State Mental Health Authorities Research Articles

A Call for Improved Prevention and Reduction of Obesity Among Persons With Serious Mental Illness

The primary purpose of this Open Forum is to alert the psychiatric community to a recently published policy paper by the National Association of State Mental Health Program Directors (NASMHPD), Obesity Reduction and Prevention Strategies for Individuals With Serious Mental Illness. The report was developed through a comprehensive review of materials and extensive discussions in an expert panel meeting held August 9-10, 2007. The report indicates that psychiatrists who disregard the physical health of their patients and focus only on treating the patient's psychiatric condition are not only neglectful but are also contributing to the epidemic of obesity among people with serious mental illness. The NASMHPD Medical Directors Council has concluded that psychiatrists in the public mental health system are doing far too little to prevent and reduce obesity among patients the system serves.

Participatory action research to establish self-directed care for mental health recovery in Texas.

This article describes a public-academic collaboration between a university research center and the Texas state mental health authority to design and evaluate a unique "money follows the person" model called self-directed care (SDC). SDC programs give participants control over public funds to purchase services and supports for their own recovery. Through a participatory action research process, the project combined use of evidence-based practice and community consensus as a tool for system change. The story of this effort and the program that resulted are described, along with quantitative and qualitative data from the project's start-up phase. Lessons learned about the importance of community collaboration are discussed in light of the current emphasis on public mental health system transformation through alternative financing mechanisms.

The Status of States' Policies to Support Evidence-Based Practices in Children's Mental Health

This study examined the efforts of states' mental health authorities to promote the use of evidence-based practices through policy. Data were drawn from three components of a national study, including a survey of state children's mental health directors (N=53), which was developed using a three-step process that involved stakeholders. Data from the directors' survey revealed that over 90% of states are implementing strategies to support the use of evidence-based practices. The scope of these efforts varies, with 36% reporting statewide reach. Further, states' strategies for implementing evidence-based practices are often not accompanied by comparable efforts to enhance information systems, even though enhancing such systems can bolster opportunities for successful implementation. Variability in the adoption of evidence-based practices, poor attention to information systems, and inconsistent fiscal policies threaten states' efforts to improve the quality of children's mental health services.

Recent Changes in Medicaid Policy and Their Possible Effects on Mental Health Services

Recent Changes in Medicaid Policy and Their Possible Effects on Mental Health Services

Changing the Oil While Driving the Car

Back to table of contents Next article Taking IssueFull AccessChanging the Oil While Driving the CarLloyd I. Sederer M.D.,Lloyd I. Sederer M.D.Search for more papers by this author,Published Online:13 Jan 2015https://doi.org/10.1176/ps.2009.60.5.575AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail A remarkable yet underappreciated fact is that efficacy studies have shown that mental health treatments are as effective as other medical interventions. Maybe mental health treatments are so unappreciated because we do such a poor job of using them. Robert Drake demonstrated in his research on co-occurring serious mental illness and substance use disorders that half get no treatment, over 40% get poor treatment, and a fortunate single-digit percent get evidence-based practices—which work! Former Surgeon General Dr. David Satcher described this sorry state as the gap between what we know and what we do; a huge gap indeed.I envy the dissemination process that Resnick and Rosenheck describe in this issue for supported employment: what great resources they had—$16 million, time, technical assistance, fidelity assessment, and the Department of Veterans Affairs closed system of care itself. How do we mental health professionals improve our performance? Demonstration projects and pilots that implement evidence-based practices work only as long as their funds flow, then they stop working. We know what works, such as supported employment and integrated treatment for co-occurring serious mental illness and substance use disorders, so why conduct more demonstrations? We need wholesale transformation—systemwide implementation of what works.What we are doing in New York State for co-occurring disorders in over 1,200 statewide mental health and chemical dependency clinics has foundation and state money for technical assistance, training, and clinical distance learning. But what do you do if you are a state that is small, poor, and short staffed?Let not the perfect be the enemy of the good. Clinical training programs can ensure that their graduates can competently use evidence-based therapies. State mental health authorities can set quality standards and import tools and training from other states, federal agencies, or academic centers; they can reduce administrative burden and show what can be done, not harp on what cannot. Providers can pursue quality improvement efforts for practices that work and proudly show the results. Payers can stop buying ineffective care and pay for what works. This will take leadership, courage, and commitment. Because no one can stop services to fix them, it will take changing the oil while driving the car.The greatest public mental health improvements we will see in the next five to ten years will be from closing the gap between what we know and what we do. Imagine if half of those who do not come for care started to come and if half of those who now get poor care received evidence-based practices. Imagine the benefits for consumers, families, and communities. Imagine the pride clinicians would feel. That is what we need to keep in mind when trying to do what can seem like the impossible. As has been said, fortune favors the bold.medical director, New York State Office of Mental Health FiguresReferencesCited byDetailsCited ByNone Volume 60Issue 5 May, 2009Pages 575-575PSYCHIATRIC SERVICES May 2009 Volume 60 Number 5 Metrics PDF download History Published online 13 January 2015 Published in print 1 May 2009

