Behavioral Health Service Delivery Research Articles

Care challenges and silver linings in HIV and behavioral health service delivery for individuals living with HIV and severe mental illness during the COVID-19 pandemic: a qualitative study

BackgroundThere has been a longstanding effort to integrate behavioral health and HIV care for people with comorbid HIV and behavioral health needs, including those with severe mental illness (SMI). As this population frequents both behavioral health and HIV care settings, they were likely to experience new obstacles to the quality and availability of care during the COVID-19 pandemic. This study aims to describe how clinics for HIV services or behavioral healthcare—as well as co-located sites providing both—sought to rapidly shift protocols to maintain a standard of patient care for people with comorbid HIV and SMI while adapting to the unprecedented circumstances of the pandemic.MethodsWe interviewed HIV and behavioral healthcare providers, clinic leaders, and support service agencies that served clients impacted by both HIV and SMI. Seventeen key informants across three settings (HIV care settings, behavioral health care settings, and integrated or co-located care settings) were interviewed in 2022. Interviews focused on changes in clinical services, protocols, and care provision strategies during and at the onset of the COVID-19 pandemic. Interviews were transcribed and coded using thematic analysis.ResultsCommonly endorsed themes included both positive and negative changes in care and care provision during the pandemic. Negative impacts of the pandemic included the loss of physical space, exacerbated mental health needs and disengagement in HIV care, patient barriers to telehealth and the digital divide, and increased healthcare workforce burnout. Positive changes included improved healthcare delivery and care engagement through telehealth, new opportunities to provide a wide range of social services, paradoxical increases in engagement in HIV care for certain patients, and broad institution of workforce wellness practices.ConclusionsThough COVID-19 presented several complex barriers to care for providers serving patients with comorbid HIV and SMI, the increased flexibility afforded by telehealth and a greater focus on collaborative approaches to patient care may benefit this patient population in the future. Additionally, the focus on workforce wellness may serve to increase retention and avoid burnout among providers. The strategies and lessons learned through adapting to COVID-19 may be invaluable moving forward as healthcare systems respond to future pandemics.

Pediatric behavioral health care utilization in integrated primary care and hospital-based clinics during the pandemic – Implications for virtual care

Introduction: The COVID-19 pandemic forced health care organizations and providers to adapt innovative approaches to ensure patient care needs are met. In particular, improving patient access to behavioral health services is essential to improving population health. 
 Methods and Aims: Clinical visit volume and utilization data were analyzed via the Tableau platform for behavioral health visits by providers within the division of Pediatric Psychology at the University of Michigan Health (UM) during the pandemic through the present. UM is a publicly funded academic medical center that manages a total of approximately 2.5 million patient visits per year. Psychologists provide care within hospital-based specialty clinics or primary care clinics, both of which utilize integrated models of care. Unprecedented changes were made with regards to care delivery format and workforce allocation, and the present paper examines the corresponding impact on patient behavior health care. 
 Results: During Fiscal Year 22 (July 2021 to June 2022), 24 pediatric psychology providers completed a total of 8,252 visits within 12,802 available patient slots, a utilization rate of 64.5%. Utilization was significantly higher in primary care clinics (80.9%) than in hospital-based clinics (51.6%), Z = 34.47, p < .00001. Services were delivered virtually in 100% of the 4549 visits completed in primary care and 72.6% of the 3703 completed hospital visits. These data are currently being analyzed for the present Fiscal Year 23. Patient satisfaction data revealed barriers impacting access to care, including scheduling issues, setting up virtual care and managing, technology problems. 
 Conclusions: Utilization data provides strong support for delivery of behavioral health services in primary care via virtual care means. However, patients area likely to encounter significant barriers to initiating and participating in care when systems are designed to exclusively or primarily support remote users. 

