County Mental Health Services Research Articles

Evaluation of a pilot implementation of a digital cognitive behavioral therapy platform for isolated older adults in county mental health services.

Technology-enabled services (TESs) have the potential to increase access to mental healthcare. However, little research has focused on how TESs can be integrated into publicly funded service settings. As part of the state-wide Help@Hand project, Marin County conducted a pilot implementation of myStrength, a digital cognitive behavioral therapy platform, to explore its potential to reduce loneliness among isolated older adults. We evaluated the pilot impact using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. A single-site 6-month pilot implementation recruited English (n = 15) and Spanish-speaking (n = 15) isolated older adults who received a digital literacy course followed by 8 weeks of myStrength access and human support. We evaluated factors related to reach, effectiveness, adoption, and implementation using the perspectives of users and County staff. Descriptive statistics were used to examine reach, adoption, and implementation. Nonparametric tests, including Friedman and Wilcoxon signed-rank, were used to examine effectiveness. Reach: Compared to overall county demographics, platform users were majority female (93.1% vs. 50.5%), ethnoracialized (62.1% vs. 24.2%), and of lower socioeconomic status (Mdn = $35,000 vs. $131,008). Effectiveness: Users reported a significant (z = -2.62, p < .001) decrease in loneliness. Adoption: Users logged into myStrength an average of 10 times and completed 33 activities during the 8 weeks of myStrength use. Implementation: Each pilot staff (N = 20) spent an average of 19.8 hr (SD = 16.51) supporting users' use of myStrength during the pilot. Pilot staff reported several adaptations to meet the needs of users. Successes included reaching the target population, reducing loneliness, and user adoption. However, pilot staff invested significant time to support those with lower digital literacy skills. As such, although TESs may address unmet needs, their use with underserved populations may require upfront and ongoing support provided by the settings where they are implemented. Testing a New Digital Therapy Tool for Isolated Older Adults in County Mental Health Services.

Facilitators of and Barriers to Integrating Digital Mental Health Into County Mental Health Services: Qualitative Interview Analyses

Digital mental health interventions (DMHIs) represent a promising solution to address the growing unmet mental health needs and increase access to care. Integrating DMHIs into clinical and community settings is challenging and complex. Frameworks that explore a wide range of factors, such as the Exploration, Preparation, Implementation, Sustainment (EPIS) framework, can be useful for examining multilevel factors related to DMHI implementation efforts. This paper aimed to identify the barriers to, facilitators of, and best practice recommendations for implementing DMHIs across similar organizational settings, according to the EPIS domains of inner context, outer context, innovation factors, and bridging factors. This study stems from a large state-funded project in which 6 county behavioral health departments in California explored the use of DMHIs as part of county mental health services. Our team conducted interviews with clinical staff, peer support specialists, county leaders, project leaders, and clinic leaders using a semistructured interview guide. The development of the semistructured interview guide was informed by expert input regarding relevant inner context, outer context, innovation factors, and bridging factors in the exploration, preparation, and implementation phases of the EPIS framework. We followed a recursive 6-step process to conduct qualitative analyses using inductive and deductive components guided by the EPIS framework. On the basis of 69 interviews, we identified 3 main themes that aligned with the EPIS framework: readiness of individuals, readiness of innovations, and readiness of organizations and systems. Individual-level readiness referred to the extent to which clients had the necessary technological tools (eg, smartphones) and knowledge (digital literacy) to support the DMHI. Innovation-level readiness pertained to the accessibility, usefulness, safety, and fit of the DMHI. Organization- and system-level readiness concerned the extent to which providers and leadership collectively held positive views about DMHIs as well as the extent to which infrastructure (eg, staffing and payment model) was appropriate. The successful implementation of DMHIs requires readiness at the individual, innovation, and organization and system levels. To improve individual-level readiness, we recommend equitable device distribution and digital literacy training. To improve innovation readiness, we recommend making DMHIs easier to use and introduce, clinically useful, and safe and adapting them to fit into the existing client needs and clinical workflow. To improve organization- and system-level readiness, we recommend supporting providers and local behavioral health departments with adequate technology and training and exploring potential system transformations (eg, integrated care model). Conceptualizing DMHIs as services allows the consideration of both the innovation characteristics of DMHIs (eg, efficacy, safety, and clinical usefulness) and the ecosystem around DMHIs, such as individual and organizational characteristics (inner context), purveyors and intermediaries (bridging factor), client characteristics (outer context), as well as the fit between the innovation and implementation settings (innovation factor).

