Leveraging Implementation Science to Integrate Digital Mental Health Interventions as part of Routine Care in a Practice Research Network.

The supply / demand issue in behavioral health care is a well-established fact, and the mental health toll of the COVID-19 pandemic continues to add challenges to an already taxed system. Existing healthcare models are not set up to adequately address the increasing mental health related needs. As such, innovative models are needed to provide patients with access to appropriate, evidence-based behavioral health care within routine clinical care. This paper introduces Precision Behavioral Health (PBH) as an example of such a model. PBH is an innovative, digital first care delivery model that provides an ecosystem of evidence-based digital mental health interventions to patients as a frontline behavioral health treatment within routine care in a large multispecialty group medical center in the United States. This paper describes the implementation of PBH within a practice research network set-up as part of an integrated behavioral health department. We will present how our team leveraged the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance; "What is RE-AIM?," n.d.) implementation science framework, which emphasizes the design, dissemination, and implementation processes at the individual, staff, and organizational levels, to prioritize key implementation constructs to enhance the successful integration of PBH within routine care. We describe how each of these constructs were operationalized to aid data gathering for rapid evaluation and lessons learned. We discuss the benefits of these types of initiatives across multiple stakeholders including patients, providers, organizations, payers, and digital intervention vendors.

Referring Adolescent Primary Care Patients to Single-Session Interventions for Anxiety and Depression: Protocol for a Feasibility Study.

BACKGROUND: Despite the growing prevalence of depression and anxiety among adolescents, fewer than half access appropriate mental health care. Single-session interventions (SSIs) for depression and anxiety offered in primary care are a promising approach to bridging the treatment gap. OBJECTIVE: We aimed to implement a clinical workflow for primary care and behavioral health providers to refer patients aged 13 to 17 years with mild to moderate depression and anxiety symptoms to Project YES (Youth Empowerment and Support), an open-access SSI platform, in a large group medical practice with an integrated behavioral health department. METHODS: Pediatric primary care and integrated behavioral health providers will be educated on the benefits of Project YES for adolescent anxiety and depression and trained in a workflow integrated within the electronic health record system, Epic, to refer patients during well-child visits and pediatric behavioral health visits. Patients with mild to moderate internalizing symptoms based on the 17-item Pediatric Symptom Checklist or youth Pediatric Symptom Checklist will be invited to try an SSI through Project YES. We will examine provider uptake and perceptions of acceptability, feasibility, and appropriateness over time. RESULTS: The rollout will take place between November 2022 and May 2023, when outcomes will be evaluated. Data analysis and manuscript writing are anticipated to be completed during the summer of 2023. CONCLUSIONS: SSIs such as those available through Project YES have the potential to provide low-cost, evidence-based mental health treatment to adolescents with mild to moderate depression and anxiety. If deemed feasible and acceptable, providing SSIs in primary care settings could significantly improve access to mental health care without taxing pediatric primary care and behavioral health providers. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/45666.

Immigration-related Legal Collaboration in Primary Care: Evaluating Impact on Knowledge and Well-being.

OBJECTIVES: To evaluate the impact of embedding an immigration attorney in a primary care clinic to address immigration-related legal needs. METHODS: We conducted a mixed-methods study of 42 legal clinic participants from May 2019-February 2020. Measures included psychological distress, understanding of legal options, and self-rated general health collected prior to, following, and 60-90 days after consultation. RESULTS: There was significant improvement in participants' understanding of their legal immigration options pre- (4.9, SD 2.9) and post-consult (8.6, SD 2.1), and 60 days later (7.0, SD 2.8) (F=11.0, p<.05), but self-rated health scores and distress did not significantly improve, although there was a high loss-to-follow up rate at 60 days (42.8%). Qualitative results underscored the interconnectedness of immigration status and health. DISCUSSION: Embedding immigration legal services in primary care improved patients' understanding of immigration-related legal options, although successfully mitigating the health impacts of vulnerable immigration status may take broader societal interventions.

The Impact of the Covid-19-Related Transition to Telehealth on Visit Adherence in Mental Health Care: An Interrupted Time Series Study.

