Safety planning intervention and follow-up: A telehealth service model for suicidal individuals in emergency department settings: Study design and protocol

BACKGROUND

The Safety Planning Intervention with follow-up services (SPI+) is a promising suicide prevention intervention, yet many Emergency Departments (EDs) lack the resources for adequate implementation. Comprehensive strategies addressing structural and organizational barriers are needed to optimize SPI+ implementation and scale-up. This protocol describes a test of one strategy in which ED staff connect at-risk patients to expert clinicians from a Suicide Prevention Consultation Center (SPCC) via telehealth.

METHOD

This stepped wedge, cluster-randomized trial compares the effectiveness, implementation, cost, and cost offsets of SPI+ delivered by SPCC clinicians versus ED-based clinicians (enhanced usual care; EUC). Eight EDs will start with EUC and cross over to the SPCC phase. Blocks of two EDs will be randomly assigned to start dates 3 months apart. Approximately 13,320 adults discharged following a suicide-related ED visit will be included; EUC and SPCC samples will comprise patients from before and after SPCC crossover, respectively. Effectiveness data sources are electronic health records, administrative claims, and the National Death Index. Primary effectiveness outcomes are presence of suicidal behavior and number/type of mental healthcare visits and secondary outcomes include number/type of suicide-related acute services 6-months post-discharge. We will use the same data sources to assess cost offsets to gauge SPCC scalability and sustainability. We will examine preliminary implementation outcomes (reach, adoption, fidelity, acceptability, and feasibility) through patient, clinician, and health-system leader interviews and surveys.

CONCLUSION

If the SPCC demonstrates clinical effectiveness and health system cost reduction, it may be a scalable model for evidence-based suicide prevention in the ED.

Helping Practitioners Stop, Drop, and Roll: Suggestions to Help Improve Responses to Intense Clinical Events

Community practitioners inconsistently implement evidence-based interventions. Implementation science emphasizes the importance of some practitioner characteristics, such as motivation, but factors such as practitioners' emotion regulation and cognitive processing receive less attention. Practitioners often operate in stressful environments that differ from those in which they received training. They may underestimate the impact of their emotional state on their ability to deliver evidence-based interventions. This "hot-cold state empathy gap" is not well studied in mental health care. In this Open Forum, the authors describe scenarios where this gap is affecting practitioners' ability to implement evidence-based practices. The authors provide suggestions to help practitioners plan for stressful situations.

A mixed-methods evaluation of organization and individual factors influencing provider intentions to use caregiver coaching in community-based early intervention

BACKGROUND

Most psycho-social interventions contain multiple components. Practitioners often vary in their implementation of different intervention components. Caregiver coaching is a multicomponent intervention for young autistic children that is highly effective but poorly implemented in community-based early intervention (EI). Previous research has shown that EI providers' intentions, and the determinants of their intentions, to implement caregiver coaching vary across components. Organizational culture and climate likely influence these psychological determinants of intention by affecting beliefs that underlie attitudes, norms, and self-efficacy to implement an intervention. Research in this area is limited, which limits the development of theoretically driven, multilevel implementation strategies to support multi-component interventions. This mixed methods study evaluated the relationships among organizational leadership, culture and climate, attitudes, norms, self-efficacy, and EI providers' intentions to implement the components of caregiver coaching.

METHODS

We surveyed 264 EI providers from 37 agencies regarding their intentions and determinants of intentions to use caregiver coaching. We also asked questions about the organizational culture, climate, and leadership in their agencies related to caregiver coaching. We used multilevel structural equation models to estimate associations among intentions, psychological determinants of intentions (attitudes, descriptive norms, injunctive norms, and self-efficacy), and organizational factors (implementation climate and leadership). We conducted qualitative interviews with 36 providers, stratified by strength of intentions to use coaching. We used mixed-methods analysis to gain an in-depth understanding of the organization and individual-level factors.

RESULTS

The associations among intentions, psychological determinants of intentions, and organizational factors varied across core components of caregiver coaching. Qualitative interviews elucidated how providers describe the importance of each component. For example, providers' attitudes toward coaching caregivers and their perceptions of caregivers' expectations for service were particularly salient themes related to their use of caregiver coaching.

CONCLUSION

Results highlight the importance of multi-level strategies that strategically target individual intervention components as well as organization-level and individual-level constructs. This approach holds promise for improving the implementation of complex, multicomponent, psychosocial interventions in community-based service systems.

Mobile service delivery in response to the opioid epidemic in Philadelphia

BACKGROUND

The harms of opioid use disorder (OUD) and HIV infection disproportionately impact marginalized populations, especially people experiencing homelessness and people who inject drugs (PWID). Mobile OUD service delivery models are emerging to increase access and reduce barriers to OUD care. While there is growing interest in these models, there is limited research about the services they provide, how they operate, and what barriers they face. We characterize the capacity, barriers, and sustainment of mobile OUD care services in a large city with a high incidence of OUD and HIV.

METHODS

From May to August 2022, we conducted semi-structured interviews with leadership from all seven mobile OUD care units (MOCU) providing a medication for OUD or other substance use disorder services in Philadelphia. We surveyed leaders about their unit's services, staffing, operating location, funding sources, and linkages to care. Leaders were asked to describe their clinical approach, treatment process, and the barriers and facilitators to their operations. Interview recordings were coded using rapid qualitative analysis.

RESULTS

MOCUs are run by small, multidisciplinary teams, typically composed of a clinician, one or two case managers, and a peer recovery specialist or outreach worker. MOCUs provide a range of services, including medications for OUD, wound care, medical services, case management, and screening for infectious diseases. No units provide methadone, but all units provide naloxone, six write prescriptions for buprenorphine, and one unit dispenses buprenorphine. The most frequently reported barriers include practical challenges of working on a MOCU (e.g. lack of space, safety), lack of community support, and patients with substantial medical and psychosocial needs. Interviewees reported concerns about funding and specifically as it relates to providing their staff with adequate pay. The most frequently reported facilitators include positive relationships with the community, collaboration with other entities (e.g. local nonprofits, the police department, universities), and having non-clinical staff (e.g. outreach workers, peer recovery specialists) on the unit.

CONCLUSIONS

MOCUs provide life-saving services and engage marginalized individuals with OUD. These findings highlight the challenges and complexities of caring for PWID and demonstrate a need to strengthen collaborations between MOCU providers and the treatment system. Policymakers should consider programmatic funding for permanent mobile OUD care services.

An exposure-based implementation strategy to decrease clinician anxiety about implementing suicide prevention evidence-based practices: protocol for development and pilot testing (Project CALMER)

BACKGROUND

Clinicians often report that their own anxiety and low self-efficacy inhibit their use of evidence-based suicide prevention practices, including gold-standard screening and brief interventions. Exposure therapy to reduce clinician maladaptive anxiety and bolster self-efficacy use is a compelling but untested approach to improving the implementation of suicide prevention evidence-based practices (EBPs). This project brings together an interdisciplinary team to leverage decades of research on behavior change from exposure theory to design and pilot test an exposure-based implementation strategy (EBIS) to target clinician anxiety to improve suicide prevention EBP implementation.

METHODS

We will develop, iteratively refine, and pilot test an EBIS paired with implementation as usual (IAU; didactic training and consultation) in preparation for a larger study of the effect of this strategy on reducing clinician anxiety, improving self-efficacy, and increasing use of the Columbia Suicide Severity Rating Scale and the Safety Planning Intervention in outpatient mental health settings. Aim 1 of this study is to use participatory design methods to develop and refine the EBIS in collaboration with a stakeholder advisory board. Aim 2 is to iteratively refine the EBIS with up to 15 clinicians in a pilot field test using rapid cycle prototyping. Aim 3 is to test the refined EBIS in a pilot implementation trial. Forty community mental health clinicians will be randomized 1:1 to receive either IAU or IAU + EBIS for 12 weeks. Our primary outcomes are EBIS acceptability and feasibility, measured through questionnaires, interviews, and recruitment and retention statistics. Secondary outcomes are the engagement of target implementation mechanisms (clinician anxiety and self-efficacy related to implementation) and preliminary effectiveness of EBIS on implementation outcomes (adoption and fidelity) assessed via mixed methods (questionnaires, chart-stimulated recall, observer-coded role plays, and interviews).

