Winter 2025 pilot awardees report final project outcomes

Investigators
Anna Ratzliff, Department of Psychiatry & Behavioral Sciences
Elizabeth Austin, Department of Health Systems and Population Health
Brittany Blanchard, Department of Psychiatry & Behavioral Sciences

Project summary
It is unknown whether the Collaborative Care Model (CoCM) reaches underserved populations equitably, but current data suggests that variable CoCM fidelity likely contributes to care disparities. Assessing CoCM fidelity is critical for equitable care, quality improvement and research, yet no measure of CoCM fidelity exists. For this Population Health Initiative Tier 2 project, our goal was to refine and evaluate the performance of a Collaborative Care fidelity tool. Initial item content was based on model components developed by the AIMS Center, which was then refined via a modified Delphi process with clinicians and academic experts. Our specific aims were to 1) develop item(s) to assess healthcare equity in CoCM delivery, 2) evaluate the psychometric properties of the CoCM Checklist and 3) identify CoCM components associated with patient improvement using clinical registry data.

Aim 1. Qualitative interviews were conducted to understand what equity in CoCM meant to clinicians, and responses indicated equitable access and individualized care. Several clinicians indicated that CoCM was a form of equitable care. Seven equity items were drafted by a multidisciplinary team, followed by cognitive interviews with clinicians. Items were perceived as interpretable and relevant. Items spanned equity in screening, access, treatment tailoring, patient barriers to care, ability to assess program equity and implementation efforts to address equity gaps.

Aim 2. The 24 fidelity items and 7 equity items were administered via REDCap survey to clinicians (combined n = 68), and retest administration occurred within 1 week (n = 56). Results indicated range restriction, with most participants endorsing “almost always” for many items. Most variation was observed for items that asked about team members’ behaviors (e.g., psychiatric consultant, leadership). The intraclass correlation coefficient (ICC) was good (ICC > .75) for only 5 of 24 fidelity items and 2 of the 7 equity items. However, ICC may be artificially low due to range restriction, so we will conduct sensitivity analyses using appropriate tests (e.g., weighted kappa; spearman’s rho). Further, over 10% endorsement of improbable responses (e.g., daily caseload reviews with psychiatric consultants) indicates inaccurate responding. This could be due to multiple factors (e.g., social desirability bias, response set bias, item misinterpretation) which we could not discern with our design. However, results indicate that self-report alone is likely insufficient to assess many components of CoCM fidelity. Data from qualitative interviews were further analyzed using Rapid Assessment Process to better understand variation in practice fidelity and opportunities for fidelity checklist enhancement.

Aim 3. We are currently merging registry and electronic health record data from both samples to maximize power for Aim 3 analyses to evaluate whether specific CoCM components predict patient improvement and evaluate whether specific equity gaps exist in current CoCM programs. This large clinical dataset will allow us to explore whether specific components predict patient improvement and inform optimization of CoCM delivery. Quantitative results will be triangulated with qualitative interview data exploring CoCM clinician perspectives on essential CoCM components.

Additional deliverables. As part of our semi-structured interviews, we asked participants to describe impacts of recent healthcare funding changes on their clinics. Qualitative analysis of 19 interview transcripts representing 24 unique clinics indicated less accessible and affordable mental health services for patients, increased acuity of patient needs for mental health and social services, increased distress, burnout and staffing shortages and increased fragility of organizational financing and support structures necessary to sustain integrated care.

Investigators
Barclay Stewart, Department of Surgery
Megan Moore, School of Social Work
Tony Machacha, King County Regional Homelessness Authority
Caitlin Orton, Department of Surgery

Project summary
The aims for the project Piloting the Equity in Injury Prevention Toolkit with People Who are Unhoused:

Aim 1: Pilot the EQUIP Toolkit with people experiencing homelessness (PEH) living within high burn injury risk areas of Seattle; and

Aim 2: Assess the EQUIP Toolkit implementation using the RE-AIM Framework (e.g., reach, effectiveness, adoption, implementation, maintenance) to support the future large-scale dissemination within King County.

We partnered with four outreach specialists from a large, local outreach organization to implement EQUIP (consumer-tested injury prevention education, PEH preferred fire extinguishing equipment and dissemination strategies). These outreach specialists integrated EQUIP into their routine outreach activities within four high fire and burn and cold injury risk areas of Seattle. They each completed online surveys every three weeks along with a post-implementation interview to capture reach, adoption and implementation outcomes (i.e., EQUIP acceptability, feasibility of EQUIP integration, fidelity to protocols, consistency of delivery, required adaptations). Data were also collected from PEH through the completion of key informant interviews at the start and end of project implementation (total of 62 interviews). These interviews also captured reach and implementation outcomes (i.e., required adaptations, use of EQUIP, confidence with using EQUIP) as well as provided additional information to inform the future scaling of EQUIP (i.e., gaps in education, future collaborators). Researcher notes tracked the cost of implementation, number and type of supplies provided and any feedback shared outside of the interviews and surveys.

