Factors Influencing Turnover and Attrition in the Public Behavioral Health System Workforce: Qualitative Study.

Many states are experiencing a behavioral health workforce crisis, particularly in the public behavioral health system. An understanding of the factors influencing the workforce shortage is critical for informing public policies to improve workforce retention and access to care. The aim of this study was to assess factors contributing to behavioral health workforce turnover and attrition in Oregon. Semistructured qualitative interviews were conducted with 24 behavioral health providers, administrators, and policy experts with knowledge of Oregon's public behavioral health system. Interviews were transcribed and iteratively coded to reach consensus on emerging themes. Five key themes emerged that negatively affected the interviewees' workplace experience and longevity: low wages, documentation burden, poor physical and administrative infrastructure, lack of career development opportunities, and a chronically traumatic work environment. Large caseloads and patients' high symptom acuity contributed to worker stress. At the organizational and system levels, chronic underfunding and poor administrative infrastructure made frontline providers feel undervalued and unfulfilled, pushing them to leave the public behavioral health setting or behavioral health altogether. Behavioral health providers are negatively affected by systemic underinvestment. Policies to improve workforce shortages should target the effects of inadequate financial and workplace support on the daily work environment.

Integrating substance use care into primary care for adolescents and young adults: Lessons learned.

BACKGROUND: Substance use disorders are common chronic conditions that often begin and develop during adolescence and young adulthood, yet the delivery of primary care is not developmentally tailored for youth who use substances. Very few primary care-based substance use treatment programs exist in the United States for adolescents and young adults and no clear guidance is available about how to provide substance use treatment in primary care. METHODS: We conducted a retrospective evaluation from July 2016 to December 2018 of a newly established primary care-based, multidisciplinary, outpatient program for youth who use substances. Components of the program include primary care, addiction treatment, harm reduction, naloxone distribution, psychotherapy, recovery support, and navigation addressing social determinants of health. We report the following patient characteristics and outcomes: demographics; proportion with substance use and mental health diagnoses; receipt of medications for opioid use disorder; retention in care at three, six, nine, and 12 months; and re-engagement in medical care. RESULTS: From July 2016 through December 2018, 148 patients had at least one visit. Demographic characteristics included: median age 21 years; 40.5% female; 94.0% spoke primarily English; 18.3% Black, 14.9% Hispanic, and 60.8% white. One-third of patients (33.8%) were homeless or housing insecure. The most common substance use disorder was opioid use disorder (60.8%), followed by nicotine (37.2%), cannabis (20.9%), and alcohol (18.2%). Overall, 29.7% of patients had depression, 32.4% had anxiety disorder, and 18.9% had post-traumatic stress disorder. Retention in care was 29.7% at six months and 12.2% at 12 months. Among the 90 patients with OUD, 90.0% received medication for OUD, and 35.5% and 15.5% of patients with OUD were retained at six and 12 months, respectively. For patients lost to follow-up (no contact during a three-month period), the median time to re-engagement was 4.8 months, and 33.3% (37/111) of patients re-engaged. The most common reason for re-engagement was to access mental health treatment (59.5%) and primary care (51.4%). CONCLUSIONS: Youth who sought care in a primary care-based substance use program presented most commonly with opioid, nicotine, cannabis, and alcohol use disorders. Co-morbid mental health diagnoses were common. While continuous retention at 12 months was low, one in three of the patients who fell out of care re-engaged. For youth receiving substance use care integrated into primary care, key components for pursing optimal retention in substance use treatment are a flexible model that anticipates the need for the treatment of mental health disorders and the use of re-engagement strategies.

Principles of Care for Young Adults With Co-Occurring Psychiatric and Substance Use Disorders.

Over 50% of young adults (defined as individuals aged 18-25 years) with substance use disorders (SUDs) have at least 1 co-occurring psychiatric disorder, and the presence of co-occurring disorders worsens SUD outcomes. Treatment of both co-occurring psychiatric disorders and SUDs in young adults is imperative for optimal treatment, yet many barriers exist to achieving this goal. We present a series of evidence-informed principles of care for young adults with co-occurring psychiatric disorders derived by a workgroup of experts convened by Boston Medical Center's Grayken Center for Addiction. The 3 principles are as follows: (1) young adults should receive integrated mental health and addiction care across treatment settings; (2) care should be responsive to the needs of young adults exposed to trauma and other adverse childhood experiences; and (3) treatment programs should regularly assess and respond to the evolving mental health needs, motivations, and treatment goals of young adults with co-occurring disorders. Our guidance for each principle is followed by a review of the evidence supporting that principle, as well as practice considerations for implementation. More research among young adults is critical to identify effective treatments and service systems for those with co-occurring disorders.

