Behavioral Health Organizations Research Articles

BH, tech collaboration aims to transform telehealth, online group therapy

A behavioral health organization and a provider of virtual classrooms and online solutions have collaborated to offer patients evidence‐based mental health and addiction treatment through an interactive and online option. Officials, who announced the partnership in September, said the effort delivers personalized individual and group treatment plans in a secure, compliant and engaging online space.

The Role of Certified Community Behavioral Health Centers in Improving Access to Peer-Supported Services.

Peer support workers (PSW) improve outcomes for people with behavioral health needs, but integrating PSWs into routine behavioral healthcare has been challenging. Certified Community Health Centers (CCBHC), a new comprehensive care model, provides new opportunities to increase access to PSWs. The present study examines whether PSW utilization changed following one organization's transition to a CCBHC. Administrative data from a large behavioral health organization was used to examine changes in peer delivered services before and after CCBHC implementation. Chi-square analyses examined changes in the number of visits delivered by peers. Logistic regression examined differences in the likelihood of accessing PSW services during pre and post timepoints. Following CCHC implementation, the overall number of PSW visits delivered within substance use and transition age youth programs increased. In contrast, the number of PSW visits in community-based intensive case management program decreased. Clients with opioid use disorders were more likely to have accessed PSW services following CCBHC implementation. Results reflect that CCBHC designation generally increased the number of PSW visits within this organization; however, changes in peer service utilization were primarily concentrated among individuals with opioid use disorders and within substance use and transitional aged youth programs. This study provides novel insight into how PSWers are being integrated into the CCBHC model.

Randomized trial of the leadership and organizational change for implementation (LOCI) strategy in substance use treatment clinics

IntroductionEvidence-based practice (EBP) implementation represents a strategic change that requires alignment of leadership and support throughout organizations. Leadership and Organizational Change for Implementation (LOCI) is a multifaceted implementation strategy that aims to improve implementation leadership and climate within organizations through iterative cycles of leadership and climate assessment and feedback, leadership training and coaching, and strategic planning with upper-level leaders. This study tested the effects of LOCI on transformational and implementation leadership, implementation climate, implementation citizenship behavior, and EBP reach. MethodsA multiple cohort, cluster randomized trial tests the effect of LOCI in 60 clinics across nine behavioral health organizations in California and Arizona, USA. The study randomized clinics within organizations to either LOCI or a leadership training webinar control condition in three consecutive cohorts. Repeated web-based surveys of direct service providers (nLOCI = 201, nControl = 179) assessed leadership, implementation climate, and implementation citizenship over time. Multilevel autoregressive modeling was the primary statistical analysis such that providers (level-1) were nested within clinics (level-2). The study predicted between-condition differences at 4-, 8-, and 12-month follow-up assessments. Provider engagement in a fidelity monitoring process assessed reach of motivational interviewing (i.e., number of sessions recorded/submitted for fidelity coding). An independent sample t-test explored between condition differences in motivational interviewing reach. ResultsResults indicated between condition differences at 4 months for implementation leadership, implementation climate, and implementation citizenship behavior such that greater improvements were evidenced in the LOCI condition compared to the control condition. Reach of MI was significantly greater in the LOCI vs control condition such that LOCI providers were significantly more likely to engage in the fidelity monitoring process (chi-square (1, n = 370) = 5.59, p = .018). ConclusionsLOCI was developed based on organizational theories of strategic leadership and climate to affect organizational change processes that communicate that innovation implementation is expected, supported, and recognized as a value of the organization. The LOCI implementation strategy resulted in more positive hypothesized outcomes compared to the control condition. Organizational change strategies have utility for implementing health innovations in complex, multilevel contexts and for greater sustainment of facilitative leader behaviors, strategic implementation climate, and improved implementation outcomes. Trial registrationThis study is registered with Clinicaltrials.gov gov (NCT03042832, 2 February 2017; retrospectively registered).

CBHOs, telehealth platform partner to increase care access, reduce no‐shows

Breaking down barriers to care and providing comprehensive support to individuals in need, four community behavioral health organizations (CBHOs) have aligned with a patient engagement and telehealth platform for mental and behavioral health. The aim is to ‘revolutionize’ access to mental health care, reduce no‐show rates and enhance mental health services within their communities.

