Clinician and Staff Perspectives on Implementing Adverse Childhood Experience (ACE) Screening in Los Angeles County Pediatric Clinics.

PURPOSE: To understand clinician and clinical staff perspectives on the implementation of routine Adverse Childhood Experience (ACE) screening in pediatric primary care. METHODS: We conducted a qualitative evaluation in 5 clinics in Los Angeles County, California, using 2 rounds of focus group discussions: during an early phase of the initiative, and 7 months later. In the first round, we conducted 14 focus group discussions with 67 participants. In the second round, we conducted 12 focus group discussions with 58 participants. Participants comprised clinic staff involved in ACE screening, including frontline staff that administer the screening, medical clinicians that use screening to counsel patients and make referrals, and psychosocial support staff who may receive referrals. RESULTS: Themes were grouped into 3 categories: (1) screening acceptability and perceived utility, (2) implementation and quality improvement, and (3) effects of screening on patients and clinicians. Regarding screening acceptability and perceived utility, clinicians generally considered ACE screening to be acceptable and useful. In terms of implementation and quality improvement, significant barriers included: insufficient time for screening and response, insufficient training, and lack of clarity about referral networks and resources that could be offered to patients. Lastly, regarding effects of screening, clinicians expressed that ACE screening helped elicit important patient information and build trust with patients. Further, no adverse events were reported from screening. CONCLUSIONS: Clinic staff felt ACE screening was feasible, acceptable, and beneficial within pediatric care settings to improve trauma-informed care and that ACE screening could be strengthened by addressing time constraints and limited referral resources.

"They Just Helped Save My Life:" Client Perspectives on the Los Angeles County Full Service Partnership (FSP) Program for Serious Mental Illness.

The purpose of this qualitative study was to elicit client perspectives on the Los Angeles County Full Service Partnership (FSP) program - an adaptation of Assertive Community Treatment (ACT). Semi-structured interviews were conducted with 20 FSP clients. Qualitative data were analyzed using thematic analysis. Two major themes were identified from the interview data: (1) Clients' acknowledgement of the material benefits of the FSP program; and (2) FSP's impact on restoring and stabilizing clients' social and treatment relationships. Interviewees greatly valued the material (i.e., basic needs, housing assistance) and relational (i.e., relationships with providers, restored personal relationships) aspects of the program, but did not ascribe the same degree of value to mental health treatment. Interviewees' emphases on material and relational aspects reflect the status of assertive mental health treatment as an intervention on intermediary determinants of health in the lives of persons diagnosed with serious mental illness.

A Qualitative Investigation of Preparedness for the Launch of 988: Implications for the Continuum of Emergency Mental Health Care.

On July 16, 2022, the 988 mental health crisis hotline launched nationwide. In addition to preparing for an increase in call volume, many jurisdictions used the launch of 988 as an opportunity to examine their full continuum of emergency mental health care. Our goal was to understand the characteristics of jurisdictions' existing continuums of care, identify factors that distinguished jurisdictions that were more- versus less-prepared for 988, and explore perceived strengths and limitations of the planning process. We conducted 15 qualitative interviews with state and local mental health program directors representing 10 states based on their preparedness for the 988 rollout. Interviews focused on 988 call centers, mobile crisis response, and crisis stabilization, as well as strengths and limitations of the 988 planning process. Data were analyzed using rapid qualitative analysis, an approach designed to draw insights on evolving processes and extract actionable findings. Interviewees from jurisdictions that reported that they were more-prepared for the launch of 988 tended to have local 988 call centers and already had local access to mobile crisis teams and crisis stabilization units. Interviewees across jurisdictions described challenges to offering a robust continuum of crisis services, including workforce shortages and geographic constraints. Though jurisdictions acknowledged the importance of integrating peer support staff and serving diverse populations, many perceived room for growth in these areas. Though 988 has launched, efforts to bolster the existing continuum will continue and hinge on efforts to expand the behavioral health workforce, engage diverse partners, and collect relevant data.

Understanding asthma-specific quality of life: moving beyond asthma symptoms and severity.

