The HMP aimed to provide new COs with emotional and tangible forms of support during their first year of employment, including peer coaching to prevent early decline in physical fitness and health. The development and implementation of the HMP occurred across five main steps: (1) participatory design focus groups with key stakeholders; (2) adaptation of an existing mentoring handbook and training methods; (3) development of mentor–mentee recruitment criteria and assignment; (4) designing assessment tools; and (5) the initiation of a mentor oversight committee consisting of union leadership, corrections management, and research staff. Correctional employee engagement in the design and implementation process proved to be efficacious in the implementation and adaptation of the program by staff. Support for the HMP remained high as program evaluation efforts continued.Correctional officers (COs) are exposed to a number of occupational stressors, and their health declines early in their job tenure. Interventions designed to prevent early decline in CO health are limited. This article describes the development, implementation, and evaluation of a one-year peer health mentoring program (HMP) guided by Total Worker Health Correctional officers (COs) are front-line employees who work in prisons and jails and are exposed to many unique risks that can jeopardize their safety and well-being ,2,3. COs® initiative of the National Institute for Occupational Safety and Health (NIOSH) recognizes work as a social determinant of health and aims to protect the safety and health of workers, and advance their well-being by creating safer and healthier work [Health Improvement Through Employee Control (HITEC) II, currently in its third phase, was a partnership with the Department of Correction (DOC) in a Northeastern state that was formed to develop, implement, and evaluate interventions intended to improve the health, safety, and well-being of correctional employees ,4. The Tier work . HITEC Iier work . Furtherier work ,2.In a preliminary study of 326 COs conducted in 2008, HITEC research staff found that CO health declines rapidly early in work tenure . DespiteIn the past decade, the public safety sector has applied and recommended peer mentoring to facilitate an easier transition for new recruits on the job ,17. ThroRecognizing the potential decline of CO health during the first years of employment, HITEC II research staff partnered with union leadership, line-level staff, and managers in the DOC in the development, implementation, and initial assessment of a one-year peer-to-peer health mentoring program (HMP) for newly hired COs  using a Total Worker Health participatory approach. The idea of developing a HMP came directly from the three regional union leaders representing line-level staff. Union leaders were concerned about the health of their members and recognized that newly hired COs may be less resistant to on-the-job training and preventative health programs, compared to more tenured staff.The HMP concept can be contrasted with traditional workplace mentoring programs that largely focus on supervisors guiding or enhancing junior employees’ (mentees) personal and career development, where there is a large gap between short-term on-the-job mentoring and later selection for eventual promotion . DespiteThe main goals of the HMP were to help newly hired COs develop positive health behaviors, and to provide them with peer coaching on health topics to prevent early decline in physical fitness and promote healthy eating, stress management, and work–family balance. In this article, we describe the five steps that were used to design and implement the HMP.The HMP was developed in five major steps , as detailed below. The overall process and design of the HMP is depicted in a logic model . The proA core planning group met regularly during the development of the HMP  and consisted of research staff and union presidents for line-level correctional staff and some of their designees. The meetings focused on the development of the mentoring program and review of draft materials. Additionally, a series of participatory design focus groups were organized with correctional officers who potentially could become mentors. The participatory design focus groups were conducted differently than conventional focus groups and were used to inform ongoing design and development of the HMP and associated materials. Summary findings of suggestions from these participatory focus groups were immediately reported back to the core planning group by research staff in order to inform ongoing program design efforts.The following results highlight the process of development and implementation of the HMP, which occurred across the following five main steps:Step 1. Designing the HMP through Participatory Design Focus Groups.In line with PAR techniques, the participatory design focus groups provided the means for engaging DOC staff as equal partners in all aspects of program design and implementation ,26,27. AFocus group participants were chosen based on their tenure and rank at DOC. Specifically, participants had to have at least 5 years on the force and prior experience in training newly hired officers on the job. One participatory design focus group consisted of members of the supervisory staff (captains and lieutenants) and two participatory design focus groups consisted of COs, representing two of the three union locals in the state. Participatory design focus groups met at local union offices; 23 officers and five captains and lieutenants participated.someone to whom one can speak freely, someone who sets a good example, and someone who demonstrates good work quality and good communication skills. Confidence was expressed among all participatory design focus groups that a well-conceived mentor training program could be developed and sustained. They also felt that the training should be jointly designed with the research team, COs, and Training Academy personnel .Participatory Design Focus Group Findings: There were differences between the groups in their recommended weighting of experience and personal qualities of prospective mentors, but there were also noted differences of this weighting among members of each participatory design focus group. For example, some considered interpersonal qualities to be more important than technical skills in prospective mentors. The interpersonal skills identified as significant were as follows: Although all such ideas gathered in the participatory design focus groups were carefully considered, some of the ideas, although desirable, would have faced structural obstacles if implemented. For example, there was a strong desire for all mentor training to occur at the Training Academy, and for mentors to meet each other monthly in order to share the knowledge gained. However, these ideas proved infeasible due to the geographic dispersion of the correctional facilities and staffing limitations for coverage of those who would be meeting. The participatory design focus group members also recommended matching the gender of mentor and mentee because of the specific challenges to women in the male-dominated workforce but this was not always possible. One unforeseen barrier identified by the participatory design focus groups involved the tenure requirement for mentors and how this would affect shift alignment. In the participatory design focus groups, it was contended that to be a mentor, a CO needed at least 7 years of tenure and a disciplinary record that was currently clear. It was argued that mentor/mentee pairs would not need to be limited to working the same hours, and that they could instead work on adjacent shifts and meet at shift change. However, the arrival of the first mentees revealed this was an unworkable plan when it became apparent that most new officers worked the third shift whereas officers with 7 years of tenure worked the first shift. The SWSC offered a solution to this problem, which was to reduce the tenure requirement to 3 years, allowing for more within-shift mentoring to occur. One principle that could not be similarly compromised by the SWSC was the provision that mentor supervision would be handled by line-level COs, rather than supervisory staff. An important participatory design focus group recommendation was that, although supervisory staff could participate in establishing formal mentor selection criteria, the actual selection of mentors needed to fall under