Exploratory analysis on payment mechanisms to Community Mental Health Centers in Chile using mixed grounded theory. / Análisis exploratorio sobre los mecanismos de pago a centros de salud mental comunitaria en Chile usando teoría fundamentada mixta.

Introduction: Research on psychiatric deinstitutionalization has neglected that reforms in this field are nested in a health system that has undergone financial reforms. This subordination could introduce incentives that are misaligned with new mental health policies. According to Chile's National Mental Health Plan, this would be the case in the Community Mental Health Centers (CMHC). The goal is to understand how the CMHCpayment mechanism is a potential incentive for community mental health. Methods: A mixed quantitative-qualitative convergent study using grounded theory. We collected administrative production data between 2010 and 2020. Following the payment mechanism theory, we interviewed 25 payers, providers, and user experts. We integrated the results through selective coding. This article presents the relevant results of mixed selective integration. Results: Seven payment mechanisms implemented heterogeneously in the country's CMHC are recognized. They respond to three schemes subject to rate limits and prospective public budget. They differ in the payment unit. They are associated with implementing the community mental health model negatively affecting users, the services provided, the human resources available, and the governance adopted. Governance, management, and payment unit conditions favoring the community mental health model are identified. Conclusions: A disjointed set of heterogeneously implemented payment schemes negatively affects the community mental health model. Formulating an explicit financing policy for mental health that is complementary to existing policies is necessary and possible.

Introducción: La investigación sobre desinstitucionalización psiquiátrica ha descuidado el hecho que las reformas en este campo se anidan en un sistema de salud que se ha sometido a reformas financieras. Esta subordinación podría introducir incentivos desalineados con las nuevas políticas de salud mental. Según el Plan Nacional de Salud Mental de Chile, este sería el caso en los centros de salud mental comunitaria. El objetivo es comprender cómo el mecanismo de pago al centro de salud mental comunitaria es un potencial incentivo para la salud mental comunitaria. Métodos: Este es un estudio mixto cuantitativo-cualitativo convergente, que utiliza la teoría fundamentada. Recolectamos datos administrativos de producción entre 2010 y 2020. Siguiendo la teoría de mecanismo de pago, entrevistamos a 25 expertos de los ámbitos pagador, proveedor y usuario. Integramos los resultados a través de la codificación selectiva. Este artículo presenta los resultados relevantes de la integración selectiva mixta. Resultados: Reconocimos siete mecanismos de pago implementados heterogéneamente en los centros de salud mental comunitaria del país. Estos, responden a tres esquemas supeditados a límites de tarifa y presupuesto público prospectivo. Se diferencian en la unidad de pago. Se asocian con la implementación del modelo de salud mental comunitaria afectando negativamente a los usuarios, los servicios provistos, los recursos humanos disponibles, la gobernanza adoptada. Identificamos condiciones de gobernanza, gestión y unidad de pago que favorecerían el modelo de salud mental comunitaria. Conclusiones: Un conjunto desarticulado de esquemas de pago implementados heterogéneamente, tiene efectos negativos para el modelo de salud mental comunitaria. Es necesario y posible formular una política de financiación explícita para la salud mental complementaria a las políticas existentes.

Improving interprofessional teamwork in a community mental health team: a team building circle program based on the restorative justice paradigm.

Improving teamwork among mental health practitioners is crucial. However, there have been few intervention studies on teamwork enhancement among community mental health practitioners in South Korea. We aimed to determine the effectiveness of the Team Building Circle program (TBC) based on the restorative justice paradigm, which sought to promote integration and cohesion. The TBC was developed to improve conflict interpretation mind-set, interpersonal skills, and teamwork among practitioners in community mental health centers. We conducted a quasi-experimental study using a pre and posttest design with a non-equivalent control group. The participants were 44 practitioners from four community mental health centers. Data were collected before the implementation TBC (pretest), just after (posttest), and 3 months after TBC (follow-up test). A generalized estimating equation model was used for analysis. Our findings indicate that the intervention group had improved scores in the ability to cope with interpersonal stress in a constructive way, interpersonal relationship skills, and teamwork compared to the control group. To improve teamwork among community mental health practitioners, managers are encouraged to consider providing TBC intervention.

