The Impact of Patient Race, Patient Socioeconomic Status, and Cognitive Load of Physician Residents and Fellows on Chronic Pain Care Decisions.

Social stereotypes are more likely to influence decision-making under conditions of high cognitive load (ie, mental workload), such as in medical settings. We examined how patient race, patient socioeconomic status (SES), physician cognitive load, and physician implicit beliefs about race and SES differences in pain tolerance impacted physicians' pain treatment decisions. Physician residents and fellows (N = 120) made treatment decisions for 12 computer-simulated patients with back pain that varied by race (Black/White) and SES (low/high). Half of the physicians were randomized to be interrupted during the decision task to make hypertension medication conversion calculations (high cognitive load group), while the other half completed the task without interruptions (low cognitive load group). Both groups were given equal time to make pain care decisions (2.5 minutes/patient). Results of multilevel ordinal logistic regression analyses indicated that physicians prescribed weaker analgesics to patients with high vs. low SES (odds ratio = .68, 95% confidence interval [.48, .97], P = .03). There was also a patient SES-by-cognitive load interaction (odds ratio = .56, 95% confidence interval [.31, 1.01], P = .05) that is theoretically and potentially practically meaningful but was not statistically significant at P < .05. These findings shed light on physician cognitive load as a clinically-relevant factor in the context of pain care quality and equity. PERSPECTIVE: These findings highlight the clinical relevance of physician cognitive load (eg, mental workload) when providing pain care for diverse patients. This line of work can support the development of interventions to manage physician cognitive load and its impact on pain care, which may ultimately help reduce pain disparities.

Communication and activation in pain to enhance relationships and treat pain with equity (COOPERATE): a randomized clinical trial.

ABSTRACT: Racialized disparities in chronic pain care are well-documented and persist despite national priorities focused on health equity. Similar disparities have been observed in patient activation (ie, having the knowledge, confidence, and skills to manage one's health). As such, interventions targeting patient activation represent a novel approach to addressing and reducing disparities in pain care. Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity is a randomized controlled trial of a 6-session telephone-delivered intervention to increase patient activation for Black patients with chronic pain. Two hundred fifty Black patients from a Midwestern Veterans Affairs medical center were randomized to the intervention or attention control. The primary outcome was patient activation; secondary outcomes included communication self-efficacy, pain, and psychological functioning. Outcomes were assessed at baseline and at 3 (primary endpoint), 6, and 9 months (sustained effects). Analyses used an intent-to-treat approach. Compared with baseline, patient activation increased 4.6 points at 3 months (versus +0.13 in control group, 95% CI: 0.48, 7.34; P = 0.03). These improvements in the intervention group were sustained, with +7 from baseline at 6 months and +5.77 at 9 months, and remained statistically significant from the control group. Communication self-efficacy increased significantly relative to the control group from baseline to 3 months. Pain intensity and interference improved at 3 months, but differences were not significant after adjusting for multiple comparisons. Most other secondary outcomes improved, but group differences were not statistically significant after controlling for multiple comparisons. Results suggest that increasing patient activation is a potentially fruitful path toward improving pain management and achieving health equity.

Racial disparities in the workplace: The impact of isolation on perceived organizational support and job satisfaction.

OBJECTIVE: Prior research indicates Black employees may be particularly vulnerable to job dissatisfaction and that social support at work is a potential resource that could influence employee outcomes. This study examined racial differences in workplace social networks and support, and how these factors may contribute to perceived organizational support and, ultimately, job satisfaction among mental health workers. METHOD: Using data from an all-employee survey in a community mental health center (N = 128), we assessed racial differences in social network supports, hypothesizing that Black employees would report smaller and less supportive social networks, and lower levels of organizational support and job satisfaction compared to White employees. We also hypothesized that workplace network size and support would be positively associated with perceived organizational support and job satisfaction. RESULTS: Hypotheses were partially supported. Compared to Whites, Blacks had smaller workplace networks that were less likely to include supervisors, were more likely to report workplace isolation (naming no workplace social ties), and were less likely to seek advice from their social ties at work. Regression analyses showed that Blacks and employees with smaller networks were more likely to perceive lower levels of organizational support, even after controlling for background variables. However, race and network size did not predict overall job satisfaction. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: These findings suggest that Black mental health services staff are less likely to have rich, diverse workplace networks than their White colleagues, which may put them at a disadvantage in terms of accessing support and other resources. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Proactive, Recovery-Oriented Treatment Navigation to Engage Racially Diverse Veterans in Mental Healthcare (PARTNER-MH), a Peer-Led Patient Navigation Intervention for Racially and Ethnically Minoritized Veterans in Veterans Health Administration Mental Health Services: Protocol for a Mixed Methods Randomized Controlled Feasibility Study.

