Perceived Effect of Research on Clinical Care for Women With Opioid Use Disorder.

OBJECTIVE: To describe the perceived effects of clinical research and program evaluation on perceptions of clinical care among women with opioid use disorder (OUD) and their health care providers. DESIGN: Qualitative descriptive. SETTING: Four specialty clinics in academic medical centers that provide care for pregnant women with OUD. PARTICIPANTS: Women with OUD during pregnancy or the postpartum period ("women participants"; n = 20) and health care providers ("provider participants"; n = 37). All staff in the clinics were invited to participate in focus groups. METHODS: We conduced focus groups and interviews with the women and provider participants to understand the perceived effects of clinical research and program evaluation on their perceptions of clinical care among women with OUD. We audio recorded, transcribed, and analyzed sessions using qualitative content analysis. RESULTS: Overall, nine themes emerged from the data. Two themes emerged in common among data from the providers and women data: Demands on Women's Time and Challenging Research Topics. Seven additional themes emerged only from the provider data: Potential to Improve Clinical Practice, FundingOpportunities to Provide Services, Burden to Clinical Flow, Overwhelming Number of Studies, Pressure to Engage in Research, Clinic Level Controls to Reduce Research Burden and Potential for Coercion, and Meaningful Input on the Research Process. CONCLUSION: Providers and women shared similar opinions about the opportunities and challenges of research focused on women with OUD. Providers suggested ways to improve the integration of research activities into clinical settings.

An economic cost analysis of an expanding, multi-state behavioural telehealth intervention.

INTRODUCTION: In this paper the economic costs associated with a growing, multi-state telepsychiatry intervention serving rural American Indian/Alaska Native populations were compared to costs of travelling to provide/receive in-person treatment. METHODS: Telepsychiatry costs were calculated using administrative, information-technology, equipment and technology components, and were compared to travel cost models. Both a patient travel and a psychiatrist travel model were estimated utilising ArcGIS software and unit costs gathered from literature and government sources. Cost structure and sensitivity analysis was also calculated by varying modeling parameters and assumptions. RESULTS AND DISCUSSION: It is estimated that per-session costs were $93.90, $183.34, and $268.23 for telemedicine, provider-travel, and patient-travel, respectively. Restricting the analysis to satellite locations with a larger number of visits reduced telemedicine per-patient encounter costs (50 or more visits: $83.52; 100 or more visits: $80.41; and 150 or more visits: $76.25). The estimated cost efficiencies of telemedicine were more evident for highly rural communities. Finally, we found that a multi-state centre was cheaper than each state operating independently. CONCLUSIONS: Consistent with previous research, this study provides additional evidence of the economic efficiency associated with telemedicine interventions for rural American Indian/Alaska Native populations. Our results suggest that there are economies of scale in providing behavioural telemedicine and that bigger, multi-state telemedicine centres have lower overall costs compared to smaller, state-level centres. Additionally, results suggest that telemedicine structures with a higher number of per-satellite patient encounters have lower costs, and telemedicine centres delivering care to highly rural populations produce greater economic benefits.

State Legislative Approach to Enumerating Behavioral Health Workforce Shortages: Lessons Learned in New Mexico.

Nationally, the behavioral health workforce is in crisis because of a lack of resources, culturally responsive services, quality clinical supervision, sufficient training in evidence-based practices, and targeted recruitment and retention. Disparities in access to behavioral health care are particularly significant in New Mexico, where 25% of the population live in rural areas, and behavioral health shortages are among the highest in the nation. Additionally, as a Medicaid expansion state, New Mexico providers experience increased demand for services at a time when the state is challenged with limited workforce capacity. To address this issue, the Health Care Work Force Data Collection, Analysis and Policy Act was legislatively enacted in 2011 to systematically survey all state licensed health professionals to determine reasons for the healthcare shortage and address the shortage through policy. The Act was amended in 2012 to transfer all data to the University of New Mexico Health Sciences Center. In 2015, a total of 4,488 behavioral health providers completed a survey as a mandatory part of their license renewal. Findings from the survey indicate a dearth of licensed behavioral health providers representative of the populations served, limited access to services via Medicaid and Medicare payer sources, limited access to providers working in public health settings, and limited access to Health Information Technology. This paper describes the workforce context in New Mexico, the purpose of the legislation, the analytic findings from the survey, the policies implemented as a result of these efforts, lessons learned, and a discussion of the relevancy of the New Mexico model for other states. SUPPLEMENT INFORMATION: This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration of the U.S. Department of Health and Human Services.

A cost comparison of travel models and behavioural telemedicine for rural, Native American populations in New Mexico.

