Showing papers in "Administration and Policy in Mental Health in 2008"
TL;DR: The role of organizational social context in services and implementation research is described and a comprehensive contextual measure, labeled Organizational Social Context (OSC), designed to assess the key latent constructs of culture, climate and work attitudes is evaluated.
Abstract: The organizational social context in which mental health services are provided is believed to affect the adoption and implementation of evidence-based practices (EBPs) as well as the quality and outcomes of the services. A fully developed science of implementation effectiveness requires conceptual models that include organizational social context and tools for assessing social context that have been tested in a broad cross-section of mental health systems. This paper describes the role of organizational social context in services and implementation research and evaluates a comprehensive contextual measure, labeled Organizational Social Context (OSC), designed to assess the key latent constructs of culture, climate and work attitudes. The psychometric properties of the OSC measure were assessed in a nationwide study of 1,154 clinicians in 100 mental health clinics with a second-order confirmatory factor analysis of clinician responses, estimates of scale reliabilities, and indices of within-clinic agreement and between-clinic differences among clinicians. Finally, the paper illustrates the use of nationwide norms in describing the OSC profiles of individual mental health clinics and examines the cross-level association of organizational-level culture and climate with clinician-level work attitudes.
482 citations
TL;DR: The current framework developed by the UCLA/RAND NIMH Center is presented to address this research-to-practice gap by providing a theoretically-grounded understanding of the multi-layered nature of community and healthcare contexts and the mechanisms by which new practices and programs diffuse within these settings.
Abstract: The effective dissemination and implementation of evidence-based health interventions within community settings is an important cornerstone to expanding the availability of quality health and mental health services. Yet it has proven a challenging task for both research and community stakeholders. This paper presents the current framework developed by the UCLA/RAND NIMH Center to address this research-to-practice gap by: (1) providing a theoretically-grounded understanding of the multi-layered nature of community and healthcare contexts and the mechanisms by which new practices and programs diffuse within these settings; (2) distinguishing among key components of the diffusion process—including contextual factors, adoption, implementation, and sustainment of interventions—showing how evaluation of each is necessary to explain the course of dissemination and outcomes for individual and organizational stakeholders; (3) facilitating the identification of new strategies for adapting, disseminating, and implementing relatively complex, evidence-based healthcare and improvement interventions, particularly using a community-based, participatory approach; and (4) enhancing the ability to meaningfully generalize findings across varied interventions and settings to build an evidence base on successful dissemination and implementation strategies.
365 citations
TL;DR: The findings suggest that strategies to support the implementation of new mental health treatments and services should attend to organizational culture and climate, and to the compatibility of organizational service structures with the demand characteristics of treatments.
Abstract: The present study incorporates organizational theory and organizational characteristics in examining issues related to the successful implementation of mental health services. Following the theoretical foundations of socio-technical and cultural models of organizational effectiveness, organizational climate, culture, legal and service structures, and workforce characteristics are examined as correlates of therapist turnover and new program sustainability in a nationwide sample of mental health clinics. Results of General Linear Modeling (GLM) with the organization as the unit of analysis revealed that organizations with the best climates as measured by the Organizational Social Context (OSC) profiling system, had annual turnover rates (10%) that were less than half the rates found in organizations with the worst climates (22%). In addition, organizations with the best culture profiles sustained new treatment or service programs over twice as long (50 vs. 24 months) as organizations with the worst cultures. Finally, clinics with separate children’s services units had higher turnover rates than clinics that served adults and children within the same unit. The findings suggest that strategies to support the implementation of new mental health treatments and services should attend to organizational culture and climate, and to the compatibility of organizational service structures with the demand characteristics of treatments.
219 citations
TL;DR: An ecological model informed by public health and organizational theories is proposed to refocus school based services in poor communities on the core function of schools to promote learning and suggest an iterative research–practice approach to program adaptation and implementation.