Overall we found disseminating EQUIP during routine outreach activities to be acceptable and feasible. Outreach specialists reported a desire to continue disseminating EQUIP after the pilot had concluded. Their barriers to adoption were level of comfort with talking about burn and cold injury prevention and time limitations as other responsibilities and tasks arose. Outreach specialists were able to reach people living outside, in tents, vehicles and RVs, however reach was limited to those who spoke English. PEH confirmed the acceptability of EQUIP and highlighted that distribution through outreach greatly reduced the barriers to prevention education and equipment. PEH stored the fire extinguishing equipment in accessible areas in their tents or in their campsites so that they and those around them could easily access if needed. The results from this pilot will inform the scaling of EQUIP: 1) integrating EQUIP into King County Regional Homelessness Authority’s tiered severe weather programing, 2) collaborating with additional community partners to include additional outreach teams, street medicine, food banks, shelters, day centers, clinics and needle exchanges and 3) scaling EQUIP across King County.

Investigators
Brittany St John, Department of Rehabilitation Medicine
Tanya St. John, Department of Speech & Hearing Sciences
Yev Veverka, Institute on Human Development & Disability
Sara Kover, Department of Speech & Hearing Sciences
Jessica Greenson, Institute on Human Development & Disability
Nicole Bergstrom, Institute on Human Development & Disability
Sarah Lemke, Institute on Human Development & Disability
Kelleen Dunley, Institute on Human Development & Disability

Project summary
The purpose of this project was to pilot the co-developed First Bite program for families of autistic children awaiting feeding intervention services at the University of Washington Autism Center (UWAC). First Bite is a 10-week caregiver education and consultation program to address feeding challenges for autistic children. Primary outcomes measured in this study include achievement of child goals and reduction of need for direct feeding services. Secondary outcomes evaluated were feasibility, acceptability and changes in caregiver feeding knowledge and efficacy post program.

First Bite was piloted with 14 families on the waitlist for feeding intervention at the UW Autism Center. Results of the pilot study suggest high rates of acceptability and high feasibility for delivery to families awaiting services. In addition, families demonstrated significant progress toward feeding goals and improvements in caregiver knowledge and feeding efficacy, suggesting the program provides clinically impactful feeding supports.

Investigators
Avanti Adhia, ScD, Department of Child, Family, and Population Health Nursing
Heather D. Hill, Daniel J. Evans School of Public Policy & Governance
Krista Neumann, Department of Pediatrics
Ann Richey, Department of Epidemiology

Project summary
Domestic violence (DV) is prevalent and has substantial individual, community and societal costs and consequences. State “safe leave” policies (including paid leave), which provide survivors with time off to address legal, medical or safety issues related to DV, serve as one potential strategy to address DV at the outer layers of the social ecology. The overall goal of this PHI Tier 2 project was to provide preliminary evidence about the potential effectiveness and implementation of paid leave programs for DV. Specifically, we completed three aims:

Aim 1: We conducted an in-depth policy landscape analysis of state safe leave programs in the context of DV. We systematically reviewed summary reports, policy documents and state legislature websites for all 50 states and the District of Columbia to examine three state policy tools that provide safe leave—paid family and medical leave, sick leave and victim leave—and their key dimensions. We organized these data to descriptively analyze policy features. We published a peer-reviewed Current Issues article in the American Journal of Preventive Medicine in March 2026 titled “State Safe Leave Policies to Address Domestic Violence” based on these findings.

Aim 2: We used data from CDC’s Pregnancy Risk Assessment Monitoring System (PRAMS) to examine the association between state paid family and medical leave programs and DV during pregnancy. Using data from 2000 to 2022, we employed a quasi-experimental difference-in-differences design. We found that state paid family and medical leave program adoption was associated with modest reductions in self-reported DV during pregnancy, with larger estimated effects observed five to eight years after implementation. A manuscript with these findings is under review. Co-I Neumann also presented findings at the Society for Epidemiologic Research Annual Meeting in June 2026 in a session titled “Violence: Context, Disparities, and Consequences.” Findings will also be presented at the Association for Public Policy Analysis and Management Fall Research Conference in November 2026.

Aim 3: We explored the use of paid leave for DV in two states with different paid leave program structures—Washington and Oregon. We interviewed a total of 25 state paid leave staff and service providers (e.g., advocates, legal providers) about their knowledge regarding paid leave being used for reasons related to DV, benefits or barriers to using paid leave for these reasons and recommendations to improve access for workers. Qualitative analyses showed that paid leave can be a mechanism for survivor safety, recovery and employment stability; however, there are some misalignments between the paid leave program design and survivors’ complex realities. Our interviews highlighted barriers to accessing and using paid leave in the context of DV, which included limited awareness, structural eligibility constraints, administrative burdens and challenges with program delivery, confidentiality and navigation. To increase support for survivors, state paid leave staff and service providers suggested adding DV as a qualifying event for Washington’s program, broadening the range of individuals authorized to certify leave, strengthening confidentiality protections and expanding training and outreach. This qualitative data collection provided rich insights into paid leave that complement analyses in Aims 1 and 2. A manuscript is in preparation, and findings will be presented at the Association for Public Policy Analysis and Management Fall Research Conference in November 2026.

