Administrative Burdens as Distinct Barriers to Accessing Mental Health Services in Community Mental Health Centers and Federally Qualified Health Centers: A Mixed-Methods Assessment.

State Mental Health Policy: Mending Missouri's Safety Net: Transforming Systems of Care by Integrating Primary and Behavioral Health Care

Community Mental Health Centers (CMHCs) and Federally Qualified Health Centers (FQHCs) are critical access points for families with adolescents needing mental health care, especially those enrolled in Medicaid. However, barriers exist which may reduce their accessibility. This study aims to describe the availability and accessibility of outpatient mental health services for children and adolescents at safety-net health centers in a large metropolitan county. Approximately one year after the COVID-19 pandemic began in the U.S., a comprehensive sample of 117 CMHCs and 117 FQHCs were called and administered a 5-minute survey. Approximately 10% of health centers were closed, and 20% (28.2% of FQHCs and 7.7% of CMHCs) reported not offering outpatient mental health services. Despite CMHCs having 5.4 more clinicians on staff on average, reported wait times were longer at CMHCs than FQHCs. These findings indicate that online directories intended to be a comprehensive and accessible resource, such as the SAMHSA Treatment Locator, are often inaccurate or out-of-date.

In April 2003 the Alberta government integrated specialized mental health services, formerly organized independently, with the health regions, which are responsible for general health services. The objective of this article is to determine whether the transfer was associated with an increase or decrease in the share of resources in the region allocated to mental health care relative to total spending for health care. The measure of the share for mental health care is the total costs for mental health care resources as a percentage of total health care spending. Resources and spending examined were those that were actually or potentially under the regions' control. Annual costs for mental health services in the province were obtained for a seven-year period (fiscal year [FY] 2000 through FY 2006) from provincial utilization records for all residents in the province. Unit costs were assigned to each visit. The trend in the share measure was plotted for each year. The share for mental health care increased overall from FY 2000 (7.6%) to FY 2003 (8.2%), but returned to pre-FY 2003 levels in the three years after the transfer (7.6%). Despite concerns expressed before the transfer by federal and provincial reports over the level of expenditures devoted to mental health care, the integration of mental health services with other health services did not result in an increase of the share for mental health care.

The authors aimed to examine how access to trauma-informed mental health services in safety-net health centers varies by insurance type and race-ethnicity of the care seeker. In this mystery shopper study, three women (White, Latina, and Black voice actresses) called community mental health centers (CMHCs) and federally qualified health centers (FQHCs) (N=229) in Cook County, Illinois, posing as mothers requesting a mental health appointment for their traumatized adolescent child. Each health center was called twice-once in the spring and once in the summer of 2021-with alternating insurance types reported (Medicaid or private insurance). Ability to schedule an appointment, barriers to access, wait times, and availability of trauma-specific treatment were assessed. Callers could schedule an appointment in only 17% (N=78 of 451) of contacts. Reasons for appointment denial varied by organization type: the primary reasons for denial were capacity constraints (67%) at CMHCs and administrative requirements to switch to in-network primary care providers (62%) at FQHCs. Insurance and organization type did not predict successful appointment scheduling. Non-White callers were significantly less likely (incidence rate ratio=1.18) to be offered an appointment than the White caller (p=0.019). The average wait time was 12 days; CMHCs had significantly shorter wait times than FQHCs (p=0.019). Only 38% of schedulers reported that their health center offered trauma-informed therapy. Fewer than one in five contacts resulted in a mental health appointment, and an apparent bias against non-White callers raises concern that racial discrimination may occur during scheduling. For equitable access to care, antidiscrimination policies should be implemented.

Mental Health Care Reforms in Latin America: Child and Adolescent Mental Health Services in Mexico

To provide a model to estimate human resource needs for community-based mental health services in South Africa. A situation analysis was conducted of current community-based mental health service provision in South Africa, which comprise outpatient and emergency services, residential care and day care. Service utilisation rates and staffing needs were estimated for two levels of service coverage, using data from the situation analysis, local epidemiological studies and consultation with key stakeholders. For a population of 100,000 people, 7.3-23.8 full-time equivalent staff would be required to provide services in outpatient services, 14.9-41.6 in day care and 11.5-23.0 in residential care at minimum and full coverage levels respectively. The model can facilitate rational planning by requiring transparency and accountability in the assumptions used. This method can be adapted to a range of countries, by entering relevant country data. The model fills a gap, particularly in low- and middle-income countries, where community-based mental health services are sparse, and decisions regarding allocations to them are hampered by a lack of good quality data. The results of the model are limited by the quality of data and the assumptions upon which the modelling are based.

