Washington State Community Research Articles

CBT+ Training Initiative in Washington State Community Mental Health: An Evaluation of Child Clinical Outcomes.

The Washington State CBT+ Initiative offers a flexible training and consultation approach for community mental health providers in evidence-based practices for four child mental health targets: cognitive behavioral therapy for depression, anxiety, trauma, and behavioral difficulties. As part of consultation, clinicians used an online system to track delivery of treatment components and clinical outcomes using standardized symptom measures. The current study used these clinician-input data to examine symptom change for children using paired sample t-tests. Additionally, we explored if time elapsed or number of sessions between measurements related to symptom change using simple linear regression. Children had significant symptom reduction across all four targets. For most measures, children did not show greater improvements with increased length of time or increased number of sessions between assessment measures. Findings suggest that children treated by a CBT+ trained clinician may demonstrate symptom reduction for their primary clinical problem. Findings add to support for flexible training approaches for community mental health clinicians.

Feasibility and usability of an electronic patient (pt)-reported outcome (ePRO) smartphone application (app) and biosensor for pts with cancer undergoing systemic therapy.

444 Background: Almost half of the nearly 370,000 pts with cancer who receive chemotherapy in the United States each year experience Emergency Department (ED) visits and unplanned inpatient (IP) stays during treatment, largely due to poorly controlled symptoms. Recent studies show that using PROs in oncology practice can improve symptom management and pt outcomes. This study examines the feasibility and usability of a PRO app paired with a biosensor to identify pts at high risk of ED and IP visits during systemic therapy. Methods: ML41539 is an ongoing prospective observational study evaluating the feasibility and usability of a clinic-provided app and smartwatch biosensor for monitoring pts undergoing systemic cancer therapy (ISRCTN25569053). Key inclusion criteria are 18–80 years old, Eastern Cooperative Oncology Group Performance Status 0–2, biopsy-proven solid tumor diagnosis (excluding non-melanoma skin cancer), and scheduled to receive a first dose of intravenous or oral cancer therapy as an initial or new line of therapy. Exclusion criteria include receiving radiation or hormone therapy only, residing in a skilled nursing facility, or participating in another clinical trial. The app collects 15 common treatment-related symptoms (PRO-CTCAE) daily. Usability and satisfaction were assessed with the modified mHealth App Usability Questionnaire (mMAUQ: score 1-7; higher score indicates better app usability and satisfaction) and the modified Quebec User Evaluation of Satisfaction with Assistive Technology (mQUEST 2.0: score 1-5; higher score indicates better sensor satisfaction). We report planned analysis results of the first 32 pts in the vanguard phase of the trial. Pts wore the biosensor and recorded symptoms on the app for 2 weeks. Results: Thirty-two pts from three Washington State community oncology clinics consented to the vanguard phase. One pt was not onboarded; two dropped out before completing the 2-week observation period. The mean age was 60 years; 68% were women. The most common cancer types were breast (41%), colorectal (13%), endometrial (9%), and melanoma (9%). Of the 29 pts, 59% completed all daily ePRO assessments and 55% wore the sensor every day during the 2-week period. The overall adherence rate was 91% (370/406 assessments) for ePRO and 86% (349/406 biosensor days) for the biosensor. The average mMAUQ score was 6.25 (n = 26); the average mQUEST score was 4.02 (n = 25). Conclusions: Pts receiving systemic cancer therapy had relatively high adherence to a daily digital monitoring system that included an ePRO app and biosensor. Participants expressed moderately high usability of the app and satisfaction with the biosensor. The results support the feasibility of monitoring pts with an app and biosensor. Future studies to assess adherence and data completeness for full courses of systemic therapy are needed. Clinical trial information: ISRCTN25569053.