Substance use disorder treatment carve outs in Medicaid managed care

IntroductionMedicaid managed care organizations (MCO) play a major role in addressing the nation's epidemic of drug overdose and mortality by administering substance use disorder (SUD) treatment benefits for over 50 million Americans. While it is known that some Medicaid MCO plans delegate responsibility for managing SUD treatment benefits to an outside “carve out” entity, the extent and structure of such carve out arrangements are unknown. This is an important gap in knowledge, given that carve outs have been linked to reductions in rates of SUD treatment receipt in several studies. To address this gap, we examined carve out arrangements used by Medicaid MCO plans to administer SUD treatment benefits in ten states. MethodsData for this study was gleaned using a purposive sampling approach through content analysis of publicly available benefits information (e.g., member handbooks, provider manuals, prescription drug formularies) from 70 comprehensive Medicaid MCO plans in 10 selected states (FL, GA, IL, MD, MI, NH, OH, PA, UT, and WV) active in 2018. Each Medicaid MCO plan's documents were reviewed and coded to indicate whether a range of SUD treatment services (e.g., inpatient treatment, outpatient treatment, residential treatment) and medications were carved out, and if so, to what type of entity (e.g., behavioral health organization). ResultsA large majority of Medicaid MCO plans carved out at least some (28.6 %) or all (40.0 %) SUD treatment services, with nearly all plans carving out some (77.1 %) or all (14.3 %) medications, mainly due to the carving out of methadone treatment. Medicaid MCO plans most commonly carved out SUD treatment services to behavioral health organizations, while most medications were carved out to state Medicaid fee-for-service plans. ConclusionsCarve out arrangements for SUD treatment vary dramatically across states, across plans, and even within plans. Given that some studies have linked carve out arrangements to reductions in treatment access, their widespread use among Medicaid MCO plans is cause for further consideration by policymakers and other key interest groups. Moreover, reliance on such complex arrangements for administering care may create challenges for enrollees who seek to learn about and access plan benefits.

Specifying cross-system collaboration strategies for implementation: a multi-site qualitative study with child welfare and behavioral health organizations

BackgroundCross-system interventions that integrate health, behavioral health, and social services can improve client outcomes and expand community impact. Successful implementation of these interventions depends on the extent to which service partners can align frontline services and organizational operations. However, collaboration strategies linking multiple implementation contexts have received limited empirical attention. This study identifies, describes, and specifies multi-level collaboration strategies used during the implementation of Ohio Sobriety Treatment and Reducing Trauma (Ohio START), a cross-system intervention that integrates services across two systems (child welfare and evidence-based behavioral health services) for families that are affected by co-occurring child maltreatment and parental substance use disorders.MethodsIn phase 1, we used a multi-site qualitative design with 17 counties that implemented Ohio START. Qualitative data were gathered from 104 staff from child welfare agencies, behavioral health treatment organizations, and regional behavioral health boards involved in implementation via 48 small group interviews about collaborative approaches to implementation. To examine cross-system collaboration strategies, qualitative data were analyzed using an iterative template approach and content analysis. In phase 2, a 16-member expert panel met to validate and specify the cross-system collaboration strategies identified in the interviews. The panel was comprised of key child welfare and behavioral health partners and scholars.ResultsIn phase 1, we identified seven cross-system collaboration strategies used for implementation. Three strategies were used to staff the program: (1) contract for expertise, (2) provide joint supervision, and (3) co-locate staff. Two strategies were used to promote service access: (4) referral protocols and (5) expedited access agreements. Two strategies were used to align case plans: (6) shared decision-making meetings, and (7) sharing data. In phase 2, expert panelists specified operational details of the cross-system collaboration strategies, and explained the processes by which strategies were perceived to improve implementation and service system outcomes.ConclusionsWe identified a range of cross-system collaboration strategies that show promise for improving staffing, service access, and case planning. Leaders, supervisors, and frontline staff used these strategies during all phases of implementation. These findings lay the foundation for future experimental and quasi-experimental studies that test the effectiveness of cross-system collaboration strategies.

