement for
the homeless patients. Data illustrates when a homeless patient is housed their hospital visits
Dual Acute Social Healthcare

24
reduce significant. Which is important to provide data to the hospital board of directors, CEOs,
the Housing Authority, City Council and also publish journal with the evidence base practice
implementation cost savings.
Lastly, on the EPIS model sustainment according to Aarons et al (2018) stated, “In the
Sustainment phase, the outer and inner context structures, processes, and supports are ongoing to
that the EBP continue to be delivered, with adaptation as necessary, to realize the resulting
public health impact of the implemented EBP” (p.5). This program can have success with the
sustainment phase of application if the social determinants of health for the chronically homeless
patients with chronic diseases. This programs outer context as the referral process for selecting
the top 50 homeless patients who visit the hospital frequently. The funding sources must be a key
measure for the first two years to be housed until the Fresno Housing Authority grant the
vouchers for long term permanent housing. Additional funding sources for research and publish
journals every year for five years. Next, the policies can help with the sustainment facilitators
such as new law in California SB 1152 Homeless patients discharge process effective June 2019.
These Federal and State initiatives can help sustain the program and keep it in
Financial Plans
The financial plan will be funded by the Fresno/Madera Continuum of Care New Project
Tier I Grant for $900,000.00 for five years then the area hospital that adopts the Transitions to
Health will provide ongoing funding within the hospital foundations. Lastly, the HUD vouchers
will fund for the long term affordable permanent housing with long term services. A pitch deck
proposal for funding presentations to areas hospitals see Appendix I: Pitch deck proposal for
funding marketing presentations on the Transitions to Health. The plan is to market the Fresno
area hospitals CEO’s, hospital program developments and hospital foundations to propose the
Dual Acute Social Healthcare

25
Transitions to Health. In Appendix II: Financial Plan item line-item budget. Line-Item Budget
Transition to Health. The Fresno/Madera Continuum of Care New Project Tier I Grand will fund
the Transitions to Health for up to 5 years. For five years five evidence-based cost savings
hospital and taxpayer from the Transitions to Health. The grand with fund staff, University
interns, direct cost, trainings, operations, office supplies, equipment, communications,
technology, meetings and transportation. The indirect cost are the Room and Boards, housing
options and the Continuum of Care Grants funds the room and boards grants 50 HUD vouchers
for reduce house cost contracts for permanent long-term housing and supportive services.
Project Impact Logic Model
Transitions to Health will take a new multidisciplinary approach by developing a five-
year pilot program. A dual referral system to end homelessness with acute hospital and street
medicine, transitional living with homeless services and contract HUD Permanent Supportive
Housing (PSH) vouchers. See appendix III: logic model as the breakdown of inputs, activities,
outputs, outcomes and impact accomplishments benefits for change. The inputs are the hospital
specialist homeless response team NP/PA, LCSW, and BSW intervention of acute care for the
homeless inpatient identified and receptive for voluntary Transitions to Health Services. The
team receives referrals by the hospital case management multidisciplinary health team. The
homeless patients acute care follow up upon a hospital discharge is cost savings for the hospital
frequent visits at the Room and Board placement for the patients. Pre and post hospital
readmissions reports monthly stats logged.
Activities are the pathways to independent livings program with additional services of In
Home Supportive Services (IHSS). An iPad is provided to each patient at their room and board
for telemedicine, primary care, medications prescriptions deliver and drug Medi-Cal and
Dual Acute Social Healthcare

26
psychiatry therapy. Other activities HUD vouchers from HUD for long term housing and hospital
comply with SB 1152 hospital homeless discharge process. The outputs are to decrease hospital
homeless patient’s length of stay and using the hospitals for medical shelters. More hospital
medical beds available for domicile patients with emergency medical treatment needs. The
outcomes are to reduce the 30 days hospitals re-admissions and reduce the cycle of homeless
patients cycling into hospitals. Data will be collected of the pre and post hospital reduction visits
and the cost savings from hospital and admissions visits. The data will be published in evidence
base practice journals of medicine and NASW. The stats will demonstrate the significant impact
accomplishments benefits and change by developing dual hospital homeless and HUD initiatives.
Accomplishments of equal opportunities for anyone experiencing chronic homelessness. Reduce
hospital social worker and case management burn out and turnover. Provide a better quality of
life for healthcare for the homeless and change the social determinants of health.

