Pilot evaluation of the Fiscal Mapping Process for sustainable financing of evidence-based youth mental health treatments: A comparative case study analysis.

Background: Sustained delivery of evidence-based treatments (EBTs) is essential to addressing the public health impacts of youth mental health problems, but is complicated by the limited and fragmented funding available to youth mental health service agencies. Supports are needed that can guide service agencies in accessing sustainable funding for EBTs. We conducted a pilot evaluation of the Fiscal Mapping Process, an Excel-based strategic planning tool that helps service agency leaders identify and coordinate financing strategies for their EBT programs. Method: Pilot testing of the Fiscal Mapping Process was completed with 10 youth mental health service agencies over a 12-month period, using trauma-focused cognitive-behavioral therapy or parent-child interaction therapy programs. Service agency representatives received initial training and monthly coaching in using the tool. We used case study methods to synthesize all available data (surveys, focus groups, coaching notes, document review) and contrast agency experiences to identify key findings through explanation building. Results: Key evaluation findings related to the process and outcomes of using the Fiscal Mapping Process, as well as contextual influences. Process evaluation findings helped clarify the primary use case for the tool and identified the importance-and challenges-of engaging external collaborators. Outcome evaluation findings documented the impacts of the Fiscal Mapping Process on agency-reported sustainment capacities (strategic planning, funding stability), which fully explained reported improvements in outcomes (extent and likelihood)-although these impacts were incremental. Findings on contextual factors documented the influence of environmental and organizational capacities on engagement with the tool and concerns about equitable impacts, but also the view that the process could usefully generalize to other EBTs. Conclusions: Our pilot evaluation of the Fiscal Mapping Process was promising. In future work, we plan to integrate the tool into EBT implementation initiatives and test its impact on long-term sustainment outcomes across various EBTs, while increasing attention to equity considerations.

Pilot-Testing a Tool for Planning the Sustainable Financing of Youth Mental Health Treatments that Work Plain Language Summary Youth mental health treatments that work must be consistently available to improve youth mental health in our communities, but funding for these treatments is often limited and hard to access. Youth mental health service agencies need tools that can help guide them in accessing sustainable funding for evidence-based treatments. We developed the Fiscal Mapping Process, an Excel-based strategic planning tool for planning sustainable financing of youth mental health treatment programs, and conducted a 1-year pilot-testing evaluation with 10 youth mental health service agencies. We used case study methods to compare and contrast agency experiences with using the tool, related to the process, outcomes, and contextual influences on using the Fiscal Mapping Process. Key findings included clarification of the ideal characteristics of contributors and treatment programs for using the tool; initial confirmation that the tool can improve agency-reported capacities for sustaining treatments that work and long-term sustainment outlooks, although these impacts were incremental; and documentation of the influence of environmental and organizational capacities on engagement with the tool, concerns about equitable impacts, and user views that the process could be applied to a wide range of treatment models. In summary, our pilot evaluation of the Fiscal Mapping Process showed that this tool is promising for supporting the financial sustainment of treatments that work in youth mental health services. In future research, we plan to incorporate the tool into real-world training initiatives with mental health service agencies, test its impact on long-term sustainment across a variety of treatment models, and incorporate attention to equity considerations.

Perspectives on Financing Strategies for Evidence-Based Treatment Implementation in Youth Mental Health Systems.