This study identifies the unique contributions of asthma severity, symptoms, control and generic measures of quality of life (QoL) to asthma-specific QoL, as measured by the 12-item RAND Negative Impact of Asthma on Quality of Life scale (RAND-IAQL-12).Using a sample of 2032 adults with asthma, we conducted multiple regression analyses that sequentially examined hypothesised predictors of asthma-specific QoL. The change in variance accounted for and total unique variance accounted for is calculated as hypothesised predictors are added in each step.Our results indicate that asthma severity and asthma symptoms are strong predictors of asthma-specific QoL only when not controlling for aspects of asthma control. In regression models that include other aspects of asthma control, the contributions of both asthma symptoms and severity were substantially reduced, with asthma control and aspects of QoL related to social roles and activities emerging as the strongest predictors of asthma-specific QoL.These findings suggest that researchers measuring the impact of asthma on QoL should also consider the importance of asthma control as measured by the RAND Asthma Control Measure (RAND-ACM) and generic QoL scales that measure aspects of daily life that are uniquely affected by asthma.

Assessing the validity of the RAND negative impact of asthma on quality of life short forms.

BACKGROUND: In response to recommendations from the 2010 National Institutes of Health Asthma Outcomes Workshop, we developed a system for measuring the negative impact of asthma on quality of life (QoL), which was referred to as the RAND Negative Impact of Asthma on Quality of Life (RAND-IAQL) item bank. The bank contains 65 items that focus on the patient's perception of the impact or bother of asthma on his or her life. OBJECTIVE: Evidence for the validity of 2 short forms, the RAND-IAQL 4-item and 12-item Short Forms, from the bank is presented. METHODS: Using a sample of 2032 adults with asthma, we validated our short forms against the Asthma Quality of Life Questionnaire-Marks (AQLQ-M), the Asthma Control Test, and generic measures of QoL developed by the Patient-reported Outcomes Measurement Information System (PROMIS). Discriminant validity was examined by comparing scores of respondents who differed according to multiple health indicators. RESULTS: Our sample ranged in age from 18 to 99 years (mean, 43 years), with 14% Hispanic, 11% Asian, 19% African American, and 56% non-Hispanic white race/ethnicity. Men had a significantly worse impact of asthma on QoL than women. The impact of asthma on QoL was greatest in African American and Hispanic subjects compared with that seen in non-Hispanic white subjects. Our measures correlated highly with the AQLQ-M and more strongly with the PROMIS global physical than mental scales. They differentiated between adults with asthma according to their perceived severity, level of control, presence or absence of exacerbations, and physical comorbidity. CONCLUSION: The RAND-IAQL item bank, measuring the impact of asthma on QoL, will complement other patient-reported outcomes, such as measures of asthma symptoms, functioning, and control.

Development and validation of the RAND Asthma Control Measure.

Patient-based measures for asthma control are important in assessing the worldwide impact of this highly prevalent chronic illness. We sought to refine an asthma symptom scale that RAND had previously developed to shorten it and validate it further, as well as reflect updated international expert definitions of asthma control. We conducted rigorous psychometric testing of new and adapted self-administered survey items in a sample of 2032 adults with asthma. The reliability and preliminary validity of the resulting measure, henceforth referred to as the RAND Asthma Control Measure (RAND-ACM), matched or exceeded that of the original RAND measure and others in the literature. RAND-ACM scores for worse asthma control were significantly associated with worse asthma-related quality of life, increased asthma-related healthcare use, Hispanic ethnicity and lower educational level. Evidence for internal consistency was strong with a Cronbach's α of 0.84. We also found adequate concordance between the RAND-ACM and the Global Initiative for Asthma categories of "uncontrolled", "partly controlled" and "controlled" asthma. The RAND-ACM, a five-item self-reported asthma control survey measure, performs well in a large ethnically-diverse sample of US adults with asthma and provides a cost-free alternative to other asthma control measures currently available.

Development of a measure of asthma-specific quality of life among adults.