the authority of the COs. One remaining concern that needed to be addressed was the possibility that a mentor might be contested by management because of an undisclosed disciplinary action that was pending, or investigation of potential criminal activity that was ongoing. As the program was further developed through participatory design over time, resolutions on such process issues were worked out within labor leadership meetings. A management oversight committee structure that was proposed and eventually adopted was found to be effectively preventive; it had yet to be convened to resolve a labor-management conflict at the time of this writing.Step 2. Adaptation of an Existing Mentoring Handbook and Training.Building on the information generated from the participatory design focus groups, the research team and frontline COs modified an existing career mentoring workbook from the Southern Region of the National Institute of Corrections Academy Division’s Regionalization Project of 2002 . The resThe subsequent training of mentors by HITEC II research staff relied on several approaches tailored to adult learners. A presentation using Microsoft PowerPoint was developed that included both lessons from the Handbook and interactive scenarios and scripts. To accommodate agency stipulations on educational travel and release time, the training session was developed to last 1 to 1.5 h with provision for later in-person follow-up. Training delivery at a centralized facility was not feasible due to the geographic distribution of mentors across 18 facilities. Consequently, training sessions were scheduled at each correctional facility during normally assigned shifts. In addition to the Handbook, mentors received a binder that included the initial goal-setting contract, record keeping forms, and materials for quarterly evaluation of their mentee’s personal development and career goals.Step 3. Mentor–Mentee Recruitment Criteria and Assignment.An important consensus recommendation from earlier participatory design focus groups was that supervisory staff could participate in establishing formal mentor selection criteria and in making mentor recommendations, but that the actual selection of mentors should fall under the authority of the COs. Focus group participants had also recommended that mentor supervision should not be handled by supervisory staff.COs working in the cadets’ destination facilities were first introduced to the HMP and the role of mentors at roll call, a regular event that is held at the start of all shifts. Research staff delivered a short presentation on the purpose of the HMP program, on the desired qualifications for mentorship, and on mentors’ obligations and their expected time commitment. Interested prospective mentors signed up either with research staff, through a confidential channel at onsite locations, or via e-mail. Requirements to become a mentor included having worked as a CO for at least 5 years (later reduced to 3) and having remained in good disciplinary standing with the DOC. Because of the unexpectedly high level of interest on the part of mentor candidates, union leadership regularly reviewed individual qualifications, although rejection was uncommon.To help avoid treatment bias and minimize the effects of a wide range of confounding variables, successive cadet classes were recruited into either the Personalized Follow-up Program (PFP) as the mentored group, or into the Standard Follow-up Program (SFP) as the non-mentored control group. Those in the SFP received conventional on-the-job training (OJT) that all new cadets receive upon transfer to a facility. In the project years 2013–2014, there were five classes matriculating at the Officers’ Training Academy, the inception point for new officers. Three of these classes were assigned to the PFP condition, and two were assigned to the SFP condition. All cadets in each class were invited to participate in the study, as either mentees or controls depending on the inception class, or to decline the invitation without consequence. Those choosing to participate were consented into the study.n = 11).Among 406 eligible cadets in the PFP classes, 183 (45.1%) elected to participate in the study. Thirteen corrections facilities within the state had mentors and mentees in the HMP . Four faParticipants completed the baseline survey and physical assessment. The ratio of mentors to mentees ranged between 1:1 and 1:3. The majority of mentees were male (76.4%), which was representative in this working population of officers. The results from the surveys and physical assessments at baseline and follow-ups are presented in a separate article reporting on the efficacy of the program .Mentees were assigned to facilities after their academy-based orientation and training was completed. Their orientation and training included a brief internship placement at a facility that may have been different from their final (destination) facility. Research staff assigned mentors to each mentee following their graduation from the training academy and being posted at their destination facility. Mentors and mentees working the same shifts were paired to allow and optimize scheduled meetings. Supervisors at the designated facilities provided relief time for these on-site mentor–mentee meetings. Following mentor–mentee assignments, study staff conducted follow-ups, usually one week later, to ensure that initial contact between mentors and mentees had occurred successfully. These and subsequent follow-ups were initiated through reminder e-mails and phone calls with the mentors. Study staff also sent mentors a reminder e-mail that reiterated the importance of the record-keeping process for study integrity. Additionally, study staff visited each facility every three months to conduct a scheduled follow-up with the mentors that included refresher training with review of the existing materials from the initial training. To support further communications and provide technical assistance, there was also ongoing phone and internet access to the study team that was made available throughout this period.Step 4. Health Mentor Program Assessment.n = 183) and in the conventional SFP arm  completed a survey and were offered a brief physical exam on a voluntary basis. Based on the initial follow-up results, and previously existing studies on declining health of COs, it was evident and necessary to evaluate the mentee outcomes after around 3–5 years of employment [At intake and at one-year post-assignment, all participants in both the PFP arm , topics discussed, health goals, perceptions of mentoring, and barriers and facilitators of peer health mentoring. The quality of the mentor–mentee relationship, and the frequency and quality of mentoring, was also assessed with a survey with mentees during their evaluation at the end of the one-year HMP. The aim of the process was to evaluate the quality of relationship overlaps and discrepancies with dual source data.Step 5. Mentoring Oversight Committee.Two different groups, separated by chronology, were charged with oversight of the HMP. In the first 2 years of the program, the major impetus came from regular meetings with the bargaining unit presidents and their representatives. The HMP was one of two major projects generated by HITEC II, and a Study Wide Steering Committee (SWSC) which was in place from 2007, beginning with HITEC I . The SWSPrograms supporting mentor–mentee relationships, based on consensual health-related goals, are relatively novel in the occupational health literature , and rar® principles, which requires an integration of individual health with working conditions and work organization. PAR methods were used to actively engage union leadership, COs, and managers in the design and implementation of Total Worker Health interventions. The presumptive value of incorporating bottom-up workforce knowledge of the stages of adaptation and of pitfalls and barriers was implicit. Another presumption, also consistent with PAR principles, was that correctional employee-driven design and involvement offered a heightened potential for participation, effectiveness, and sustainability [Key to the development of this HMP were the two concepts that define CPH-NEW. These two concepts are PAR methods, based around active participation at the line level in program design and implementation efforts, and adherence to Total Worker Healthnability . Given iSupport for organizational change was maintained through