Integrating primary care into a community mental health center.

Our initiation of a reverse-integration practice model revealed numerous advantages and rewards, as well as many challenges, for which we found solutions.

The well-being and perspectives of community-based behavioral health staff during the COVID-19 pandemic.

With high levels of burnout, turnover, and secondary traumatic stress, the well-being of the behavioral health workforce was an area of concern prior to the coronavirus disease 2019 (COVID-19) pandemic. How the COVID-19 crisis has impacted social workers, psychologists, psychiatrists, and other behavioral health professionals is unclear but should be examined. A brief survey evaluated the impact of the pandemic on the well-being of 168 behavioral health clinical and administrative staff serving in an urban behavioral health center in the United States. Staff experienced several personal and organizational-related challenges related to work-life balance, emotional distress, and organizational communication. Nevertheless, staff found an abundance of positive experiences when engaging with clients. Supportive, positive feedback and statements of appreciation from clients, colleagues, and supervisors helped staff to feel at their best. The well-being of behavioral health staff may be facilitated by consistent and supportive communication at the team, supervisory, and organizational levels and by involving staff in planning agency policy.

The case for prescribing PrEP in community mental health settings.

Pre-exposure prophylaxis (PrEP) is a biomedical HIV prevention modality that is up to 99% effective in preventing HIV acquisition through sex if taken as directed. People with serious mental illness (eg, schizophrenia and bipolar disorder) are at high risk of acquiring HIV due to sexual behaviours, injection drug use, social factors, and structural discrimination that limits access to all types of preventive health services. We seek to show the importance of prioritising access to PrEP for people living with serious mental illness treated in community mental health settings. We describe barriers to prescribing PrEP, including provider attitudes and provider knowledge gaps, patient attitudes and knowledge, and systems issues. We also address the concerns that community mental health clinic administrators might have about taking on the responsibility of offering PrEP. In summary, despite the barriers to prescribing PrEP in these settings, we believe that there is a unique opportunity for community mental health settings to help address the HIV epidemic by facilitating the prescribing of PrEP to the at-risk populations they currently serve.

Implementing COVID-19 Mitigation in the Community Mental Health Setting: March 2020 and Lessons Learned.

In March 2020, at the beginning of the COVID-19 pandemic, state-funded community mental health service programs (CMHSP) in Michigan, organized into 10 regions known as a "Prepaid Inpatient Health Plan" (PIHP), grappled with the task of developing a modified plan of operations, while complying with mitigation and social distancing guidelines. With the premise that psychiatric care is essential healthcare, a panel of physician and non-physician leaders representing Region 5, met and developed recommendations, and feedback iteratively, using an adaptive modified Delphi methodology. This facilitated the development of a service and patient prioritization document to triage and to deliver behavioral health services in 21 counties which comprised Region 5 PIHP. Our procedures were organized around the principles of mitigation and contingency management, like physical health service delivery paradigms. The purpose of this manuscript is to share region 5 PIHP's response; a process which has allowed continuity of care during these unprecedented times.

Adaptations and Innovations to Minimize Service Disruption for Patients with Severe Mental Illness during COVID-19: Perspectives and Reflections from an Assertive Community Psychiatry Program.

Changes to community psychiatry during COVID-19 are unprecedented and without clear guidelines. Minimizing disruption, ensuring quality care to the already vulnerable people with serious mental illness is crucial. We describe and reflect our adaptations and innovations at one community psychiatry program, based on three key principles. In (i) Defining and maintaining essential services while limiting risk of contagion, we discuss such strategies and ways to assess risks, implement infection control, and other creative solutions. In (ii) Promoting health and mitigating physical and mental health impacts, we reflect on prioritizing vulnerable patients, dealing with loss of community resources, adapting group programs, and providing psychoeducation, among others. In (iii) Promoting staff resilience and wellness, we describe building on strength of the staff early, addressing staff morale and avoiding moral injury, and valuing responsive leadership. We also identify limitations and potential further improvements, mindful that COVID-19 and similar crises are likely recurring realities.