Abstract: School based mental health services for children in poverty can capitalize on schools’ inherent capacity to support development and bridge home and neighborhood ecologies. We propose an ecological model informed by public health and organizational theories to refocus school based services in poor communities on the core function of schools to promote learning. We describe how coalescing mental health resources around school goals includes a focus on universal programming, mobilizing indigenous school and community resources, and supporting core teaching technologies. We suggest an iterative research–practice approach to program adaptation and implementation as a means toward advancing science and developing healthy children.
200 citations
TL;DR: Results of RRMs evaluating relations between director ratings of the importance to new treatment and service implementation of three factors suggest greater importance to public than private organizations of these factors.
Abstract: A structured interview survey of directors of a large national sample (n = 200) of mental health service organizations treating children examined the governance, financing, staffing, services, and implementation practices of these organizations; and, director ratings of factors important to implementation of new treatments and services. Descriptive analyses showed private organizations financing services with public (particularly Medicaid) funds are prevalent and that employment of professional staff, clinical supervision and training, productivity requirements, and outcomes monitoring are common. Results of random effects regression models (RRMs) evaluating associations between governance, financing, and organizational characteristics and the use of new treatments and services showed for-profit organizations more likely to implement such treatments, and organizations with more licensed clinical staff and weekly clinical supervision in place less likely to do so. Results of RRMs evaluating relations between director ratings of the importance to new treatment and service implementation of three factors—fit with existing implementation practices, infrastructure support, and organizational mission and support—suggest greater importance to public than private organizations of these factors. Implications for EST implementation and future research are described.
143 citations
TL;DR: Future help-seeking models need to capture the iterative referral process that many parents experience, and how parents navigate the various services available.
Abstract: Parents seeking help for their child's mental health problem face a complicated system of services. We examined how parents navigate the various services available. Sixty parents contacting a children's mental health center were interviewed regarding their efforts and rationale in seeking help for their child. On average, in the year prior to the interview parents sought help for two different child problems, contacted five different agencies or professionals for help, and parents and/or children received two different treatments. One fifth of the time parents said they accepted treatments that they did not want. Almost all parents (87%) were simultaneously in contact with more than one agency at some point within the previous year. Future help-seeking models need to capture the iterative referral process that many parents experience.
135 citations
TL;DR: Results using a contrasting groups approach indicate that 30 is a reasonable “clinical” cut-off score and a ROC curve analysis suggests that the CSI is “fair to good” discriminator of individuals with psychiatric disabilities.
Abstract: The Colorado Symptom Index (CSI: Shern et al. 1994, Milbank Quart 72:123-148) is widely used in research as a self-report measure of psychiatric symptomatology, yet little information exists regarding the scale's psychometric properties. Additionally, the CSI has no cut-off score denoting the need for further psychiatric assessment. This study examined the CSI's psychometric properties and established a cut-off score. Analyses were based on 3,874 adult Florida Medicaid respondents. The CSI had excellent internal consistency (.92) and test-retest reliability (.71). Evidence of the CSI's validity was strong; CSI scores distinguished among individuals with and without mental health services needs and were significantly correlated with functioning. Results using a contrasting groups approach indicate that 30 is a reasonable "clinical" cut-off score. At this score, the CSI had respectable sensitivity (.76) and specificity (.68) and a ROC curve analysis suggests that the CSI is "fair to good" discriminator of individuals with psychiatric disabilities.
125 citations
TL;DR: Officers trained in CIT demonstrated enhanced self-efficacy for interacting with individuals with depression, cocaine dependence, schizophrenia, and alcohol dependence and reduced social distance regarding individuals with these four psychiatric conditions.