the SWSC. The SWSC provided ongoing program oversight pertaining to allocation of compensated time for training, mentoring, and evaluation, and instructed supervisory staff in program accommodation. As noted, the SWSC had a normalizing function. It assumed the ad hoc introductory work performed by the bargaining unit presidents, the study team, and DOC administration, when the start-up phase was complete. This two-part maturation process grew naturally as the bargaining units pursued initial dominance of design and implementation. It was found that many of the predictions of conflict did not arise, even though the developmental process of the program was largely exclusive of supervisory representation. Whether or not a more direct preliminary action phase is a necessity will likely depend on local, rather than elemental, conditions. However, it is clear that the autonomous contributions of the line workforce, even if temporarily in isolation, are elemental.More than a decade before the HMP, the DOC had introduced a more traditional but concerted mentoring program which was principally top-down in its implementation. It proved to be unsustainable. The HMP offered a different level of engagement in which line-level staff, union leaders, and DOC management worked together in program design and took responsibility for its continuity. The HMP within HITEC II could not have been, however, a purely bottom-up creation. Bargaining unit leadership is largely consumed in contractual affairs, and program management is a learned and selective skill. Moreover, the constraints over aligned scheduling, coverage, and compensation fall outside of bargaining unit jurisdiction. A high level of programmatic autonomy had been negotiated and maintained through the SWSC. Thus, there was always an institutional readiness to address critical barriers and promote engaged activity. Conversely, a purely line officer program is likely to fail because officers change facilities and have insufficient administrative experience and authority to manage a complex program such as the HMP. The ability of administrators and supervisors to flexibly facilitate, rather than direct, within defined parameters, is essential to program success and has required a sophisticated SWSC.Additionally, the HMP was part of a research study requiring the support of HITEC II research staff. HITEC II research staff presented a research design and created a battery of process assessment tools that were vetted through the participatory design focus groups and the SWSC, but which would not have evolved without academic engagement. The goal of the HMP program was to help COs develop and maintain positive health behaviors; to provide COs with peer coaching around physical fitness; to prevent early decline in fitness; and to improve stress management. HITEC II research staff also provided support with training mentors, and baseline and follow-up assessments. Further, research staff created a website for COs with customized health information, in addition to a newsletter that was circulated to various facilities on a quarterly basis. The HITEC II research team has placed its methods in the public domain with the development of a toolkit to guide peer mentoring in correctional workforce , but it Certain adaptations also occurred during program implementation. These included changes to mentor eligibility criteria and supervisor involvement. Initially, eligible mentors were required to have had five years of experience or more on the job. However, it become evident early in the program initiation that interested tenured staff at various facilities were in the process of retirement, which resulted in scheduling problems. To increase the pool of mentors interested in the HMP, the eligibility criteria changed from five to three years’ experience, and even less in some cases. It became clear that highly motivated younger officers were capable of superior performance. As the selection process matured, a more personalized approach to admission replaced rigid guidelines, in some cases. Additionally, younger, less tenured COs were considered to suffer from less burnout and could be expected to provide a more positive and healthy perspective on the job. In later program review, there was a realization that the process of development from engaged mentor to health and well-being advocate and champion was continuous, and in the long run may be constructed along continuous improvement lines.During program design, the supervisors’ role in program implementation was secondary to that of CO leadership. However, during implementation, supervisors played a key role in relieving mentees and mentors from their shift assignments in order for them to meet during work hours. Supervisors also helped recruit mentors, and their possible role in training mentors was also discussed by the SWSC. Ultimately, the supervisors developed their own health promotion programs for supervisors. The traditional division between supervisory and CO staff softened on issues involving health and well-being. The need for changes in program design for continuous improvement played a key role in determining the important function that the SWSC played, especially during implementation of the HMP.It is also important to highlight some of the barriers that were overcome in the process of developing the mentoring program. First, there was a lack of precedent materials for a CO mentoring program. As such, it was necessary to bring all levels of correctional staff to work together in creating and formatting the training materials. Second, COs have limited formal administrative and/or organizational experience in conducting and evaluating programs. This necessitated union leadership and SWSC engagement, in addition to engagement of study staff to design and conduct this participatory program. Third, problems of vetting and confidentiality during the recruitment of mentors were handled with an elaborate mitigation process that was acceptable to the administration and the union, which initially followed the formal administration-union grievance practices. Over time, actual working relations softened these restrictions. Finally, barriers around varying shift and work slots between mentors and mentees were identified and addressed early during the design and implementation of the mentoring program. Considerations over scheduling meeting time and shift alignments of mentors and mentees were discussed at labor management to maximize the amount of time available for mentors and mentees to meet.The HMP benefited from being introduced in the context of the ongoing HITEC II study that included efforts to compare two different means of engaging employees in the participatory design of Total Worker Health interventions . SeparatPromoting employee efficacy in the design of Total Worker Health interventions and programs such as peer health mentoring has important implications for the future of work. With so many internal and external factors impacting present-day workplaces in ways that critically affect health, including COVID-19 and the accelerating pace of technological change, work organizations must not only respond quickly but also in a manner that draws upon expertise from all levels of their organization. Peer-to-peer programs have gained recognition in addressing job satisfaction and worker health ,24,38. HIn the first wave of practice, the preparation proved to be effective because of its reach; nearly 100 mentors were trained, and 269 participants (mentees and controls) signed up and completed baseline testing. Evaluation findings of the HMP are discussed in a separate article within this Special Issue .CO involvement in participatory design efforts can serve to overcome widespread resistance and distrust by COs towards preventive health and work programs. CO involvement could also be effective in alleviating the culture of reluctance by COs to share health and well-being issues of a confidential and personal nature with their peers/DOC staff. In addition to initial planning efforts with union leaders and corrections management, support for the HMP remained high as program evaluation efforts continued, suggesting the likelihood of program sustainability. HMP has shown promise as an intervention within the correctional sector; further evaluation is needed to demonstrate generalizability and adaptability of such programs across state lines and specific correctional settings (such as jails).