A portion of the funding for this award came via a partnership with the UW Office of Global Affairs, which seeks to enhance the UW’s global engagement and reach.

Investigators
Mehmet Kurt, Department of Mechanical Engineering (and by courtesy, Bioengineering and Radiology)
Jacob Ruzevick, Department of Neurosurgery
Udunna Anazodo, McGill University and Crestview Radiology Ltd., Lagos, Nigeria
Maruf Adewole, Medical Artificial Intelligence Laboratory (MAI Lab), Crestview Radiology Ltd., Lagos, Nigeria

Project summary
The goal of this project was to develop and validate equitable artificial intelligence methods for ischemic stroke diagnosis that can remain useful in settings where MRI is limited and CT-based imaging is the most practical acute-care option. The work focused on improving stroke lesion segmentation from noncontrast CT, CT angiography and CT perfusion by incorporating clinically informed image preprocessing, validating the approach against MRI-derived lesion labels and building international training and data partnerships that can support future evaluation in underrepresented populations and resource-constrained clinical environments.

A major technical outcome was a clinically informed preprocessing pipeline that uses brain extraction, targeted intensity windowing and vessel-aware CTA information before nnU-Net segmentation. In the attached study, the approach increased mean Dice score from 0.162 to 0.224 across ten folds, a 38.4% relative improvement over baseline nnU-Net preprocessing. Replacing raw CTA with binary vessel segmentations produced a further 21% mean improvement across five folds. The best model was submitted to the ISLES’24 challenge and placed first overall, providing blinded external validation of the core approach.

The project also established a stronger translational dataset base. We curated 160 paired CT-MRI stroke datasets from Harborview Medical Center in collaboration with the Stroke and Applied Neuroscience Center. These paired studies will allow direct MRI-referenced evaluation of CT-based lesion prediction in a real clinical population. In parallel, ethics and regulatory submissions were initiated to support acquisition of stroke lesion datasets from multiple Sub-Saharan African countries, including Uganda and Nigeria. Ethics/IRB application fees associated with establishing these international cohorts were supported by the grant, and data acquisition and curation are now being organized with partner sites.

Capacity building was an integral part of the project. PHI funds helped sponsor three SPARK Academy trainees to travel to MICCAI 2025 and participate in the broader MIRASOL community focused on medical image computing in resource-constrained settings. The project’s stroke-related SPARK mentorship also included T. Musah, P. E. Adjei and K. O. Otoo, whose work addressed automated ischemic stroke lesion segmentation from non-contrast CT. Juampablo Heras Rivera and Dr. Kurt provided mentorship around stroke segmentation, clinically meaningful preprocessing, model evaluation and the challenges of building robust AI for settings with limited imaging and compute resources.

Together, these activities moved the project from proof-of-concept algorithm development toward multisite validation and sustainable global collaboration. The technical results show that relatively simple, clinically motivated processing can materially improve CT-based stroke segmentation, while the training and international partnership activities have created a pathway to test whether these gains generalize to populations and clinical environments that remain underrepresented in current medical AI datasets.

Investigators

Lesley Steinman Department of Health Systems & Population Health
Najma Mohamed, Neighborhood House
Jacob Bentley, Department of Rehabilitation Medicine
Tricia Aung, Department of Human Centered Design & Engineering
Roberto Orellana, School of Social Work
KeliAnne Hara-Hubbard, Department of Health Systems & Population Health
Farhiya Osman, Neighborhood House

Project summary
Our goal was to evaluate whether and how adapted Problem Management Plus (PM+) worked for social service providers and Somali clients. We trained CBO providers in PM+ and assessed PM+ impact and delivery. We also honed methods for CBO-engaged mental health research.

The project trained five social service providers in PM+ and delivered the five-week intervention to 11 Somali clients. Participants demonstrated improvements in well-being, functioning and PTSD symptoms, with 10 of 11 participants improving their PSYCHLOPS scores by an average of 35%, WHO-5 well-being scores increasing by 24.6% and PCL-5 PTSD scores decreasing by 48%. Interview and diary data suggested that adaptations integrating Islamic prayers and prophet stories were acceptable, appropriate, usable and feasible. Participants reported using PM+ skills, especially slow breathing and connecting with faith and family, alongside Neighborhood House social services to cope with health challenges, social needs and immigration-related stressors. The project suggests it is possible to re-imagine mental health care that meets people where they are mentally, spiritually and physically.