Understanding the Role of Support in Digital Mental Health Programs With Older Adults: Users' Perspective and Mixed Methods Study.

Digital mental health interventions have the potential to increase mental health support among isolated older adults. However, the older adult population can experience several barriers to accessing and using digital health resources and may need extra support to experience its benefits. This paper aimed to understand what older adults experience as an important aspect of support during engagement in a digital mental health program. The program entailed 3 months of staff support to participate in digital literacy training and engage with the digital mental health platform myStrength, which offers support for a range of mental health challenges, including depression and anxiety. A total of 30 older adults participated in surveys and interviews to assess their experience of participating in a digital mental health program provided by county mental health services. As part of the program, participants attended 4 classes of digital literacy training, had access to the digital mental health platform myStrength for 2 months with staff support (and 10 months after the program without support), and received support from program staff during the entire 3-month program. Survey data were analyzed using descriptive statistics, and interview data were analyzed using thematic analysis. A thematic analysis of the interview data revealed that participants valued ongoing support in 3 main areas: technical support to assist them in using technology, guided support to remind them to use myStrength and practice skills they had learned, and social support to enable them to connect with others through the program. Furthermore, participants reported that social connections was the most important aspect of the program and that they were mainly motivated to participate in the program because it was recommended to them by trusted others such as a community partner or because they believed it could potentially help others. Our findings can be used to inform the design of future digital mental health programs for older adults who may have unique support needs in terms of dedicated technical support and ongoing guided support to use technology and social support to increase social connectedness.

Upheaval in mental health court could signal broader county reform

The departure of the Multnomah County, Oregon, mental health court's entire staff of court monitors after an investigation into worker misconduct stands as the latest development in a broader examination of operations in the county's Mental Health and Addiction Services Division. Given a long history of upheaval within the county government's behavioral health agency, it remains open to speculation as to whether this most recent event will help generate lasting reform of the county's mental health service system.

The Community-targeted Self-management of Epilepsy and Mental Illness (C-TIME) initiative: A research, community, and healthcare administration partnership to reduce epilepsy burden

AimsComorbid mental health conditions (MHCs) such as depression and anxiety are common in people with epilepsy. Targeted Self-Management for Epilepsy and Mental Illness (TIME) is a behavioral program that targets mood symptoms in adults with epilepsy and comorbid MHCs. Building upon positive findings of a randomized controlled study to establish the efficacy of TIME, the Community-TIME (C-TIME) initiative assessed the implementation feasibility and pre-/post-outcomes of this new evidence-based epilepsy self-management intervention in a community setting and in collaboration with key stakeholders. MethodsThe C-TIME program is a group-format curriculum-based intervention delivered in ten 60–90 sessions over the course of 12 weeks. The C-TIME initiative used research staff to guide intervention performance evaluation, staff of a regional epilepsy advocacy agency to assist with community engagement and a county mental health services agency to support the transition from science to service. Process evaluations included outreach and engagement efforts needed to reach people with epilepsy and MHCs, the barriers and facilitators to roll out, and the participants' retention and satisfaction. The primary intervention participant outcome was depressive symptom severity at 4-month follow-up. ResultsReferrals came from a variety of sources and approximately 1 in 3 referrals resulted in an enrollment. Thirty individuals were enrolled in 3 “cohorts” of 10. The most common reason for not being enrolled postscreening was that individuals did not show up for the baseline evaluation. Mean age of participants was 49.1 (12.8) years, 50% (N = 15) female, 55.2% (N = 16) white, 34.5% (N = 10) African-American. With respect to participation, 2/3 of the enrolled sample attended at least 7 out of the maximum 10 C-TIME sessions. Mean number of C-TIME sessions attended was 6.9 (4.1). Five participants (17%) had family members attend the C-TIME sessions, although family members were encouraged to play a supportive rather than primary role. Four-month follow-up outcome evaluation was available for 66% of the enrolled group. There was a significant reduction in depression severity, and patient satisfaction was over 90%. ConclusionsThe C-TIME program can be successfully implemented in the community and is associated with improved outcomes in adults with epilepsy and comorbid MHCs. Continued and broader scale-up of C-TIME and similar approaches could reach larger groups of adults with epilepsy and improve the health of our communities.

Experience of Psychiatric Mental Health Nurse Practitioners in Public Mental Health.