Principles of Care for Young Adults With Substance Use Disorders.

Despite the disproportionate impact of substance use on young adults, as well as their unique developmental circumstances, there has historically been little attention given to the substance use care needs of this population. As a result, there are currently few evidence-based recommendations to guide clinicians in caring for young adults with substance use disorders. The Grayken Center for Addiction Medicine at Boston Medical Center convened an interdisciplinary meeting of experts to establish principles of care to guide the management of young adults with substance use disorders, to help health care organizations establish effective care systems for these patients, and to help guide policy. In this article, we review the care principles and introduce a series of linked articles that go into further details of principles in the domains of evidence-based substance use treatment, family engagement in care, recovery support services, comorbid psychiatric illness, harm reduction, and criminal justice system reform.

Evidence-Based Treatment of Young Adults With Substance Use Disorders.

In summarizing the proceedings of a longitudinal meeting of experts in substance use disorders (SUDs) among adolescents and young adults, in this special article, we review principles of care related to SUD treatment of young adults. SUDs are most commonly diagnosed during young adulthood, but most of the evidence guiding the treatment of this population has been obtained from older adult study participants. Extrapolating evidence from older populations, the expert group asserted the following principles for SUD treatment: It is important that clinicians who work with young adults effectively identify and address SUD to avert long-term addiction and its associated adverse health outcomes. Young adults receiving addiction treatment should have access to a broad range of evidence-based assessment, psychosocial and pharmacologic treatments, harm reduction interventions, and recovery services. These evidence-based approaches should be tailored to young adults' needs and provided in the least restrictive environment possible. Young adults should enter care voluntarily; civil commitment to treatment should be a last resort. In many settings, compulsory treatment does not use evidence-based approaches; thus, when treatment is involuntary, it should reflect recognized standards of care. Continuous engagement with young adults, particularly during periods of relapse, should be considered a goal of treatment and can be supported by care that is patient-centered and focused on the young adult's goals. Lastly, substance use treatments for young adults should be held to the same evidence and quality standards as those for other chronic health conditions.

Principles of Harm Reduction for Young People Who Use Drugs.

In summarizing the proceedings of a longitudinal meeting of experts on substance use disorders among adolescents and young adults, we review 2 principles of care related to harm reduction for young adults with substance use disorders. The first is that harm reduction services are critical to keeping young adults alive and healthy and can offer opportunities for future engagement in treatment. Such services therefore should be offered at every opportunity, regardless of an individual's interest or ability to minimize use of substances. The second is that all evidence-based harm reduction strategies available to older adults should be available to young adults and that whenever possible, harm reduction programs should be tailored to young adults and be developmentally appropriate.

Effectiveness of mobile produce markets in increasing access and affordability of fruits and vegetables among low-income seniors.

OBJECTIVE: Mobile produce markets (MPM) offering Supplemental Nutrition Assistance Program (SNAP) incentive programmes have the potential to provide accessible and affordable fruits and vegetables (FV) to populations at risk of food insecurity. The objective of this study is to characterise the customer base of an MPM and describe their participation at twelve market sites serving low-income seniors. DESIGN: In 2018, customers from an MPM in Rhode Island (RI) participated in a cross-sectional survey (n 330; 68 % response rate), which measured dietary patterns, food security and food shopping behaviours. We compared the shopping habits and market experiences of customers who currently received SNAP benefits with those who did not currently receive SNAP benefits. SETTING: An MPM in RI which offers a 50 % discount for FV purchased with SNAP benefits. PARTICIPANTS: This study describes current market customers at twelve market sites serving low-income seniors. RESULTS: Market customers were mostly low-income, female, over the age of 50 years and Hispanic/Latino. Most customers received SNAP benefits, and almost half were food insecure. In addition, three quarters of SNAP customers reported their SNAP benefits last longer since shopping at the markets. Mixed logistic regression models indicated that SNAP customers were more likely to report buying and eating more FV than non-SNAP customers. CONCLUSIONS: MPM are critical resources of affordable produce and have been successful in improving access to FV among individuals of low socio-economic status in RI. This case study can inform policy and programme recommendations for MPM and SNAP incentive programmes.