What can we do when the smoke rolls in? An exploratory qualitative analysis of the impacts of rural wildfire smoke on mental health and wellbeing, and opportunities for adaptation

BackgroundExtreme, prolonged wildfire smoke (WFS) events are becoming increasingly frequent phenomena across the Western United States. Rural communities, dependent on contributions of nature to people’s quality of life, are particularly hard hit. While prior research has explored the physical health impacts of WFS exposure, little work has been done to assess WFS impacts on mental health and wellbeing, or potential adaptation solutions.MethodsUsing qualitative methods, we explore the mental health and wellbeing impacts experienced by community members in a rural Washington State community that has been particularly hard hit by WFS in recent years, as well as individual, family, and community adaptation solutions. We conducted focus groups with residents and key informant interviews with local health and social service providers.ResultsParticipants identified a variety of negative mental health and wellbeing impacts of WFS events, including heightened anxiety, depression, isolation, and a lack of motivation, as well as physical health impacts (e.g., respiratory issues and lack of exercise). Both positive and negative economic and social impacts, as well as temporary or permanent relocation impacts, were also described. The impacts were not equitably distributed; differential experiences based on income level, outdoor occupations, age (child or elderly), preexisting health conditions, housing status, and social isolation were described as making some residents more vulnerable to WFS-induced physical and mental health and wellbeing challenges than others. Proposed solutions included stress reduction (e.g., meditation and relaxation lessons), increased distribution of air filters, development of community clean air spaces, enhancing community response capacity, hosting social gatherings, increasing education, expanding and coordination risk communications, and identifying opportunities for volunteering. Findings were incorporated into a pamphlet for community distribution. We present a template version herein for adaptation and use in other communities.ConclusionsWildfire smoke events present significant mental health and wellbeing impacts for rural communities. Community-led solutions that promote stress reduction, physical protection, and community cohesion have the opportunity to bolster resilience amid this growing public health crisis.

Which aspects of coalition functioning are key at different stages of coalition development? A qualitative comparative analysis.

Coalitions are increasingly utilized to promote positive community health outcomes. Typically, coalitions produce more desirable outcomes when coalition functioning is strong and the coalition model is implemented with fidelity. Although theory indicates that coalitions proceed through predictable stages of development, minimal research explicitly examines functioning and fidelity at these different stages. Within a larger evaluation of Washington State Community Prevention and Wellness Initiative, this cross-sectional study employs qualitative comparative analysis to illuminate the coalition functioning conditions necessary and sufficient to produce high model fidelity at different stages of development in 43 substance misuse prevention coalitions in one state. In the formation stage, only the presence of high levels of coalition leadership was sufficient to produce high model fidelity. In the maintenance stage, three combinations of conditions were sufficient: (1) sustainability planning if, and only if, accompanied by the absence of coalition participation costs, (2) coordinator leadership, and (3) a combination of coalition leadership and team cohesion. In the institutionalization stage, two solutions were sufficient: (1) coalition leadership if, and only if, accompanied by the absence of sustainability planning, and (2) sustainability planning if, and only if, accompanied by the absence of coordinator leadership. This study illustrates several tangible steps technical assistance providers may take to increase the likelihood of achieving model fidelity. In the formation stage, skillful and inclusive coalition leadership is important. In the maintenance stage, technical assistance should focus on reducing participant-perceived costs; increasing sustainability planning; enhancing coordinator-specific leadership; and developing team cohesion and coalition leadership. For coalitions in the institutionalization stage, coalition leadership and sustainability planning may be prime targets for technical assistance.Plain Language Summary: Community coalition approaches to addressing social problems are common and have some evidence of producing positive community outcomes. Research shows that coalitions produce more desirable outcomes when coalition functioning is strong and the coalition model is implemented as it was designed. Although theory suggests that coalitions proceed through predictable stages of development, few studies look at which supports are most needed, at each stage, to improve coalition functioning and implementation. This study aims to help answer that question by determining which aspects of coalition functioning, in which combinations, are key to strong, well-functioning coalitions at different developmental stages in a sample of prevention coalitions in Washington State focused on youth substance misuse. The results suggest that having a strong coalition leadership team is key for all coalitions, regardless of development stage. For coalitions earlier in their formation, this was especially true. For coalitions further into their development, the combination of strong coordinator leadership and strong team cohesion was particularly important. Finally, for the most well-established coalitions, if sustainability planning was weak, strong coalition team leadership was key; but if coordinator leadership was weak, strong sustainability planning was critical to offset the lack of strong leadership. The results can be used to inform the types of technical assistance provided to support coalitions at different developmental stages.

