Behavioral Health Care Organizations Research Articles

Identifying Barriers and Implementation Strategies to Inform TBI Screening Adoption in Behavioral Healthcare Settings.

Identify barriers to the adoption of the Ohio State University Traumatic Brain Injury Identification Method (OSU TBI-ID) in behavioral healthcare organizations and match these barriers to implementation strategies to inform future implementation efforts. Twenty behavioral health providers. Qualitative study involving individual, semi-structured interviews regarding barriers to adopting the OSU TBI-ID. Data were thematically analyzed around constructs from the Consolidated Framework for Implementation Research (CFIR). Results were matched to strategies using the Expert Recommendations for Implementing Change (CFIR/ERIC) matching tool. Ten barriers were identified across 4 CFIR domains. Inner-Setting barriers were inadequate leadership engagement, priorities, resources, and organizational incentives. Individual-Characteristics barriers were insufficient knowledge about the connection between TBI and behavioral health and how to conduct the OSU TBI-ID with fidelity, low self-efficacy to conduct screening, and inadequate motivation and buy-in to conduct screening. Outer-Setting barriers were lack of state-level mandates and inadequate incentives to conduct screenings. The Process domain barrier was an insufficient engagement of key personnel. Strategy recommendations include: identify and prepare champions; alter incentive and allowance structures; inform local opinion leaders; build a coalition; access new funding; conduct local consensus discussions; involve executive boards; capture/share local knowledge; conduct educational meetings; assess for readiness and identify determinants; identify early adopters; fund and contract for the clinical innovation; create a learning collaborative; and conduct a local needs assessment. This is the first study to examine barriers to adopting the OSU TBI-ID in real-world practice settings. Our results suggest that multilevel implementation strategies addressing mechanisms of change are necessary at the provider, organizational, and systems levels to overcome the complex barriers affecting TBI screening adoption and implementation. Future research is needed to test these strategies and their mechanisms of action on the adoption, implementation, and sustainment of TBI screening, as well as their effect on client-level outcomes.

Levels of Telehealth Use, Perceived Usefulness, and Ease of Use in Behavioral Healthcare Organizations After the COVID-19 Pandemic.

The use of telehealth in behavioral healthcare increased significantly since the start of the COVID-19 pandemic and remains high even as a return to in-person care is now feasible. The use of telehealth is a promising strategy to increase access to behavioral healthcare for underserved and all populations. Identifying opportunities to improve the provision of telehealth is vital to ensuring access. An online survey about the current use of, and attitudes toward, telehealth was conducted by five Mental Health Technology Transfer Center (MHTTC) regional centers and the MHTTC Network Coordinating Office. The national MHTTC network provides training and technical assistance, to support the behavioral health workforce to implement evidence-based treatments. Three hundred and sixty-five respondents from 43 states and Puerto Rico participated. The majority of respondents were clinical providers (69.3%). Nearly all (n = 311) respondents reported providing at least one telehealth service at their organization, but the number and type of services varied substantially. Respondents had positive views of both video-based and phone-based services, but most had some preference for video-based telehealth services. Other services, including text message reminders, medication services, and mobile apps for treatment or recovery, were offered via telehealth by ~ 50% or fewer of respondents' organizations. Many organizations have areas where they could expand their telehealth use, allowing them to extend the reach of their services and increase access for populations that experience barriers to service access, though organizational barriers may still prevent this.

Temporal Patterns of Suicidality Among Adolescents Receiving Behavioral and Mental Health Services in the Community: A Survival Analysis.

Adolescent suicide is a major public health concern, particularly among adolescents who have endured Adverse Childhood Experiences (ACEs). Adolescents who have been exposed to multiple ACEs are as much as three times more likely to present with suicidality compared to the general adolescent population. Adolescents who have been exposed to multiple ACEs are also more likely to receive behavioral and mental health services in the community. It is therefore important to understand patterns of suicidality among this sub-population of adolescents in order to provide the best clinical care. The present study examined the temporal patterns of suicidality among adolescents who have been exposed to multiple ACEs and are receiving behavioral and mental health services in the community. Using Electronic Health Record (EHR) data from a community-based behavioral and mental health care organization, an exploratory survival analysis was conducted on time to suicidal thoughts and behaviors (STBs) after suicidality risk screen at intake. Average time from suicidality risk screen at intake to STB was 185 days (6.2 months). Youth who screened negative for suicidality risk at intake had a longer survival time than youth who screened positive for suicidality risk, and the survival distributions between the two groups was significant. Predictors of STBs were also examined, with gender being a significant predictor of an STB occurring during the follow-up period. These findings may be used to guide suicidality screening and clinical practice at community-based behavioral and mental health care organizations serving adolescents who have been exposed to multiple ACEs.