Expansion of health insurance coverage under the Accountable Care Act has meant that millions of people are now insured for mental health treatment, but with no significant increase in the mental health workforce. Services of psychiatric mental health nurse practitioners (PMHNPs) may be best utilized to improve access to and quality of public mental health services if the financial, political, scope of practice, and treatment model barriers that limit their ability or willingness to practice in these settings are better understood. This article reports qualitative results from a study that assessed barriers and best practices in the use of PMHNPs in county mental health services in California. Results indicate that PMHNPs are valued for their "whole person" perspective, collaborative approach, and interpersonal communication skills, but that significant knowledge gaps, regulatory constraints, and bureaucratic barriers in public mental health systems inhibit PMHNPs from practicing at the top of their scope.

Effect of Decreasing County Mental Health Services on the Emergency Department

We evaluate the effect of decreasing county mental health services on the emergency department (ED). This is a retrospective before-and-after study at a Level I academic university hospital adjacent to the county mental health treatment center. On October 1, 2009, the county decreased its inpatient psychiatric unit from 100 to 50 beds and closed its outpatient unit. Electronic health record data were collected for ED visits for the 8 months before the decrease in county services (October 2008 to May 2009) and the 8 months after the decrease (October 2009 to May 2010). Data for all adult patients (≥18 years) evaluated for a psychiatric consultation by a licensed clinical social worker were included. Outcome measures included the number of patients evaluated and the ED length of stay for those patients. One thousand three hundred ninety-two patient visits included a psychiatry consultation for the study period. The median age was 38 years (interquartile range [IQR] 27, 49), with no difference in age between periods. The mean number of daily psychiatry consultations increased from 1.3 (95% confidence interval [CI] 1.2 to 1.5) before closure to 4.4 (95% CI 4.1 to 4.7) afterward, with a difference in means of 3.0 visits (95% CI 2.7 to 3.3 visits). Average ED length of stay for psychiatry consultation patients was 14.1 hours (95% CI 13.1 to 15.0 hours) before closure and 21.9 hours (95% CI 20.7 to 23.2 hours) afterward, with a difference in means of 7.9 hours (95% CI 5.5 to 10.2 hours). The number of visits and length of stay for patients undergoing psychiatric consultation in the ED increased significantly after a decrease in county mental health services. This phenomenon has important implications for future policy to address the challenges of caring for patients with psychiatric needs in our communities.

The meaning of social support for persons with serious mental illness.

This study sought to better understand the population-specific types of social support relevant to adults living with serious mental illness (SMI). Our study was exploratory and used a qualitative approach that centered on uncovering the types of social support meaningful and relevant to persons with SMI. The sample comprised of 52 adults receiving county mental health services in the San Francisco Bay Area. Data was gathered from 6 focus groups and analyzed using NVivo10 and Consensual Qualitative Research (CQR; Hill et al., 2005; Hill et al., 1997). Six qualitative domains were identified: (a) supportive conditions, (b) day-to-day living, (c) illness management, (d) resources and information, (e) guidance and advice, and (f) community participation support. While the 6 support domains share some broad-based conceptual underpinnings with traditional models of emotional and instrumental support, the domains emerging from our study represent supports uniquely tied to the stressors associated with living with SMI, and therefore hold conceptual distinction from traditional types of support. Findings from this study offer a conceptual framework for understanding social support for persons living with SMI and lay the groundwork for the development of a SMI-specific measure of social support. In addition, our research permits future researchers to investigate the conditions under which social support buffers the impact of SMI stressors, assisting service providers in more effective identification of individual support needs for clinical intervention.

EMF-229 Impact of Decreased County Mental Health Services on the Emergency Department

EMF-229 Impact of Decreased County Mental Health Services on the Emergency Department

