PERSPECTIVE: A Path to Value-Based Insurance Design for Mental Health Services.

BACKGROUND: Aligning cost of mental health care with expected clinical and functional benefits of that care would incentivize the delivery of high value treatments and services. In turn, ineffective or untested care could still be offered but at costs high enough to offset the delivery of high value care. AIMS: The authors comment on Benson and Fendrick's paper on Value-Based Insurance Design (VBID) for mental health in the September 2023 special issue of this journal. The authors also present a preliminary framework of key ingredients needed to consider VBID for mental health treatments and services. METHODS: The authors briefly review current and past efforts to contain costs and improve quality of mental health care, which include (for example) use of carve-out and carve-in programs, evaluation of cost sharing models, impact of accountable care organizations, and studying other benefit designs and impact of federal and state policies. RESULTS: Using PTSD as an example, key ingredients of VBID for mental health services were identified and include the following: tools for case identification and monitoring progress over time at the population level; specific treatments and services with evidence of clinical effectiveness, cost-effectiveness, and health equity; and an approach to document the specific treatment or service was delivered (versus another treatment or service that may lack evidence). DISCUSSION: The inability to afford mental health care is a top barrier to treatment seeking. People who do elect to spend time and money on mental health care are further disadvantaged by accessing care that is not well regulated and the quality at best is questionable. VBID could be an important lever for increasing access to and use of high value mental health care. Partnerships among the research, practice, and policy communities can help ensure research solutions meet needs of these two communities. IMPLICATIONS FOR HEALTH CARE: VBID holds promise to make high value mental health care more affordable while discouraging low value treatments and services. IMPLICATIONS FOR HEALTH POLICIES: While evidence gaps remain, these gaps can be filled concurrently with pursuit of VBID for mental health services. IMPLICATIONS FOR FUTURE RESEARCH: This paper identifies important research opportunities to help make VBID a reality for mental health care.

PERSPECTIVE: Health Economic Interests at NIMH and NIDA to Improve Delivery of Behavioral Health Services.

BACKGROUND: Effective financing mechanisms are essential to ensuring that people can access and utilize effective treatments and services. Financing mechanisms are needed not only to pay for the delivery of those treatments and services, but also ancillary costs, while also keeping care affordable. AIMS: This article highlights key areas of the interest of the National Institute of Mental Health (NIMH) and the National Institute on Drug Abuse (NIDA) in supporting applied health economics and health care financing research. Specifically, this article discusses the long-range impact of NIH's earlier investments in applied health economics research, and NIH's ongoing efforts to communicate its interests in health economics research. We discuss the 2023 NIMH-NIDA-sponsored health economics conference, and the ideas presented there for developing and assessing innovative behavioral health care financing models; three of the presented papers were recently published in the Journal of Mental Health Policy and Economics. METHODS: We describe the history and impact of NIMH- and NIDA-sponsored economic research and identify current research interests as identified in the NIMH and NIDA Strategic Plans and recent funding announcements. We examine themes presented at the NIMH-NIDA Health Economics conference. The conference included over 300 participants from 20 countries, from six continents. RESULTS: The topics highlighted at the conference highlight the ways in which NIH-funded research has promoted the development of innovative health care financing methods, both from the supply side (e.g., providers and payers) and demand side (e.g., service users and families). Invited speakers discussed the findings from NIH-supported research in the topic areas of payment and financing, behavioral economics and social determinants of health. Keynote speakers highlighted emerging topics in the field, including the economics of health equity, biases in mental health models in health care, and value-based insurance design. DISCUSSION: We demonstrate a resurgence of and explicit interest in health economics and policy research at NIMH and NIDA. However, more work is needed in order to design funding mechanisms that fully provide access to and facilitate use of effective evidence-based practices to improve mental health outcomes. For example, it is important that policy and health economic research projects include decision makers who will be the end users of data and study results, to ensure that results can be meaningfully put into practice. IMPLICATIONS FOR HEALTH CARE: Designing effective and efficient funding mechanisms can help ensure that service users have access to effective treatments and that clinicians and provider organizations are adequately compensated for their work. IMPLICATIONS FOR HEALTH POLICIES: Federal, state, and local policies, as well as policies of payers and health care organizations, can influence the type of care that is supported and incentivized. IMPLICATIONS FOR FURTHER RESEARCH: As demonstrated by the research interests as outlined in their respective Strategic Plans and funding announcements, NIMH and NIDA continue to fund health economic and policy research that aims to improve health care access, quality and outcomes for people with or at risk of developing behavioral health conditions in the US and around the world.