Abstract: Objective The Crisis Intervention Team (CIT) program is a collaborative model involving mental health professionals and law enforcement officers that is being implemented in a multitude of localities across the country. This study had two main objectives: (1) To assess perceptions of self-efficacy and desired social distance of control officers and officers entering CIT training with regard to individuals with psychiatric syndromes (depression and schizophrenia) and individuals with substance dependence (alcohol and cocaine), and (2) To examine the effects, if any, of CIT training on self-efficacy and social distance. Methods Between March and July 2006, a survey was administered to 34 control police officers, 58 officers just before a 40-h CIT training program, and 40 of these officers upon completion of the training. Results At baseline, pre-CIT officers did not differ from control non-CIT officers in terms of self-efficacy or social distance relating to the four disorders. Officers trained in CIT demonstrated enhanced self-efficacy for interacting with individuals with depression, cocaine dependence, schizophrenia, and alcohol dependence. Additionally, CIT-trained officers reported reduced social distance regarding individuals with these four psychiatric conditions. Regarding the schizophrenia vignette, there was a significant interaction between pre-CIT/post-CIT status and family history of psychiatric treatment in the prediction of social distance. Conclusions Enhancements in self-efficacy and reductions in social distance may have important implications in terms of improving officers’ interactions with people with mental illnesses and substance use disorders. Given the importance of the problem of law enforcement/criminal justice involvement among people with such illnesses, and the dearth of research on this growing collaborative service model, further research is needed on officer-level outcomes of the CIT program.
120 citations
TL;DR: This article describes one example of a behavioral health reporting system designed to facilitate clinical and administrative use of evidence-based practices, and the design processes underlying this system can be implemented to support clinical practice in a wide variety of settings.
Abstract: This paper illustrates the application of design principles for tools that structure clinical decision-making. If the effort to implement evidence-based practices in com- munity services organizations is to be effective, attention must be paid to the decision-making context in which such treatments are delivered. Clinical research trials commonly occur in an environment characterized by structured deci- sion making and expert supports. Technology has great potential to serve mental health organizations by supporting these potentially important contextual features of the research environment, through organization and reporting of clinical data into interpretable information to support deci- sions and anchor decision-making procedures. This article describes one example of a behavioral health reporting system designed to facilitate clinical and administrative use of evidence-based practices. The design processes underly- ing this system—mapping of decision points and distillation of performance information at the individual, caseload, and organizational levels—can be implemented to support clinical practice in a wide variety of settings.
116 citations
TL;DR: 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), which may be able to help organizations in continuing with the implementation process.
Abstract: 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.
113 citations
TL;DR: Using procedural justice theory as a sensitizing framework, in-depth semi-structured interviews were used to explore the experiences of twenty persons with mental illness in 67 encounters with police, finding that they feel vulnerable and fearful of police and the way police treated them mattered.
Abstract: Programs to improve police interactions with persons with mental illness are being initiated across the country. In order to assess the impact of such interventions with this population, we must first understand the dimensions of how police encounters are experienced by consumers themselves. Using procedural justice theory as a sensitizing framework, we used in-depth semi-structured interviews to explore the experiences of twenty persons with mental illness in 67 encounters with police. While participants came into contact with police in a variety of ways, two main themes emerged. First, they feel vulnerable and fearful of police, and second, the way police treated them mattered. Findings elaborate on dimensions of procedural justice theory and are informative for police practice and mental health services.
TL;DR: Overall, the pattern of differences point to possible directions for adaptation of treatments for use with children with anxiety disorders served in public mental health systems.
Abstract: Compared two groups of children with anxiety disorders served at a single mental health clinic whose referral source differed: private referrals (i.e., parent/legal guardian initiated) and public referrals (e.g., via state contracts—Departments of Health and Education, juvenile justice system). Comparisons were made across three domains of variables: (a) symptoms/diagnoses, (b) func- tioning, and (c) environments. Few symptom differences emerged. However, large differences were evident for contextual variables like family income and life stressors. Overall, the pattern of differences point to possible direc- tions for adaptation of treatments for use with children with anxiety disorders served in public mental health systems.
TL;DR: Investigation of the relations among therapist adherence to an evidence-based treatment for youth with serious antisocial behavior, organizational climate and structure, and improvement in youth behavior problems one-year post treatment found results showed therapist adherence predicted improvement in Youth behavior.
