Behavioral Health System Research Articles

IN SEARCH OF THE HOLY GRAIL: WHAT IS THE RIGHT NUMBER OF INPATIENT BEDS?

This session will describe a yearlong collaboration between the American Psychiatric Association (APA) and AACAP to develop an algorithm for determining the inpatient bed capacity needed in a state or county children’s behavioral health system.

A Value Framework for Transforming Behavioral Health

Summary The behavioral health system in the United States is failing at a time when we need it the most. Rates of mental health and substance use disorders are rising in the wake of Covid-19, and increased suicide and drug overdose deaths can be expected to follow. Effective behavioral health treatments exist, but access is limited by multiple barriers, including inadequate care delivery, workforce shortages, lack of outcome measurement, and payment methodologies that disincentivize value. To overcome these limitations and meet the growing demand, a comprehensive overhaul of the current system is required. The author adopts the Porter-Lee value agenda and applies it to behavioral health, building on current pockets of innovation to deliver an effective and efficient system at a national scale. Changes in policy needed to expedite these advances also are defined.

Telehealth Acceptability and Feasibility Among People Served in a Community Behavioral Health System During the COVID-19 Pandemic.

The authors examined the acceptability and feasibility of telehealth services shortly after their rapid introduction into a community behavioral health agency as part of the response to the COVID-19 pandemic. Individuals receiving services during May 8-18, 2020, from behavioral health programs that had introduced telehealth in March 2020, were invited to participate in a survey regarding their perceptions of the telehealth services. Ordinal logistic regressions were used to test for differences in survey responses in three ways: between program types, between the 2020 sample and a 2018 sample, and between individuals reported by staff to be distressed or not distressed by the COVID-19 pandemic. Of 1,482 survey respondents, >80% reported that their ability to connect to staff, receive support, and get an appointment was at least as great as before the pandemic. Among 80% of respondents indicating interest in continuing remote services after the pandemic ended, 83% preferred a mix of remote and face-to-face services. From February 2020 to April 2020, total service utilization remained stable for treatment, outreach, and housing programs. In addition, mental health-related hospital utilization did not increase. The findings of this study suggest that telehealth, including telephone-based services, is an acceptable and even preferred service delivery mode for clients with severe mental illness. Continued investigation into the optimal dosing of face-to-face versus remote services in various settings is needed to inform service practice during and after the COVID-19 pandemic.

Transporting to treatment: Evaluating the effectiveness of a mobile engagement unit

BackgroundSubstance use treatment providers have increasingly developed novel engagement and low-threshold treatment services (such as mobile treatment units) to meet the needs of people with opioid use disorder (OUD). Use of these service models has outpaced the research on their effectiveness. The current study examines the effectiveness of a mobile engagement unit in connecting individuals with OUD to a treatment program. MethodsThis retrospective cohort study included 468 Medicaid-enrolled individuals served through a managed care behavioral health system. Analyses used administrative data from 2018 to 2019 to compare the characteristics and service use of individuals transported to an intake appointment by a mobile engagement unit with individuals who arrived through typical referral routes such as walk-in, other providers, and court order. The authors employed a difference-in-differences analysis to adjust for prior service history. The outcomes of interest were any utilization of substance use treatment services. ResultsThe groups were virtually identical in age and gender, prior to matching, except for race where there was a lower proportion of Black individuals (17% versus 44%) and lower pre-service utilization of outpatient and methadone services by the mobile group. Following intake, mobile participants used significantly more outpatient substance use treatment services (23 percentage point relative increase) and methadone maintenance (32 percentage point relative increase) than the comparison group. ConclusionsThe results of this study suggest that mobile engagement units designed to identify and serve individuals with OUD in the community hold promise for reaching underserved high-risk populations and reduce barriers to treatment entry and recovery.