PURPOSE: A key goal in asthma treatment is improvement in quality of life (QoL), but existing measures often confound QoL with symptoms and functional impairment. The current study addresses these limitations and the need for valid patient-reported outcome measures by using state-of-the-art methods to develop an item bank assessing QoL in adults with asthma. This article describes the process for developing an initial item pool for field testing. METHODS: Five focus group interviews were conducted with a total of 50 asthmatic adults. We used "pile sorting/binning" and "winnowing" methods to identify key QoL dimensions and develop a pool of items based on statements made in the focus group interviews. We then conducted a literature review and consulted with an expert panel to ensure that no key concepts were omitted. Finally, we conducted individual cognitive interviews to ensure that items were well understood and inform final item refinement. RESULTS: Six hundred and sixty-one QoL statements were identified from focus group interview transcripts and subsequently used to generate a pool of 112 items in 16 different content areas. CONCLUSIONS: Items covering a broad range of content were developed that can serve as a valid gauge of individuals' perceptions of the effects of asthma and its treatment on their lives. These items do not directly measure symptoms or functional impairment, yet they include a broader range of content than most existent measures of asthma-specific QoL.

Financial Interventions to Improve Screening in Primary Care: A Systematic Review.

INTRODUCTION: Although health screenings offer timely detection of health conditions and enable early intervention, adoption is often poor. How might financial interventions create the necessary incentives and resources to improve screening in primary care settings? This systematic review aimed to answer this question. METHODS: Peer-reviewed studies published between 2000 and 2023 were identified and categorized by the level of intervention (practice or individual) and type of intervention, specifically alternative payment models (APMs), fee-for-service (FFS), capitation, and capital investments. Outcomes included frequency of screening, performance/quality of care (e.g., patient satisfaction, health outcomes), and workflow changes (e.g., visit length, staffing). RESULTS: Of 51 included studies, a majority focused on practice-level interventions (n=32), used APMs (n=41) that involved payments for achieving key performance indicators (KPIs; n=31) and were of low or very low strength of evidence based on GRADE criteria (n=42). Studies often included screenings for cancer (n=32), diabetes care (n=18), and behavioral health (n=15). KPI payments to both practices and individual providers corresponded with increased screening rates, whereas capitation and provider-level FFS models yielded mixed results. A large majority of studies assessed changes in screening rates (n=48) with less focus on quality of care (n=11) or workflow changes (n=4). DISCUSSION: Financial mechanisms can enhance screening rates with evidence strongest for KPI payments to both practices and individual providers. Future research should explore the relationship between financial interventions and quality of care, in terms of both clinical processes and patient outcomes, as well as the role of these interventions in shaping care delivery.

Clinic Readiness for Trauma-Informed Health Care Is Associated With Uptake of Screening for Adverse Childhood Experiences.

INTRODUCTION: Adverse childhood experiences (ACEs) are strongly correlated with many of the most common causes of preventable illness, preventable death, and health disparities. In January 2020, California launched the first statewide initiative to integrate ACE screening throughout its Medicaid system. A key element of the initiative was the California ACEs Learning and Quality Improvement Collaborative, a 48-clinic, 16-month learning collaborative. This evaluation aimed to determine whether developing a trauma-informed environment of care was associated with uptake of ACE screening. METHODS: Participants included 40 of 48 clinics that participated in the statewide learning collaborative. Clinics completed an assessment of progress in 5 essential components of trauma-informed health care at baseline and 1-year follow-up. Clinics tracked data on ACE screens completed on an ongoing basis and submitted data quarterly. A hierarchical linear model was used to examine the association between change in readiness for trauma-informed health care and change in quarterly screens. RESULTS: Readiness for trauma-informed health care increased for all participating clinics over the course of the learning collaborative. The average number of quarterly screens also increased, with considerable variability among clinics. Clinics with larger increases in readiness for trauma-informed health care had larger increases in quarterly screens. DISCUSSION: The findings align with long-standing recommendations for trauma screening to occur in the context of trauma-informed environments of care. CONCLUSION: A trauma-informed clinic is the foundation for successful adoption of ACE screening. ACE screening initiatives should include education and sufficient support for clinics to embrace a trauma-informed systems change process.

Evaluation of Los Angeles County's 2022 WeRise Mental Health Events.

WeRise-a component of the Los Angeles County Department of Mental Health's (LACDMH's) broader campaign, WhyWeRise-is an annual set of events targeting prevention and early intervention for mental health challenges. This evaluation indicates that WeRise events successfully reached groups of Los Angeles County residents particularly in need of mental health support, such as youth; mobilized them around mental health issues; and may have boosted awareness of mental health resources in the county. Perceptions of the events were very positive, with the vast majority saying that the event they attended connected them with resources and community, showed some of the strengths of their community, and empowered them to take care of their well-being.

Evaluation of Los Angeles County's L.A. Dodgers 2022 Mental Health Campaign.