Disclosing Recovery: A pilot randomized controlled trial of a patient decision aid to improve disclosure processes for people in treatment for opioid use disorder

IntroductionPeople engaged in treatment for opioid use disorder (OUD) report struggling with whether and how to disclose, or share information about their OUD history and/or treatment with others. Yet, disclosure can act as a gateway to re-establishing social connection and support during recovery. The current study describes a pilot randomized controlled trial of Disclosing Recovery: A Decision Aid and Toolkit, a patient decision aid designed to facilitate disclosure decisions and build disclosure skills. MethodsParticipants (n = 50) were recruited from a community-based behavioral health organization in 2021–2022 and randomized to receive the Disclosing Recovery intervention versus an attention-control comparator. They responded to surveys immediately after receiving the intervention as well as one month following the intervention at a follow-up appointment. Primary outcome analyses examined indicators of implementation of the intervention to inform a future efficacy trial. Secondary outcome analyses explored impacts of the intervention on the decision-making process, disclosure rates, and relationships. ResultsParticipants were successfully recruited, randomized, and retained, increasing confidence in the feasibility of future efficacy trials to test the Disclosing Recovery intervention. Moreover, participants in the Disclosing Recovery intervention agreed that the intervention is acceptable, feasible, and appropriate. They additionally reported a higher quality of their decision-making process and decisions than participants in the comparator condition. At their follow-up appointment, participants with illicit opioid use who received the Disclosing Recovery intervention were less likely to disclose than those who received the comparator condition. Moreover, significant interactions between illicit opioid use and the intervention condition indicated that participants without illicit opioid use who received the Disclosing Recovery intervention reported greater closeness to and social support from their planned disclosure recipient than those who received the comparator condition. ConclusionsThe Disclosing Recovery intervention appears to be an acceptable, feasible, and appropriate patient decision aid for addressing disclosure processes among people in treatment for OUD. Moreover, preliminary results suggest that it shows promise in improving relationship closeness and social support in patients without illicit opioid use. More testing is merited to determine the intervention's efficacy and effectiveness in improving relationship and treatment outcomes for people in treatment for OUD.

Coping with COVID-19: Standing up a comprehensive behavioral health response to the pandemic.

Integrating behavioral health (BH) into disaster preparedness and response is essential to mitigate and address the BH impacts of disasters, support incident response personnel well-being, and to integrate disaster BH concepts into response strategies and communications. This article describes the development, implementation, and lessons learned from a statewide BH response to this disaster by the COVID-19 Behavioral Health Group (COVID-19 BHG). Operating within the Washington State Department of Health (WA DOH), the BHG is comprised of psychologists and psychiatrists with expertise in disaster BH and response, BH epidemiologists, data analysts, systems specialists, emergency managers, and other DOH staff. The wide array of expertise on the team allowed the COVID-19 BHG to build response functions to match the demands created by the pandemic. This included an Impact & Capacity Assessment function, which developed and distributed monthly impact forecasts and weekly BH situational reports. A Training and Guidance team then collaborated with partners to develop and deliver trainings, resource documents, and public messaging. Additionally, the COVID-19 BHG worked closely with the Health Care Authority (HCA) and BH organizations statewide to maintain the ability of the BH system to deliver care and expand services to meet additional needs. This article describes the development and deployment of an innovative and unique statewide BH response, within the WA DOH during the COVID-19 pandemic.

BH organization launches AI platform to address recovery gap

Observing the need to address the one‐year recovery gap when industry relapse rates are exceedingly high, an Irvine, California‐based behavioral health organization last week announced the launch of a new artificial intelligence (AI)‐driven platform to track patient progress for 12 months after discharge from a behavioral health treatment program.

Whole person care: Outcomes from a 5-year care model integrating primary care into a behavioral health clinic.

