Scaling-up Child and Youth Mental Health Services: Assessing Coverage of a County-Wide Prevention and Early Intervention Initiative During One Fiscal Year.

PURPOSE: In the U.S., the percentage of youth in need of evidence-based mental health practices (EBPs) who receive them (i.e., coverage rate) is low. We know little about what influences coverage rates. In 2010, the Los Angeles County Department of Mental Health (LACDMH) launched a reimbursement-driven implementation of multiple EBPs in youth mental health care. This study examines two questions: (1) What was the coverage rate of EBPs delivered three years following initial implementation? (2) What factors are associated with the coverage rates? METHODS: To assess coverage rates of publicly insured youth, we used LACDMH administrative claims data from July 1, 2013 to June 30, 2014 and estimates of the size of the targeted eligible youth population from the 2014 American Community Survey (ACS). The unit of analysis was clinic service areas (n = 254). We used Geographic Information Systems and an OLS regression to assess community and clinic characteristics related to coverage. RESULTS: The county coverage rate was estimated at 17%, much higher than national estimates. The proportion of ethnic minorities, individuals who are foreign-born, adults with a college degree within a geographic area were negatively associated with clinic service area coverage rates. Having more therapists who speak a language other than English, providing care outside of clinics, and higher proportion of households without a car were associated with higher coverage rates. CONCLUSION: Heterogeneity in municipal mental health record type and availability makes it difficult to compare the LACDMH coverage rate with other efforts. However, the LACDMH initiative has higher coverage than published national rates. Having bilingual therapists and providing services outside the clinic was associated with higher coverage. Even with higher coverage, inequities persisted.

Patterns of Child Mental Health Service Utilization Within a Multiple EBP System of Care.

The current study (1) characterizes patterns of mental health service utilization over 8 years among youth who received psychotherapy in the context of a community implementation of multiple evidence-based practices (EBPs), and (2) examined youth-, provider- and service-level predictors of service use patterns. Latent profile analyses were performed on 5,663,930 administrative claims data furnished by the county department of mental health. Multinomial logistic regression with Vermunt's method was used to examine predictors of care patterns. Based on frequency, course, cost, and type of services, three distinct patterns of care were identified: (1) Standard EBP Care (86.3%), (2) Less EBP Care (8.5%), and (3) Repeated/Chronic Care (5.2%). Youth age, ethnicity, primary language, primary diagnosis and secondary diagnosis, provider language and provider type, and caregiver involvement and service setting were significant predictors of utilization patterns. Although the majority of youth received care aligned with common child EBP protocols, a significant portion of youth (13.7%) received no evidence-based care or repeated, costly episodes of care. Findings highlight opportunities to improve and optimize services, particularly for youth who are adolescents or transition-aged, Asian-American/Pacific Islander, Spanish-speaking, or presenting with comorbidities.

Outer-context determinants in the sustainment phase of a reimbursement-driven implementation of evidence-based practices in children's mental health services.

BACKGROUND: Although there is increasing investment to implement evidence-based practices (EBPs) in public systems across the USA, continued or sustained use of EBPs after initial implementation remains a challenge. The low integration of EBPs in routine practice severely limits their public health impact, highlighting the need to understand factors that affect the return on costly investments in EBP implementation. This study aims to (1) characterize trajectories of EBP delivery volume through a reimbursement-driven implementation and (2) examine impacts of system-level policy regulatory activity and state-level mental health services funding on the implementation reimbursement strategy. METHODS: This study involved secondary data analyses. Psychotherapy administrative claims and regulatory site visit data from the Los Angeles County Department of Mental Health and California state mental health expenditures were extracted from 2010 to 2017. Multilevel regression examined EBP claims volume over time with state expenditures and regulatory compliance as predictors. RESULTS: EBP claims volume trajectories demonstrated a rapid initial increase, followed by a period of decrease, and a small increase in the final year. State mental health expenditures increased across time reflecting increased funding availability. State mental health expenditures and system regulatory compliance were inversely related to EBP claims volume. CONCLUSIONS: The impact of reimbursement-driven EBP implementation strategy is sensitive to multiple outer-context determinants. At the system level, commitment to fidelity of implementation regulations resulted in reduced use of the reimbursement strategy. Alternative reimbursement streams not tied to EBPs coupled with an expanded array of reimbursable services also impacted the use of the reimbursement strategy to implement EBPs.

Mental Health Community and Health System Issues in COVID-19: Lessons from Academic, Community, Provider and Policy Stakeholders.

