Behavioral Health System Research Articles

Infrastructure development in children's behavioral health systems of care: essential elements and implementation strategies.

To improve the outcomes of children's behavioral health systems, states must invest in expanding infrastructure; however, infrastructure is a commonly used and poorly understood concept. This paper aims to provide a definition of infrastructure in the context of state-level children's behavioral system of care development and describes five essential infrastructure elements: an integrated governance and decision-making structure; structures and processes for blended and braided funding; a central point of access for information, referral, and linkage; workforce development, training, and coaching in effective practices; and data and quality improvement mechanisms. Suggested implementation activities are offered for each of the five proposed infrastructure components. The important role of public-private partnership, particularly with intermediary organizations, is described, and future directions for research and scholarship are proposed.

Managing Eating Disorders Within Medicaid-Funded Health Care Systems in California.

This study describes the current management of patients with eating disorders (EDs) served by publicly-funded Medicaid behavioral health systems. Behavioral health leaders across nine counties in California met on a quarterly basis to share experiences, challenges, and lessons in the management of EDs within publicly-funded service systems. Detailed notes were taken, and a qualitative content analysis was undertaken to identify key themes. County leadership noted insufficient outpatient capacity and difficulty building capacity for ED treatment, in addition to extraordinary challenges when facilitating admission to out-of-network higher level of care programs, at significant expense. Several challenges were identified in building an internal ED workforce, including the fact that many providers weren't eager to treat EDs due to training burden, patient complexity, and high levels of clinician burnout. When a higher level of care was required due to lack of outpatient resources or patient symptom severity or complexity, leaders dedicated significant resources to identify and contract with an appropriate program and secure the necessary funds. Our study supports the need for specialized ED treatment and case management, as well as standardized processes and centralized resources, in Medicaid-managed care. Findings also indicate the importance of protecting against clinician burnout, possibly through reduced caseload expectations, financial incentives, or increased support. Future policy change could reduce administrative burden and clinician burnout by facilitating admission to and reimbursement for higher levels of care.

The Role of Local Health Departments in Addressing the Opioid Crisis and Deploying Opioid Settlement Funds.

This article examines the evolving role of local health departments in North Carolina's opioid crisis response. Highlighting strategies like community mobilization, data prioritization, and regional partnerships, it illustrates the impact of opioid settlement funds in empowering local health departments to manage behavioral health systems and implement effective opioid abatement interventions.

An Applied Research Partnership to Improve The Children’s Behavioral Health System Of Care

Objective and ApproachThis session describes a doctoral student-led process to align research, policy, and practice partners around the use of integrated data to address a policy priority—the mounting youth mental health crisis. The project partners engaged in a five-year governance process to leverage integrated administrative data from a large health and human service agency in one U.S. state. Qualitative field notes—collected while conducting quantitative analyses and engaging partners—were analyzed to document a realistic timeline and process for ethical, actionable research using cross-sector data. ResultsFive key lessons for partnership-engaged research emerged, emphasizing the importance of adapting to changes in project themes, leveraging strong partnership to address data quality concerns, nurturing existing and new relationships, balancing data access and data privacy, and supplementing administrative data with contextual data. ConclusionsThough engaging deeply with partners takes substantial time and energy, there are benefits to researchers, policymakers, practitioners, and most importantly, residents whose data are represented. Furthermore, building pathways to legally and ethically access integrated data can promote the efficient, strategic use of data for social policy research, and ultimately, be leveraged to support evidence-based policymaking in an ever-changing world. ImplicationsThis session underscores the value of forming applied research partnerships and building legal and ethical pathways to access integrated data when tackling complex social policy issues.

Factors Influencing Turnover and Attrition in the Public Behavioral Health System Workforce

Factors Influencing Turnover and Attrition in the Public Behavioral Health System Workforce

Use of standardized decision support instruments to inform child welfare decision-making: lessons from an implementation study

Research has demonstrated children in out-of-home care have experienced trauma and a significant proportion are in need of behavioral health services (e.g. Casaneuva et al., NSCAW II baseline report: Child well-being, US Department of Health and Human Services, Washington, DC, 2011). Accessing services requires interagency coordination between child welfare and behavioral health professionals; however, challenges to coordination and collaboration may result in lack of service utilization for many youth (Hanson et al. 2016). Utilizing a mixed methodological approach, this paper describes the results of a study conducted five years after full state-wide implementation of processes designed to promote the use of evidence-based practices to inform decision-making for youth dually served by the child welfare and behavioral health systems. Outcomes from the study were used to develop strategies to address programmatic concerns and reinforce implementation supports. Study findings may aid organizations seeking to reinforce data-informed practices and employ strategies for addressing barriers at the worker and agency level.