Parent attitudes and perceptions of integrated behavioral health care delivery for pediatric patients

Introduction: Patient access to high-quality behavioral health services has been a well-documented problem that has only been further complicated by the COVID-19 pandemic, especially within the pediatric population. Although integrated models of care have demonstrated efficacy for improving access, there is little research examining parents’ preferences for key elements of integrated practice, which now include increased utilization of virtual care. Parent/caregiver perspectives are essential to understand and enhance behavioral health service delivery within an integrated model of care because they are largely responsible for initiating, facilitating, and intimately participating in their children’s behavioral health care.
 Methods and Aims: The Parent Acceptance of Pediatric Integrated Care Survey Revised (PAPICS-R) was developed by a multidisciplinary panel of integrated care experts to evaluate caregiver perceptions of behavior health care delivery models for pediatric patients. A major component of the revised survey was a focus on virtual care, which has become ubiquitous since the beginning of the Covid-19 pandemic. Eight hundred thirty-four parents from diverse backgrounds across the United States who had children under 18-years old completed the revised survey online. Survey responses were analyzed using various statistical modeling techniques. Detailed demographic data was collected and associations of demographic variables with item responses were assessed using ANOVA and Chi-square tests.
 Results: Results indicated parent support for core components of integrated care such as co-location of medical and behavioral health care, interactive communication between providers, and shared access to health records. Parents also tended to prefer to be involved in their child’s therapy and indicated acceptability of virtual behavioral health care. Significant differences in parent responses were evident across several demographic variables such as race/ethnicity, parent age, child age, number of children and parent education. Notably, patient privacy and stigma were primary concerns for certain groups. These key findings will be shared to explore how specific demographic differences affect parent integrated care perspectives and how best to address these differences in practice.
 Conclusions: Results from the PAPICS-R provide valuable insight into parent perceptions of integrated behavioral health care. Notably, parent attitudes toward the integrated model of care (including virtual healthcare delivery methods) are largely positive. The findings have directly impacted multiple key aspects of the IBH program including future format of care delivery, trainee education, program expansion, and quality improvement. These adaptations will be discussed along with broader implications.
 Future Directions: Additional data are being gathered to examine the impact of various parent demographic variables on perspectives of an integrated primary care model. We are also currently working to disseminate results from the PAPICS-R survey to health care providers and organizations as the data are expected to provide valuable insight for those looking to establish integrated pediatric primary care clinics or improve their current model of care. Applicability of implementation within a diverse range of communities and regions will be discussed.

Behavioral health services for urban American Indians and Alaska Natives: A thematic analysis of interviews with 10 program directors.

Urban Indian Health Programs (UIHPs) are one of the primary sources of government-funded health care for the millions of American Indian and Alaskan Native (AI/AN) people living in urban areas. The goal of this study is to better understand what services are available at UIHPs and how resources are being used to support these services. Semistructured interviews with behavioral health directors at 10 UIHPs were reported, transcribed, and thematically analyzed to address this knowledge gap. Our analysis indicates that UIHP behavioral health services were broad, encompassing numerous commitments that extend far beyond purely psychotherapeutic interactions and interventions to the periphery of behavioral health. An accurate accounting of behavioral health services at UIHPs must consider not only the ways that these services are shaped by distinctive visions to provide Indigenous cultural education and traditional healing, but also by expansive commitments to offering a full range of social services, case management, and community building under the broad umbrella of behavioral health. Implications of these findings include the need for additional funding for UIHPs, greater sponsorship of pathway training programs for AI/ANs in the mental health professions to increase the availability of AI/AN providers, future expansion of traditional healing practices, and direct empirical observation of behavioral health service delivery. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Innovation in the Delivery of Behavioral Health Services.

Several factors motivate the need for innovation to improve the delivery of behavioral health services, including increased rates of mental health and substance use disorders, limited access to services, inconsistent use of evidence-based practices, and persistent racial and ethnic disparities. This narrative review identifies promising innovations that address these challenges, assesses empirical evidence for the effectiveness of these innovations and the extent to which they have been adopted and implemented, and suggests next steps for research. We review five categories of innovations: organizational models, including a range of novel locations for providing services and new ways of organizing services within and across sites; information and communication technologies; workforce; treatment technologies; and policy and regulatory changes. We conclude by discussing the need to strengthen and accelerate the contributions of implementation science to close the gap between the launch of innovative behavioral health services and their widespread use.