Residents Interested in Public Sector Career Would Benefit From Geriatric Training

Back to table of contents Previous article Next article ProfessionalFull AccessResidents Interested in Public Sector Career Would Benefit From Geriatric TrainingHana Ali, M.D., Melanie Scharrer, M.D.Hana AliSearch for more papers by this author, M.D., Melanie ScharrerSearch for more papers by this author, M.D.Published Online:3 Mar 2021https://doi.org/10.1176/appi.pn.2021.2.31AbstractThe U.S. population is rapidly aging, and many have serious mental illness. Psychiatry residents should consider geriatric training to augment training in community psychiatry.“Do you like it?” Ms. M asked, fluffing her newly permed hair. It did seem unbelievable that several months ago, she had been referred for hospice care. At the time, the patient rarely spoke or ate during her frequent discharges and readmissions to the state geriatric psychiatric hospital and the university hospital nearby. Slowly, through collaboration among specialists from geriatric psychiatry, palliative care, and geriatric primary care, her multiple comorbid conditions were addressed, and her complex psychotropic medication regime was simplified. She experienced a remarkable recovery and was now ready to go on living.Community psychiatrists constantly use the skills acquired during a geriatric psychiatry fellowship, which can allow them to provide more comprehensive care for aging patients with serious mental illness (SMI), most of whom have multiple psychiatric and medical comorbidities.As the nation’s population ages, so too are individuals living with SMI. These individuals have unique needs that fall at the intersection of the subspecialties of public psychiatry and geriatric psychiatry. Today, many older patients with SMI receive care at public mental health clinics where they are cared for by community psychiatrists and in Assertive Community Treatment programs. However, the shortage of geriatric psychiatrists in this country is well known, and more public-sector psychiatrists with expertise in geriatric psychiatry are needed.In the last decade, fellowship programs in public and community psychiatry have gained popularity among psychiatry residents. A survey of psychiatry trainees found that most had a significant level of interest in public psychiatry. Since 2006 the number of public and community psychiatry fellowship programs in the United States has expanded from two to 21 programs, according to the American Association for Community Psychiatry. These programs equip trainees with skills needed to navigate increasingly complex public mental health infrastructures to provide care for individuals living with SMI. To provide more comprehensive and high-quality care for the rapidly aging population in the United States, trainees who intend to work in public mental health clinics will benefit from geriatric psychiatry training and should consider completing a postgraduate fellowship in geriatric psychiatry.Geriatric psychiatry and public psychiatry already overlap significantly. Geriatric psychiatrists care for patients with complex disease presentations that require collaboration with other medical specialists. They work on interdisciplinary teams to navigate complicated behavioral health and social service systems and are often at the forefront of developing innovative systems of care to meet the needs of our nation’s aging population. In many ways, geriatric training is a natural fit for residents interested in working in the public sector.The challenges that excite individuals interested in public and community psychiatry are the same challenges that exist in the field of geriatric psychiatry: working collaboratively with health care professionals in other disciplines; navigating complex health systems; effectively utilizing local, state, and federal resources; and developing other structural interventions to meet the mental health needs of underserved populations. The overlap is clear. Exposing trainees who have an interest in community and public psychiatry to experiences in geriatric mental health can help alleviate the geriatric workforce shortage and ultimately result in better treatment for our aging SMI population. ■To learn more about geriatric training and other opportunities in the field, please visit the American Association for Geriatric Psychiatry (AAGP) website here.Psychiatry residents and medical students are also encouraged to apply to the AAGP Scholars Program. Both authors are alumni of the AAGP Honors Scholars Program.Hana Ali, M.D., is a PGY-4 psychiatry resident at Yale University.Melanie Scharrer, M.D., is a community psychiatrist who recently completed her geriatric psychiatry fellowship training at the University of Wisconsin School of Medicine and Public Health. ISSUES NewArchived

Implications of COVID-19 on School Services for Children with Disabilities: Opportunities for Interagency Collaboration.

The transition to virtual and hybrid schooling given the COVID-19 pandemic in the United States has upended the education system and may be widening gaps in service disparities, particularly for children with disabilities. Schools often function as "de facto" service systems for most children with disabilities, particularly those from racially and ethnically minoritized, economically vulnerable, and bilingual populations. The impact of school closures on children with disabilities poses significant ramifications for the medical, behavioral health, and educational systems in which they are served, necessitating the need for pediatric clinicians to collaborate with schools in purposeful ways. This commentary (1) presents an overview of the current guidance for providing school-based services to children with disabilities during the COVID context with many schools operating in virtual or hybrid formats, (2) reviews potential service inequities exacerbated by school closures and lack of on-site services, and (3) offers recommendations for collaborating with school staff and community agencies in support of children and families with disabilities.