BACKGROUND: Evidence-based treatments (EBTs) are critical to effectively address mental health problems among children and adolescents, but costly for mental health service agencies to implement and sustain. Financing strategies help agencies overcome cost-related barriers by obtaining financial resources to support EBT implementation and/or sustainment. AIMS: We sought to (i) understand how youth mental health system decision-makers involved with EBT implementation and sustainment view key features (e.g., relevance, feasibility) that inform financing strategy selection and (ii) compare service agency, funding agency, and intermediary representative perspectives. METHOD: Two surveys were disseminated to 48 representatives across U.S. youth mental health service agencies, funding agencies, and intermediaries who were participating in a larger study of financing strategies. Quantitative and qualitative data were gathered on 23 financing strategies through quantitative ratings and open-ended responses. Data were analyzed using descriptive statistics and rapid content analysis. RESULTS: The financing strategies rated as most relevant include braided funding streams, contracts for EBTs, credentialing/rostering providers, fee-for-service reimbursement (regular and increased), and grant funding. All other strategies were unfamiliar to 1/3 to 1/2 of participants. The six strategies were rated between somewhat and quite available, feasible, and effective for EBT sustainment. For sustaining different EBT components (e.g., delivery, materials), the mix of financing strategies was rated as somewhat adequate. Qualitative analysis revealed challenges with strategies being non-recurring or unavailable in representatives' regions. Ratings were largely similar across participant roles, though funding agency representatives were the most familiar with financing strategies. DISCUSSION: Despite the breadth of innovative financing strategies, expert representatives within the youth mental health services ecosystem had limited knowledge of most options. Experts relied on strategies that were familiar but often did not adequately support EBT implementation or sustainment. These findings underscore more fundamental issues with under-resourced mental health systems in the U.S.; financing strategies can help agencies navigate EBT use but must be accompanied by larger-scale system reforms. Limitations include difficulties generalizing results due to using a small sample familiar with EBTs, high agreement as a potential function of snowball recruiting, and limited responses to the open-ended survey questions. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Although EBTs have been found to effectively address mental health problems in children and adolescents, available strategies for financing their implementation and sustainment in mental health systems are insufficient. This constraint prevents many children and adolescents from receiving high-quality services. IMPLICATIONS FOR HEALTH POLICIES: Financing strategies alone cannot solve systematic issues that prevent youth mental health service agencies from providing EBTs. Policy changes may be required, such as increased financial investment from the U.S. government into mental health services to support basic infrastructure (e.g., facility operations, measuring outcomes). IMPLICATIONS FOR FURTHER RESEARCH: Future work should examine expert perspectives on EBT financing strategies in different contexts (e.g., substance use services), gathering targeted feedback on financing strategies that are less well known, and exploring topics such as strategic planning, funding stability, and collaborative decision-making as they relate to EBT implementation and sustainment.

Coordination of sustainable financing for evidence-based youth mental health treatments: protocol for development and evaluation of the fiscal mapping process.

BACKGROUND: Sustained delivery of evidence-based treatments (EBTs) is essential to addressing the public health and economic impacts of youth mental health problems, but is complicated by the limited and fragmented funding available to youth mental health service agencies (hereafter, "service agencies"). Strategic planning tools are needed that can guide these service agencies in their coordination of sustainable funding for EBTs. This protocol describes a mixed-methods research project designed to (1) develop and (2) evaluate our novel fiscal mapping process that guides strategic planning efforts to finance the sustainment of EBTs in youth mental health services. METHOD: Participants will be 48 expert stakeholder participants, including representatives from ten service agencies and their partners from funding agencies (various public and private sources) and intermediary organizations (which provide guidance and support on the delivery of specific EBTs). Aim 1 is to develop the fiscal mapping process: a multi-step, structured tool that guides service agencies in selecting the optimal combination of strategies for financing their EBT sustainment efforts. We will adapt the fiscal mapping process from an established intervention mapping process and will incorporate an existing compilation of 23 financing strategies. We will then engage participants in a modified Delphi exercise to achieve consensus on the fiscal mapping process steps and gather information that can inform the selection of strategies. Aim 2 is to evaluate preliminary impacts of the fiscal mapping process on service agencies' EBT sustainment capacities (i.e., structures and processes that support sustainment) and outcomes (e.g., intentions to sustain). The ten agencies will pilot test the fiscal mapping process. We will evaluate how the fiscal mapping process impacts EBT sustainment capacities and outcomes using a comparative case study approach, incorporating data from focus groups and document review. After pilot testing, the stakeholder participants will conceptualize the process and outcomes of fiscal mapping in a participatory modeling exercise to help inform future use and evaluation of the tool. DISCUSSION: This project will generate the fiscal mapping process, which will facilitate the coordination of an array of financing strategies to sustain EBTs in community youth mental health services. This tool will promote the sustainment of youth-focused EBTs.