DISCUSSION

Outcomes from this study will yield insight into the feasibility and utility of directly targeting clinician anxiety and self-efficacy as mechanistic processes informing the implementation of suicide prevention EBPs. Results will inform a fully powered hybrid effectiveness-implementation trial to test EBIS' effect on implementation and patient outcomes.

TRIAL REGISTRATION

Clinical Trials Registration Number: NCT05172609 . Registered on 12/29/2021.

Years of life lost to drug overdose in the Latinx community during the most recent wave of overdose deaths

BACKGROUND AND OBJECTIVES

This study estimated years of life lost (YLL) among US Latinx individuals during the most recent wave of drug overdose deaths.

METHODS

A serial cross-sectional study of YLL (life expectancy minus age at death) from death certificate records of Latinx individuals who died from drug overdoses from 2015 to mid-2022.

RESULTS

Over the study period, 58,209 Latinx individuals aged 15-64 years died from drug overdoses resulting in 2,266,784 YLL. Age-group YLL differences remained stable, but gender YLL trajectories diverged.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

This study extends our understanding of the immense loss to Latinx communities from preventable drug deaths.

Systematic review: emotion dysregulation and challenging behavior interventions for children and adolescents on the autism spectrum with graded key evidence-based strategy recommendations

Challenging behavior, such as aggression, is highly prevalent in children and adolescents on the autism spectrum and can have a devastating impact. Previous reviews of challenging behavior interventions did not include interventions targeting emotion dysregulation, a common cause of challenging behavior. We reviewed emotion dysregulation and challenging behavior interventions for preschoolers to adolescents to determine which evidence-based strategies have the most empirical support for reducing/preventing emotion dysregulation/challenging behavior. We reviewed 95 studies, including 29 group and 66 single case designs. We excluded non-behavioral/psychosocial interventions and those targeting internalizing symptoms only. We applied a coding system to identify discrete strategies based on autism practice guidelines with the addition of strategies common in childhood mental health disorders, and an evidence grading system. Strategies with the highest quality evidence (multiple randomized controlled trials with low bias risk) were Parent-Implemented Intervention, Emotion Regulation Training, Reinforcement, Visual Supports, Cognitive Behavioral/Instructional Strategies and Antecedent-Based Interventions. Regarding outcomes, most studies included challenging behavior measures, while few included emotion dysregulation measures. This review highlights the importance of teaching emotion regulation skills explicitly, positively reinforcing replacement/alternative behaviors, using visuals and metacognition, addressing stressors proactively, and involving parents. It also calls for more rigorously designed studies and for including emotion dysregulation as an outcome/mediator in future trials.

Adapting psychotherapy in collaborative care for treating opioid use disorder and co-occurring psychiatric conditions in primary care

INTRODUCTION

Opioid use disorder (OUD) and psychiatric conditions commonly co-occur yet are infrequently treated with evidence-based therapeutic approaches, resulting in poor outcomes. These conditions, separately, present challenges to treatment initiation, retention, and success. These challenges are compounded when individuals have OUD and psychiatric conditions.

METHOD

Recognizing the complex needs of these individuals, gaps in care, and the potential for primary care to bridge these gaps, we developed a psychotherapy program that integrates brief, evidence-based psychotherapies for substance use, depression, and anxiety, building on traditional elements of the Collaborative Care Model (CoCM). In this article, we describe this psychotherapy program in a primary care setting as part of a compendium of collaborative services.

RESULTS

Patients receive up to 12 sessions of evidence-based psychotherapy and case management based on a structured treatment manual that guides treatment via Motivational Enhancement; Cognitive Behavioral Therapies for depression, anxiety, and/or substance use disorder; and/or Behavioral Activation components.

DISCUSSION

Novel, integrated treatments are needed to advance service delivery for individuals with OUD and psychiatric conditions and these programs must be rigorously evaluated. We describe our team's efforts to test our psychotherapy program in a large primary care network as part of an ongoing three-arm randomized controlled trial. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Fatal drug overdose among middle-aged Black men: A life table analysis

BACKGROUND

For Black men of middle-age, the overdose mortality statistics are increasingly dire. To better understand the severity of the crisis, we estimated the cumulative risk of drug overdose deaths among non-Hispanic Black men in mid-life using a period life table approach. We report the chances of Black men aged 45 years dying of a drug overdose before age 60.

METHODS

A period life table reflects what would happen to a hypothetical cohort if it experienced the prevailing age-specific probabilities of death. In our hypothetical cohort, we followed 100,000 non-Hispanic Black men aged 45 years for 15 years. All-cause death probabilities were obtained from the National Center for Health Statistics (NCHS) 2021 life table series. Overdose mortality rates were obtained from the National Vital Statistics System through the Wide-Ranging Online Data for Epidemiologic Research of the Centers for Disease Control and Prevention (CDC WONDER) database. We also constructed a period life table for a comparison group of White men.

RESULTS

The life table shows that, for Black men who are 45 years of age in the United States, 1 in 52 (nearly 2%) is expected to die of drug overdose before reaching age 60, if current mortality rates persist. For White men, the estimate is 1 in 91 men (about 1%). The life table also shows that from age 45 to 59 years, the number of overdose deaths increased in the cohort of Black men but decreased in White men.

CONCLUSIONS

This study extends our understanding of the immense loss to Black communities from the preventable drug deaths of Black men in middle-age.

Implementation resources to support teachers' use of behavioral classroom interventions: protocol of a randomized pilot trial

BACKGROUND

Teacher-delivered behavioral classroom management interventions are effective for students with or at-risk for attention-deficit/hyperactivity disorder (ADHD) or other disruptive behavior challenges, but they can be difficult for teachers to use in the classroom. In this study, we will pilot test a package of implementation strategies to support teachers in using behavioral classroom interventions for students with ADHD symptoms.

METHODS

We will use a 2-group, randomized controlled trial to compare outcomes for teachers who receive Positive Behavior Management Implementation Resources (PBMIR), a theory and data-driven implementation resource package designed to increase teacher implementation of behavioral classroom management interventions, with those who do not receive this additional implementation support. We will measure teacher implementation outcomes (e.g., observed fidelity to behavioral classroom interventions) and student clinical outcomes (e.g., ADHD-related impairment, ADHD symptoms, student-teacher relationship, academic performance) before and after an 8-week intervention period for both groups; we will also measure teacher-reported acceptability, appropriateness, and feasibility for the PBMIR group following the intervention period.

DISCUSSION

If there is preliminary evidence of feasibility and effectiveness, this pilot study will provide the foundation for evaluation the PBMIR at a larger scale and the potential to improve outcomes for students with or at risk for ADHD.

TRIAL REGISTRATION

This clinical trial was registered at ClinicalTrials.gov. ( https://clinicaltrials.gov/ ) on 8/5/2022 which was prior to the time of first participant enrollment. The registration number is: NCT05489081.

Effect of Integrating Patient-Generated Digital Data Into Mental Health Therapy: A Randomized Controlled Trial

OBJECTIVE

The authors sought to determine whether providing summaries of patients' social media and other digital data to patients and their clinicians improves patients' health-related quality of life (HRQoL) measured by the RAND 36-Item Short Form Health Survey (SF-36).

METHODS

The authors randomly assigned 115 adults receiving outpatient mental health therapy to usual care or to periodic sharing of summaries of their digital data with their clinician providing psychosocial therapy. The study was conducted October 2020-December 2021.

