Evaluation of Training in Identifying and Responding to Suicide Risk by Staff of a Behavioral Health Managed Care Organization

PURPOSE OF STUDY

Gatekeeper training for individuals who may be in contact with someone contemplating suicide is a recommended suicide prevention strategy. This study assessed organizational-level gatekeeper training.

PRIMARY CARE SETTINGS

Gatekeeper training was conducted in a behavioral health managed care organization (BHMCO), which facilitates integrated behavioral and physical health services for 1.4 million Medicaid-enrolled Pennsylvanians.

METHODOLOGY AND SAMPLE

Gatekeeper training was offered to BHMCO staff via a new training policy. Gatekeeper trainers were qualified BHMCO staff. Approximately half (47%) of trained staff served as care managers. Pre- and posttraining surveys were administered to assess self-reported confidence in ability to identify and assist individuals at risk for suicide. Post-training, staff responded to a hypothetical vignette involving suicide risk, which was evaluated for skills by gatekeeper trainers.

RESULTS

Eighty-two percent of staff completed training. Mean confidence scores improved significantly from pre- (η = 615) to posttraining (η = 556) (understanding = 3.41 vs. 4.11, respectively; knowledge = 3.47 vs. 4.04; identification = 3.30 vs. 3.94; respond = 3.30 vs. 4.04, p < .0001 for each). Intermediate and advanced skills to address suicide risk were demonstrated post-training in 68.6% and 17.2% of staff, respectively. More care managers versus other BHMCO staff demonstrated advanced skills (21.6% vs. 13.0%); however, both groups showed significant improvement pre- to post-training.

IMPLICATIONS FOR CASE MANAGEMENT

Care managers benefit from suicide prevention training and are uniquely positioned to serve as organizational leaders to successful population health initiatives to decrease suicide through training and education.

Peer support to reduce readmission in Medicaid-enrolled adults with substance use disorder

INTRODUCTION

Peer support service in substance use disorder systems (PS SUD) is an optional supplement to treatment services for Medicaid-enrolled individuals across Pennsylvania. The value of PS SUD was defined through association with improved service utilization patterns. We examined service utilization in a subset of individuals receiving PS SUD following an acute service (hospitalization or withdrawal management) compared to utilization in propensity-score-matched controls via an observational analysis.

METHODS

We identified all Medicaid-enrolled adults with receipt of PS SUD from 2016 to 2019 and included those with prior acute service (n = 349); the study successfully matched all to individuals receiving outpatient SUD services without peer support (n = 698). Individuals were matched on age, gender, race, ethnicity, diagnosis, and prior utilization of acute care. A large percentage of individuals receiving PS SUD (74 %) had co-occurring mental health diagnoses, which we included in matching. We examined service utilization rates via administrative paid claims data for both groups in the first 90 days following peer support/outpatient discharge.

RESULTS

Acute service utilization differed between groups over time, p = .0014. We observed a larger reduction in the rate of acute care during PS SUD service (8.6 %) versus outpatient service (21.2 %), with lower rates remaining 90 days following PS SUD (13.8 %) or outpatient discharge (16.8 %). Individuals receiving PS SUD showed connection to community-based services in the 90 days following discharge from PS SUD, including 45.0 % receiving outpatient SUD and 31.8 % receiving outpatient mental health services.

CONCLUSIONS

Peer support may help individuals to navigate the behavioral health system and reduce hospitalization or other restrictive levels of care.

Promoting collaborative psychiatric care decision-making in community mental health centers: Insights from a patient-centered comparative effectiveness trial

OBJECTIVE

Mental health service-users face important medication decisions; yet not all are active participants in the decision-making process. Little is known about which technology-supported interventions might effectively promote collaborative decision-making in psychiatric care. We compared the effectiveness of two technology-supported collaborative care decision-making approaches.

METHOD

We used a cluster-randomized design with a mixed-methods approach. Participants were Medicaid-enrolled adults receiving psychiatric care in participating community mental health centers. Measurement-based care used computerized systematic symptom and medication screenings to inform provider decision-making. Person-centered care supported participants in completing computerized Health Reports and preparing to work with providers on collaborative decision-making about psychiatric care. Primary study outcomes included the patient experience of medication management and shared decision-making during psychiatric care. Analyses examined the impact of both approaches and explored moderating variables. We used qualitative methods to understand participation and implementation experiences.