Incorporating the Patient and Caregiver Voice in Palliative Care Quality Measure Development.

CONTEXT: Despite rapid growth in outpatient palliative care, we lack an understanding of patient and caregiver experiences of care received in this context. OBJECTIVES: As part of a national effort to develop palliative care quality metrics for use in accountability programs, we sought to develop survey items assessing patients' experiences of outpatient palliative care, incorporating the patient's voice. METHODS: We conducted 25 one-hour telephone cognitive interviews using a convenience sample of outpatient palliative care patients and caregivers to cognitively test survey items. Guided by a semi-structured protocol, we assessed the comprehensibility, ambiguity, and adaptability of survey instructions and specific items/response options. RESULTS: Participants generally understood the intended meaning of the question content. Some participants struggled with the stated time period of three months as a reference period for reporting their experiences. While some expressed preferences for question wording, no clear patterns emerged across participants. CONCLUSION: In general, question wording and response options did not present challenges to understanding content. Respondents ascribed a variety of meanings to the concepts, validating that the measures capture a range of experiences. However, the referenced timeframe of three months was more difficult to answer for some questions than others. Implications for research, policy or practice: Based on the findings from the cognitive testing, the survey items are being tested as part of a national study to understand the quality of care for patients. These measures may be used in the future by Medicare to help outpatient palliative care programs improve their care.

Assessing Assessments: Substance use disorder treatment providers' perceptions of intake assessments.

Background: Assessments to determine patients' treatment needs and preferences when they begin substance use disorder (SUD) treatment are essential. The objectives of this paper are to identify the perspectives of providers who conduct assessments on (1) assessments' utility in determining the level of care where patients will receive treatment, (2) strategies to engage patients in treatment during assessments, and (3) assessment strengths and shortcomings. Methods: Semi-structured interviews were conducted with 30 California treatment providers who routinely perform SUD assessments for Medicaid beneficiaries. Interviews asked about the utility of assessment tools in determining appropriate levels of care, patient engagement during assessments, and strengths and shortcomings of intake assessment processes. Interviews were audio-recorded, transcribed, and analyzed by multiple researchers using template analysis. Results: Providers reported that assessments linked to level-of-care decision rules sometimes generate recommendations inconsistent with their clinical judgment, and that the timing of assessments can influence the quality of the information collected. Providers described engagement strategies that help patients feel more comfortable during assessments and that encourage more thoughtful and accurate responses. Providers valued assessments that helped ensure comprehensive collection of patient information, that allowed flexibility to probe for additional information and context, and that facilitated treatment planning. Providers did not like assessments that were long and repetitive or those that did not collect detailed information about patients' mental health and recovery environments. Conclusions: Assessments can be improved if providers conduct them in a manner that makes patients feel comfortable while building trust and rapport. Ensuring that assessments are not long or repetitive and giving comprehensive assessments once patients have developed trusting relationships with treatment programs can improve assessment processes. Further research is needed to optimize SUD assessments.

Addiction Treatment and Telehealth: Review of Efficacy and Provider Insights During the COVID-19 Pandemic.