Covid-19 has led to an unprecedented shift to telemental health (TMH) in mental healthcare. This study examines the impact of this transition on visit adherence for mental health services in an integrated behavioral health department. Monthly visit data for 12,245 patients from January, 2019 to January, 2021 was extracted from the electronic medical record. Interrupted time series (ITS) analysis examined the impact of the Covid-19 transition to TMH on immediate level and trend changes in the percentage of cancelled visits and no shows in the 10 months following the transition. ITS also compared changes across the three largest services types: adult, pediatric, and substance use. Following the TMH-transition, completed visits increased by 10% amounting to an additional 3644 visits. In April, 2020, immediately following the TMH-transition, no shows increased by 1.4%, (95% CI 0.1, 2.7, p < 0.05) and cancellations fell by 13.5% (95% CI - 17.9, - 9.0, p < 0.001). Across the 10-month post-TMH period, 18.2% of visits were cancelled, compared to 28.3% across the 14-month pre-TMH period. The proportion of no-shows remained the same. The pattern was similar for pediatric and adult sub-clinics, but no significant changes in cancellations or no shows were observed in the substance use sub-clinic. TMH during the Covid-19 pandemic is associated with improved visit adherence over time and may be a promising model for improving the efficiency of mental health care delivery once it is safe to resume in person care.

Associations between psychiatric morbidity and COVID-19 vaccine hesitancy: An analysis of electronic health records and patient survey.

Psychiatric illness confers significant risk for severe COVID-19 morbidity and mortality; identifying psychiatric risk factors for vaccine hesitancy is critical to mitigating risk in this population. This study examined the prevalence of vaccine hesitancy among those with psychiatric illness and the associations between psychiatric morbidity and vaccine hesitancy. Data came from electronic health records and a patient survey obtained from 14,365 patients at a group medical practice between February and May 2021. Logistic regression was used to calculate odds for vaccine hesitancy adjusted for sociodemographic characteristics and physical comorbidity. Of 14,365 participants 1,761 (12.3%) participants reported vaccine hesitancy. Vaccine hesitancy was significantly more prevalent among participants with substance use (29.6%), attention deficit and hyperactivity (23.3%), posttraumatic stress (23.1%), bipolar (18.0%), generalized anxiety (16.5%), major depressive (16.1%), and other anxiety (15.5%) disorders, tobacco use (18.6%), and those previously infected with COVID-19 (19.8%) compared to participants without . After adjusting for sociodemographic characteristics and physical comorbidities, substance use disorders and tobacco use were significantly associated with increased odds for vaccine hesitancy and bipolar disorder was significantly inversely associated with vaccine hesitancy. Interventions to improve uptake in these populations may be warranted.

Essential Principles of Preoperative Assessment in Internal Medicine: A Case-Based Teaching Session.

Introduction: Preoperative assessment is a core competency for internal medicine residents, but one with limited educational resources available presently. Ideally, residencies would provide an introduction to this topic prior to their residents performing preoperative assessments in clinic or during internal medicine consultation rotations. Methods: We developed a 120-minute case-based teaching session on preoperative assessment for PGY 2 residents where they reviewed a series of cases, applied preoperative risk calculators, and made recommendations on medication management using the same online tools they employ while working clinically. Interspersed lecture sections reviewed guiding principles, detailed key trials, and explored nuances of the topic. We performed pre- and posttests of knowledge and also obtained learner feedback. Results: Thirty-three out of 40 participants completed the pre- and posttests. The session was rated highly (M = 4.0 out of 5) and was viewed as preferable to a lecture-based approach (M = 4.4 out of 5); mean participant knowledge improved from 11.7 to 17.5 (p < .001) out of 22 points possible. The most consistently offered feedback was to give more time for the session than the 120 minutes allotted. Discussion: A teaching session mixing lecture with review of composite cases and application of preoperative assessment tools with immediate feedback improved knowledge and was viewed as enjoyable and preferable to lecture alone by participants. We recommend providing more time for the teaching by increasing the session length from 120 minutes to 140 minutes.

Associations Between Work-Related Factors and Psychological Distress Among Construction Workers.

