Local Mental Health Authorities Research Articles

CIC 2023: Enhancing Referrals to the Supplemental Nutrition Assistance Program (SNAP) through Clinical Integration of a Standards-Based Decision Support System.

The Supplemental Nutrition Assistance Program (SNAP) is one of the most successful national programs to reduce poverty and improve health outcomes, but millions of Americans who qualify still do not have access to SNAP, and limited data is available to determine how referrals to the program can be completed successfully. We aimed to design and develop a standards-based digital care coordination platform to support closed-loop social services referrals between patients and social and health care providers; and demonstrate the feasibility to screen, diagnose, plan, and complete interventions with selected patients in real-settings. We partnered with community members to design the platform through Community Engagement Studios and with a Federally Qualified Health Center, Local Mental Health Authority, and Food Bank to determine the features and workflow requirements of the platform design. We customized currently available systems to use Fast Healthcare Interoperability Resources (FHIR) Application Programming Interfaces (APIs) that could exchange information in real-time across providers and participants. The platform was successfully demonstrated through a pilot where patients were recruited in clinical settings and referred to a Food Bank that provided SNAP application assistance to study participants. We translated the requirements of the platform to national standards and required workflows of providers and patients. Study participants were notified electronically of the specific steps to follow to complete their SNAP applications while receiving support from specialists from the Food Bank. The pilot demonstrated the feasibility of collecting granular social service referral information that can be used to better address gaps in social care. The pilot also highlighted the importance of further coordination on the usage and harmonization of needs assessment nationally and that current digital systems are still not ready to fully utilize national Social Determinants of Health (SDOH) data standards.

Navigating Uncertainty: Adapting Guidance for Mental Health During the COVID-19 Public Health Emergency & the Crucial Role of Bi-directional Feedback.

In response to the COVID-19 public health emergency, state and local mental health authorities rapidly developed and disseminated guidance to community mental health agencies. While tailored communication is effective to reach target audiences under usual circumstances, strategies to facilitate the implementation of guidance amidst a rapidly evolving public health emergency are not well understood. This project sought to understand factors informing decision-making about adaptations to guidance, and strategies used to disseminate and facilitate guidance implementation among system-level community partners in OnTrackNY Coordinated Specialty Care (CSC) programs for early psychosis. Semi-structured interviews were conducted with New York State Office of Mental Health (NYS OMH) state and local mental health authorities including state leaders (n = 3) and NYS OMH field office directors (n = 4), OnTrackNY program directors (n = 4), and leadership and trainers of an intermediary organization, OnTrack Central (n = 12). Interviews were analyzed using content analysis. Code reports relevant to guidance decision-making and dissemination were reviewed to identify emerging themes. For state and local mental health authorities, decision-making was influenced by changing COVID-19 risk levels, need for alignment between federal and local guidance, and balancing support for workforce capacity and mental health service continuity. For OnTrackNY program directors, decision-making was influenced by internal infrastructure and processes (e.g., program autonomy), availability of resources (e.g., technology), and perspective on managing risk and uncertainty (e.g., COVID-19, regulatory waiver expiration). For OnTrack Central, decision-making focused on balancing CSC model fidelity with OnTrackNY team capacity and resources. Dissemination of guidance consisted of mass and targeted strategies. Information flow was bidirectional such that top-down dissemination of guidance (e.g., from state mental health authorities to providers) was informed and refined with bottom-up feedback (e.g., from providers to state leadership) through surveys and professional forums (e.g., COVID-19 town halls, provider learning collaboratives). Unlike a planned approach to disseminate new policies, public health emergencies create variable landscapes that may warrant a deeper understanding of how guidance may be adapted to fit rapidly evolving community partner needs. Findings may inform efforts to identify processes that contribute to adaptation and dissemination of guidance for mental health during future public health emergencies.

Abstract 2152: Evaluating beliefs and perceived competence about tobacco cancer prevention practices in Texas local mental health authorities