Integrated mental and physical health care has the potential to improve health outcomes. A behavioral health organization established a reverse integration program site using a co-located model to provide primary care services to patients receiving behavioral health services. We ask whether this model of co-located care was effective in improving a range of physical health outcomes for clients. This program was funded with a grant from the Substance Abuse and Mental Health Services Administration Primary and Behavioral Health Care Integration. Patients received services in a community mental health setting that embedded primary care services. The population included adult patients with mental illness, substance use disorder (SUD), or co-occurring medical diagnoses in an urban setting. Just under half of the patients identified as non-White, and over one quarter identified as Hispanic. These characteristics demonstrate a medically complex and underserved population. This description and exploratory analysis utilized National Outcome Measures data and clinical health measures from electronic health records. We stratified data by SUD and mental illness diagnoses. We measured changes in health outcomes for this complex population of 532 patients from 2015 to 2019. From enrollment to last visit, patient outcomes improved for blood pressure and cholesterol. Conversely, waist circumference and breath carbon monoxide levels significantly worsened. This reverse integration co-location program demonstrates that positive health outcomes can be achieved through evidence-based care, adaptable clinic arrangements, and robust community connections and support. More work is needed to generate positive health outcomes in medically complex patients. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Reconnecting Hope: The Treatment of Eating Disorders in Rural America

Eating disorders (EDs), a significant public health concern, impact millions of Americans every year. Many people with EDs are often overlooked for multiple reasons, including the stereotype that EDs predominantly affect thin, White, affluent young women and girls. One historically overlooked group is impoverished individuals in rural areas of the United States (U.S.), who may, in fact, be at an increased risk for EDs. The Reconnect Eating Disorders treatment program (REDTP) at Ozark Center is the first comprehensive, evidence-based, multidisciplinary ED treatment program to be developed in a Certified Community Behavioral Health Organization (CCBHO) in the U.S. CCBHOs are a unique model of financially sustainable integrated care well-suited to the treatment of biopsychosocial illnesses such as EDs because CCBHOs offer a full range of services to treat both physical and mental health. This paper details the development of REDTP, including its team, barriers, and successes. The role of Community Support Specialists/Reconnect Coaches and Healthcare Home/Medical Support is reviewed, which includes providing outpatient care and intensifying treatment for the most acute clients. Key domains of growth for REDTP included selecting core evidence-based treatments, building a team and defining team roles, and intensive training to develop evidence-based ED expertise. Persistent barriers included staffing limitations for providing intensive treatment to a small number of clients. Adult case studies of REDTP clients are presented. Recommendations for future ED and other specialized treatment programs in low resource agencies are provided.

Principles for secondary traumatic stress-responsive practice: An expert consensus approach.

Though research on secondary traumatic stress (STS) has greatly increased in the past decade, to date the field lacks a coherent set of guiding principles for practice that behavioral health providers and organizations can use to mitigate the occurrence and impact of STS. As such it is important to identify effective strategies, grounded in research and professional experience, to reduce the occurrence and impact of STS among behavioral health professionals and organizations. We conducted a four-stage modified Delphi survey. Thirty-one international STS experts were invited to participate, with a minimum of 19 responding in each round. Thematic analysis was conducted on qualitative data, which was incorporated into revisions of the principles. Consensus was achieved on 14 principles, seven targeted at individual professionals, and seven targeted at organizations. This is the first effort to delineate principles for practice intended to reduce the occurrence and impact of STS in individual and organizational practice in behavioral health services. The principles are intended to inform best practices for individuals and organizations providing services to persons and communities who have experienced trauma and thereby improve the quality and effectiveness of services to traumatized populations. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Predicting successful placements for youth in child welfare with machine learning

Out-of-home placement decisions have extremely high stakes for the present and future well-being of children in care because some placement types, and multiple placements, are associated with poor outcomes. We propose that a clinical decision support system (CDSS) using existing data about children and their previous placement success could inform future placement decision-making for their peers. The objective of this study was to test the feasibility of developing machine learning models to predict the best level of care placement (i.e., the placement with the highest likelihood of doing well in treatment) based on each youth’s behavioral health needs and characteristics. We developed machine learning models to predict the probability of each youth’s treatment success in psychiatric residential care (i.e., Psychiatric Residential Treatment Facility [PRTF]) versus any other placement (AUROCs > 0.70) using data collected in standard care at a behavioral health organization. Placement recommendations based on these machine learning models distinguished between youth who did well in residential care versus non-residential care (e.g., 80% of those who received care in the recommended setting with the highest predicted likelihood of success had above average risk-adjusted outcomes). Then we developed and validated machine learning models to predict the probability of each youth’s treatment success across specific placement types in a state-wide system, achieving an average AUROC score of >0.75. Machine learning models based on risk-adjusted behavioral health and functional data show promise in predicting positive placement outcomes and informing future placement decisions for youth in care. Related ethical considerations are discussed.