RESULTS

Across 14 sites 2,363 participants enrolled (1,162 in measurement-based care, 1,201 in person-centered care). We observed statistically significant improvements in patient experience of medication management scores for both study arms; however, the clinical significance of this change was minor. We found no significant changes for shared decision-making. Qualitative interviews revealed a range of factors associated usefulness of intervention assessment, provider-service-user communication, and site-level logistics.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

We observed modest positive findings related to our patient-centered outcomes. We identified important implementation facilitators and barriers that can inform the implementation of future comparative effectiveness patient-centered research. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

First-Person Perspectives on Prescriber-Service User Relationships in Community Mental Health Centers

OBJECTIVE

Because of changes in health care, there is a greater focus on brief medication management visits as the primary method of providing psychiatric care in community mental health settings. Research on the first-person perspectives of service users and prescribers in these settings is limited. The objective of this study was to describe first-person perspectives on medication management visits and the service user-prescriber relationship.

METHODS

Researchers conducted qualitative interviews as part of a larger comparative effectiveness trial at 15 community mental health centers, researchers interviewed service users (N=44) and prescribers (N=25) about their perspectives on the typical elements of a medication management visit and asked service users about their relationship with their prescriber.

RESULTS

Both service users and prescribers described medication management visits as very brief encounters focused on medication and symptoms. Most service users reflected on the service user-prescriber relationship in positive or neutral terms; they did not describe the development of a strong therapeutic relationship or a meaningful clinical encounter with prescribing clinicians.

CONCLUSIONS

Service users described the service user-prescriber relationship and medication management visit as largely transactional. Despite the transactional nature of these encounters, most service users described relationships with prescribing clinicians in positive or neutral terms. Their satisfaction with the visit did not necessarily mean that they were receiving high-quality care. Satisfaction may instead suggest service users' disengagement from care. They may need more support to fully participate in their own care.

Value of psychiatric rehabilitation in a behavioral health medicaid managed care system

OBJECTIVE

The present study was designed to describe individuals receiving psychiatric rehabilitation (PR) service and investigate program outcomes and factors associated with progress in a multisite, descriptive evaluation across Pennsylvania.

METHOD

Through an outcomes-monitoring process integrated into routine service delivery, survey responses from 408 individuals participating in PR were summarized. Linear mixed models were used to examine change over time in self-reported progress ratings in rehabilitation domains and factors associated with progress.

RESULTS

Significantly lower utilization of inpatient psychiatric service was observed in the 12 months after initiating PR versus the 12 months before service (15% vs. 24%; p = .002). Peer and case management service increased after initiation of PR. Specifying a domain as a goal in the service plan was associated with higher progress ratings in the learning (β = .75, p < 0001), working (β = 1.06, p < .0001), and physical wellness (β = 1.27, p < .0001) domains. Average hopefulness rating was positively and significantly associated with self-reported progress in all domains.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The current investigation provides some evidence that individuals participating in PR decrease utilization of inpatient service. This finding and the goals and activities reported in domains over time support the added value of PR as a Medicaid-reimbursable service to managed care efforts to promote rehabilitation outcomes and recovery for individuals with psychiatric disabilities. (PsycINFO Database Record

A Successful Implementation Strategy to Support Adoption of Decision Making in Mental Health Services

Individual involvement in treatment decisions with providers, often through the use of decision support aids, improves quality of care. This study investigates an implementation strategy to bring decision support to community mental health centers (CMHC). Fifty-two CMHCs implemented a decision support toolkit supported by a 12-month learning collaborative using the Breakthrough Series model. Participation in learning collaborative activities was high, indicating feasibility of the implementation model. Progress by staff in meeting process aims around utilization of components of the toolkit improved significantly over time (p < .0001). Survey responses by individuals in service corroborate successful implementation. Community-based providers were able to successfully implement decision support in mental health services as evidenced by improved process outcomes and sustained practices over 1 year through the structure of the learning collaborative model.

In managed behavioral health care, a seat at the table is not enough

TOPIC

The involvement of individuals in recovery and their families has helped drive change in the behavioral health field. Medicaid managed care organizations (MCOs) can promote meaningful involvement by empowering stakeholders at every level of the organization.

PURPOSES

Roles for self-identified service recipients, including membership on boards, advisory committees, and grievance committees; in research and evaluation; in employment at all levels of the MCO; and in individual interactions with providers--as well as the impact of this involvement on individuals and the organization--is explored.

SOURCES USED

Research on the implications of service user involvement is reviewed and actual practice at an MCO is highlighted.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Research on the benefits to organizations of service user involvement is scarce. However, based on their experiences, the authors believe it is not only the right thing to do, but the smart thing to do. They challenge the field to join them in involving service users and seeking ways to measure the impact of this empowerment on managed behavioral health care.

Education and training column: the learning collaborative

TOPIC

This column describes the key components of a learning collaborative, with examples from the experience of 1 organization.

PURPOSE

A learning collaborative is a method for management, learning, and improvement of products or processes, and is a useful approach to implementation of a new service design or approach.