Abstract Tobacco use is causally associated with 18 cancers and is a leading cause of preventable death. Individuals experiencing mental illness use tobacco at an elevated rate and consequently suffer from greater cancer-related morbidity and mortality. Unfortunately, local mental health authorities (LMHAs), a common setting to receive mental health services, do not prioritize tobacco dependence treatment despite robust evidence that tobacco cessation can enhance mental health in addition to reducing cancer incidence. Beliefs (Health Belief Model) and competence (Self Determination Theory) both play an integral role in shaping behavior. Consequently, this study examined employee and provider tobacco-related beliefs and competence in LMHAs to contextualize their tobacco intervention practices. The frequency of beliefs and competence related to provision of evidence-based tobacco cessation care was collected by e-survey from organizational representatives of 30 of the 39 LMHAs in Texas in 2021. Queries included if respondents agreed that patients should concurrently quit drugs/alcohol and tobacco (N=30 employees) and if they believed patients want to quit cigarette and non-cigarette (i.e., other) tobacco products (n=16 direct service providers). Providers were also asked if they thought that they had the competence to help patients quit smoking and other tobacco use, if they could tailor cessation treatment to patient needs, and about their intervention practices. Only 40% of LMHA representatives endorsed that patients should quit tobacco at the same time as other drugs. Furthermore, only 50% of providers believed that patients want to quit smoking and other tobacco use, respectively. About 70% of providers believed that they have the skills to help patients quit smoking and other tobacco use, respectively, but only 56% reported that they can tailor treatment. Finally, only 56% and 38% of providers recommend that patients stop smoking or other tobacco use, respectively, with 25% recommending smokers switch to vapes or smokeless tobacco products. Contrary to LMHA employee and provider beliefs, research indicates that most patients want to quit tobacco use and that concurrent tobacco use treatment can enhance patient sobriety for non-nicotine substance use disorders. Results demonstrate high levels of misinformation on concurrent tobacco and substance use treatment in LMHAs, which can subvert the provision of evidence-based cessation care. Educational interventions are needed to shift these beliefs, increase competence, and increase tobacco use intervention provision. This will not only help to address cancer disparities among patients but also improve mental health- a critical goal of LMHAs. Future research should investigate how to target tobacco-related beliefs, competence, and intervention behavior in LMHAs to broaden the reach of cancer prevention strategies. Citation Format: Ammar D. Siddiqi, Maggie Britton, Tzuan A. Chen, Isabel Martinez Leal, Anastasia Rogova, Midhat Z. Jafry, Bryce Kyburz, Teresa Williams, Lorraine R. Reitzel. Evaluating beliefs and perceived competence about tobacco cancer prevention practices in Texas local mental health authorities [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 2152.

Examining the Role of Self-Harm in the Relationship between Emergency Department Service Utilization and Trauma-Induced Homelessness among Homeless Individuals in Texas.

Homelessness is a complex public health problem in the United States. Current or ongoing history of trauma among individuals adds to the complexity and challenges of homelessness. Our study assessed the moderating role of self-harm in the association between emergency department (ED) service utilization and trauma-induced homelessness (TIH) among adults in Texas. Homeless adults (N = 282) who completed their baseline Vulnerability Index Service Prioritization Decision Assistance Prescreen Tool survey between February 2021 and February 2022 at a Local Mental Health Authority in Texas were selected. The outcome variable, TIH, was assessed by current period of homelessness due to experiencing trauma or abuse. The main independent variable was ED utilization, while self-harm in the past year was assessed as the moderating variable. A multivariate logistic regression with a moderation analysis was conducted while adjusting for the covariates. Individuals who utilized ED services and engaged in self-harm and risky behaviors had greater odds of experiencing current period of TIH. Male respondents were less likely to experience TIH. Finally, engaging in self-harm significantly moderated the association between ED service use and TIH. This study may help inform efforts to develop tailored interventions and promote resilience-based approaches to improve health outcomes among individuals experiencing homelessness due to TIH.

Total vs Partial Workplace Tobacco Use Bans in Texas Behavioral Health Centers: Employees’ Perceptions Related to Best Practices Implementation

Objective: Tobacco-free workplace policies (TFWPs) at behavioral health treatment centers can curb clients’ tobacco use and secondhand smoke/vape exposure. However, there is little extant observational research about how total versus partial workplace tobacco use bans are associated with employees’ perceptions of best tobacco-related practices in behavioral health centers. Little is understood about the relationship between total or partial TFWPs and other factors that influence evidence-based client care including employees’ beliefs and their tobacco treatment practices. In this study, we examined these associations within Local Mental Health Authorities (LMHAs) providing behavioral healthcare throughout Texas. Methods: Employees from 30 of 39 LMHAs (> 75% of Texas’ statewide service area) responded to a 2021 survey on their TFWP characteristics. We explored associations between the TFWP (total vs partial) and variables of interest using independent proportions tests (p < .10). Results: LMHAs with total TFWPs reported clearer signage, more consistent enforcement, and greater client, contractor, and visitor awareness (ps = .013 to .078). They were also more likely to offer tobacco screening training, promote the Quitline, and believe in the benefits of concurrent treatment of behavioral health needs and tobacco use (ps = .024 to .079). Conclusions: LMHAs with partial TFWPs had weaknesses in communication, enforcement, awareness, and greater barriers to tobacco use care. There are opportunities for collaboration between LMHAs to share policies and care-facilitation practices to reduce the research-to-practice gap and resultant tobacco use inequities statewide.