Gastos com internações psiquiátricas no estado de São Paulo: estudo ecológico descritivo, 2014 e 2019 / Gasto en hospitalizaciones psiquiátricas en el estado de São Paulo, Brasil: estudio ecológico descriptivo, 2014 y 2019 / Expenditure on psychiatric hospitalizations in the State of São Paulo, Brazil: a descriptive ecological study, 2014 and 2019

Objetivo: Analisar os gastos com internações psiquiátricas no estado de São Paulo, Brasil, nos anos de 2014 e 2019. Métodos: Estudo ecológico descritivo, com análise de dados das internações hospitalares psiquiátricas no estado, obtidos do Sistema de Informações Hospitalares do Sistema Único de Saúde. Resultados: Foram analisadas 115.652 internações ocorridas em 2014, e 79.355 em 2019 (redução de 31,38%). Observaram-se reduções nos valores gastos com internações psiquiátricas (-42,94%), destacando-se as internações de caráter de urgência, de pessoas do sexo feminino (-46,46%), nas idades de 15 a 49 (-36,85%) e mais de 50 anos (-51,54%). Conclusão: As reduções de frequência e de valores gastos com internações psiquiátricas fornecem elementos para a avaliação e alocação de recursos destinados à atenção da saúde mental, no âmbito das internações hospitalares e da utilização de serviços de base comunitária.

Objetivo: Analizar el gasto en hospitalizaciones psiquiátricas en el Estado de São Paulo, Brasil, en los años 2014 y 2019. Métodos: Estudio ecológico descriptivo, con análisis de datos de ingresos hospitalarios psiquiátricos en el Estado de São Paulo, obtenidos del Sistema de Información Hospitalaria del Sistema Único de Salud. Resultados: Se analizaron 115,652 hospitalizaciones ocurridas en 2014 y 79,355 ocurridas en 2019 (reducción del 31.38%). Hubo reducciones en los montos gastados en hospitalizaciones psiquiátricas (-42,94%), con énfasis en hospitalizaciones de urgencia, de pacientes del sexo femenino (-46,46%), en los grupos de edad de 15 a 49 años (-36,85%) y mayores de 50 años (-51,54%). Conclusión: Las reducciones en la frecuencia y los montos gastados en hospitalizaciones psiquiátricas proporcionan elementos para la evaluación y asignación de recursos para la atención de la salud mental, dentro del alcance de las admisiones hospitalarias y el uso de servicios comunitarios.

Objective: To analyze expenditure on psychiatric hospitalizations in the State of São Paulo in 2014 and 2019. Methods: This was a descriptive ecological study, with analysis of data on psychiatric hospital admissions in the State of São Paulo, retrieved from the Hospital Information System. Results: 115,652 hospitalizations that occurred in 2014 and 79,355 that occurred in 2019 were analyzed (reduction of 31.38%). There were reductions in the amounts spent on psychiatric hospitalizations (-42.94%), in particular expenditure on urgency hospitalizations, on female patients (-46.46%), on people aged 15-49 years (-36.85%) and on those aged over 50 years (-51.54%). Conclusion: The reduction in expenditure on psychiatric hospitalizations and the reduction in their frequency provide elements for the assessment and allocation of resources for mental health care, within the scope of hospital admissions and use of community-based services.

[Qualitative Evaluation of the Implementation of Group Psychoeducation for Bipolar Disorder in Clinical Settings in Quebec]. / Évaluation qualitative de l'implantation de groupes psychoéducatifs pour le trouble bipolaire à Québec.