Rural Psychiatrists Creating Value for Academic Institutions

Rural areas comprise 98% of our nation’s territory but are typically isolated from larger academic medical centers. Collaborations between rural practitioners and such centers can serve to benefit providers, patients, and academicians. We report on a collaboration that turned an outpatient rural practice into a center providing clinical care, education, and research opportunities for the community and for distant academic medical centers. Challenges particular to rural psychiatry include patient confidentiality and therapeutic boundary issues, overlapping relationships, cultural and ethical demands, lack of subspecialty support, professional isolation, absence of academic collaboration, and difficulties in recruiting psychiatrists. We describe the highlights of our experience since 1994 at the Sun Valley Behavioral and Research Center in Imperial, California, a rural county where 160,600 mostly Hispanic and Latino people were residing when we launched our clinical and service initiatives. Among the successful programs is a linked outpatient and consultation liaison service for patients admitted to local general hospitals in a locale where the nearest inpatient unit is 120 miles away. This service has eliminated the need for psychiatric hospitalizations in about two-thirds of consultations. In a community that lacks a dementia unit, we established an adult day treatment center for the elderly population, which helps delay institutionalization. In 2008 we set up a clinical trials division that has collaborated in 38 research projects to date. Since 2011, cooperation between federally qualified health centers and county mental health services has allowed our psychiatrists to train a community clinic team to triage, identify at-risk-patients, follow patients in their homes, and assist with transportation. Our unsuccessful efforts included a partial hospitalization program that closed when Medicare no longer accepted the host hospital because it was in a different county and an electroconvulsive therapy service that never launched because of perceived stigma and controversy in the community. A National Alliance on Mental Illness chapter and a support group both failed after two sessions because participants were reluctant to disclose private information in this small, tightly interwoven community. Other programs ceased for lack of a large enough base to support group work—again, we believe, a function of the low-density population. We have learned that rural barriers can be overcome when the services launched are culturally sensitive, scientifically sound, dispensed by competent staff, affordable to the consumer, and have a priori advice from qualified people. Most of our unsuccessful initiatives lacked one or more of these components. A persistent difficulty is finding capable staff. The likelihood of low practice income and the challenges of a “rural lifestyle” seem to be the main obstacles to recruiting psychiatrists. To address concerns about professional isolation and lack of psychiatrist availability, we created our own supervision program to enhance recruitment of mid-level practitioners such as physician assistants, master’s-level trained therapists, and medical assistants. Having trained in a large academic center, we have maintained contact with our residency mentor by phone, e-mail, and in person, and we eventually became volunteer faculty at the same university. Collaborating with academicians has helped us understand the importance of publishing as a way of communicating with other psychiatrists, thereby decreasing our isolation, receiving constructive criticism, and stimulating ideas to create new clinical services or improve the existing ones. These collaborations have also resulted in numerous publications focusing on rural psychiatry. Being liaisons between large academic centers and our rural community has been both challenging and satisfying. The main obstacles to implementing funded research interventions include recruitment, transportation, and attrition. One challenge to recruitment is stigma that is partially overcome with extensive education. A second factor is our low-density population and poor public transportation, such that anyone applying for funds must include a larger-than-usual dedicated travel budget. Even after enrollment, some participants drop out for a variety of reasons, such as family illness, new employment, and time spent applying for benefits, such that flexible schedules for research activities should be considered. We believe that psychiatric leadership plays an essential role in initiating and implementing these efforts and can help disseminate the idea that rural psychiatry is not only a clinical placement but also an opportunity to perform research and academic activities. Both those already in rural practices and new recruits can be encouraged to collect data, present at meetings, find a mentor, foster online collaborations, and submit to journals. We recommend reaching out to neighboring departments of psychiatry to ignite interest in rural psychiatry and to build academic bridges; we are convinced that rural psychiatrists can create value for academic centers.

Providers’ Attitudes Toward Evidence-Based Practices: Is it Just About Providers, or Do Practices Matter, Too?

Evidence-based practice (EBP) attitudes were measured in a sample of Los Angeles County mental health service providers. Three types of data were collected: provider demographic characteristics, attitudes toward EBP in general, and attitudes toward specific EBPs being implemented in the county. Providers could reliably rate characteristics of specific EBPs, and these ratings differed across interventions. Preliminary implementation data indicate that appealing features of an EBP relate to the degree to which providers use it. These findings suggest that assessing EBP-specific attitudes is feasible and may offer implementation-relevant information beyond that gained solely from providers' general attitudes toward EBP.

Racial and Ethnic Disparities in the Continuation of Community-Based Children’s Mental Health Services

This paper examines racial and ethnic disparities in continuation of mental health services for children and youth in California and how English language proficiency moderates the effect of race/ethnicity on the continuation of service. While previous research indicated racial/ethnic or geographic disparities in accessing mental health services among children and youth, few studies specifically focused on the continuation of mental health care. The authors used administrative data from California county mental health services users under age 25. Applying logistic regression, English language proficiency was found to be the major determinant of continuation of mental health services in this age group. With the exception of children of Asian descent, non-English speaking children and youth of diverse racial/ethnic background were significantly less likely to continue receiving mental health services compared with White English-speaking peers, even after controlling for sociodemographic, clinical and county characteristics.