PERSPECTIVE: Economic and Policy Research Interests Highlighted in the 25th NIMH-Sponsored Mental Health Services Research Conference.

BACKGROUND: The National Institute of Mental Health (NIMH) remains committed to addressing real-world challenges with delivering high quality mental health care to people in need by advancing a services research agenda to improve access, continuity, quality, equity, and value of mental healthcare nationwide, and to improve outcomes for people with serious mental illnesses (SMI). The NIMH-Sponsored Mental Health Services Research Conference (MHSR) is a highly productive venue for discussing topics of interest to NIMH audiences and disseminating NIMH's latest research findings directly to mental health clinicians, policy makers, administrators, advocates, consumers, and scientists who attend. AIMS: This Perspective summarizes and provides highlights from the 25th MHSR. It also reviews three papers presented at the 25th MSHR and subsequently published in the June 2023 special issue of The Journal of Mental Health Policy and Economics (JMHPE). METHODS: The authors review three papers published in the June 2023 special issue of JMHPE, identifying common themes across the papers and illustrating how the papers' findings promote key areas of NIMH research interests. RESULTS: Three important areas are highlighted in this review: (i) service user engagement in the research enterprise, (ii) financing the implementation of the 988 Suicide and Crisis Lifeline, and (iii) methods to predict mental health workforce turnover. DISCUSSION: These three papers illustrate key areas in which policy research can help to promote quality mental health care. One notable common theme across the papers is that of the role that end users play in the research enterprise. The papers focus on (i) service users and the value they bring to informing the practice of research, (ii) policy makers and the information they need to make evidence-informed decisions, and (iii) provider organization leadership, by using an innovative machine learning process to help organizations predict and address staff turnover. IMPLICATIONS FOR HEALTH CARE: NIMH encourages and often requires strong research practice partnerships to help ensure findings will be of value to end users and make their way into the practice setting. The three papers reviewed in this perspective are exemplars of how necessary stakeholder partnerships are to improve care for those with mental illness. IMPLICATIONS FOR HEALTH POLICIES: The highlighted papers (i) provide recommendations for structural changes to research institutions to increase service user engagement in all aspects of the research enterprise, (ii) identify policy solutions to improve fiscal readiness to address increased demand of 988, and (iii) pilot a novel data-driven approach to predict mental health workforce turnover, a significant problem in community mental health clinics, offering health system leaders and policy makers an opportunity to proactively intervene to help maintain continuity of staffing. IMPLICATIONS FOR FURTHER RESEARCH: Consistent with NIMH's Strategic Plan for Research and current funding announcements, there remains an urgent need to (i) develop strategies to better implement, scale, and sustain existing evidence-supported treatments and services, particularly in historically underserved communities, and (ii) develop, test, and evaluate new solutions to improve access, continuity, quality, equity, and value of care.ing and clinical outcomes remains uncertain.

Rates of Inpatient and Emergency Room Use Before and After Discharge Among Medicaid Enrollees in OnTrackNY.

OBJECTIVE: This study examined hospital and emergency room (ER) use among Medicaid enrollees before and after discharge from OnTrackNY, a coordinated specialty care program for recent-onset psychosis. METHODS: Medicaid claims data were linked to program data. Inpatient hospitalization, inpatient days, and ER visits were assessed in the 6 months prior to OnTrackNY enrollment and 6 months prior to and after discharge. The sample consisted of 138 participants with continuous Medicaid enrollment during the study. RESULTS: Inpatient visits significantly declined from the pre-OnTrackNY enrollment period to the predischarge period (ß=-1.23, standard error [SE]=0.22, p<0.001), did not significantly change in the first 6 months after discharge (ß=0.19, SE=0.26, p=0.48), and remained significantly lower than before OnTrackNY enrollment (ß=-1.05, SE=0.20, p<0.001). Similar patterns were observed for inpatient days and ER use. CONCLUSIONS: ER and hospital use declined during OnTrackNY participation and did not significantly change in the first 6 months after discharge.