Coronavirus Disease 2019 (COVID-19): Radiology Department Financial Impact and Planning for Post-COVID Recovery.

Coronavirus Disease 2019 (COVID-19): Radiology Department Financial Impact and Planning for Post-COVID Recovery.

Court orders records production

Case name: Doe #1, et al. v. Washington State Community College District 17, et al., No. 36030‐0‐III (Wash. Ct. App. 06/18/19).

Lessons From Reporting National Performance Measures in a Regional Setting: Washington State Community Cancer Care Report.

Regional public reporting of performance measures in oncology can facilitate local decision making across stakeholders, but small numbers of patients and clinics pose a challenge to creating statistically robust measures. In this article, we describe our development of the Community Cancer Care in Washington State: Quality and Cost Report, the first publicly available report showing clinic-level quality and cost measures at the regional level. We learned key lessons in how to adapt national performance reporting to our regional setting using a registry-linked multipayer claims database. In short, limited numbers of eligible patients for some nationally recognized metrics led us to group metrics and use a 3-year performance window. After completing clinic attribution and other requirements of metric construction, the final metrics included between 62.9% and 88.4% of the eligible patients. To link total costs to some quality measures, we had to define a treatment and surveillance episode of care. Risk adjustment was challenged by the ability to include a limited number of risk adjustors and their potential concentration in a few clinics. We used a different quality score than national performance reporting to account for variation in the range of risk-standardized rates. Current methodology does not permit us to determine whether clinically meaningful differences in quality or costs exist, which inhibits value comparisons. Stakeholder engagement was critical for providing methodologic feedback. In conclusion, we found that refining national metrics was necessary to facilitate public reporting in a regional setting. Further methodologic development can strengthen public reporting and future applications.

Lessons from Reporting National Performance Measures in a Regional Setting: Washington State Community Cancer Care Report.

105 Background: While many quality metrics are generated and reported at a national level, regionally reported metrics may be more meaningful to stakeholders and more amenable to locally-generated interventions aimed at improving quality. We present the lessons learned from adapting national performance reporting standards to our regional setting. Methods: We linked 2014-2016 Washington State cancer registry records with Medicare and commercial insurance claims, capturing about 70% of the state’s cancer patients. A consortium of payers, oncology providers, and patients selected metrics from national initiatives (QOPI, MACRA, OCM, and the Choosing Wisely Campaign). We then searched the National Quality Forum and the National Quality Measures Clearinghouse for published specifications on those metrics. If none were available or there was a lack of consensus, we constructed algorithms with clinical and technical expert review. We calculated clinic-level risk standardized rates (RSRs) using hierarchical regression modeling to adjust for variation in clinic size and constructed quality composites. Results: We generated 13 quality metrics for 36,900 cancer patients cared for at 27 clinics. Our adaptation of national performance measures and implications include: 1) Many treatment process measures had too few numbers to individually report annually requiring us to group quality metrics and cancer types, and report over a three year period. 2) Although we were able to include tumor characteristics (e.g. AJCC stage) from registry records, risk adjustment was challenged by limitations in the number of risk adjustors due to the smaller number of patients. 3) After applying the hierarchical models, risk adjustment had minimal effect on clinic rankings. 4) The small number of clinics and limited range of clinic RSRs were more accurately captured by a quality composite that reflected clinic level differences to the regional average rather than national quintile groupings. Conclusions: Refinement of national metrics is necessary for public reporting in a regional setting. Further methodological development is critical for robust reporting and applications to value based purchasing.

Washington State Community Cancer Care Report: Implications for value-based purchasing.

