Advancing the adoption, integration and testing of technological advancements within existing care systems

Technologic and Nontechnologic Barriers to Implementing Behavioral Health Homes in Community Mental Health Settings During the COVID-19 Pandemic

Background

Persons with serious mental illnesses (SMIs) experience disparities in health care and are more likely to die from physical health conditions than the general population. Behavioral health homes are used in public sector mental health programs to deploy collaborative care to improve physical health for those with SMIs. During the COVID-19 pandemic, these programs faced new challenges in delivering care to this vulnerable group.

Purpose

To describe barriers to implementing or sustaining behavioral health homes, experienced by community mental health workers during the COVID-19 pandemic, and the strategies used to address these challenges.

Methods

In-depth qualitative interviews were conducted among the behavioral health workforce in Maryland and Michigan community mental health programs. Interview questions were derived from the Consolidated Framework for Implementation Research (CFIR), and responses related to implementing and sustaining health homes during the pandemic were coded and themes were analyzed by using an inductive approach.

Results

Overall, 72 staff members across 21 sites in Maryland and Michigan were interviewed. Implementation barriers/strategies identified occurred across multiple CFIR domains (client, mental health system, physical health system). Interviewees discussed technologic and nontechnologic challenges as well as strategies to address technology issues. Strategies were more frequently discussed by providers when the barrier was viewed at the client level (eg, low technology literacy) versus the broader system (eg, canceled primary care visits).

Conclusions

Community mental health staff described barriers beyond technology in caring for individuals with SMIs and physical health conditions. Further research should examine how implementation strategies address both technologic and nontechnologic barriers to collaborative care.

Caregivers' and Young Children's Emotional Health Needs After Pediatric Traumatic Injury

Pediatric traumatic injury (PTI) is associated with emotional health difficulties, but most US trauma centers do not adequately address emotional recovery needs. This study aimed to assess families' emotional health needs following PTI and determine how technology could be used to inform early interventions. Individual semi-structured, qualitative interviews were conducted with caregivers of children admitted to a Level I trauma center in the Southeastern United States to understand families' experiences in-hospital and post-discharge. Participants included 20 caregivers of PTI patients under age 12 (M = 6.4 years; 70% male, 45% motor vehicle collision). Thematic analysis was used to analyze data from interviews that were conducted until saturation. Caregivers reported varying emotional needs in hospital and difficulties adjusting after discharge. Families responded enthusiastically to the potential of a technology-enhanced resource for families affected by PTI. A cost-effective, scalable intervention is needed to promote recovery and has potential for widespread pediatric hospital uptake.

Chatbots to Support Young Adults’ Mental Health: an Exploratory Study of Acceptability

Despite the prevalence of mental health conditions, stigma, lack of awareness and limited resources impede access to care, creating a need to improve mental health support. The recent surge in scientific and commercial interest in conversational agents and their potential to improve diagnosis and treatment seems a potentially fruitful area in this respect, particularly for young adults who widely use such systems in other contexts. Yet, there is little research that considers the acceptability of conversational agents in mental health. This study, therefore, presents three research activities that explore whether conversational agents and, in particular, chatbots can be an acceptable solution in mental healthcare for young adults. First, a survey of young adults (in a university setting) provides an understanding of the landscape of mental health in this age group and of their views around mental health technology, including chatbots. Second, a literature review synthesises current evidence relating to the acceptability of mental health conversational agents and points to future research priorities. Third, interviews with counsellors who work with young adults, supported by a chatbot prototype and user-centred design techniques, reveal the perceived benefits and potential roles of mental health chatbots from the perspective of mental health professionals, while suggesting preconditions for the acceptability of the technology. Taken together, these research activities: provide evidence that chatbots are an acceptable solution to offering mental health support for young adults; identify specific challenges relating to both the technology and environment; and argue for the application of user-centred approaches during development of mental health chatbots and more systematic and rigorous evaluations of the resulting solutions.

A pilot study of the functionality and clinician acceptance of a clinical decision support tool to improve primary care of opioid use disorder

OBJECTIVE

Most Americans with opioid use disorder (OUD) do not receive indicated medical care. A clinical decision support (CDS) tool for primary care providers (PCPs) could address this treatment gap. Our primary objective was to build OUD-CDS tool and demonstrate its functionality and accuracy. Secondary objectives were to achieve high use and approval rates and improve PCP confidence in diagnosing and treating OUD.

METHODS

A convenience sample of 55 PCPs participated. Buprenorphine-waivered PCPs (n = 8) were assigned to the intervention. Non-waivered PCPs (n = 47) were randomized to intervention (n = 24) or control (n = 23). Intervention PCPs received access to the OUD-CDS, which alerted them to patients at potentially increased risk for OUD or overdose and guided diagnosis and treatment. Control PCPs provided care as usual.

