Association of emergency department characteristics with presence of recommended pediatric-specific behavioral health policies.

Objectives: In the United States, pediatric emergency department (ED) visits for behavioral health (BH) are increasing. We sought to determine ED-level characteristics associated with having recommended BH-related policies. Methods: We conducted a retrospective serial cross-sectional study of National Pediatric Readiness Project assessments administered to US EDs in 2013 and 2021. Changes in responses related to BH items over time were examined. Multivariable logistic regression models examined ED characteristics associated with the presence of specific BH-related policies in 2021. Results: Of 3554 EDs that completed assessments in 2021, 73.0% had BH-related policies, 66.5% had transfer guidelines for children with BH issues, and 38.6% had access to BH resources in a disaster. Of 2570 EDs that completed assessments in both 2013 and 2021, presence of specific BH-related policies increased from 48.6% to 72.0% and presence of appropriate transfer guidelines increased from 56.2% to 64.9%. The adjusted odd ratios (aORs) of having specific BH-related policies were lower in rural (aOR 0.73; 95% confidence interval [CI] 0.57, 0.92) and remote EDs (aOR 0.65; 95% CI 0.48, 0.88) compared to urban EDs; lower among EDs with versus without trauma center designation (aOR 0.80; 95% CI 0.67, 0.95); and higher among EDs with a nurse and physician pediatric emergency care coordinator (PECC) (aOR 1.89; 95% CI 1.54, 2.33) versus those without a PECC. Conclusion: Although pediatric readiness for BH conditions increased from 2013 to 2021, gaps remain, particularly among rural EDs and designated trauma centers. Having nurse and physician PECCs is a modifiable strategy to increase ED pediatric readiness pertaining to BH.

Identifying implementation barriers and facilitators in an integrated behavioral health training program to improve workforce development.

Integrated behavioral health (IBH) in pediatric primary care settings can improve access to needed care and outcomes. Behavioral Health Workforce Education and Training (BHWET) programs can better prepare the workforce and support improved care access. This case study identified factors that impede and facilitate the implementation of practice-based training in a BHWET program using the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. Surveys were administered to BHWET trainees and primary care partners to assess stakeholder perspectives on field-based training processes. Qualitative data were extracted from surveys and trainee clinical logs. Providers reported high levels of satisfaction with IBH care training experiences. Data analysis identified several implementation facilitators and barriers. Implementation facilitators were associated with two EPIS outer context factors (leadership and collaboration) and one inner context factor (partner staffing). Identified barriers were associated with two inner context factors (organizational characteristics and data collection). Although the facilitators and barriers identified in this study were program specific, they have relevance for similar programs. Barriers identified at the organizational level reflect those identified in the research literature and provide insights for university programs regarding factors that must be considered when integrating IBH training components in primary care settings.

Federally funded Behavioral Health Workforce Education and Training (BHWET) programs can better prepare the workforce and support integrated behavioral health (IBH) care in primary care settings. Using evaluation data gathered from primary care providers and trainees at partner clinics, this case study identified barriers that posed challenges to increasing behavioral health care for patients with identified needs, as well as factors that facilitated care. Barriers identified at the organizational level within partner clinics reflect those identified in the research literature and provide insights for medical professionals on factors they should consider when integrating behavioral health in primary care settings.

Outcomes that Matter to Youth and Families in Behavioral Health Services.