An evaluation of the biological activity and cellular responses with respect to bone regeneration indicated a 4-week sustainability on the FN9-10ELP functionalized titanium surface without an initial burst effect. In particular, the adhesion and proliferation of human mesenchymal stem cells (hMSCs) was significantly increased on the FN9-10ELP coated titanium compared to that observed on the non-coated titanium. The FN9-10ELP coated titanium induced osteogenic differentiation such as the alkaline phosphatase (ALP) activity and mineralization activity. In addition, expressions of osteogenesis-related genes such as a collagen type I (Col I), Runt-related transcription factor 2 (RUNX2), osteopontin (OPN), osteocalcin (OCN), bone sialo protein (BSP), and PDZ-binding motif (TAZ) were further increased. Thus, in vitro the FN9-10ELP functionalization titanium not only sustained bioactivity but also induced osteogenic differentiation of hMSCs to improve bone regeneration.Titanium is a biomaterial that meets a number of important requirements, including excellent mechanical and chemical properties, but has low bioactivity. To improve cellular response onto titanium surfaces and hence its osseointegration, the titanium surface was bio-functionalized to mimic an extracellular matrix (ECM)-like microenvironment that positively influences the behavior of stem cells. In this respect, fibronectin and elastin are important components of the ECM that regulate stem cell differentiation by supporting the biological microenvironment. However, each native ECM is unsuitable due to its high production cost and immunogenicity. To overcome these problems, a recombinant chimeric fibronectin type III Implantable materials play an important role in dental and orthopedic procedures . In partIn this respect, the extracellular matrix (ECM) is a biomolecule that provides a microenvironment to induce specific signaling pathways in stem cells, resulting in positive effects ,6. Howev5β1 integrin, which is the most common FN-receptor [5β1 integrin interaction [Fibronectin (FN) is an important component of the ECM and is crucial for the regulation of cellular functions such as cell migration, proliferation, differentiation, and viability –13. As sreceptor . Meanwhieraction . The FNⅢeraction –22.Elastin is an ECM protein found in connective tissues and blood vessels and is important for the mechanical properties of extensible ligaments and organs (like lungs and aorta) . Elastinin vitro conditions and can be isolated from a variety of tissues, including umbilical cord, endometrial polyps, menses blood, bone marrow, and adipose tissue [Human mesenchymal stem cells (hMSCs) have the potential to differentiate into various lineages such as bone, fat, chondrocyte, muscle, neuron, and liver cells under specific e tissue . In parte tissue . Recentle tissue ,37. Nadde tissue . Conserve tissue . Thus, hELP on the adhesion, proliferation, and differentiation of hMSCs on titanium for bone tissue engineering. An additional purpose was to examine FN9-10ELP’s the release kinetics to assess the sustainability of FN9-10ELP from titanium. The results of the present study demonstrated that FN9-10ELP can promote the osteogenic differentiation of hMSCs on titanium disc, and the release profiles indicate sustained biological activity of hMSCs on the titanium during the period of osteogenesis.The purpose of present study was to investigate the effect of FN9-10ELP fusion protein was produced as previously described by Lee et al [SacⅠ and HindⅢ. The FN9-10ELP construct was transformed into E. coli TOP10, as the expression host.The FN9-10ee et al . BrieflyELP, the transformed TOP10 cells were incubated overnight at 37°C in lysogeny broth (LB) medium containing 100 μg·mL−1 ampicillin (LB-Amp+). When the culture medium reached OD600 = 0.6, induction was performed for 6 h by adding 0.1% (w/v) L-arabinose to induce protein expression. The bacteria were harvested and pelleted by centrifugation at 6000 g for 10 min, lysed in NaCl-Tris-EDTA (STE) buffer and sonicated. The soluble extract was centrifuged at 13,000 g for 2 x 10 min. The collected supernatant was purified by passing through a chromatography column containing a nickel-nitrilotriacetic acid resin .To express FN9-10ELP purity was evaluated using coomassie blue staining on 12% (v/v) SDS-PAGE gels. In addition, the molecular weight and expression of recombinant FN9-10ELP were confirmed by western blotting using the horseradish peroxidase (HRP) conjugate of monoclonal anti-polyhistidine antibody .The recombinant FN9-10The hMSCs were derived from nasal inferior turbinate tissue obtained from preoperative patients with the approval of the Institutional Review Board of Seoul St. Mary’s Hospital, the Catholic University of Korea  and used in this study. Written consents of donors were obtained, documented, and witnessed. The isolation of hMSCs were reported in detail in previous studies [−1 streptomycin, and 100 U/mL penicillin G sodium at 37°C under 5% CO2 atmosphere. The cultured cells were detached using 0.25% trypsin-EDTA and sub-cultured in fresh cell dishes (diameter 100 mm).The hMSCs were cultured in α-minimal essential medium  containing 10% (v/v) fetal bovine serum , 100 μg·mLThe titanium discs (25mm diameter and 1mm thickness) are consisted of grade 2 commercial titanium sheet. Before coating with the fusion protein, all the titanium discs were degreased and passivated by washing with acetone, 2% ammonium fluoride, and 2% hydrofluoric acid-10% nitric acid. Finally, the discs were autoclaved and dried in an oven at 50°C and stored at room temperature (RT).ELP that binds to the titanium discs, the discs were immersed overnight in various concentrations (0−25 μg) of FN9-10ELP made up to a volume of 30 μL/disc in 6-well plates at 4°C. The nonspecific binding capacity was reduced by blocking with 2% (w/v) bovine serum albumin  solution. After washing with Dulbecco’s phosphate-buffered saline , 400 μL of monoclonal anti-polyhistidine antibody was diluted 1:1000, added to the discs, and reacted at RT for 1h. After washing with tris-buffered saline/polysorbate 20 , 200 μL of 3,3′,5,5′-tetramethylbenzidine (TMB) substrate solution  was added to the discs and reacted at RT for 30 min in the absence of light. Next, 100 μL of the reaction solution and stop solution (2M sulfuric acid) were added to a 96-well plate. The absorbance of each sample was quantified at 450 nm using a microplate reader .The protein attachment to the titanium surface was confirmed by an ELISA using a His antibody probe. To confirm the maximum