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.

Assessment of Selective and Universal Screening for Suicide Risk in a Pediatric Emergency Department.

According to National Patient Safety Goal 15.01.01, all individuals being treated or evaluated for behavioral health conditions as their primary reason for care in hospitals and behavioral health care organizations accredited by The Joint Commission should be screened for suicide risk using a validated tool. Existing suicide risk screens have minimal or no high-quality evidence of association with future suicide-related outcomes. To test the association between results of the Ask Suicide-Screening Questions (ASQ) instrument in a pediatric emergency department (ED), implemented through selective and universal screening approaches, and subsequent suicide-related outcomes. In this retrospective cohort study at an urban pediatric ED in the United States, the ASQ was administered to youths aged 8 to 18 years with behavioral and psychiatric presenting problems from March 18, 2013, to December 31, 2016 (selective condition), and then to youths aged 10 to 18 years with medical presenting problems (in addition to those aged 8-18 years with behavioral and psychiatric presenting problems) from January 1, 2017, to December 31, 2018 (universal condition). Positive ASQ screen at baseline ED visit. The main outcomes were subsequent ED visits with suicide-related presenting problems (ie, ideation or attempts) based on electronic health records and death by suicide identified through state medical examiner records. Association with suicide-related outcomes was calculated over the entire study period using survival analyses and at 3-month follow-up for both conditions using relative risk. The complete sample was 15003 youths (7044 47.0%] male; 10209 [68.0%] black; mean [SD] age, 14.5 [3.1] years at baseline). The follow-up for the selective condition was a mean (SD) of 1133.7 (433.3) days; for the universal condition, it was 366.2 (209.2) days. In the selective condition, there were 275 suicide-related ED visits and 3 deaths by suicide. In the universal condition, there were 118 suicide-related ED visits and no deaths during the follow-up period. Adjusting for demographic characteristics and baseline presenting problem, positive ASQ screens were associated with greater risk of suicide-related outcomes among both the universal sample (hazard ratio, 6.8 [95% CI, 4.2-11.1]) and the selective sample (hazard ratio, 4.8 [95% CI, 3.5-6.5]). Positive results of both selective and universal screening for suicide risk in pediatric EDs appear to be associated with subsequent suicidal behavior. Screening may be a particularly effective way to detect suicide risk among those who did not present with ideation or attempt. Future studies should examine the impact of screening in combination with other policies and procedures aimed at reducing suicide risk.Appeared originally in JAMA Netw Open 2019; 2:e1914070.

Special Report: Measurement-Based Care—Using Data to Augment Psychotherapy

Special Report: Measurement-Based Care—Using Data to Augment Psychotherapy

Applying Behavioral Theory To Inform How Provider-Level Characteristics Affect TBI Screening Adoption In Behavioral Healthcare

<h3>Research Objectives</h3> To test hypotheses that behavioral health providers' intentions to screen for TBI mediate the relationship between provider attitudes, perceived behavioral control (PBC), and subjective norms on TBI screening adoption as informed by the Theory of Planned Behavior. <h3>Design</h3> Prospective surveys with two consecutive time-points spaced one-month apart. Structural equation modeling (SEM) with logistic regressions was used for data analysis. <h3>Setting</h3> Behavioral healthcare organizations. <h3>Participants</h3> A convenience sample of 215 licensed, behavioral health providers in the United States. <h3>Interventions</h3> N/A. <h3>Main Outcome Measures</h3> Theory of Planned Behavior Questionnaire assessing attitudes, PBC, subjective norms, and intentions measured at Time 1, and TBI screening adoption measured at Time 2. <h3>Results</h3> Approximately 25% (N = 55/215) of providers adopted TBI screening. The structural model yielded excellent model fit (χ2 = 346.13, p < 0.01; CFI = 0.98; TLI = 0.98; SRMR = 0.04; RMSEA = 0.09; 90% CI = 0.08 – 0.10). Intentions to screen for TBI fully mediated the relationships between provider attitudes toward TBI screening and subjective norms on TBI screening adoption. Specifically, providers who viewed the adoption of TBI screening more favorably and had higher subjective norms demonstrated increased odds of intending to screen for TBI (OR: 0.67; p < .001 and OR: 0.12, p < .001, respectively). Greater intentions to adopt screening significantly predicted TBI screening adoption (OR: 0.30, p < .01). However, PBC did not affect intentions or adoption. <h3>Conclusions</h3> Consistent with the Theory of Planned Behavior, attitudes, norms, and intentions affected whether behavioral health providers adopted TBI screening. Implementation strategies that target professional norms around responding to TBI within behavioral healthcare contexts, and providers' attitudes toward TBI have potential to increase the adoption of TBI screening in these settings. <h3>Author(s) Disclosures</h3> Funding: National Institute of Neurological Disorders and Stroke of the National Institutes of Health (F31-NS124263; Hyzak, PI); Alumni Grants for Graduate Research Scholarship; College of Social Work PhD Seed Grant. Authors have no conflicts of interest to declare.

