Client Outreach in Los Angeles County's Assisted Outpatient Treatment Program: Strategies and Barriers to Engagement

Purpose

Assisted Outpatient Treatment (AOT) programs can compel treatment-refusing individuals to participate in mental health treatment via civil court order. In California's AOT programs, individuals first must be offered 30 days of outreach services and can accept services voluntarily. This study examines the use of outreach strategies in an AOT program with the potential for voluntary or involuntary enrollment.

Methods

Outreach staff completed a survey in which they reported and rated outreach strategies and barriers to treatment for 487 AOT-referred individuals.

Results

Outreach staff reported using a broad array of strategies to persuade and engage clients. Supportive and persuasive strategies were most common. More coercive strategies, including court order, were used when needed. More clients enrolled voluntarily (39.4%) than involuntarily (7.2%).

Conclusions

Outreach, coupled with the strategic used of potential court involvement, can lead to voluntary enrollment of treatment-refusing individuals with many, often severe, barriers to engaging in outpatient treatment.

Mental Health Conservatorship Among Homeless People With Serious Mental Illness

OBJECTIVE

The purpose of this study was to examine associations between homelessness and length of psychiatric hospitalization and to explore the role of mental health conservatorship in determining discharge location for patients who are homeless and have a grave disability from serious mental illness.

METHODS

This observational study used administrative data from a safety-net psychiatric hospital in Los Angeles. The sample included 795 adults (≥18 years) who were hospitalized on an involuntary psychiatric hold between 2016 and 2018. The outcome variables were length of stay (days) and discharge location (home, locked psychiatric facility, unlocked psychiatric facility, unhoused). The predictor variables were homelessness status and whether a mental health conservatorship was initiated during hospitalization. Multiple regression models were used to estimate associations between variables.

RESULTS

Homelessness status was associated with 27.5 additional days (SE=3.5 days) of hospitalization in adjusted models. Homeless patients for whom conservatorship was initiated comprised 6% of the sample but 41% of total inpatient days. Among people who were homeless, initiation of a conservatorship was associated with significantly longer length of inpatient stay (mean=154.8 days versus 25.6 days for the whole sample) but also with lower odds of being unhoused at the time of discharge (risk ratio=0.19, 95% confidence interval=0.09-0.34).

CONCLUSIONS

A mental health conservatorship can be a mechanism for helping homeless people with a grave disability from mental illness to transition from the streets to residential psychiatric treatment, but it requires substantial resources from facilities that initiate such conservatorships and does not guarantee resolution of long-term supportive housing needs.

Recovery in Context: Thirty Years of Mental Health Policy in California

Over the past quarter century, Recovery has become the hegemonic model guiding mental health policy. Advocates presented Recovery as a radical departure from the past, with the promise of dramatically improved outcomes for those with serious mental illness. This article looks at the implementation of Recovery-based policies in California from the 1990s to the present and interrogates the ways these policies emerged out of and reinforced many of the problems they were intended to solve. Against the backdrop of welfare reform, managed care, and a growing belief in market forces and individual responsibility, California policymakers pivoted from rigorously studied pilot programs that were intended to provide intensive, long-term treatment to Recovery-oriented programs that, while initially intensive, promised to "flow" increasingly independent and self-sufficient patients to less-intensive services. Moreover, these new programs promised to produce cost savings by reducing homelessness, hospitalization, and incarceration. Reported outcomes from these programs have been overwhelmingly positive but are based on flawed evaluations that lean more heavily on belief than on evidence. While proclaiming a comprehensive, patient-centered approach, Recovery's embrace of independence over long-term care and social supports has justified a system of care that systematically fails the sickest patients by abandoning them to the streets and jails.

The Community and Patient Partnered Research Network (CPPRN): Application of Patient-Centered Outcomes Research to Promote Behavioral Health Equity

Objective

We describe the rationale, development, and progress on the Community and Patient Partnered Research Network (CPPRN). The CPPRN builds on more than a decade of partnered work and is designed to promote health equity by developing partnered research on behavioral health and social risk factors in Los Angeles and New Orleans.

Setting

A community-academic partnership across Los Angeles County and New Orleans.

Methods

Review of rationale, history, structure, activities and progress in applying community partnered participatory research (CPPR) to CPPRN.

Findings

Patient and community stakeholders participated in all phases of development, including local and national activities. Key developments include partnered planning efforts, progress on aggregating a large, de-identified dataset across county agencies, and development of an information technology-supported screening approach for behavioral and social determinants in health care, social, and community-based settings.