Abstract: The current study investigated the relations among therapist adherence to an evidence-based treatment for youth with serious antisocial behavior (i.e., Multisystemic Therapy), organizational climate and structure, and improvement in youth behavior problems one-year post treatment. Participants were 1979 youth and families treated by 429 therapists across 45 provider organizations in North America. Hierarchical Linear Modeling (HLM) results showed therapist adherence predicted improvement in youth behavior. Two structure variables and one climate variable predicted changes in youth behavior, and the climate variable also predicted therapist adherence. No statistical support for formal mediation of organizational effects through adherence was found, though examination of changes in parameter estimates suggest a possible interplay of organizational climate with adherence and youth behavior change.
TL;DR: Why the epidemiology of child mental health problems poses difficulties for disorder-specific mental health interventions, and whether there are evidence-based skills to allow providers to immediately begin treatment for children with emotional and behavioral problems while diagnostic procedures are being pursued, are discussed.
Abstract: To expand the mental health service capacity of pediatric primary care, we ask whether there are evidence-based skills to allow providers to 1) immediately begin treatment for children with emotional and behavioral problems while diagnostic procedures are being pursued, and 2) offer evidence-based care to children who do not meet criteria for a specific diagnosis. We discuss why the epidemiology of child mental health problems poses difficulties for disorder-specific mental health interventions, and review evidence that “common factors” contributing to the outcome of mental health treatments define a core set of skills that primary care providers might use to complement disorder-specific interventions.
TL;DR: The initial phase of a randomized trial that tests two methods of implementing Multidimensional Treatment Foster Care in 40 non-early adopting California counties supports the feasibility of using a randomized design to rigorously test contrasting implementation models and engaging system leaders to participate in the trial.
Abstract: There is a growing consensus that implementation of evidence-based intervention and treatment models holds promise to improve the quality of services in child public service systems such as mental health, juvenile justice, and child welfare. Recent policy initiatives to integrate such research-based services into public service systems have created pressure to expand knowledge about implementation methods. Experimental strategies are needed to test multi-level models of implementation in real world contexts. In this article, the initial phase of a randomized trial that tests two methods of implementing Multidimensional Treatment Foster Care (an evidence-based intervention that crosses child public service systems) in 40 non-early adopting California counties is described. Results are presented that support the feasibility of using a randomized design to rigorously test contrasting implementation models and engaging system leaders to participate in the trial.
TL;DR: A brief review of organizational measures related to implementation of new practices and technologies in sectors other than mental health, and potential application of these measures to mental health implementation research is discussed.
Abstract: This paper presents a brief review of organizational measures related to implementation of new practices and technologies in sectors other than mental health, and discusses potential application of these measures to mental health implementation research. A few standardized organizational measures are presented along with considerations regarding the appropriateness of adapting existing measures rather than creating novel ones or using additional methodologies. Challenges and opportunities for researchers in measuring key organizational constructs related to implementation in mental health settings are discussed.
TL;DR: Pilot study data demonstrated that factors associated with the adoption of FFT included: the program fitting with the mission of the organization, the organization having a strong interest in evidence-based treatments, and the degree to which it fit with organizational characteristics influenced the ease with which it was implemented.
Abstract: Numerous challenges persist in providing evidence-based treatments to children and families in community-based settings Functional Family Therapy (FFT), one such evidence-based treatment, is a family prevention and intervention program for adolescents with conduct disorder or oppositional defiant disorder This paper presents pilot data in support of a conceptual framework explaining the adoption and implementation of FFT in a small sample of family and child mental health services organizations in New York State The conceptual framework is grounded in the diffusion of innovations and the organizational behavior literatures, as well as previously published accounts of the adoption and implementation of evidence-based treatments in mental health Pilot study data demonstrated that factors associated with the adoption of FFT included: The program fitting with the mission of the organization, as well as the organization having a strong interest in evidence-based treatments Once a decision to adopt FFT was made, the degree to which it fit with organizational characteristics (eg, available resource sets, organizational structure, and culture) influenced the ease with which it was implemented Implications for the adoption and implementation of other evidence-based treatments are discussed
TL;DR: The papers in this special issue describe research undertaken by the MacArthur Foundation-funded Research Network on Youth Mental Health, designed to understand the challenges of implementing evidence-based treatments in community-based mental health practices.
