Impact on Health Care Utilization and Costs of a Medicaid Community Health Worker Program in Detroit, 2018-2020: A Randomized Program Evaluation.

Objectives. To compare health care utilization and costs between beneficiaries randomly assigned to usual services versus a community health worker (CHW) program implemented by 3 Medicaid health plans. Methods. From February 2018 to June 2019, beneficiaries residing in Detroit, Michigan's Cody Rouge neighborhood with more than 3 emergency department (ED) visits or at least 1 ambulatory care‒sensitive hospitalization in the previous 12 months were randomized. CHWs reached out to eligible beneficiaries to assess their needs and link them to services. We compared ED and ambulatory care visits, hospitalizations, and related costs over 12 months. Results. In intention-to-treat analyses among 2457 beneficiaries, the 1389 randomized to the CHW program had lower adjusted ratios of ED visits (adjusted rate ratio [ARR] = 0.96; P < .01) and ED visit costs (ARR = 0.96; P < .01), but higher adjusted ratios of ambulatory care costs (ARR = 1.15; P < .01) and no differences in inpatient or total costs compared with the usual-care group. Conclusions. Initial increases in ambulatory care use from effective programs for underserved communities may mitigate savings from decreased acute care use. Longer-term outcomes should be followed to assess potential cost savings from improved health. Trial Registration: ClinicalTrials.gov identifier: NCT03924713. (Am J Public Health. 2022;112(5):766-775. https://doi.org/10.2105/AJPH.2021.306700).

Barriers and Facilitators to Community Health Worker Outreach and Engagement in Detroit, Michigan: A Qualitative Study.

An effective approach to engaging populations who face health care access barriers is support from community health workers (CHWs). There is little research, however, on specific barriers and facilitators related to two key areas of CHW practice: outreach, defined as the ability to make any initial contact with the priority population, and engagement, defined as the ability to continue to work with the priority population after initial contact is made. The current qualitative study is ancillary to a randomized evaluation of a CHW-led program for Medicaid Health Plan enrollees. Implementation experiences with outreach and engagement led the evaluators to develop the current study in which health plan and nonhealth plan CHWs (n = 12) serving low-income, predominantly Black populations in Detroit participated in qualitative semistructured interviews to elucidate barriers and facilitators to outreach and engagement. All audio recordings were transcribed verbatim. The study team used inductive qualitative data analysis techniques. Barriers to outreach included inaccurate contact information and mistrust. Barriers to engagement included lack of ability to provide needed resources, leading to hopelessness and diminished trust, and discontinuity of services due to eligibility changes and terminated programs. Facilitators included adapting outreach schedules and strategies to community needs, availability of resources, and relational strategies that leveraged CHW social proximity. Further research should systematically investigate the relative success of different CHW-led outreach and engagement strategies for specific populations so as to better design and implement CHW programs.

Reflections on Integrating a Therapist-guided CBT Website Into Routine Clinical Practice.

Psychotherapy remains a scarce resource for patients, as problems such as provider shortages result in waitlists and lack of timely access. In their academic medical center outpatient clinic, the coauthors piloted use of a therapist-guided CBT website, Good Days Ahead, in routine clinical practice. They reflect on the benefits and challenges of this approach in this guest column.

Longitudinal association of therapeutic alliance and clinical outcomes in supported housing for chronically homeless adults.

General psychotherapy research has underscored the importance of the therapeutic alliance in client outcomes. This study examined the association between therapeutic alliance and client outcomes specifically between chronically homeless clients in a supported housing program and their case managers. Using data from a federal supported housing initiative, participants were categorized into those who rated their therapeutic alliance with case managers at 3 months as relatively high (top 75th percentile; n = 123), relatively low (bottom 25th percentile; n = 128), or did not identify any primary mental health provider at 3 months (n = 205). Controlling for baseline differences, there were no group differences on any outcomes, except that participants who rated high therapeutic alliance at 3 months reported the highest subjective quality of life and perceived social support. Client outcomes in supported housing may rely more on practical assistance and access to other services than the quality of the therapeutic relationship with their primary mental health provider.

Oral Health Recovery: A Peer Support Specialist-Led Health Education Program for People With Serious Mental Illness.