Field leaders call on Biden administration to move forward on BH agenda

With the Biden administration taking the helm and appointments to key positions being made, leaders in the field expressed a “call to action” for the new administration to address key concerns, such as the need for behavioral health workforce development, health and racial equity, the need for federal agency partnerships and a message that the behavioral health system needs to be transformed.

Community stakeholder preferences for evidence-based practice implementation strategies in behavioral health: a best-worst scaling choice experiment

BackgroundCommunity behavioral health clinicians, supervisors, and administrators play an essential role in implementing new psychosocial evidence-based practices (EBP) for patients receiving psychiatric care; however, little is known about these stakeholders’ values and preferences for implementation strategies that support EBP use, nor how best to elicit, quantify, or segment their preferences. This study sought to quantify these stakeholders’ preferences for implementation strategies and to identify segments of stakeholders with distinct preferences using a rigorous choice experiment method called best-worst scaling.MethodsA total of 240 clinicians, 74 clinical supervisors, and 29 administrators employed within clinics delivering publicly-funded behavioral health services in a large metropolitan behavioral health system participated in a best-worst scaling choice experiment. Participants evaluated 14 implementation strategies developed through extensive elicitation and pilot work within the target system. Preference weights were generated for each strategy using hierarchical Bayesian estimation. Latent class analysis identified segments of stakeholders with unique preference profiles.ResultsOn average, stakeholders preferred two strategies significantly more than all others—compensation for use of EBP per session and compensation for preparation time to use the EBP (P < .05); two strategies were preferred significantly less than all others—performance feedback via email and performance feedback via leaderboard (P < .05). However, latent class analysis identified four distinct segments of stakeholders with unique preferences: Segment 1 (n = 121, 35%) strongly preferred financial incentives over all other approaches and included more administrators; Segment 2 (n = 80, 23%) preferred technology-based strategies and was younger, on average; Segment 3 (n = 52, 15%) preferred an improved waiting room to enhance client readiness, strongly disliked any type of clinical consultation, and had the lowest participation in local EBP training initiatives; Segment 4 (n = 90, 26%) strongly preferred clinical consultation strategies and included more clinicians in substance use clinics.ConclusionsThe presence of four heterogeneous subpopulations within this large group of clinicians, supervisors, and administrators suggests optimal implementation may be achieved through targeted strategies derived via elicitation of stakeholder preferences. Best-worst scaling is a feasible and rigorous method for eliciting stakeholders’ implementation preferences and identifying subpopulations with unique preferences in behavioral health settings.

Concept mapping study of stakeholder perceptions of implementation of cognitive-behavioral social skills training on assertive community treatment teams.

This study aimed to identify factors associated with implementation of cognitive behavioral social skills training (CBSST) on assertive community treatment (ACT) teams in a large public sector behavioral health system. This study used concept mapping (a mixed-method approach) and involved a sample including diverse stakeholder participants including patients, ACT team members, team leaders, organization leaders, and system leaders. We identified 14 distinct issues related to implementing CBSST on ACT teams: (a) CBSST fit with ACT structure, (b) CBSST fit with ACT process, (c) provider perceptions about CBSST, (d) staff pressures/other demands; (e) CBSST and ACT synergy, (f) client characteristics, (g) benefits of CBSST, (h) coordination/interaction among ACT providers, (i) government/regulatory factors, (j) integration of CBSST into ACT, (k) training support, (l) training resources, (m) multilevel agency leadership, and (n) provider characteristics. Each of these dimensions were rated in regard to importance and changeability with the top 5 rated dimensions including effective training support; alignment of leadership across levels of the community-based organizations delivering services; perceived benefits of CBSST, CBSST and ACT synergy; and provider perceptions of CBSST. The most critical issues for CBSST implementation on ACT teams should be addressed in future studies. Implementation strategies that capitalize on enhancing leadership and organizational climate hold promise to address all of these issues. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Results of the Behavioral Health Readiness Evaluation and Decision-Making Instrument Study.