Patient-centered outcomes research helps youth and families using behavioral health services make informed decisions about treatments to help them achieve the outcomes most important to them. However, there are few efforts to identify the outcomes valued by youth and families systematically. This project aimed to support the development of behavioral health services that deliver outcomes valued by families by identifying the outcomes that youth and young adults with behavioral health needs and caregivers say matter most to them. We engaged 34 youth and young adults (YYA) with behavioral health needs, alongside 42 caregivers from six U.S. regions, in two rounds of one-hour virtual focus groups. The initial round involved participants identifying what they hoped to gain from using behavioral health services for personal, familial, and parental or child well-being and the attributes of positive service experiences. We coded responses using qualitative analytical software, culminating in synthesized reports. Subsequently, the second round entailed participants' review and refinement of initial findings. Across sessions, each group reported the top three outcomes deemed most important for children, YYA, parents, families, and their service experiences. YYA identified being understood by others, improving their interpersonal relationships, and feeling heard as the highest priority behavioral health service outcomes. Caregivers of children and youth with behavioral health needs identified having accessible services that meet their needs, having providers that collaborate effectively with parents and other service systems, and experiencing consistent and continuous behavioral health care for their child as the most important behavioral health service outcomes. Both YYA with behavioral health needs and caregivers of children and youth prioritized gaining the necessary knowledge, resources, and tools to support their or their child's behavioral health. Additionally, both participant groups emphasized the importance of effective communication with providers, within their families, and with peers. Minimizing judgment and stigma from society, providers, and other professionals also emerged as a critical outcome for these groups. It is essential for research and policy development to focus on and cater to the outcomes that are important and valued by YYA and their families to maximize family engagement in care.

Cultivating Connections: An Interprofessional Peer Support Model.

Peer support models have existed for decades in behavioral health care and are being developed for health care professionals to help address high rates of burnout and stress in the health care environment. Such models typically involve individuals from the same profession. With the concurrent increase of interprofessional integrated behavioral health care models, interprofessional peer support seems a viable model. This Open Forum describes how a peer support program for physicians and faculty scientists evolved to include a broader range of health care professionals, providing a framework for interprofessional peer support programs for the behavioral health care workforce.

Technology for advancing behavioral health integration: implications for behavioral health practice and policy.

Behavioral health integration (BHI) encompasses the integration of general health, mental health, and substance use care. BHI has promise for healthcare improvement, yet several challenges limit its uptake and successful implementation. Translational Behavioral Medicine published the Continuum-Based Framework by Goldman et al., 2020 to create comprehensive guidance for BHI within primary care settings. Technology can help advance BHI and provide evidence to support it. This commentary describes challenges and illustrative use cases in which technology solutions help organizations achieve BHI through the Continuum-Based Framework domains. Two rounds of semi-structured interviews with field leaders, practice sites, and technology stakeholders identified key barriers in BHI amenable to technology solutions, applications of technologies, and how they facilitate BHI. Findings showed that technology can facilitate the implementation and scaling of BHI by reducing care fragmentation and improving patient engagement, accountability and financial sustainability, provider experience and support, and equitable access to culturally competent care. Continued efforts by stakeholders to address legacy policy and implementation issues (e.g. incentives, investment, privacy, and workforce) are needed to optimize the impact of technology on BHI.

Behavioral health integration (BHI) combines physical, mental, and substance use care to enhance overall well-being. While BHI offers benefits, it faces challenges. Researchers developed the Continuum-Based Framework to aid primary healthcare centers in implementing BHI. Technology is key to supporting BHI effectiveness. Researchers examined how technology can assist with BHI by interviewing experts and analyzing real-world examples. They found that technology helps healthcare centers address BHI challenges by ensuring comprehensive and equitable care delivery, promoting patient engagement, and supporting healthcare providers. Technology can improve BHI practices over time, but policy, investment, and privacy changes are necessary for optimal integration.

Integrating Behavioral Health Into Monitoring and Surveillance During Public Health Emergencies: Challenges and Opportunities.

OBJECTIVE: Limited guidance exists for public health agencies to use existing data sources to conduct monitoring and surveillance of behavioral health (BH) in the context of public health emergencies (PHEs). METHODS: We conducted a literature review and environmental scan to identify existing data sources, indicators, and analytic methods that could be used for BH surveillance in PHEs. We conducted exploratory analyses and interviews with public health agencies to examine the utility of a subset of these data sources for BH surveillance in the PHE context. RESULTS: Our comprehensive search revealed no existing dedicated surveillance systems to monitor BH in the context of PHEs. However, there are a few data sources designed for other purposes that public health agencies could use to conduct BH surveillance at the substate level. Some of these sources contain lagging indicators of BH impacts of PHEs. Most do not consistently collect the sociodemographic data needed to explore PHEs' inequitable impacts on subpopulations, including at the intersection of race, gender, and age. CONCLUSIONS: Public health agencies have opportunities to strengthen BH surveillance in PHEs and build partnerships to act based on timely, geographically granular existing data.