The coronavirus pandemic of 2019 (COVID-19) has created unprecedented changes to everyday life for millions of Americans due to job loss, school closures, stay-at-home orders and health and mortality consequences. In turn, physicians, academics, and policymakers have turned their attention to the public mental health toll of COVID-19. This commentary reporting from the field integrates perceptions of academic, community, health system, and policy leaders from state, county, and local levels in commenting on community mental health needs in the COVID-19 pandemic. Stakeholders noted the broad public health scope of mental health challenges while expressing concern about exacerbation of existing disparities in access and adverse social determinants, including for communities with high COVID-19 infection rates, such as African Americans and Latinos. They noted rapid changes toward telehealth and remote care, and the importance of understanding impacts of changes, including who may benefit or have limited access, with implications for future services delivery. Needs for expanded workforce and training in mental health were noted, as well as potential public health value of expanding digital resources tailored to local populations for enhancing resilience to stressors. The COVID-19 pandemic has led to changes in delivery of health care services across populations and systems. Concerns over the mental health impact of COVID-19 has enhanced interest in remote mental care delivery and preventive services, while being mindful of potential for enhanced disparities and needs to address social determinants of health. Ongoing quality improvement across systems can integrate lessons learned to enhance a public mental well-being.

Caregiver Attendance as a Quality Indicator in the Implementation of Multiple Evidence-Based Practices for Children.

OBJECTIVE: This study investigated a quality indicator for children's mental health, caregiver attendance in youth psychotherapy sessions, within a system-driven implementation of multiple evidence-based practices (EBPs) in children's community mental health services. METHOD: Administrative claims from nine fiscal years were analyzed to characterize and predict caregiver attendance. Data included characteristics of therapists (n = 8,626), youth clients (n = 134,368), sessions (e.g., individual, family), and the EBP delivered. Clients were primarily Latinx (63%), male (54%) and mean age was 11; they presented with a range of mental health problems. Three-level mixed models were conducted to examine the association between therapist, youth, service, EBP characteristics and caregiver attendance. RESULTS: Caregivers attended, on average, 46.0% of sessions per client for the full sample and 59.6% of sessions for clients who were clinically indicated, based on age and presenting problem, to receive caregiver-focused treatment. Following initial EBP implementation, the proportion of caregiver attendance in sessions increased over time. Caregivers attended a higher proportion of youth psychotherapy sessions when clients were younger, had an externalizing disorder, were non-Hispanic White, and were male. Further, higher proportions of caregiver attendance occurred when services were delivered in a clinic setting (compared with school and other settings), by bilingual therapists, and the EBP prescribed caregiver attendance in all sessions. CONCLUSIONS: Overall, the patterns of caregiver attendance appear consistent with evidence-informed practice parameters of client presenting problem and age. Yet, several improvement targets emerged such as client racial/ethnic background and service setting. Potential reasons for these disparities are discussed.

Health Outcomes and Costs Associated with the Provision of Culturally Competent Services for Underrepresented Ethnic Populations with Severe Mental Illness.

Underrepresented racial/ethnic populations (UREPs) face disparities in their use of behavioral health services for multiple reasons including lack of culturally competent services and stigma. This paper employs mixed methods to compare health outcomes and costs among clients in 14 culturally competent behavioral health programs targeting specific UREPs to five programs without a specific racial or ethnic focus. We found that UREP-focused programs were associated with similar improvements in health outcomes, but greater costs relative to the comparison programs. Main themes from the qualitative analysis included: addressing stigma, building trust and understanding confidentiality, looking for a cure, and moving beyond linguistic competency.

Implementation of Integrated Health Homes and Health Outcomes for Persons With Serious Mental Illness in Los Angeles County.

OBJECTIVE: The Medicaid health home option of the Affordable Care Act provides a new opportunity to address the fragmented system of care for persons with serious mental illness. This study examined the implementation of integrated health homes in Los Angeles County. METHODS: Longitudinal data on client-reported physical health status, clinician-reported mental health recovery, and screening for common chronic conditions among 1,941 persons enrolled in integrated care programs for serious mental illness and chronic general medical illness were combined with site visit data measuring the level of integration of general medical and mental health care among ten integrated care programs. Various analyses were used to compare outcomes by level of program integration (generalized estimating equations for physical health status and mental health recovery and logistic regression and chi-square tests for screening for common chronic conditions and clinical risk factors). RESULTS: Clients in more highly integrated programs had greater improvements in physical health status and mental health recovery and higher rates of screening for common chronic conditions compared with clients in less integrated programs. They also had greater reductions in hypertension but a worrisome increase in prediabetes and diabetes. CONCLUSIONS: Highly integrated mental health and general medical programs were associated with greater improvements in health outcomes compared with less integrated programs. Additional research is necessary to identify predictors of integration, to determine which aspects of integration drive improvements in health outcomes, and to identify strategies to increase integration within less integrated programs. Efforts are needed to coordinate pharmacotherapy, including increased consideration of the metabolic effects of antipsychotic medication.