Adopting a Novel Approach to Prevent and Address Patient Mistreatment of Staff in a Community Mental Health Center.

Verbal mistreatment of staff by patients is common in health care settings. Experiencing or witnessing mistreatment can have harmful psychological impacts, affecting well-being and clinical practice. As part of an effort to become an antiracist organization, an academic community mental health center based in Connecticut developed an initiative to address verbal mistreatment. Training in the Expect, Recognize, Address, Support, Establish (ERASE) framework was provided to 140 staff members. This training and subsequent actions to enhance the culture of safety were perceived as helpful by staff. Further development of the initiative is proceeding as the center's primary performance improvement program.

Implementing the Street Psychiatry Model in New Haven, CT: Community-Based Care for People Experiencing Unsheltered Homelessness.

"Street psychiatry" is an innovative model that serves people experiencing unsheltered homelessness, a vulnerable population with increased rates of mental illness and substance use disorders. Through community-based delivery of mental health and addiction treatment, street psychiatry helps the street-dwelling population overcome barriers to accessing care through traditional routes. Throughout the United States, street psychiatry programs have arisen in multiple cities, often in partnership with street medicine programs. We discuss the philosophy of street psychiatry, document operational highlights involved in the development of a street psychiatry program in New Haven, CT, suggest key ingredients to implementing a street psychiatry program, and explore challenges and future frontiers. Street psychiatry is an effective person-centered model of service delivery with the potential to be applied in a variety of urban settings to serve people experiencing street homelessness.

Establishing an Integrated Health Care Clinic in a Community Mental Health Center: Lessons Learned.

Integrating primary care with behavioral health services at community mental health centers is one response to the disparity in mortality and morbidity experienced by adults with serious mental illnesses and co-occurring substance use disorders. Many integration models have been developed in response to the Primary and Behavioral Health Care Integration (PBHCI) initiative of the Substance Abuse and Mental Health Services Administration (SAMHSA). One model is a primary care clinic co-located within the mental health center. The Connecticut Mental Health Center (CMHC) Wellness Center is one such co-located clinic developed as a partnership between CMHC and a Federally Qualified Health Center (FQHC). In this article, we describe the process of developing this on-site clinic along with lessons learned during implementation. We review different aspects of building and maintaining such a clinic and outline lessons learned from both successes and challenges. We briefly describe the demographics and health characteristics of the patient population served in this clinic. We make recommendations for providers and agencies that are considering or are already developing a model for integrating care. Finally, we briefly review status of our clinic after completion of grant funding.

The Connecticut Mental Health Center: Celebrating 50 Years of a Successful Partnership Between the State and Yale University.

September 28, 2016, marked the 50th anniversary of the Connecticut Mental Health Center, a state-owned and state-operated joint venture between the state and Yale University built and sustained with federal, state, and university funds. Collaboration across these entities has produced a wide array of clinical, educational, and research initiatives, a few of which are described in this column. The missions of clinical care, research, and education remain the foundation for an organization that serves 5,000 individuals each year who are poor and who experience serious mental illnesses and substance use disorders.

Barriers and Facilitators of Healthcare for People with Mental Illness: Why Integrated Patient Centered Healthcare Is Necessary.

Understanding barriers and facilitators of healthcare for people with mental illness is essential for healthcare and mental healthcare organizations moving towards patient centered care. This paper presents findings of a measure on barriers and facilitators of healthcare completed by 204 patients being served at a co-located wellness center (primary healthcare clinic) located in an urban mental health center. The top 10 results show important findings for planning healthcare services that are responsive to the needs of people with mental illness. Basic structural issues as a result of poverty are extremely important (transportation, housing, payment) as well as difficulty with public healthcare that often involves long wait-times for appointments and at the doctor's office and hours that might not be convenient. Healthcare services that want to meet the needs of people with mental illness need to address these issues. What facilitates healthcare is not just removing the barriers to receiving healthcare services but instead involves more interpersonal aspects of healthcare such as liking your provider, being able to talk with your provider, feeling your provider cares about you and listens to you. Structural supports such as also being in mental health services, having systems for remembering appointments, and/or having appointment times that are convenient also facilitate seeking healthcare. Facilitating healthcare seeking also seems to involve a sense of agency-looking forward to taking charge of your health and feeling capable of following healthcare provider instructions. Healthcare systems for people with mental illness need to support these facilitators to give care-seekers the support they need. Key points are provided on how organizations and staff can work more effectively in implementing patient centered care.