Personnel time required for supported employment and education services for individuals in a recent-onset psychosis treatment program.

AIM: Individual Placement and Support (IPS) improves vocational outcomes in first-episode psychosis patients, but policy makers need information on costs (and personnel time required) to conduct effective IPS. METHODS: Using chart records of 42 clients in a first-episode psychosis study, we examined service time for specific activities over 18 months. RESULTS: The IPS specialist averaged 92 (SD = 62) minutes per client per week: 39% of time was spent in direct client contact, 9% in meetings without the client, 14% in meetings with the treatment team, 14% in supervision and 24% on travel time. Time required was significantly higher when participants were seeking work/school placements, decreased over duration of enrolment and was similar for those using work vs school support. CONCLUSIONS: IPS service time covers numerous activities, is reduced when not seeking work/school placements and required less time over enrolment duration. Financing structures should support the full range of IPS services.

Design of a Payment Decision-Support Tool for Coordinated Specialty Care for Early Psychosis.

A strengthened evidence base and earmarked federal funding have spurred the implementation of coordinated specialty care (CSC) for people experiencing early psychosis. However, existing funding mechanisms are insufficient and unsustainable to support population-wide deployment of CSC. This article describes the design framework of an innovative payment model for CSC that includes a bundled case rate payment and an optional outcome-based payment. To assist CSC payer and provider organizations in designing payment systems tailored to local preferences and circumstances, the research team is developing a decision-support tool that allows users to define design choices and provide input. The authors document the analytical algorithms underlying the tool and discuss how it could be further developed or expanded for CSC and other behavioral health interventions that feature an interdisciplinary team of clinicians and nonclinical professionals, public education and outreach, patient centeredness, and a recovery orientation.

OnTrackNY's learning healthcare system.

Worldwide, early intervention services for young people with recent-onset psychosis have been associated with improvements in outcomes, including reductions in hospitalization, symptoms, and improvements in treatment engagement and work/school participation. States have received federal mental health block grant funding to implement team-based, multi-element, evidence-based early intervention services, now called coordinated specialty care (CSC) in the USA. New York State's CSC program, OnTrackNY, has grown into a 23-site, statewide network, serving over 1800 individuals since its 2013 inception. A state-supported intermediary organization, OnTrackCentral, has overseen the growth of OnTrackNY. OnTrackNY has been committed to quality improvement since its inception. In 2019, OnTrackNY was awarded a regional hub within the National Institute of Mental Health-sponsored Early Psychosis Intervention Network (EPINET). The participation in the national EPINET initiative reframes and expands OnTrackNY's quality improvement activities. The national EPINET initiative aims to develop a learning healthcare system (LHS); OnTrackNY's participation will facilitate the development of infrastructure, including a systematic approach to facilitating stakeholder input and enhancing the data and informatics infrastructure to promote quality improvement. Additionally, this infrastructure will support practice-based research to improve care. The investment of the EPINET network to build regional and national LHSs will accelerate innovations to improve quality of care.

COVID-19, mental health, and opioid use disorder: Old and new public health crises intertwine.

The United States is facing both the coronavirus disease 2019 (COVID-19) pandemic and an ongoing epidemic of opioid overdose. Opioid use disorder is associated with other mental health problems, trauma, and social and health disparities. While the United States has acted to improve access to treatment for mental health and opioid use, research will be needed to understand the effectiveness of new policies in the context of COVID-19. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Building capacity for collaborative research on opioid and other substance use disorders through the Clinical and Translational Science Award Program.