OBJECTIVE: Addiction treatment via telehealth expanded to unprecedented levels during the COVID-19 pandemic. This study aimed to clarify whether the research evidence on the efficacy of telehealth-delivered substance use disorder treatment and the experience of providers using telehealth during the pandemic support continued use of telehealth after the pandemic and, if so, under what circumstances. METHODS: Data sources included a literature review on the efficacy of telehealth for substance use disorder treatment, responses to a 2020 online survey from 100 California addiction treatment providers, and interviews with 30 California treatment providers and other stakeholders. RESULTS: Eight published studies were identified that compared addiction treatment via telehealth with in-person treatment. Seven found telehealth treatment as effective but not more effective than in-person treatment in terms of retention, therapeutic alliance, and substance use. One Canadian study found that telehealth facilitated methadone prescribing and improved retention. In the survey results reported here, California addiction treatment providers said that more than 50% of their patients were being treated via telehealth for intensive outpatient treatment, individual counseling, group counseling, and intake assessment. They were most confident that individual counseling via telehealth was as effective as in-person individual counseling and less sure about the relative effectiveness of telehealth-delivered medication management, group counseling, and intake assessments. CONCLUSIONS: Telehealth may help engage patients in addiction treatment by improving access and convenience. Additional research is needed to confirm that benefit and to determine how best to tailor telehealth to each patient's circumstances and with what mix of in-person and telehealth services.

Impact of the Coronavirus Pandemic on Substance Use Disorder Treatment: Findings from a Survey of Specialty Providers in California.

BACKGROUND: As the coronavirus pandemic public health emergency begins to ebb in the United States, policymakers and providers need to evaluate how the addiction treatment system functioned during the public health emergency and draw lessons for future emergencies. One important question is whether the pandemic curtailed the use of addiction treatment and the extent to which telehealth was able to mitigate access barriers. METHODS: To begin to answer this question, we conducted a survey of specialty addiction treatment providers in California from June 2020 through July 2020. The survey focused specifically on provider organizations that served Medicaid beneficiaries. RESULTS: Of the 133 respondents, 50% reported a decrease in patients since the stay-at-home order in March 2020, with the largest decline among new patients, and 58% said more patients were relapsing. Eighty-one percent of providers said that telemedicine use had increased since the stay-at-home order. Most said that telemedicine had moderately (48%) or completely (30%) addressed access barriers. CONCLUSION: More efforts are needed to ensure that patients, and in particular new patients, receive addiction treatment during public health emergencies.

"The assessment really helps you with the first step in recovery." What do clients think substance use disorder treatment intake assessments should look like?

Background: In general, research has found that patient-centered substance use disorder treatment is positively correlated with improved patient outcomes. However, little research has examined what factors make intake assessments-the first step in addiction treatment-patient-centered. Methods: We conducted interviews with 30 Medicaid-enrolled individuals who received addiction treatment in California about their experiences with the intake assessment process. Results: Participants reported that the intake assessment process evoked strong feelings, both positive and negative. Some participants said that answering detailed questions about their substance use, mental health, and social relationships, for example, was cathartic and gave them helpful insights. Other participants found the questions invasive, exhausting, and anxiety provoking. Participants also emphasized how critical it is for the person conducting the assessment to be supportive, nonjudgmental, and attentive. Participants recommended delaying the comprehensive assessment because they did not feel physically or emotionally ready to complete the intake. Conclusions and recommendations: Patients' introduction to addiction treatment is typically the intake assessment. By understanding how patients experience intake assessments, providers can make the process more patient-centered, which may lead to improved patient outcomes.

HIV and Mother-Child Conflict: Associations with Mother's Mental and Physical Health.

Maternal illness is a stressor that can disrupt family processes and contribute to negative child outcomes, and researchers have considered family variables that mediate or moderate the maternal illness-child outcome relationship. Through reliance on a diverse sample (ethnically and racially, as well as geographically), the current study expands prior literature with a focus on parent-child conflict. Specifically, associations between aspects of HIV positive mothers' illness and mother-child conflict were explored. One goal of the study was to determine if there were direct or indirect associations with aspects of mothers' HIV and mother-child conflict. HIV-positive mothers (N = 136) provided CD4 count and completed measures assessing their perceived level of physical functioning, depressive symptoms, HIV health-related anxiety, and mother-child conflict with their healthy school-age children. Path analysis considered the pattern of relationships across variables. Results showed maternal vitality and depressive symptoms were directly associated with mother-child conflict. CD4 cell count and health-related anxiety operated indirectly through maternal depressive symptoms. Mediation analyses further assessed the influence of maternal CD4 cell count on mother-child conflict behavior; results indicated an indirect effect was mediated by vitality. HIV health-related anxiety and vitality separately showed indirect effects on mother-child conflict, mediated by maternal depressive symptoms. These findings are the first to focus on mother-child conflict among children affected by maternal HIV and highlight the need for screening and intervention to address depressive symptoms among HIV-positive mothers.