RESULTS

Patients' mean±SD age was 31.3±10.5 years, and 82% were women. At 60 days after enrollment, no statistically significant change was detected in SF-36 scores for patients randomly allocated to the intervention (mean difference=-0.39, 95% CI=-4.17, 3.39) or to usual care (mean difference=-1.98, 95% CI=-5.74, 1.77), and no significant between-arm difference was observed (between-arm difference=1.60, 95% CI=-3.67, 6.86).

CONCLUSIONS

Collecting and summarizing digital data for use in mental health treatment was feasible for patients but did not significantly improve their HRQoL or other measures of mental health.

A Digital Mental Health App Incorporating Wearable Biosensing for Teachers of Children on the Autism Spectrum to Support Emotion Regulation: Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

As much as 80% of children on the autism spectrum exhibit challenging behaviors (ie, behaviors dangerous to the self or others, behaviors that interfere with learning and development, and behaviors that interfere with socialization) that can have a devastating impact on personal and family well-being, contribute to teacher burnout, and even require hospitalization. Evidence-based practices to reduce these behaviors emphasize identifying triggers (events or antecedents that lead to challenging behaviors); however, parents and teachers often report that challenging behaviors surface with little warning. Exciting recent advances in biometric sensing and mobile computing technology allow the measurement of momentary emotion dysregulation using physiological indexes.

OBJECTIVE

We present the framework and protocol for a pilot trial that will test a mobile digital mental health app, the KeepCalm app. School-based approaches to managing challenging behaviors in children on the autism spectrum are limited by 3 key factors: children on the autism spectrum often have difficulties in communicating their emotions; it is challenging to implement evidence-based, personalized strategies for individual children in group settings; and it is difficult for teachers to track which strategies are successful for each child. KeepCalm aims to address those barriers by communicating children's stress to their teachers using physiological signaling (emotion dysregulation detection), supporting the implementation of emotion regulation strategies via smartphone pop-up notifications of top strategies for each child according to their behavior (emotion regulation strategy implementation), and easing the task of tracking outcomes by providing the child's educational team with a tool to track the most effective emotion regulation strategies for that child based on physiological stress reduction data (emotion regulation strategy evaluation).

METHODS

We will test KeepCalm with 20 educational teams of students on the autism spectrum with challenging behaviors (no exclusion based on IQ or speaking ability) in a pilot randomized waitlist-controlled field trial over a 3-month period. We will examine the usability, acceptability, feasibility, and appropriateness of KeepCalm as primary outcomes. Secondary preliminary efficacy outcomes include clinical decision support success, false positives or false negatives of stress alerts, and the reduction of challenging behaviors and emotion dysregulation. We will also examine technical outcomes, including the number of artifacts and the proportion of time children are engaged in high physical movement based on accelerometry data; test the feasibility of our recruitment strategies; and test the response rate and sensitivity to change of our measures, in preparation for a future fully powered large-scale randomized controlled trial.

RESULTS

The pilot trial will begin by September 2023.

CONCLUSIONS

Results will provide key data about important aspects of implementing KeepCalm in preschools and elementary schools and will provide preliminary data about its efficacy to reduce challenging behaviors and support emotion regulation in children on the autism spectrum.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05277194; https://www.clinicaltrials.gov/ct2/show/NCT05277194.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/45852.

Racial, Ethnic, and Sex Differences in Methadone-Involved Overdose Deaths Before and After the US Federal Policy Change Expanding Take-home Methadone Doses

Importance

In March 2020, the Substance Abuse and Mental Health Services Administration (SAMHSA) permitted states to relax restrictions on take-home methadone doses for treatment-adherent patients to minimize COVID-19 exposures.

Objective

To assess whether the methadone take-home policy change was associated with drug overdose deaths among different racial, ethnic, and sex groups.

Design, Setting, and Participants

Interrupted time series analysis from January 1, 2018, to June 30, 2022. Data analysis was conducted from February 18, 2023, to February 28, 2023. In this population-based cohort study of drug overdose mortality including 14 529 methadone-involved deaths, monthly counts of methadone-involved drug overdose deaths were obtained for 6 demographic groups: Hispanic men and women, non-Hispanic Black men and women, and non-Hispanic White men and women.

Exposure

On March 16, 2020, in response to the first wave of the COVID-19 pandemic, SAMHSA issued an exemption to the states that permitted up to 28 days of take-home methadone for stable patients and 14 days for less stable patients.

Main Outcome Measures

Monthly methadone-involved overdose deaths.

Results

From January 1, 2018, to June 30, 2022 (54 months), there were 14 529 methadone-involved deaths in the United States; 14 112 (97.1%) occurred in the study's 6 demographic groups (Black men, 1234; Black women, 754; Hispanic men, 1061; Hispanic women, 520; White men, 5991; and White women, 4552). Among Black men, there was a decrease in monthly methadone deaths associated with the March 2020 policy change (change of slope from the preintervention period, -0.55 [95% CI, -0.95 to -0.15]). Hispanic men also experienced a decrease in monthly methadone deaths associated with the policy change (-0.42 [95% CI, -0.68 to -0.17]). Among Black women, Hispanic women, White men, and White women, the policy change was not associated with a change in monthly methadone deaths (Black women, -0.27 [95% CI, -1.13 to 0.59]; Hispanic women, 0.29 [95% CI, -0.46 to 1.04]; White men, -0.08 [95% CI, -1.05 to 0.88]; and White women, -0.43 [95% CI, -1.26 to 0.40]).

Conclusions and Relevance

In this interrupted time series study of monthly methadone-involved overdose deaths, the take-home policy may have helped reduce deaths for Black and Hispanic men but had no association with deaths of Black or Hispanic women or White men or women.

Parent Coaching in Early Intervention for Autism Spectrum Disorder: A Brief Report

Coaching caregivers of young children on the autism spectrum is a critical component of parent-mediated interventions. Little information is available about how providers implement parent coaching for children on the autism spectrum in publicly funded early intervention systems. This study evaluated providers' use of parent coaching in an early intervention system. Twenty-five early intervention sessions were coded for fidelity to established caregiver coaching techniques. We found low use of coaching techniques overall, with significant variability in use of coaching across providers. When providers did coach caregivers, they used only a few coaching strategies (e.g., collaboration and in-vivo feedback). Results indicate that targeted training and implementation strategies focused on individual coaching components, instead of coaching more broadly, may be needed to improve the use of individual coaching strategies. A focus on strengthening the use of collaboration and in-vivo feedback may be key to improving coaching fidelity overall.

Clinician Intentions to use the Components of Parent Coaching Within Community Early Intervention Systems

PURPOSE

Parent coaching is a complex, psychosocial intervention with multiple core components. Clinicians' use of these core components may be influenced by distinct factors; no research has examined whether clinician perceptions of parent coaching vary across core coaching components. This study aimed to examine the extent to which clinicians working with families of young autistic children in publicly funded early intervention intend to use core parent coaching components, and to examine how closely psychological factors relate to providers' intentions to use each component.

METHODS

Using the Theory of Planned Behavior as a framework, this study compared the strength of clinicians' intentions across five core parent coaching components: collaboration with parents, delivering the intervention within daily routines, demonstrating the intervention, providing in-vivo feedback, and reflection and problem solving. We examined the associations between intentions and psychological determinants of intentions (i.e., attitudes, norms, and self-efficacy) for each component.

RESULTS

Clinicians' average intentions varied by core component, with strongest intentions for demonstrating the intervention strategy for a parent. The associations between intentions and psychological determinants also varied by core component. Attitudes, injunctive norms, and self-efficacy, but not descriptive norms, significantly related to clinicians' intentions to use collaboration and daily routines, whereas attitudes and descriptive norms, but not injunctive norms and self-efficacy, significantly related to clinicians' intentions to use feedback and reflection and problem solving.

