Placement into Scattered-Site or Place-Based Permanent Supportive Housing in Los Angeles County, CA, During the COVID-19 Pandemic.

There are two dominant approaches to implementing permanent supportive housing (PSH), namely place-based (PB) and scattered-site (SS). Formal guidance does not distinguish between these two models and only specifies that PSH should be reserved for those who are most vulnerable with complex health needs. To consider both system- and self-selection factors that may affect housing assignment, this study applied the Gelberg-Anderson behavioral model for vulnerable populations to compare predisposing, enabling, and need factors among people experiencing homelessness (PE) by whether they were assigned to PB-PSH (n = 272) or SS-PSH (n = 185) in Los Angeles County during the COVID-19 pandemic. This exploratory, observational study also included those who were approved but did not receive PSH (n = 94). Results show that there are notable differences between (a) those who received PSH versus those who did not, and (b) those in PB-PSH versus SS-PSH. Specifically, PEH who received PSH were more likely to be white, US-born, have any physical health condition, and have lower health activation scores. PEH who received PB- versus SS-PSH were more likely to be older, Black, have any alcohol use disorder, and have higher health activation scores. These findings suggest that homeless service systems may consider PB-PSH more appropriate for PEH with higher needs but also raises important questions about how race may be a factor in the type of PSH that PEH receive and whether PSH is received at all.

Adult use cannabis legalization and cannabis use disorder treatment in California, 2010-2021.

INTRODUCTION: Many nations and jurisdictions have legalized non-medical adult use of cannabis, or are considering doing so. This paper contributes to knowledge of adult use legalization's associations with cannabis use disorder (CUD) treatment utilization. METHODS: This study collected data from a dataset of all publicly funded substance use disorder treatment delivered in California from 2010 to 2021 (1,460,066 episodes). A logistic regression model estimates adult use legalization's impacts on CUD treatment utilization using an individual-level pre-post time series model, including individual and county-level characteristics and county and year-fixed effects. RESULTS: Adult use legalization was associated with a significant decrease in the probability of admission to CUD treatment (average marginal effect (AME): -0.005, 95 % CI: -0.009, 0.000). Adult use legalization was also associated with a decrease in the probability of admission to CUD treatment for males (AME: -0.025, 95 % CI: -0.027, -0.023) Medi-Cal beneficiaries (AME: -0.025, 95 % CI: -0.027, -0.023) adults ages 21+ (AME: -0.011, 95 % CI: -0.014, -0.009) and Whites (AME: -0.012, 95 % CI: -0.015, -0.010), and an increase in the probability of admission to CUD treatment for patients referred from the criminal justice system (AME: 0.017, 95 % CI: 0.015, 0.020) and Blacks (AME: 0.004, 95 % CI: 0.000, 0.007) and Hispanics (AME: 0.009, 95 % CI: 0.006, 0.011). CONCLUSIONS: Adult use legalization is associated with declining CUD treatment admissions, even though cannabis-related problems are becoming more prevalent. Policies and practices that protect public health, and engage people with CUD in treatment are needed.

Bringing Lived Experience to Research on Health and Homelessness: Perspectives of Researchers and Lived Experience Partners.

Improving health and healthcare for people experiencing homelessness (PEH) has become a national research priority. It is critical for research related to homelessness to be guided by input from PEH themselves. We are a group of researchers and individuals who have personally experienced homelessness collaborating on a study focused on homelessness and housing. In this Fresh Focus, we describe our partnership, lessons learned from our work together, what we have gained from our collaboration, and considerations for future homelessness research-lived experience partnerships.

Investigating the Comparative Effectiveness of Place-Based and Scatter-Site Permanent Supportive Housing for People Experiencing Homelessness During the COVID-19 Pandemic: Protocols for a Mixed Methods, Prospective Longitudinal Study.