Assessing the Training for Certified Peer Support Specialists Who Provide Mental Health and Substance Use Services.

The behavioral health system's peer support workforce must be adequately trained to perform peer support services, but evidence of the adequacy of their training needs to be improved. With survey data from 667 certified peer support specialists (CPSS) from North Carolina, Kentucky, Virginia, and Tennessee, this study used (a) binomial probability test to assess perceptions about the adequacy of the workforce's training, (b) latent profile analysis to identify patterns and predictors of perceptions about the SAMHSA core competencies covered in their training, and (c) thematic analysis to identify additional training needs. Most respondents identified as White (72%), female (73%), and had some college education (83%). Most of the workforce (> 90%) felt prepared to provide services, regardless of their state. Highly and moderately sufficient coverage emerged as two distinct response patterns regarding coverage of the SAMSHA core competencies, with respondents' years of experience, state of residence, education level, race, and sense of preparedness predicting the probability of fitting into either profile. Participants desired additional training in trauma-informed practices, motivational interviewing, and new treatment approaches. Peers' experiences and perspectives were similar across different states. The findings suggest booster training sessions or continuing education opportunities are needed to maintain a robust and well-prepared peer support workforce. States should consider reciprocity agreements to enable the trained workforce to practice across states. A key implication for the training content is the need to incorporate contemporary issues relating to mental health and substance use disorders to better meet behavioral health needs.

Back to the basics: Addressing our individual and societal despair.

It started with a simple question on social media, "How is everybody doing?" (Elmo [@elmo], 2024). With this basic check-in from one of our most beloved Sesame Street characters, Elmo was able to reach millions of people and elicit responses that gave words to the feelings that the authors have been personally experiencing and noticing within my behavioral health (BH) colleagues and patients for some time now. Quite simply, we are struggling. Responses to Elmo's collective check-in demonstrated the depths of the current human experience, ranging from individual sadness, trauma, existential crises, despondence, mere survival, disbelief, and societal despair. Resilience for BH providers is possible if we return to the basics, what we are foundationally trained to do, and what Elmo reminded us works so well: facilitate human connection within ourselves, with our colleagues, with our patients, and to continue to advocate for this connection at a systemic level. Exploring fundamental questions about our well-being, showing empathy for each other's pain, and openly acknowledging our shared struggles allows for a way through this, together. As we practice these efforts at the individual level, broader policies to support the BH system must follow to offer an effective, resilient, and enduring BH system necessary for the world we live in. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Early development of local data dashboards to depict the substance use care cascade for youth involved in the legal system: qualitative findings from end users

IntroductionRates of substance use are high among youth involved in the legal system (YILS); however, YILS are less likely to initiate and complete substance use treatment compared to their non legally-involved peers. There are multiple steps involved in connecting youth to needed services, from screening and referral within the juvenile legal system to treatment initiation and completion within the behavioral health system. Understanding potential gaps in the care continuum requires data and decision-making from these two systems. The current study reports on the development of data dashboards that integrate these systems’ data to help guide decisions to improve substance use screening and treatment for YILS, focusing on end-user feedback regarding dashboard utility.MethodsThree focus groups were conducted with n = 21 end-users from juvenile legal systems and community mental health centers in front-line positions and in decision-making roles across 8 counties to gather feedback on an early version of the data dashboards; dashboards were then modified based on feedback.ResultsQualitative analysis revealed topics related to (1) important aesthetic features of the dashboard, (2) user features such as filtering options and benchmarking to compare local data with other counties, and (3) the centrality of consistent terminology for data dashboard elements. Results also revealed the use of dashboards to facilitate collaboration between legal and behavioral health systems.ConclusionsFeedback from end-users highlight important design elements and dashboard utility as well as the challenges of working with cross-system and cross-jurisdiction data.

