Behavioral Health System Research Articles

Creating the necessary infrastructure for a trauma-informed system of care for children and youth.

Understanding and addressing the impact of adverse life events is an important priority in the design of helping systems. However, creating trauma-informed systems requires efforts to embed effective trauma-informed work in routine practice. This article discusses a model for developing trauma-informed systems using the Transformational Collaborative Outcomes Management (TCOM) framework, a strategy for engineering person-centered care. Person-centered care is naturally congruent with trauma-informed care. We describe the initial stages of implementation of a trauma-informed standardized assessment process to support the sustained evolution of trauma-informed care. Distinguishing between traumatic experiences and traumatic stress is fundamental to an effective trauma-informed system. We describe two sets of analyses-one in a statewide child welfare system and the other in a statewide behavioral health system. These projects found opportunities in the analysis of the detection of traumatic stress based on traumatic experiences to inform practice and policy. Being trauma-informed in child welfare is distinct from being trauma-informed in behavioral health. In child welfare, it appears that a number of children are resilient in the face of traumatic experiences and do not require trauma treatment interventions. However, delayed and missed traumatic stress responses are common. In behavioral health, misses often occur among adolescents, particularly boys, who engage in acting out behavior. Opportunities for the ongoing development of trauma-informed systems using the TCOM framework are discussed.

Factors Influencing Turnover and Attrition in the Public Behavioral Health System Workforce: Qualitative Study.

Many states are experiencing a behavioral health workforce crisis, particularly in the public behavioral health system. An understanding of the factors influencing the workforce shortage is critical for informing public policies to improve workforce retention and access to care. The aim of this study was to assess factors contributing to behavioral health workforce turnover and attrition in Oregon. Semistructured qualitative interviews were conducted with 24 behavioral health providers, administrators, and policy experts with knowledge of Oregon's public behavioral health system. Interviews were transcribed and iteratively coded to reach consensus on emerging themes. Five key themes emerged that negatively affected the interviewees' workplace experience and longevity: low wages, documentation burden, poor physical and administrative infrastructure, lack of career development opportunities, and a chronically traumatic work environment. Large caseloads and patients' high symptom acuity contributed to worker stress. At the organizational and system levels, chronic underfunding and poor administrative infrastructure made frontline providers feel undervalued and unfulfilled, pushing them to leave the public behavioral health setting or behavioral health altogether. Behavioral health providers are negatively affected by systemic underinvestment. Policies to improve workforce shortages should target the effects of inadequate financial and workplace support on the daily work environment.

Building a Community-Academic Partnership to Expand Workforce Development in Underserved, High-Need/High-Demand Areas.

This case study highlights the partnership development between a large, urban, public, community-based behavioral health system and an academic program. Using principles of partnership building and facilitators that enhance partnership building, we describe the process of initiating, building, and sustaining the partnership. The Health Resources and Services Administration (HRSA) workforce development initiative was the primary catalyst for the partnership development. The public, community-based behavioral health system is located in an urban, medically underserved area and health care professional shortage area. The academic partner is a master in social work (MSW) program in Michigan. We assessed partnership development by using process and outcome measures that captured changes in the partnerships and in implementation of the HRSA workforce development grant. The goals of this partnership were to develop the infrastructure to support the training of MSW students, expand workforce skills in integrated behavioral health, and increase the number of MSW graduates who work with medically underserved populations. During 2018-2020, the partnership trained 70 field instructors, engaged 114 MSW students in HRSA field placements, and developed 35 community-based field sites (including 4 federally qualified health centers). The partnership provided training for field supervisors and for HRSA MSW students and developed new courses/trainings focusing on integrated behavioral health assessment/intervention practices, trauma-informed care, cultural awareness, and telebehavioral health practices. Of 57 HRSA MSW graduates who responded to a postgraduation survey, 38 (66.7%) were employed in medically underserved, high-need/high-demand urban areas. Partnership sustainability was helped by formal agreements, regular communication, and a collaborative decision-making approach.

Retrospective State Medicaid Claims Analysis of Children and Adults With Obsessive-Compulsive Disorder.

With a lifetime U.S. prevalence of 2.3%, obsessive-compulsive disorder (OCD) is a chronic condition often producing reduced quality of life and disability when left untreated. Little is known about the prevalence or treatment of diagnosed OCD in public behavioral health systems. Using a claims analysis of 2019 New York State Medicaid data (N=2,245,084 children; N=4,274,100 adults), the authors investigated the prevalence and characteristics of children and adults with OCD. The authors also examined whether these individuals received treatment with medication or psychotherapy. The prevalence of OCD was 0.2% among children and 0.3% among adults. Fewer than half of children (40.0%) and adults (37.5%) received U.S. Food and Drug Administration-approved medications (with or without psychotherapy); another 19.4% of children and 11.0% of adults received 45- or 60-minute psychotherapy alone. These data demonstrate the need for public behavioral health systems to increase their capacity to identify and treat OCD.