The Recovering Citizenship Learning Collaborative: a system-wide intervention to increase citizenship practices and outcomes

PurposeThis paper aims to describe the Recovering Citizenship Learning Collaborative (RCLC), a training, consultation and implementation effort for 13 local mental health authorities and two state hospitals.Design/methodology/approachThe learning collaborative used a Recovering Citizenship approach, which holds that recovery occurs in the context of people’s lives in their communities and society, that is, their citizenship. The RCLC was implemented by the Connecticut Department of Mental Health and Addiction Services (DMHAS) in the USA and the Yale Program for Recovery and Community Health along with lived experience leaders. The RCLC supported system change through training DMHAS staff on concepts of recovery and citizenship and developing agency action plans, with the long-term goal of improving citizenship-oriented care at the agency-level and recovery and citizenship-related outcomes for people receiving services.FindingsLessons learned include the importance of assessing organizational readiness for change, addressing leadership investment and attention to systemic barrier, and offering tools to promote structure and accountability. Next steps are supporting agency action plans through technical assistance, state-wide educational offerings and a resource library.Research limitations/implicationsSystemic barriers are considerable and must be addressed before system transformation is possible.Practical implicationsThe authors are hopeful that the RCLC has been part of overcoming those challenges and can be a tool for building foundations for improving citizen practices and people’s citizenship-related outcomes.Social implicationsNext steps are sustaining agency action plans, ongoing agency-specific technical assistance, ongoing state-wide educational offerings and a resource library.Originality/valueThe RCLC has provided tools and supports to build the foundation for improved citizenship practices and client outcomes at the multiagency system level.

Texas tobacco quitline knowledge, attitudes, and practices within healthcare agencies serving individuals with behavioral health needs: A multimethod study

Patients with behavioral health conditions have disproportionately high tobacco use rates and face significant barriers to accessing evidence-based tobacco cessation services. Tobacco quitlines are an effective and accessible resource, yet they are often underutilized. We identify knowledge, practices, and attitudes towards the Texas Tobacco Quitline (TTQL) within behavioral healthcare settings in Texas. Quantitative and qualitative data were collected in 2021 as part of a statewide needs assessment in behavioral healthcare settings. Survey respondents (n = 125) represented 23 Federally Qualified Health Centers, 29 local mental health authorities (LMHAs), 12 substance use treatment programs in LMHAs, and 61 standalone substance use treatment centers (26 people participated in qualitative interviews).Over half of respondents indicated familiarity with the TTQL and believed that the TTQL was helpful for quitting. Qualitative findings reveal potential concerns about inconsistency of services, long wait time, and the format of the quitline. About half of respondents indicated that their center promoted patient referral to TTQL, and few indicated that their center had an electronic referral system with direct TTQL referral capacity. Interview respondents reported overall lack of systematic follow up with patients regarding their use of the TTQL services.Findings suggest the need for (1) increased TTQL service awareness among healthcare providers; (2) further investigation into any changes needed to better serve patients with behavioral health conditions who use tobacco; and (3) electronic health record integration supporting direct referrals and enhanced protocols to support patient follow up after TTQL referral.

Behavioral health care provider’s beliefs, confidence, and knowledge in treating cigarette smoking in relation to their use of the 5A’s intervention

IntroductionEvidence-based smoking cessation interventions are underused settings where behavioral health treatment is provided, contributing to smoking-related health disparities in this patient group. This study assessed the relationship of provider’s beliefs about patients’ smoking, perceptions of treatment capability, and knowledge of referral options and their use of the 5A’s (Ask, Advise, Assess, Assist, and Arrange) intervention for smoking cessation. MethodsSurveys were collected from providers in healthcare settings in Texas where patients receive behavioral health care (N = 86; 9 federally qualified health centers, 16 Local Mental Health Authorities (LMHAs), 6 substance use treatment programs in LMHAs, and 55 stand-alone substance use treatment centers). Logistic regression analyses were used to assess the association between provider’s beliefs about patients’ concern and desire to quit smoking; perceptions of their confidence, skills, and effectiveness in treating smoking; their knowledge of referral options; and their use of the 5A’s with patients who smoked. ResultsProviders who believed that patients were concerned about smoking and wanted to quit; who perceived themselves as confident in providing cessation care, having the required skills, and being effective in providing advice; and/or who had greater referral knowledge were more likely to use the 5A’s with patients who smoked than their (respective) provider counterparts (ps < 0.05). ConclusionProvider-level constructs affect their 5A’s provision for patients with behavioral health needs. Future work should train providers to correct misconceptions about patients’ interest in quitting, bolster their confidence, and provide referral options to support tobacco provision efforts.