OBJECTIVE: Identify work-related factors associated with the mental health and well-being of construction workers. METHODS: We completed eight key informant interviews, six worker focus groups, and a survey, informed by the interviews and focus groups, of 259 construction workers on five construction sites. Negative binomial regressions examined associations between psychological distress and work-related factors including safety climate, work-to-family conflict, psychological demands, social support, harassment, and job security. RESULTS: Three themes emerged from the interviews and focus groups, job demands and structure, social support and workplace relations, and job precarity. From the survey higher psychological demands, higher work-to-family conflict, lower supervisor support, higher discrimination, and higher likelihood of losing a job were associated with higher psychological distress. When combined into a single model job demands and work-to-family conflict remained significant. CONCLUSIONS: Work-related factors were associated with high levels of distress.

Can You Hear Me Now? Helping Faculty Improve Feedback Exchange for Internal Medicine Subspecialty Fellows.

Introduction: Feedback is an important tool that describes an individual's performance in a specific activity. Trainees at all levels grow from feedback exchanges to develop knowledge, skills, and attitudes in their specialty. However, there is a dearth of faculty development on providing advanced trainees feedback effectively. Methods: We designed and delivered internal medicine subspecialty-focused 60- or 90-minute interactive workshop to train faculty to improve feedback exchange with fellows. The workshop included addressing barriers to feedback specific to fellowship, tool and skills for feedback exchange, and case-based skills practice specific to scenarios seen in each subspecialty fellowship program. We utilized surveys of faculty assessing comfort with feedback exchange with fellows before and after the workshop. Results: We delivered the workshop to two separate specialty sections, gastroenterology and endocrine. Overall, faculty (N = 14) self-reported comfort improved significantly from pretest to posttest (p < .01). Ten participants' comfort ratings increased, while four remained the same at posttest. The evaluation identified several common themes as important learning points including labeling feedback, setting expectations around feedback exchange, and identifying elements of high-quality feedback exchange. Discussion: This workshop for faculty was designed to improve the skills, knowledge, and attitudes related to feedback exchange specifically within an internal medicine subspecialty fellowship training program. Analysis of pre- and postsurvey data demonstrated increased faculty comfort providing fellows-in-training with feedback.

Prevalence and Predictors of Limited Literacy in Public Mental Health Care.

Literacy is an important predictor of health care utilization and outcomes. We examine literacy among people seeking care in a state funded mental health clinic (Site 1) and a safety-net hospital clinic (Site 2). Limited literacy was defined as literacy at or below the 8th grade level. At Site 1, 53% of participants had limited reading literacy and 78% had limited aural literacy. At Site 2, 72% had limited reading and 90% had limited aural literacy. Regression analyses examined associations among limited literacy and psychiatric, neurocognitive and sociodemographic characteristics. Few associations among psychiatric and neurocognitive factors, and literacy were found. At Site 2, black and "other" race participants had higher odds for limited literacy compared to white participants suggesting that limited literacy may be an under-examined mechanism in understanding racial disparities in mental health. Work is needed to understand the relationships among literacy, mental health and mental health care.

Mental Health Stigma and Wellbeing Among Commercial Construction Workers: A Mixed Methods Study.

OBJECTIVE: The aim of this study was to understand the relationship between mental health stigma and wellbeing in a sample of commercial construction workers. METHODS: A sequential quantitative to qualitative mixed methods study was conducted. First, 264 workers were surveyed and logistic regression examined the associations between mental health stigma and psychological distress, substance abuse, and sleep; then, data from eight key informant interviews and six focus groups with workers were analyzed thematically. RESULTS: Stigma was significantly associated with psychological distress and impaired sleep, but not with substance abuse. Key informants and workers discussed the prominence of stigma on worksites and how the masculine culture of the industry and job insecurity contributed to stigma. CONCLUSION: Stigma poses a barrier to addressing mental health among workers; peer support and improved human resources may be promising.

Firearm access and adolescent suicide risk: toward a clearer understanding of effect size.