National preparedness for 988—the new mental health emergency hotline in the United States

988, a national mental health emergency hotline number, went live throughout the United States in July 2022. 988 connects callers to the 988 Crisis & Suicide Lifeline, previously known as the National Suicide Prevention Lifeline. The transition to the three-digit number aimed to respond to a growing national mental health crisis and to expand access to crisis care. We examined preparedness throughout the U.S. for the transition to 988. In February and March 2022, we administered a national survey of state, regional, and county behavioral health program directors. Respondents (n = 180) represented jurisdictional coverage of 120 million Americans. We found that communities throughout the U.S. appeared ill-prepared for rollout of 988. Fewer than half of respondents reported their jurisdictions were ‘somewhat’ or ‘very’ prepared for 988 in terms of financing (29%), staffing (41%), infrastructure (41%), or service coordination (47%). Counties with higher representation of Hispanic/Latinx individuals were less likely to report being prepared for 988 in terms of staffing (OR: 0.62, 95 %CI: 0.45, 0.86) and infrastructure (OR: 0.68, 95 %CI: 0.48, 0.98). In terms of existing services, sixty percent of respondents reported a shortage of crisis beds and fewer than half reported availability of short-term crisis stabilization programs in their jurisdictions. Our study highlights components of local, regional, and state behavioral health systems in the U.S. that require greater investments to support 988 and mental health crisis care.

"Give up your mic": Building capacity and sustainability within community-based participatory research initiatives.

Community-based participatory research (CBPR) partnerships strive to promote community capacity building and sustainability, yet initiatives often suffer when grants or relationships with academic partners end. To address these concerns, researchers hoping to develop truly sustainable CBPR partnerships should consider factors that promote the development of community capacity and, ultimately, independence. In this first-person account, using perspectives gathered from FAVOR, a Connecticut-based family-led advocacy organization and an academic researcher, we examine the practices and experiences of the members of a CBPR partnership focused on using community voice to inform changes in the state's children's behavioral health system of care. These practices ultimately led to FAVOR developing the necessary skills to assume full ownership of the community data-gathering initiative, ensuring that the initiative would be sustained. Through the perspectives of five FAVOR staff and an academic researcher, we describe the factors that contributed to the organization being able to develop the capacity to independently continue their community data-gathering initiative, including description of the training process and staff members' perspectives on training, autonomy, community value, and lessons learned. We use these stories and experiences to provide recommendations for other partnerships striving to promote capacity building and sustainability through community ownership of the research process.

Human Services and Behavioral Health Integration: A Model for Whole-Person Medicaid Managed Care.

A comprehensive, whole-person approach to individuals' health care can be achieved by aligning, integrating, and coordinating health services with other human services. HealthChoices, Pennsylvania's managed Medicaid program, delegates responsibility for Medicaid-funded behavioral health service management to individual counties or multicounty collaboratives. County administrators' programmatic and fiscal oversight of Medicaid-funded services allows them to create synergies between behavioral health and other human service delivery systems and to set priorities on the basis of local needs. This model supports access to community-based care, integration of general medical and behavioral health services, and programs that address social determinants of health.

The Utilization Profiles of Comprehensive School Mental and Behavioral Health Needs Among Adolescents.

Schools have become a primary access point for mental health services to cover the gap between need and service utilization that has long existed, particularly among vulnerable populations. This study aims to identify the profiles of comprehensive school mental and behavioral health system (CSMBHS) needs and examine related characteristics. We used the 2019 National Survey of Drug Use and Health (NSDUH) collected from a nationally representative sample in the United States. The sample included 6th through 12th-grade adolescents who had received CSMBHS services in the last 12 months (N=1346). The study conducted latent class analysis and multinomial logistic regression using Vermunt's 3-step approach. The analysis identified 3 profiles of student CSMBHS service need: depression needs (42%), multiple endorsements in most needs (depressed, friend, and school problems; 6.5%), and low endorsement (51.4%). Findings suggest that the profiles differed by age, a lifetime major depressive episode, family income, and use of other mental health services. Emphasis should be placed on proactively identifying student needs and advocating for appropriate interventions based on student needs. The study reveals important information regarding how schools best support students in need and in seeking services.