P01-387 - Innovative practice. applying academic psychosmatic medicine in rural California

BackgroundImperial County is designated as medically underserved and one of the poorest counties in CA. Our practice started in 1994 and serves the gap between the County Mental Health Services (CMHS) that treats the severely and chronically ill and the general medical community that faces the unmet need of specialty care for “less” severe patients.MethodsA plan was started to provide both psychiatric care and liaison activities. The community has 2 community general hospitals. Contracts were established with CMHS and private insurers to assure coverage of services. The plan was extended to dialysis units and long term facilities. Systematic collection of consult data was started in 1998.An electronic medical record was established with specific fields designated for research purposes. Working in association with UCSD, we established a number of IRB approved protocols. In addition, we contracted with a number of pharmaceutical companies to become a research site for mult-center trials.ResultsOver 300 consultations were performed yearly. The most common consultations involved assessments of: elderly agitated patients, conservatorship evaluations and suicide attempts.ConclusionPM strategies added value in the provision of psychiatric services and contract negotiation in this rural community. Applying an academic model decreased the gap between CMHS and the medical community. Patients appeared satisfied to see the same psychiatrists at different treatment settings (i.e. general hospital, dialysis unit, NSF). All interventions were covered by the diverse payment sources.

Point of entry and functional impairment as predictors of treatment amount and cost for patients with mental illness and substance abuse disorders in Santa Barbara County Mental Health Services.

Point of entry and functional impairment as predictors of treatment amount and cost for patients with mental illness and substance abuse disorders in Santa Barbara County Mental Health Services.

Metabolic Risk Factors Among Medicaid Outpatients With Schizophrenia Receiving Second-Generation Antipsychotics

Metabolic Risk Factors Among Medicaid Outpatients With Schizophrenia Receiving Second-Generation Antipsychotics

Transformation of the California Mental Health System: Stakeholder-Driven Planning as a Transformational Activity

This study describes strategies developed by California counties to transform their mental health systems under the 2004 Mental Health Services Act (MHSA). This voter initiative places a 1% tax on annual incomes over $1 million; tax monies are earmarked to transform county-operated mental health services into systems that are oriented more toward recovery. MHSA implementation itself can be considered "transformational" by balancing greater standardization of mental health service delivery in the state with a locally driven planning process. A qualitative content analysis of the three-year plans submitted by 12 counties to receive funds under MHSA was conducted to identify common themes, as well as innovative approaches. These 12 (out of 58) counties were chosen to represent both small and large counties, as well as geographic diversity, and they represent 62.3% of the state population. This analysis showed that the state guidelines and local planning process generated consistency across counties in establishing full-service partnerships with a "whatever it takes" approach to providing goal-directed services and supports to consumers and their families. There was, however, little convergence around the specific strategies to achieve this vision, reflecting both the local planning process and a relative lack of clear policy and guidance on evidence-based practices. There are many obstacles to the successful implementation of these ambitious plans. However, the state-guided, but stakeholder-driven, transformation in California appears to generate innovative approaches to recovery-oriented services, involve consumers and family members in service planning and delivery, and build community partnerships that create new opportunities for consumers to meet their recovery goals.

Transformation of the California Mental Health System: Stakeholder-Driven Planning as a Transformational Activity

Transformation of the California Mental Health System: Stakeholder-Driven Planning as a Transformational Activity

Trends in Use of Antipsychotics and Mood Stabilizers Among Medicaid Beneficiaries With Bipolar Disorder, 2001-2004

Trends in Use of Antipsychotics and Mood Stabilizers Among Medicaid Beneficiaries With Bipolar Disorder, 2001-2004

Community mental health service use by older adults in California

The objective of this research was to examine older Californians who used county mental health services between 1999 and 2002. We estimated treated prevalence rates, identified repeat service users, depicted service mix patterns and tested for differences among these service process outcomes. We observed 36,230 older Californians who used at least one service between 1999 and 2002. Logistic regressions estimated the effects of time, geographic region, age, diagnosis and insurance status on service process outcomes across 49 county mental health departments. The number of older adults who used services increased significantly during the observation period. Odds of accessing care were higher in the state's northern region, for those diagnosed with mood disorders and Medi-Cal beneficiaries. Repeat service use increased over time, and odds were higher for mood disorders and Medi-Cal beneficiaries. Odds of one-time service use were higher for persons with dementia and other psychiatric diagnoses; mood disorders and Medi-Cal beneficiaries had higher odds of consistent and continuous service use. The counties entered a period of diversification between 1999 and 2002, and varied significantly across treated prevalence rates, service continuity and service mix patterns. We considered how these differences may relate to administrative polices, service management practices, local market conditions and individual characteristics, and called for future research to determine how the public mental health system can assume a more critical role in providing care to older adults.

Initiation and Use of Public Mental Health Services by Persons With Severe Mental Illness and Limited English Proficiency

Initiation and Use of Public Mental Health Services by Persons With Severe Mental Illness and Limited English Proficiency