The opioid crisis in the USA requires immediate action through clinical and translational research. Already built network infrastructure through funding by the National Institute on Drug Abuse (NIDA) and National Center for Advancing Translational Sciences (NCATS) provides a major advantage to implement opioid-focused research which together could address this crisis. NIDA supports training grants and clinical trial networks; NCATS funds the Clinical and Translational Science Award (CTSA) Program with over 50 NCATS academic research hubs for regional clinical and translational research. Together, there is unique capacity for clinical research, bioinformatics, data science, community engagement, regulatory science, institutional partnerships, training and career development, and other key translational elements. The CTSA hubs provide unprecedented and timely response to local, regional, and national health crises to address research gaps [Clinical and Translational Science Awards Program, Center for Leading Innovation and Collaboration, Synergy paper request for applications]. This paper describes opportunities for collaborative opioid research at CTSA hubs and NIDA-NCATS opportunities that build capacity for best practices as this crisis evolves. Results of a Landscape Survey (among 63 hubs) are provided with descriptions of best practices and ideas for collaborations, with research conducted by hubs also involved in premier NIDA initiatives. Such collaborations could provide a rapid response to the opioid epidemic while advancing science in multiple disciplinary areas.

Promoting interdisciplinary research to respond to public health crises: The response of the Columbia University CTSA to the opioid crisis.

Effectively addressing public health crises requires dynamic and nimble interdisciplinary collaborations across the translational spectrum, from bench to clinic to community. The Clinical and Translational Science Award (CTSA) Program hubs are uniquely suited to facilitate interdisciplinary collaborations across universities and academic medical centers. This paper describes the activities at the Columbia University CTSA Program hub to address a current public health crisis, the opioid epidemic. Columbia's CTSA Program hub led a three-phase approach, based on the Conceptual Model of Transdisciplinary Scientific Collaboration as described by Stokols et al.: (1) a university-wide planning and brainstorming phase to identify key leaders across many domains who are influential in addressing the opioid epidemic, (2) a campus-wide and community outreach to identify all interested parties, and (3) ongoing targeted support for collaboration development. Preliminary metrics of success are interdisciplinary collaborations and grant funding. We describe recent examples of how interdisciplinary collaboration, academic-community partnership, and pilot funding contributed to the development and funding of innovative interdisciplinary research, including the New York site of the HEALing Communities initiative. The processes are now being used to support interdisciplinary approaches for other translational public health issues.

Supported Education and Employment Services for Young People with Early Psychosis in OnTrackNY.

BACKGROUND: Psychosis onset commonly occurs at ages 16-30 when individuals are typically developing their education, employment and career trajectories. Coordinated specialty care (CSC) programs provide access to team-based early invention services for psychosis, including supported education and employment (SEE) services. AIMS OF STUDY: We examine factors associated with the use of SEE services and whether use of SEE services (for supported education, supported employment, or both) is associated with education and employment participation within New York's CSC program, OnTrackNY. METHODS: Participants (n=779) enrolled in OnTrackNY from October 2013-September 2017. Assessments were collected by clinical staff at admission, quarterly, and at discharge. Logistic regression models were specified to identify factors associated with the probability of use of SEE specialist services during the first year of program participation, using generalized estimating equations with an autoregressive covariance structure to account for within-subject correlations over time. Logistic models were also used to predict whether use of SEE services in the prior quarter predict the probability of work and school participation in the subsequent quarter, respectively; these were analyzed cross-sectionally for each time period. Models controlled for other factors associated with work/school outcomes for young people with early psychosis. RESULTS: Participants who were younger, and who had lower rates of work/school participation had greater odds of SEE service use. Use of SEE services for education support in the first quarter among clients under age 23 is significantly associated with school enrollment in the second quarter and this continued through the first year. Use of SEE services for employment support in the first quarter is significantly associated with employment in the second quarter, but significant associations for employment were not found at later periods of participation. Use of SEE services for both education and employment support was inconsistently associated with subsequent school enrollment or employment in the subsequent quarter. Results were upheld when limiting the sample to those not receiving other SEE services. DISCUSSION: Rates of school and work participation increased over the duration of OnTrackNY participation. Clients with lower work/school participation were more likely to use SEE services. Supported education services are associated with greater school participation during the first year for clients under age 23. However, this association is only significant in the first quarter for supported employment services, and is inconsistent when examining those who used both simultaneously. It is possible that we may find significant associations for employment as the program continues. It is also possible that clients may end supported employment services after obtaining employment, while those in school may require ongoing services (e.g. to renew educational accommodations). Additionally, it is possible that OnTrackNY's supported education model, designed to adhere to Individual Placenment and Support (IPS) principles, may be helping clients stay in school. However, as this is an observational study with no control condition, we cannot say that OnTrackNY, or SEE services participation, caused the observed outcomes. IMPLICATIONS FOR FURTHER RESEARCH: Future research should continue to develop the evidence base for supported education services.