Stakeholder Involvement
The Transitions to Health will have external stakeholders board of directors to oversee
the community engagements operations. Stakeholders can consist of landlords from the room
and boards as well as post homeless focus groups who would provide client services delivery
evaluations and feedback from their medical regimen status based on program services. In
addition, the internal stakeholders that will be affected by Transitions to Health are the hospitals
homeless response team by the NP//PA, LCSW and BSW with their specialty in the health for
the homeless healthcare comprehensive case management. The team will be affected by policy
changes on their case management the post homeless patients at the hospital, medical home, out-
Dual Acute Social Healthcare

27
patient scattered bridge line transitional of 20 room and boards housing contracted by the
hospitals.
Communications Products Plans
The purpose of the innovation is to request for grant funding from the Fresno/Madera
Continuum of Care Homeless Federal funding request of $900,000.00 for the first year to
establish a new prototype hospital homeless response team in the area of Fresno, CA. This
innovation supports the hospital case management healthcare team who specialize in acute
medical care and are taking a comprehensive combination of these dual elements’ inpatient
hospital and out-patient, looking both acute safe healthcare systems approach. There are
currently no collaboration for readiness of this state-of-the-art healthcare homeless delivery
system. See the Appendix IV Timeline for details on the action plan for success. Research has
been conducted and the next step is implementation for funding from the Continuum of Care.
Once completed, conduct the pitch deck proposal for grant funding after the five years for a
hospital to adopt the program and fund it ongoing.
Ethical Concerns and Unintended Consequences
To ensure that Transitions to Health will have success from its multiple protocols that do
not align within an inpatient hospital systems and outpatient community system. Hospitals have
liability HIPPA laws to protect all patients’ medical rights. Transitions to Health response team
will keep all medical records confidential and ensue no HIPPA laws are not violated.
This can cause stigmas to arise and view social change within social norms of society.
The services offered can be declined by the homeless patients with serious out of control mental
illness. The public have stigmas toward the homeless with mental illness who do not want help
Dual Acute Social Healthcare

28
to change and continue their same behaviors that led them to be homeless. The healthcare system
have a duty to provide medical services to all people of diversity and inclusive backgrounds.

Area V: Conclusion, Actions, and Implications
Homeless people with mental illnesses and chronic diseases that use hospitals for medical
shelter are on the rise. Every day in the United States over 500,000 people are homeless largely
driven with the increase of mental illnesses and chronic diseases (Tobey, 2017). Stigmas
associate with people experiencing homelessness are that they are lazy and have mental illnesses.
They are lacking representation during their homeless crisis, which silences the chronic homeless
patients with mental illnesses. The homeless people with mental illnesses use the hospitals for a
safe heaven which are costing hospitals a burden and are using up the capacity of hospital beds.
Hospitals are not designed to house homeless patients with mental illnesses and chronic diseases.
Homelessness is a social determinant of health. Therefore, ending homelessness within hospitals
interventions is a grand challenge and it takes united community agencies to reduce or end
homelessness.
Transitions to Health can save hospitals and taxpayers millions of financial burdens.
Hospitals can use this prototype and can impact implementation for social change and social
good. This is an innovative combination of the broader of both healthcare factors for taking the
first step in treatment chronic homeless patients with mental illness and chronic diseases who are
vulnerable. The aim is that Transitions to Health can ameliorate hospitals in the Central
California/San Joaquin Valley dual acute hospital homeless response team for social healthcare
through housing program. The innovational is the hospital pathways for in-patient and out-
patient continuum of care collaborative initiatives for the chronically homeless patients with
Dual Acute Social Healthcare