Employee Health in the Mental Health Workplace: Clinical, Administrative, and Organizational Perspectives.

Issues of mental health and employee health have risen to increasing prominence in recent years. However, there have been few explorations of the clinical and administrative challenges that these issues raise, particularly in settings that are themselves mental health workplaces. In order to identify and understand such challenges, a brief case of acute employee illness in a mental health workplace is described followed by a discussion of salient clinical, administrative, and organizational considerations. The case raises questions about medicolegal responsibilities and relationships between clinicians and patients in mental health settings, illuminates tensions between clinical staff and human resources processes, and draws attention to the need for illness prevention and mental health promotion initiatives in the workplace. Increased awareness of these issues, complications, and potential solutions would benefit clinicians, administrators, and mental health institutions.

Stakeholders' perspectives on community-based participatory research to enhance mental health services.

Historically, consumers of mental health services have not been given meaningful roles in research and change efforts related to the services they use. This is quickly changing as scholars and a growing number of funding bodies now call for greater consumer involvement in mental health services research and improvement. Amidst these calls, community-based participatory research (CBPR) has emerged as an approach which holds unique promise for capitalizing on consumer involvement in mental health services research and change. Yet, there have been few discussions of the value added by this approach above and beyond that of traditional means of inquiry and enhancement in adult mental health services. The purpose of this paper is to add to this discussion an understanding of potential multilevel and multifaceted benefits associated with consumer-involved CBPR. This is accomplished through presenting the first-person accounts of four stakeholder groups who were part of a consumer-involved CBPR project purposed to improve the services of a local community mental health center. We present these accounts with the hope that by illustrating the unique outcomes associated with CBPR, there will be invigorated interest in CBPR as a vehicle for consumer involvement in adult mental health services research and enhancement.

The evolution of public psychiatry fellowships.

OBJECTIVE: The growth of Public Psychiatry Fellowships (PPFs) has reached a new developmental stage, providing a wide array of academic partnerships and educational opportunities in psychiatric leadership and administration. The authors examine the evolution of these programs and illustrate three distinct models. METHODS: Data from yearly surveys and discussions with PPF directors were used to identify key similarities and areas of divergence as the programs have evolved. RESULTS: The first period of program expansion took place 8-10 years ago when new programs were modeled on the Columbia PPF, and key elements of that program and the American Association of Community Psychiatrists (AACP) guidelines were incorporated broadly. Examples of multiple source (Columbia), single source (Yale and UCSF), and grant-funded programs (Alabama and UCSD) are presented. CONCLUSIONS: A review of the current status of PPFs reveals a diversity of structures and strategies for success, which can be attributed to the range of their funding sources. The advantages and potential disadvantages of those models are outlined with respect to the educational experience and opportunities for growth and sustainability.

Public psychiatry fellowships: a developing network of public-academic collaborations.

In response to the expanding public behavioral health care system, a network of 15 public-community psychiatry fellowships has developed over the past six years. The fellowship directors meet yearly to sustain and develop fellowships to recruit and retain psychiatrists in the public sector. This column describes five types of public-academic collaborations on which the fellowships are based. The collaborations focus on structural and fiscal arrangements; recruitment and retention; program evaluation, program research, and policy; primary care integration; and career development. These collaborations serve to train psychiatrists who will play a key role in the rapidly evolving health care system.

Teaching an interdisciplinary approach to the treatment of chronic mental illness: challenges and rewards.

OBJECTIVE: National policy makers and psychiatric educators have established the goals of teaching and promoting interdisciplinary care as high priorities. This article describes the implementation of an interprofessional seminar for which the dual aims were to provide a knowledge base for treating individuals with serious mental illness and to teach how to work collaboratively with other disciplines. METHOD: A seminar, the "Treatment of chronic or recurrent mental illness: recovery, rehabilitation and interdisciplinary collaboration," was developed in an academic community mental health center. Pre- and postseminar surveys were administered in order to test the hypothesis that the seminar would have a positive impact on trainees' attitudes about working with the seriously mentally ill and within an interdisciplinary team. A combination of 5-point Likert scales and open-ended questions were used to gather the data. Paired samples t tests were conducted to test for significant differences between the pre- and postmeasures. RESULTS: The seminar participants included 24 students from psychiatry, nursing, social work, and psychology with a wide range of experience. Complete pre- and postseminar data were obtained from 14 participants. Although participants valued the seminar experience, they reported that the actual interdisciplinary work with the seriously mentally ill was less gratifying than expected. They described several advantages and challenges of care-oriented collaboration and shared learning. CONCLUSION: Bringing together a diverse group of graduate and postgraduate trainees to learn together and to learn about each other's disciplines appeared to be a successful venture, but the authors were not able to detect a positive impact on their actual work life during the course of the year. Further development of strategies to inspire professionals to engage in and promote interdisciplinary care of the seriously mentally ill is needed.