BACKGROUND: Permanent supportive housing (PSH) is an evidence-based practice to address homelessness that is implemented using 2 distinct approaches. The first approach is place-based PSH (PB-PSH), or single-site housing placement, in which an entire building with on-site services is designated for people experiencing homelessness. The second approach is scatter-site PSH (SS-PSH), which uses apartments rented from a private landlord while providing mobile case management services. OBJECTIVE: This paper describes the protocols for a mixed methods comparative effectiveness study of 2 distinct approaches to implementing PSH and the patient-centered quality of life, health care use, and health behaviors that reduce COVID-19 risk. METHODS: People experiencing homelessness who are placed in either PB-PSH or SS-PSH completed 6 monthly surveys after move-in using smartphones provided by the study team. A subsample of participants completed 3 qualitative interviews at baseline, 3 months, and 6 months that included photo elicitation interviewing. Two stakeholder advisory groups, including one featuring people with lived experience of homelessness, helped guide study decisions and interpretations of findings. RESULTS: Study recruitment was supposed to occur over 6 months starting in January 2021 but was extended due to delays in recruitment. These delays included COVID-19 delays (eg, recruitment sites shut down due to outbreaks and study team members testing positive) and delays that may have been indirectly related to the COVID-19 pandemic, including high staff turnover or recruitment sites having competing priorities. In end-July 2022, in total, 641 people experiencing homelessness had been referred from 26 partnering recruitment sites, and 563 people experiencing homelessness had enrolled in the study and completed a baseline demographic survey. Of the 563 participants in the study, 452 had recently moved into the housing when they enrolled, with 272 placed in PB-PSH and 180 placed in SS-PSH. Another 111 participants were approved but are still waiting for housing placement. To date, 49 participants have been lost to follow-up, and 12% of phones (70 of the initial 563 distributed) were reported lost by participants. CONCLUSIONS: Recruitment during the pandemic, while successful, was challenging given that in-person contact was not permitted at times either by program sites or the research institutions during COVID-19 surges and high community transmission, which particularly affected homelessness programs in Los Angeles County. To overcome recruitment challenges, flexible strategies were used, which included extending the recruitment period and the distribution of cell phones with paid data plans. Given current recruitment numbers and retention rates that are over 90%, the study will be able to address a gap in the literature by considering the comparative effectiveness of PB-PSH versus SS-PSH on patient-centered quality of life, health care use, and health behaviors that reduce COVID-19 risk, which can influence future public health approaches to homelessness and infectious diseases. TRIAL REGISTRATION: ClinicalTrials.gov NCT04769349; https://clinicaltrials.gov/ct2/show/NCT04769349. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/46782.

Medical conditions of primary care patients with documented cannabis use and cannabis use disorder in electronic health records: a case control study from an academic health system in a medical marijuana state.