BACKGROUND: Mental health care disparities are persistent and have increased in recent years. Compared with their White counterparts, members of racially and ethnically minoritized groups have less access to mental health care. Minoritized groups also have lower engagement in mental health treatment and are more likely to experience ineffective patient-provider communication, which contribute to negative mental health care experiences and poor mental health outcomes. Interventions that embrace recovery-oriented practices to support patient engagement and empower patients to participate in their mental health care and treatment decisions may help reduce mental health care disparities. Designed to achieve this goal, the Proactive, Recovery-Oriented Treatment Navigation to Engage Racially Diverse Veterans in Mental Healthcare (PARTNER-MH) is a peer-led patient navigation intervention that aims to engage minoritized patients in mental health treatment, support them to play a greater role in their care, and facilitate their participation in shared treatment decision-making. OBJECTIVE: The primary aim of this study is to assess the feasibility and acceptability of PARTNER-MH delivered to patients over 6 months. The second aim is to evaluate the preliminary effects of PARTNER-MH on patient activation, patient engagement, and shared decision-making. The third aim is to examine patient-perceived barriers to and facilitators of engagement in PARTNER-MH as well as contextual factors that may inhibit or promote the integration, sustainability, and scalability of PARTNER-MH using the Consolidated Framework for Implementation Research. METHODS: This pilot study evaluates the feasibility and acceptability of PARTNER-MH in a Veterans Health Administration (VHA) mental health setting using a mixed methods, randomized controlled trial study design. PARTNER-MH is tested under real-world conditions using certified VHA peer specialists (peers) selected through usual VHA hiring practices and assigned to the mental health service line. Peers provide PARTNER-MH and usual peer support services. The study compares the impact of PARTNER-MH versus a wait-list control group on patient activation, patient engagement, and shared decision-making as well as other patient-level outcomes. PARTNER-MH also examines organizational factors that could impact its future implementation in VHA settings. RESULTS: Participants (N=50) were Veterans who were mostly male (n=31, 62%) and self-identified as non-Hispanic (n=44, 88%) and Black (n=35, 70%) with a median age of 45 to 54 years. Most had at least some college education, and 32% (16/50) had completed ≥4 years of college. Randomization produced comparable groups in terms of characteristics and outcome measures at baseline, except for sex. CONCLUSIONS: Rather than simply documenting health disparities among vulnerable populations, PARTNER-MH offers opportunities to evaluate a tailored, culturally sensitive, system-based intervention to improve patient engagement and patient-provider communication in mental health care for racially and ethnically minoritized individuals. TRIAL REGISTRATION: ClinicalTrials.gov NCT04515771; https://clinicaltrials.gov/ct2/show/NCT04515771. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/37712.

Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity (COOPERATE): Rationale, study design, methods, and sample characteristics.

BACKGROUND: Chronic pain is associated with profound negative effects, and racial disparities are well-documented in chronic pain treatment. In addition, Black patients report poorer communication with providers and exhibit lower levels of patient activation (self-management self-efficacy) than White patients. Although the causes of healthcare disparities are complex and require intervention at multiple levels, empowering patients is one critical path to achieving health equity. The current study is a coaching intervention focused on increasing patient activation and building communication skills for Black patients with chronic pain. METHODS: In this randomized controlled trial, 250 Black patients with chronic pain were randomized to either the coaching intervention or an attention control arm. Intervention patients attended 6 telephone-delivered individual coaching sessions over 12 weeks. Coaching focused on clarifying and prioritizing goals and on communication skills, such as agenda setting. The primary outcome is patient activation. Secondary outcomes include communication self-efficacy, pain intensity and interference, and psychological functioning. DISCUSSION: Having the knowledge and confidence to participate in one's pain care, coupled with the skills needed to effectively communicate with providers, is essential to optimize chronic pain care. This is particularly important for Black patients who often experience lower quality pain care. Interventions such as COOPERATE hold promise for helping patients to acquire the requisite tools to take greater control of their chronic pain care. TRIAL REGISTRATION: clinicaltrials.gov, # NCT03562793.