Best practices: surveillance and management of diabetes in a CMHC population.

To improve detection and management of diabetes at a community mental health center, a cross-sectional study of the prevalence and management of type 2 diabetes mellitus was conducted among patients receiving maintenance antipsychotic medication (N=494). Diabetes was more than two-and-a-half times as prevalent among participants (17.4%) as in the general population. Fourteen percent of patients classified as diabetic had previously undiagnosed disease, compared with national sample rates of over 30%. Impaired fasting glucose was found for 26% of the sample. Glucose dysregulation was common. The known poor cardiovascular profile of persons with serious mental illness, reflected in the high rates of tobacco use and obesity in the sample, requires contextualizing efforts to screen and monitor for diabetes within overall efforts to monitor cardiovascular health.

Managing risk: systems approach versus personal responsibility for hospital incidents.

As hospitals grapple with the intense scrutiny of medical errors, administrators may find themselves in the midst of conflicting approaches to improving overall patient safety. One approach to addressing incidents that have been caused by individual practitioners is to consider weaknesses in the system of care at multiple levels that may have enabled an incident to occur. An alternative approach is to hold the individuals responsible for their performance errors and to impose penalties that have specific consequences for those individuals. These two approaches, though not mutually exclusive, can produce conflict among staff.

Teaching psychiatric residents about women and leadership.

OBJECTIVE: The purpose of this project was to develop a seminar on women as leaders within an academic department of psychiatry and to evaluate its effectiveness. METHODS: A seminar was offered as an elective to all residents within the Yale University Department of Psychiatry. Didactic presentations and open discussion were structured around the following topics: 1) exploration of leadership roles in various areas, including research, clinical practice, teaching, and administration; 2) organizational dynamics and gender; 3) negotiation skills and conflict resolution strategies; 4) role of consultation, seminars, peer support and mentoring by both men and women in the development of leadership skills; and 5) "keeping the balance: work, relationships, and personal health." The 13 participants were queried at the completion of the seminar, and a follow-up survey was performed 18 months later. RESULTS: The initial and follow-up evaluations were quite positive, with average ratings in the "excellent" range at both points. The 10 respondents at 18 months were unanimous that there had been a positive and lasting effect on their professional lives. CONCLUSION: A seminar on women as leaders was a successful venture within an academic department of psychiatry. The structure of the course, which incorporated specific teaching materials plus "local" expertise, could serve as a model for such seminars in other programs or could be integrated into an existing course for all residents.

Development of an interdisciplinary women's health training model.

In response to expanded residency training requirements in women's health, faculty from internal medicine, obstetrics/gynecology, and psychiatry at Yale University School of Medicine established an interdisciplinary women's health training and education model, the Interdisciplinary Women's Health Clinic (IWHC). The model was one component of a larger, comprehensive women's health program at Yale funded by the Department of Health and Human Services between 1996 and 2000 under the National Centers of Excellence in Women's Health (CoE) designation. This article describes the structure and function of the model, its value to residents and the institution, and its limitations that led to its closure when Department of Health and Human Services support ended. The IWHC was designed as a consultation service that augmented the primary care provided to low-income, minority-group women in an established outpatient primary care setting. An interdisciplinary team of residents and faculty provided and coordinated a range of services for patients and participated in a weekly core curriculum. The model was an important resource to residents and provided high-level integrated care to patients. The combined educational experience helped refine a core interdisciplinary women's health curriculum. Despite these benefits, the IWHC could not be sustained outside the financial and programmatic structure of the larger CoE program. This experience suggests that longitudinal models where residents from different disciplines train in a shared educational and clinical setting may be more durable. Interdisciplinary models are effective ways to train residents and provide integrated care to women. The model's success depends on highly developed collaborative relationships between faculty, nonclinical sources of support, and long-term institutional commitment.