ABSTRACTObjectivesThe objective of this study is to update estimates of comprehensive service availability among CCBHCs and compare them to other settings serving individuals with severe mental illness, including community mental health centers (CMHCs) and federally qualified health centers (FQHCs).Study Design and SettingThis study is a cross‐sectional secondary data analysis.Data Sources and Analytic SampleUsing 2022 National Substance Use and Mental Health Services Survey (N‐SUMHSS) data, logistic regression examined associations between service setting (CCBHC, CMHC, FQHC) and the availability of psychiatric, health management, and navigation, and social care services.Principle FindingsCompared to CCBHCs, FQHC designation was associated with a decreased likelihood of offering psychiatric rehabilitation services, including ACT (marginal effect = −0.26, 95% CI: −0.33 to −0.19) and peer coaching (marginal effect = −0.36, 95% CI: −0.43 to −0.29), and psychiatric crisis intervention (marginal effect = −0.14, 95% CI: −0.22 to −0.07). Rates of health management services were comparable to those at CCBHCs. CMHCs were also less likely to offer health management services (marginal effect = −0.26, 95% CI: −0.32 to −0.21) and a range of psychiatric rehabilitation services relative to CCBHCs.ConclusionsCCBHC certified clinics were more likely to offer psychiatric and social services than FQHC or CMHC clinics serving individuals with severe mental illness.

Get Started in Integrated Care by Picking Up the Phone

Federally qualified health centers (FQHCs) provide care in underserved areas, regardless of an individual’s ability to pay, and can be a critical source of care for children with public or no insurance who have greater difficulty getting care from providers in the community. In 2013, about one‐third of FQHC patients nationally were children. The Affordable Care Act (ACA) increased federal funding for FQHCs by $11 billion between 2011 and 2015, with the policy goal of increasing access to care for underserved populations. We examined the effects of the increased funding for FQHCs on children and adults in Massachusetts.We used 2010‐2013 claims data from the Massachusetts All Payer Claims Database (APCD) to examine changes in visits to FQHCs among enrollees included in the APCD (Medicaid, commercial insurance, and visits by uninsured residents covered by the Health Safety Net).We obtained FQHC funding information from the Uniform Data Set. To assess the impact of changes in funding (federal and state) on FQHC visits, we used a shift‐share instrument to measure local exposure (5‐digit ZIP code‐level) to changes in funding: we weighted the year‐to‐year percentage change in FQHC funding by the local share of each FQHC’s patient population in 2009 and summed across FQHCs in the ZIP. We used a multivariate linear regression model to assess the association between the year‐to‐year percentage change in local exposure to FQHC funding and the percentage change in the total number of FQHC visits or number of residents with FQHC visits in 2010‐13, adjusting for each ZIP codes’ demographic and health characteristics (eg, age, median comorbidity scores). We used similar models to examine changes in ED visits and stratified models for children vs. adults. Models were weighted by the ZIP code population, and standard errors were clustered by ZIP.Children (N = 1 145 205 in 2010) and adults (N = 5 038 277 in 2010) included in the Massachusetts APCD and 31 FQHCs that received funding from the Community Health Center Fund between 2010 and 13.Annual pediatric visits at MA FQHCs increased by 10% and adult FQHC visits by 14% from 2010 to 2013. Those with vs. without FQHC visits were more likely to have Medicaid insurance (67% vs. 17%) and live in low‐income neighborhoods (37% vs. 22%). Increased visits to FQHCs by children were associated with increases in FQHC funding, for example, +6.8 percentage point (95% CI [1.7, 11.8]) with +1SD change in prior year funding. ED visits by children also decreased with greater local exposure to FQHC funding, for example, −1.3pp ([−2.4, −0.2]) with +1SD change in prior year funding. FQHC visits for adults did not vary significantly with FQHC funding, but ED visits decreased by a similar magnitude as children.Increases in FQHC funding resulted in significant increases in use of FQHC services, especially for children. ED visits for children and adults also decreased with greater FQHC funding.The ACA funding increases for FQHCs appeared to increase access to community health center services for low‐income children and reduced costly emergency department care for underserved communities.Agency for Healthcare Research and Quality.