Patient-Centered Care Through Nurse Practitioner-Led Integrated Behavioral Health: A Case Study.

Integrated behavioral health can improve primary care and mental health outcomes. Access to behavioral health and primary care services in Texas is in crisis because of high uninsurance rates, regulatory restrictions, and lack of workforce. To address gaps in access to care, a partnership formed among a large local mental health authority in central Texas, a federally designated rural health clinic, and the Texas A&M University School of Nursing to create an interprofessional team-based health care delivery model led by nurse practitioners in rural and medically underserved areas of central Texas. Academic-practice partners identified 5 clinics for an integrated behavioral health care delivery model. From July 1, 2020, through December 31, 2021, a total of 3183 patient visits were completed. Patients were predominantly female (n = 1719, 54%) and Hispanic (n = 1750, 55%); 1050 (33%) were living at or below the federal poverty level; and 1400 (44%) were uninsured. The purpose of this case study was to describe the first year of implementation of the integrated health care delivery model, barriers to implementation, challenges to sustainability, and successes. We analyzed data from multiple sources, including meeting minutes and agendas, grant reports, direct observations of clinic flow, and interviews with clinic staff, and identified common qualitative themes (eg, challenges to integration, sustainability of integration, outcome successes). Results revealed implementation challenges with the electronic health record, service integration, low staffing levels during a global pandemic, and effective communication. We also examined 2 patient cases to illustrate the success of integrated behavioral health and highlighted lessons learned from the implementation process, including the need for a robust electronic health record and organizational flexibility.

Lung Cancer Screening Eligibility and Referral Practices in Texas Organizations Serving People with Substance Use Disorders

For people at elevated risk for lung cancer, lung cancer screening (LCS) reduces lung cancer mortality. People with non-nicotine substance use disorders (SUDs) have elevated rates of smoking compared with the general population, highlighting them as a priority population for LCS consideration. Although research has shown LCS is underutilized, there is little literature to inform whether organizations that serve individuals with SUDs have existing clinical protocols surrounding LCS. In the current study, we examine the LCS eligibility and referral practices among these organizations. We conducted a statewide needs assessment survey in 2021 to discern how tobacco use was being addressed at Texas organizations that provide treatment or services to individuals with SUDs. Respondents were asked to report on their center's LCS eligibility and referral practices. The analytic sample consists of 125 respondents who represented 23 federally qualified health centers, 29 global local mental health authorities (LMHAs), 12 substance use treatment programs in LMHAs, and 61 standalone substance use treatment centers. Very few respondents indicated that healthcare providers at their center made referrals to LCS for patients (8.8%); a few respondents indicated that their healthcare providers assessed patients' eligibility for LCS but did not make referrals (3.2%). Intervention and implementation efforts are needed in these and other SUD healthcare settings to bolster organizational capacity and ensure that patients are being navigated to lung cancer screening at multiple touch points across the care continuum.

Influence of Provider and Leader Perspectives about Concurrent Tobacco-Use Care during Substance-Use Treatment on Their Tobacco Intervention Provision with Clients: A Mixed-Methods Study.

People with substance-use disorders have elevated rates of tobacco use compared with the general population, yet rarely receive tobacco-dependence treatment within substance-use treatment settings (SUTS). One barrier to delivering evidence-based interventions in SUTS is providers' misconception that treating tobacco use and non-nicotine substance use concurrently jeopardizes clients' substance-use recovery, although research indicates that it enhances support for recovery and relapse prevention. A total of 86 treatment providers employed in SUTS (i.e., 9 Federally Qualified Health Centers, 16 Local Mental Health Authorities (LMHAs), 6 substance-use treatment programs in LMHAs, and 55 stand-alone substance-use treatment centers) in Texas, USA, answered survey questions about their (1) thoughts about treating tobacco during substance-use treatment, and (2) delivery of the 5A's tobacco-use intervention (Ask, Advise, Assess, Assist, Arrange). Twenty-six providers and leaders were interviewed about attitudes toward tobacco-free workplace policies and tobacco dependence and the relative importance of treating tobacco (vs. other substance-use disorders) at their center. Providers who did not believe tobacco use should be addressed as soon as clients begin treatment (i.e., endorsed responses of after 1 year, it depends on the client, or never) had lower odds of Asking clients about their tobacco use (OR = 0.195), Advising clients to quit smoking (OR = 0.176), and Assessing interest in quitting smoking (OR = 0.322). Qualitative results revealed barriers including beliefs that clients need to smoke to relieve the stress of substance-use recovery, are disinterested in quitting, fears that concurrent treatment would jeopardize substance use, and limited resources; additional training and education resources was the key facilitator theme. The results demonstrate a critical need to eliminate barriers to tobacco-treatment provision for clients in SUTS through education to correct misperceptions, specialized training to equip providers with knowledge and skills, and resources to build center capacity. Integrating evidence-based smoking interventions into routine care is key to support the recovery efforts of clients in SUTS.