Competing allegiance in an unclear role: Peer and non-peer understanding of peer support in Massachusetts, United States

Lack of role clarity is a central challenge to the growth and retention of the peer workforce as peer support specialists (PSS) increasingly work alongside non-peer providers in traditional mental healthcare settings. This study examined role clarity among peer and non-peer workers and identifies areas of consensus and disagreement in understanding the peer role. Qualitative interviews were conducted with PSS (N = 18), non-peer direct care staff (N = 15), and non-peer clinical staff (N = 6) employed at two behavioral health organizations in the Northeast. Thematic analysis was conducted. Most non-peer staff have generally positive attitudes towards the inclusion of PSS in behavioral healthcare organizations, and task overlap was not indicated as problematic. Non-peer staff report and demonstrate a wide range of understanding but little clarity about the peer role, and peer staff themselves describe diverging descriptions of their own role. A consensus emerged regarding peer roles related to individual and group support, facilitating community integration, and relationship building. Key areas of disagreement include peer inclusion on clinical teams and role in service engagement. Competing peer and organizational ethos were identified as a central challenge of workplace integration. In sum, while peer tasks, roles, and responsibilities are perceived as valuable and non-overlapping with non-peer tasks, they remain ill-defined. Existing role tension is not based on task overlap but rather emerges from competing peer and organizational ethos and allegiances. Education and cultural humility among non-peer staff are critical to reducing interprofessional tension. Simultaneously, peer teams must develop cohesive peer ethos and role identity to ensure internal role clarity.

The role of health plans in addressing the opioid crisis: A qualitative study

IntroductionHealth plans are key players in substance use treatment in the United States, and the opioid crisis presents new challenges for them. This article is part of the HEALing Communities Study (HCS) funded by NIH, which seeks to facilitate communities' adoption of activities that might reduce overdose deaths, including overdose prevention education and naloxone distribution, medication for opioid use disorder, and safer opioid prescribing. We examine how health plans in one state (Massachusetts) are adapting to encourage and sustain activities that help communities to address opioid use disorder (OUD). MethodsWe conducted semi-structured interviews with managers of behavioral health services at eight health plans in Massachusetts that that have Medicare, Medicaid, and commercial lines of business. Two plans in this sample contract with a specialized behavioral health organization (“carve-out”). The interviewees also completed a survey on policies regarding access to treatment and opioid prescribing. Interviews were recorded and transcribed and analyzed using thematic analysis. Analysis of the data included intended influence of the policies at three levels: member level (micro), group or community level (meso), and system or institutional level (macro). ResultsAll health plans developed strategies to increase access to treatment for OUD, primarily through eliminating or decreasing cost-sharing, eliminating pre-authorization for MOUD, and increasing supply of providers. Health plans encourage qualified practitioners to offer MOUD, but most do not provide incentives or training. Identifying high risk populations is a focus of health plans in this sample. Naloxone is a covered benefit in all health plans, although with variation in monthly limits and cost-sharing. Most health plans take measures to influence opioid prescribing. Health plans' activities are predominately aimed at the micro (member) level with little ability to influence at the macro (wider system-level changes). ConclusionThis study provides insight into how health plans develop strategies to address the rise in OUD and fatal opioid overdoses, many of which are key in the HCS initiative. How active a role health plans play in addressing the opioid crisis varies, even within the insurance industry in one state (Massachusetts).