29
mental illnesses and chronic diseases to preserve cost savings, better quality of life and liability
by California law SB 1152 hospital homeless discharge process. The prevention of acute hospital
medical staff, nurses and social worker burn out from the complex homeless patients discharge
plans. Additionally, the initiative will demonstrate evidence-based artificial intelligence
innovative social work practice by publishing journals of medicine on Transitions to Health
interventions. The practice is for other hospitals and healthcare facilities departments to
implement different lens of social systems prospective for the social healthcare for the chronic
homeless patients and save 50 homeless lives at a time.
Transitions to Health team consist of PA/NP, RN, LCSW and BSW. This team will
measure and ensure better quality of healthcare for the post homeless patients. The team will
achieve ongoing visits at the room and board placements, for medications refills, home health
education, mental health stabilization, social and emotional supportive resource. The innovations
is that the patients will receive iPads to conduct telehealth medicine with virtual consults with
their primary care medical doctor and psychiatrist for ongoing consultations. The use of
telehealth consultations by iPads are a key component to the intervention. There are limitations
and risks are that the iPads can be lost, stolen or sold or HIPPA consents. Other risks factors
hospitals have concerns of liability by practicing outside the traditional hospital practices. A third
ethical consideration homeless patients participating in the study for five years.
The cost saving solutions are to look in changing and improving the behavioral and
mental health symptoms to be able to comply with their medical regimen and better quality of
life. The Transitions to Health dual hospital response team and community homeless response
can intercept a hospital emergency department by refilling medications. The relevant overview
on hospital homeless discharge models that most outcomes the coordinators provided various
Dual Acute Social Healthcare

30
outpatient services but also provided hospital staff educational protocols for discharging
homeless patients. Other outcomes on the models used it increased networking, care
coordination, decrease ED and re-admissions to hospitals, reduced the length of stay and hospital
care (Coleman, 2013).
The goal within five years is to create a new system by collecting, maintaining and
analyzing the data of the pre and post hospital visits since the initial Transitions to Health. Pre-
homeless and post-homeless hospital visits cost savings as stabilizing the patient’s mental health
illnesses and chronic health diseases. By publishing five evidence base research articles on
outcomes of the significant changes with hospitals and communities working together to and see
systems from different lenses. The goal is to market the hospitals in the Fresno areas and adopt
Transitions to Health for implementation. The funding source distributed by the United States
Interagency Council on Homelessness to the Fresno/Madera Continuum of Care homeless
funding source public applications process.
There is hope for the chronic homeless patients with mental illness and chronic diseases
in the San Joaquin Valley and Fresno California and the hospitals. It is time to rescue the
oppressed and most vulnerable. It is important to advocate for the homeless with mental illness
with chronic diseases and stabilize their medical regimen. Transitions to Health can implement
social change for social good and eradicate the wicket chronic homeless patients using the
hospital for shelters. It is time to make a difference for their quality of life for all those who are
experiencing homelessness with mental illness and chronic diseases.

Dual Acute Social Healthcare

31

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Appendix I: Pitch Deck Proposal for Grant Transitions to Health

Appendix II: Line-Item Budget

Line-Item Budget: Transition to
Health Hospital Homeless Response
Team
5 Year Pilot Program
YR 2020 YR 2021 YR2022 YR023 YR 2024 Fresno/Madera
Continuum of
Care/Grants
100% OF TOTAL
FUNDING
I. Staff 1- MSW/NP/BSW $200,000 $200,000 $200,000 $200,000 $200,000 $900,000
II. Other Direct Costs
Trainings

1,000

1,000

1,000

1,000

1,000

0
A. Office Operations 10,000 10,000 10,000 10,000 10,000 0
B. Communications 1,000 1,000 1,000 1,000 1,000 0
C. Meetings 1,000 1,000 1,000 1,000 1,000 0
D. Transportation 1,000 1,000 1,000 1,000 1,000 0

Subtotal 214,000 214,000 214,000 214,000 214,000 0
III. Indirect Costs 1,000 1,000 1,000 1,000 1,000 0
IV. Equipment/Research 5,000 5,000 5,000 5,000 5,000 0
V. Contract Housing Options 480,000 480,000 480,000 480,000 480,000 0