Abstract P025: Tobacco screening practices and perceived barriers in offering tobacco cessation services in the primary prevention of lung cancer among Texas healthcare centers providing behavioral health treatment

Abstract Cigarette smoking is the leading cause of preventable death and illness globally and accounts for over 80% of all lung cancer diagnoses in the U.S. Patients with behavioral health (e.g., mental health and/or substance use) needs have elevated levels of smoking relative to the general population and are thus disparately impacted by tobacco-related cancers. Tobacco screenings, a precursor to providing evidence-based interventions for smoking cessation, play a critical role in the primary prevention of lung cancer. However, their use in behavioral health treatment centers has historically been inconsistent. The aim of this study was to analyze barriers and facilitators to tobacco screening in settings where Texans receive behavioral health care to contextualize current screening trends and, in turn, provide recommendations for improvement. This study assessed the prevalence of mandated tobacco screenings in 80 centers providing healthcare to Texans with behavioral health needs. We examined key factors that could enhance screening conduct (i.e., provision of a tobacco use assessment template, hard stop in the electronic health record [EHR] for patient tobacco use status, and the availability of tobacco screening training), assessed associations between center practices and mandated tobacco screenings, and delineated providers’ perceived barriers to tobacco use intervention provision. Results indicated that 80% of surveyed centers mandated tobacco use screenings; those that did were significantly more likely than those that did not to have a hard stop for tobacco use status in the EHR (p&amp;lt;0.008) and to make training on tobacco screening available to providers (p=0.016). The most widespread barriers to tobacco use disorder care provision, endorsed by at least 50% of all respondents at &amp;gt;1 type of healthcare center (e.g. federally qualified health centers, global local mental health authorities, substance use treatment centers in local mental health authorities, and stand-alone substance use treatment centers), were relative perceived importance of competing diagnoses, lack of community resources for referral, perceived lack of time, lack of provider knowledge or confidence, and belief that patients do not comply with cessation treatment. Overall, there are opportunities for centers providing care to Texans with behavioral health needs to bolster their tobacco screening and intervention capacity to prevent cancer-related disparities in this group. Healthcare centers can support their providers to intervene upon tobacco use by mandating screenings, streamlining clinical workflow with hard stops in patient records, and by educating providers about patient’s interest in quitting along with the importance of treating tobacco with brief evidence-based intervention strategies. Future work should focus on how these healthcare centers can facilitate providers’ ability to link tobacco screenings with smoking cessation services and lung cancer eligibility screening to increase the early detection of lung cancers and prevent tobacco-related cancer disparities. Citation Format: Ammar D. Siddiqi, Maggie Britton, Tzuan A. Chen, Brian J. Carter, Carol Wang, Isabel Martinez Leal, Anastasia Rogova, Bryce Kyburz, Teresa Williams, Mayuri Patel, Lorraine R. Reitzel. Tobacco screening practices and perceived barriers in offering tobacco cessation services in the primary prevention of lung cancer among Texas healthcare centers providing behavioral health treatment. [abstract]. In: Proceedings of the AACR Special Conference: Precision Prevention, Early Detection, and Interception of Cancer; 2022 Nov 17-19; Austin, TX. Philadelphia (PA): AACR; Can Prev Res 2023;16(1 Suppl): Abstract nr P025.

Providers' Non-Cigarette Tobacco Use Intervention Practices in Relation to Beliefs about Patients, Prioritization of and Skills for Intervention, and Referral Knowledge in Texas Healthcare Centers Providing Care to Persons with Behavioral Health Needs.