RESULTS

The OUD-CDS was functional and accurate following extensive multi-phased testing. PCPs used the OUD-CDS in 5% of encounters with at-risk patients, far less than the goal of 60%. OUD screening confidence increased for all intervention PCPs and OUD diagnosis increased for non-waivered intervention PCPs. Most PCPs (65%) would recommend the OUD-CDS and found it helpful with screening for OUD and discussing and prescribing OUD medications.

DISCUSSION

PCPs generally liked the OUD-CDS, but use rates were low, suggesting the need to modify CDS design, implementation strategies and integration with existing primary care workflows.

CONCLUSION

The OUD-CDS tool was functional and accurate, but PCP use rates were low. Despite low use, the OUD-CDS improved confidence in OUD screening, diagnosis and use of buprenorphine. NIH Trial registration NCT03559179. Date of registration: 06/18/2018. URL: https://clinicaltrials.gov/ct2/show/NCT03559179.

Assistive technology and schizophrenia

Purpose

Assistive technology (AT) has been highlighted as a tool that can support self-management for people living with schizophrenia. A gap in the literature exists regarding the views held by the stakeholders involved in the health care of an individual living with schizophrenia regarding the potential use of AT to enable the self-management of this condition. The purpose of this paper is to explore how individuals living with schizophrenia, their relatives and their mental health care professionals view AT as a tool to facilitate self-management.

Design/methodology/approach

This mixed methods research paper will discuss the findings of the second stage of a two-stage research study. The paper will discuss the findings of questionnaires that were disseminated to service users living with schizophrenia, their relatives and the health-care professionals of a community mental health service in the Greater Dublin area.

Findings

The results indicate that the introduction of AT for the self-management of schizophrenia would be accepted by key stakeholders.

Research limitations/implications

As AT continues to develop, it is clear from the findings presented in this paper that the main stakeholder groups involved in the care of an individual living with schizophrenia are amenable to the use of AT to facilitate the self-management of this condition. Further research is required to explore correct policing and management of its implementation.

Originality/value

This study is the first study of its kind within an Irish context to explore the use of assistive technology as a tool for self-management from the perspective of those experiencing schizophrenia, their relatives and the health-care professionals working alongside them.

Potential of personal health record portals in the care of individuals with spinal cord injuries and disorders: Provider perspectives

CONTEXT/OBJECTIVE

Although personal health record (PHR) portals are designed for patients, healthcare providers are a key influence in how patients use their features and realize benefits from them. A few studies have examined provider attitudes toward PHR portals, but none have focused on those who care for individuals with spinal cord injuries and disorders (SCI/D). We characterize SCI/D provider perspectives of PHR portals, including perceived advantages and disadvantages of PHR portal use in SCI/D care.

DESIGN

Cross-sectional; semi-structured interviews.

SETTING

Spinal Cord Injury (SCI) Centers in the Veterans Health Administration.

PARTICIPANTS

Twenty-six SCI/D healthcare providers.

INTERVENTIONS

None.

OUTCOME MEASURES

Perceived advantages and disadvantages of PHR portals.

RESULTS

The complex situations of individuals with SCI/D shaped provider perspectives of PHR portals and their potential role in practice. Perceived advantages of PHR portal use in SCI/D care included the ability to coordinate information and care, monitor and respond to outpatient requests, support patient self-management activities, and provide reliable health information to patients. Perceived disadvantages of PHR portal use in SCI/D care included concerns about the quality of patient-generated health data, other potential liabilities for providers and workload burden, and the ability of individuals with SCI/D to understand clinical information accessed through a portal.

CONCLUSION

Our study highlights advantages and disadvantages that should be considered when promoting engagement of SCI/D healthcare providers in use of PHR portals, and portal features that may have the most utility in SCI/D care.

Measuring and improving the quality of mental health care: a global perspective

Mental disorders are common worldwide, yet the quality of care for these disorders has not increased to the same extent as that for physical conditions. In this paper, we present a framework for promoting quality measurement as a tool for improving quality of mental health care. We identify key barriers to this effort, including lack of standardized information technology-based data sources, limited scientific evidence for mental health quality measures, lack of provider training and support, and cultural barriers to integrating mental health care within general health environments. We describe several innovations that are underway worldwide which can mitigate these barriers. Based on these experiences, we offer several recommendations for improving quality of mental health care. Health care payers and providers will need a portfolio of validated measures of patient-centered outcomes across a spectrum of conditions. Common data elements will have to be developed and embedded within existing electronic health records and other information technology tools. Mental health outcomes will need to be assessed more routinely, and measurement-based care should become part of the overall culture of the mental health care system. Health care systems will need a valid way to stratify quality measures, in order to address potential gaps among subpopulations and identify groups in most need of quality improvement. Much more attention should be devoted to workforce training in and capacity for quality improvement. The field of mental health quality improvement is a team sport, requiring coordination across different providers, involvement of consumer advocates, and leveraging of resources and incentives from health care payers and systems.