BACKGROUND: Approximately 3.8% of adults worldwide have used cannabis in the past year. Understanding how cannabis use is associated with other health conditions is crucial for healthcare providers seeking to understand the needs of their patients, and for health policymakers. This paper analyzes the relationship between documented cannabis use disorders (CUD), cannabis use (CU) and other health diagnoses among primary care patients during a time when medical use of marijuana was permitted by state law in California, United States of America. METHODS: The study utilized primary care electronic health record (EHR) data from an academic health system, using a case-control design to compare diagnoses among individuals with CUD/CU to those of matched controls, and those of individuals with CUD diagnoses with individuals who had CU otherwise documented. Associations of documented CU and CUD with general medical conditions and health conditions associated with cannabis use (both medical and behavioral) were analyzed using conditional logistic regression. RESULTS: Of 1,047,463 patients with ambulatory encounters from 2013-2017, 729 (0.06%) had CUD diagnoses and 3,731 (0.36%) had CU documented in their EHR. Patients with documented CUD and CU patients had significantly (p < 0.01) higher odds of most medical and behavioral diagnoses analyzed. Compared to matched controls, CUD-documented patients had highest odds of other substance use disorders (OR = 21.44: 95% CI 9.43-48.73), any mental health disorder (OR = 6.99; 95% CI 5.03-9.70) social anxiety disorder (OR = 13.03; 95% CI 2.18-77.94), HIV/AIDS (OR = 7.88: 95% CI 2.58-24.08), post-traumatic stress disorder (OR = 7.74: 95% CI 2.66-22.51); depression (OR = 7.01: 95% CI 4,79-10.27), and bipolar disorder (OR = 6.49: 95% CI 2.90-14.52). Compared to matched controls, CU-documented patients had highest odds of other substance use disorders (OR = 3.64; 95% CI 2.53-5.25) and post-traumatic stress disorder (OR = 3.41; 95% CI 2.53-5.25). CUD-documented patients were significantly more likely than CU-documented patients to have HIV/AIDS (OR = 6.70; 95% CI 2.10-21.39), other substance use disorder (OR = 5.88; 95% CI 2.42-14.22), depression (OR = 2.85; 95% CI 1.90-4.26), and anxiety (OR = 2.19: 95% CI 1.57-3.05) diagnoses. CONCLUSION: The prevalence of CUD and CU notation in EHR data from an academic health system was low, highlighting the need for improved screening in primary care. CUD and CU documentation were associated with increased risk for many health conditions, with the most elevated risk for behavioral health disorders and HIV/AIDS (among CUD-documented, but not CU-documented patients). Given the strong associations of CUD and CU documentation with health problems, it is important for healthcare providers to be prepared to identify CU and CUD, discuss the pros and cons of cannabis use with patients thoughtfully and empathically, and address cannabis-related comorbidities among these patients.

Homelessness and publicly funded substance use disorder treatment in California, 2016-2019: Analysis of treatment needs, level of care placement, and outcomes.

INTRODUCTION: Both homelessness and substance use have increased in recent years. People experiencing homelessness (PEH) are at increased risk for health problems and early mortality, both of which can be exacerbated by substance use disorders (SUD). Specialty SUD treatment is likely needed to address substance use among PEH, and more than 232,000 PEH received treatment from U.S. publicly funded SUD programs in 2015. The objective of this paper is to develop a better understanding of the SUD services that PEH receive in publicly funded treatment programs by (1) describing the characteristics and needs of the PEH population served in publicly funded SUD treatment programs, compared to non-PEH populations; (2) determining if differences exist in treatment placement (level of care) for PEH and non-PEH; and (3) gauging how successful programs are in treating PEH compared to non-PEH. METHODS: Observational study using a two-way fixed effect model to determine associations among homelessness, retention, and outcomes among Medicaid beneficiaries receiving SUD treatment in California from 2016 to 2019 (n = 638,953). The study team used ordinary least squares (OLS) regression to measure the degree to which homelessness was associated with baseline characteristics, SUD services received, and treatment outcomes. RESULTS: PEH were significantly more likely than non-PEH to be having methamphetamine or heroin as their primary substance. PEH had greater frequency of primary substance use prior to entering treatment, greater ER and hospital utilization, more criminal justice involvement, and greater prevalence of mental health diagnoses and unemployment. PEH were 9.82% more likely than non-PEH to receive residential treatment and 7.11% less likely than non-PEH to receive treatment intensive outpatient modalities. Homelessness was associated with an 11.90% decrease in retention, and a 19.40% decrease in successful discharge status. These trends were consistent across outpatient, intensive outpatient, and residential modalities. CONCLUSIONS: Developing SUD treatment capacity and housing supports can improve treatment outcomes for PEH. Potential strategies to improve SUD services for PEH include providing more contingency management, opioid pharmacotherapies, programming designed to treat individuals with co-occurring mental health disorders, and resources for housing options that can support PEH in their recovery.

What's in an "ASAM-based Assessment?" Variations in Assessment and Level of Care Determination in Systems Required to Use ASAM Patient Placement Criteria.