The State Health Authority Yardstick (SHAY)

State mental health authorities have a leadership role in implementing evidence-based practices (EBPs), but few instruments are available to assess the impact of this role. We describe the development of the State Mental Health Authority Yardstick (SHAY), a behaviorally anchored instrument designed to assess state-level facilitating conditions associated with successful implementation of EBPs in community mental health centers. The SHAY assesses the SMHA role in seven domains: Planning, Financing, Training, Leadership, Policies and Regulations, Quality Improvement, and Stakeholders. Preliminary evidence from the National Evidence-Based Practices Project partially supports the construct and criterion-oriented validity of this instrument for rating state-level activities supporting or blocking the implementation of evidence-based practices.

Implementing the Illness Management and Recovery Program in Community Mental Health Settings: Facilitators and Barriers

Implementing the Illness Management and Recovery Program in Community Mental Health Settings: Facilitators and Barriers

Assertive Community Treatment: Facilitators and Barriers to Implementation in Routine Mental Health Settings

This study identified barriers and facilitators to the high-fidelity implementation of assertive community treatment. As part of a multistate implementation project for evidence-based practices, training and consultation were provided to 13 newly implemented assertive community treatment teams in two states. Model fidelity was assessed at baseline and at six, 12, 18, and 24 months. Key informant interviews, surveys, and monthly on-site visits were used to monitor implementation processes related to barriers and facilitators. Licensing processes of the state mental health authority provided critical structural supports for implementation. These supports included a dedicated Medicaid billing structure, start-up funds, ongoing fidelity monitoring, training in the model, and technical assistance. Higher-fidelity sites had effective administrative and program leadership, low staff turnover, sound personnel practices, and skilled staff, and they allocated sufficient resources in terms of staffing, office space, and cars. Lower-fidelity sites were associated with insufficient resources, prioritization of fiscal concerns in implementation, lack of change culture, poor morale, conflict among staff, and high staff turnover. In cross-state comparisons, the specific nature of fiscal policies, licensing processes, and technical assistance appeared to influence implementation. State mental health authorities can play a critical role in assertive community treatment implementation but should carefully design billing mechanisms, promote technical assistance centers, link program requirements to fidelity models, and limit bureaucratic requirements. Successful implementation at the organizational level requires committed leadership, allocation of sufficient resources, and careful hiring procedures.

State Mental Health Policy: Washington State's Initiative to Disseminate and Implement High-Fidelity ACT Teams

State Mental Health Policy: Washington State's Initiative to Disseminate and Implement High-Fidelity ACT Teams

State Mental Health Policy: Washington State's Initiative to Disseminate and Implement High-Fidelity ACT Teams

This column describes Washington State's historic statewide initiative to implement ten high-fidelity assertive community treatment teams. Legislative support and administrative leadership facilitated the implementation of this evidence-based practice as part of a comprehensive transformation initiative within public mental health services for people with serious mental illness. Stakeholder feedback and initial fidelity reviews suggest that the first year has been successful. Crucial strategies that were important to the teams' successful implementation, such as training and consultation, are examined. Challenges, such as staff turnover, are described along with targeted approaches that have been integral to overcoming them. Next steps to promote sustainability and implications for state mental health authorities are discussed.