Oral health affects whole health and quality of life. This is especially true for people with serious mental illness, a population with heightened risks for oral disease and needs for oral treatment. Studies have previously shown the effectiveness of peer support specialist (PSS)-led wellness interventions. Oral health educational materials and a health education approach were collaboratively developed by a multidisciplinary team and then implemented at one community mental health center and three PSS-run drop-in centers. PSSs provided health education and linked consumers to dental care. Program evaluation (N=41 respondents) indicated the approach's acceptability, feasibility, and sustainability.

Implementing a State-Funded Peer-Run Mental Health Warmline During the COVID-19 Pandemic.

The advent of COVID-19 was associated with an upsurge of "warmlines," or telephone lines staffed by non-clinicians that provide non-crisis mental health support. This paper describes a state-funded warmline initiative that was part of a public health approach to mitigating the harms of COVID-19 among people living with mental illness.

Patients' recovery and non-recovery narratives after intravenous ketamine for treatment-resistant depression.

BACKGROUND: Intravenous (IV) ketamine is an effective therapy for treatment-resistant depression. A large data base is confirmatory and steadily expanding. Qualitative studies can inform best practices and suggest new research directions. As part of a clinical trial designed to identify biomarkers of ketamine response, a qualitative study was conducted to characterize experiences with: receiving infusions; recovering or not recovering from depression; and beliefs about why ketamine worked or did not work. METHODS: Adults with treatment-resistant depression received three IV ketamine infusions in a two-week period and were characterized as remitters or non-remitters via symptom reduction 24 h after the third infusion. Qualitative interviews of a subset of participants were audio recorded, transcribed verbatim, and coded using deductive and inductive methods. Themes were derived and compared across a broader construct of recovery status. RESULTS: Of the 21 participants, nine (43 %) were characterized as having experienced remission and 12 (57 %) non-remission. Of the 12 non-remitters, five were characterized as having experienced partial recovery based on their subjective experiences, reporting substantial benefit from ketamine infusions despite non-remission status based on scale measurements. Attributions for ketamine's effects included biological and experiential mechanisms. Among non-remitters there was risk of disappointment when adding another failed treatment. LIMITATIONS: A more diverse sample may have yielded different themes. Different patients had different amounts of time elapsed between ketamine infusions and qualitative interview. CONCLUSIONS: Qualitative methods may enhance researchers' characterization of IV ketamine's impact on treatment-resistant depression. While requiring confirmation, patients may benefit from a preparatory milieu that prepares them for multiple recovery pathways; decouples the psychedelic experience from clinical outcomes; and addresses potential risks of another failed treatment.

Integrating oral health into community health worker and peer provider certifications in Michigan: A community action report.

INTRODUCTION: A multi-disciplinary, community-university-government collaboration resulted in the development of Oral Health for Community Workers, a brief, oral health online e-learning module. The e-learning module was designed to improve oral health literacy among frontline health workers who are members of underserved communities, and to address oral health disparities in safety net medical and behavioral health settings. METHODS: Community-based participatory methods were used to design and evaluate the e-learning module. Participants took pre-, post-, and 3-month follow-up surveys. RESULTS: Oral health literacy and confidence in incorporating oral health into practice improved. Satisfaction with the module was high. DISCUSSION: Oral Health for Community Workers is now sustained as a standard module within Community Health Worker, Peer Support Specialist, and Peer Recovery Coach Certification and continuing education offerings in Michigan.

Characterizing suicide-related self-disclosure by peer specialists: a qualitative analysis of audio-recorded sessions.

Objective: We characterized peer support specialists' self-disclosures related to suicide and recipient responses to inform services for high-risk individuals that may include peer support. Method: We used an inductive approach and thematic analysis to identify themes from audio recordings of initial sessions between peer support specialists trained in suicide-related self-disclosure and 10 study participants who were admitted to inpatient psychiatry units with suicidal ideation or a suicide attempt. Results: The first theme, "I've been suicidal, but those details are not important", reflects that peers mentioned suicide-related aspects of their histories briefly, often as part of introductions, without participants responding specifically to those aspects. The second theme, "Being suicidal is one of the challenges I've faced", reflects that in more detailed disclosures by peer specialists and in participant responses, suicide is a part of the mental health challenges and life stressors discussed, not the focus. The third theme "Let's focus on my recovery and what I've learned" reflects that peers steered their self-disclosures away from suicide and towards what was helpful in their recovery. Conclusions: Suicide-related self-disclosures embedded within peer specialists' introduction or overall recovery narrative convey a shared experience while focusing conversation on mental health challenges other than suicide.