concentration of FN9-10ELP-coated titanium discs was measured for 28 days by ELISA-based retention assay using a His antibody probe. The titanium discs were immersed overnight in 10 μg·mL−1 FN9-10ELP made up to a volume of 500 μL/disc in a 6-well plate at 4°C. The discs were then incubated in PBS  at 4°C and replenished with fresh buffer every day. The collected discs were then dried using compressed air and blocked with 2% (w/v) BSA solution for 90 min. After washing with DPBS, horseradish peroxidase (HRP) conjugate of a His antibody (dilution at 1:1000) was reacted at RT for 1 h. The unbound antibody was removed with TBST, then 200 μL of TMB substrate solution was added to the discs and incubated at RT for 30 min under dark conditions. To complete the reaction, 100 μL of the reaction solution and stop solution (2M H2SO4) were mixed. The degree of release of FN9-10ELP attached to titanium discs was quantified using a microplate reader at 450 nm, with 5% (w/v) BSA solution as the control. The control profile was measured for 28 days using a Bradford protein assay. For this experiment the BSA coating and in vitro release using PBS were performed using the same procedure as above, then 50 μL of PBST (PBS + 0.1% Tween 20) was added to release the BSA from the collected discs, and reacted at RT for 30 min. Next, 50 μL of Coomassie Plus Assay Reagent was added and reacted for 30 min under dark conditions at RT. The degree of release of the control marker from the titanium discs was quantified using a microplate reader at 570 nm.The release profile from the FN9-10−1 FN9-10ELP made up to a volume of 500 μL/disc at 4°C. The un-coated titanium discs were used as the control. All discs were blocked with 2% (w/v) BSA solution for 2 h. After washing with DPBS, hMSCs were seeded at a density of 1 × 105 cells/disc and incubated at 37°C. To determine the optimal cell adhesion time, the cells were incubated for up to 150 min at 30 min intervals. After incubation, the discs were washed with DPBS, and the cells attached to the discs were fixed with 3.7% (w/v) formalin solution at RT for 30 min. The cells fixed on the discs were stained with 0.25% (w/v) crystal violet in 2% ethanol/water  and washed with DPBS after 1 h. The stained cells were lysed by adding 2% SDS solution to the discs and transferred to a 96-well plate. The absorbance of each sample was measured at 570 nm using a microplate reader.The cell adhesion activity on the titanium discs was evaluated via a crystal violet assay. The titanium discs were immersed overnight in 10 μg·mL−1 at 4°C, then hMSCs were seeded at a density of 1 × 104 cells/disc and incubated for 4 and 8 days at 37°C. In addition, non-coated titanium discs were seeded with hMSCs as a control experiment. Each disc was washed with DPBS, then viable cells on the discs were incubated with 500 μL MTT solution (5 mg·mL-1 in DPBS) at 37°C in the dark. After 3 h of reaction, the MTT solution was removed, and the cells were lysed with 150 μL DMSO to dissolve the purple formazan crystals contained in the cells. The absorbance of each sample was determined at 570 nm using a microplate reader.The cell proliferation activity on the titanium discs was determined using an MTT assay, which measures cellular metabolic activity as an indicator of cell viability and growth. This assay was performed according to the manufacturer’s instructions . First, the titanium discs were immersed overnight in 10 μg·mL−1 FN9-10ELP at 4°C. Then, hMSCs were plated at a density of 5 × 103 cells/disc and incubated for 5 and 10 days at 37°C. Next, the discs were rinsed with DPBS and the cells on the discs were lysed with 100 μL 0.1% Triton x-100 at RT for 30 min. After removing the insoluble materials by centrifugation at 4°C for 10 min, the ALP activity of the soluble cell lysate was evaluated using an alkaline phosphatase assay kit (Sigma). The absorbance of the colored reaction mixture was read at 405 nm using a microplate reader, and the ALP activity was normalized to the control .Osteoblast differentiation on the titanium discs was investigated using an ALP assay, which measures the activity of ALP as an osteogenic marker expressed by early osteoblast during bone formation. The titanium discs were placed overnight in the presence or absence of 10 μg·mL−1 FN9-10ELP at 4°C. Then, hMSCs were cultured at a density of 5 × 103 cells/disc for 5 and 10 days. The discs were then rinsed with DPBS, fixed in 4% paraformaldehyde at RT for 30 min. Fixed hMSCs on the discs were stained using an Alizarin Red S solution (Sigma) overnight. Stained cells on the discs were washed with distilled water and destained with 250 μL of 10% cetylpyridinium chloride solution at RT for 30 min. The concentration of Alizarin Red S staining was quantified by measuring the absorbance at 450 nm using a microplate reader.Late osteoblast differentiation on the titanium discs was determined by Alizarin Red S staining. Mineralization is known to late phase of osteogenic differentiation expressed by mature osteoblast during bone formation. The titanium discs were immersed overnight in 10 μg·mL−1 FN9-10ELP. The total RNA was extracted using an Easy-spin RNA extraction kit . The RNA purity was quantified by confirming the absorbance at 260nm and 280nm  with a NanoDrop 2000 spectrometer (Thermo Scientific). 2 micrograms of total RNA were reverse transcribed using a 20 μL reaction mixture including 50 units of SuperScript II reverse transcriptase , 0.5 μM of random hexanucleotide primers (Invitrogen), 40 units of RNaseOUT recombinant ribonuclease inhibitor (Invitrogen), 500 μM of dNTP mixture (Invitrogen), and 5 μM DTT. The reverse transcription was performed at 50°C for 1 h. Then, the reaction mixture was heated at 70°C for 15 min to stop the reaction. The cDNA product was stored at −20°C.For this experiment, hMSCs were incubated for 20 days on titanium discs coated with 10 μg·mL2). The PCR cycles were as follows: 1 cycle at 94°C for 10 min (enzyme activation), 40 cycles at 94°C for 15 s (denaturation), 60°C for 1 min , and 60°C for 1 min (extension).The mRNA expression of osteogenesis-related genes  was examined by quantitative real-time PCR. The primer sequences of these genes used in this experiment are listed in −1 FN9-10ELP for 20 days and then were lysed using a sodium dodecyl sulfate buffer. Extracted proteins were denatured by heating, then separated on 7.5 and 12% (v/v) SDS-PAGE gels and transferred to PVDF membrane. After blocking with 10% skim milk, the membrane was probed with mouse monoclonal Col I, OPN, and OCN antibody  at RT for 2 h. β-actin