Assessing the Recovery Assessment Scale Across Time.

OBJECTIVE: The Recovery Assessment Scale (RAS) is one of the most used recovery measures in recovery-oriented practice evaluation of people with mental health conditions. Although its psychometric properties have been extensively studied, one critical piece of information that is missing from the literature is evidence of its longitudinal factorial invariance-that is, whether the RAS measures the same recovery construct across time. The authors empirically tested the longitudinal factorial invariance assumption for the RAS. METHODS: Structural equation modeling was used to test the longitudinal factorial invariance of the RAS with data longitudinally obtained at three time points from 167 people with severe mental illness. RESULTS: The longitudinal factorial invariance assumption was supported (i.e., configural, metric, partial scalar, factor variance and covariance invariance). CONCLUSIONS: This study found empirical evidence that the RAS can measure the same recovery construct over time and thus meets one of the important prerequisites for longitudinal assessment.

Mediational paths from supervisor support to turnover intention and actual turnover among community mental health providers.

OBJECTIVE: Turnover is a critical problem for community mental health providers, and supervisors may play an important role in mitigating turnover. The current study examined the potential impact of supervisory support on turnover intention and actual turnover among community mental health providers. METHOD: We conducted path analyses with data collected longitudinally from 186 direct clinical care providers at two community mental health centers. RESULTS: Increased supervisory support was associated with lower turnover intention 6 months later, as well as reduced actual turnover 12 months later. Type of supervisory support mattered: supervisors' emotional support was most strongly associated with reduced turnover intention and turnover. However, client goal alignment support (supporting providers to help consumers achieve their goals) was directly associated with increased turnover. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The current study suggests an important role for direct supervisors to attend to care providers' emotional support needs, which may reduce turnover intention and actual turnover. Differential supervisory support functions might impact turnover in unique ways; thus, examining more detailed change mechanisms would facilitate our understanding of factors that may prevent future turnover. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Integrating Self-Determination and Job Demands-Resources Theory in Predicting Mental Health Provider Burnout.

Limited progress has been made in reducing burnout in mental health professionals. Accordingly, we identified factors that might protect against burnout and could be productive focal areas for future interventions. Guided by self-determination theory, we examined whether supervisor autonomy support, self-efficacy, and staff cohesion predict provider burnout. 358 staff from 13 agencies completed surveys. Higher levels of supervisor autonomy support, self-efficacy, and staff cohesion were predictive of lower burnout, even after accounting for job demands. Although administrators may be limited in their ability to reduce job demands, our findings suggest that increasing core job resources may be a viable alternative.

Comparing the Costs and Acceptability of Three Fidelity Assessment Methods for Assertive Community Treatment.

Successful implementation of evidence-based practices requires valid, yet practical fidelity monitoring. This study compared the costs and acceptability of three fidelity assessment methods: on-site, phone, and expert-scored self-report. Thirty-two randomly selected VA mental health intensive case management teams completed all fidelity assessments using a standardized scale and provided feedback on each. Personnel and travel costs across the three methods were compared for statistical differences. Both phone and expert-scored self-report methods demonstrated significantly lower costs than on-site assessments, even when excluding travel costs. However, participants preferred on-site assessments. Remote fidelity assessments hold promise in monitoring large scale program fidelity with limited resources.

Comparison of Assertive Community Treatment Fidelity Assessment Methods: Reliability and Validity.

Assertive community treatment is known for improving consumer outcomes, but is difficult to implement. On-site fidelity measurement can help ensure model adherence, but is costly in large systems. This study compared reliability and validity of three methods of fidelity assessment (on-site, phone-administered, and expert-scored self-report) using a stratified random sample of 32 mental health intensive case management teams from the Department of Veterans Affairs. Overall, phone, and to a lesser extent, expert-scored self-report fidelity assessments compared favorably to on-site methods in inter-rater reliability and concurrent validity. If used appropriately, these alternative protocols hold promise in monitoring large-scale program fidelity with limited resources.

Core domains of shared decision-making during psychiatric visits: scientific and preference-based discussions.

Shared decision-making (SDM) is imperative to person-centered care, yet little is known about what aspects of SDM are targeted during psychiatric visits. This secondary data analysis (191 psychiatric visits with 11 providers, coded with a validated SDM coding system) revealed two factors (scientific and preference-based discussions) underlying SDM communication. Preference-based discussion occurred less. Both provider and consumer initiation of SDM elements and decision complexity were associated with greater discussions in both factors, but were more strongly associated with scientific discussion. Longer visit length correlated with only scientific discussion. Providers' understanding of core domains could facilitate engaging consumers in SDM.