Objectives Bipolar disorder is a chronic condition which significantly impacts the functioning and quality of life of patients with the disorder. Recognized efficacious psychological interventions, such as group psychoeducation, can help better address some of the limitations observed when pharmacotherapy is used alone in the management of bipolar disorder. However, access to these evidence-based interventions seems to be limited for most patients. Indeed, the translation of knowledge acquired through research towards actual clinical settings poses a significant challenge. Assessing the implementation of these efficacious interventions in clinical practice is thus a priority. The objective of this study is to describe the implementation of a psychoeducative intervention, the Life Goals Program (LGP), for the treatment of bipolar disorder in community mental health settings in Quebec City. Methods The LGP was implemented in three different clinical settings located in Quebec City. Fifteen healthcare service providers chosen by their respective clinical site were trained to deliver the intervention. They delivered the treatment to 73 patients with a diagnosis of bipolar disorder. Healthcare service providers filled a log book after each group session, in order to assess whether they had properly delivered the content of the program. At the end of the study, they also participated in a group interview in order to get a better understanding of their experience delivering the intervention and their appreciation of the research process. Results Following qualitative content analysis, four main categories of factors that could influence the implementation of the intervention were identified: 1) healthcare service providers' characteristics (academic training, clinical experience, personality, knowledge of the program, and dynamic between animators); 2) participants' characteristics; 3) organizational context (physical and material environment, staff stability, administrative management and research requirements); and 4) facilitation (perception of research, research team support, and facilitation tools). These categories derived from data analysis coincide with those observed in the literature. The following factors seemed to have had the most impact in the differences observed between sites in the implementation of the LGP: the support offered by the research team; staff stability; and the academic training of healthcare services providers. Conclusion Dissemination and implantation studies can not only help determine factors that are important to consider when implementing a program, but can also help improve and adapt these programs in order to increase acceptability and effectiveness in real world clinical settings.

Implementation of guidelines on family involvement for persons with psychotic disorders in community mental health centres (IFIP): protocol for a cluster randomised controlled trial.

BACKGROUND: Family involvement for persons with psychotic disorders is under-implemented in mental health care, despite its firm scientific, economic, legal and moral basis. This appears to be the case in Norway, despite the presence of national guidelines providing both general recommendations on family involvement and support in the health- and care services, and specific guidance on family interventions for patients with psychotic disorders. The aim of this project is to improve mental health services and the psychosocial health of persons with psychotic disorders and their relatives, by implementing selected recommendations from the national guidelines in community mental health centres, and to evaluate this process. METHODS: The trial is cluster randomised, where 14 outpatient clusters from community mental health centres undergo stratified randomisation with an allocation ratio of 1:1. The seven intervention clusters will receive implementation support for 18 months, whereas the control clusters will receive the same support after this implementation period. The intervention consists of: 1. A basic level of family involvement and support. 2. Family psychoeducation in single-family groups. 3. Training and guidance of health care personnel. 4. A family coordinator and 5. Other implementation measures. Fidelity to the intervention will be measured four times in the intervention arm and two times in the control arm, and the differences in fidelity changes between the arms constitute the primary outcomes. In each arm, we aim to include 161 patients with psychotic disorders and their closest relative to fill in questionnaires at inclusion, 6 months and 12 months, measuring psychosocial health and satisfaction with services. Clinicians will contribute clinical data about patients at inclusion and 12 months. Use of health and welfare services and work participation, for both patients and relatives, will be retrieved from national registries. We will also perform qualitative interviews with patients, relatives, health care personnel and leaders. Finally, we will conduct a cost-effectiveness analysis and a political economy analysis. DISCUSSION: This project, with its multilevel and mixed methods approach, may contribute valuable knowledge to the fields of family involvement, mental health service research and implementation science. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT03869177 . Registered 11.03.19.

Organizational structure, climate, and collaboration between juvenile justice and community mental health centers: implications for evidence-based practice implementation for adolescent substance use disorder treatment.

BACKGROUND: Substance use disorders are prevalent among youth involved with the criminal justice system, however, evidence-based substance use disorder treatment is often unavailable to this population. The goal of this study was to identify barriers to effective implementation of evidence-based practices among juvenile justice and community mental health organizations through the lens of an adopter-based innovation model. METHODS: In this mixed-methods study, qualitative interviews were conducted with n = 15 juvenile justice staff and n = 14 community mental health staff from two counties implementing substance use services for justice involved youth. In addition, n = 28 juvenile justice staff and n = 85 community mental health center staff also completed quantitative measures of organizational effectiveness including the implementation leadership scale (ILS), organizational readiness for change (ORIC), and the implementation climate scale (ICS). RESULTS: Organizationally, staff from community mental health centers reported more "red tape" and formalized procedures around daily processes, while many juvenile justice staff reported a high degree of autonomy. Community mental health respondents also reported broad concern about their capacity for providing new interventions. Staff across the two different organizations expressed support for evidence-based practices, agreed with the importance of treating substance use disorders in this population, and were enthusiastic about implementing the interventions. CONCLUSIONS: While both community mental health and juvenile justice staff express commitment to implementing evidence-based practices, systems-level changes are needed to increase capacity for providing evidence-based services.