Relationship Between Self-Assessed Fidelity and Self-Reported Employment in the Individual Placement and Support Model of Supported Employment.

OBJECTIVE: A growing body of literature demonstrates that high-fidelity implementation of the individual placement and support (IPS) model of supported employment increases the chances of achieving desired outcomes. This study examined the relationship between IPS fidelity, as self-reported by program sites, and employment outcomes and determined whether this relationship was maintained over time. METHODS: A total of 78 outpatient programs in New York State provided data on self-reported IPS fidelity and employment outcomes. Pearson correlations were used to determine the relationship between fidelity scores and competitive employment rates. A mixed-effects model examined the relationship between repeated fidelity and employment measures over time. RESULTS: A significant positive relationship was found between better self-reported IPS fidelity and greater employment. The relationship between IPS fidelity and employment was sustained over time (up to one year). CONCLUSIONS: Higher-fidelity implementation of the IPS model, as self-assessed by program sites, was associated with higher employment rates, which were sustained over time.

Association of participant preferences on work and school participation after a first episode of psychosis.

AIM: To explore baseline ratings of importance (ROI) across life domains for participants in the Recovery After an Initial Schizophrenia Episode Connection Program (RAISE CP), and investigate whether ratings were correlated with intervention outcomes over time. METHODS: At baseline, 63 participants rated the importance of reducing symptoms, side-effects, confusion, increasing energy and school/work functioning and improving social relations. ROIs were examined in relation to work/school participation (n = 41) and occupational functioning (n = 37) after 12 months. Participants' mean age was 22.3 (±4.2). RESULTS: The ROI domain rated as most important was school/work functioning, and higher school/work ROI at baseline predicted work/school participation after 12 months of participation. CONCLUSIONS: It is particularly important to assess participant preferences and priorities when treating psychotic disorders because most areas of life are affected. Understanding the impact of participant goals on outcomes is essential as programs design patient-centred treatment plans.

Life Is Precious: Views of Adolescents and Their Mothers on Methods to Reduce Suicidal Behavior in Latinas.

Life is Precious (LIP) was developed to help reduce suicidal behavior in Latina adolescents. As part of an external evaluation of the LIP program, we conducted focus groups with adolescent participants and mothers to learn whether participants and families believe that the activities of LIP address risks for suicidal behavior. Four focus groups were conducted: three with Latina adolescent LIP participants ( n = 31) and one with mothers ( n = 8). Transcripts were analyzed using ATLAS.ti. A grounded theory approach was used to identify themes and subthemes. The following themes emerged: (1) challenges contributing to suicidal behavior and self-harm among Latina adolescents, (2) how respondents believe that LIP is helping to reduce suicidal behavior, and 3) ongoing challenges. Participants say that the LIP program helps adolescents feel better and improve social relationships, academic performance, and relationships with their family. School nurses may wish to identify community-based programs offering similar services.

Characteristics associated with the pursuit of work and school among participants in a treatment program for first episode of psychosis.

OBJECTIVE: In this study, we examined the pursuit of education and employment among participants in the Recovery After an Initial Schizophrenia Episode (RAISE) Connection Program (Dixon et al., 2015; Essock et al., 2015), a first-episode psychosis (FEP) treatment program emphasizing participation in school and work. METHOD: Data were collected between 2011 and 2013 from all 65 individuals in the RAISE Connection Program. Descriptive statistics, analysis of variance, and multinomial logit random-effects models were used to examine rates and predictors of work/school participation. RESULTS: Most participants who eventually engaged in vocational activities did so within the first year of participation. Many engaged in both school and work. Those working (alone or with school) had better premorbid functioning and cognition and less severe concurrent symptoms. CONCLUSION AND IMPLICATIONS FOR PRACTICE: Participants in FEP programs emphasizing school and work can have high rates of vocational participation and early engagement, often simultaneously in work and school. (PsycINFO Database Record

Is There a Role for Fidelity Self-Assessment in the Individual Placement and Support Model of Supported Employment?