Care Delivery in Community Health Centers Before, During, and After the COVID-19 Pandemic (2019-2022).

Health centers provide primary and behavioral health care to the nation's safety net population. Many health centers served on the frontlines of the COVID-19 pandemic, which brought major changes to health center care delivery. To elucidate primary care and behavioral health service delivery patterns in health centers before and during the COVID-19 public health emergency (PHE). We compared annual and monthly patients from 2019 to 2022 for new and established patients by visit type (primary care, behavioral health) and encounter visits by modality (in-person, telehealth) across 218 health centers in 13 states. There were 1581,744 unique patients in the sample, most from health disparate populations. Review of primary care data over 4 years show that health centers served fewer pediatric patients over time, while retaining the capacity to provide to patients 65+. Monthly data on encounters highlights that the initial shift in March/April 2020 to telehealth was not sustained and that in-person visits rose steadily after November/December 2020 to return as the predominant care delivery mode. With regards to behavioral health, health centers continued to provide care to established patients throughout the PHE, while serving fewer new patients over time. In contrast to primary care, after initial uptake of telehealth in March/April 2020, telehealth encounters remained the predominant care delivery mode through 2022. Four years of data demonstrate how COVID-19 impacted delivery of primary care and behavioral health care for patients, highlighting gaps in pediatric care delivery and trends in telehealth over time.

Substance Use and Mental Health Comorbidities and Receipt of Specialty Care Among Patients Enrolled in a Low-Barrier HIV Clinic.

Low-barrier care is one model of a differentiated service delivery approach for people with HIV (PWH) who are not engaged in conventionally-organized HIV care. Although psychiatric and substance use disorders are common among patients in low-barrier clinics, approaches to behavioral health service delivery within this context have not been well-described. We conducted a descriptive analysis using retrospective review of medical records to evaluate substance use and psychiatric comorbidities and receipt of behavioral health services among patients in the Max Clinic in Seattle, Washington. Among 227 patients enrolled from 2015 to mid-2020, most had a history of hazardous substance use (85%), a psychiatric diagnosis (69%) or unstable housing (69%) documented in the medical record. Less than half of patients referred for depression treatment (33%) or for opioid use disorder treatment (40%) completed even one specialty care visit. More effective approaches are needed to engage patients in behavioral health services within the context of low-barrier HIV care.

Development of Training to Prepare Army Medics to Address Behavioral Health Needs of Soldiers in Far-Forward Environments Utilizing Mobile App Technology.

Multi-domain operational combat environments will likely restrict key components of current behavioral health (BH) service delivery models. Combat teams in far-forward outposts or extended missions may need to rely on their own internal assets to manage combat and operational stress reactions for extended periods of time. As such, combat medics are expected to take on additional responsibilities as providers of BH support for isolated teams. As they receive limited BH training, medics require additional training to sufficiently respond to combat and operational stress reactions in their assigned teams. This study provided combat medics with a BH training and a mobile application-based support tool that would assist them in identifying and responding to BH concerns in their soldiers. The current analysis examines pre- to post-training changes in attitudes related to utilizing BH skills. We created a brief training aimed to increase medics' ability and confidence regarding managing BH issues. Its development was part of a study on the feasibility of the Soldier and Medic Autonomous Connectivity Independent System for Remote Environments (AIRE) apps (NOCTEM, LLC), a digital system designed for far-forward BH and sleep monitoring and management. Participants were combat medics from two Army combat brigades preparing for a training rotation through a combat training center (CTC). A total of 16 medics consented to participation with nine medics available at the follow-up after the field exercise. Medics were surveyed before the training and after their return from the CTC. In pre-training surveys, most medics indicated it was within their scope to assess for stress/anxiety, suicidal risk, stress reaction, and sleep problems; assist soldiers with optimizing work performance; and provide interventions for BH concerns and sleep problems. Less than half believed it was within their scope to assess and address team communication issues or provide intervention for stress reactions. After the CTC rotation, more medics endorsed that it was in their scope to provide interventions for acute stress reactions to traumatic events. Before the CTC rotation, at most 60% of the group felt at least moderately confident in utilizing the BH skills of discussing problems, assessing for concerns, and providing interventions. After CTC, the confidence levels for each skill increased or remained the same for most medics. Intervention skills had the highest proportion of medics (66%) reporting increased confidence in using the skills. A larger proportion of medics believed it was within their scope of work and felt confident in assessing BH problems, and a smaller proportion believed it is within their scope of work and felt confident in applying interventions. The training increased most medics' confidence to administer interventions for BH and team communication issues. Similar training programs can help medics serve as support for a wide variety of circumstances when the brigade's mental health teams are inaccessible. Additionally, the Medic AIRE app expanded the ability to evaluate and provide interventions without extensive training in treatment modalities or BH conditions. This concept shows promise for providing medics with actionable tools when training time is limited such as during preparation for extended deployments.