Innovations in Psychiatry: Ambulatory services for the mentally ill

Byline: H. Chandrashekar, N. Prashanth, C. Naveenkumar, P. Kasthuri In India, mental morbidity is set to overtake that of cardiovascular diseases by 2010. There are over two crore persons with serious mental disorders and about five crore people with common mental disorders. About 30 to 35 lakh need hospitalization at any time. But, a huge treatment gap exists, with around 50 to 90% of the people not being able to access the required services.[sup] [1] Thus, there exists an urgent need to augment health care infrastructure. Moreover, the focus of care is being shifted towards community participation. In view of the above, short duration of hospitalization have become a norm. This has led to a revolving door policy where in patients get admitted at the time of crisis and discharged soon after the crisis gets resolved. Psychiatric patients pose distinct challenges to the treating physicians, families and society at large. Aggression, agitation, confusion, violence, suicidality, non-adherence and exacerbation of psychotic symptoms are situations during which interventions are most required. Many a times, patients refuse care due to lack of insight. Family members by themselves find it impossible to convince patients to come to the hospital. Lack of knowledge among general practitioners compounds the whole problem. The consequences of such events may be dangerous and disastrous to both parties. During those times, families have expressed need for psychiatric ambulance services (in which members of the treating team could go to their homes and help them manage such patients). Existing services have been unable to handle psychiatric crisis. There have been instances where such services have simply refused to serve psychiatric patients. Also, these have been misused causing medico-legal problems as well as violation of human rights.[sup] [2] Research in the west notes that an important proportion of patients brought in by an ambulance can be described as high risk referrals.[sup] [3] Such models have included a psychiatrist accompanying the treating team.[sup] [4] Indeed, families have expressed high levels of satisfaction after interventions.[sup] [5] One similar service (in our country) to homeless mentally ill has proved successful.[sup] [6] Potential advantages of such services could be many: i0 mproved treatment access, the capability to avert a crisis or decrease its severity, reduction in family burden, reduced criminalization of the mentally ill and cost-effectiveness. However due to gross deficiency of trained mental health professionals, inclusion of psychiatrists and qualified psychiatric nurses in the ambulance services is impractical. In this context, 'Ambulatory services for the mentally ill' is an initiative taken by the Karnataka State Mental Health Authority (KSMHA), in coordination with Government of Karnataka, Rotary Club, Bangalore West, and ACMI, a non-governmental organization (NGO). The request for such services had come from NGOs formed by families of the mentally ill. Guidelines were framed and approved by the KSMHA. Funding for this project has come from NGOs and the KSMHA. This has been functioning from October 2008 onwards. The logistics of this service consists of an ambulance van with equipments for first aid, two pilots and three trained nurses. These personnel were trained in handling psychiatric emergencies. The ambulance staff have been provided with a cell phone. This number was advertised in mass media. After getting the call, the staff will collect background information about the patient and the caller. Then the ambulance reaches patients' residence. …

How Medicaid Agencies Administer Mental Health Services: Results From a 50-State Survey

This brief report describes some notable variations in how state Medicaid agencies administer and fund Medicaid mental health services. Hour-long telephone interviews were conducted with all state and District of Columbia Medicaid directors or their designees. Responses indicated that Medicaid and mental health agencies were located within the same umbrella agency in 28 states, potentially facilitating collaboration. The mental health agency provided funding for some Medicaid mental health services in 32 states, and counties provided such funding in 22 states. Medicaid agencies generally delegated more authority to state mental health agencies in states where some Medicaid funding came from mental health sources and also in states where both agencies were in the same umbrella agency. The increasing role of Medicaid in funding state mental health services, combined with new federal limits on Medicaid financing of these services, underscores the importance of interagency collaboration and better alignment of Medicaid and mental health responsibilities.