104 Background: As quality reports are released for regions and individual clinics, an important question is whether those reports can be used for value based purchasing, particularly for community oncology clinics. We evaluated the reliability of select quality measures and estimated the likelihood that a clinic’s performance would be incorrectly categorized (misclassified) in the top quartile. Methods: We linked 2014-2016 cancer registry records for patients with enrollment and claims from Medicare and two major commercial insurers in Washington State. We calculated risk standardized rates (RSRs) for ED and hospital use during treatment and 3 quality measures for end of life care. Reliability (0-1 scale: 0-unreliabile, > 0.7 good reliability, 1 perfectly reliable) was calculated as signal/(signal + statistical noise) from hierarchical logistic regression modeling for each metric. Misclassification was characterized as the probability of false negative and false positive assignment of clinics to the top quartile of performers in the region. We generated results for 3 and 1 year performance periods. Results: Over the 3 year period, the hospitalization metrics included 7,373 patients, 25 clinics; end of life metrics included 8,165 patients; 24 clinics. Conclusions: Although these metrics had fairly high levels of reliability, approximately one-third of clinics could be incorrectly identified as a top quartile performer. Use of these metrics in value based purchasing should account for potential misclassification to minimize unintended consequences.[Table: see text]

The Washington State Community Cancer Care Report: A multi-stakeholder effort to characterize quality of care and costs for Washington State oncology practices.

31 Background: Although many quality measures exist in oncology, there have been few efforts to prioritize, measure, and report quality and costs for an entire region. Here, we report the results of a multi-year, multi-stakeholder effort aimed at public reporting of nationally recognized quality metrics for oncology practices in Washington State. Methods: Quality metrics were selected from nationally-recognized measures through a structured process involving oncology providers, health insurance leaders, patient advocates, and policy experts. Cancer registry records from 2014 to 2016 were linked with claims data from two commercial insurers and Medicare, representing approximately 70% of cancer patients in the state. Patients were assigned to oncology clinics using claims data; 27 clinics were large enough for inclusion in at least one measure in the report. Thirteen metrics were combined to produce one clinic-level quality score per measure. Each quality score was mapped to total episode cost per patient. Results were adjusted to account for clinic size, cancer characteristics (e.g. stage), demographics, and comorbidity where appropriate. Results: Conclusions: The Community Cancer Care in Washington State: Quality and Cost Report 2018 is the first publicly accessible report showing clinic-level quality measures linked to cost in oncology. Its ultimate goal is to improve care and lower costs by spurring collaboration, research and innovation.[Table: see text]

Guided Pathways to Careers

Objective: Some have hypothesized that community college programs are not sufficiently structured to support student success and that students would benefit from more highly structured programs. This study examines the specific ways that structure is expressed in policy and practice at representative community colleges. Method: Using data obtained from interviews and program websites at Washington State community and technical colleges, we examine the structure of community college career-technical programs along four dimensions: program prescription, program alignment, access to information, and active advising and support. Results: We find high levels of structure on all dimensions in the allied health, computer and information science, and mechanics and repair programs. There are moderate levels of structure in the business and marketing programs. Contributions: This study documents the specific ways that community college career-technical programs are structured to support student success, and it provides a framework for examining structure to inform practice and guide future research efforts.

Labor Market Returns to Sub-Baccalaureate Credentials

This study provides one of the first estimates of the returns to different types of community college credentials—short-term certificates, long-term certificates, and associate degrees—across different fields of study. We exploit a rich data set that includes matched, longitudinal college transcripts and Unemployment Insurance records for students who entered a Washington State community college in 2001–2002. Our findings based on an individual fixed effect model suggest that earning an associate degree or a long-term certificate is associated with increased wages, particularly for women. We find that there is greater variation in returns to wages by the field of study than by degree type.