BackgroundFederally Qualified Health Centers (FQHCs) are a critical source of care for medically underserved populations and often serve as medical homes for individuals with serious mental illness (SMI). Many FQHCs provide mental health services and could facilitate access to mental health treatment within and outside of FQHCs. This study compared mental health care utilization and acute care events for adult Medicaid enrollees with SMI who receive care at Federally Qualified Health Centers (FQHCs) vs. other settings.MethodsThis study used the 2015–2016 Massachusetts All-Payer Claims Database to examine outpatient mental health care and acute care events for 32,330 Medicaid adults, ages 18–64 and with major depressive, bipolar, or schizophrenia spectrum disorders (SSD), who resided in FQHC service areas and received care from FQHCs vs. other settings in 2015. Multivariable linear regressions assessed associations between receiving care at FQHCs and outpatient mental health visits, psychotropic medication fills, and acute care events in 2016.ResultsThere were 8,887 (27.5%) adults in the study population (N = 32,330) who had at least one FQHC visit in 2015. Those who received care at FQHCs were more likely to have outpatient mental health visits (73.3% vs. 71.2%) and psychotropic medication fills (73.2% vs. 69.0%, both p < .05), including antidepressants among those with depressive disorders and antipsychotics among those with SSD. They were more likely to have ED visits (74.0% vs. 68.7%), but less likely to be hospitalized (27.8% vs. 31.9%, both p < .05). However, there was no significant difference in the likelihood of having an acute psychiatric hospitalization (9.5% vs. 9.8%, p = .35).ConclusionsAmong Medicaid enrollees with SMIs who had access to care at FQHCs, those receiving care at FQHCs were more likely to have outpatient mental health visits and psychotropic medication fills, with lower rates of hospitalization, suggesting potentially improved quality of outpatient care. Higher ED visit rates among those receiving care at FQHCs warrant additional investigation.

A disproportionate share of Federally Qualified Health Center (FQHC) users have a behavioral health condition, but there exists limited research examining changes in behavioral health provision in FQHCs. The objectives of this study were to describe how the provision of behavioral health services by FQHCs to the population of people with behavioral health conditions has changed over time in the US, how these trends varied across states, and whether the proportion of total delivered services that are behavioral health services has changed within FQHCs over time. Descriptive analysis using the Uniform Data System and Global Burden of Disease Datasets from years 2012 to 2019. From 2012 to 2019, FQHC behavioral health visits per 1,000 population with any behavioral health condition grew 103%, with a 26-fold difference in average rates across states during the study period. Annual behavioral health visits per patient increased from 3.2 to 2012 to 3.4 in 2019. From 2012 to 2019, the number of behavioral health visits per 1,000 FQHC patients grew by 51%, whereas the rate of asthma visits declined by 14%, heart disease visits declined by 4%, and hypertension and diabetes related visits remained stable (changing < 1% for both). Behavioral health visit growth at FQHCs outpaced national prevalence of behavioral health conditions. This growth was driven by FQHCs serving an increasing number of patients with behavioral health conditions, without sacrificing the frequency of visits for individual patients with behavioral health conditions.