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.

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

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

Training health service psychology students in an in-person and telehealth integrated behavioral health service delivery model in primary care.

Telehealth has become an integral part of integrated behavioral health (IBH) service delivery in light of the global pandemic. In order to accommodate the rapid changes in service delivery, integrated behavioral health settings have transformed to provide services via telehealth alongside in-person services. While traditionally believed to be an in-person model, this article demonstrates the potential for using telehealth technology to continue offering training and service delivery in an IBH setting in response to the COVID-19 pandemic and beyond. The purpose of this catalyst report is to describe an IBH service delivery and training model including creative adaptations to the model using telehealth and present an evaluation plan of health service psychology trainee experiences. A mixed-methods design will be used to capture student experiences and competency. Data methods will include interviews with participants (qualitative) and the Interprofessional Collaborative Competency Attainment Survey (quantitative). (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The Behavioral Health Needs of Youth With Preexisting Psychiatric Disorders in the Aftermath of COVID-19

Children and adolescents with psychiatric disorders are a sizable population of children and youth with special health care needs. While the capabilities of behavioral health resources to meet these youth's needs were already strained, the Coronavirus Disease 2019 (COVID-19) pandemic extended resource limitations just as this subgroup of children and youth with special health care needs faced new stressors and potential exacerbations of their underlying psychiatric illnesses. In this article, we provide a brief narrative review of the factors' manifestations with an emphasis upon their disproportionate impact upon children of color and their families and particularly those from disadvantaged communities. We proceed to provide policy proposals for addressing these disparities. These include raising reimbursement for behavioral health services, increasing telehealth care delivery, reducing inter-state licensing requirements, increasing community-based services, and addressing social determinants of health. Conclusions and directions for strengthening behavioral health service delivery capabilities and addressing systemic injustices are made.

Social Work Answers the (Video) Call: Tele-Behavioral Health Use During COVID-19

Objective: The COVID-19 pandemic disrupted access to and the delivery of behavioral health services for social work providers and their clients. This study examined the use of tele-behavioral health by social workers before and during the pandemic, as well as the perceived barriers and supports to technology use. Method: We developed an electronic survey, which was distributed to a convenience sample of practicing social work professionals in the United States through a national listserv. A mixed-methods study design was used to analyze responses (N = 585). Results: Over 92% of social workers reported using tele-behavioral health since the beginning of the pandemic, compared to 28% prior. About half of respondents received training on tele-behavioral health since COVID-19, whereas only 23% had received training prior. The vast majority (87%) indicated one or more barriers to the use of tele-behavioral health, with client barriers (73%) being the area of greatest concern. Yet, social workers overwhelmingly reported the desire for tele-behavioral health to continue beyond the pandemic. Conclusions: Based on our findings, we propose the following recommendations: (a) Ensure parity and reimbursement for tele-behavioral health; (b) train current and future social work practitioners in tele-behavioral health; and (c) provide supports for client use of tele-behavioral health.