Adoption of Technology-Enhanced Treatments: Conceptual and Practical Considerations

As the efficacy of technology-enhanced mental health service delivery models (i.e., supportive or adjunctive technological tools) are examined, we must inform and guide clinician decision-making regarding acceptance and, in turn, uptake. Accordingly, this review aims to move beyond traditional discussions of geographic barriers by integrating, reconciling, and extending literatures on dissemination and implementation, as well as technology uptake, in order to anticipate and address organizational and clinician barriers to adoption of technology-enhancements. Specifically, a five-stage model is proposed to address organizational readiness for and clinician acceptance of technology-enhancements to evidence-based treatments, as well as the relevance of current adoption strategies for technology-enhanced services. Our aim is to provide a guiding framework for future research and practice.

The Impact of an eHealth Portal on Health Care Professionals' Interaction with Patients: Qualitative Study

Background

People who undergo weight loss surgery require a comprehensive treatment program to achieve successful outcomes. eHealth solutions, such as secure online portals, create new opportunities for improved health care delivery and care, but depend on the organizational delivery systems and on the health care professionals providing it. So far, these have received limited attention and the overall adoption of eHealth solutions remains low. In this study, a secure eHealth portal was implemented in a bariatric surgery clinic and offered to their patients. During the study period of 6 months, 60 patients and 5 health care professionals had access. The portal included patient information, self-management tools, and communication features for online dialog with peers and health care providers at the bariatric surgery clinic.

Objective

The aim of this study was to characterize and assess the impact of an eHealth portal on health care professionals’ interaction with patients in bariatric surgery.

Methods

This qualitative case study involved a field study consisting of contextual interviews at the clinic involving observing and speaking with personnel in their actual work environment. Semi-structured in-depth interviews were conducted with health care professionals who interacted with patients through the portal. Analysis of the collected material was done inductively using thematic analysis.

Results

The analysis revealed two main dimensions of using an eHealth portal in bariatric surgery: the transparency it represents and the responsibility that follows by providing it. The professionals reported the eHealth portal as (1) a source of information, (2) a gateway to approach and facilitate the patients, (3) a medium for irrevocable postings, (4) a channel that exposes responsibility and competence, and (5) a tool in the clinic.

Conclusions

By providing an eHealth portal to patients in a bariatric surgery program, health care professionals can observe patients’ writings and revelations thereby capturing patient challenges and acting and implementing measures. Interacting with patients through the portal can prevent dropouts and deterioration of patients’ health. However, professionals report on organizational challenges and personal constraints related to communicating with patients in writing online. Further development of guidelines and education of health care professionals about how to handle, prioritize, communicate, and facilitate patients online is required in addition to increased attention to the organizational infrastructures and incentives for enabling such solutions in health care.

Use of mobile technology in a community mental health setting

INTRODUCTION

mHealth holds promise in transforming care for people with serious mental illness (SMI) and other disadvantaged populations. However, information about the rates of smartphone ownership and usage of mobile health apps among people with SMI is limited. The objective of this research is to examine the current ownership, usage patterns, and existing barriers to mobile health interventions for people with SMI treated in a public sector community mental health setting and to compare the findings with national usage patterns from the general population.

METHODS

A survey was conducted to determine rates of ownership of smartphone devices among people with SMI. Surveys were administered to 100 patients with SMI at an outpatient psychiatric clinic. Results were compared with respondents to the 2012 Pew Survey of mobile phone usage.

RESULTS

A total of 85% of participants reported that they owned a cell phone; of those, 37% reported that they owned a smartphone, as compared with 53% of respondents to the Pew Survey and 44% of socioeconomically disadvantaged respondents to the Pew Survey.

DISCUSSION

While cell phone ownership is common among people with SMI, their adoption of smartphone technology lags behind that of the general population primarily due to cost barriers. Efforts to use mHealth in these populations need to recognize current mobile ownership patterns while planning for anticipated expansion of new technologies to poor populations as cost barriers are reduced in the coming years.

Demographic, clinical and psychosocial factors identify a high-risk group for depression screening among predominantly Hispanic patients with Type 2 diabetes in safety net care

OBJECTIVE

Identify biopsychosocial factors associated with depression for patients with Type 2 diabetes.