Translating the Adenoma Detection Rate as a Quality Measure for Endoscopists to a Public Health Approach to Screening Underserved Patients for Colorectal Cancer

More than 1 in 5 children in low-income families report a mental health (MH) problem, yet most face barriers accessing MH services. Integrating MH services into primary care at pediatric practices such as federally qualified health centers (FQHCs) may address these barriers. To examine the association of a comprehensive MH integration model with health care utilization, psychotropic medication use, and MH follow-up care among Medicaid-enrolled children at FQHCs. This retrospective cohort study used Massachusetts claims data from 2014 to 2017 to conduct difference-in-differences (DID) analyses before vs after implementation of a complete FQHC-based MH integration model. The sample included Medicaid-enrolled children aged 3 to 17 years who received primary care at 3 intervention FQHCs or 6 geographically proximal nonintervention FQHCs in Massachusetts. Data were analyzed in July 2022. Receipt of care at an FQHC implementing the Transforming and Expanding Access to Mental Health Care in Urban Pediatrics (TEAM UP) model, which began fully integrating MH care into pediatrics in mid-2016. Utilization outcomes included primary care visits, MH service visits, emergency department (ED) visits, inpatient admissions, and psychotropic medication use. Follow-up visits within 7 days of a MH-related ED visit or hospitalization were also examined. Among the 20 170 unique children in the study sample, at baseline (2014), their mean (SD) age was 9.0 (4.1) years, and 4876 (51.2%) were female. In contrast to nonintervention FQHCs, TEAM UP was positively associated with primary care visits with MH diagnoses (DID, 4.35 visits per 1000 patients per quarter; 95% CI, 0.02 to 8.67 visits per 1000 patients per quarter) and MH service use (DID, 54.86 visits per 1000 patients per quarter; 95% CI, 1.29 to 108.43 visits per 1000 patients per quarter) and was negatively associated with rates of psychotropic medication use (DID, -0.4%; 95% CI -0.7% to -0.01%) and polypharmacy (DID, -0.3%; 95% CI, -0.4% to -0.1%). TEAM UP was positively associated with ED visits without MH diagnoses (DID, 9.45 visits per 1000 patients per quarter; 95% CI, 1.06 to 17.84 visits per 1000 patients per quarter), but was not significantly associated with ED visits with MH diagnoses. No statistically significant changes were observed in inpatient admissions, follow-up visits after MH ED visits, or follow-up visits after MH hospitalizations. The first 1.5 years of MH integration enhanced access to pediatric MH services while limiting the use of psychotropic medications. Additional implementation time is necessary to determine whether these changes will translate into reductions in avoidable utilization.

Public-Academic Partnerships: Early Intervention for Psychotic Disorders in a Community Mental Health Center

BackgroundMore than half of cancers could be prevented by employing evidence-based interventions (EBIs), including prevention interventions targeting nutrition, physical activity, and tobacco. Federally qualified health centers (FQHCs) are the primary source of patient care for over 30 million Americans — making them an optimal setting for ensuring evidence-based prevention that advances health equity. The aims of this study are to (1) determine the degree to which primary cancer prevention EBIs are being implemented within Massachusetts FQHCs and (2) describe how these EBIs are implemented internally and via community partnerships.MethodsWe used an explanatory sequential mixed methods design to assess the implementation of cancer prevention EBIs. First, we collected 34 quantitative surveys from staff at 16 FQHCs across Massachusetts to determine the frequency of EBI implementation. We followed up with 12 qualitative one-on-one interviews among a sample of staff to understand how the EBIs selected on the survey were implemented. Exploration of contextual influences on implementation and use of partnerships was guided by the Consolidated Framework for Implementation Research (CFIR). Quantitative data were summarized descriptively, and qualitative analyses used reflexive, thematic approaches, beginning deductively with codes from CFIR, then inductively coding additional categories.ResultsAll FQHCs indicated they offered clinic-based tobacco interventions, such as clinician-delivered screening practices and prescription of tobacco cessation medications. Quitline interventions and some diet/physical activity EBIs were available at all FQHCs, but staff perceptions of penetration were low. Only 38% of FQHCs offered group tobacco cessation counseling and 63% referred patients to mobile phone-based cessation interventions. We found multilevel factors influenced implementation across intervention types — including the complexity of intervention trainings, available time and staffing, motivation of clinicians, funding, and external policies and incentives. While partnerships were described as valuable, only one FQHC reported using clinical-community linkages for primary cancer prevention EBIs.ConclusionsAdoption of primary prevention EBIs in Massachusetts FQHCs is relatively high, but stable staffing and funding are required to successfully reach all eligible patients. FQHC staff are enthusiastic about the potential of community partnerships to foster improved implementation—providing training and support to build these relationships will be key to fulfilling that promise.