Abstract: The papers in this special issue describe research undertaken by the MacArthur Foundation-funded Research Network on Youth Mental Health. The project is designed to understand the challenges of implementing evidence-based treatments in community-based mental health practices. This Introduction and the following articles describe the impetus and conceptual framework underlying one cluster of the Network’s activity—i.e., the Clinic Systems Project (CSP). The CSP studies examined the organizational and service system environments in a large national sample of community mental health and affiliated organizations that provide services to children. The main goal is to identify leverage points for, and barriers to, the adoption and implementation of evidence-based practices for children.
TL;DR: This study used summary tables drawn from the 1999 Medicaid Analytic Extract (MAX) files, the first available Medicaid data for the entire US, to examine fee-for-service Medicaid in 23 selected states.
Abstract: Mental health care is a critical component of Medicaid for children. This study used summary tables drawn from the 1999 Medicaid Analytic Extract (MAX) files, the first available Medicaid data for the entire US, to examine fee-for-service Medicaid in 23 selected states. Data show that 9% of children and youth (ages 0–21) had a mental health-related diagnosis on a claim, varying from 5% to 17% across the states. The proportion increased with age, and was higher for boys. Over half of those diagnosed received psychotropic medication, and approximately 7% had an inpatient psychiatric admission during the year. Mental health costs accounted for 26.5% of total fee-for-service Medicaid expenditures, varying from 14% to 61% depending on the state.
TL;DR: This summary describes some of the constructs relevant to implementation research and presents research questions that, if studied, will lay a solid foundation for implementation research.
Abstract: While much has been written about reducing the gap between science and practice, relatively little progress has been made to develop a sound knowledge base underlying implementation of effective interventions. To respond to these challenges, the National Institute of Mental Health organized a workshop entitled, "Advancing the Science of Implementation: Improving the Fit between Mental Health Intervention Development and Service Systems." Over the 2-day workshop, a multi-disciplinary group of intervention and services researchers, implementers, methodologists, organizational theorists, and clinicians was brought together in an "engaged scholarship" * format composed of small and large-group settings to discuss the development of a sound knowledge base on the implementation of evidence-based practices. Using three specific intervention categories, participants identified constructs seen to be important to the implementation of the model in real-world systems. Following each breakout session, attendees reconvened for a full group discussion and brief presentations were conducted to highlight interventions in the areas of organizational measures, social network analysis and field opportunities. This summary describes some of the constructs relevant to implementation research and presents research questions that, if studied, will lay a solid foundation for implementation research.
TL;DR: Overall mean Medicare expenditures per elderly NDPI inpatient stay declined by $2,254 (in 2002 dollars) and covered days by 2.8 from 1992 to 2002, suggesting that inpatient treatment for NDPI is shifting into less expensive settings which may reflect cost-cutting strategies, preferences for less restrictive settings, and outpatient treatment advances.
Abstract: We summarize Medicare utilization and payment for inpatient treatment of non-dementia psychiatric illnesses (NDPI) among the elderly during 1992 and 2002. From 1992 to 2002, overall mean Medicare expenditures per elderly NDPI inpatient stay declined by $2,254 (in 2002 dollars) and covered days by 2.8. However, these changes are complicated by expanded use of skilled nursing facilities and hospital psychiatric units, and decreased use of long-stay hospitals and general hospital beds. This suggests that inpatient treatment for NDPI is shifting into less expensive settings which may reflect cost-cutting strategies, preferences for less restrictive settings, and outpatient treatment advances.
TL;DR: Findings portray a network of family advocacy, support and education organizations that are strategically poised to effect substantive change and characterized by significant fiscal instability.