OBJECTIVES: When clients begin substance use disorder (SUD) treatment, it is critical to ensure that they receive treatment that matches their needs and preferences. A growing number of payors are requiring the use of multidimensional assessments such as assessments based on the American Society of Addiction Medicine (ASAM) criteria, which describe 6 dimensions that should be used to inform decisions about patient placement. However, ASAM guidance does not list specific questions to ask or instruments to use to elicit this information. This paper evaluates differences among the assessment tools being used by SUD service systems that are required to use ASAM-based assessments to make patient placement decisions. METHODS: We analyzed 29 different ASAM-based assessments being used by California counties to make patient placement decisions using conventional and summative content analysis techniques. RESULTS: All assessments were organized by the 6 ASAM dimensions. However, some of them only ask 1 or 2 questions per dimension, while others ask over 20, and some ask over 100 depending on patient responses. There is significant heterogeneity in the information the assessments collect and how it is used to generate patient placement decisions. Among the 29 assessments examined, there are 8 different algorithms or instructions on how to translate information from assessments into level of care recommendations. CONCLUSIONS: The differences among the ASAM-based assessments examined in this paper suggest a need to implement fidelity standards, enhance training, and create resources to help systems create and utilize assessment and patient placement tools that are consistent across the SUD treatment field.

Assessing Assessments: Substance use disorder treatment providers' perceptions of intake assessments.

Background: Assessments to determine patients' treatment needs and preferences when they begin substance use disorder (SUD) treatment are essential. The objectives of this paper are to identify the perspectives of providers who conduct assessments on (1) assessments' utility in determining the level of care where patients will receive treatment, (2) strategies to engage patients in treatment during assessments, and (3) assessment strengths and shortcomings. Methods: Semi-structured interviews were conducted with 30 California treatment providers who routinely perform SUD assessments for Medicaid beneficiaries. Interviews asked about the utility of assessment tools in determining appropriate levels of care, patient engagement during assessments, and strengths and shortcomings of intake assessment processes. Interviews were audio-recorded, transcribed, and analyzed by multiple researchers using template analysis. Results: Providers reported that assessments linked to level-of-care decision rules sometimes generate recommendations inconsistent with their clinical judgment, and that the timing of assessments can influence the quality of the information collected. Providers described engagement strategies that help patients feel more comfortable during assessments and that encourage more thoughtful and accurate responses. Providers valued assessments that helped ensure comprehensive collection of patient information, that allowed flexibility to probe for additional information and context, and that facilitated treatment planning. Providers did not like assessments that were long and repetitive or those that did not collect detailed information about patients' mental health and recovery environments. Conclusions: Assessments can be improved if providers conduct them in a manner that makes patients feel comfortable while building trust and rapport. Ensuring that assessments are not long or repetitive and giving comprehensive assessments once patients have developed trusting relationships with treatment programs can improve assessment processes. Further research is needed to optimize SUD assessments.

Addiction Treatment and Telehealth: Review of Efficacy and Provider Insights During the COVID-19 Pandemic.

OBJECTIVE: Addiction treatment via telehealth expanded to unprecedented levels during the COVID-19 pandemic. This study aimed to clarify whether the research evidence on the efficacy of telehealth-delivered substance use disorder treatment and the experience of providers using telehealth during the pandemic support continued use of telehealth after the pandemic and, if so, under what circumstances. METHODS: Data sources included a literature review on the efficacy of telehealth for substance use disorder treatment, responses to a 2020 online survey from 100 California addiction treatment providers, and interviews with 30 California treatment providers and other stakeholders. RESULTS: Eight published studies were identified that compared addiction treatment via telehealth with in-person treatment. Seven found telehealth treatment as effective but not more effective than in-person treatment in terms of retention, therapeutic alliance, and substance use. One Canadian study found that telehealth facilitated methadone prescribing and improved retention. In the survey results reported here, California addiction treatment providers said that more than 50% of their patients were being treated via telehealth for intensive outpatient treatment, individual counseling, group counseling, and intake assessment. They were most confident that individual counseling via telehealth was as effective as in-person individual counseling and less sure about the relative effectiveness of telehealth-delivered medication management, group counseling, and intake assessments. CONCLUSIONS: Telehealth may help engage patients in addiction treatment by improving access and convenience. Additional research is needed to confirm that benefit and to determine how best to tailor telehealth to each patient's circumstances and with what mix of in-person and telehealth services.