CONCLUSION

These results suggest that implementation strategies should be tailored to the specific intervention component to be most efficient and effective. The results also provide examples of potentially malleable factors that implementation strategies can strategically target.

Systematic Review: Emotion Dysregulation and Challenging Behavior Interventions for Children andAdolescents with Autism with Graded Key Evidence-Based Strategy Recommendations

Challenging behavior, such as aggression, is highly prevalent in children and adolescents with autism and can have a devastating impact. Previous reviews of challenging behavior interventions did not include interventions targeting emotion dysregulation, a common cause of challenging behavior. We reviewed emotion dysregulation and challenging behavior interventions for preschoolers to adolescents to determine which evidence-based strategies have the most empirical support for reducing/preventing emotion dysregulation/challenging behavior. We reviewed 95 studies, including 29 group and 66 single-case designs. We excluded non-behavioral/psychosocial interventions and those targeting internalizing symptoms only. We applied a coding system to identify discrete strategies based on autism practice guidelines with the addition of strategies common in childhood mental health disorders, and an evidence grading system. Strategies with the highest quality evidence (multiple randomized controlled trials with low bias risk) were Parent-Implemented Intervention, Emotion Regulation Training, Reinforcement, Visual Supports, Cognitive Behavioral/Instructional Strategies and Antecedent-Based Interventions. Regarding outcomes, most studies included challenging behaviors measures while few included emotion dysregulation measures. This review highlights the importance of teaching emotion-regulation skills explicitly, positively reinforcing replacement/alternative behaviors, using visuals and metacognition, addressing stressors proactively, and involving parents. It also calls for more rigorously-designed studies and for including emotion dysregulation as an outcome/mediator in future trials.

Identifying Common and Unique Barriers and Facilitators to Implementing Evidence-Based Practices for Suicide Prevention across Primary Care and Specialty Mental Health Settings

OBJECTIVE

We identified common and unique barriers and facilitators of evidence-based suicide prevention practices across primary care practices with integrated behavioral health services and specialty mental health settings to identify generalizable strategies for enhancing future implementation efforts.

METHOD

Twenty-six clinicians and practice leaders from behavioral health (n = 2 programs) and primary care (n = 4 clinics) settings participated. Participation included a semi-structured qualitative interview on barriers and facilitators to implementing evidence-based suicide prevention practices. Within that interview, clinicians participated in a chart-stimulated recall exercise to gather additional information about decision making regarding suicide screening. Interview guides and qualitative coding were informed by leading frameworks in implementation science and behavioral science, and an integrated approach to interpreting qualitative results was used.

RESULTS

There were a number of similar themes associated with implementation of suicide prevention practices across settings and clinician types, such as the benefits of inter-professional collaboration and uncertainties about managing suicidality once risk was disclosed. Clinicians also highlighted barriers unique to their settings. For primary care settings, time constraints and competing demands were consistently described as barriers. For specialty mental health settings, difficulties coordinating care with schools and other providers in the community made implementation of suicide prevention practices challenging.

CONCLUSION

Findings can inform the development and testing of implementation strategies that are generalizable across primary care and specialty mental health settings, as well as those tailored for unique site needs, to enhance use of evidence-based suicide prevention practices in settings where individuals at risk for suicide are especially likely to present.HIGHLIGHTSWe examined barriers and facilitators to suicide prevention across health settings.Common and unique barriers and facilitators across health-care settings emerged.Findings can enhance suicide prevention implementation across health-care settings.

Exploring Teachers' Intentions to Use Behavioral Classroom Interventions

Multi-tiered systems of behavioral supports offer teachers tools to implement positive, antecedent- or consequence-based interventions for all students (i.e., Tier 1), and for those who need additional support (i.e., Tier 2), such as students with ADHD. Because these interventions may be challenging to use, targeted, theory-driven implementation strategies may assist teachers in implementing them with fidelity. This exploratory study examined teachers' intended and self-reported use of specific Tier 1 and Tier 2 behavioral classroom interventions. Sixty-five K-8 teachers from five urban public schools completed an online survey about their intentions to use and self-reported use of four Tier 1 and Tier 2 behavioral classroom interventions. Teachers' intentions varied by intervention, with the weakest intentions for using a daily behavior report (Tier 2), and weaker intentions for using high rates of specific praise than for other Tier 1 interventions. Teacher's self-reported use was significantly lower than intended use for Tier 1 interventions, but not Tier 2 interventions. Results were generally similar whether the referent group was students with ADHD symptoms or the entire class. These results suggest specific factors to target to support teachers' use of behavioral classroom interventions.

Years of Life Lost to Drug Overdose Among Black Female Individuals in the US, 2015-2021

This cross-sectional study calculates years of life lost to drug overdose in non-Hispanic Black female individuals and describes the changes in years of life lost that have occurred during the current overdose crisis.

Association Between Medicaid Waivers and Medicaid Disenrollment Among Autistic Adolescents During the Transition to Adulthood

This cohort study examines whether Medicaid waivers were associated with a reduced risk of Medicaid disenrollment among autistic adolescents who are transitioning to adulthood.

"There's absolutely no downside to this, I mean, except community opposition:" A qualitative study of the acceptability of vending machines for harm reduction

BACKGROUND

Vending machines for harm reduction (VMHR) are an innovative approach to deliver life-saving materials, information, and treatment for hard-to-reach populations, particularly for persons who inject drugs. The current study explores stakeholders' perspectives on the feasibility and acceptability of VMHR in Philadelphia.

METHODS

From October 2021 to February 2022, we conducted 31 semi-structured interviews with potential end users, staff, and leadership at a local federally qualified health center, and community members. Trained coders extracted themes from interview transcripts across four key domains: materials and logistics, location, access, and community introduction.

RESULTS

Interviewees from all stakeholder groups endorsed using VMHR to provide supplies for wound care, fentanyl test strips, naloxone, and materials to connect individuals to treatment and other services. Dispensing syringes and medications for opioid use disorder were commonly endorsed by health center staff but were more controversial among potential end users. Even within stakeholder groups, views varied with respect to where to locate the machines, but most agreed that the machine should be placed in the highest drug use areas. Across stakeholder groups, interviewees suggested several strategies to introduce and gain community acceptance of VMHR, including community education, one-on-one conversations with community members, and coupling the machine with safe disposal of syringes and information to link individuals to treatment.

CONCLUSIONS

Stakeholders were generally receptive to VMHR. The current study findings are consistent with qualitative analyses from outside of the USA and contribute new ideas regarding the anticipated community response and best methods for introducing these machines to a community. With thoughtful planning and design, VMHR could be a feasible and acceptable modality to reduce death and disease transmission associated with the opioid and HIV epidemics in cities like Philadelphia.

The Effect of Psychiatric Comorbidity on Healthcare Utilization for Youth With Newly Diagnosed Systemic Lupus Erythematosus

OBJECTIVE

To examine the effect of psychiatric diagnoses on healthcare use in youth with systemic lupus erythematosus (SLE) during their first year of SLE care.

METHODS

We conducted a retrospective cohort study using claims from 2000 to 2013 from Clinformatics Data Mart (OptumInsight). Youth aged 10 years to 24 years with an incident diagnosis of SLE (≥ 3 International Classification of Diseases, 9th revision, codes for SLE 710.0, > 30 days apart) were categorized as having: (1) a preceding psychiatric diagnosis in the year before SLE diagnosis, (2) an incident psychiatric diagnosis in the year after SLE diagnosis, or (3) no psychiatric diagnosis. We compared ambulatory, emergency, and inpatient visits in the year after SLE diagnosis, stratified by nonpsychiatric and psychiatric visits. We examined the effect of childhood-onset vs adult-onset SLE by testing for an interaction between age and psychiatric exposure on outcome.