Consumer and relationship factors associated with shared decision making in mental health consultations.

OBJECTIVE: This study explored the association between shared decision making and consumers' illness management skills and consumer-provider relationships. METHODS: Medication management appointments for 79 consumers were audio recorded. Independent coders rated overall shared decision making, minimum level of shared decision making, and consumer-provider agreement for 63 clients whose visit included a treatment decision. Mental health diagnoses, medication adherence, patient activation, illness management, working alliance, and length of consumer-provider relationships were also assessed. Correlation analyses were used to determine relationships among measures. RESULTS: Overall shared decision making was not associated with any variables. Minimum levels of shared decision making were associated with higher scores on the bond subscale of the Working Alliance Inventory, indicating a higher degree of liking and trust, and with better medication adherence. Agreement was associated with shorter consumer-provider relationships. CONCLUSIONS: Consumer-provider relationships and shared decision making might have a more nuanced association than originally thought.

Using simulation to assess the influence of race and insurer on shared decision making in periviable counseling.

INTRODUCTION: Sociodemographic differences have been observed in the treatment of extremely premature (periviable) neonates, but the source of this variation is not well understood. We assessed the feasibility of using simulation to test the effect of maternal race and insurance status on shared decision making (SDM) in periviable counseling. METHODS: We conducted a 2 × 2 factorial simulation experiment in which obstetricians and neonatologists counseled 2 consecutive standardized patients diagnosed with ruptured membranes at 23 weeks, counterbalancing race (black/white) and insurance status using random permutation. We assessed verisimilitude of the simulation in semistructured debriefing interviews. We coded physician communication related to resuscitation, mode of delivery, and steroid decisions using a 9-point SDM coding framework and then compared communication scores by standardized patient race and insurer using analysis of variance. RESULTS: Sixteen obstetricians and 15 neonatologists participated; 71% were women, 84% were married, and 75% were parents; 91% of the physicians rated the simulation as highly realistic. Overall, SDM scores were relatively high, with means ranging from 6.4 to 7.9 (of 9). There was a statistically significant interaction between race and insurer for SDM related to steroid use and mode of delivery (P < 0.01 and P = 0.01, respectively). Between-group comparison revealed nonsignificant differences (P = <0.10) between the SDM scores for privately insured black patients versus privately insured white patients, Medicaid-insured white patients versus Medicaid-insured black patients, and privately insured black patients versus Medicaid-insured black patients. CONCLUSIONS: This study confirms that simulation is a feasible method for studying sociodemographic effects on periviable counseling. Shared decision making may occur differentially based on patients' sociodemographic characteristics and deserves further study.

Why are you here again? Concordance between consumers and providers about the primary concern in recurring psychiatric visits.

Patient-centered care has become increasingly important over the last decade, both in physical and mental health care. In support of patient-centered care, providers need to understand consumers׳ primary concerns during treatment visits. The current study explored what primary concerns were brought to recurring psychiatric visits for a sample of adults with severe mental illness (N=164), whether these concerns were concordant with those recognized by providers, and which factors predicted concordance. We identified 17 types of primary concerns, most commonly medications and symptoms, with only 50% of visits showing evidence of at least partial agreement between consumers and providers. Contrary to expectations, consumer demographics, activation, trust, and perceptions of patient-centeredness were not predictive, while greater preferences for autonomy predicted poorer agreement. Our findings highlight the need for interventions to promote a shared understanding of primary concerns in recurring psychiatric visits. Further attention is needed to ensure the provision of patient-centered care such that consumer concerns are acknowledged and addressed within recurring psychiatric visits.

Consumer and provider responses to a computerized version of the Illness Management and Recovery Program.

OBJECTIVE: To explore mental health consumer and provider responses to a computerized version of the Illness Management and Recovery (IMR) program. METHOD: Semistructured interviews were conducted to gather data from 6 providers and 12 consumers who participated in a computerized prototype of the IMR program. An inductive-consensus-based approach was used to analyze the interview responses. RESULTS: Qualitative analysis revealed consumers perceived various personal benefits and ease of use afforded by the new technology platform. Consumers also highly valued provider assistance and offered several suggestions to improve the program. The largest perceived barriers to future implementation were lack of computer skills and access to computers. Similarly, IMR providers commented on its ease and convenience, and the reduction of time intensive material preparation. Providers also expressed that the use of technology creates more options for the consumer to access treatment. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The technology was acceptable, easy to use, and well-liked by consumers and providers. Clinician assistance with technology was viewed as helpful to get clients started with the program, as lack of computer skills and access to computers was a concern. Access to materials between sessions appears to be desired; however, given perceived barriers of computer skills and computer access, additional supports may be needed for consumers to achieve full benefits of a computerized version of IMR.