Total $590,000 $590,000 $590,000 $590,000 $590,000 $900,000

50 Homeless Patients / HUD New Grand Tier 1 Continuums of care granted reduce house contract cost

Dual Acute Social Healthcare

39

Appendix III: Transitions to Health Dual Acute Homeless Response Team Social Healthcare
Through Housing Logic Model
INPUTS ACTIVITIES OUTPUTS OUTCOME IMPACT THEN WE
ACCOMPLISHED A
BENEFIT/CHANGE
Dual Acute Social Healthcare

40
Funding
$900,000
Project
Team
1 MSW,
RNP/PA and
BSW
Hospital
Homeless
Response Teams
Dual
inpatient &
outpatient
Street
Medicine

Contract
with
landlords,
Housing,
Room and
Boards

Hospital
Contract
HUD
50 patients
Acute Intensive
Case
Management
Services for
homeless
patients,

Assessments
Pre and
Post
participation

Highest cost
hospital and
highest visits,
50 homeless
patients.

Pathways ILP
placement upon
hospital
discharge

Five-year pilot
program.
Homeless focus
support groups,
home
telemedicine
psychiatry
mental
health
counseling,
home visit with
drug Medi-Cal
telehealth
addictions
services,
primary care,
jobs,
re-connect
within their
community.

Reduce
homeless
patient’s
hospital visits,

More medical
beds
for domicile
patients
with emergency
medical
treatment,
reduced
taxpayers.

Fresno Housing
Authority,
Annual
Continuum of
Care grant
writing,
comply with

SB 1152
homeless
hospital
discharge
process
Decrease hospital
length
of stay
for homeless patients
at
hospitals.
Reduce 30-day
re-admissions.

Reduce the cycle of
homeless
patients with
chronic illnesses
cycling
into
hospitals.

Pre and Post reports of
cost saving from
reducing
hospitals ED/AD visits.

Publish research EBP
journals

Healthier communities

Connect the
pathways dual
hospitals homeless
inpatients and
outpatient to
long term
affordable housing.

Equal
opportunities for
anyone
experiencing
chronic
homelessness.

Hospitals
reduce homeless
patient
senses

City and County
of Fresno reduce
homelessness,

Research findings
saving taxpayers

Reduced
case management
burn out and
turnover.

Provide better
quality of
healthcare and
save homeless lives.

Changing Social
Determinants of
Health
Dual Acute Social Healthcare

41

Appendix IV. Timeline
Transit
ions to
Health
Social
Healthc
are
Throug
h
Housin
g 2019 2020
Tasks
Octo
ber
Nove
mber
Dece
mber
Janua
ry
Febr
uary
Ma
rch
April May June
Phase 1
-
Presenta
tion on
new
dual
health
homeles
s
program
Rese
arch

Hospi
tals

Phase 2
- Solicit
&
Evaluat
e
Interven
tion
Proposa
ls
Protype

HUD

Phase 3
-
Hospital
Presenta
tions

Pilot

Contra
ct
transiti
onal
housin
g

Dual Acute Social Healthcare

42
Phase 4
-
Summar
y
Exercis
e /
Lessons
Learned
/ Next
Steps

Grant
Fundin
g
Contin
uum of
care

Stakeho
lders

Abstract (if available)

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University of Southern California Dissertations and Theses

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Asset Metadata

Creator Manriquez, Edgar Alfredo (author)

Core Title Transitions to health a cost savings impact new pilot prototype dual acute hospital homeless response team social healthcare through housing...

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Degree Conferral Date 2021-12

Publication Date 12/17/2021

Defense Date 11/22/2019

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag board and care,healthcare social workers,homeless,Homelessness,Hospitals,House,housed,houseless,OAI-PMH Harvest,room and boards

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Enrile, Annalisa (committee chair)

Creator Email eamanriq@usc.edu,eamanriquez08@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC18652801

Unique identifier UC18652801

Legacy Identifier etd-ManriquezE-10304

Document Type Capstone project

Format application/pdf (imt)

Rights Manriquez, Edgar Alfredo

Type texts

Source 20211221-wayne-usctheses-batch-905-nissen (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright. The original signature page accompanying the original submission of the work to the USC Libraries is retained by the USC Libraries and a copy of it may be obtained by authorized requesters contacting the repository e-mail address given.

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Repository Email cisadmin@lib.usc.edu