Behavioral healthcare organizations’ experiences related to use of telehealth as a result of the COVID-19 pandemic: an exploratory study

BackgroundDue to the COVID-19 pandemic, healthcare providers were forced to shift many services quickly from in-person to virtual, including substance use disorder (SUD) and mental health (MH) treatment services. This led to a sharp increase in telehealth services, with health systems seeing patients virtually at hundreds of times the rate as before the onset of the COVID-19 pandemic.By analyzing qualitative data about SUD and MH care organizations’ experiences using telehealth, this study aims to elucidate emergent themes related to telehealth use by the front-line behavioral health workforce.MethodsThis study uses qualitative data from large-scale web surveys distributed to SUD and MH organizations between May and August 2020. At the end of these surveys, the following question was posed in free-response form: “Is there anything else you would like to say about use of telehealth during or after the COVID-19 pandemic?” Respondents were asked to answer on behalf of their organizations. The 391 responses to this question were analyzed for emergent themes using a conventional approach to content analysis.ResultsThree major themes emerged: COVID-specific experiences with telehealth, general experiences with telehealth, and recommendations to continue telehealth delivery. Convenience, access to new populations, and lack of commute were frequently cited advantages of telehealth, while perceived ineffectiveness of and limited access to technology were frequently cited disadvantages. Also commonly mentioned was the relaxation of reimbursement regulations. Respondents supported continuation of relaxed regulations, increased institutional support, and using a combination of telehealth and in-person care in their practices.ConclusionsThis study advanced our knowledge of how the behavioral health workforce experiences telehealth delivery. Further longitudinal research comparing treatment outcomes of those receiving in-person and virtual services will be necessary to undergird organizations’ financial support, and perhaps also legislative support, for virtual SUD and MH services.

Effects of a Systems-Level Intervention to Improve Trainer Integrity in a Behavioral Healthcare Organization.

ObjectivesDirect support professionals (DSPs) play a critical role in health-related outcomes for individuals with intellectual and developmental disabilities (IDD) who reside in congregate living settings. Large behavioral healthcare organizations often rely on staff to function as peer trainers for newly hired DSPs. Organizations should adopt empirically supported training techniques to prepare peer trainers for their role and develop systems to ensure ongoing integrity of the training system. The purpose of this program description is to summarize consultation activities that attempted to create these systems.MethodsStaff members were trained to function as peer trainers, an assessment was conducted to determine the barriers to training in the natural environment, and a systems-level intervention informed by the assessment was implemented to improve peer trainer integrity.ResultsThe assessment revealed peer trainers were often unaware when they were expected to train and did not receive feedback or programmed consequences for training newly hired DSPs. A systems-level intervention containing a prompt (reminder) about upcoming training and feedback plus a monetary incentive produced improvements in trainer integrity.ConclusionsA systems-level intervention based on an assessment can improve peer trainer integrity. Ensuring peer trainer integrity increases the likelihood that newly hired DSPs will implement health-related protocols with individuals with IDD.

Building Resilience in the Face of Crisis: Lessons Learned from a Community Behavioral Healthcare Organization.

The novel coronavirus (SARS-CoV-2 or COVID19) has defied the healthcare system at every turn. The impact of this pandemic on ensuring the health and safety of individuals with serious and persistent mental illness—particularly those living in community-based residential settings—has been challenging. As one of the largest community behavioral health organizations in Oregon, the authors present a descriptive study of an organizational response to the COVID-19 pandemic. This paper presents barriers, strategies, and lessons learned, through firsthand experience and interviews with key residential staff. This paper is not formal research, but the integration and assessment of staff perspective, and organizational experience and knowledge. By sharing these insights and experience, this paper contributes to a collective roadmap for the future, to guide responses to public health crises or other unprecedented events that threaten organizations caring for some of the most vulnerable members of the community.