was used as the internal control. The blots were detected and quantified using a ChemiDoc Touch Imaging System .The protein expression of osteogenic differentiation was investigated by western blotting. The hMSCs were cultured on titanium discs coated with 0 or 10 μg·mLt-test. In all statistical analyses, a p value < 0.05 is recognized to be statistically significant for the difference between the two groups. .All experiments were performed in triplicate. The experimental data were reported as the mean ± standard deviation (SD). The statistical analysis was performed using the Student’s ELP, the sequence encoding FN9-10ELP was cloned into a pBAD/His expression vector. This vector contains an ara BAD promoter (pBAD) that controls host expression and N-terminal polyhistidine for affinity purification and protein quantification.To construct the fusion FN9-10ELP was purified by affinity chromatography using an Ni-NTA column, and its purity was confirmed to be greater than 90% via Coomassie blue staining  of FN9-10ELP overnight at 4°C and measured by the enzyme-linked immunosorbent assay (ELISA) using a His antibody probe as specified in the Materials and Methods Section. As shown in ELP coated titanium disc increased with increasing proportion of FN9-10ELP up to a maximum of 10 μg and remained constant thereafter (p < 0.001). These results indicated that the maximum concentration of FN9-10ELP attached to the titanium discs was 10 μg. Thus, 10 μg of FN9-10ELP was used in all further experiments to functionalize the surface of the titanium disc.To confirm the adhesion of FN9-10ELP (10 μg·mL−1) and a control substance (5% BSA) were coated onto separate titanium discs overnight at 4°C, and the amount of released from the FN9-10ELP-coated titanium discs, and from the BSA-coated control discs, was quantified after immersion in phosphate-buffered saline (PBS) for up to 28 days (4 weeks). The amount of samples released from the titanium disc then was then calculated as the difference between the initial amount (100%) and the remaining amount. The results presented in ELP was initially high and gradually decreased over time without early burst effect. Thus, 54% of the FN9-10ELP was released from the titanium discs during the first week of immersion, with a release rate of 7.7% per day. For subsequent 3 weeks, a release rate of about 1.4% per day was observed. By contrast, the release profile of BSA-coated (control) titanium discs exhibited an early burst pattern for up to 3 days, with about 83% of the BSA being released at a rate of 7.7% per day during this time. Moreover, the BSA was completely removed from the titanium discs after only one week. These results showed that the release profile of FN9-10ELP-coated titanium discs follows a sustained pattern over a period of 4 weeks and that biological activity is retained during this time.To assess the release profile of the functionalized titanium discs, an ELISA-based retention assay was performed for 28 days using a His antibody probe. The FN9-10ELP coated on titanium discs, a cell adhesion assay was performed using crystal violet. The hMSCs were incubated for up to 150 min (in 30-min increments) in serum-free medium and adhered to the titanium discs with or without 10 μg·mL−1 of FN9-10ELP. As indicated in ELP-titanium than on the control titanium (p < 0.001). As shown by the results, the adhesion rate was seen to increase during the initial 120 min and then became saturated. These results presented that the coating of titanium discs with FN9-10ELP promoted the adhesion of hMSCs and that the optimal adhesion time is 120 min.To determine the hMSCs adhesion effect of FN9-10ELP coated on titanium discs, cell proliferation was examined using a MTT assay. The results presented in ELP-titanium was significantly increased for up to 8 days (p < 0.001). Moreover, the proliferation of the hMSCs after 8 days on FN9-10ELP titanium was 2.8-fold that on the control discs. These results demonstrated that the proliferation of hMSCs on titanium discs was enhanced by bio-functionalization with FN9-10ELP.To evaluate the hMSCs proliferative activity of FN9-10ELP for the osteogenic differentiation in protein level of hMSCs on titanium discs, alkaline phosphatase (ALP) assay and Alizarin Red S staining were performed.To investigate the effect of FN9-10−1 FN9-10ELP-titanium for 10 days. As indicated in ELP-titanium) than on control titanium (p < 0.01).ALP activity, an important early phase activity of osteogenic differentiation, was evaluated after incubating hMSCs on 0 or 10 μg·mL−1 FN9-10ELP-titanium for 10 days. As shown in ELP-titanium) than on non-coated titanium (p < 0.05). These results indicated that FN9-10ELP treatment resulted in enhanced osteogenic differentiation of hMSCs on titanium discs.Mineralization activity, an important late phase activity of osteogenic differentiation, was examined after incubating hMSCs on 0 or 10 μg·mL−1 FN9-10ELP, the mRNA expression levels of osteogenesis-related genes such as Col I, RUNX2, OPN, OCN, BSP, and TAZ were measured using the real-time- polymerase chain reaction (PCR) with β-actin as an internal control. As shown in ELP-titanium compared to the control. Treatment with FN9-10ELP for 20 days upregulated significantly (p < 0.05) the mRNA expression of Col I (1.5-fold), RUNX2 (2.15-fold), OPN (2-fold), OCN (4.1-fold), and BSP (5.5-fold). Cui CB et al. reported that TAZ positively regulates bone formation in vivo, which seems to be mediated by the enhancement of both RUNX2 [ELP for 20 days resulted in significant (p < 0.05) upregulation of the TAZ (2-fold) genes. Thus, these results suggested that FN9-10ELP treatment resulted in enhanced mRNA level of five osteogenic markers in hMSCs and TAZ might be involved in the activation of hMSCs associated with osteogenic differentiation.To further examine the osteogenic differentiation activity of hMSCs on the titanium discs with or without 10 μg·mLth RUNX2  and TGF-th RUNX2  signalinELP for 20 days compared to the control (p < 0.05). Taken together, these results indicated that the expression of osteogenesis-related genes was upregulated in the presence of FN9-10ELP compared with control titanium.In addition, the protein expressions of Col I, OPN, and OCN were analyzed by western blotting. As shown in ELP protein for more direct bone healing.ECMs such as FN and ELP have been demonstrated to regulate osteogenesis-related cellular processes by signaling with MSC integrin ,45. In pELP could be achieved at various concentration of FN9-10ELP up to a maximum 10 μg Click here for additional data file.