Rapid Adoption of Low-Threshold Buprenorphine Treatment at California Emergency Departments Participating in the CA Bridge Program.

STUDY OBJECTIVE: We retrospectively evaluated the implementation of low-threshold emergency department (ED) buprenorphine treatment at 52 hospitals participating in the CA Bridge Program using the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework. METHODS: The CA Bridge model included low-threshold buprenorphine, connection to outpatient care, and harm reduction. Implementation began in March 2019. Participating hospitals reported aggregated clinical data monthly after program initiation. Outcomes included identification of opioid use disorder, buprenorphine administration, and linkage to outpatient addiction treatment. Multivariable models assessed associations between hospital location (rural versus urban) and teaching status (clinical teaching hospital versus community hospital) and outcomes in adopting the CA Bridge Program. RESULTS: Reach: A diverse and geographically distributed group of 52 California hospitals were enrolled in 2 phases (March and August 2019); 12 (23%) were rural and 13 (25%) were teaching hospitals. Effectiveness: Over a 14-month implementation period, 12,009 opioid use disorder patient encounters were identified, including 7,179 (59.7%) where buprenorphine was administered and 4,818 (40.1%) where follow-up visits were attended. Adoption: In multivariable analysis, adoption did not differ significantly between rural and urban or teaching and nonteaching hospitals. IMPLEMENTATION: By program completion, all 52 (100%) hospitals treated opioid use disorder with buprenorphine; 45 (86.5%) administered buprenorphine after naloxone reversal; 41 (84.6%) offered buprenorphine for inpatients; 48 (92.3%) initiated buprenorphine in pregnant women; and 29 (55.8%) offered take-home naloxone. Maintenance: At 8-month follow-up, all 52 sites reported continued buprenorphine treatment. CONCLUSION: Low-threshold ED buprenorphine treatment implemented with a harm reduction approach and active navigation to outpatient addiction treatment was successful in achieving buprenorphine treatment for opioid use disorder in diverse California communities.

Impact of the Coronavirus Pandemic on Substance Use Disorder Treatment: Findings from a Survey of Specialty Providers in California.

BACKGROUND: As the coronavirus pandemic public health emergency begins to ebb in the United States, policymakers and providers need to evaluate how the addiction treatment system functioned during the public health emergency and draw lessons for future emergencies. One important question is whether the pandemic curtailed the use of addiction treatment and the extent to which telehealth was able to mitigate access barriers. METHODS: To begin to answer this question, we conducted a survey of specialty addiction treatment providers in California from June 2020 through July 2020. The survey focused specifically on provider organizations that served Medicaid beneficiaries. RESULTS: Of the 133 respondents, 50% reported a decrease in patients since the stay-at-home order in March 2020, with the largest decline among new patients, and 58% said more patients were relapsing. Eighty-one percent of providers said that telemedicine use had increased since the stay-at-home order. Most said that telemedicine had moderately (48%) or completely (30%) addressed access barriers. CONCLUSION: More efforts are needed to ensure that patients, and in particular new patients, receive addiction treatment during public health emergencies.

Is implementation of ASAM-based addiction treatment assessments associated with improved 30-day retention and substance use?