Facilitators of and barriers to County Behavioral Health System Transformation and Innovation: an interview study

BackgroundInadequate and inequitable access to quality behavioral health services and high costs within the mental health systems are long-standing problems. System-level (e.g., fee-for-service payment model, lack of a universal payor) and individual factors (e.g., lack of knowledge of existing resources) contribute to difficulties in accessing resources and services. Patients are underserved in County behavioral health systems in the United States. Orange County’s (California) Behavioral Health System Transformation project sought to improve access by addressing two parts of their system: developing a template for value-based contracts that promote payor-agnostic care (Part 1); developing a digital platform to support resource navigation (Part 2). Our aim was to evaluate facilitators of and barriers to each of these system changes.MethodsWe collected interview data from County or health care agency leaders, contracted partners, and community stakeholders. Themes were informed by the Consolidated Framework for Implementation Research.ResultsFive themes were identified related to behavioral health system transformation, including 1) aligning goals and values, 2) addressing fit, 3) fostering engagement and partnership, 4) being aware of implementation contexts, and 5) promoting communication. A lack of fit into incentive structures and changing state guidelines and priorities were barriers to contract development. Involving diverse communities to inform design and content facilitated the process of developing digital tools.ConclusionsThe study highlights the multifaceted factors that help facilitate or hinder behavioral health system transformation, such as the need for addressing systematic and process behaviors, leveraging the knowledge of leadership and community stakeholders, fostering collaboration, and adapting to implementation contexts.

Family Medicine Physician Readiness to Treat Behavioral Health Conditions: A Mixed Methods Study.

Behavioral and mental health conditions present significant challenges in the United States where access to care is limited. Family medicine physicians play a crucial role in addressing these challenges, often serving as frontline clinicians for behavioral and mental health conditions. This study examined the current behavioral and mental health system in a predominantly rural 10-county region in the Southeastern United States through gap analysis in addition to a survey of preparedness and barriers among family medicine physicians in the region. Gap analysis results indicated that (1) stigma and lack of accessible education about behavioral and mental health, (2) fragmented resources, (3) inaccessible care, and (4) workforce shortage and burnout were primary drivers of poor outcomes in the region. Survey results indicated that physicians feel prepared to treat anxiety and depression but feel less prepared to manage bipolar disorder, schizophrenia, and substance use disorders. Respondents disagreed that there are adequate local resources and referral options for patients with behavioral and mental health conditions. Lack of timely access, distance, cost/insurance status, were all cited by respondents as barriers to appropriate care. Findings underscore the importance of supporting family medicine physicians to enhance behavioral and mental healthcare outcomes. Behavioral health integration in primary care settings is a promising strategy to improve care accessibility and clinician preparedness. Bridging gaps in health care outcomes requires collaborative efforts, enhanced training, and policy advocacy within the family medicine community to ensure comprehensive and equitable behavioral and mental healthcare delivery.

The Intersections Between Sexual Orientation, Latine Ethnicity, Social Determinants of Health, and Lifetime Suicide Attempts in a Sample Being Assessed for Entry to Co-Occurring Mental Health and Substance Use Disorder Treatment.

Few studies have examined the relationship between the intersections of lesbian, gay, and bisexual (LGB) sexual orientation, Latine ethnicity, and lifetime suicide attempts in Latine individuals with substance use disorder. This study examines this intersection and controls for social determinants of health, mental health disorder symptoms, and substance use disorder symptoms in a sample of Latine adults entering treatment for co-occurring disorders. Bivariate statistics and multivariate logistic regression were used to analyze assessment data (n = 360) from a bilingual/bicultural integrated behavioral health system serving Latine communities in Massachusetts to examine the relationship between sexual orientation, Latine ethnicity, and history of lifetime suicide attempts. We controlled for social determinants of health, mental health disorders, and substance use disorder (SUD) factors significantly associated with lifetime suicide attempts at the bivariate level. Over 27% of the sample and 35% of Puerto Ricans (PR) reported lifetime suicide attempts. The logistic regression identified that PR clients were 78% more likely to have attempted suicide in a lifetime compared to non-PR clients. Clients identifying as LGB were 3.2 times more likely to report having attempted suicide in their lifetime compared to heterosexual clients. Unemployed clients were 2.4 times more likely to report having attempted suicide in their lifetime compared to employed clients. Findings identify high rates of lifetime suicide attempts among LGBs and PRs entering SUD treatment. Targeted outreach and treatment efforts designed to address intersectionality for this underserved population are needed.

Science for behavioral health systems change: evolving research-policy-public partnerships.