Recent systematic reviews have described initiatives utilized by ACGME programs to increase scholarship.3 Tripler Army Medical Center (TAMC) Internal Medicine (IM) residency program educates a diverse group of civilian and active duty military residents. We initiated simple, reproducible interventions to improve resident participation in and understanding of the medical research process, based on previously published methods.6The Accreditation Council for Graduate Medical Education (ACGME) stipulates that residents must participate in scholarship, and programs must provide curricula to accomplish this. Residents understand that they should participate in scholarly activity, but are often dissatisfied with their program’s approach.As a process improvement study, a structural framework was developed for scholarly activity within the TAMC IM residency program. A total of 32–39 IM residents per year participated. The interventions took place at the start of the 2016–2017 academic year. Metrics were collected from July 2016 to June 2019. Metrics from July 2015 to June 2016, before interventions occurred, served as the control. No additional monetary funding was provided.A Scholarly Activity Council (SAC) was assembled, with a volunteer faculty member serving as Chair (CSAC). The council contained representatives from each IM subspecialty, to act as human resources for projects in their area of expertise. All SAC members were volunteers. The CSAC created a shared access database, including a bulletin of projects needing assistance, deadlines, and a list of project statuses and pending tasks. It was reviewed and updated monthly at a dedicated research conference on the academic schedule, where residents also practiced presentations and discussed projects. Faculty members in attendance at the meeting could give feedback and advice for these presentations or projects. A research curriculum was designed, including monthly lectures on statistical analysis, critical literature appraisal, and guides for manuscript writing. Protected longitudinal research time was added to resident schedules, with 4 weeks of dedicated time per academic year. This time replaced one elective rotation block.From July 2016 to June 2019, residents were requested to report any new scholarly activity to the Chief of Medical Residents. Metrics collected to evaluate participation included quantity and type of manuscripts published, presentations at local/regional/national conferences, and ongoing or new Institutional Review Board (IRB)–reviewed studies. Abstracts’ or manuscripts’ pending acceptance and in-house scholarship, such as morning report or grand rounds, were excluded.From July 2015 to June 2016, 4 manuscripts and 2 book chapters were published, and 22 presentations were given. This represented the program’s baseline scholarly activity. During the 2016–2017 academic year, presentations increased to 45 (Table 6 requiring minimal resources. Overall, the interventions described established a collaborative environment between faculty and residents (Table Scholarship increased within the TAMC IM residency program after instituting reproducible, evidenced-based interventionsts Table .Table 26 Among primary care specialties, lack of mentorship and protected time to complete scholarship impacts their ability to fulfill the requirement.4 Other factors, e.g., prior research experience and desire for fellowship training, may also affect scholarship.6 Our project presents a standardized, literature-derived approach that is transferable across ACGME programs.Other programs have utilized similar interventions to improve scholarly activity.Limitations include a small sample size and limited pre-intervention data. It is difficult to quantify which aspects of the multi-pronged interventions were most successful, and to what degree the culture change, signaled by an overt focus on scholarship, augmented the individual interventions. We posit that the cumulative effect of the interventions outweighed the sum of their parts.By developing a stable research environment with designated mentors, we increased our production of peer-reviewed publications. Key to the success of the program was the designation of the CSAC, who was empowered to make substantial, meaningful changes. Further work is needed to evaluate how other specialties may benefit from similar interventions, and to refine further the approach to scholarship across ACGME programs.


MIND at Home, a well-researched holistic, family-centered dementia care coordination program, provides collaborative support to community-dwelling persons living with dementia (PLWD) and their informal care partners (CP). Through comprehensive home-based assessment of 13 memory-care domains covering PLWD and CPs, individualized care plans are created, implemented, monitored, and revised over the course of the illness. Non-clinical Memory Care Coordinators (MCCs) working with an interdisciplinary team provide education and coaching to PLWD and their identified CP, and serve as a critical liaison and resource and between families, medical professional, and formal and informal community resources. This paper will describe a statewide pilot implementation of the program within a health plan across diverse sites in Texas and will present qualitative and quantitative descriptions of a key component of the program's effective translation to practice, the virtual collaborative case-based learning sessions. Health plan teams completed online interactive training modules and an intensive in-person case-based training with the Johns Hopkins team prior to program launch, and then engaged in weekly, hour-long virtual collaborative sessions that included health plan teams (site-based field teams, health plan clinical supervisory and specialty personnel  and Johns Hopkins MIND program experts and geriatric psychiatrists. To date, the program has enrolled 350 health plan members, conducted 65 virtual collaborative sessions, and provided 423 CME/CEU units to team members. We will provide an overview of virtual collaborative session structure, participant contributions and discussion topics, case complexity, as well as didactic learning topics covered.


The United States Department of Veterans Affairs established a program in which actors incognito portray veterans experiencing homelessness with pre-determined needs to identify barriers to access and services at community-based organizations.From 2017 to 2019, actors who varied in gender, skin color and age portrayed one of three scripts at all VA Community-Based Resource and Referral Centers (CRRCs) serving veterans experiencing homelessness in 30 cities and completed an evaluative survey. They carried authentic VA identification and were registered in a VA patient database for each identity. CRRCs were provided with reports annually and asked to implement corrective plans. Data from the survey were analysed for change over time.P < 0.05 adjusted for script present). A significant disparity in access for African American actors resolved following more uniform adherence to pre-existing policies.Access to food, counselling, PTSD treatment, and hypertension/prediabetes care services increased significantly from 68–77% in year 2 to 83–97% in year 3 (each The ‘unannounced standardized veteran’ (USV) can identify previously unrecognized barriers to needed services and care. Audit and feedback programs based on direct covert observation with systematic data collection and rapid feedback may be an effective strategy for improving services to highly vulnerable populations. The program was established to evaluate 30 Community Resource and Referral Centers (CRRCs) nationally. CRRCs are located in strategically selected areas to provide both a refuge from the streets and a central location to engage veterans experiencing homelessness and at-risk veterans in services. Veterans are assessed and referred to appropriate health and mental health care resources, job development programs, housing options and other VA and non-VA benefits.,,The VA had invested heavily since the 1980s in programs serving veterans experiencing homelessness and, since 2009, embarked on an initiative to end veteran homelessness, spending over $1.2 billion annually on services.The QI program was created by an HPO working group, starting in 2016, composed of content experts including staff who had first-hand experience working on the front lines at CRRCs directly serving veterans experiencing homelessness. In consultation with a team at the University of Illinois at Chicago (UIC) that has extensive experience employing USVs in VHA, three scripts were developed, each a prototype of veterans requiring specific services:In addition to these scripts, a checklist was developed to be completed by USVs following each visit. It included measures of access to a range of services, customer services ratings, waiting time and number of steps, each scored and weighted. The checklist is included as an Appendix. Note that the VA utilizes the ICARE model to define and measure customer service. ICARE articulates the value and concomitant behaviors that apply across the entire organization.USVs were provided with valid VA photo identification cards to match the fake identities they portrayed. Matching identification information was entered into VA information systems so it could be accessed by CRRC staff during intake, and data were removed following encounters so as not to corrupt downstream data with false information. We followed a similar protocol that had been implemented for a study employing USVs several years earlier, updated for this project in partnership with several central VA offices.The working group agreed on several principles to guide the program. Foremost was that it would not be