Rates of non-cigarette (colloquially, other) tobacco use is elevated among adults with behavioral health conditions. Little is known about whether behavioral health providers are using brief interventions, including the evidence-based 5As (Ask, Advise, Assess, Assist, and Arrange) for other tobacco use, or what provider factors may be associated with use of these interventions. The current study redressed this gap. Overall, 86 providers in Texas (9 Federally Qualified Health Centers, 16 Local Mental Health Authorities (LMHAs) that provide a broad range of mental and behavioral health services, 6 substance use treatment programs in LMHAs, and 55 stand-alone substance use treatment programs) took a survey assessing their beliefs regarding (1) patients' concerns about other tobacco use; (2) their desire to quit; (3) importance of intervening on other tobacco use with cessation counseling; (4) perceived skills to intervene; (5) knowledge of referral options for treatment. Logistic regression analyses were conducted to determine the association between each factor and use of the 5As. Results showed that 70.9% of providers asked patients about other tobacco use status, 65.1% advised them to quit, 59.3% assessed quit interest, 54.7% assisted with a quit attempt, and 31.4% arranged a follow-up. Providers who believed patients were concerned about other tobacco use, recognized the importance of offering other tobacco use cessation counseling, believed they had the necessary skills to treat other tobacco use, and possessed knowledge of referral options, respectively, were more likely to deliver the 5As (ps < 0.05). Results add to a limited literature on provider intervention practices for other tobacco use in settings where behavioral health care is provided, highlighting the significance of provider beliefs, perceived skills, and referral knowledge to care delivery. Findings reveal opportunities to increase delivery of the 5As for other tobacco use to behavioral health patients and suggest provider factors that could be targeted to build this capacity.

Collaborative Learning: A Qualitative Study Exploring Factors Contributing to a Successful Tobacco Cessation Train-the-Trainer Program as a Community of Practice.

Individuals with behavioral health conditions account for 50% of annual smoking-related deaths, yet rarely receive tobacco dependence treatment within local mental health authorities (LMHAs). As lack of training and knowledge are key barriers to providing tobacco dependence treatment, Taking Texas Tobacco-Free (TTTF) developed an iterative, 4–6-months train-the-trainer program to embed expertise and delivery of sustained education on tobacco-free workplace policies and practices in participating centers. We explore the employee “champions’” train-the-trainer program experiences using a community of practice (CoP) model to identify key contributors to successful program implementation. Across 3 different LMHAs, we conducted semi-structured individual and group interviews online at 2 time points. We interviewed each champion twice (except for 1 champion who dropped out between measurements); pre-implementation (3 group interviews; N = 4 + 4 + 3 = 11 champions); post-implementation (7 individual interviews and 1 group interview; 7 + 3 = 10 champions). Therefore, 11 champions participated in pre- and post-implementation interviews from July 2020–May 2021. Guided by an iterative, thematic analysis and constant comparison process, we inductively coded and summarized data into themes. Five factors contributed to successful program implementation: value of peer support/feedback; building knowledge, champion confidence, and program ownership; informative curriculum, adaptable to targeted populations; staying abreast of current tobacco/nicotine research and products; and TTTF team responsiveness and practical coaching/assistance. Champions reported the TTTF train-the-trainer program was successful and identified attitudes and CoP processes that effectively built organizational capacity and expertise to sustainably address tobacco dependence. Study findings can guide other agencies in implementing sustainable tobacco-free training programs.

Implementation and Outcomes of a Train-the-Trainer Program at Behavioral Health Treatment Centers as a Mechanism to Maintain Organizational Capacity to Address Tobacco Use Disorder.

Despite prior successful implementation of Taking Texas Tobacco Free (TTTF), an evidence-based tobacco-free workplace program, in local mental health authorities (LMHAs), post-implementation employee attrition necessitated continuing education on tobacco-free policies and tobacco treatment practices. Here, we report on the outcomes of a train-the-trainer program which trained “champions” to deliver tobacco cessation education at their LMHAs. Three LMHAs participated in program implementation via 10 champions, iteratively trained and coached by TTTF. Measures administered evaluated four goals: (1) increase champions’ self-efficacy in delivering trainings, (2) achieve program fidelity via TTTF staff evaluation of trainer effectiveness and knowledge increases among attending employees, (3) achieve stakeholder program acceptability, and (4) achieve program adoption via an increase in follow-up trainings. Champions’ self-efficacy increased throughout TTTF training. TTTF staff ratings of champion-led trainings met the targeted range for trainer effectiveness; employees had a 28.71% knowledge increase over baseline post-training (p < 0.001). Employees rated champions’ training delivery “very good” to “excellent”, on average; both champions and employees were, on average, “satisfied” to “extremely satisfied” with the curriculum and training received. There was an increase over baseline in trainings delivered during follow-up, and trainings increased in length and topic coverage. Ultimately, the train-the-trainer program achieved the intended goals, although not all changes were statistically significant, likely at least partially attributable to small sample sizes. Overall, these results suggest that TTTF’s train-the-trainer program was successful in its delivery and intention to build capacity for the provision of in-house tobacco education trainings to behavioral health employees/providers. However, further evaluation in additional settings, with more champions, et cetera, is necessary to validate these findings, ensure their replicability, link program implementation with reduced patient tobacco use rates, and assess long-term sustainability.