Effects of Surprises During Quality Improvement Projects: A Longitudinal Study on Method-Driven Learning in Behavioral Healthcare

Quality improvement teams engage in multiple learning opportunities during an improvement project. These learning opportunities consist of both induced opportunities, such as formal training efforts, and incidental opportunities due to surprises (i.e., events that violate expectations) encountered during problem solving activities. In this paper, we propose that these two types of team learning opportunities can result in method-driven learning (MDL) at the team level. Our data are collected using a unique longitudinal survey design spanning 31 weeks that involved 33 participants in five design for Six Sigma projects conducted in different behavioral healthcare organizations, yielding a total of 562 weekly survey responses. We examine two modes of surprises. Those occurring spontaneously (measured based on self-rated and coder-rated variables) and reflective surprises (measured as externally-induced treatments). Our results show that: 1) the proportion of surprises occurring spontaneously during problem solving activities is positively correlated with team learning (i.e., MDL); and 2) collective reflections on surprises also facilitate team learning. Furthermore, we find evidence that surprises occurring spontaneously can negatively moderate the effect of induced learning opportunities (measured as efforts expended on training) on team learning. However, we find no evidence of such a negative moderation effect for surprises from reflection. Overall, our paper develops a nuanced understanding about the direct and moderating effects of surprises on team learning in the behavioral healthcare context, thereby contributing not only to the quality management literature but also quality improvement practices in behavioral healthcare.

Facing social disparity and racial justice issues regarding Covid-19 and access to behavioral health care in the U.S.

The Covid-19 pandemic exposed and amplified many problems in political and healthcare systems around the world, and the United States has been no exception. One such issue is racial injustice, including its impact as a social determinant of health and its manifestation in disparities in healthcare access - including behavioral healthcare. This paper examines this problem in detail and highlights the work of the Center for Practice Innovations. This intermediary organization provides training and implementation support to behavioral healthcare organizations across New York State. This work includes changes and awareness building related to racial injustice within its organization that will drive changes in training and supports provided to behavioral healthcare organizations across New York State.

Factors Associated With Discharge Planning Practices for Patients Receiving Inpatient Psychiatric Care.

This study examined associations of patient, hospital, and service system factors with provision of discharge planning to individuals treated in hospital psychiatric units. This retrospective cohort analysis used 2012-2013 New York State Medicaid claims data of 18,185 patients ages <65 years who were treated in hospital psychiatric units and discharged to the community. The claims data were linked to data from managed behavioral health care organizations indicating whether inpatient staff scheduled a follow-up outpatient appointment with a mental health provider. Additional data regarding hospital and service system characteristics were obtained from the American Hospital Association Annual Survey, the Area Health Resource File, and other state administrative databases. Rates and adjusted odds ratios were assessed for the likelihood of inpatient staff scheduling a follow-up appointment. Inpatient staff scheduled outpatient appointments for 79.8% of discharges. The adjusted odds of not having an outpatient appointment scheduled as part of the patient's discharge plan were significantly associated with several factors, including being homeless on admission, having a diagnosis of a co-occurring substance use disorder, having high levels of medical comorbid conditions, and not being engaged in psychiatric outpatient services in the month prior to admission. Patient characteristics were more strongly associated with failure to receive discharge planning than were hospital and service system characteristics.

Award for Distinguished Professional Contributions to Independent Practice: Adam S. Weissman.

This award is intended to recognize outstanding independent practitioners in psychology. Nominations are considered for psychologists working in any area of clinical specialization, health services provision, or consulting, and services provided to any patient population or professional clientele in an independent setting. Services provided to diverse client groups or patient populations, including but not limited to children/adolescents/ adults/older adults, urban/rural/frontier populations, minority populations, and persons with serious mental illness are considered. Contributions are judged distinguished by virtue of peer recognition, advancement of the public's recognition of psychology as a profession, relevant professional association honors, or other meritorious accomplishments denoting excellence as a practitioner, including advancement of the profession. The 2020 recipient of the APA Professional Contributions Awards were selected by the 2019 Board of Professional Affairs (BPA). Adam S. Weissman is a health care innovator, leader, and visionary, with a mission to revolutionize the mental and behavioral health field by increasing access to, disseminating, and implementing best practices and evidencebased treatments for underserved communities. Adam S. Weissman has passionately pursued his quest, achieving unparalleled success in developing a 15-site, multistate, mission-based behavioral health care organization, The Child & Family Institute, and the nonprofit Weissman Children's Foundation, currently providing large-scale pro bono COVID-19 relief nationally. Adam S. Weissman is president of numerous psychological and mental health associations, a prolific writer and researcher, and a recipient of many service and academic awards. Undoubtedly, he will continue to transform lives and revolutionize the field. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

New York BH providers face revenue, tech, other challenges amid COVID‐19

Even though the pandemic hit more than seven months ago, there are few reports that address specific barriers and challenges being faced by behavioral health care providers and organizations, according to researchers of a qualitative content analysis of survey findings. The Rutgers survey of New York mental health and addiction providers focused on behavioral health delivery in response to COVID‐19 in April and May.