Opening the “black box” of organizational coaching for implementation

BackgroundOrganizational coaching to promote the implementation of evidence-informed interventions is becoming more popular in healthcare organizations. In order to open the “black box” of coaching for implementation, we first developed, then tested the rigor and utility of a model of coaching for implementation.MethodsInterviews with nine experienced coaches were conducted and inductively coded to develop a model of coaching for implementation. Later, forty coaching calls with behavioral health organizations in Ohio, Wisconsin, and Florida were analyzed with directed content analysis using a priori codes based on this model.ResultsThe coaching work that occurred during these calls aligned closely with the model of coaching for implementation developed by our team. Most coaching work was devoted to building capacity; almost as much work focused on building relationships. Very little coaching work was dedicated to building sustainability. Use of tools for organizational change and implementation remained relatively consistent across all coaching periods.ConclusionUnderstanding what occurs during a successful coaching intervention will improve the effectiveness of coaching as an implementation strategy. Future research should focus on which processes and patterns make coaching more likely to promote specific implementation outcomes.

15.2 Psychotropic Medication and Quality Improvement Opportunities Within a Medicaid Behavioral Health Managed Care Organization

Managed care organizations (MCOs) have the responsibility to monitor utilization of behavioral health services and psychotropic medications, along with quality and safety of care, and can use their data to develop quality improvement activities (QIAs). Community Care Behavioral Health Organization, a public behavioral health MCO (BH-MCO), developed a QIA regarding pediatric polypharmacy, because the use of concurrent psychotropics has limited evidence raising quality and safety concerns.

Maine's Overdose Prevention Through Intensive Outreach, Naloxone and Safety (OPTIONS) Initiative.

This article outlines the successes, barriers, and lessons learned in implementing the Overdose Prevention Through Intensive Outreach, Naloxone and Safety (OPTIONS) initiative in Maine during its first year. With leadership from the Governor's Office, the Department of Health and Human Services, and the Department of Public Safety, the Office of Behavioral Health contracted with behavioral health organizations to hire and provide supervision for 16 clinicians. These behavioral health clinicians, known as OPTIONS liaisons, were each assigned to provide services for one county in the state and were embedded within a public safety agency. A technical assistance team was also assembled to assist in guiding implementation and improving this public health and public safety partnership.

Substance Use Screening, Brief Intervention, and Referral to Treatment in Multiple Settings: Evaluation of a National Initiative

PurposeThis study evaluated the implementation and outcomes of a multisite initiative to identify and intervene in adolescent substance use across the many settings where youth interact. This paper focuses on the implementation and intermediate outcomes of the initiative, while others in the supplement address impact and ultimate outcomes. MethodsA mixed-methods cross-grantee evaluation was conducted from 2014 to 2019 among 56 recipients of funding from the Conrad N. Hilton Foundation to implement screening, brief intervention, and referral to treatment (SBIRT) across more than 1,266 youth-facing settings. Qualitative and quantitative data were collected from grantees on a quarterly basis, as well as from grantee proposals, progress reports, monthly grantee monitoring calls, and survey findings. ResultsGrantees reported increased capacity to provide SBIRT to youth across various settings: pediatric and primary care practices, community behavioral health organizations, juvenile justice programs, schools, and community-based organizations. Collectively, grantees screened 141,230 youth for substance use, 12,272 received a brief intervention, and 2,212 were referred to treatment. As part of the initiative, grantees provided SBIRT training to over 37,000 nursing and social work students, medical residents, addiction medicine fellows, and others. Implementation challenges included fitting screening into the workflow of primary care settings, confidentiality and consent in schools, reimbursement, and lack of specialist providers to refer to for substance use disorder treatment. Intermediate outcomes collected include total numbers of youth screened, received a brief intervention, and/or referred to more intensive treatment based on their screening scores. ConclusionsResearch on SBIRT in adolescents has been limited to date despite positive outcomes reported in adults. This mixed-methods evaluation of an initiative to expand SBIRT implementation demonstrates feasibility of expanding access to substance use screening and intervention for youth across multiple settings and identifies challenges of implementation that differ somewhat based on settings.

Utilizing SBIRT as a Framework for Transforming How We Think About Prevention and Early Intervention for Youth and Young Adults

Utilizing SBIRT as a Framework for Transforming How We Think About Prevention and Early Intervention for Youth and Young Adults