RESULTS

We identified 650 youth with an incident diagnosis of SLE, of which 122 (19%) had a preceding psychiatric diagnosis and 105 (16%) had an incident psychiatric diagnosis. Compared with those without a psychiatric diagnosis, youth with SLE and a preceding or incident psychiatric diagnosis had more healthcare use across both ambulatory and emergency settings for both nonpsychiatric and psychiatric-related care. These associations were minimally affected by age at time of SLE diagnosis.

CONCLUSION

Psychiatric comorbidity is common among youth with newly diagnosed SLE and is associated with greater healthcare use. Interventions to address preceding and incident psychiatric comorbidity may decrease healthcare burden for youth with SLE.

Large and small financial incentives may motivate COVID-19 vaccination: A randomized, controlled survey experiment

INTRODUCTION

Experts continue to debate how to increase COVID-19 vaccination rates. Some experts advocate for financial incentives. Others argue that financial incentives, especially large ones, will have counterproductive psychological effects, reducing the percent of people who want to vaccinate. Among a racially and ethnically diverse U.S. sample of lower income adults, for whom vaccine uptake has lagged compared with higher income adults, we empirically examine such claims about relatively large and small guaranteed cash payments.

METHODS

In 2021, we conducted a randomized, controlled experiment among U.S. residents with incomes below $80,000 who reported being unvaccinated against COVID-19. Study participants were randomized to one of four study arms. In two arms, respondents first learned about a policy proposal to pay $1,000 or $200 to those who received COVID-19 vaccination and were then asked if, given that policy, they would want to vaccinate. In the two other arms, respondents received either an educational message about this vaccine or received no vaccine information and were then asked if they wanted to vaccinate for COVID-19. The primary analyses estimated and compared the overall percentage in each study arm that reported wanting to vaccinate for COVID-19. In other analyses, we estimated and compared these percentages for subgroups of interest, including gender, race/ethnicity, and education.

MAIN RESULTS

Among 2,290 unvaccinated adults, 79.7% (95%CI, 76.4-83.0%) of those who learned about the proposed $1,000 payment wanted to get vaccinated, compared with 58.9% (95%CI, 54.8-63.0%) in the control condition without vaccine information, a difference of 20 percentage points. Among those who learned of the proposed $200 payment, 74.8% (95% CI, 71.3-78.4%) wanted to vaccinate. Among those who learned only about the safety and efficacy of COVID-19 vaccines, 68.9% (95% CI, 65.1-72.7%) wanted to vaccinate. Findings were consistent across various subgroups.

DISCUSSION

Despite several study limitations, the results do not support concerns that the financial incentive policies aimed to increase COVID-19 vaccination would have counterproductive effects. Instead, those who learned about a policy with a large or small financial incentive were more likely than those in the control condition to report that they would want to vaccinate. The positive effects extended to subgroups that have been less likely to vaccinate, including younger adults, those with less education, and racial and ethnic minorities. Financial incentives of $1,000 performed similarly to those offering only $200.

Not in my treatment center: Leadership's perception of barriers to MOUD adoption

INTRODUCTION

Despite their well-established effectiveness, medications for opioid use disorder (MOUD) are widely underutilized across the United States. In the context of a large publicly funded behavioral health system, we examined the relationship between a range of implementation barriers and a substance use disorder treatment agency's level of adoption of MOUD.

METHODS

We surveyed leadership of publicly funded substance use disorder treatment centers in Philadelphia about the significance of barriers to implementing MOUD related to their workforce, organization, funding, regulations, and beliefs about MOUD's efficacy and safety. We queried leaders on the percentage of their patients with opioid use disorder who receive MOUD and examined associations between implementation barriers and MOUD adoption.

RESULTS

Ratings of regulatory, organizational, or funding barriers of respondents who led high MOUD adopting agencies (N = 20) were indistinguishable from those who led agencies that were low adopting of MOUD (N = 23). In contrast, agency leaders who denied MOUD-belief or workforce barriers were significantly more likely to lead high-MOUD-adopting organizations.

CONCLUSIONS

These findings suggest that leadership beliefs about MOUD may be a key factor of the organizational decision to adopt and should be a target of implementation efforts to increase direct provision of these medications.

Reasons for missed opportunities to screen and test for TB in healthcare facilities

Missed opportunities for TB screening and/or passive testing in clinics continues to contribute to the number of missed cases. To understand reasons for these missed opportunities, we conducted focus group discussions with clinic-based nurses. Nurses described low indices of suspicion, prioritization of seemingly more urgent ailments and clinic operational challenges as barriers to TB screening and testing. To improve TB screening and testing in clinics, standard patients should be used to identify real-time factors that impact nurses' clinical decision-making and engage in real-time feedback and discussion with nurses to help optimize opportunities for TB screening and testing.

A Randomized Trial to Identify Accurate Measurement Methods for Adherence to Cognitive-Behavioral Therapy

Clinician fidelity to cognitive behavioral therapy (CBT) is an important mechanism by which desired clinical outcomes are achieved and is an indicator of care quality. Despite its importance, there are few fidelity measurement methods that are efficient and have demonstrated reliability and validity. Using a randomized trial design, we compared three methods of assessing CBT adherence-a core component of fidelity-to direct observation, the gold standard. Clinicians recruited from 27 community mental health agencies (n = 126; M age = 37.69 years, SD = 12.84; 75.7% female) were randomized 1:1:1 to one of three fidelity conditions: self-report (n = 41), chart-stimulated recall (semistructured interviews with the chart available; n = 42), or behavioral rehearsal (simulated role-plays; n = 43). All participating clinicians completed fidelity assessments for up to three sessions with three different clients that were recruited from clinicians' caseloads (n = 288; M age = 13.39 years SD = 3.89; 41.7% female); sessions were also audio-recorded and coded for comparison to determine the most accurate method. All fidelity measures had parallel scales that yielded an adherence maximum score (i.e., the highest-rated intervention in a session), a mean of techniques observed, and a count total of observed techniques. Results of three-level mixed effects regression models indicated that behavioral rehearsal produced comparable scores to observation for all adherence scores (all ps > .01), indicating no difference between behavioral rehearsal and observation. Self-report and chart-stimulated recall overestimated adherence compared to observation (ps < .01). Overall, findings suggested that behavioral rehearsal indexed CBT adherence comparably to direct observation, the gold-standard, in pediatric populations. Behavioral rehearsal may at times be able to replace the need for resource-intensive direct observation in implementation research and practice.

Ho'ouna Pono implementation: applying concept mapping to a culturally grounded substance use prevention curriculum in rural Hawai'i schools

BACKGROUND

Despite their potential to ameliorate health disparities and address youth substance use, prevention programs have been poorly disseminated and implemented across Hawai'i, which begs the question: Why are effective prevention programs not being used in communities most in need of them? Implementing and sustaining culturally grounded prevention programs is critical to address equitable healthcare and minimize health disparities in communities. The field of implementation science provides frameworks, theories, and methods to examine factors associated with community adoption of these programs.

METHOD

Our project applies concept mapping methods to a culturally grounded youth drug prevention program with state level educational leadership in rural Hawai'i schools. The goal is to integrate barrier and facilitator salience collected through teacher and school staff surveys and specific implementation strategies to regionally tailored implementation plans on Hawai'i island. This protocol paper describes the concept mapping steps and how they will be applied in public and public-charter schools.

DISCUSSION

Improving prevention program implementation in rural schools can result in sustained support for populations that need it most. The project will integrate implementation science and culturally grounded methods in rural Hawai'i, where most youth are of Native Hawaiian and Pacific Islander descent. This project addresses health disparities among Native Hawaiian and Pacific Islander youth and provides actionable plans for rural Hawai'i communities to implement effective prevention programming.