UBH Internal Documents Show Focus on Short-Term Stabilization

UBH Internal Documents Show Focus on Short-Term Stabilization

Assessment of Selective and Universal Screening for Suicide Risk in a Pediatric Emergency Department

According to National Patient Safety Goal 15.01.01, all individuals being treated or evaluated for behavioral health conditions as their primary reason for care in hospitals and behavioral health care organizations accredited by The Joint Commission should be screened for suicide risk using a validated tool. Existing suicide risk screens have minimal or no high-quality evidence of association with future suicide-related outcomes. To test the association between results of the Ask Suicide-Screening Questions (ASQ) instrument in a pediatric emergency department (ED), implemented through selective and universal screening approaches, and subsequent suicide-related outcomes. In this retrospective cohort study at an urban pediatric ED in the United States, the ASQ was administered to youths aged 8 to 18 years with behavioral and psychiatric presenting problems from March 18, 2013, to December 31, 2016 (selective condition), and then to youths aged 10 to 18 years with medical presenting problems (in addition to those aged 8-18 years with behavioral and psychiatric presenting problems) from January 1, 2017, to December 31, 2018 (universal condition). Positive ASQ screen at baseline ED visit. The main outcomes were subsequent ED visits with suicide-related presenting problems (ie, ideation or attempts) based on electronic health records and death by suicide identified through state medical examiner records. Association with suicide-related outcomes was calculated over the entire study period using survival analyses and at 3-month follow-up for both conditions using relative risk. The complete sample was 15 003 youths (7044 [47.0%] male; 10 209 [68.0%] black; mean [SD] age, 14.5 [3.1] years at baseline). The follow-up for the selective condition was a mean (SD) of 1133.7 (433.3) days; for the universal condition, it was 366.2 (209.2) days. In the selective condition, there were 275 suicide-related ED visits and 3 deaths by suicide. In the universal condition, there were 118 suicide-related ED visits and no deaths during the follow-up period. Adjusting for demographic characteristics and baseline presenting problem, positive ASQ screens were associated with greater risk of suicide-related outcomes among both the universal sample (hazard ratio, 6.8 [95% CI, 4.2-11.1]) and the selective sample (hazard ratio, 4.8 [95% CI, 3.5-6.5]). Positive results of both selective and universal screening for suicide risk in pediatric EDs appear to be associated with subsequent suicidal behavior. Screening may be a particularly effective way to detect suicide risk among those who did not present with ideation or attempt. Future studies should examine the impact of screening in combination with other policies and procedures aimed at reducing suicide risk.

In Case You Haven't Heard…

Centerstone, a national leader in behavioral health care, along with a coalition of over 40 other behavioral health care organizations and nonprofits, extends its strong support for H.R. 4194 — The National Suicide Hotline Designation Act to establish 988 as the three‐digit telephone number for a national suicide prevention and mental health crisis hotline, according to a news release. The legislation, introduced by Rep. Chris Stewart (R‐Utah), has bipartisan support in Congress, led by Reps. Seth Moulton (D‐Massachusetts), Greg Gianforte (R‐Montana) and Eddie Bernice Johnson (D‐Texas). Behavioral health leaders from across the nation are urging Congress to pass the bill and ensure this service is universally available and fully funded. An easy‐to‐remember three‐digit hotline for mental health and suicide prevention would make crisis resources more accessible and help save lives (see MHW, Aug. 26). “The need for an easy‐to‐recall number during times of mental health crisis, like 988, is more urgent than ever as suicides are on the rise in nearly all demographics across the nation,” said Becky Stoll, LCSW, vice president of crisis and disaster management at Centerstone.

Florida BH agency, law enforcement partner to divert arrests

Citing a recommendation from the local sheriff's office to identify individuals who may be falling through the cracks in Florida's law enforcement system, a community‐based behavioral health care organization is partnering with the agency to provide mental health support and divert them from arrest.

Joint Commission Issues Update for Suicide Prevention

The elements of performance are intended to support institutions in preventing suicide, with specific requirements for behavioral health care organizations and psychiatric and nonpsychiatric units in general hospitals.