Grow Your Own School Mental Health Specialists: A Policy Pilot to Address Behavioral Health Workforce Shortages in Schools.

The capacity of schools to address behavioral health concerns presents an emerging challenge, exacerbated by major shortages in the workforce. Schools across the U.S. are struggling to hire licensed behavioral health professionals, with additional barriers encountered when seeking to hire practitioners with experience in educational settings. In 2023, a school district in the suburbs of Columbus, Ohio, partnered with The Ohio State University to launch a "grow your own" policy pilot. The priorities focused on addressing workforce shortages and leveraging the experiences of current teachers/staff to support growing needs related to student mental health and well-being. More specifically, the district utilized COVID-19 relief funds to recruit, train, and transition 25 teachers/staff into school mental health positions by underwriting the costs of each professional's Master of Social Work (MSW) degree. Here, we (a) describe the district-university partnership and the processes guiding the implementation of the "grow your own" model, (b) distill preliminary findings about district needs regarding behavioral health, and (c) explore facilitators, barriers, and outcomes associated with learning among participants in the program. The findings from a district-wide staff survey indicated a high level of need for individual counseling, crisis intervention, and small group interventions. Additionally, qualitative interviews revealed that learning among the program's participants was facilitated by effective classroom strategies and specific learning experiences integral to the program's design. These facilitators supported key learning outcomes, including general social work knowledge, self-awareness, and therapeutic skills that are foundational for engaging with students, parents/families, teachers/staff, and the broader school community. This innovative policy pilot and training model demonstrate how universities and local educational agencies can partner to address workforce development challenges at the intersection of behavioral health and education.

Harnessing the Power of Integrated Behavioral Health to Enhance Insomnia Intervention in Primary Care.

Insomnia is prevalent in primary care and associated with co-morbid physical and mental health conditions and poor health outcomes. While there are effective treatments for insomnia in specialty mental health care, many patients have difficulty accessing these interventions. To begin, patients do not always report their sleep challenges to physicians; meanwhile, primary care providers often do not screen for insomnia symptoms. Furthermore, patients may experience several barriers to accessing specialty care for insomnia treatment, such as a limited number of available providers, financial burden, lack of transportation, and low perceptions of treatment effectiveness. Primary care behavioral health (PCBH) is well-equipped to address the challenges of accessing evidence-based care for insomnia through (1) identifying sleep issues, (2) providing psychoeducation on the possible treatments for insomnia, (3) intervening with poor sleep habits and acute insomnia early to prevent chronic insomnia, and (4) delivering appropriate evidence-based interventions for chronic insomnia. Primary care clinics should leverage behavioral health providers to increase screening and embed interventions into routine care for the benefit of improved outcomes for patients with insomnia and other sleep challenges.

Exploratory Factor Analysis of a Patient-Facing PCBH Adherence Measure: The PPAQ-Patient.

Model adherence indicates the degree to which a program or intervention is delivered as intended. In integrated primary care, where mental health services are embedded into primary care clinics, appraisal of model adherence provides insight into whether these services align with key features of this unique practice environment (e.g., brief, interdisciplinary care). To date, such evaluations have emphasized system and provider factors. This study is a preliminary evaluation of whether a novel patient-facing measure, the Primary Care Behavioral Health Provider Adherence Questionnaire-Patient Version (PPAQ-Patient), can provide insight into adherence to the Primary Care Behavioral Health (PCBH) model of integrated primary care. Survey data were collected from 281 veterans who received PCBH care. Exploratory factor analyses evaluated the data structure. Results suggest that 19 items spanning three temporally-referenced subscales may feasibly capture patient perspectives on PCBH adherence at various stages of treatment. Future work is needed to refine the measure.

The Impact of Collaborative Documentation on Person-Centered Care: Textual Analysis of Clinical Notes.