Differentiating Between Youth with a History of Suicidal Thoughts, Plans, and Attempts

Limited research has examined factors distinguishing between patterns of adolescent suicidal thoughts and behaviors. The current study examined demographic, school, family, and mental health differences across patterns identified by Romanelli and colleagues (2022): history of thoughts only, plans with thoughts, attempt with thoughts and/or plans, and attempt without thoughts. The current study includes 4,233 students (Mage = 14.65 years, SD = 2.06) with a history of suicide risk referred to school Student Assistance Program teams. The sample was approximately 60.7% female, 59.8% White (16.0% Black, 15.4% multiracial, 8.8% other), and 14.4% Hispanic. Results indicated that the “attempt without thoughts” group was small with no differentiating characteristics. However, membership in the other three groups was predicted by demographic, school, family, and mental health factors. These results support the importance of examining suicidal thoughts, plans, and attempts as distinct indicators and assessing key biopsychosocial factors. Further research could improve how behavioral health systems identify at risk youth.

Virginia governor's MH plan focuses on crisis care in year

Virginia Gov. Glenn Youngkin last month set the stage for what should be a comprehensive discussion of the state's mental health service needs during this year's legislative session. The debate is likely to focus on whether the governor's proposed three‐year plan to transform the state's behavioral health system is sufficiently targeted to have the greatest impact.

Implementing trauma-focused cognitive behavioral therapy in Philadelphia: A 10-year evaluation.

Background: In 2012, Philadelphia's Department of Behavioral Health and Intellectual disAbility Services (DBHIDS) developed an initiative to implement an evidence-based treatment for posttraumatic stress disorder (PTSD), trauma-focused cognitive behavioral therapy (TF-CBT), across the city's behavioral health system. This report evaluates the initiative's 10-year implementation and effectiveness outcomes. Method: The Exploration, Preparation, Implementation, and Sustainment framework guided our implementation evaluation. The implementation outcomes include adoption, reach, and sustainment; these were obtained during regular evaluation data collection from publicly funded behavioral health agencies participating in the TF-CBT initiative. We analyze effectiveness outcomes (i.e., changes in PTSD symptoms) from a subset of patients receiving TF-CBT, which were collected in 6-month intervals by our research team between 2013 and 2021. Results: From 2012 to 2021, DBHIDS trained 478 clinicians in TF-CBT across 20 behavioral health agencies. During this time, 23,401 youths were screened for potentially traumatic events and PTSD symptoms, and 7,550 youths received TF-CBT. Through the TF-CBT initiative, the city expanded the network of TF-CBT providers from 3 to 20 agencies. DBHIDS sustained this network by maintaining the participation of 16 behavioral health agencies over the course of a decade. The subset of 202 youths who were evaluated to assess TF-CBT effectiveness was drawn from 94 therapists and 20 agencies across Philadelphia. All participating youths completed a baseline assessment, and 151 (75%) completed at least one follow-up assessment. Linear mixed-effects models accounting for observations nested within participants and nested within clinicians found that treatment significantly reduced PTSD symptoms. Conclusion: Between 2012 and 2021, DBHIDS successfully implemented and sustained TF-CBT across the city's behavioral health system. Adoption, reach, and sustainment of TF-CBT were high. Despite the considerable adverse experiences faced by youths seeking treatment in Philadelphia's behavioral health system, TF-CBT was effective. Future directions to improve TF-CBT implementation in the next iteration of the initiative are described.

Fatherhood, Behavioral Health, and Criminal Legal System Contact over the Life Course.

Life course theories suggest that fathers' lifetime criminal legal system contact could contribute to poor parent-child outcomes via deterioration in couple relationship quality and fathers' behavioral health. Using paired, longitudinal data from the Multi-site Family Study (N = 1,112 couples), the current study examines the influence of three dimensions of fathers' life course legal system contact on individual and parent-child outcomes. In fitted models, accumulated system contact in adulthood predicts fathers' later depressive symptoms and drug misuse, which in turn predict diminished father-child relationship quality (as reported by both co-parents). Fathers who were older at the time of their first arrest had poorer relationships with their children's mothers and, in turn, poorer behavioral health and parent-child outcomes. Conditions of confinement during fathers' most recent prison stay do not significantly predict later parent-child outcomes, net of the influence of age at first arrest and accumulated criminal legal system contact in adulthood.