Influence of an Implementation Support Intervention on Barriers and Facilitators to Delivery of a Substance Use Prevention Program.

Implementation support interventions have helped organizations implement programs with quality and obtain intended outcomes. For example, a recent randomized controlled trial called Preparing to Run Effective Programs (PREP) showed that an implementation support intervention called Getting To Outcomes (GTO) improved implementation of an evidence-based substance use prevention program (CHOICE) run in community-based settings. However, more information is needed on how these interventions affect organizational barriers and facilitators of implementation. This paper aims to identify differences in implementation facilitators and barriers in sites conducting a substance use prevention program with and without GTO. PREP is a cluster-randomized controlled trial testing GTO, a two-year implementation support intervention, in Boys & Girls Clubs. The trial compares 15 Boys & Girls Club sites implementing CHOICE (control group), a five-session evidence-based alcohol and drug prevention program, with 14 Boys & Girls Club sites implementing CHOICE supported by GTO (intervention group). All sites received CHOICE training. Intervention sites also received GTO manuals, training, and onsite technical assistance to help practitioners complete implementation best practices specified by GTO (i.e., GTO steps). During the first year, technical assistance providers helped the intervention group adopt, plan, and deliver CHOICE, and then evaluate and make quality improvements to CHOICE implementation using feedback reports summarizing their data. Following the second year of CHOICE and GTO implementation, all sites participated in semi-structured interviews to identify barriers and facilitators to CHOICE implementation using the Consolidated Framework for Implementation Research (CFIR). This paper assesses the extent to which these facilitators and barriers differed between intervention and control group. Intervention sites had significantly higher average ratings than control sites for two constructs from the CFIR process domain: planning and reflecting and evaluating. At the same time, intervention sites had significantly lower ratings on the culture and available resources constructs. Findings suggest that strong planning, evaluation, and reflection-likely improved with GTO support-can facilitate implementation even in the face of perceptions of a less desirable implementation climate. These findings highlight that implementation support, such as GTO, is likely to help low-resourced community-based organizations improve program delivery through a focus on implementation processes. TRIAL REGISTRATION: This project is registered at ClinicalTrials.gov with number NCT02135991 (URL: https://clinicaltrials.gov/show/NCT02135991). The trial was first registered May 12, 2014.

Discretionary calorie intake a priority for obesity prevention: results of rapid participatory approaches in low-income US communities.

BACKGROUND: Since resources are limited, selecting the most promising targets for obesity interventions is critical. We examined the relative associations of physical activity, fruit and vegetable consumption and 'junk food' consumption with BMI and the prevalence of relevant policies in school, work, food outlets and health-care settings. METHODS: We conducted intercept surveys in three low-income, high-minority California communities to assess fruit, vegetable, candy, cookie, salty snacks and sugar-sweetened beverage consumption and self-reported height, weight and physical activity. We also assessed relevant policies in selected worksites, schools and health-care settings through key informant interviews. RESULTS: Data were collected from 1826 respondents, 21 schools, 40 worksites, 14 health-care settings and 29 food outlets. The average intake of salty snacks, candy, cookies and sugar-sweetened beverages was estimated at 2226 kJ (532 kcal) daily, 88% higher than the US Department of Agriculture/Department of Health and Human Services guidelines recommend. Energy from these sources was more strongly related to BMI than reported physical activity, fruit or vegetable consumption. Policies to promote healthy eating and physical activity were limited in worksites. Fruits and vegetables were less salient than junk food in community food outlets. CONCLUSION: Targeting consumption of salty snacks, candy cookies and sugar-sweetened beverages appeared more promising than alternative approaches.