Background: Collaborative documentation (CD) is a behavioral health practice involving shared writing of clinic visit notes by providers and consumers. Despite widespread dissemination of CD, research on its effectiveness or impact on person-centered care (PCC) has been limited. Principles of PCC planning, a recovery-based approach to service planning that operationalizes PCC, can inform the measurement of person-centeredness within clinical documentation. Objective: This study aims to use the clinical informatics approach of natural language processing (NLP) to examine the impact of CD on person-centeredness in clinic visit notes. Using a dictionary-based approach, this study conducts a textual analysis of clinic notes from a community mental health center before and after staff were trained in CD. Methods: This study used visit notes (n=1981) from 10 providers in a community mental health center 6 months before and after training in CD. LIWC-22 was used to assess all notes using the Linguistic Inquiry and Word Count (LIWC) dictionary, which categorizes over 5000 linguistic and psychological words. Twelve LIWC categories were selected and mapped onto PCC planning principles through the consensus of 3 domain experts. The LIWC-22 contextualizer was used to extract sentence fragments from notes corresponding to LIWC categories. Then, fixed-effects modeling was used to identify differences in notes before and after CD training while accounting for nesting within the provider. Results: Sentence fragments identified by the contextualizing process illustrated how visit notes demonstrated PCC. The fixed effects analysis found a significant positive shift toward person-centeredness; this was observed in 6 of the selected LIWC categories post CD. Specifically, there was a notable increase in words associated with achievement (ß=.774, P<.001), power (ß=.831, P<.001), money (ß=.204, P<.001), physical health (ß=.427, P=.03), while leisure words decreased (ß=-.166, P=.002). Conclusions: By using a dictionary-based approach, the study identified how CD might influence the integration of PCC principles within clinical notes. Although the results were mixed, the findings highlight the potential effectiveness of CD in enhancing person-centeredness in clinic notes. By leveraging NLP techniques, this research illuminated the value of narrative clinical notes in assessing the quality of care in behavioral health contexts. These findings underscore the promise of NLP for quality assurance in health care settings and emphasize the need for refining algorithms to more accurately measure PCC.

A Study of the Psychometric Properties of the Pediatric Symptom Checklist-17 for Children With Developmental Delays and Disorders.

Primary care physicians (PCPs) frequently serve pediatric patients with developmental delays and disorders (DD/D). Although the most widely used primary care behavioral health screener, the Pediatric Symptom Checklist-17 (PSC-17), is validated for use with children without DD/D, it is unclear whether this measure accurately identifies behavioral health symptoms in youth with DD/D. Thus, the purpose of this study was to assess the psychometric properties of the PSC-17 for children with DD/D. Medical record data from 3596 pediatric patients at a primary care clinic were analyzed. Descriptive analyses, measurement invariance testing, and internal consistency evaluations were conducted to assess the psychometric properties of the PSC-17. The results of these analyses support the use of the PSC-17 for behavioral health screening for children with DD/D. Behavioral health screening in this population is critical, because the timely identification of behavioral health concerns can facilitate early intervention, which may enhance long-term functioning.

A "Whole Child Approach": Parent Experiences with Acute Care Hospitalizations for Children with Autism Spectrum Disorder and Behavioral Health Needs.

Children with Autism Spectrum Disorder (ASD) experience increased hospitalizations as compared to the general population, particularly in the context of mental health crises. Given the unique needs of children with ASD and behavioral health needs that can either lead to or emerge during hospitalization, an understanding of hospital experiences is critical. To date, research on caregiver experiences in acute care medical hospital settings is limited. Therefore, the purpose of this qualitative study was to investigate caregiver experiences with inpatient care for children with ASD and behavioral health needs, including factors and practices that impacted or were desirable for care. Two focus groups were conducted with a total of 12 parents of children with ASD admitted to a large pediatric hospital. Data were analyzed using interpretive description. Emerging themes pointed to the child, family, and staff factors and practices that intersect to influence hospitalization experiences. Child factors included the child's communication, sensory, behavioral, medical, and safety needs. Family factors included the family's relationship with the healthcare team, own needs, and advocacy experiences. Staff factors included staff communication practices, comfort, and knowledge when providing care. Overall, this research demonstrates the complexity of factors and practices that impact the behavioral health hospitalization experience for children with ASD and their caregivers. Experiences varied widely and were guided by the unique needs of each child. Findings point to care practices that can be adopted to best meet the needs of all stakeholders during hospitalization and offer implications for future educational initiatives.