Acceptability and Feasibility of Peer Specialist-Delivered Virtual Reality Job Interview Training for Individuals with Serious Mental Illness: A Qualitative Study.

This study explored peer specialists' perspectives on delivering vocational interventions, especially Virtual Reality Job Interview Training (VR-JIT). Five focus groups of peer specialists (N = 34) explored their beliefs about vocational services, including VR-JIT. We trained eight peer specialists to be VR-JIT "instructors" and interviewed them about using VR-JIT in their mental health practice. Generally, participants discussed tailoring their vocational services to include sharing their story of recovery. Specifically, participants perceived VR-JIT as acceptable and feasibly implemented within their practice. Overall, participants viewed VR-JIT as a higher level of service and they would be uniquely qualified to support consumers using the tool.

Peer mentorship to reduce suicide attempts among high-risk adults (PREVAIL): Rationale and design of a randomized controlled effectiveness-implementation trial.

RATIONALE: Novel approaches to suicide prevention are needed to address increasing rates of suicide deaths. Research suggests that interventions led by certified Peer Specialists may improve suicide protective factors such as hope and connectedness; however, the effectiveness of a Peer Specialist intervention for reducing suicidal thoughts or behaviors has not previously been tested empirically. DESIGN: We describe the methodology of a randomized controlled hybrid effectiveness-implementation trial of a peer specialist intervention known as PREVAIL (Peers for Valued Living). The primary effectiveness aim is to determine whether the 3-month peer mentorship intervention compared to a minimally enhanced usual care condition reduces suicide attempts and suicidal ideation among adults at high risk for suicide who have been psychiatrically hospitalized. Secondary effectiveness outcomes include medically serious suicide attempts according to chart review and self-reported self-efficacy to avoid suicide. We also describe suicide risk management, supervision, and fidelity monitoring in the context of Peer Specialist providers and our methods for assessing implementation barriers and facilitators. CONCLUSION: The PREVAIL trial will demonstrate novel methods for incorporating peer providers into a suicide prevention effectiveness trial with high-risk study participants. PREVAIL's hybrid effectiveness-implementation design aims to maximize the likelihood of rapid implementation in the community if shown to be effective.

Study protocol for a Community Health Worker (CHW)-led comprehensive neighborhood-focused program for medicaid enrollees in detroit.

Residents of low income neighborhoods disproportionately experience poor health, and many have unmet social needs. Clinical trials have shown the efficacy of Community Health Worker (CHW) programs in improving outcomes for a variety of health conditions. An important next step is developing and evaluating financially sustainable CHW program models in real-life settings. This program evaluation examines health care utilization among participants in a geographically targeted program led by salaried CHWs from three Medicaid health plans. Beneficiaries who reside in the Cody Rouge neighborhood of Detroit and had more than 3 Emergency Department (ED) visits or at least 1 ambulatory care-sensitive hospitalization in the prior 12 months are eligible for the program. Health plan CHWs assigned to the program reach out to eligible beneficiaries to provide an assessment; link them to resources; and provide follow-up. At 12-month follow up, claims data on ED visits, ambulatory care-sensitive hospitalizations, primary care visits, and related costs will be compared between beneficiaries who participated and eligible beneficiaries randomized to receive usual outreach. We hypothesize that patients enrolled in the CHW intervention will experience a reduction in acute care usage resulting in cost savings compared to those receiving usual health plan outreach. This study is among the first to evaluate the impact on health care utilization of augmented services delivered by health plan CHWs for high-utilizing health plan members as part of a health plan-community-academic partnership. This study will provide important information on CHW program sustainability and provide insights into effective implementation of such programs. TRIAL REGISTRATION: NCT03924713.

Mental Health Interventions with Community Health Workers in the United States: A Systematic Review.

Mental health conditions are common in the United States, yet the mental health workforce is limited in its capacity to reach disadvantaged populations. While a number of recent reviews demonstrate that community health worker (CHW)-supported physical health interventions are effective, and increase access to services, there are no recent reviews that systematically assess CHW-supported mental health interventions. To address this gap, the authors conducted a systematic review of mental health interventions with CHWs in the United States, and assessed the methodological rigor of such studies. Nine studies met review criteria. Though most of the studies reviewed showed inadequate methodological rigor, findings suggest CHW-supported mental health interventions show promise, particularly given evidence of feasibility and acceptability with underserved populations. The authors describe the rationale for mental health CHWs in the workforce, offer recommendations to strengthen the evidence base, and discuss implications of mental health interventions with CHWs for underserved populations.