WhyWeRise is a social marketing campaign conducted by the Los Angeles County Department of Mental Health (LACDMH) to promote community engagement with mental health issues, reduce barriers to care, and increase awareness of how to seek mental health care. LACDMH has partnered with the Los Angeles Dodgers for several years to expand the reach of the campaign to the Major League Baseball team's audience and spread the WhyWeRise messages to the Dodgers' extensive Hispanic fan base-a key county demographic with attitudes toward mental illness that sometimes differ from those of other ethnic groups. The LACDMH/Dodgers campaign focused on awareness of resources and stigma reduction among Hispanic county residents. This study builds on prior RAND work and provides an evaluation of the reach of the 2022 Dodgers campaign overall and a focus on the reach to (and potential impact of outreach on) attendees of 2022 Dodger games. Results indicate that the Dodgers campaign reached a substantial percentage of Los Angeles County residents: 12 percent of adults and 27 percent of youth reported exposure to the campaign, translating to more than 800,000 adults and more than 400,000 youth reached. The campaign was effective in targeting Hispanic- or Latino-identifying residents, who made up 71 percent of youth who were campaign-exposed and 58 percent of adults exposed. In summary, there is evidence that the Dodgers campaign successfully reached Los Angeles County residents, particularly Hispanics and young adults, and that those reached were more aware of key county mental health resources.

Mental Health Emergency Hotlines in the United States: A Scoping Review (2012-2021).

OBJECTIVE: Mental health emergency hotlines provide clinical supports and connection to services. This scoping review describes the current literature on hotlines in the United States, including which populations they do and do not reach, typical call volumes and engagement levels, barriers to and facilitators of implementation, and common call outcomes. The review also identifies gaps in the literature and presents recommendations. METHODS: A systematic search of peer-reviewed articles on U.S.-based telephone, text, and chat hotlines published between January 2012 and December 2021 retrieved 1,049 articles. In total, 96 articles met criteria for full-text review, of which 53 met full inclusion criteria. RESULTS: Approximately half of the included studies (N=25) focused on descriptive information of callers, most of whom were females, younger adults, and White; veteran hotlines typically reached older men. Common reasons for calling were suicidality, depression, and interpersonal problems. Of studies examining intervention effects (N=20), few assessed hotlines as interventions (N=6), and few evaluated caller behavioral outcomes (N=4), reporting reduced distress and suicidality among callers after hotline engagement. However, these studies also suggested areas for improvement, including reaching underrepresented high-risk populations. Six studies reported implementation needs, such as investments in data collection and evaluation, staff training, and sustainable funding. CONCLUSIONS: Hotlines appear to be more effective at reaching some populations than others, indicating that more intensive outreach efforts may be necessary to engage underrepresented high-risk populations. The findings also indicated limited evidence on the relationship between use of hotlines-particularly local text and chat hotlines-and caller outcomes, highlighting an area for further investigation.

National preparedness for 988-the new mental health emergency hotline in the United States.

988, a national mental health emergency hotline number, went live throughout the United States in July 2022. 988 connects callers to the 988 Crisis & Suicide Lifeline, previously known as the National Suicide Prevention Lifeline. The transition to the three-digit number aimed to respond to a growing national mental health crisis and to expand access to crisis care. We examined preparedness throughout the U.S. for the transition to 988. In February and March 2022, we administered a national survey of state, regional, and county behavioral health program directors. Respondents (n = 180) represented jurisdictional coverage of 120 million Americans. We found that communities throughout the U.S. appeared ill-prepared for rollout of 988. Fewer than half of respondents reported their jurisdictions were 'somewhat' or 'very' prepared for 988 in terms of financing (29%), staffing (41%), infrastructure (41%), or service coordination (47%). Counties with higher representation of Hispanic/Latinx individuals were less likely to report being prepared for 988 in terms of staffing (OR: 0.62, 95 %CI: 0.45, 0.86) and infrastructure (OR: 0.68, 95 %CI: 0.48, 0.98). In terms of existing services, sixty percent of respondents reported a shortage of crisis beds and fewer than half reported availability of short-term crisis stabilization programs in their jurisdictions. Our study highlights components of local, regional, and state behavioral health systems in the U.S. that require greater investments to support 988 and mental health crisis care.