Familias con Orgullo: Pilot Study of a Family Intervention for Latinx Sexual Minority Youth to Prevent Drug Use, Sexual Risk Behavior, and Depressive Symptoms.

Families are key in the healthy development of Latinx sexual minority youth (Latinx SMY), a group that experiences behavioral, mental, and sexual health disparities. Despite this, there are no family-based interventions for Latinx SMY and their families to prevent drug use, sexual risk behaviors, and depressive symptoms. The purpose of this pilot study was to evaluate the preliminary impact (i.e., estimated effect sizes) of Familias con Orgullo (FcO) and examine its feasibility and acceptability among 30 Latinx SMY and their parents. Parents and adolescents were randomized to FcO or a control condition and assessed pre/post-intervention. Feasibility was measured based on session completion and effect sizes. Focus groups were conducted to evaluate intervention acceptability. Findings showed promising effects favoring FcO on parent-adolescent communication (d = 0.46) and parental involvement (d = 0.34). There were also promising effects favoring FcO on suicidal thoughts (OR = 0.75) and depression symptoms (OR = 0.69). Finally, 100% of the adolescents in FcO either continued to remain drug-free or transitioned from current use to no use (from baseline to post-intervention) compared to 74% in the control. Effect sizes for condomless sex, parental monitoring, and positive parenting were small. Session completion (above 80%) and focus group findings indicated strong feasibility and acceptability. FcO holds promise for reducing drug use and depressive symptoms and improving family functioning among Latinx SMY.

The SoCAP (Social Communication, Affiliation, and Presence) Taxonomy of Social Features: Scoping Review of Commercially Available eHealth Apps.

BACKGROUND: eHealth interventions have proven to be valuable resources for users with diverse mental and behavioral health concerns. As these technologies continue to proliferate, both academic researchers and commercial app creators are leveraging the use of features that foster a sense of social connection on these digital platforms. Yet, the literature often insufficiently represents the functionality of these key social features, resulting in a lack of understanding of how they are being implemented. OBJECTIVE: This study aimed to conduct a methodical review of commercially available eHealth apps to establish the SoCAP (social communication, affiliation, and presence) taxonomy of social features in eHealth apps. Our goal was to examine what types of social features are being used in eHealth apps and how they are implemented. METHODS: A scoping review of commercially available eHealth apps was conducted to develop a taxonomy of social features. First, a shortlist of the 20 highest-rated eHealth apps was derived from One Mind PsyberGuide, a nonprofit organization with trained researchers who rate apps based on their (1) credibility, (2) user experience, and (3) transparency. Next, both mobile- and web-based versions of each app were double-coded by 2 trained raters to derive a list of social features. Subsequently, the social features were organized by category and tested on other apps to ensure their completeness. RESULTS: Four main categories of social features emerged: (1) communication features (videoconferencing, discussion boards, etc), (2) social presence features (chatbots, reminders, etc), (3) affiliation and identity features (avatars, profiles, etc), and (4) other social integrations (social network and other app integrations). Our review shows that eHealth apps frequently use resource-intensive interactions (eg, videoconferencing with a clinician and phone calls from a facilitator), which may be helpful for participants with high support needs. Furthermore, among commercially available eHealth apps, there is a strong reliance on automated features (eg, avatars, personalized multimedia, and tailored content) that enhance a sense of social presence without requiring a high level of input from a clinician or staff member. CONCLUSIONS: The SoCAP taxonomy includes a comprehensive list of social features and brief descriptions of how these features work. This classification system will provide academic and commercial eHealth app creators with an understanding of the various social features that are commonly implemented, which will allow them to apply these features to enhance their own apps. Future research may include comparing the synergistic effects of various combinations of these social features.