Implementation of Integrated Dual Disorders Treatment: A Qualitative Analysis of Facilitators and Barriers

Implementation of Integrated Dual Disorders Treatment: A Qualitative Analysis of Facilitators and Barriers

The Family Member Provider Outreach Program

The Family Member Provider Outreach Program

The Role of Staff Turnover in the Implementation of Evidence-Based Practices in Mental Health Care

This study examined turnover rates of teams implementing psychosocial evidence-based practices in public-sector mental health settings. It also explored the relationship between turnover and implementation outcomes in an effort to understand whether practitioner perspectives on turnover are related to implementation outcomes. Team turnover was measured for 42 implementing teams participating in a national demonstration project examining implementation of five evidence-based practices between 2002 and 2005. Regression techniques were used to analyze the effects of team turnover on penetration and fidelity. Qualitative data collected throughout the project were blended with the quantitative data to examine the significance of team turnover to those attempting to implement the practices. High team turnover was common (M+/-SD=81%+/-46%) and did not vary by practice. The 24-month turnover rate was inversely related to fidelity scores at 24 months (N=40, beta=-.005, p=.01). A negative trend was observed for penetration. Further analysis indicated that 71% of teams noted that turnover was a relevant factor in implementation. The behavioral health workforce remains in flux. High turnover most often had a negative impact on implementation, although some teams were able to use strategies to improve implementation through turnover. Implementation models must consider turbulent behavioral health workforce conditions.

Special Section on Implications of CATIE: Impact of the CATIE Findings on State Mental Health Policy

The authors, who are medical directors of three state mental health agencies and members of the Medical Directors' Council of the National Association of State Mental Health Program Directors (NASMHPD), describe the impact on public mental health policy of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE). Before publication of the CATIE results, the preponderance of information indicated substantial and broad-ranging advantages of second-generation antipsychotics over first-generation agents. State mental health authorities focused on improving access to and increasing utilization of the newer agents. In many states, expenditures for these agents accounted for 10% of the total pharmacy budget of the Medicaid program. After CATIE, state policy makers have had to take a more critical look at the data and formulate more nuanced approaches. The authors summarize policy recommendations of the NASMHPD Medical Directors' Council, which reviewed efficacy studies of antipsychotics and formulated a position statement. The recommendations cover three broad areas of policy. First, neither complete open access for all patients at all times nor a uniform fail-first trial of a first-generation antipsychotic is an optimal approach. A more nuanced middle ground is necessary. Second, excessive emphasis on the cost of second-generation antipsychotics has led to a lack of focus on optimizing use of all antipsychotic medication in usual practice. More research and management attention must be focused on improving how these medications are prescribed for individual patients. Third, more resources should be invested in clinical trials that more clearly and accurately reflect current practice.

Impact of the CATIE Findings on State Mental Health Policy

Impact of the CATIE Findings on State Mental Health Policy

Service Use and Cost in 2002 Among Clients in Community Settings Who Were Discharged From a State Hospital in 1989

Service Use and Cost in 2002 Among Clients in Community Settings Who Were Discharged From a State Hospital in 1989

The De-adoption of Innovative Mental Health Practices (IMHP): Why Organizations Choose not to Sustain an IMHP

The de-adoption or discontinuance of innovative mental health practices (IMHPs) was investigated among twelve mental health providers in Ohio. Researchers used mixed methodology to investigate factors that led the organizations to de-adopt the IMHPs. Findings suggest at least five indicators that an organization is likely to discontinue an IMHP (e.g., lack of financial resources and problems related to attracting and retaining qualified staff). Adopting agencies, state and local mental health authorities, and external technical assistance groups may be able to use this information to assist organizations in continuing with the implementation process.

The Role of State Mental Health Authorities in Managing Change for the Implementation of Evidence-Based Practices

The evidence-based practice demonstration for services to adults with serious mental illness has ended its pilot stage. This paper presents the approaches states employed to combine traditional policy levers with more strategic/institutional efforts (e.g., leadership) to facilitate implementation of these practices. Two rounds of site visits were completed and extensive interview data collected. The data were analyzed to find trends that were consistent across states and across practices. Two themes emerged for understanding implementation of evidence-based practices: the support and influence of the state mental health authority matters and so does the structure of the mental health systems.