SOURCES USED

This description draws from published material on learning collaboratives and the authors' experiences.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The learning collaborative approach offers an effective method to improve service provider skills, provide support, and structure environments to result in lasting change for people using behavioral health services. This approach is consistent with psychiatric rehabilitation principles and practices, and serves to increase the overall capacity of the mental health system by structuring a process for discovering and sharing knowledge and expertise across provider agencies. (PsycINFO Database Record

Integrating personal medicine into service delivery: empowering people in recovery

OBJECTIVE

Illness management and recovery strategies are considered evidence-based practices. The article describes how a web-based application, CommonGround, has been used to support implementation of such strategies in outpatient mental health services and assess its impact. The specific focus of this article is Personal Medicine, self-management strategies that are a salient component of the CommonGround intervention.

METHOD

With support from counties and a not-for-profit managed care organization, CommonGround has been introduced in 10 medication clinics, one Assertive Community Treatment (ACT) team, and one peer support center across Pennsylvania. Methods include analysis of data from the application's database and evaluation of health functioning, symptoms, and progress toward recovery.

RESULTS

Health functioning improved over time and use of self-management strategies was associated with fewer concerns about medication side effects, fewer concerns about the impact of mental health medicine on physical health, more reports that mental health medicines were helping, and greater progress in individuals' recovery.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Using Personal Medicine empowers individuals to work with their prescribers to find a "right balance" between what they do to be well and what they take to be well. This program helps individuals and their service team focus on individual strengths and resilient self-care strategies. More research is needed to assess factors that may predict changes in outcomes and how a web-based tool focused on self-management strategies may moderate those factors.

A Comparison of Perceptions of Factors in the Job Accommodation Process Among Employees With Disabilities, Employers, and Service Providers

Job accommodation is a multifaceted and interactive process. Stakeholder groups (i.e., employees with disabilities, employers, and in some cases service providers) make decisions about requesting or providing job accommodations based on multiple factors in this process. An understanding of stakeholder differences in their perceptions of these factors may mitigate the myths and misconceptions about accommodations, and facilitate the accommodation process. Stakeholder perspectives on the importance of factors involved in the accommodation process are compared. How these perceptions may affect the likelihood of requesting or providing accommodations is discussed, along with the implications for rehabilitation professionals.

Development of the Reasonable Accommodation Factor Survey: Results and Implications

The purpose of this study was (a) to explore the latent factors in the Reasonable Accommodation Factor Survey (RAFS) instrument and (b) to compare scores on the latent factors of the RAFS by participant’s role. Eight latent factors were identified through an exploratory factor analysis with orthogonal rotation. The reliability tests indicated satisfactory reliability scores on each of the eight latent factors of the RAFS. Comparison of scores by roles of stakeholders (employee, employer, and service provider) indicated statistically significant differences in scores on three latent factors: Employee Competence in Reasonable Accommodation, Workplace Impact, and Employee Work Record. Implications for practice and research are discussed.

Managing Disclosure of Psychiatric Disabilities to Employers

Deciding about disclosure of psychiatric disabilities to an employer is an issue with multiple facets and is regarded as a topic in rehabilitation with few accepted simple answers. Much of the published literature related to disclosure describes the legal guidelines governing disclosure, dilemmas regarding the disclosure decision, and personal accounts regarding telling an employer or keeping this information secret. The few studies published on disclosure are primarily qualitative in nature, describing issues, experiences, or benefits and risks for people with psychiatric disabilities. Although a handful contains quantitative data about disclosure within a larger study on accommodations or supported employment, little information is provided on the process of disclosure. This article examines the benefits, risks, and other factors to consider in making the disclosure decision, reviews the guidelines in the literature about the disclosure process, and proposes practical guidelines to decide about disclosure and to successfully accomplish disclosure of psychiatric disabilities in the workplace.

An investigation of reasonable workplace accommodations for people with psychiatric disabilities: quantitative findings from a multi-site study

Despite the requirement of many employers to provide accommodations in the workplace for individuals with disabilities under Section 504 of the Rehabilitation Act of 1973, the preponderance of accommodations that have been described in the literature concern physical rather than psychiatric disabilities. This study was an exploratory, descriptive, longitudinal, multi-site investigation of reasonable workplace accommodations for individuals with psychiatric disabilities involved in supported employment programs. We discuss the functional limitations and reasonable accommodations provided to 191 participants and the characteristics of 204 employers and 22 service provider organizations participating in the study. Implications for service providers and administrators in supported employment programs are discussed.

Supported Employment for People with Psychiatric Disability

Supported employment services have expanded through recent federal funding initiatives. For programs to be effective they should be tailored to the varying needs and situations of their participants. The Choose-Get-Keep approach to supported employment was specifically developed to assist people with psychiatric disability to select, obtain, and maintain competitive employment positions. This article presents the theory and research base for the Choose-Get Keep approach and describes its implementation. illustrative examples are provided.