Perspectives of Behavioral Health Clinicians in a Rural Integrated Primary Care/Mental Health Program

This study compares the perspectives of rural and urban mental health clinicians working in various Washington State Community Health Centers that have implemented an integrated primary care/mental health program. We conducted a Web-based survey of mental health clinicians (n = 71) who work in an integrated primary care/mental health program ("the program") in 1 of 150 safety net primary care clinics in Washington State. Most participating clinics are Federally Qualified Health Centers or Rural Health Clinics. Pooled survey results from clinicians working in rural settings were compared to those working in urban settings. Semistructured interviews were conducted with a subset (n = 32) of survey respondents. Comments made during these interviews were analyzed for themes. In the survey phase, both rural and urban clinicians generally agreed that the program benefitted their patients. Rural respondents were particularly appreciative of the flexibility that the program offered when planning care. Not surprisingly, social service limitations (such as housing or transportation services) were more often mentioned as program limitations. Rural clinicians were more likely to note a lack of awareness of program resources among other medical providers on the team. Clinicians working in rural primary care clinics value the availability and flexibility of an integrated primary care/mental health program as an option for providing mental health care for their patients. Clinicians working in rural settings could benefit from additional training and program implementation support to best meet the needs of their patients.

The utility of a caseload registry: perceptions of behavioral health clinicians working in an integrated primary care and mental health program

ObjectivesThis study evaluated the perceived benefits and limitations of a Web-based clinical support tool for behavioral health clinicians serving patients in an integrated primary care and mental health program in Washington State community health centers. MethodsWe surveyed 71 clinicians who utilize a Web-based clinical support tool (“the caseload registry”) in treating patients. Follow-up interviews were scheduled with a subset (n=32) of respondents. Comments made during these interviews were analyzed using qualitative methods. ResultsSurvey responses were favorable on 4 of 7 questions regarding specific benefits of the caseload registry. Notably, clinicians agreed that the caseload registry helps track patients and their clinical progress. Clinicians also agreed that the caseload registry adds an additional documentation burden to their work duties.The most common positive themes identified during follow-up interviews were that the registry is useful and improves care. The most common critical themes identified were that the tool is burdensome and sometimes does not encompass important elements of care. ConclusionsBehavioral health clinicians working in an integrated primary care and mental health program report that use of a caseload registry adds value and improves care. They express that it helps provide more comprehensive care and tracks patient progress.

Multicultural Curriculum Development in Online Classes: Practices From Washington State Community Colleges

The community college system is based on an open-door mission and serves to provide access to students of diverse backgrounds. Online learning is one of the fastest growing segments of community college offerings. If the community college system embraces its open-door mission, it must also embrace new ways of providing multicultural experiences within online classes. Yet, little research has been conducted in looking at connections between online learning and multicultural education within community colleges. This study asked if multiculturalism plays a significant role in the traditional face-to-face college classroom—what role, if any, does it play in an online classroom? Literature on multicultural education, distance learning, educational theory, and social psychology were explored within the context of community colleges. Community college faculty who reported using multicultural approaches within their online classes were interviewed and observed. The results indicated that these online instructors generally had a collection of instructional methods that correlated to Banks’ (2004) Multicultural Dimensions. This article shares practices used by the faculty that can affect change in online students’ experiences with multiculturalism.

What Are Online Teaching Faculty Telling Us About Building Community?

This article describes the results of a mixed-methods study that examined the perceptions of community among online faculty in Washington state community and technical colleges. Twelve community and technical colleges were randomly selected from the 34 colleges in Washington state. Results indicated significant differences between females versus males on questions related to motivators, time, and interactions. A significant difference existed among program area faculty related to regularly scheduled community-building activities. There were no significant differences between responses from full-time versus adjunct faculty or among the responses based on instructors’ number of years teaching online or their age. The results of this study suggest a strong agreement (87%) among all faculty on the value and importance of interacting with other online colleagues regarding effective online teaching practices.