A comparison of phone-based and on-site assessment of fidelity for assertive community treatment in Indiana.

OBJECTIVE: This study investigated the reliability and validity of a phone-administered fidelity assessment instrument based on the Dartmouth Assertive Community Treatment Scale (DACTS). METHODS: An experienced rater paired with a research assistant without fidelity assessment experience or a consultant familiar with the treatment site conducted phone-based assessments of 23 teams providing assertive community treatment in Indiana. Using the DACTS, consultants conducted on-site evaluations of the programs. RESULTS: The pairs of phone raters revealed high levels of consistency [intraclass correlation coefficient (ICC)=.92] and consensus (mean absolute difference of .07). Phone and on-site assessment showed strong agreement (ICC=.87) and consensus (mean absolute difference of .07) and agreed within .1 scale point, or 2% of the scoring range, for 83% of sites and within .15 scale point for 91% of sites. Results were unaffected by the expertise level of the rater. CONCLUSIONS: Phone-based assessment could help agencies monitor faithful implementation of evidence-based practices.

Impact of illness management and recovery programs on hospital and emergency room use by Medicaid enrollees.

OBJECTIVE: Illness management and recovery is a structured program that helps consumers with severe mental illness learn effective ways to manage illness and pursue recovery goals. This study examined the impact of the program on health service utilization. METHODS: This was a retrospective cohort study of five assertive community treatment (ACT) teams in Indiana that implemented illness management and recovery. With Medicaid claims data from July 1, 2003, to June 30, 2008, panel data were created with person-months as the level of analysis, resulting in 14,261 observations for a total of 498 unique individuals. Zero-inflated negative binomial regression models were used to predict hospitalization days and emergency room visits, including covariates of demographic characteristics, employment status, psychiatric diagnosis, and concurrent substance use disorder. The main predictor variables of interest were receipt of illness management and recovery services, dropout from the program, and program graduation status. RESULTS: Consumers who received some illness management and recovery services had fewer hospitalization days than those receiving only ACT. Graduates had fewer emergency room visits than did ACT-only consumers. CONCLUSIONS: This is the first study to examine the impact of illness management and recovery on service utilization. Controlling for a number of background variables, the study showed that illness management and recovery programs were associated with reduced inpatient hospitalization and emergency room use over and above ACT.

A cross-sectional study of recovery training and staff attitudes in four community mental health centers.

OBJECTIVE: Recovery has become a concept often incorporated in mental health staff trainings. However, little research has investigated the influence of training on recovery attitudes. The current study examined whether recovery-related trainings in community mental health centers is associated with differences in staff attitudes and reported organizational practices. METHODS: A total of 318 staff members at four community mental health centers completed questionnaires about their recovery attitudes and trainings they had received in the past year. RESULTS: Compared to staff who had no recovery-related training in the past year, staff who had at least one recovery-related training reported significantly higher consumer optimism and a greater agency recovery orientation towards consumers' life goals. The number of recovery-related trainings was significantly correlated with scores on personal optimism, consumer optimism, and agency recovery orientation towards consumers' life goals. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The findings suggest recovery training is positively related to staff recovery attitudes and agency practices. Community mental health centers may benefit from a systematic approach to recovery training. Further research is needed to determine directionality of these relationships and to parse the mechanisms of action.

Recovery orientation in hospital and community settings.

There has been an increasing emphasis on community integration, consumer involvement, and recovery-focused treatment; but the extent to which these recovery-oriented principles have been adopted in state hospitals is unknown. This study surveyed 1,150 staff at three state hospitals and 230 staff at four community mental health centers on personal optimism, consumer optimism, and agency recovery orientation. Responses were obtained from 729 (63.4%) hospital staff and 181 (78.7%) community staff. Staff at state hospitals scored significantly lower on all three recovery measures even after controlling for background differences. Treatment setting may be an important factor in the dissemination of recovery-oriented care principles.