Establishing an occupational therapy assessment clinic in a public mental health service: A pragmatic mixed methods evaluation of feasibility, utilisation, and impact.

INTRODUCTION: Employment of occupational therapists in generic roles in public mental health services (PMHSs) constrains capacity to undertake discipline-specific activity meaning consumers may be unable to access valuable occupational therapy assessments and interventions that could promote recovery. Establishing a dedicated occupational therapy clinic has been identified as one way of improving care provided and outcomes for organisations, therapists, and consumers. To inform such developments, this paper reports evaluation of feasibility, acceptability, and sustainability of a pilot clinic established within a PMHS. METHODS: An observational evaluation was used combining quantitative and qualitative data collected from service documents, clinic records, and in semi-structured interviews with 42 stakeholders. Quantitative data were used to describe referrals and flow through the clinic. Framework analysis of qualitative data examined the process and outcomes of referrals and enabled understanding of acceptability, perceived impact and areas for improvement. RESULTS: Substantial ground work, particularly stakeholder engagement, and redistribution of resources enabled establishment and successful operation of an assessment clinic for 12 months. Assessments were completed for 68% of the 100 accepted referrals, with the remainder in process or unable to be completed. Stakeholders agreed that the clinic enabled clinicians' timely access to specialist assessment, improving care for consumers. Occupational therapists valued the opportunity to deploy and develop discipline-specific skills and when there was some impact on work flow of occupational therapists' 'home teams', team managers judged the investment worthwhile. Strong leadership by the discipline lead and support from team managers who enabled allocation of occupational therapists to the clinic were critical to success. CONCLUSION: An occupational therapy assessment clinic can be established and operate successfully within a public mental health setting. Redistribution of resources supported increased efficiency and consumer access to specialist interventions that support their recovery.

A Systematic Review of Organizational and Workforce Interventions to Improve the Culture and Climate of Youth-Service Settings.

Both organizational culture and climate are associated with service quality and outcomes across youth-service settings. Increasing evidence indicates capacity of organizational interventions to promote a positive and effective culture and climate. Less is known about common intervention components across studies and service settings. The current systematic review reviewed 9223 citations and identified 31 studies, across six youth-service settings, measuring changes over time in organizational culture and climate following implementation of an organizational or workforce support intervention. Results highlight the promise of organizational interventions, a need for more comparison and randomized designs, and future directions for maximizing capacity of organizations to promote health for frontline providers and the children they serve.

Opening the Black Box: Identifying Common Practice Approaches in Urban and Rural Rape Crisis Centers.

This study sought to open the black box of services at rape crisis centers (RCCs), particularly related to counseling, to better understand what is available to survivors in urban and rural settings. Findings from a survey of directors and counselors in Texas RCCs reveal a number of strengths: supporting services for survivors of sexual assault and insights that can help to further advance the implementation of evidence-based trauma treatments in this sector. Although many areas of congruence were found between urban and rural settings, differences were noted that have implications for implementation of evidence-based trauma treatments.

Factors associated with the physical and mental health of drug users participating in community-based drug rehabilitation programmes in China.

Since the promulgation and implementation of a new anti-drug law in 2008, the Chinese central government has encouraged local governments to carry out community-based drug rehabilitation programmes. This study explores the association between community-based drug rehabilitation programmes and drug users' physical and mental health. This study collected data between October 2018 and February 2019 from a community-based rehabilitation programme in a community in Foshan Municipality in Guangdong Province of China. A total of 162 drug users participating in a community-based drug rehabilitation program were selected to complete a self-administered and anonymous questionnaire. A cover letter interpreting the purpose of the study and a self-administered questionnaire was provided to the drug users. Ethics approval for this study was obtained from the Academic Committee of School of Public Administration, JiNan University, Guangzhou, China. All participants gave verbal informed consent. Four multiple linear regression models were used to explain social services that influence drug users' physical and mental health. The findings show that the number of service items provided by the social service organization was significantly associated with physical and mental health among drug users. Particularly, the employment assistance service influenced the drug user's physical and mental health status significantly.