BACKGROUND: The American Society of Addiction Medicine (ASAM) criteria were developed to provide a systematic, evidence-based, and transparent approach to addiction treatment assessment and level-of-care recommendations. In 2017, California began a Medicaid demonstration that required that providers in participating counties to adopt ASAM-based intake assessments and level-of-care criteria. We hypothesized that ASAM implementation would increase the proportion of patients retained in addiction treatment and successfully completing their treatment plan. METHODS: We implemented a comparative interrupted time series analysis with 407,792 treatment episodes by Medicaid beneficiaries in specialty addiction treatment settings from 2015 to mid-2019. We compared the change in retention rates and successful completion rates in counties that adopted ASAM-based assessments relative to counties that did not adopt ASAM-based assessments and used only clinical judgment for level-of-care decisions. Treatment retention was defined as staying in addiction treatment for at least 30 days. Successful completion of the treatment plan was determined by the patient's clinician. RESULTS: After one year, ASAM implementation was associated with a 9% increase in 30-day retention among treatment episodes that started in a residential setting, but no change in retention among episodes starting in outpatient settings. We found no statistically significant association between ASAM adoption and successful treatment completion. CONCLUSIONS: Implementation of ASAM-based assessment may lead to improved retention for individuals who begin treatment in residential treatment, which may be encouraging to the many state Medicaid programs that are adopting ASAM-based criteria. More research is needed to clarify the mechanism by which ASAM leads to improved outcomes and to clarify how to maximize the potential benefits of ASAM, such as through patient-centered implementation.

"The assessment really helps you with the first step in recovery." What do clients think substance use disorder treatment intake assessments should look like?

Background: In general, research has found that patient-centered substance use disorder treatment is positively correlated with improved patient outcomes. However, little research has examined what factors make intake assessments-the first step in addiction treatment-patient-centered. Methods: We conducted interviews with 30 Medicaid-enrolled individuals who received addiction treatment in California about their experiences with the intake assessment process. Results: Participants reported that the intake assessment process evoked strong feelings, both positive and negative. Some participants said that answering detailed questions about their substance use, mental health, and social relationships, for example, was cathartic and gave them helpful insights. Other participants found the questions invasive, exhausting, and anxiety provoking. Participants also emphasized how critical it is for the person conducting the assessment to be supportive, nonjudgmental, and attentive. Participants recommended delaying the comprehensive assessment because they did not feel physically or emotionally ready to complete the intake. Conclusions and recommendations: Patients' introduction to addiction treatment is typically the intake assessment. By understanding how patients experience intake assessments, providers can make the process more patient-centered, which may lead to improved patient outcomes.

How Patient Centered Are Addiction Treatment Intake Processes?

OBJECTIVES: The substance use disorder (SUD) treatment field has conducted significant research on creating intake tools and processes that best match patients to the most appropriate treatment setting, but less research has been conducted on how those tools impact the patient experience. The study took advantage of a natural experiment in California to evaluate whether the implementation of American Society of Addiction Medicine (ASAM) assessment criteria and a computer-facilitated intake assessment based on the ASAM criteria affects patient experiences and patient-centeredness during intake relative to patients receiving intake assessments not based on ASAM criteria. METHODS: We analyzed surveys completed by 851 patients covered by Medi-Cal who were receiving specialty SUD treatment at 33 providers across 10 California counties about their experiences and perceptions of the intake assessment process. To account for differences in patient mix, we used inverse-probability weighting and computed differences in the weighted means for patients across non-ASAM, ASAM, and computerized-ASAM patients. RESULTS: We have found that patients who underwent intake based on ASAM assessment criteria or computerized ASAM assessment experienced a more patient-centered intake. We also found that patients who received ASAM-based assessments were more satisfied with their choice of treatment setting. CONCLUSIONS: This evidence is encouraging for the SUD treatment field, especially considering that many Medicaid programs are adopting ASAM or similar patient placement criteria and multidimensional assessments. Future research should consider whether increases in the patient-centeredness of assessments are associated with increased retention in SUD treatment and other positive treatment outcomes.

Program Capacity to Deliver Prevention Services to Children of Adult Clients Receiving Substance Use Disorder Treatment.