Potent partnerships among researchers, policymakers, and community members have potential to produce positive changes in communities on a range of topics, including behavioral health. The paper provides a brief illustrative review of such partnerships and then describes the development and evolution of one partnership in particular in Virginia. The origin of the partnership is traced, along with its founding vision, mission, and values. Some of its several projects are described, including (a) needs assessment for implementation of evidence-based programs (EBPs) pursuant to the Family First Prevention Services Act; (b) statewide fidelity monitoring of key EBPs; and (c) projects to synergize state investments in specific EBPs, like multisystemic therapy, functional family therapy, and high fidelity wraparound. The paper concludes with some themes around which the center has evolved to serve the state and its citizens more effectively.

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.

Mitigating the impact of intimate partner violence in pregnancy and early childhood: A dyadic approach to psychotherapy

AbstractIntimate partner violence (IPV) is often considered an adult problem despite profound consequences for the children who are exposed toviolent relational patterns. About a third of children and adolescents report past exposure to parental IPV, and a majority were first exposed as infants. Exposure to IPV during pregnancy through the first 5 years of a child's life has consequences ranging from adverse birth outcomes to diagnosable emotional problems and lasting physiological dysregulation. This article reviews risks and consequences of IPV in pregnancy and early childhood and discusses a relational psychotherapeutic treatment approach (Child–Parent Psychotherapy) applied to both developmental stages to mitigate the adverse consequences of family violence on parents and their children. Research evidence for the effectiveness of Child–Parent Psychotherapy (CPP) among IPV‐exposed families is reviewed as are specific treatment components which seek to restore relational safety following familial violence. Additionally, clinical considerations unique to families with histories of or ongoing exposure to IPV are discussed. Finally, recommendations are presented to improve the integration between medical and early childhood behavioral health systems for families at highest risk for chronic IPV.

Behavioral health and legal system involvement among transition-age youth in foster care: a longitudinal analysis of youth in California

ABSTRACT Research shows that young people in foster care experience high levels of behavioral health problems that may lead to life obstacles, including legal system involvement (LSI) during the transition to adulthood. However, few longitudinal studies have examined LSI among foster youth from a behavioral health perspective during the transition to adulthood. To understand adolescent behavioral health conditions associated with adult LSI, we used longitudinal survey data of young people in foster care (n = 540) to compare the prevalence of different behavioral health disorders (age 17) between youth who later reported LSI and those who did not (ages 19–21). We also examined associations between adolescent behavioral health disorders and adult LSI, accounting for other covariates. We find that compared to those who did not, youth who reported later LSI in early adulthood had significantly higher rates of four behavioral health disorders at age 17: alcohol use, drug use, conduct disorder, and oppositional defiant disorder. Regression results showed drug use disorder at age 17 to be a particularly strong predictor of later LSI after accounting for other covariates. Many individuals experience various risk factors for LSI, including behavioral health needs. We discuss implications for practice, policy, and research in the child welfare context.

Building an Integrated Data Infrastructure to Examine the Spectrum of Suicide Risk Factors in Philadelphia Medicaid.

While there are many data-driven approaches to identifying individuals at risk of suicide, they tend to focus on clinical risk factors, such as previous psychiatric hospitalizations, and rarely include risk factors that occur in nonclinical settings, such as jails or emergency shelters. A better understanding of system-level encounters by individuals at risk of suicide could help inform suicide prevention efforts. In Philadelphia, we built a community-level data infrastructure that encompassed suicide death records, behavioral health claims, incarceration episodes, emergency housing episodes, and involuntary commitment petitions to examine a broader spectrum of suicide risk factors. Here, we describe the development of the data infrastructure, present key trends in suicide deaths in Philadelphia, and, for the Medicaid-eligible population, determine whether suicide decedents were more likely to interact with the behavioral health, carceral, and housing service systems compared to Medicaid-eligible Philadelphians who did not die by suicide. Between 2003 and 2018, there was an increase in the number of annual suicide deaths among Medicaid-eligible individuals, in part due to changes in Medicaid eligibility. There were disproportionately more suicide deaths among Black and Hispanic individuals who were Medicaid-eligible, who were younger on average, compared to suicide decedents who were never Medicaid-eligible. However, when we accounted for the racial and ethnic composition of the Medicaid population at large, we found that White individuals were four times as likely to die by suicide, while Asian, Black, Hispanic, and individuals of other races were less likely to die by suicide. Overall, 58% of individuals who were Medicaid-eligible and died by suicide had at least one Medicaid-funded behavioral health claim, 10% had at least one emergency housing episode, 25% had at least one incarceration episode, and 22% had at least one involuntary commitment. By developing a data infrastructure that can incorporate a broader spectrum of risk factors for suicide, we demonstrate how communities can harness administrative data to inform suicide prevention efforts. Our findings point to the need for suicide prevention in nonclinical settings such as jails and emergency shelters, and demonstrate important trends in suicide deaths in the Medicaid population.