BACKGROUND: Strong and consistent associations between access to firearms and suicide have been found in ecologic and individual-level observational studies. For adolescents, a seminal case-control study estimated that living in a home with (vs without) a firearm was associated with a fourfold increase in the risk of death by suicide. METHODS: We use data from a nationally representative study of 10 123 US adolescents aged 13-18 years to (1) measure how much adolescents who live in a home with a firearm differ from those who do not in ways related to their risk of suicide, and (2) incorporate these differences into an updated effect estimate of the risk of adolescent suicide attributable to living in a home with firearms. RESULTS: Almost one-third (30.7%) of adolescents reported living in a home with firearms. Relative to those who did not, adolescents reporting living in a home with a firearm were slightly more likely to be male, older and reside in the South and rural areas, but few differences were identified for mental health characteristics. The effect size found by Brent and colleagues appeared robust to sources of possible residual confounding: updated relative risks remained above 4.0 across most sensitivity analyses and at least 3.1 in even the most conservative estimates. CONCLUSIONS: Although unmeasured confounding and other biases may nonetheless remain, our updated estimates reinforce the suggestion that adolescents' risk of suicide was increased threefold to fourfold if they had lived in homes with a firearm compared with if they had not.

An Interprofessional Nutrition Education Session for Senior Medical Students on Evidence-Based Diet Patterns and Practical Nutrition Tips.

Introduction: Dietary factors are recognized as a major contributor to the global burden of disease, and the obesity epidemic continues to be a major public health problem. Patients rely on doctors for dietary advice and to serve as role models for health behaviors. However, nutrition content is significantly underrepresented in medical school curricula. Methods: We created an interactive session to address this gap during the ambulatory medicine rotation for senior medical students and delivered it as a 90- to 120-minute interactive monthly didactic session. We focused on reviewing evidence-based diet patterns for weight loss and hypertension and on use of practical tools for diet assessment and counseling. Immediately and 1 month after delivery, we administered a knowledge and confidence assessment survey to evaluate the session impact. Results: We incorporated the session into the regular didactic time of the clerkship. Sixty-six students attended over an 8-month period, of whom 42 completed the survey. Immediately and 1 month after delivery, participants reported statistically significant improvements (p < .001) in their confidence in the domains measured. Participants' knowledge scores increased immediately and 1 month after the session compared to before participation. Discussion: We delivered a single recurring seminar on diet patterns and practical tips that was well received by fourth-year medical students during the ambulatory medicine clerkship. The seminar was a practical and interactive way of delivering important nutrition content to the medical school curriculum, and we demonstrated retention of confidence and knowledge of the delivered content.

Online preschool teacher training to promote physical activity in young children: A pilot cluster randomized controlled trial.

This study tested the Wellness Enhancing Physical Activity in Young Children (WE PLAY) program, a 4-week online preschool teacher training, on children's moderate-to-vigorous physical activity (MVPA). In this cluster RCT, six Head Start preschools were randomized to an intervention and comparison group. Children's MVPA was measured using accelerometers at pre- and posttest. The magnitude of the difference in MVPA between groups at posttest was small, but in the expected direction: Δ min/hour = 1.60, 95% CI [-0.97, 4.18], p = .22, Cohen's d = 0.32. We observed a pre/post within group increase in average minutes per hour of MVPA in school with a medium effect size for the intervention group: Δ mean min/hour = 2.09, 95% CI [0.51, 3.67], p = .0096, Cohen's d = 0.42. An increase was not seen for the comparison group: Δ mean min/hour = 0.44, 95% CI [-0.70, 1.59], p = .45, Cohen's d = 0.07. WE PLAY children in 6 hr/day programs gained 63 min of MVPA per week in school, providing preliminary evidence of the benefits of WE PLAY on children's physical activity levels. WE PLAY deserves further testing with larger groups of children and teachers. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Improving Medical Students' Skills to Address Social Determinants of Health during the Internal Medicine Clerkship.

We developed a quality improvement educational experience to equip third-year medical students (MS3) with tools to address social determinants of health (SDOH) during their internal medicine clerkship. Students used THRIVE, Boston Medical Center's SDOH screening tool and resource referral platform, to screen patients for social needs and provide them with information on resources. We evaluated changes in students' knowledge, attitudes, confidence, and practices in regard to addressing SDOH. Feasibility and acceptability of the experience were also evaluated. Analysis of pre-and post-experience surveys revealed improvement in MS3 confidence providing resources to help patients address SDOH (p<.001, n=41). Of all MS3 (n=158), 63% accessed the THRIVE Directory, and 45% successfully utilized it to print or e-mail resources. One MS3 focus group revealed challenges and time constraints faced by students. While benefits were identified, simplification of the workflow is needed to improve the feasibility and acceptability of the experience.