Survey of Peer Support Specialists: Professional Activities, Self-Rated Skills, Job Satisfaction, and Financial Well-being.

As the certified peer support specialist (CPSS) workforce matures, their roles evolve, leading to gaps in knowledge about their activities. This study aimed to address these gaps through a survey on CPSS activities, self-rated skills, job satisfaction, and financial well-being. The project team recruited a community advisory board of CPSSs to lead survey development. A survey link was e-mailed to all known CPSSs in the state of Michigan (N=1,128), yielding 394 respondents (35% response rate), of whom 319 were included in the analysis. The highest skill self-ratings included sharing recovery stories (rated very strong by 80%); the lowest included vocational support (rated very strong by 33%). More than 75% were satisfied with their workplace supportiveness; less than one-half were satisfied with their promotion opportunities. When asked if they could generate adequate funds to address a common financial shock, 115 of 301 respondents (38%) were "certain" they could not, suggesting financial vulnerability. These results support developing career ladder opportunities for CPSSs.

An Interprofessional Approach to Exploring the Social Determinants of Health with Dental Hygiene Students.

The University of Michigan (U-M) Dental Hygiene Program collaborated with the U-M School of Social Work in developing a course entitled "Skills for Patient- and Family-Centered Care with Diverse Populations." Drawing upon disciplines including dentistry, social work, psychology, and sociology, this course transformed mandatory outreach rotations in safety-net dental settings from a freestanding senior-year experience to an integrated part of the dental hygiene curriculum. The course provided a space in which to discuss the interpersonal aspects of patient care, particularly those related to the social determinants of health. Among the students, a broad range of emotions, frustrations, and hopes were evident, suggesting that there is a need for forums through which students can connect their affective experiences to their practice of patient-centered care. While the course was designed for bachelor's level dental hygiene students, the content and process presented in this paper may be of interest to faculty housed within any allied health professional program, because core themes such as social justice, service-learning, and self-reflection transcend all health professions.

Toward a better understanding of dental appointment-keeping behavior.

OBJECTIVE: Broken appointments cause adverse outcomes in healthcare systems: They interrupt continuity of care, waste resources, affect workflow, and reduce population-wide access to care. A better understanding of dental appointment-keeping behavior would support efforts toward designing novel interventions aimed at reducing rates of broken appointments. METHODS: The authors conducted a conceptual review of quantitative and qualitative research on dental appointment-keeping in the United States. RESULTS: Research in this area is limited. Providers tend to use a blunt instrument to improve appointment-keeping: a system of reminder calls. There is evidence that patients with higher rates of broken dental appointments are the very ones who are most in need of care. Appointment-keeping barriers are multifactorial and related to social issues. They can be described as falling into three overlapping categories: psychological barriers, structural barriers, and health literacy barriers. CONCLUSIONS: Appointment-keeping interventions could simultaneously address social factors that exacerbate illness and improve workflow and finances. There arises an opportunity to design innovative patient-centered interventions tailored to particular barriers.

Is a mid-level dental provider model acceptable to potential patients?

OBJECTIVE: This study aims to assess patient attitudes toward mid-level dental providers, known as dental therapists (DTs), by surveying those likely to be their patients. The recent adoption of accreditation standards by the Commission on Dental Accreditation has reignited a debate surrounding the state-by-state legalization of DTs in the United States; while the dental profession is divided on DTs, it is important to understand how potential patients may view the DT model. METHODS: A questionnaire that asks about oral health experience, and comfort with the model of a dually trained dental therapist-hygienist, based on a provided definition, was administered to 600 patients and their waiting room companions at a large urban university-based dental clinic. RESULTS: Forty percent of respondents indicated they would be comfortable being treated by a DT for all 7 of the procedures referenced, and over 75% were comfortable with each of 5 procedures. Having caps or crowns placed was the only treatment about which respondents were evenly divided. Factors associated with greater odds of comfort with various procedures include being uninsured and being under the age of 65. Uninsured patients were 1.5 to 2 times more likely than privately insured patients to accept a DT. CONCLUSIONS: The introduction of mid-level dental providers is a strategy that those lacking regular care appear on the whole to be comfortable with.