A Case Study of Implementing Grant-Funded Integrated Care in a Community Mental Health Center.

The US government funds integrated care demonstration projects to decrease health disparities for individuals with serious mental illness. Drawing on the Exploration Preparation Implementation Sustainability (EPIS) implementation framework, this case study of a community mental health clinic describes implementation barriers and sustainability challenges with grant-funded integrated care. Findings demonstrate that integrated care practices evolve during implementation and the following factors influenced sustainability: workforce rigidity, intervention clarity, policy and funding congruence between the agency and state/federal regulations, on-going support and training in practice application, and professional institutions. Implementation strategies for primary care integration within CMHCs include creating a flexible workforce, shared definition of integrated care, policy and funding congruence, and on-going support and training.

Comparison of a co-produced mental health service to traditional services: A co-produced mixed-methods cross-sectional study.

This study investigates the differences between a co-produced experimental mental health centre and traditional day centres. For this purpose, we used a collaborative and mixed-method approach in two complementary studies: (i) a quantitative cross-sectional study designed to compare users' hospitalization rates and their use of psychiatric medications and (ii) a qualitative study designed to explore and document the experienced differences between co-produced and traditional services. In the quantitative cross-sectional study, surveys were administered to 37 users of one co-produced mental health service and to 40 users of traditional mental health services. A negative binomial regression analysis was performed to examine the relationships between predictors and users' hospitalization rates. After adjusting for the potential confounders, users of the co-produced centre reported a 63.2% reduced rate of hospitalizations compared with users of traditional mental health services (P = 0.002). Furthermore, 39% of users of the co-produced centre reported a reduction or even withdrawal from psychiatric medications against 22% of the comparison group (P = 0.036). In the qualitative study, six main differences emerged from a thematic analysis of a large user-led focus group. In the participants' experiences, the co-produced service focused on (i) parity and respectful relationships, (ii) people's strengths, (iii) freedom, (iv) psychological continuity, (v) social inclusion, and (vi) recovery orientation. Our research provides empirical evidence concerning the 'preventive aspect' of co-produced mental health services. Additionally, new insights into how different stakeholders, particularly users of co-produced mental health services, experience the differences between co-produced and traditional mental health services are provided.

The Choice and Partnership Approach to community mental health and addictions services: a realist-informed scoping review protocol.

INTRODUCTION: Early identification and appropriate treatment of child and adolescent mental health disorders can often be hampered by patchwork services with poorly planned or unclear pathways. The Choice and Partnership Approach (CAPA) is an evidence-based transformational model of community (community-based or outpatient) mental health and addictions services for children and adolescents that aims to better match services to needs and to improve timely access to care. CAPA has been variably implemented across jurisdictions but has not been comprehensively evaluated for its impact on system and client outcomes. Our research question is, 'To what degree does CAPA work, for whom and under what circumstances?'. The purpose of this review is twofold: (1) to gain an understanding of the extent and outcomes of the implementation of CAPA in community mental health and addictions services; and (2) to identify the role of context as it influences the implementation of CAPA and resulting client and system outcomes. METHODS AND ANALYSIS: We will conduct a realist-informed scoping review of the literature related to CAPA in either child and adolescent or adult community mental health and addictions services. Relevant studies, reports and documentation will be identified by searching the following online databases: MEDLINE, Embase, CINAHL, PsycINFO, Academic Search Premier, ERIC, Web of Science, Cochrane, Dissertations Abstracts, NCBI Bookshelf, PubMed Central and the Canadian Health Research Collection. The search strategy was developed by a health sciences library scientist and informed by a multidisciplinary team comprising methodological and content knowledge experts. The search will gather evidence from multiple online databases of peer-reviewed literature and grey literature repositories. All articles will be independently assessed for inclusion by pairs of reviewers. The key themes derived from a thematic analysis of extracted data will be presented in a narrative overview. ETHICS AND DISSEMINATION: Research ethics review is not required for this scoping review. The results will be disseminated through meetings with stakeholders (including clients and families, clinicians and decision-makers), conference presentations and peer-reviewed publication. The results of this review will inform an overarching programme of research, policy and quality indicator development to ultimately improve mental health and addictions care and subsequent mental health outcomes for children and adolescents.