Conclusion

The CPPRN represents a promising approach for research data networks, balancing the potential benefit of information technology and data analytic approaches while addressing potential risks and priorities of relevant stakeholders.

System Transformation Under the California Mental Health Services Act: Implementation of Full-Service Partnerships in L.A. County

OBJECTIVE

The study evaluated the effect of California's Mental Health Services Act (MHSA) on the structure, volume, location, and patient centeredness of Los Angeles County public mental health services.

METHODS

This prospective mixed-methods study (2006-2013) was based in five Los Angeles County public mental health clinics, all with usual care and three with full-service partnerships (FSPs). FSPs are MHSA-funded programs designed to "do whatever it takes" to provide intensive, recovery-oriented, team-based, integrated services for clients with severe mental illness. FSPs were compared with usual care on outpatient services received (claims data) and on organizational climate, recovery orientation, and provider-client working alliance (surveys and semistructured interviews), with regression adjustment for client and provider characteristics.

RESULTS

In the first year after admission, FSP clients (N=174) received significantly more outpatient services than did usual care clients (N=298) (5,238 versus 1,643 minutes, p<.001), and a larger proportion of these services were field based (22% versus 2%, p<.001). Compared with usual care clients, FSP clients reported more recovery-oriented services (p<.001) and a better provider-client working alliance (p=.01). Compared with usual care providers (N=130), FSP providers (N=42) reported more stress (p<.001) and lower morale (p<.001).

CONCLUSIONS

Los Angeles County's public mental health system was able to transform service delivery in response to well-funded policy mandates. For providers, a structure emphasizing accountability and patient centeredness was associated with greater stress, despite smaller caseloads. For clients, service structure and volume created opportunities to build stronger provider-client relationships and address their needs and goals.

Screening for domestic violence among adult women in the United States

BACKGROUND

Domestic violence is a problem frequently encountered in health care settings and a risk factor for physical and mental health problems.

OBJECTIVE

To provide nationally representative estimates of rates of domestic violence screening among women, to identify predictors of screening, and to describe settings where women are screened.

DESIGN AND PARTICIPANTS

We examined 4,821 women over the age of 18 from the second wave of Healthcare for Communities, a nationally representative household telephone survey conducted in 2000-2001.

MEASUREMENTS

Self-reports concerning whether the respondent was ever asked about domestic or family violence by any health care provider.

RESULTS

Only 7% (95% CI, 6%-8%) of women reported they were ever asked about domestic violence or family violence by a health care professional. Of women who were asked about abuse, nearly half (46%) were asked in a primary care setting, and 24% were asked in a specialty mental health setting. Women with risk factors for domestic violence were more likely to report being asked about it by a health care professional, but rates were still low.

CONCLUSIONS

Self-reported rates of screening for domestic violence are low even among women at higher risk for abuse. These findings reinforce the importance of developing training and raising awareness of domestic violence and its health implications. This is especially true in primary care and mental health specialty settings.

Generalizability of studies on mental health treatment and outcomes, 1981 to 1996

OBJECTIVE

This study operationalized and measured the external validity, or generalizability, of studies on mental health treatment and outcomes published in four journals between 1981 and 1996.

METHOD

MEDLINE was searched for articles on mental health treatment and outcomes that were published in four leading psychiatry and psychology journals between 1981 and 1996. A 156-item instrument was used to assess generalizability of study findings.

RESULTS

Of more than 9,000 citations, 414 eligible studies were identified. Inclusion of community sites and patients from racial or ethnic minority groups were documented in only 12 and 25 percent of studies, respectively. Random or systematic sampling methods were rare (3 percent), and 75 percent of studies did not explicitly address sample representativeness. Studies with funding from the National Institute of Mental Health (NIMH) were more likely than those without NIMH funding to document the inclusion of patients from minority groups (30 percent compared with 20 percent). Randomized studies were more likely than nonrandomized studies to document the inclusion of patients from minority groups (28 percent compared with 17 percent), include patients with comorbid psychiatric conditions (31 percent compared with 19 percent), and attend to sample representativeness (28 percent compared with 15 percent). Modest improvements were seen over time in inclusion of patients from minority groups, inclusion of patients with psychiatric comorbidities, and attention to sample representativeness.

CONCLUSIONS

Generalizability of studies on treatments and outcomes, whether experimental or observational, remained low and poorly documented over the 16-year period.