Tracing the missteps of stepped care: Improving the implementation of stepped care through contextual behavioral science

Stepped care is an organizational model of healthcare service provision that organizes interventions into a hierarchy from least-to-most intensive, intrusive, and costly. The intervention intensity should be based on feasibility, cost, severity of the presenting case, and patient and clinician preferences. Patients can be “stepped” up or down, depending on progress. Despite the rich, theoretical literature suggesting the effectiveness of stepped care, its implementation is accompanied by challenges that impede its proliferation in applied settings. This paper provides a review of the barriers to stepped care, including negative perceptions, tendency toward defensive medicine, lack of guidance in decision-making, the need for measurement tools designed for stepped care, and healthcare system factors that discourage stepped care. Specific recommendations are discussed for how a contextual behavioral science approach can reduce barriers to implementing stepped care models of behavioral health service delivery.

The impact of COVID-19 on the continuum of integrated perinatal, infant, and early childhood behavioral health services.

This is a brief introduction to four papers examining the impact of the COVID-19 pandemic on the continuum of integrated infant and early childhood mental health services offered across hospital and community settings. The COVID-19 pandemic profoundly impacted the delivery of perinatal, infant, and early childhood behavioral health services. Perinatal and early childhood integrated behavioral health services ensured access to early childhood and family mental health services, adapted service delivery to meet the needs of the populations being served and comply with public health guidelines, and promoted appropriate utilization of preventive, primary care, and hospital services for populations with and without medical complexity during the COVID-19 pandemic.

Asynchronous Telepsychiatry Interviewer Training Recommendations: A Model for Interdisciplinary, Integrated Behavioral Health Care.

Objective: Asynchronous telepsychiatry (ATP) is an integrative model of behavioral health service delivery that is applicable in a variety of settings and populations, particularly consultation in primary care. This article outlines the development of a training model for ATP clinician skills. Methods: Clinical and procedural training for ATP clinicians (n = 5) was provided by master's-level, clinical mental health providers developed by three experienced telepsychiatrists (P.Y. D.H., and J.S) and supervised by a tele-psychiatrist (PY, GX, DL) through seminar, case supervision, and case discussions. A training manual and one-on-one sessions were employed for initial training. Unstructured expert discussion and feedback sessions were conducted in the training phase of the study in year 1 and annually thereafter over the remaining 4 years of the study. The notes gathered during those sessions were synthesized into themes to gain a summary of the study telepsychiatrist training recommendations for ATP interviewers. Results: Expert feedback and discussion revealed three overarching themes of recommended skill sets for ATP interviewers: (1) comprehensive skills in brief psychiatric interviewing, (2) adequate knowledge base of behavioral health conditions and therapeutic techniques, and (3) clinical documentation, integrated care/consultation practices, and e-competency skill sets. The model of training and skill requirements from expert feedback sessions included these three skill sets. Technology training recommendations were also identified and included: (1) awareness of privacy/confidentiality for electronic data gathering, storage, management, and sharing; (2) technology troubleshooting; and (3) video filming/retrieval. Conclusions: We describe and provide a suggested training model for the use of ATP integrated behavioral health. The training needs for ATP clinicians were assessed on a limited convenience sample of experts and clinicians, and more rigorous studies of training for ATP and other technology-focused, behavioral health services are needed. Clinical Trials number: NCT03538860.

Faith leaders' perceptions of needle exchange programs in the rural Illinois Delta Region: Religion as a social determinant of health.