OBJECTIVE: The purpose of this study was to model the cost of delivering behavioural health services to rural Native American populations using telecommunications and compare these costs with the travel costs associated with providing equivalent care. METHODS: Behavioural telehealth costs were modelled using equipment, transmission, administrative and IT costs from an established telecommunications centre. Two types of travel models were estimated: a patient travel model and a physician travel model. These costs were modelled using the New Mexico resource geographic information system program (RGIS) and ArcGIS software and unit costs (e.g. fuel prices, vehicle depreciation, lodging, physician wages, and patient wages) that were obtained from the literature and US government agencies. RESULTS: The average per-patient cost of providing behavioural healthcare via telehealth was US$138.34, and the average per-patient travel cost was US$169.76 for physicians and US$333.52 for patients. Sensitivity analysis found these results to be rather robust to changes in imputed parameters and preliminary evidence of economies of scale was found. CONCLUSION: Besides the obvious benefits of increased access to healthcare and reduced health disparities, providing behavioural telehealth for rural Native American populations was estimated to be less costly than modelled equivalent care provided by travelling. Additionally, as administrative and coordination costs are a major component of telehealth costs, as programmes grow to serve more patients, the relative costs of these initial infrastructure as well as overall per-patient costs should decrease.

Disability and comorbidity: diagnoses and symptoms associated with disability in a clinical population with panic disorder.

Background. Anxiety disorders are associated with considerable disability in the domains of (1) work, (2) social, and (3) family and home interactions. Psychiatric comorbidity is also known to be associated with disability. Methods. Data from the Cross-National Collaborative Panic Study was used to identify rates of comorbid diagnoses, anxiety and depression symptom ratings, and Sheehan disability scale ratings from a clinical sample of 1165 adults with panic disorder. Results. Comorbid diagnoses of agoraphobia, major depression, and social phobia were associated with disability across the three domains of work, social, and family and home interactions. The symptom of agoraphobic avoidance makes the largest contribution to disability but there is no single symptom cluster that entirely predicts impairment and disability. Limitations. The findings about the relative contributions that comorbid diagnoses make to disability only apply to a population with panic disorder. Conclusions. Although panic disorder is not generally considered to be among the serious and persistent mental illnesses, when it is comorbid with other diagnoses, it is associated with considerable impairment. In particular, the presence of agoraphobic avoidance should alert the clinician to the likelihood of important functional impairment. When measuring the functional impact of comorbid anxiety disorders, both the categorical and the dimensional approaches to diagnosis make valuable contributions.

Organizational factors influencing implementation of evidence-based practices for integrated treatment in behavioral health agencies.

Objective. In recent years, New Mexico has prioritized integrated treatment for cooccurring mental health and substance use disorders within its public behavioral health system. This report describes factors likely to be important when implementing evidence-based practices (EBPs) in community agencies. Methods. Our mixed-method research design consisted of observations, semistructured interviews, and surveys undertaken with employees at 14 agencies at baseline and after 18 months. We developed four-agency typologies based on iterative coding and analysis of observations and interviews. We then examined survey data from employees at the four exemplar agencies to validate qualitative findings. Results. Financial resources and strong leadership impacted agency capacity to train providers and implement EBPs. Quantitative analysis of service provider survey responses from these agencies (N = 38) supported qualitative findings and demonstrated significant mean score differences in leadership, organizational climate, and attitudes toward EBPs in anticipated directions. Conclusion. The availability of strong leadership and financial resources were key components to initial implementation success in this study of community agencies in New Mexico. Reliance only on external funding poses risks for sustainment when demoralizing work climates precipitate employee turnover. Strong agency leadership does not always compensate for deficient financial resources in vulnerable communities.

Training psychiatrists for rural practice: a 20-year follow-up.

OBJECTIVE: This report describes the Rural Psychiatry Residency Program at the University of New Mexico (UNM RPRP) and presents findings from a survey of program graduates. METHODS: Current practice location of residency graduates was identified to learn whether graduates of the UNM RPRP continued to practice in rural communities compared to the graduates of the traditional residency program. Additionally, a web-based survey was completed by 37 of the 60 graduates who participated in the UNM RPRP since its inception in 1991 through 2010. Questions addressed current practice, perceived barriers, and perceptions of experiences. RESULTS: Thirty-seven percent of the graduates from the UNM RPRP currently practice in rural communities compared to 10 % of the graduates from the traditional residency track. Of the survey respondents, 95 % continue to work with underserved individuals. Reported barriers to practice in rural areas include professional isolation, lack of referral resources, and travel distances. Respondents reported valuing education about systems based practice and telepsychiatry. CONCLUSION: Purposeful and well-coordinated educational opportunities situated in rural community health clinics can address some of the barriers for recruiting and retaining practicing psychiatrists in rural areas. Practical skill building at the individual, agency, and system level is integral in training psychiatrists for work in these communities. In particular, the use of telepsychiatry emerged as an important practical application for the provision of rural mental health care.