Recent reports have demonstrated behavioral health (BH) system and individual provider challenges to BH readiness success. These pose a risk to winning on the battlefield and present a significant safety issue for the Army. One of the most promising areas for achieving better BH readiness results lies in improving readiness decision-making support for BH providers. The Walter Reed Army Institute of Research (WRAIR) has taken the lead in addressing this challenge by developing and empirically testing such tools. The results of the Behavioral Health Readiness Evaluation and Decision-Making Instrument (B-REDI) field study are herein described. The B-REDI study received WRAIR Institutional Review Board approval, and BH providers across five U.S. Army Forces Command installations completed surveys from September 2018 to March 2019. The B-REDI tools/training were disseminated to 307 providers through random clinic assignments. Of these, 250 (81%) providers consented to participate and 149 (60%) completed both initial and 3-month follow-up surveys. Survey items included a wide range of satisfaction, utilization, and proficiency-level outcome measures. Analyses included examinations of descriptive statistics, McNemar's tests pre-/post-B-REDI exposure, Z-tests with subgroup populations, and chi-square tests with demographic comparisons. The B-REDI resulted in broad, statistically significant improvements across the measured range of provider proficiency-level outcomes. Net gains in each domain ranged from 16.5% to 22.9% for knowledge/awareness (P = .000), from 11.1% to 15.8% for personal confidence (P = .001-.000), and from 6.2% to 15.1% for decision-making/documentation (P = .035-.002) 3 months following B-REDI initiation, and only one (knowledge) failed to maintain a statistically significant improvement in all of its subcategories. The B-REDI also received high favorability ratings (79%-97% positive) across a wide array of end-user satisfaction measures. The B-REDI directly addresses several critical Army BH readiness challenges by providing tangible decision-making support solutions for BH providers. Providers reported high degrees of end-user B-REDI satisfaction and significant improvements in all measured provider proficiency-level domains. By effectively addressing the readiness decision-making challenges Army BH providers encounter, B-REDI provides the Army BH health care system with a successful blueprint to set the conditions necessary for providers to make more accurate and timely readiness determinations. This may ultimately reduce safety and mission failure risks enterprise-wide, and policymakers should consider formalizing and integrating the B-REDI model into current Army BH practice.

Transforming Mental Health And Addiction Services.

Even with great advances in behavioral health policy in the last decade, the problems of mental illness and addiction persist in the United States-so more needs to be done. In this article, which is part of the National Academy of Medicine's Vital Directions for Health and Health Care: Priorities for 2021 initiative, we describe the steps needed to improve outcomes, focusing on three strategies. We argue for transforming the behavioral health system to meet people where they are, decriminalizing mental illness and substance use disorders to facilitate recovery, and raising awareness of social context and social needs as essential to effective care. We call for supporting structures in the workforce and structures of accountability, outcome measurement, and more generous financing of behavioral health care. These steps have costs, but the enormous benefits of a major transformation in behavioral health policy far outweigh the expenses.

Rapid expansion of direct-to-consumer telemental health during the COVID-19 pandemic: A case series.

The coronavirus disease 2019 (COVID-19) pandemic brought many challenges to patient care delivery. The need for social distancing and relaxing of federal and state telemental health regulations paved the way for widespread adoption of direct-to-consumer (DTC) ambulatory mental health video visits. We present cases that demonstrate the use of video visits across 6 clinical areas, each serving a unique population of patients, in a large behavioral health system. The benefits and limitations of this modality are illustrated in children, adults, and older adults with mood disorders, anxiety disorders, intellectual disability, substance use disorders, neurocognitive disorders, and schizophrenia. Although telephone visits were acceptable and necessary to serve some patients, there are many advantages to video visits in providing best patient care. Education and support for telemental health-delivered to both patients and clinicians-is critical to the success of the DTC model. DTC telemental health is a widespread clinical tool used during the COVID-19 pandemic. Because this model has many strengths and advantages compared with traditional telemental health delivered in a clinic, regulators and insurers should be open to its continued use postpandemic when clinically appropriate.