Psychiatric and Substance Use Disorder Bed Capacity, Need, and Shortage Estimates in California: Merced, San Joaquin, and Stanislaus Counties.

Psychiatric and substance use disorder (SUD) treatment beds are essential infrastructure for meeting the needs of individuals with behavioral health conditions. However, not all psychiatric and SUD beds are alike: They represent infrastructure within different types of facilities. For psychiatric beds, these vary from acute psychiatric hospitals to community residential facilities. For SUD treatment beds, these vary from facilities offering short-term withdrawal management services to others offering longer duration residential detoxification services. Different settings also serve clients with different needs. For example, some clients have high-acuity, short-term needs; others have longer-term needs and may return for care on multiple occasions. California's Merced, San Joaquin, and Stanislaus Counties, like other counties throughout the United States, have sought to assess shortages in psychiatric and SUD treatment beds. In this study, the authors estimated psychiatric bed and residential SUD treatment capacity, need, and shortages for adults and children and adolescents at various levels of care: acute, subacute, and community residential services for psychiatric treatment and SUD treatment service categories defined by American Society of Addiction Medicine clinical guidelines. Drawing from various data sets, literature review findings, and facility survey responses, the authors computed the number of beds required-at each level of care-for adults and children and adolescents and identified hard-to-place populations. The authors draw from these findings to offer Merced, San Joaquin, and Stanislaus Counties recommendations to help ensure all their residents, especially nonambulatory individuals, have access to the behavioral health care that they need.

The effect of adverse childhood experience training, screening, and response in primary care: a systematic review.

Background: Adverse childhood experiences (ACEs) can have harmful, long-term health effects. Although primary care providers (PCPs) could help mitigate these effects, no studies have reviewed the impacts of ACE training, screening, and response in primary care. Methods: This systematic review searched four electronic databases (PubMed, Web of Science, APA PsycInfo, CINAHL) for peer-reviewed articles on ACE training, screening, and/or response in primary care published between Jan 1, 1998, and May 31, 2023. Searches were limited to primary research articles in the primary care setting that reported provider-related outcomes (knowledge, confidence, screening behavior, clinical care) and/or patient-related outcomes (satisfaction, referral engagement, health outcomes). Summary data were extracted from published reports. Findings: Of 6532 records, 58 met inclusion criteria. Fifty-two reported provider-related outcomes; 21 reported patient-related outcomes. 50 included pediatric populations, 12 included adults. A majority discussed screening interventions (n = 40). Equal numbers (n = 25) discussed training and clinical response interventions. Strength of evidence (SOE) was generally low, especially for adult studies. This was due to reliance on observational evidence, small samples, and self-report measures for heterogeneous outcomes. Exceptions with moderate SOE included the effect of training interventions on provider confidence/self-efficacy and the effect of screening interventions on screening uptake and patient satisfaction. Interpretation: Primary care represents a potentially strategic setting for addressing ACEs, but evidence on patient- and provider-related outcomes remains scarce. Funding: The California Department of Health Care Services and the Office of the California Surgeon General.

Patient and Caregiver Perspectives on Implementation of ACE Screening in Pediatric Care Settings: A Qualitative Evaluation.

INTRODUCTION: This qualitative research study explored the perspectives of adolescents, 12 to 19-years-old, and caregivers of children under 12-years-old on the acceptibility of adverse childhood experiences (ACEs) screenings in five pediatric clinics. METHOD: A constructivist grounded theory approach was utilized. One-on-one semistructured phone interviews were conducted with 44 adolescents and 95 caregivers of children less than 12 years old. Interviews were analyzed using thematic analysis. RESULTS: Most participants reported feeling comfortable discussing ACEs with their providers. Some reported that screening helped build trust. Others expressed privacy concerns and did not receive information about the reason for screening. Adolescent patients shared conflicting feelings-of both comfort and discomfort. Caregivers attending to multiple children, foster parents, and monolingual Spanish speakers disclosed unique challenges to ACEs screening. We found no evidence of lasting adverse effects. DISCUSSION: Participants generally found ACEs screenings acceptable. Some adolescents identified benefits from the experience. However, clinics planning to adopt routine ACEs screening should ensure clear messaging on why screening is occurring, anticipate and address privacy concerns, and adopt workflows to discuss screening results.