Perspectives on trauma-informed care from mothers with a history of childhood maltreatment: a qualitative study.

Women who experienced abuse or neglect as children are more likely to have health problems during pregnancy and postpartum, but can be reluctant to seek help due to a lack of trauma-informed services. As part of a larger mixed method study, this component aimed to obtain qualitative data from trauma-exposed new mothers about their health care preferences during the perinatal period with the ultimate goal to design personalized, supportive interventions. Fifty-two trauma-exposed mothers completed a semi-structured interview at seven months postpartum about health care preferences including ideas for programs that promote wellness, thoughts about the influences of being a new mother and possible names for a program serving trauma-exposed mothers. Interviews were transcribed and coded using N-Vivo. Participants described ambivalence about seeking help but also a sincere desire for healing, coupled with hope for the future. This tension was apparent in the discussions highlighting the importance of access to experienced, nonjudgmental, and knowledgeable health and social care staff and volunteers, the wish for both formal, integrated physical and mental health services, and for informal opportunities to meet other trauma-exposed mothers in a non-stigmatizing, child-friendly setting. Finally, positive relationship-building, respect, and safety were identified as key elements of services critical to counteract trauma-related shame and mistrust in others. Services for trauma-exposed mothers should acknowledge the normal ambivalence surrounding seeking help, but promote hope-affirming practices in a family-centered, safe, non-clinical setting that involves children, builds social support, and provides peer interaction. Program names should reflect optimism and healing rather than trauma.

"An Old Way to Solve an Old Problem": Provider Perspectives on Recovery-Oriented Services and Consumer Capabilities in New Mexico.

The goal of recovery has emerged as a core value in the reformation of public and private mental health services in the last twenty years. However, definitions of recovery remain as varied as methods of implementation. Through an ethnographic lens, we examine meanings of recovery in the context of a major statewide reform of mental health services in New Mexico, focusing specifically on provider-voiced concerns regarding recovery and recovery-oriented care. We argue that the concept of recovery functions as a symbol that seemingly reconciles the long-standing tension between biological and social explanations of mental illness. Drawing upon provider perspectives, we also discuss concerns that popular rhetoric about recovery may mask some needed fundamental changes to transform the mental health system to a recovery orientation. Finally, we consider recovery from a capabilities standpoint and discuss how this view lends itself to addressing both individual and social components of mental illness.

Understanding the goals of service learning and community-based medical education: a systematic review.

PURPOSE: To understand the educational goals of projects described as "service learning" or "community-based medical education" and to learn how relationships between medical schools and community members are discussed in these projects. METHOD: In 2008, the authors performed a systematic qualitative content analysis of 57 articles, published since 1990, that addressed community placements for U.S. medical students. After the initial analysis, the academic-based authors conveyed their findings to their community partner and coauthor, received input on relevance and priority of themes, and then refined their analysis accordingly. RESULTS: The authors identified five main findings: (1) Considerable heterogeneity existed across projects, (2) although medical schools aimed to improve the health of the community, they did not routinely involve community members in the identification of local health priorities, (3) educators were enthusiastic about community-based education as a method for teaching complicated ideas such as social determinants of health, (4) many authors emphasized community placements as being equivalent to traditional curricula, and (5) the articles did not emphasize the concept of reciprocal knowledge transfer. CONCLUSIONS: The authors found little emphasis on the reciprocal nature of partnerships between communities and medical schools. They propose that the principle of community partnership within medical education could train a cohort of medical students prepared to practice in the rapidly changing health care environment-one that now includes an important new agenda of community accountability.

Are second generation antipsychotics a distinct class?

INTRODUCTION: Second generation antipsychotic medications have become synonymous with "atypicality." To support the clinical lore of equivalent efficacy with reduced risk of extrapyramidal symptoms, clinical trials have overwhelmingly chosen a high-potency first-generation antipsychotic (e.g., haloperidol) as a comparator. Very few clinical trials have compared a second-generation antipsychotic with a low- or mid-potency first-generation antipsychotic medication. METHODS: We identified eight completed, published, double-blind, randomized clinical trials that compared a second-generation antipsychotic with a low- or mid-potency first-generation antipsychotic and reviewed outcome measures for efficacy and extrapyramidal symptoms; 1,241 patients were represented in these eight trials. RESULTS: Although data are very limited, mid- and low-potency first-generation antipsychotics show efficacy and extrapyramidal side effects that are comparable to those of second-generation antipsychotics. CONCLUSION: Aside from clozapine, first-generation and second-generation antipsychotics represent a diverse group of medications that have heterogenous receptor profiles and side effects but comparable clinical efficacy and potential to cause extrapyramidal symptoms. Clinicians may provide better treatment for patients by considering the unique pharmacological and side-effect profile of each particular antipsychotic independent of its classification as a first- or second-generation agent.