Required sample size to detect mediation in 3-level implementation studies

Background

Statistical tests of mediation are important for advancing implementation science; however, little research has examined the sample sizes needed to detect mediation in 3-level designs (e.g., organization, provider, patient) that are common in implementation research. Using a generalizable Monte Carlo simulation method, this paper examines the sample sizes required to detect mediation in 3-level designs under a range of conditions plausible for implementation studies.

Method

Statistical power was estimated for 17,496 3-level mediation designs in which the independent variable (X) resided at the highest cluster level (e.g., organization), the mediator (M) resided at the intermediate nested level (e.g., provider), and the outcome (Y) resided at the lowest nested level (e.g., patient). Designs varied by sample size per level, intraclass correlation coefficients of M and Y, effect sizes of the two paths constituting the indirect (mediation) effect (i.e., X→M and M→Y), and size of the direct effect. Power estimates were generated for all designs using two statistical models—conventional linear multilevel modeling of manifest variables (MVM) and multilevel structural equation modeling (MSEM)—for both 1- and 2-sided hypothesis tests.

Results

For 2-sided tests, statistical power to detect mediation was sufficient (≥0.8) in only 463 designs (2.6%) estimated using MVM and 228 designs (1.3%) estimated using MSEM; the minimum number of highest-level units needed to achieve adequate power was 40; the minimum total sample size was 900 observations. For 1-sided tests, 808 designs (4.6%) estimated using MVM and 369 designs (2.1%) estimated using MSEM had adequate power; the minimum number of highest-level units was 20; the minimum total sample was 600. At least one large effect size for either the X→M or M→Y path was necessary to achieve adequate power across all conditions.

Conclusions

While our analysis has important limitations, results suggest many of the 3-level mediation designs that can realistically be conducted in implementation research lack statistical power to detect mediation of highest-level independent variables unless effect sizes are large and 40 or more highest-level units are enrolled. We suggest strategies to increase statistical power for multilevel mediation designs and innovations to improve the feasibility of mediation tests in implementation research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01235-2.

Integrating peer support services into primary care-based OUD treatment: Lessons from the Penn integrated model

Opioid use disorder (OUD) is a major public health emergency in the United States. In 2020, 2.7 million individuals had an OUD. Medication for opioid use disorder is the evidence-based, standard of care for treating OUD in outpatient settings, especially buprenorphine because it is effective and has low toxicity. Buprenorphine is increasingly prescribed in primary care, a setting that provides greater anonymity and convenience than substance use disorder treatment centers. Yet two-thirds of people who begin buprenorphine treatment discontinue within the first six months. Treatment dropout elevates the risks of return to use, infections, higher levels of medical care and related costs, justice system involvement, and death. One promising form of retention support is peer service programs. Peers combine their lived experience of substance use and recovery with formal training to help patients engage and persist in OUD treatment. They provide a range of services, including health education, encouragement and empathy, coping skills, recovery modeling, and concrete assistance in overcoming the situational barriers to retention. However, guidance is needed to define the peer role in primary care, the specific tasks peers should perform, the competencies those tasks require, training and professional development needs, and peer performance standards. Guidance also is needed to integrate peers into the care team, allocate and coordinate responsibilities among care team members, manage peer operations and workflow, and facilitate effective team communication. Here we describe a peer support program in the University of Pennsylvania Health System (UPHS or Penn Medicine) network of primary care practices. This paper details the program's core components, values, and activities. We also report the organizational challenges, unresolved questions, and lessons for the field in administering a peer support program to meet the needs of patients served by a large, urban medical system with an extensive suburban and rural catchment area. CLINICAL TRIALS REGISTRATION: www.clinicaltrials.gov registration: NCT04245423.

Comparing output from two methods of participatory design for developing implementation strategies: traditional contextual inquiry vs. rapid crowd sourcing

Background

Participatory design methods are a key component of designing tailored implementation strategies. These methods vary in the resources required to execute and analyze their outputs. No work to date has examined the extent to which the output obtained from different approaches to participatory design varies.

Methods

We concurrently used two separate participatory design methods: (1) field observations and qualitative interviews (i.e., traditional contextual inquiry) and (2) rapid crowd sourcing (an innovation tournament). Our goal was to generate and compare information to tailor implementation strategies to increase the use of evidence-based data collection practices among one-to-one aides working with children with autism. Each method was executed and analyzed by study team members blinded to the output of the other method. We estimated the personnel time and monetary costs associated with each method to further facilitate comparison.

Results

Observations and interviews generated nearly double the number of implementation strategies (n = 26) than did the innovation tournament (n = 14). When strategies were classified into implementation strategies from the Expert Recommendations for Implementing Change (ERIC) taxonomy, there was considerable overlap in the content of identified strategies. However, strategies derived from observations and interviews were more specific than those from the innovation tournament. Five strategies (13%) reflected content unique to observations and interviews and 3 (8%) strategies were unique to the innovation tournament. Only observations and interviews identified implementation strategies related to adapting and tailoring to context; only the innovation tournament identified implementation strategies that used incentives. Observations and interviews required more than three times the personnel hours than the innovation tournament, but the innovation tournament was more costly overall due to the technological platform used.

Conclusions

There was substantial overlap in content derived from observations and interviews and the innovation tournament, although there was greater specificity in the findings from observations and interviews. However, the innovation tournament yielded unique information. To select the best participatory design approach to inform implementation strategy design for a particular context, researchers should carefully consider unique advantages of each method and weigh the resources available to invest in the process.

Making Progress Monitoring Easier and More Motivating: Developing a Client Data Collection App Incorporating User-Centered Design and Behavioral Economics Insights

Data collection is an important component of evidence-based behavioral interventions for children with autism, but many one-to-one aides (i.e., behavioral support staff) do not systemically collect quantitative data that are necessary for best-practice client progress monitoring. Data collection of clients' behaviors often involves labor-intensive pen-and-paper practices. In addition, the solitary nature of one-to-one work limits opportunities for timely supervisor feedback, potentially reducing motivation to collect data. We incorporated principles from behavioral economics and user-centered design to develop a phone-based application, Footsteps, to address these challenges. We interviewed nine one-to-one aides working with children with autism and seven supervisors to ask for their app development ideas. We then developed the Footsteps app prototype and tested the prototype with 10 one-to-one aides and supervisors through three testing cycles. At each cycle, one-to-one aides rated app usability. Participants provided 76 discrete suggestions for improvement, including 29 new app features (e.g., behavior timer), 20 feature modifications (e.g., numeric type-in option for behavior frequency), four flow modifications (e.g., deleting a redundant form), and 23 out-of-scope suggestions. Of the participants that tested the app, 90% rated usability as good or excellent. Results support continuing to develop Footsteps and testing its impact in a clinical trial.

Stakeholder intention to engage in fidelity measurement methods in community mental health settings: A mixed methods study

Background

The current gold standard for measuring fidelity (specifically, adherence) to cognitive behavioral therapy (CBT) is direct observation, a costly, resource-intensive practice that is not feasible for many community organizations to implement regularly. Recent research indicates that behavioral rehearsal (i.e., role-play between clinician and individual with regard to session delivery) and chart-stimulated recall (i.e., brief structured interview between clinician and individual about what they did in session; clinicians use the client chart to prompt memory) may provide accurate and affordable alternatives for measuring adherence to CBT in such settings, with behavioral rehearsal yielding greater correspondence with direct observation.

Methods

Drawing on established causal theories from social psychology and leading implementation science frameworks, this study evaluates stakeholders’ intention to use behavioral rehearsal and chart-stimulated recall. Specifically, we measured attitudes, self-efficacy, and subjective norms toward using each, and compared these factors across the two methods. We also examined the relationship between attitudes, self-efficacy, subjective norms, and intention to use each method. Finally, using an integrated approach we asked stakeholders to discuss their perception of contextual factors that may influence beliefs about using each method. These data were collected from community-based supervisors ( n = 17) and clinicians ( n = 66).