Prospective associations of screen time at age 2 with specific behavioral subscales at age 3: a cohort study.

BACKGROUND: We aim to discover which, if any, of the subscales of internalizing and externalizing behavioral problems at age 3 are still associated with screen time (ST) at age 2 after adjusting for behavioral problems scores at age 2. METHODS: This study was conducted under the Tohoku Medical Megabank Project Birth and Three-Generation Cohort Study. Information was gathered prospectively, with 7207 mother-child pairs included in the analysis. Children's ST was categorized in hours a day at age 2 (<1, 1-<2, 2-<4, ≥4). We assessed children's behavioral problems using the Child Behavior Checklist for Ages 1½-5 (CBCL) at ages 2 and 3. 'Having behavioral problems' was defined by them being within a clinical range for internalizing behaviors (withdrawn, somatic complaints, anxious/depressed and emotionally reactive) and externalizing behaviors (attention problems and aggressive behaviors) at age 3. Continuous scores on each of the behavioral problem scales at age 2 were used as covariates. RESULTS: Greater ST for children at age 2 was associated with specific subscales for emotionally reactive and aggressive behaviors at age 3. CONCLUSIONS: This study found that ST is prospectively associated with some behavioral scales but not others.

Translating research evidence into youth behavioral health policy and action: using a community-engaged storyboard approach.

Introduction: There is nationwide shortage of child and adolescent behavioral health providers. Lack of diversity in the mental health care profession compounds workforce capacity issues, contributing to greater disparities in treatment access and engagement for youth from historically disenfranchised communities. Strategies are needed to foster cross-sector alignment to inform policy which can improve mental health care access and reduce disparities. This current case study details a specific research-practice-policy partnership strategy, storyboarding, as a method to engage community partners in Washington State to deliberate on information drawn from research on non-specialist models of child and adolescent mental health care to support the behavioral workforce expansion. Method: Research evidence from a scoping literature review on non-specialist models of child and adolescent mental health care was shared via storyboards with community partners to inform policy efforts around the behavioral health workforce expansion. In Phase 1, community members with lived experience and clinical expertise contributed to the storyboard design process. In Phase 2, a broader community partner group shared their perspectives on the models of care presented in the storyboards via Qualtrics survey with open-ended questions. Listening sessions were also held with non-English speaking refugee and immigrant communities to elicit feedback on whether these models of care would meet their needs. Qualitative data was coded to explore emerging themes using a rapid deductive approach. Results: Community partners shared mixed responses to models of care presented from the research literature. Immigrant and refugee communities explicitly stated these existing models would not fit their context. Regarding partnership strategy success, the smaller community partner group was engaged in the storyboard design process. The broader community interacted with and provided detailed responses to the models of care presented in the storyboards. Success was also reflected in community partners' continued participation in the next stage of the project. Discussion: Findings demonstrate how storyboarding can be effectively used to translate research evidence into accessible information to promote community partner engagement and capture community voice in policy processes. More work is needed exploring how such methods can be used to increase the use of research evidence in policy and practice spaces.

Pre-implementation planning to enhance integration of HIV and behavioral health care services at two Ryan White-funded HIV care centers.

Behavioral health conditions are disproportionately experienced by people living with Human immunodeficiency virus (HIV), including young Black gay, bisexual, and other men who have sex with men (GBMSM). Left unaddressed, these symptoms can adversely impact HIV care outcomes. Improving the integration of behavioral health and HIV care services has been proposed as a strategy to address this challenge. To conduct a pre-implementation study exploring barriers and facilitators to improving HIV and behavioral health care integration at two HIV clinics in Atlanta, Georgia. We conducted a mixed-methods study guided by the Consolidated Framework for Implementation Research (CFIR). Sixty (60) HIV care providers, behavioral health care providers, and social service providers participated in cross-sectional surveys, and a subset of survey participants (15) also participated in a qualitative in-depth interview to explore CFIR constructs in greater depth. We focused on Intervention Characteristics, Outer Setting, and Inner Setting as the most relevant CFIR domains. Within each of these domains, we identified both facilitators and barriers to improving HIV and behavioral care integration in the two clinics. Participants agreed that enhancing integration would provide a relative advantage over current practice, would address young Black GBMSM and other patient needs, and would be compatible with the organizational mission. However, they also expressed concerns about complexity, resource availability, and priority relative to other clinic initiatives. Participants were enthusiastic about improving care integration but also invoked practical challenges to translating this idea into practice. Future research should test specific implementation strategies and their potential effectiveness for improving the integration of behavioral health and HIV care, as a strategy for improving well-being among young Black GBMSM and other people living with HIV.

