PONE-D-23-12980Impact of San Francisco’s new Street Crisis Response Team on service use among people experiencing homelessness with mental and substance use disorders: A mixed methods study protocolPLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Partly

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3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

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4. Have the authors described where all data underlying the findings will be made available when the study is complete?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The protocol described represents an important step in establishing best practices for mobile crisis units and their evaluation.

The authors propose to use mixed methods (quantitative and qualitative approaches) to examine a recently-established mobile crisis unit in San Francisco, California.

Using an interrupted time series analysis, they will measure four main outcomes after an index crisis episode: routine care utilization and housing services assessment (outcomes consistent with stabilization) and crisis care reutilization and jail entry (consistent with de-stabilization). They will compare these outcomes before and after the rollout of the SCRT mobile crisis service in San Francisco, including a pilot period in which the service was rolled out in only some zip codes, providing both time and place-related comparisons. They have appropriately described ways to control for secular patterns in the data.

Using semi-structured interviews, they will obtain qualitative data regarding recipients’ experience with crisis services in the 7 to 90 days following a crisis episode.

The procedures to integrate data from multiple sources are adequately described and seem feasible.

Specific Suggestions:

One potential obstacle to the hoped-for improvements to come from the mobile crisis service and referral plan is a lack of available service providers. For instance, a person could go through the housing assessment but still experience a re-utilization of crisis services because there were not enough housing units, they remained unhoused and a crisis once again ensued on the street. The authors should provide some way of evaluating the availability of such services, perhaps in the qualitative analysis. At the very least, they should comment on it.

Second, in the ITS section (page 12-13), please clarify how the “total target population” will be calculated. Also, how is it estimated that there will be between 8-12 data points per time period?

Third, in the description of the semi-structured interviews, it is unclear whether these have already been performed and remain to be analyzed, or if they will be performed on subjects whose usage of the crisis services does not overlap with the time frame of the qualitative analysis (2020-2022). Please clarify.

Similarly, if the interviews have not yet been performed, will the authors be able to obtain service utilization records for the interview participants as described on page 16, lines 358-359, along with appropriate consent?

Fourth, Figure 1 was very difficult to see, both in the PDF version and when printed.

Finally, please add a statement describing how data will (or will not) be made available after the study is complete.

Reviewer #2: First let me congratulate you on your ambitious and significant study. I enjoyed reading the protocol and think that the methods you are employing could be used in a number of studies to evaluate implementation of real-world interventions that cannot be easily randomized. A few minor comments.

It might be useful to include some hypotheses so that readers can better understand how you expect the outcomes to change. For example, I am assuming that visits to housing services or to primary care would be seen as a positive outcome, while no change or an increase in arrest would be seen negatively.

In describing the equity analysis you write, "Furthermore, we will be able to identify if potential baseline disparities are perpetuated or reduced by implementation of the SCRT, as has been described in the RE-AIM model." Since you have not really described the RE-AIM framework in the paper, it would be good to briefly describe what changes in equity you expect to see (e.g., reach, adoption).

How will eligibility be determined for potential qualitative participants who self-recruit by responding to a flyer. Will you check to see if they have received SCRT services?

When describing methods for matching data you switch unexpectedly to the past tense. Since, I assume that the matching has not yet happened, it would seem better to use the future tense with this as well. In the discussion, "The electronic records used to describe health, housing and jail service utilization does not capture all services provided..." I believe it should be do not capture.

Reviewer #3: This is a significant and worthy study of a critical topic. The QUANT-QUAL implementation methods are appropriate for examining this program launch. Two weaknesses that are correctable:

1. There is a serious imbalance between the detailed quantitative methodology and the sketchy outline provided for the qualitative methodology. In a QUANT-QUAL design, both must be addressed with rigor and (this is missing) a precise plan for staging the merging or integration of the two methods. The protocol falls apart on this dimension. I recommend that the authors consult the NIH guidelines for combining QUANT-QUAL:

https://obssr.od.nih.gov/research-resources/mixed-methods-research

Another helpful resource is:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7756351/

Both resources describe a clearly designed plan for bringing data from both approaches together and note that a precise plan about when and how should be described. The second resource describes the basic qualifications for rigor in qualitative methods which are missing from the protocol.

2. While the quantitative analytic design is well-described, the equity analysis suffers from inattention to intersectionality and cumulative stress of multiple social identities. The design did not clearly identify how singular versus multiple identities would be accounted for, i.e. the differences between inequities experienced by a white male with serious mental illness symptoms and a black female with similar symptoms is not addressed. The analysis should fully represent these intersecting factors -- it appears that they are treated as discreet factors, not cumulative.

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Reviewer #1: Yes: Nicole L. Schramm-Sapyta

Reviewer #2: No

Reviewer #3: No

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Impact of San Francisco’s new Street Crisis Response Team on service use among people experiencing homelessness with mental and substance use disorders: A mixed methods study protocol

PONE-D-23-12980R1

Dear Dr. Goldman,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

De-Chih Lee, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: My only comment remaining is about the use of future tense voice. It seems appropriate to use past-tense when referring to recruitment of subjects for the qualitative analysis (subjects were recruited; subjects were interviewed) and future tense when referring to the analysis (transcripts will be analyzed, etc.). However, i defer to the editor on this matter and would not delay the publication of this important plan based on that issue.

This is very important work and I look forward to the results!

Reviewer #2: Your version with untracked changes does not incorporate the changes found in the tracked changes version. I don't know if the original was included with the resubmission, but it caused some confusion. The second version with tracked changes has the changes described in the authors' response.

Reviewer #3: The authors have been responsive to the reviewers' and editors' requests. Refreshing! Thank you! The responses are thoughtful and have received full responses.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Nicole L. Schramm-Sapyta

Reviewer #2: No

Reviewer #3: Yes: Linda S. Beeber

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