Abstract: In conjunction with the national survey of mental health service organizations (Schoenwald et al. this issue), a separate but complementary national survey was conducted of family advocacy, support and education organizations (FASEOs). Directors of FASEOs within the same localities as the mental health agencies responded to a survey and provided information in four areas: (1) structure and funding; (2) factors influencing advocacy decisions about children’s mental health; (3) types of services provided by FASEOs and factors perceived as related to improved outcomes; and (4) the types of working relationships between FASEOs and local mental health clinics. Findings from a total of 226 (82% response rate) portray a network of family advocacy, support and education organizations that are strategically poised to effect substantive change and characterized by significant fiscal instability. Results from this survey and implications for delivery of family-based services are provided.
TL;DR: Results suggest that four interrelated factors contributed to whether agencies successfully implemented Outcome Monitoring-agency data collection methods, agency culture, practitioner skill, and how well “consumer outcomes” are defined.
Abstract: Objective This study reports participating agencies use of a single fidelity dimension, Outcome Monitoring, during the 2-year National EBP Implementation Project. Method The study involved an emerging theme qualitative approach for analyzing the implementation of fidelity achieved for five EBPs in 49 sites across eight states. Results Twenty-seven percent of the sites reached a high level of implementation fidelity. Conclusion Results suggest that four interrelated factors contributed to whether agencies successfully implemented Outcome Monitoring-agency data collection methods, agency culture, practitioner skill, and how well “consumer outcomes” are defined.
TL;DR: Strategies to overcome barriers to integrated care may require cooperation across different organizational levels, including administrators, providers, and health care payers in order for integrated care to be established and sustained over time.
Abstract: The historical fragmentation of physical and mental health services has impeded efforts to improve quality and outcomes of care for persons with mental disorders. However, there is little information on effective strategies that might reduce fragmentation and improve integrated services within non-academic, community-based healthcare settings. Twenty-three practices from across the U.S. participated in a learning community meeting designed to identify barriers to integrated care and strategies for reducing such barriers. Barriers were initially identified based on a quantitative survey of organizational factors. Focus groups were used to elaborate on barriers to integrated care and to identify strategies for reducing barriers that are feasible in community-based settings. Participants identified key barriers, including administrative (e.g., lack of common medical records for mental health and general medical conditions), financial (e.g., lack of reimbursement codes to bill for mental health and general medical care in the same setting), and clinical (e.g., lack of an integrated care protocol). Top strategies recommended by participants included templates (i.e., for memoranda of understanding) to allow providers to work across practice settings, increased medical record security to enable a common medical record between mental health and general medical care, working with state Medicaid agencies to establish integrated care reimbursement codes, and guidance in establishing workflows between different providers (i.e., avoid duplication of tasks). Strategies to overcome barriers to integrated care may require cooperation across different organizational levels, including administrators, providers, and health care payers in order for integrated care to be established and sustained over time.
TL;DR: I thought I would never write this in ‘‘public’’ but one of the paradoxical problems with the authors' mental health services is that they are not visibly harmful.
Abstract: I thought I would never write this in ‘‘public’’ but one of the paradoxical problems with our mental health services is that they are not visibly harmful. Most of the research shows that treatment as usual (TAU) is neither harmful nor effective. Ineffective mental health services do not usually produce dramatic negative outcomes. In most cases the client will drop out of services, especially in the public system where the no show and dropout rates are phenomenally high. Certainly there are suicides and assaults, and sometimes killings. However these incidents are usually attributed to inadequate supervision or custody rather than to ineffective treatment. Unlike the surgeon who leaves an instrument in a patient or a plumber who leaves a leaky fitting, there is no trail left by unsuccessful treatment. But poor outcomes are not buried only because they are insufficiently dramatic or visible. We hide the ineffective services from ourselves and the public by not collecting information that measures their effectiveness. Even the clients may not be aware that they have received ineffective services.
TL;DR: This paper reviewed case records for 583 juvenile delinquency intakes in four county juvenile probation offices; 14.4% were receiving mental health or substance use services at case opening, and 24.9% were newly identified during probation contact.