Implementation evaluation of an early intensive behavioral intervention program across three agencies serving young children with Autism: A mixed methods study

IntroductionAutism evidence-based practices (EBPs), including early intensive behavioral interventions (EIBIs), are associated with improved and sustained positive outcomes for children with autism spectrum disorder (ASD). However, little is known about the quality of EIBIs delivered within community-based behavioral health systems, where many children with ASD receive services. These systems vary in their use and delivery of EBPs. Barriers and facilitators play a role in EIBI implementation within these settings. Therefore, this study sought to examine the naturally occurring implementation of the Early Learning Institute (ELI) program across three sites over a one-year period, in order to understand the implementation processes, identify barriers and facilitators to implementation, and explore staff perspectives of implementation outcomes. MethodsA multi-phase mixed methods (QUAN → QUAL) design was utilized to: (1) examine implementation outcomes of acceptability, appropriateness, and feasibility of the EIBI; (2) explore staff perspectives of implementation strategy use; and (3) identify areas of strength and growth to deliver EIBIs in community-based settings. Twenty-three participants at time-point 1 and 29 participants at time-2, including behavioral technicians and directors/supervisors (n = 4) from three implementation sites participated in the study. All participants completed the Acceptability of Intervention, Intervention Appropriateness, Feasibility of Intervention measures, and Organizational Readiness for Change Context Subscale, at two time-points. Informed by QUAN findings at time-point 1, semi-structured interviews were conducted with a sub-sample of participants (n = 13) who completed the surveys at time-point 1. Thematic analysis was completed with a comparison and consensus methodology. Quantitative and qualitative data were then integrated using a joint display to provide an in-depth assessment of implementation outcomes. ResultsQuantitative results indicated positive endorsements of implementation outcomes over time; notably, these results aligned with the qualitative data suggesting that the majority of staff shared positive attitudes about the implementation of this EIBI within their organizations. Qualitative results also highlighted key facilitators and barriers to implementation that fell within two major themes: inner contextual factors and innovation factors. ConclusionsFindings highlighted several determinants to the naturally occurring implementation of ELI across three settings. These findings may be generalized to inform the implementation processes of EIBIs in usual-care settings thereby facilitating uptake in organizations providing services to children with ASD.

Outcomes, evidence-based treatments, and disparities in a statewide outpatient children’s behavioral health system

Abstract Purpose Many questions remain about the effectiveness of behavioral health treatments for children in large systems of care, including the use of evidence-based treatments (EBTs). The goals of this study were to 1) describe outcomes of children receiving treatment in a statewide system, overall and separately for demographic groups; 2) describe penetration rates of EBTs and examine outcomes by treatment type and 3) examine moderation of treatment type by demographic group. Methods Participants were 46,399 children receiving behavioral health services at one of 25 outpatient clinics in a state system between 2013 and 2017. Administrative data included child demographic characteristics, treatment type, and problem severity based on the Ohio Scales. Propensity score methods were used to analyze EBT effects compared to no EBT conditions, and interactions with demographic groups. Results The overall pre- to post-treatment effect size across all treatment types was medium (Cohen’s d = 0.49 to 0.51) and similar to prior research. White children showed greater improvements than Black or Hispanic children, 7 to 12-year olds improved more than younger and older children, and females improved more than males. Almost half (47%) of children received cognitive behavioral therapy, and an additional 12.4% received another EBT. Children receiving EBTs showed greater improvement than those not receiving an EBT. The relative benefits of EBTs were mostly consistent across sex, age, and race/ethnicity, but EBTs were associated with some reductions in disparities by race/ethnicity (particularly for Hispanic youth and more modestly for Black youth) and age. Conclusions Outcomes for children receiving behavioral health treatment in a statewide system were modest. EBTs can be disseminated within large systems and have potential for improving overall outcomes for children from diverse backgrounds.