New Virginia task force announced to address TDO in MH crisis

Virginia Gov. Glenn Youngkin announced on Dec. 12 a major initiative, the Prompt Placement Temporary Detention Order (TDO) task force, ABC8 News reported. The task force is expected to bring together “government agencies, public and private hospitals, law enforcement, and other community partners to address the crisis facing people with TDOs who are waiting for behavioral health services,” according to a news release. “Virginia's current TDO process is bad for patients, care providers, families and law enforcement who wait with these patients for a placement,” said Virginia Secretary of Health and Human Resources John Littel in a release. “This task force is a key step in improving the behavioral health system across the Commonwealth [of Virginia].” The task force initiation comes after a year in which five of Virginia's eight mental health facilities shut their doors to new patients amid a staffing crisis that created dangerous conditions for workers. The facilities halted admissions in late July 2021 after 63 patients and employees were injured at the state's mental hospitals within just one month. TDO patients are often in a crisis and unable to receive care due to a lack of resources and barriers in the process, a spokesperson for the governor's office said. The goals of the TDO task force include: “Ending the TDO waitlist, finding rapid placements for individuals under a TDO, releasing police officers from spending significant hours away from patrolling the streets, ensuring the safety of all parties and setting the stage for lasting systematic change to the way Virginia processes TDOs,” said Youngkin.

Adverse childhood experiences are associated with increased overdose risk in predominately Latinx adults seeking treatment for substance use disorders.

Almost no previous studies explored the relationship between adverse childhood experiences (ACEs) and overdose risk for individuals with substance use disorders (SUDs), and these did not focus on a Latinx population. This study examined the relationship between ACEs, reporting PTSD symptoms, and lifetime experience of overdose in a sample (n = 149) of primarily Latinx adults seeking treatment for substance use disorder (SUD). Administrative data from an integrated behavioral health and primary care treatment system in Massachusetts were analyzed through bivariate analyses and multiple logistic regression. The final model examined the association between self-reported ACEs, PTSD screen, and lifetime drug overdose. We controlled for demographic characteristics and heroin use and explored alternative measure specifications. ACEs scores were high with 58% having experienced 4+ ACEs. Female gender was associated with a 24% higher ACE score than male gender (p < 0.01). In the multiple logistic model each additional ACE was associated with 1.3 times greater odds of overdose (p < 0.01). Those reporting heroin use had 8.8 times greater odds of reporting overdose compared to those reporting no heroin use (p < 0.001). Gender, age, Puerto Rican ethnicity, years of cocaine use, receiving public assistance income, and a positive initial PTSD screen were not significant. Findings were robust in sensitivity testing. We found the number of ACEs and reported heroin use significantly and positively associated with self-report of overdose in both bivariate and multiple logistic regression analyses. In contrast, a positive initial screen for PTSD was only significantly associated with overdose in the bivariate analysis. Increased screening for ACEs is warranted and ACE-specific treatment is suggested for SUD treatment programs offering trauma-informed services for adults.

Hearing Their Voices: Engaging Certified Peer Specialists in Dialogues About Racism and Recovery.

Certified peer specialists (CPSs) may be uniquely situated to help address inequities within the behavioral health system. However, CPSs and other mental health care providers often do not have opportunities to discuss their experiences with racism in the workplace. The Southeast Mental Health Technology Transfer Center and Georgia Mental Health Consumer Network offered the six-part Racism and Recovery event series as a space for such discussions (N=356 participants). Participant responses on the Government Performance and Results Act survey (N=239) and supplemental Qualtrics survey (N=213) identified potential actions at the individual and organizational levels for disrupting racism. The responses indicated that the series was a feasible and well-received model for engaging diverse participants.

Assessing County-Level Behavioral Health and Justice Systems with the Sequential Intercept Model Practices, Leadership, and Expertise Scorecard.

The Sequential Intercept Model has helped conceptualize interventions for people with serious mental illness in the criminal/legal system. This paper operationalizes the Sequential Intercept Model into a 35-item scorecard of behavioral health and legal practices. Using interviews, survey, and observational methods, the scorecard assesses an exploratory sample of 19 counties over 27 independent data collections. A series of ordinary least squares regression models assessed the predictor scores on four jail outcomes: prevalence of serious mental illness, length of stay, connections to treatment, and recidivism. Increases in pre-booking scores showed significant decreases in jail prevalence of serious mental illness at the p < 0.05 level, and post-booking scores and overall scores showed significant positive associations with connections to treatment at the p < 0.05 level, though these were non-significant after correcting for multiple comparisons. Preliminary findings suggest a combination of practices across the Sequential Intercept Model could have synergistic impacts on key jail diversion outcomes.