OBJECTIVE: Fidelity assessments help ensure that evidence-based practices are implemented properly. Although assessments are typically conducted by independent raters, some programs have implemented self-assessments because of resource constraints. Self-assessments were compared with independent assessments of programs implementing individual placement and support supported employment. METHODS: Eleven community-based outpatient programs in New York State completed both self- and independent assessments. Intraclass correlation coefficients and paired t tests were used to compare scores from self- and independent assessments. RESULTS: For both assessment methods, mean scores for all programs were within the range of fair fidelity. Self- and independent assessment total scores were not significantly different; however, significant differences were found on some scale items in this small sample. CONCLUSIONS: Self-assessment may be valid for examining a program's overall functioning and useful when resource constraints prevent independent assessment. Independent assessors may be able to identify nuances, particularly on individual assessment items, that can point to areas for program improvement.

Factors Associated With Outpatient Visit Attendance After Discharge From Inpatient Psychiatric Units in a New York City Hospital.

OBJECTIVE: A class action lawsuit in New York (Koskinas v. Cuomo) established the right of psychiatric inpatients to receive discharge planning, including arranging outpatient treatment. The attendance rate of the initial outpatient appointment after discharge from inpatient treatment in one city hospital was examined to determine whether rates varied by inpatient unit type. METHODS: The authors performed retrospective chart review of 1,884 discharges to outpatient care. Multivariate regression models were used to examine the odds of attending the initial appointment. RESULTS: Eighty-four percent of patients attended the initial appointment. Higher odds of attendance were associated with case management, living in a shelter or being homeless, general medical comorbidity, and inpatient treatment in a co-occurring disorders unit. Lower odds were associated with being non-Latino black. Inpatient treatment in a Latino unit had no significant effect. CONCLUSIONS: Hospital characteristics, patient population, and availability of local outpatient services may influence continuity of care.

Life is Precious: A Community-Based Program to Reduce Suicidal Behavior in Latina Adolescents.

Latina adolescents have high rates of suicidal behavior. Life is Precious (LIP), a community-based program in New York City, helps adolescents and families address risk factors facing Latinas. Participants are assessed for suicidal ideation, depressive and other psychiatric symptoms, and family functioning, at program entry and every 4 months during participation. Demographic characteristics and suicide attempts are also tracked. In the study period, there were no attempted or completed suicides in this high-risk population. Suicidal ideation, depressive symptoms, anger, and posttraumatic stress symptoms decreased significantly during participation. The LIP model shows promise for helping to address suicidal risk factors facing Latinas. However, in the absence of a comparison group, participants' improvement may be due to their engagement in mental health treatment more generally, or to the passage of time, rather than specifically to LIP. Nevertheless, as very little is known about how to address risk factors unique to Latina adolescents, these early findings may be of interest to the community serving Latina adolescents and the lessons may be of interest to programs serving adolescents from other racial/ethnic groups. Future research should develop comparison groups and test LIP implementation in other settings.

Comparing the impact on Latinos of a depression brochure and an entertainment-education depression fotonovela.

OBJECTIVE: The purpose was to evaluate the impact of a depression fotonovela in increasing knowledge of depression symptoms and treatments and reducing stigma among Latinos. METHODS: Data were from a randomized controlled trial in which Latinos from adult schools (N=132) were assigned to receive the fotonovela or a depression brochure and were assessed on knowledge and stigma measures before and after reading the material and one month later. Random-effects linear and logistic regression models assessed changes within and between groups. RESULTS: No significant differences were found between groups in symptom knowledge, social distance, and perceptions of dangerousness. Gains in depression treatment knowledge were significantly greater for the fotonovela than for the depression brochure group. CONCLUSIONS: Findings suggest that a depression fotonovela informed by an entertainment-education approach is a useful tool for improving depression treatment knowledge among Latinos but is limited in improving symptom knowledge and reducing stigma related to social distance and perceptions of dangerousness.