Process and outputs from a community codesign workshop on reducing impact of heat exposure on pregnant and postpartum women and newborns in Kilifi, Kenya.

Ambient heat exposure is increasing due to climate change and is known to affect the health of pregnant and postpartum women, and their newborns. Evidence for the effectiveness of interventions to prevent heat health outcomes in east Africa is limited. Codesigning and integrating local-indigenous and conventional knowledge is essential to develop effective adaptation to climate change. Following qualitative research on heat impacts in a community in Kilifi, Kenya, we conducted a two-day codesign workshop to inform a set of interventions to reduce the impact of heat exposure on maternal and neonatal health. Participants were drawn from a diverse group of purposively selected influencers, implementers, policy makers, service providers and community members. The key domains of focus for the discussion were: behavioral practices, health facilities and health system factors, home environment, water scarcity, and education and awareness. Following the discussions and group reflections, data was transcribed, coded and emerging intervention priorities ranked based on the likelihood of success, cost effectiveness, implementation feasibility, and sustainability. Twenty one participants participated in the codesign discussions. Accessibility to water supplies, social behavior-change campaigns, and education were ranked as the top three most sustainable and effective interventions with the highest likelihood of success. Prior planning and contextualizing local set-up, cross-cultural and religious practices and budget considerations are important in increasing the chances of a successful outcome in codesign. Codesign of interventions on heat exposure with diverse groups of participants is feasible to identify and prioritize adaptation interventions. The codesign workshop was used as an opportunity to build capacity among facilitators and participants as well as to explore interventions to address the impact of heat exposure on pregnant and postpartum women, and newborns. We successfully used the codesign model in co-creating contextualized socio-culturally acceptable interventions to reduce the risk of heat on maternal and neonatal health in the context of climate change. Our interventions can be replicated in other similar areas of Africa and serve as a model for co-designing heat-health adaptation.

Operationalizing person-centered care in residential substance use disorder treatment

Introduction Person-centered care (PCC) is an ethical imperative with eight domains, but operation of some PCC domains in substance use disorder (SUD) treatment has been underexplored. Objective We sought to identify strategies for operationalizing eight PCC domains in SUD treatment facilities and themes across these strategies. Methods We recruited 36 clients and staff from a large publicly funded behavioral health system for individual, semi-structured qualitative interviews. Interviews explored preferences and care experiences for each PCC domain. We analyzed data using iterative categorization, identifying specific operationalization strategies and themes across operationalization strategies within each domain. Results PCC operationalization themes for residential SUD treatment included addressing social vulnerability of clients (e.g., through assistance with housing and navigation of criminal/legal systems), involving peer support specialists (e.g., to provide emotional support and aid transition out of care), supporting the client’s family throughout treatment (e.g., providing progress updates; increasing visitation opportunities in residential treatment), and facilitating patient choice within each domain (e.g., treatment type; housing type; roommate preferences in residential treatment.) Discussion & Conclusion Some PCC operationalization strategies are unique to SUD treatment. Several PCC operationalization strategies applied to multiple domains, suggesting conceptual overlap between domains.

A pilot of a veteran suicide prevention learning collaborative among community organizations: Initial results and outcomes.

Veteran suicide remains an ongoing public health concern in need of fresh, community-based initiatives. The Department of Veterans Affairs (VA) has built an enterprise-wide integrated behavioral health system that has pioneered numerous suicide prevention methods. However, most Veterans receive healthcare outside the VA, from organizations that may not be equipped to address Veteran suicide risk. One solution is implementing a VA/community suicide prevention learning collaborative to support organizations in implementing suicide prevention best practices for Veterans. Although learning collaboratives have a history of supporting improved patient safety in healthcare systems, to our knowledge, none have focused on Veteran suicide prevention. The current quality improvement project sought to pilot a VA/community suicide prevention learning collaborative in the broader Denver and Colorado Springs areas with 13 organizations that served, interacted with, or employed Veterans. The collaborative had a large footprint in the region, with organizations interacting with over 24,000 community members and over 5000 Veterans. Organizations implemented 92 Veteran suicide prevention program components within a 16-month period. Overall, the learning collaborative made significant strides in Veteran suicide prevention. Findings suggest that this method facilitates rapid implementation of Veteran suicide prevention practices and may be promising for accelerating uptake within communities.