Results

Quantitative analyses suggest moderately strong intention to use both methods across stakeholders. There were no differences in supervisors’ or clinicians’ attitudes, self-efficacy, subjective norms, or intention across methods. More positive attitudes and greater reported subjective norms were associated with greater reported intention to use either measure. Qualitative analyses identified participants’ specific beliefs about using each fidelity measure in their organization, and results were organized using the Consolidated Framework for Implementation Research.

Conclusions

Strategies are warranted to overcome or minimize potential barriers to using fidelity measurement methods and to further increase the strength of intention to use them. Plain Language Summary: The best way to measure fidelity, or how closely a clinician follows the protocol, to Cognitive Behavioral Therapy (CBT) is watching the session. This is an expensive practice that is not feasible for many community organizations to do regularly. Recent research indicates that behavioral rehearsal, or a role-play between the clinician and individual with regard to session delivery, and chart-stimulated recall, or a brief discussion between an individual and the clinician about what they did in session with the clinician having access to the chart to help them remember, may provide accurate and affordable alternatives for measuring fidelity to CBT. We just completed a study demonstrating that both methods are promising, with behavioral rehearsal offering scores that are the most similar to watching the session. Drawing on established theories from social psychology and leading implementation science frameworks, this study evaluates future supervisor and clinician motivation to use these fidelity measurement methods. Specifically, we measured supervisor (n = 17) and clinician (n = 66) attitudes, norms, self-efficacy, intentions, and anticipated barriers and facilitators to using each of these fidelity measurement tools. Quantitative and qualitative analyses suggest similar intention to use both methods, and concerns about barriers to using each method. Further research is warranted to minimize the burden associated with implementing fidelity measurement methods and deploying strategies to increase use.

Assessing Causal Pathways and Targets of Implementation Variability for EBP use (Project ACTIVE): a study protocol

Background

Advancing causal implementation theory is critical for designing tailored implementation strategies that target specific mechanisms associated with evidence-based practice (EBP) use. This study will test the generalizability of a conceptual model that integrates organizational constructs and behavioral theory to predict clinician use of cognitive-behavioral therapy (CBT) techniques in community mental health centers. CBT is a leading psychosocial EBP for psychiatric disorders that remains underused despite substantial efforts to increase its implementation.

Methods

We will leverage ongoing CBT implementation efforts in two large public health systems (Philadelphia and Texas) to recruit 300 mental health clinicians and 600 of their clients across 40 organizations. Our primary implementation outcomes of interest are clinician intentions to use CBT and direct observation of clinician use of CBT. As CBT comprises discrete components that vary in complexity and acceptability, we will measure clinician use of six discrete components of CBT. After finishing their CBT training, participating clinicians will complete measures of organizational and behavior change constructs delineated in the model. Clinicians also will be observed twice via audio recording delivering CBT with a client. Within 48 h of each observation, theorized moderators of the intention-behavior gap will be collected via survey. A subset of clinicians who report high intentions to use CBT but demonstrate low use will be purposively recruited to complete semi-structured interviews assessing reasons for the intention-behavior gap. Multilevel path analysis will test the extent to which intentions and determinants of intention predict the use of each discrete CBT component. We also will test the extent to which theorized determinants of intention that include psychological, organizational, and contextual factors explain variation in intention and moderate the association between intentions and CBT use.

Discussion

Project ACTIVE will advance implementation theory, currently in its infancy, by testing the generalizability of a promising causal model of implementation. These results will inform the development of implementation strategies targeting modifiable factors that explain substantial variance in intention and implementation that can be applied broadly across EBPs.

Who gets coached? A qualitative inquiry into community clinicians' decisions to use caregiver coaching

LAY ABSTRACT

Providers' beliefs about an intervention's fit with a family can affect whether or not they use that intervention with a family. The factors that affect providers' decisions to use evidence-based practices for young autistic children have not been studied. These factors may play a role in the major differences we see in the quality of and access to early intervention services in the community. We looked at differences in providers' use of caregiver coaching, an evidence-based practice, with families from minority or vulnerable backgrounds, and the possible reasons for those differences. We did this to figure out what factors affect providers' use of caregiver coaching. We interviewed 36 early intervention providers from early intervention agencies in two different parts of the United States. Providers pointed out things like what they thought about a family's circumstances that affected their beliefs about how well coaching fits with minority and vulnerable families. Our findings bring attention to these beliefs that likely make accessing evidence-based practices for minority and vulnerable families harder and lessen the quality of care for these families of young autistic children. These findings highlight the need to come up with and use strategies to improve both access to and the quality of evidence-based practices for young autistic children from minority and vulnerable groups.

The implementation of opioid prescribing report cards in Medicaid managed care: a community quality collaborative

Philadelphia, Pennsylvania, is an urban epicenter of the opioid epidemic, and inappropriate opioid prescribing remains a top concern. To help address this issue, the Philadelphia Medicaid Opioid Prescribing Initiative, a type of community quality collaborative, mailed thousands of local Medicaid providers an individualized prescribing report card in 2017 and 2018. The report card featured details of providers' opioid prescribing, including peer comparison measures and inappropriate prescribing measures like concomitant opioid and benzodiazepine prescribing. This case study describes the unique process of developing and distributing the opioid prescribing report cards, with a particular focus on the role of Medicaid managed care organizations. Using Medicaid pharmacy claims, the extensive variation in prescribing measures within and across specialties is also illustrated. The report card's implementation points to the potential value of collaborations between public health departments and Medicaid managed care organizations and can provide insight for other locally grown policies.

Scale-Up Study Protocol of the Implementation of a Mobile Health SBIRT Approach for Alcohol Use Reduction in Mozambique

BACKGROUND

Hazardous drinking imposes a major public health burden worldwide, especially in low-income countries such as Mozambique. Implementation of the Screening, Brief Intervention, Referral to Treatment (SBIRT) approach to address problem drinking is recommended. However, evidence regarding the best strategies to implement SBIRT at scale is needed.

METHODS

Guided by the Reach Effectiveness Adoption Implementation Maintenance model, the authors will conduct a 2-year, cluster-randomized, hybrid type-2 implementation-effectiveness trial in 12 districts in Mozambique evaluating implementation, clinical effectiveness, outcomes, and cost. Eight districts will be randomly assigned to a mobile application-based health SBIRT condition and four to SBIRT-Conventional Training and Supervision. Interventions will be delivered by clinic-based community health workers. The Consolidated Framework for Implementation Research will guide the authors' mixed-methods assessments throughout the study.

RESULTS

The study arm showing better cost-effectiveness will be scaled up in the other arms' districts. During this 12-month scale-up phase, Ministry of Health personnel will be charged with providing training, clinical activities, and supervision in all 12 districts without research team support. The SBIRT scale-up phase is critical to identify facilitators and barriers for tracking internal and external factors in clinics that continue using the superior arm and those that switch to it.

NEXT STEPS

In a multistep process with stakeholders from multiple sectors, outcomes and lessons learned from this study will inform the development of an implementation tool kit to guide SBIRT scale-up of community services addressing hazardous drinking in other low- and middle-income countries and low-resource settings in high-income countries.

Lessons From Maslow: Prioritizing Funding to Improve the Quality of Community Mental Health and Substance Use Services

Evidence-based practices (EBPs) are frequently proposed as an approach to close the quality chasm in behavioral health treatment, and many U.S. municipalities are investing in EBPs as a primary way to improve the quality of care delivered to individuals most in need. In this Open Forum, the authors argue that EBPs often cannot be successfully implemented because basic organizational needs are not met in the current fiscal environment. The authors summarize research that supports why EBPs, along with other approaches to improve quality, are likely to fail until there is adequate financing. They also propose a policy and research agenda to ameliorate and address the fiscal challenges inherent in community mental health and substance use services.