METHOD

A quasi-experimental clinical trial of 1293 patients was predominantly Hispanic (91%) female (62%), mean age 53 and average diabetes duration 10 years; 373 (29%) patients were depressed and assessed by Patient Health Questionnaire-9. Demographic, baseline clinical and psychosocial variables were compared between depressed and nondepressed patients.

RESULTS

Bivariate analyses found depression significantly associated (p<0.05) with female gender, diabetes emotional burden and regimen distress, BMI ≥ 30, lack of an A1C test, diabetes duration, poor self-care, number of diabetes symptoms and complications, functional and physical characteristics (pain, self-rated health condition, Short-Form Health Survey SF-physical, disability score and comorbid illnesses), as well as higher number of ICD-9 diagnoses and emergency room use. A multivariable regression model with stepwise selection identified six key risk factors: greater disability, diabetes symptoms and regimen distress, female gender, less diabetes self-care and lack of A1C. In addition, after controlling for identified six factors, the number of psychosocial stressors significantly associated with increased risk of depression (adjusted odds ratio=1.37, 95% confidence intervals: 1.18-1.58, p<.0001).

CONCLUSION

Knowing biopsychosocial factors could help primary care physicians and endocrinologists identify a high-risk group of patients needing depression screening.

Using Interactive Web-Based Screening, Brief Intervention and Referral to Treatment in an Urban, Safety-Net HIV Clinic

Substance use among people living with HIV is high, and screening, brief intervention, and referral to treatment (SBIRT) is an evidence-based approach to addressing the issue. We examined whether patients would participate in a technology-based SBIRT program in an urban HIV clinic. An SBIRT intervention was programmed into the clinic's web-based patient portal linked to their personal health record. We examined: demographic, health, HIV, and substance use characteristics of participants who completed the web-based intervention compared to those who did not. Fewer than half of the 96 participants assigned to the web-based SBIRT completed it (n = 39; 41 %). Participants who completed the web-based intervention had significantly higher amphetamine SSIS scores than those who did not complete the intervention. Participants whose substance use is more harmful may be more motivated to seek help from a variety of sources. In addition, it is important that technology-based approaches to behavioral interventions in clinics take into consideration feasibility, client knowledge, and comfort using technology.

Using electronic health records to improve the physical healthcare of people with serious mental illnesses: a view from the front lines

Individuals with serious mental illnesses (SMI) treated in the public mental health sector die decades younger than the general population. Poor quality and fragmentation of care are risk factors underlying the poor health of this population. Integrated electronic health records (EHR) can play a vital role in efforts to improve quality and outcomes of care in patients with SMI. The objective of this paper is to describe the current state of efforts to integrate and improve the mental and physical care of individuals with SMI in the public sector, with an emphasis on the use of electronic health records (EHR). While a range of encouraging initiatives exists throughout the country, technological and medico-legal challenges are providing significant barriers for the successful integration of care and EHRs for many partnering organizations. Furthermore, there is a lack of rigorous research studying the effectiveness and sustainability of these programmes. Recommendations are made for the alleviation of policy barriers and future areas of inquiry.

Behavioral Health Homes: an opportunity to address healthcare inequities in people with serious mental illness

People with serious mental illness (SMI) face striking reductions in lifespan versus the general population, in part due to the inadequacy of healthcare systems in meeting the substantial physical health needs of this group. Integrated care, the strategic combination and coordination of behavioral health and primary care services, has been proposed as a potential healthcare service delivery solution to address these care gaps. Inspired by the primary care Patient-Centered Medical Home concept, Behavioral Health Homes bring primary care services into the community mental health center in various ways. In this paper the authors review the literature describing Behavioral Health Home interventions and highlight an integration project that provides co-located and coordinated primary care and wellness services in a community mental health center. Such approaches hold great promise for improving the health and healthcare of people with SMI.

A feasibility pilot study on the use of text messages to track PTSD symptoms after a traumatic injury

OBJECTIVE

Monitoring posttraumatic stress disorder (PTSD) symptoms after a traumatic injury is beneficial for patients and providers. Text messages can be used to automatically monitor symptoms and impose minimal burden to patients and providers. The present study piloted such a strategy with traumatic injury patients.

METHOD

An automated daily text message was piloted to evaluate PTSD symptoms after discharge from the hospital. Twenty-nine patients who experienced a traumatic injury received 15 daily texts and were then followed up at 1-month and 3-months after discharge.

RESULTS

82.8% of the sample responded at least once and the average response rate per participant was 63.1%. Response rates were correlated with PTSD symptoms at baseline but not at any other time. Patient satisfaction with this approach was high.

CONCLUSION

Text messages are a viable method to monitor PTSD symptoms after a traumatic injury. Such an approach should be evaluated on a larger scale as part of a more comprehensive early intervention for traumatic stress.