Adapting coordinated specialty care in the post-COVID-19 era: study protocol for an integrative mixed-methods study

BackgroundCoordinated Specialty Care (CSC) programs provide evidence-based services for young people with a recent onset of a psychotic disorder. OnTrackNY is a nationally recognized model of CSC treatment in New York state. In 2019, OnTrackNY was awarded a hub within the Early Psychosis Intervention Network (EPINET) to advance its learning health care system (LHS). The OnTrackNY network is comprised of 23 CSC teams across New York state. OnTrack Central, an intermediary organization, provides training and implementation support to OnTrackNY teams. OnTrack Central coordinates a centralized data collection protocol for quality improvement and evaluation of program fidelity and a mechanism to support practice based-research. OnTrackNY sites’ breadth coupled with OnTrack Central oversight provides an opportunity to examine the impacts of the COVID-19 crisis in New York State, and supplementary funding was awarded to the OnTrackNY EPINET hub in 2021 for that purpose.MethodsThis project will examine the implications of modifications to service delivery within the OnTrackNY LHS during and after the COVID-19 crisis. We will use the Framework for Reporting Adaptations and Modification-Enhanced (FRAME) to classify systematically, code, and analyze modifications to CSC services and ascertain their impact. We will utilize integrative mixed methods. Qualitative interviews with multi-level stakeholders (program participants, families, providers, team leaders, agency leaders, trainers (OnTrack Central), and decision-makers at the state and local levels) will be used to understand the process of making decisions, information about modifications to CSC services, and their impact. Analysis of OnTrackNY program data will facilitate examining trends in team staffing and functioning, and participant service utilization and outcomes. Study findings will be summarized in a CSC Model Adaptation Guide, which will identify modifications as fidelity consistent or not, and their impact on service utilization and care outcomes.DiscussionA CSC Model Adaptation Guide will inform CSC programs, and the state and local mental health authorities to which they are accountable, regarding modifications to CSC services and the impact of these changes on care process, and participant service utilization and outcomes. The guide will also inform the development of tailored technical assistance that CSC programs may need within OnTrackNY, the EPINET network, and CSC programs nationally.Trial registrationNCT04021719, July 16th, 2019.

Organizational Characteristics and Readiness for Tobacco-Free Workplace Program Implementation Moderates Changes in Clinician's Delivery of Smoking Interventions within Behavioral Health Treatment Clinics.

BackgroundSmoking is elevated amongst individuals with behavioral health disorders, but not commonly addressed. Taking Texas Tobacco Free is an evidence-based, tobacco-free workplace program that addresses this, in-part, by providing clinician training to treat tobacco use in local mental health authorities (LMHAs). This study examined organizational moderators of change in intervention delivery from pre- to post-program implementation. MethodsLMHA leaders completed the Organizational Readiness for Implementing Change (ORIC) and provided organization demographics pre-implementation. Clinicians (N = 1237) were anonymously surveyed about their consistent use of the 5As (Asking about smoking; Advising clientele to quit; Assessing willingness to quit; Assisting them to quit; Arranging follow-up) pre- and post-program implementation. Adjusted generalized linear mixed models were used for analyses (responses nested within LMHAs), with interaction terms used to assess moderation effects. ResultsClinician delivery of 5As increased pre- to post-implementation (p < .001). LMHAs with fewer employees (ref = ≤300) demonstrated greater increases in Asking, Assessing, and Assisting over time. LMHAs with fewer patients (ref = ≤10 000) evinced greater changes in Asking over time. Less initial ORIC Change Efficacy, Change Commitment, and Task Knowledge were each associated with greater pre- to post-implementation changes in Asking. Less initial Task Knowledge was associated with greater increases in Advising, Assessing, and Assisting. Finally, less initial Resource Availability was associated with greater increases in Assisting (all moderation term ps < .025).ConclusionThe smallest and least ready LMHAs showed the largest gains in tobacco cessation intervention delivery; thus, low initial readiness was not a barrier for program implementation, particularly when efficacy-building training and resources are provided.ImplicationsThis study examined organizational moderators of increases in tobacco cessation treatment delivery over time following the implementation of a comprehensive tobacco-free workplace program within 20 of 39 LMHAs across Texas (hundreds of clinics; servicing >50% of the state) from 2013 to 2018. Overall, LMHAs with fewer employees and patients, and that demonstrated the least initial readiness for change, evinced greater gains in intervention delivery. Findings add to dissemination and implementation science by supporting that low initial readiness was not a barrier for this aspect of tobacco-free workplace program implementation when resources and clinician training sessions were provided.