Eliminating Defects in Behavioral Health Treatment.

To improve care, clinicians should seek to eliminate defects in behavioral health systems. The proposed framework to eliminate defects has three parts: designing a vision for defect-free care, designing analytics to guide care delivery, and identifying and alleviating defects that impede expected outcomes. To shepherd this process, psychiatrists need to embrace the role of systems engineer. An ideal system should work to not only help people recover (get better) from acute illness, but also manage chronic disease effectively (get well) and establish preventive care whenever possible (stay well).

Evaluating the Need for Trauma-Informed Care in a Behavioral Health System of Care

Potentially traumatic events (PTE) can occur in the life of an individual and can cause long-term psychological harm, including symptoms or diagnosis of posttraumatic stress disorder (PTSD). A large number of youth currently receiving mental and behavioral health services have been exposed to PTE, and a subset of those struggle with distressing and impairing symptoms of PTSD. Often, these youth have not and will not receive appropriate care, which can include Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) and trauma-informed care (e.g., Sanctuary). We sought to identify rates of exposure to PTE and expression of PTSD symptoms in youth receiving services in a system of care and found that 95% of the sample reported exposure to at least one PTE (mean = 5). One third of the sample reported a significant burden of PTSD symptoms (5 or more rated highly in the past month). These findings support the trauma-informed care principle of universal precautions in environments that provide mental and behavioral health services to youth. Case vignettes are presented and implications for practice are discussed.

Clinical Implications of Violence Risk After Civil Commitment in Florida.

In their article, Swanson and colleagues examine the long-term risk of firearm-related and other violent crime in a large population of adults with serious mental illnesses following a gun-disqualifying involuntary civil commitment, compared with similar individuals who were evaluated for commitment but released or voluntarily admitted and with a third group with no holds or commitments. They build on prior research from a sample of individuals from public behavioral health systems of two large counties in Florida. This commentary provides further context for their research by highlighting additional factors related to mental health in the state of Florida. Understanding recent legislation regarding the medical privacy of firearm owners, mental health spending, trends in involuntary examinations, and related firearm laws in Florida will contribute to describing the backdrop of the current study. While Swanson's research proposes greater policy implications, this commentary will examine the direct impact on the practice of clinical psychiatrists.

Bridging Systems to Implement HIV/STI Programming Within the Juvenile Justice System: Strengths and Challenges of a Local Change Team Approach.

Justice-involved youth are at risk for HIV/STIs but do not access services. The complex challenges of improving the delivery of health-related services within juvenile justice (JJ) settings warrant exploration of strategies to close this service gap. This study describes the successes and challenges of utilizing a local change team (LCT) strategy comprising JJ and health agency staff to implement HIV/STI programming in JJ settings, across six counties in six states in the U.S. Five focus groups comprising n = 28 JJ and health agency staff who served as LCT members were conducted. Results demonstrated the structured nature of the collaborative process and strength of commitment among LCT members were necessary for successful implementation of HIV/STI programming. The use of LCTs comprising membership of JJ and (behavioral) health systems has broader applicability to other health and behavioral health issues faced by youth on probation that JJ staff may feel ill equipped to address.

The Behavioral Health System and Its Response to COVID-19: A Snapshot Perspective.

The global experience of the COVID-19 pandemic is unprecedented. The magnitude, pace, and uncertainty of the pandemic have taxed systems and catalyzed innovation in many fields, including behavioral health. Behavioral health leaders have absorbed changing information about regulations and laws, proper use of personal protective equipment, isolation and quarantine, telepsychiatry practices (broadly defined here as the use of virtual and telephonic means to providebehavioral health care), and financial opportunities and challenges while attending to the mental health needs of local populations. This Open Forum reviews many of the adaptations of the behavioral health system in response to COVID-19 on the basis of a point-in-time snapshot and describes needed multidimensional policy and practice considerations for the future.

Special Report: America’s First Asylum for African Americans Marks 150th Anniversary

<i>Special Report:</i> America’s First Asylum for African Americans Marks 150th Anniversary