Pathways and Persistence: Basic Skills Students at One Washington State Community College

Pressures to increase accountability in basic skills education have encouraged policy makers and postsecondary institutions to focus on student achievement. Using the Washington State Student Achievement Initiative Database and two consecutive years of data, this study examines the academic progress of basic skills students at one community college over the course of a year. Overall, one program, I-BEST short-term education and training leading to a certificate or further education or training, was the most successful route to earning college credit. However, other basic skills students frequently earned college credit that could lead to degrees and transferable credits. Many students in all basic skills programs made no measured academic skill gains. Demographic differences suggest that self-selection bias must be considered in drawing conclusions from the course-taking patterns. These findings indicate more attention should be paid not only to college credits earned but to enrollment as well.

Medication reconciliation in the emergency department: opportunities for workflow redesign

AimTo examine the role of workflow redesign to improve medication reconciliation at four Washington State community hospital emergency departments.MethodLean redesign methodology was used for workflow process mapping and redesign workshops...

Sustainability of pharmacy-based innovations: The case of in-house immunization services

To examine the effect of organization-level factors on sustainability of pharmacy-based in-house immunization services. Cross-sectional study. Washington State community pharmacies in 2006. Key informants of 490 community pharmacies. Mixed-mode survey; five mail and telephone contacts were used. Effectiveness of champions (i.e., influential individuals within the host organization who actively and continuously promote the service), formal evaluation process, degree of modifications made to in-house services, degree of compatibility between in-house services and the host pharmacy, and sustainability of in-house immunization services were measured and included in the proposed model. Using survey responses, factor analysis and path analysis were performed to determine the relationships among these variables. Of the 490 survey instruments sent, 1 was undeliverable, 2 were incomplete, and 206 were completed (42.1% response rate). A total of 104 pharmacies that reported offering immunization services in 2006 were included in the analysis. Compatibility, which was defined as the fit between in-house immunization services and the host pharmacy, was the key to sustainability of immunization services. To enhance compatibility between in-house services and the host pharmacy, two pathways were found. First, in-house services underwent formal evaluations and subsequent modifications were made to the services. The second pathway bypassed the adaptation process. Through the second pathway, an operational champion implemented in-house services in a way that was already compatible with the host pharmacy. Organizational leaders and practitioners had the potential to sustain in-house services. The key factors included in the model should be incorporated as an integral part of programs planning to foster sustainability of in-house immunization services.

Forward and backward transitions in pharmacy-based immunization services

Background Community pharmacies can engage in immunization services by contracting with an external workforce (outsourced mechanism) or staff pharmacists (in-house mechanism) to deliver the services. Because an outsourced mechanism generally requires lower organizational commitment, pharmacies often start with an outsourced mechanism. Later, these pharmacies can have 1 of the following transitions: sit on a fence by continuing with an outsourced mechanism, move backward by abandoning any immunization services, or move forward by implementing an in-house mechanism. Objectives Using Rogers' Diffusion of Innovations model and Behavioral Theory of the Firm as guidance, this study identified the associations between perceived characteristics of immunization services and backward/forward transitions. Methods A cross-sectional mail survey was conducted to collect data from key informants of Washington State community pharmacies during May-July 2004 (response rate = 46.9%). A total of 106 pharmacies were included in the analysis. Based on pharmacy's immunization service transitions, these pharmacies were identified as Fence sitters, Backward movers, or Forward movers. Relationships between these transitions, pharmacy characteristics, and perceived characteristics of immunization services were analyzed using bivariate and multinomial logistic regression techniques. Results Backward and Forward movers had less positive assessments of outsourced services when compared with Fence sitters. Backward and Forward movers differed in their perceptions of in-house services; Backward movers generally perceived no differences between these 2 services, whereas Forward movers generally perceived in-house services to be superior to outsourced services. Furthermore, the odds of being a Forward mover increased as perceived technical and social benefits of outsourced services decreased, perceived compatibility of in-house services increased, and perceived complexity of in-house services decreased. Conclusions Perceived characteristics of outsourced and in-house innovations were associated with backward and forward transitions. Findings can be used to guide the development of strategies for facilitating organizational change and preventing the abandonment of immunization services.