punitive. Programs designed to improve quality and reduce error are notoriously ineffective if they focus on individuals rather than systems.The program went live in 2017, with a USV visiting each CRRC annually between February and August. Since sites were located across the vast expanse of the United States, most site visits required plane travel. Prior to the initiation of the first round, all CRRCs were informed of the program as were VA leaders and union representatives through email notices and several national calls. Following the first round of visits, aggregate and site-specific findings were shared with each CRRC director. When barriers to access or other deficits were discovered, sites were asked to implement correctives based on information from sites that did not have similar deficits. The process was repeated between the second and third round. A new feature added to the program in the third round, in 2018–19, was rapid feedback to sites when significant barriers to access were experienced during visits. For instance, when a USV was turned away despite having the required documentation to obtain services, the HPO office was promptly notified and could then reach out to the site to alert them and institute immediate corrective measures.Using data on CRRCs from the QI program, we compared changes over the 3 year period 2017–19 in measures of access to needed services, customer service and the number of steps and amount of time from arrival at a CRRC to receipt of services. We also compared changes in reported barriers to services and changes in receipt of expected services. Finally, because of an observed difference in access to services for African American USVs compared to Caucasian USVs in the baseline year, we conducted a subgroup analysis of access based on skin color adjusted for case. The Veterans Affairs Central Institutional Review Board determined that the analysis of the HPO’s QI program did not constitute human subjects research.n . From 2017 to 2018, the process score significantly increased, indicating fewer steps to receipt of services, and the time score significantly decreased signifying longer time to receipt of services. Changes in reported barriers to needed services are documented in Mean USV-scored measures of access, customer service (ICARE), process and time are provided, along with mean total, in n (i.e. 30–31 CRRC sites).Whereas In the first round of the program, in 2017, a marked discrepancy was noted between the access scores of the two USVs portrayed by Caucasian actors and the one portrayed by an African American actor. As noted in The establishment of a USV quality improvement program has provided the Homeless Program Office with actionable information obtained by direct observation about how it is serving its clients. That information, in turn, has been utilized to institute changes in policy and practice, communicated to field-based service units, the CRRCs. In year 3 of the program, significant improvements have been documented in access to food, counselling, PTSD treatment referral and hypertension/prediabetes services, and a disparity in access for African American compared to Caucasian veterans when portrayed by USVs has resolved.These changes all occurred in the third year. Although there were changes noted in the second year of the program —a decreaThe elimination of a disparity in access to services for the African American actors occurred after the USV program uncovered non-uniform application of VA policy regarding the documentation requirements to demonstrate eligibility for VA services—specifically with regard to the DD-214, which is not required . As brieThere is an extensive literature on ‘street level bureaucracy’ that describes how front line workers in human service organizations, interfacing with ‘non-voluntary clients’ exercise wide discretion with relatively little accountability.These studies point to the capricious nature of social service delivery attributable to the variability in decision-making of front-line staff related both to their understanding and application of policy, and to their exercise of discretion in the absence of policy. The findings establish the need for a standardized process comparing service delivery based on direct, covert observation. A concern raised regarding such a process has been the element of deception. In the research context, deception is mitigated through an informed consent process in which the subjects voluntarily agree not to know when they are seeing a fake patient or client. In the context of a quality improvement program, such as the one reported on here, employees are similarly informed. Ethicists generally distinguish between deception protocols in which individuals are provided false information for the purposes of misleading them, and those in which they are fully informed about what is going to happen. USVs fall into the latter category, for which the threshold for demonstrating a benefit in excess of risk is lower.Our analysis illustrates the potential benefits of a program utilizing direct covert observation from the client’s perspective, with rapid actionable feedback, to improve services to a vulnerable population. A strength of USV data collection is that it uncovers hidden variations enabling rapid transfer of best practices from one site to another. For instance, at some CRRCs, USVs were told that they would have to first commute to a local VA medical centre to register and then return for further processing. Other sites simply had a direct phone line to the nearest facility so they could register without the additional step. As a result of the USV program, this ‘best practice’ was disseminated to all sites, with many adopting it, removing a barrier to service.In addition, direct observation data collection methods, such as this USV approach, offer organizational leaders an authentic picture of what is happening on the front lines where services are actually delivered.,A fruitful area for future research on USV/USP type programs may be on social return on investment and cost effectiveness. While it was beyond the scope of this study to assess, such programs may be highly cost effective. The cost of the USV program was modest: about $114,000 United States Dollars (USD) per year to evaluate a federal program serving tens of thousands of veterans in 30 locations nationally. And there are economies of scale: the recent inclusion of another a larger VA program serving Veterans in which our USVs visited 70 sites, primarily in the same cities, increased the overall cost of the program by just $20 000 USD. Analytic models are available for measuring the value added of improving social service programs.There are several limitations to this study. First, because we conducted an analysis of just one program, it is difficult to generalize about whether the positive changes documented would occur in another setting. The recent addition of a second, larger, program, as noted above, may provide additional insight. Second, because this was an analysis of a QI program, not a randomized controlled trial, we did not have a control group against which to compare our findings. And third, it is possible that sites detected when they were visited by a USV and improved their performance selectively. We think this latter scenario is unlikely for several reasons: we did not send the same actors to the same sites in sequential years so as to avoid the risk of their being recognized; they presented with typical conditions indistinguishable from thousands of other clients; and they carried identification and were registered to be indistinguishable from real veterans.The views expressed in this manuscript are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.Appendix_USV_Checklist_fdab062Click here for additional data file.


ABSTRACT IMPACT: Investigators in clinical and translational research will be better supported by CTSAs that reduce barriers to the efficient and effective utilization of their program services. OBJECTIVES/GOALS: Evidence from three CTSAs show that investigators do not take advantage of all program services provided. This session will explore the patterns and sources of underutilization by sharing preliminary results from investigators and program managers. METHODS/STUDY POPULATION: Interviews with investigators at all three CTSA sites were conducted in Spring 2020. Investigators who had only used one program service and those who had used multiple program services across a span of three-years (2016 to 2018) were included in the sample. Investigators who had only used REDCap, were excluded. Interviews numbered about six interviews per site. Content analysis helped identify emerging themes and patterns. A survey with program managers at the three CTSA sites will be deployed in January 2021. Program managers across all programs will be included in the sample. Basic descriptive analysis will be used to analyze the data. RESULTS/ANTICIPATED RESULTS: Interviews with investigators at all sites illuminated ways different investigators use, learned about and leveraged services, as well as the barriers they encountered to using cross-program services. Investigators also provided thoughts on ways to address lack of program service use. Survey results are expected to clarify program managers’ knowledge of other program services in their CTSA, programs’ referral processes, and the barriers program managers face when recommending other services to users. DISCUSSION/SIGNIFICANCE OF FINDINGS: When investigators do not take full advantage of all program services provided, investigators are put at risk of having longer, less successful projects. Knowing the sources of underutilization can help curb this trend and effectively address investigator needs throughout the research process.