People living with Human immunodeficiency virus (HIV), including young Black gay, bisexual, and other men who have sex with men, often experience challenges related to behavioral health. We did a study to explore barriers and facilitators to improving the integration of behavioral health and HIV services at two HIV clinics in Atlanta, Georgia. Our study included interviews and surveys with sixty care providers. Participants shared that improving care integration was a good idea and would address patients' needs. However, they also expressed concerns about challenges that might get in the way of integrating care effectively. Future research should test different ways of improving care integration in these types of settings.

A Mixed-Methods Exploration of the Implementation of Policies That Earmarked Taxes for Behavioral Health.

Policy Points Earmarked tax policies for behavioral health are perceived as having positive impacts related to increasing flexible funding, suggesting benefits to expand this financing approach. Implementation challenges related to these earmarked taxes included tax base volatility that impedes long-term service delivery planning and inequities in the distribution of tax revenue. Recommendations for designing or revising earmarked tax policies include developing clear guidelines and support systems to manage the administrative aspects of earmarked tax programs, cocreating reporting and oversight structures with system and service delivery agents, and selecting revenue streams that are relatively stable across years. CONTEXT: Over 200 cities and counties in the United States have implemented policies earmarking tax revenue for behavioral health services. This mixed-methods study was conducted with the aim of characterizing perceptions of the impacts of these earmarked tax policies, strengths and weaknesses of tax policy designs, and factors that influence decision making about how tax revenue is allocated for services. METHODS: Study data came from surveys completed by 274 officials involved in behavioral health earmarked tax policy implementation and 37 interviews with officials in a sample of jurisdictions with these taxes-California (n = 16), Washington (n = 12), Colorado (n = 6), and Iowa (n = 3). Interviews primarily explored perceptions of the advantages and drawbacks of the earmarked tax, perceptions of tax policy design, and factors influencing decisions about revenue allocation. FINDINGS: A total of 83% of respondents strongly agreed that it was better to have the tax than not, 73.2% strongly agreed that the tax increased flexibility to address complex behavioral health needs, and 65.1% strongly agreed that the tax increased the number of people served by evidence-based practices. Only 43.3%, however, strongly agreed that it was easy to satisfy tax-reporting requirements. Interviews revealed that the taxes enabled funding for services and implementation supports, such as training in the delivery of evidence-based practices, and supplemented mainstream funding sources (e.g., Medicaid). However, some interviewees also reported challenges related to volatility of funding, inequities in the distribution of tax revenue, and, in some cases, administratively burdensome tax reporting. Decisions about tax revenue allocation were influenced by goals such as reducing behavioral health care inequities, being responsive to community needs, addressing constraints of mainstream funding sources, and, to a lesser degree, supporting services considered to be evidence based. CONCLUSIONS: Earmarked taxes are a promising financing strategy to improve access to, and quality of, behavioral health services by supplementing mainstream state and federal financing.

Protocol of a randomized controlled trial examining psychosocial enhancement and standard medication treatment for co-occurring opioid use and mental health disorders: A half fractional factorial randomized controlled trial.