Evaluation of Los Angeles County Department of Mental Health's 2020-2021 L.A. Dodgers Mental Health Campaign.

WhyWeRise is a social marketing campaign conducted by the Los Angeles County Department of Mental Health (LACDMH) to promote community engagement with mental health issues along a continuum from self-care to professional treatment services, reduce barriers to care, and increase awareness of how to seek mental health care. In 2020 and 2021, LACDMH partnered with the Los Angeles Dodgers to expand the reach of the campaign to the Major League Baseball team's audience and spread the WhyWeRise messages to the Dodgers' extensive Hispanic fan base-a key county demographic with attitudes toward mental illness that sometimes differ from those of other ethnic groups. The LACDMH/Dodgers campaign focused on awareness of resources and stigma-reduction among Hispanic county residents. This study builds on prior RAND work and provides an evaluation of the reach of the 2020 and 2021 Dodgers campaign overall and a focus on the reach and potential impact of outreach to attendees of 2021 Dodger games.

Psychiatric and Substance Use Disorder Bed Capacity, Need, and Shortage Estimates in Sacramento County, California.

Psychiatric and substance use disorder (SUD) treatment beds are essential infrastructure for meeting the needs of individuals with behavioral health conditions. However, not all psychiatric and SUD beds are alike: They represent infrastructure within different types of facilities. For psychiatric beds, these vary from acute psychiatric hospitals to community residential facilities. For SUD treatment beds, these vary from facilities offering short-term withdrawal management services to others offering longer duration residential detoxification services. Different settings also serve clients with different needs. For example, some clients have high-acuity, short-term needs; others have longer-term needs and may return for care on multiple occasions. Sacramento County, like other counties throughout the United States, has sought to assess shortages in psychiatric and SUD treatment beds. In this study, the authors estimated psychiatric bed and residential SUD treatment capacity, need, and shortages for adults and children/adolescents at various levels of care: acute, subacute, and community residential services for psychiatric treatment and SUD treatment service categories defined by American Society of Addiction Medicine (ASAM) clinical guidelines. Drawing from various data sets, literature review findings, and facility survey responses, the authors computed the number of beds required-at each level of care-for adults and children/adolescents and identified hard-to-place populations. The authors draw from these findings to offer Sacramento County recommendations to help ensure all its residents, especially Medi-Cal recipients, have access to the behavioral health care that they need.

Adult Psychiatric Bed Capacity, Need, and Shortage Estimates in California-2021.

Psychiatric beds are essential infrastructure for meeting the needs of individuals with mental health conditions. However, not all psychiatric beds are alike: They represent infrastructure within different types of facilities, ranging from acute psychiatric hospitals to community residential facilities. These facilities, in turn, serve clients with different needs: some who have high-acuity, short-term needs and others who have chronic, longer-term needs and may return multiple times for care. California, much like many parts of the United States, is confronting a shortage of psychiatric beds. In this article, the authors estimated California's psychiatric bed capacity, need, and shortages for adults at each of three levels of care: acute, subacute, and community residential care. They used multiple methods for assessing bed capacity and need in order to overcome limitations to any single method of estimating the potential psychiatric bed shortfall. The authors identified statewide shortfalls in beds at all levels of inpatient and residential care. They also documented regional differences in the shortfall and identified special populations that contributed to bottlenecks in the continuum of inpatient and residential care in the state.

A Process Evaluation of Primary Care Behavioral Health Integration in the Military Health System.

Behavioral health (BH) problems are common in the military and can adversely affect force readiness. Research suggests that primary care-behavioral health (PCBH) integration can improve BH outcomes by making high-quality BH care available in more accessible settings. However, sustaining high-quality implementation of PCBH is challenging. The authors conducted a process evaluation of the PCBH program in the military health system to understand why the program is working as it is and provide recommendations for quality improvement. They conducted semistructured interviews, rigorously coded the qualitative data to identify causal links, and created and validated causal loop diagrams that provide a visualization of how the system is working. Findings fall into four key areas: staffing and capabilities, valued tasks, program stewardship, and fostering program awareness and support. Overall, the authors found that the PCBH program is highly valued by primary care staff. However, the PCBH care model is inconsistently adhered to, owing to a combination of staff preferences, local pressures, and lack of knowledge of PCBH staff roles. Recommendations are offered to improve program implementation.