Despite increasing drug use in rural communities, potentially life-saving harm reduction interventions, such as needle exchange programs (NEPs), remain underutilized. Religion is an integral component of the rural culture that has been shown to influence health, yet no studies to date have explored rural faith leaders' perceptions of harm reduction strategies. An online cross-sectional survey was conducted among rural faith leaders (n = 133) in the rural Illinois Delta Region. While most of the respondents felt that drug abuse was an issue in their communities, support was mixed regarding whether they were in favor of NEPs with the majority of respondents having never heard of an NEP before this survey. While the majority believed that NEPs would help decrease bloodborne disease transmission, it was also perceived that NEPs would increase drug use. Significant differences in perceptions based on race, marital status, and political party also exist. Congruent with previous harm reduction literature, many rural faith leaders have varied perceptions of NEPs. Rural faith leaders could benefit from education about NEPs, including the possible positive and negative impacts they can have on the community. Future studies should explore contextual differences among rural faith leaders. To date, no studies have examined faith-based organizations' perceptions of NEPs. The findings have the potential to increase the current body of knowledge and provide data to support recommendations for engaging faith-based organizations in behavioral health service delivery.

Using mobile apps in social work behavioral health care service: The case for China

Mobile apps have increasingly become an innovative tool that can provide information and resources to those who have service needs but often lack access to and knowledge about how to improve their well-being in today’s society. In China, although the number of Internet users has increased substantively, there has been little discussion on how mobile apps can help social workers in their delivery of behavioral health services. This article features three highly used apps that facilitate behavioral health care service delivery in the United States and provides recommendations for developing apps for social work practice in China.

Far Forward Behavioral Health Service Delivery in Future Combat Environments: A Qualitative Needs Assessment.

It is expected that future multi-domain operational (MDO) combat environments will be characterized by limited capabilities for immediate combat stress control support services for soldiers or immediate evacuation from theater. The operational requirements of the future battlefield make it unlikely that current models for behavioral health (BH) treatment could be implemented without significant adjustments. We conducted a qualitative study with Special Forces medics and operators and soldiers who had deployed to austere conditions in small groups in an effort to inform construction of a BH service delivery model for an MDO environment. The objectives of this study were (1) characterizing stressors and BH issues that were encountered and (2) describing mitigation strategies and resources that were useful or needed in these types of deployments. Six focus groups were conducted at three army installations with 23 active duty soldiers, including three groups of medics using a semi-structured interview guide focused on stressors they encountered during deployments to austere conditions, and the impact of those stressors on mission and focus. Focus group recordings were transcribed, imported into NVivo software (version 12), and independently coded by two researchers. An analysis was then conducted to develop themes across participants. The study was reviewed by the Walter Reed Army Institute of Research Human Subjects Protection Board. Behavioral health concerns were commonly cited as a stressor in far forward environments. Other common stressors included ineffective or inexperienced leaders, as well as poor team dynamics (e.g., communication and cohesion). Four primary strategies were mentioned as mitigations for deployment stressors: leadership, morale, resilience training, and strength of the team. When asked about resources or training that would have helped with these types of deployments, participants frequently mentioned the availability of BH providers and development of new and realistic BH skills trainings for non-providers and leaders. Current models for treating BH problems need to be adapted for the future MDO environments in which soldiers will be expected to deploy. Understanding what issues need to be addressed in these environments and how they can best be delivered is an important first step. This study is the first to use qualitative results from those who have already deployed to such environments to describe the stressors and BH issues that were most commonly encountered, the mitigation strategies used, and the resources that were useful or needed.

Column on Telebehavioral Health Education, Training, and Competency Development: Current and Future Impact of the COVID-19 Pandemic.

The COVID-19 pandemic in 2020 has resulted in many worldwide rapid and major changes in how behavioral health education, training, supervision, and service delivery are being done and will have significant long-term implications for the future of telebehavioral health (TBH). Mandates for social distancing during the pandemic necessitated urgently changing from in-person forms of education, training, supervision, and service delivery to uses of telecommunications, often with minimal preparation. This column on telebehavioral health education, training, supervision, and competencies presents some examples of how organizations, programs, and practitioners generally successfully adapted and responded to these sudden circumstances. How some of the major barriers to the adoption of telebehavioral services in the USA were quickly changed, and considerations for the future education, training, and service delivery of telebehavioral health are identified.