Abstract: We reviewed case records for 583 juvenile delinquency intakes in four county juvenile probation offices; 14.4% were receiving mental health or substance use services at case opening, and 24.9% were newly identified during probation contact. Youths were significantly more likely to be newly identified if they were repeat offenders, if their probation officer knew more about mental health and if they resided in a county without a shortage of available mental health professionals. Probation officers were especially likely to underidentify internalizing disorders. Policy implications for promoting identification of mental health needs and improving linkage to community service providers are discussed.
TL;DR: Treatment effects were largest for subgroups characterized by high levels of PTSD, whereas the effects for those in the low symptom group were near zero, which underscores the need for clinicians to conduct careful assessments of trauma-related symptoms and to target the most intensive trauma- related interventions to individuals with PTSD symptoms.
Abstract: National attention to the effects of interpersonal trauma has led mental health systems to adopt policies on trauma-related services; however, there is a lack of clarity regarding targeting of these services. Data from the Women, Co-occurring Disorders and Violence Study (WCDVS) were reanalyzed by grouping women on their baseline PTSD and substance abuse presentation and assessing the differential response to an integrated mental health/substance abuse intervention. Treatment effects were largest for subgroups characterized by high levels of PTSD, whereas the effects for those in the low symptom group were near zero. These findings underscore the need for clinicians to conduct careful assessments of trauma-related symptoms and to target the most intensive trauma-related interventions to individuals with PTSD symptoms.
TL;DR: Structured facilitation can significantly reduce barriers to PAD completion, however, the intervention did not eliminate barriers.
Abstract: Objective Psychiatric advance directives (PADs) allow individuals to plan for future mental health treatment. However, little is known about barriers to PAD completion. This paper examines an intervention’s effect in reducing barriers to PAD completion. Method Patients were randomly assigned to a facilitated PAD session or control group. Barriers associated with (1) the PAD documents and (2) external support for PADs were assessed at baseline (n = 462), 6 months (n = 380) and 1 year (n = 362). Results There were no significant baseline between-group differences on the two barriers. However, at follow-up both barriers were significantly lower in the experimental group. Further, barriers were predictive of PAD completion. Conclusions Structured facilitation can significantly reduce barriers to PAD completion. However, the intervention did not eliminate barriers. Findings are discussed in the context of possible system-level changes to further reduce barriers to PAD completion.
TL;DR: Directives were more likely to be accessed over time and for people who had repeated crises, fewer prior hospitalizations, no substance use, and no prior outpatient commitment orders.
Abstract: This paper presents the first empirical data regarding the rates and predictors of using psychiatric advance directives. Directives were accessed in only 20% of crisis events for the 69 participants selected on the basis of frequent use of psychiatric emergency and hospital services. Directives were 10 times more likely to be accessed when a surrogate decision-maker was involved in the crisis event. Directives were also more likely to be accessed over time and for people who had repeated crises, fewer prior hospitalizations, no substance use, and no prior outpatient commitment orders. Creation of more directives to increase clinician and system familiarity and more consistent appointment of surrogate decision-makers could increase use of directives.
TL;DR: Four aspects of the work of quality assurance and improvement professionals in mental health were explored in this qualitative study: their perceived roles, their major activities, their QA/I targets, and their contributions.
Abstract: Accompanying the rise in the number of mental health agency personnel tasked with quality assurance and improvement (QA/I) responsibilities is an increased need to understand the nature of the work these professionals undertake. Four aspects of the work of quality assurance and improvement (QA/I) professionals in mental health were explored in this qualitative study: their perceived roles, their major activities, their QA/I targets, and their contributions. In-person interviews were conducted with QA/I professionals at 16 mental health agencies. Respondents perceived their roles at varying levels of complexity, focused on different targets, and used different methods to conduct their work. Few targets of QA/I work served as indicators of high quality care. Most QA/I professionals provided concrete descriptions of how they had improved agency services, while others could describe none. Accreditation framed much of agency QA/I work, perhaps to its detriment.