Self-regulation predicts companionship in children with autism

 Self-regulation is associated with many positive outcomes in children with and without autism, including increased mental health and academic achievement, and decreased problem behavior. Less is known regarding whether and how self-regulation and symptoms of mental health challenges (internalizing and externalizing problems) relate to social outcomes, such as friendship quality and loneliness. Parents and teachers of 106 children with autism aged 5-12 reported on children's self-regulation difficulties and externalizing and internalizing symptoms. Four-to-five months later, children reported on the quality of their friendship with their best friend (companionship, conflict, helpfulness, sense of relationship security, closeness), and their feelings of loneliness. Linear regression was used to examine the effects of self-regulation and symptoms of mental health challenges on friendship quality and loneliness. Less self-regulation difficulties predicted stronger companionship and girls had better quality friendships with their best friend than did boys, in terms of companionship, helpfulness, security and closeness, confirming that they have a protective advantage in friendship development. Autism symptoms, IQ, and age were not associated with friendship quality or loneliness. Results highlight the importance of self-regulation and mental health interventions for school-aged children with autism.

Transforming Mental Health Care Delivery Through Implementation Science and Behavioral Economics

Psychiatric disorders account for more years lived with disability globally than any other disease category. Currently, effective mental health treatments are variably deployed in community practice and patient outcomes are less robust than clinical trials. A major frontier in psychiatry is to develop strategies that increase the use of evidence-based assessment, prevention, and intervention approaches, galvanizing the new field of implementation science. In this Viewpoint, we argue that we must bring concepts from behavioral economics to implementation science to accelerate the reach and impact of psychiatric treatments.

Mental Health Services for Autistic Individuals Across the Lifespan: Recent Advances and Current Gaps

PURPOSE OF REVIEW

This synthesis of recent mental health services research with autistic individuals presents significant advances, current gaps, and recommendations for improving mental healthcare for this population.

RECENT FINDINGS

Recent advances include improved understanding of co-occurring mental health conditions among autistic individuals, a growing evidence base for interventions to address them, the development and implementation of new service models to support mental health for this population, and a substantial increase in mental health services and implementation research focused on autism. Ongoing challenges include a lack of mental health interventions designed for community implementation with autistic individuals, limited workforce capacity, complex and disconnected service systems, and racial, ethnic, and socioeconomic disparities in accessibility and quality of mental health services. Despite the advances in our understanding of mental health needs and mental health services for autistic individuals, several critical gaps remain. We encourage future efforts to develop and test interventions that can be used in community settings, train and incentivize the workforce to provide them, realign policies and funding with best practice, and embrace an equity-focused approach to autism research and care.

The Association of the Medicaid 1915(c) Home and Community-Based Services Waivers with Emergency Department Utilization among Youth with Autism Spectrum Disorder

Using the 2008-2013 Medicaid Analytic eXtract files, this retrospective cohort study was to evaluate the effect of Medicaid home and community-based services (HCBS) waiver programs on emergency department (ED) utilizations among youth with autism spectrum disorder (ASD). Our study showed that the annual ED utilization rates were 13.5% and 18.8% for individuals on autism specific and intellectual and developmental disabilities (IDD) waivers respectively, vs. 28.5% for those without a waiver. Multivariable logistic regression showed that, compared to no waiver, autism specific waivers (adjusted odds ratio: 0.62; 95% Confidence Interval: [0.58-0.66]) and IDD waivers (0.65; [0.64-0.66]) were strongly associated with reduced ED. These findings suggest that HCBS waivers are effective in reducing the incidence of ED visits among youth with ASD.

County-level variation in geographic access to Board Certified Behavior Analysts among children with Autism Spectrum Disorder in the United States

LAY ABSTRACT

This study looked at whether access to Board Certified Behavior Analysts for children with autism spectrum disorder is different between U.S. counties. The study included all U.S. counties and county equivalents in 48 states and D.C. (N = 3108). Between March and May 2019, we combined data from the U.S. Department of Education's Civil Rights Data Collection, Behavior Analyst Certification Board's certificant registry, and U.S. Census. We assigned Board Certified Behavior Analysts to counties based on their address, matched children in school districts to counties, and determined how many children with autism spectrum disorder there were in a county compared with how many Board Certified Behavior Analysts there were in a county. The results show uneven numbers of Board Certified Behavior Analysts between U.S. counties. More than half of all counties had no Board Certified Behavior Analysts. National maps illustrate clusters of high and low accessibility to Board Certified Behavior Analysts. To improve access to Board Certified Behavior Analysts in underserved areas, we must identify what contributes to the differences in access.

Addressing Common Challenges in the Implementation of Collaborative Care for Mental Health: The Penn Integrated Care Program

PURPOSE

We developed and implemented a new model of collaborative care that includes a triage and referral management system. We present initial implementation metrics using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework.

METHODS

Primary care clinicians in 8 practices referred patients with any unmet mental health needs to the Penn Integrated Care program. Assessments were conducted using validated measures. Patients were primarily triaged to collaborative care (26%) or specialty mental health care with active referral management (70%). We conducted 50 qualitative interviews to understand the implementation process and inform program refinement. Our primary outcomes were reach and implementation metrics, including referral and encounter rates derived from the electronic health record.

RESULTS

In 12 months, 6,124 unique patients were referred. Assessed patients reported symptoms consistent with a range of conditions from mild to moderate depression and anxiety to serious mental illnesses including psychosis and acute suicidal ideation. Among patients enrolled in collaborative care, treatment entailed a mean of 7.2 (SD 5.1) encounters over 78.1 (SD 51.3) days. Remission of symptoms was achieved by 32.6% of patients with depression and 39.5% of patients with anxiety. Stakeholders viewed the program favorably and had concrete suggestions to ensure sustainability.

CONCLUSIONS

The Penn Integrated Care program demonstrated broad reach. Implementation was consistent with collaborative care as delivered in seminal studies of the model. Our results provide insight into a model for launching and implementing collaborative care to meet the needs of a diverse group of patients with the full range of mental health conditions seen in primary care.

Collaborative care in the treatment of opioid use disorder and mental health conditions in primary care: A clinical study protocol

BACKGROUND

People with opioid use disorder (OUD) often have a co-occurring psychiatric disorder, which elevates the risk of morbidity and mortality. Promising evidence supports the use of collaborative care for treating people with OUD in primary care. Whether collaborative care interventions that treat both OUD and psychiatric disorders will result in better outcomes is presently unknown.

METHODS

The Whole Health Study is a 3-arm randomized controlled trial designed to test collaborative care treatment for OUD and the psychiatric disorders that commonly accompany OUD. Approximately 1200 primary care patients aged ≥18 years with OUD and depression, anxiety, or PTSD will be randomized to one of three conditions: (1) Augmented Usual Care, which consists of a primary care physician (PCP) waivered to prescribe buprenorphine and an addiction psychiatrist to consult on medication-assisted treatment; (2) Collaborative Care, which consists of a waivered PCP, a mental health care manager trained in psychosocial treatments for OUD and psychiatric disorders, and an addiction psychiatrist who provides consultation for OUD and mental health; or (3) Collaborative Care Plus, which consists of all the elements of the Collaborative Care arm plus a Certified Recovery Specialist to help with treatment engagement and retention. Primary outcomes are six-month rates of opioid use and six-month rates of remission of co-occurring psychiatric disorders.

DISCUSSION

The Whole Health Study will investigate whether collaborative care models that address OUD and co-occurring depression, anxiety, or PTSD will result in better patient outcomes. The results will inform clinical care delivery during the current opioid crisis.

CLINICAL TRIALS REGISTRATION

www.clinicaltrials.gov registration: NCT04245423.