Pandemic brings accessible mental health care to rural Texas

The COVID‐19 pandemic has created widespread fear and economic anxiety across Texas, and mental health experts and advocates say rural areas — which already had fewer providers and higher rates of suicide and drug overdoses — could see more severe mental health impacts than the state's urban areas. They are predicting a lingering wave of trauma and depression even after the pandemic's immediate effects recede and lockdowns lift, the Fort Worth Business Press reported June 9. “There's a lot of bad things happening right now because of COVID‐19,” said Andy Keller, president and CEO of the Texas‐based Meadows Mental Health Policy Institute. “But in some ways, people in rural Texas have better access to health care than they'd ever had before. All the barriers to them accessing physicians across the state have been lifted.” In April, Gov. Greg Abbott temporarily waived restrictions on telehealth, allowing mental health care providers and local mental health authorities to broadly expand services and collect reimbursement for online appointments more easily. The state also implemented a mental health hotline in March that offers free over‐the‐phone support and provides resources and information to callers who need help.

Randomized Trial of Reverse Colocated Integrated Care on Persons with Severe, Persistent Mental Illness in Southern Texas.

Persons with severe, persistent mental illness (SPMI) are at high risk for poor health and premature mortality. Integrating primary care in a mental health center may improve health outcomes in a population with SPMI in a socioeconomically distressed region of the USA. To examine the effects of reverse colocated integrated care on persons with SPMI and co-morbid chronic disease receiving behavioral health services at a local mental health authority located at the US-Mexico border. Randomized trial evaluating the effect of a reverse colocated integrated care intervention among chronically ill adults. Participants were recruited at a clinic between November 24, 2015, and June 30, 2016. Receipt of at least two visits with a primary care provider and at least one visit with a chronic care nurse or dietician, compared with usual care (behavioral health only). The primary outcome was blood pressure. Secondary outcomes included HbA1c, BMI, total cholesterol, and depressive symptoms. Sociodemographic data were collected at baseline, and outcomes were measured at baseline and 6- and 12-month follow-ups. A total of 416 participants were randomized to the intervention (n = 249) or usual care (n = 167). Groups were well balanced on almost all baseline characteristics. At 12months, intent-to-treat analysis showed intervention participants improved their systolic blood pressure (β = - 3.86, p = 0.04) and HbA1c (β = - 0.36, p = 0.001) compared with usual care participants when controlling for age, sex, and other baseline characteristics. No participants withdrew from the study due to adverse effects. Per-protocol analyses yielded similar results to intent-to-treat analyses and found a significantly protective effect on diastolic blood pressure. Older and diabetic populations differentially benefited from this intervention. Colocation and integration of behavioral health and primary care improved blood pressure and HbA1c after 1-year follow-up for persons with SPMI and co-morbid chronic disease in a US-Mexico border community. clinicaltrials.gov , Identifier: NCT03881657.

A Reverse Colocated Integrated Care Model Intervention among Persons with Severe Persistent Mental Illness at the U.S.-Mexico Border: A Randomized Controlled Trial Protocol

Persons with severe persistent mental illness (SPMI)—which include individuals with schizophrenia, bipolar disorder, and mood disorders such as major depression—are at high risk for poor health outcomes and premature death. Persons with SPMI are largely absent from research evaluating innovative health care models due to recruitment and retention barriers. This paper presents the protocol for a randomized control trial testing a reverse colocated integrated care model in an SPMI population receiving care at a mental health clinic at the U.S.-Mexico border. The study employs a randomized control trial design to determine whether reverse colocated integrated care improves physical and mental health of persons with SPMI. Participants will be randomized to receive the integrated primary care intervention or usual care (behavioral health only). All study participants will complete baseline, 6-, and 12-month assessments. Study outcomes included blood pressure, HbA1c, cholesterol, body mass index, depression, and adult functioning. Despite challenges in recruiting and retaining SPMI patients, co-locating primary care services within a local mental health authority has the potential to improve health and reduce health disparities experienced by persons with SPMI. The study will determine the impacts of this colocated integrated care model among SPMI patients in a socio-economically disadvantaged region.Clinical Trials.gov Identifier: NCT03881657.