Children whose parents have a history of substance use are at elevated risk of developing substance use disorders (SUDs) and related debilitating behaviors. Although specialty treatment programs are uniquely positioned to deliver prevention care to children of adult clients, these programs may have limited capacity to implement prevention and early intervention care services, particularly in racial and ethnic minority communities. We merged data from program surveys and client records collected in 2015 to examine the extent to which program capacity factors are associated with the odds of delivering prevention and early intervention services for children of adult clients attending outpatient SUD treatment in low-income minority communities in Los Angeles County, California. Our analytic sample consisted of 16,712 clients embedded in 82 programs. Our results show that 85% of these programs reported delivering prevention care services, while 71% of programs delivered early intervention services. Programs with organizational climates supporting change and those that served a high number of clients annually were more likely to implement both prevention and early intervention practices. Programs accepting Medicaid payments and serving clients whose primary drug was marijuana were more than three times as likely to implement prevention services. Overall, our findings suggest both program- and client-level characteristics are associated with delivering preventive care offered to children of adult clients receiving SUD treatment in communities of color. As Medicaid has become a major payor of SUD treatment services and marijuana use has been legalized in California, findings identify capacity factors to deliver public health prevention interventions in one of the nation's largest public SUD treatment systems.

Adapting substance use brief interventions for adolescents: perspectives of adolescents living with adults in substance use disorder treatment.

BACKGROUND: Brief interventions (BIs) have shown potential to reduce both alcohol and drug use. Although BIs for adults have been studied extensively, little is known about how to adapt them to meet the needs and preferences of adolescents. This article examines adolescents' preferences to consider when adapting BIs for use with adolescents. METHODS: Eighteen adolescents (age 9-17 years) living in Los Angeles County with adults receiving substance use disorder treatment were interviewed and asked about their perspectives on how to adapt a BI originally developed for adults for use with adolescents. Questions focused on adolescents' preferences for who should deliver BIs, how BIs should be delivered, and what content they would want to be included in BIs. Interviews were recorded, transcribed, and coded using summative content analysis. RESULTS: Adolescents did not express any discernable opinions concerning who delivers BIs or what content they would want to be included, but they did share perspectives on how BIs should be delivered. Most adolescents did not endorse incorporating text messaging or social media into BIs. Instead they preferred having BIs delivered face-to-face or over the telephone. They reported that they did not want BIs to incorporate text messaging or social media due to concerns about trust, the quality of information they would receive, and challenges communicating in writing instead of speaking. CONCLUSION: Although the study has limitations because of its small sample size, findings indicate that adolescents may not want text messaging or social media to be incorporated into BIs for substance use. These findings warrant further research and consideration, particularly as work to enhance BIs for adolescents continues.

Real-World Strategies to Engage and Retain Racial-Ethnic Minority Young Men Who Have Sex with Men in HIV Prevention Services.

Racial/ethnic minority young men who have sex with men (YMSM)-particularly African Americans and Hispanics/Latinos-are at particularly high risk for HIV infection. Devising strategies to improve engagement and retention in HIV prevention services among minority YMSM is critical if the United States is going to achieve the National HIV/AIDS Strategy goal of reducing HIV health-related disparities. This article presents findings from a national summit on racial/ethnic YMSM services convened by the Substance Abuse and Mental Health Services Administration-funded Center of Excellence on Racial and Ethnic Minority Young Men Who Have Sex with Men and Other Lesbian, Gay, Bisexual, and Transgender Populations (YMSM + LGBT CoE) in September 2015. The summit included (1) subgroup discussions focused on issues related to treatment access, outreach/engagement/retention, continuing care/recovery support, and health literacy for minority YMSM; and (2) a ranking process, where the NIATx Nominal Group Technique was used to identify the strategies and approaches that summit participants believed to be most promising for engaging and retaining minority YMSM in HIV prevention services. Analyses of results from summit activities highlight four key cross-cutting strategies-utilizing peers, providing holistic care, making services fun, and utilizing technology-as critical for engaging minority YMSM in HIV prevention care. Examples of programs that utilize these strategies and implications of these findings for policy and practice are discussed.

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.