Snudgers

Liz Hathaway, Ph.D., MPH,is a UC Foundation associate professor in Health and Human Performance (HHP) at the University of Tennessee at Chattanooga, TN. She teaches Health Behavior Change and Psychology of Sport & Exercise in the Exercise and Health Sciences undergraduate program and serves as the program coordinator for the Healthy Eating and Active Living Through HHP Residential Learning Community for HHP freshmen. Beginning fall 2022, she decided to do the unthinkable and moved into a freshmen residence hall to serve as a faculty-in-residence. Her interests include learning how to best motivate individuals, especially college students, to make lasting positive behavior change. Her dislikes include 2 a.m. blaring fire alarms. Becca O'Shields, MATS, LCSW,is a graduate of the University of Georgia's School of Social Work in Athens, Georgia. She currently serves as the integrated care clinical lead for Advantage Behavioral Health Systems of Athens, Georgia, where one of her duties includes helping clients engage in long-term positive behavior change. Her interests include spending time with her daughter, son, husband, and two dogs. Disclosure:The authors declare no conflict of interest and do not have any financial disclosures.

New guide developed to provide trauma‐informed care to youth

The National Child Traumatic Stress Network Multisystem Involved Youth Collaborative Work Group and Georgetown University's McCourt School of Public Policy Center for Juvenile Justice Reform have partnered to develop “A Trauma‐Informed Guide for Working with Youth Involved in Multiple Systems.” The purpose of this guide is to help those working with youth involved in multiple systems (YIMS) and their families to use a traumatic stress perspective and provide trauma‐informed care, the executive summary stated. YIMS are children and adolescents who are under the care or supervision of multiple child and family serving systems. They include “crossover youth” or “dually involved youth” who are involved in child welfare (CW) and in the juvenile justice (JJ) system. In addition to CW and JJ involvement, YIMS are also often simultaneously involved in an array of other service systems including immigration, legal, education, family services, physical and behavioral health systems and systems designed to serve those with developmental disabilities or those who experience homelessness.

Not in my treatment center: Leadership's perception of barriers to MOUD adoption

IntroductionDespite their well-established effectiveness, medications for opioid use disorder (MOUD) are widely underutilized across the United States. In the context of a large publicly funded behavioral health system, we examined the relationship between a range of implementation barriers and a substance use disorder treatment agency's level of adoption of MOUD. MethodsWe surveyed leadership of publicly funded substance use disorder treatment centers in Philadelphia about the significance of barriers to implementing MOUD related to their workforce, organization, funding, regulations, and beliefs about MOUD's efficacy and safety. We queried leaders on the percentage of their patients with opioid use disorder who receive MOUD and examined associations between implementation barriers and MOUD adoption. ResultsRatings of regulatory, organizational, or funding barriers of respondents who led high MOUD adopting agencies (N = 20) were indistinguishable from those who led agencies that were low adopting of MOUD (N = 23). In contrast, agency leaders who denied MOUD-belief or workforce barriers were significantly more likely to lead high-MOUD-adopting organizations. ConclusionsThese findings suggest that leadership beliefs about MOUD may be a key factor of the organizational decision to adopt and should be a target of implementation efforts to increase direct provision of these medications.

Peer support to reduce readmission in Medicaid-enrolled adults with substance use disorder

IntroductionPeer support service in substance use disorder systems (PS SUD) is an optional supplement to treatment services for Medicaid-enrolled individuals across Pennsylvania. The value of PS SUD was defined through association with improved service utilization patterns. We examined service utilization in a subset of individuals receiving PS SUD following an acute service (hospitalization or withdrawal management) compared to utilization in propensity-score-matched controls via an observational analysis. MethodsWe identified all Medicaid-enrolled adults with receipt of PS SUD from 2016 to 2019 and included those with prior acute service (n = 349); the study successfully matched all to individuals receiving outpatient SUD services without peer support (n = 698). Individuals were matched on age, gender, race, ethnicity, diagnosis, and prior utilization of acute care. A large percentage of individuals receiving PS SUD (74 %) had co-occurring mental health diagnoses, which we included in matching. We examined service utilization rates via administrative paid claims data for both groups in the first 90 days following peer support/outpatient discharge. ResultsAcute service utilization differed between groups over time, p = .0014. We observed a larger reduction in the rate of acute care during PS SUD service (8.6 %) versus outpatient service (21.2 %), with lower rates remaining 90 days following PS SUD (13.8 %) or outpatient discharge (16.8 %). Individuals receiving PS SUD showed connection to community-based services in the 90 days following discharge from PS SUD, including 45.0 % receiving outpatient SUD and 31.8 % receiving outpatient mental health services. ConclusionsPeer support may help individuals to navigate the behavioral health system and reduce hospitalization or other restrictive levels of care.