BACKGROUND: The opioid epidemic disproportionately affects individuals with co-occurring opioid use and mental health disorders (COD), who often have poor treatment engagement. Multicomponent treatment models are popular solutions to increase treatment access and engagement for those with COD. Maintaining Independence and Sobriety through Systems Integration, Outreach and Networking (MISSION) is a hybrid multicomponent linkage and treatment approach that provides assertive community outreach combined with psychosocial treatment. This protocol paper describes a randomized controlled trial comparing MISSION and medication for opioid use disorder (MOUD), its multicomponent parts along with MOUD, and MOUD treatment as usual (TAU) to assess improvements in health and social outcomes. METHODS: This study will use a half fractional factorial design and randomize 1000 patients with COD to one of five treatment conditions: (1) the full MISSION intervention plus MOUD; (2-4) a combination of two out of three MISSION components plus MOUD; or (5) TAU. Secondary aims include examination of mechanisms of action, economic evaluation of the implementation of MISSION and/or its components plus MOUD versus TAU, and exploratory predictive modeling to match optimal MISSION parts with patient needs. DISCUSSION: This randomized controlled trial will help determine the effectiveness of MISSION (or its parts) and MOUD compared to TAU to improve engagement in treatment, substance use, and mental health symptoms. This trial is the first to compare MISSION and its parts with MOUD versus TAU in a real-world treatment scenario to determine which components are necessary and sufficient to drive treatment outcomes according to patient needs.

Expectations and Preferences for Digital Cessation Treatment: Multimethods Study Among Older Adults Who Smoke Cigarettes.

BACKGROUND: To address enduring age-related tobacco disparities, it is critical to promote cessation treatment among older adults (aged 65+ years). Digital health platforms offer opportunities for wide dissemination of evidence-based behavioral cessation support. However, existing digital cessation treatments are not tailored to unique aging-related needs and preferences, resulting in low uptake. Detailed information is needed about how to best adapt these treatments for this age group. OBJECTIVE: We aimed to collect detailed, hypothesis-generating information about expectations and preferences for cessation digital treatment among older adults who smoke cigarettes. METHODS: Semistructured interviews were conducted with adults aged 65+ years currently smoking or who had quit within the past month. Interviews included open-ended questions regarding prior experiences with digital health platforms and expectations and preferences for cessation treatment via various modalities (app-delivered, texting-based, or videoconferencing counseling). Interviews also elicited questions regarding digital modalities that integrated social components (app-delivered social forums and group videoconferencing counseling). Using an iterative, team-based approach, the thematic analysis identified meaningful themes. Interviews were supplemented with quantitative measures assessing sociodemographics, digital literacy, and physical health symptoms. RESULTS: Participants (12/20, 60% men; 15/20, 75% White; 4/20, 20% Black or African American; 1/20, 5% Asian) were currently smoking (17/20, 85%) or had recently quit (3/20, 15%). Thematic analysis identified 3 meaningful themes across all digital modalities: convenience, accessibility, and personalization. Expected benefits of digital platforms included convenient treatment access, without reliance on transportation. Participants preferred treatments to be personalized and deliver content or strategies beyond standard education. Most (17/20, 85%) were unfamiliar with cessation apps but found them appealing given the potential for offering a novel quitting strategy. App ease of use (eg, easy navigation) was preferred. Half (10/20, 50%) would try a texting-based intervention, with many preferring texting with a counselor rather than automated messaging. Most (17/20, 85%) would use videoconferencing and expected this modality to deliver better quality counseling than via telephone. Expected videoconferencing challenges included looking presentable onscreen, technological difficulties, and privacy or security. Videoconferencing was regarded as the most personalized digital treatment, yet benefits unique to app-delivered and texting-based treatments included anonymity and access to treatment 24/7. Participants expected integrating social components into digital treatment to be useful for quit success and social connection, yet were concerned about possible interpersonal challenges. CONCLUSIONS: Because a long history of quit attempts and familiarity with standard quitting advice is common among older adults who smoke cigarettes, digital platforms might offer appealing and novel strategies for cessation that are accessible and convenient. Overall, this population was open to trying digital cessation treatments and would prefer that these platforms prioritize ease of use and personalized content. These findings challenge the bias that older adults are uninterested or unwilling to engage with digital treatments for behavioral health.