Growth and impact of Project ECHO for workforce development in age-friendly care.

BACKGROUND: Use of the Project ECHO® (Extension for Community Healthcare Outcomes) model in geriatrics has increased dramatically largely because of the Health Resources and Services Administration-funded Geriatrics Workforce Enhancement Programs (GWEP) utilizing it as a key tool for age-friendly, interprofessional workforce development. This manuscript describes the scope and impact of geriatrics ECHOs under the GWEP. METHODS: A survey of GWEPs was conducted to measure the reach, foci, evaluation methods, and other characteristics of ECHO networks. RESULTS: All 48 (100%) GWEPs responded to the survey, and 30 (63%) reported using ECHO. GWEP ECHOs have both rural and urban-underserved reach across the United States, and their hub teams include many health professions. Age-friendly care is incorporated through multiple methods and is taught across foci including primary care, dementia, long term care, and novel topics. GWEP ECHOs have many academic and community partners including Area Agencies on Aging, and reach varied health professions, trainees, and caregivers. Geriatrics ECHOs collect outcomes across the evidence continuum including the community-level outcome of Age-Friendly Health System designation. CONCLUSIONS: The ECHO model has been widely adopted by GWEPs as a key approach for workforce training in age-friendly care. Project ECHO is a valuable tool to expand interprofessional training for the geriatrics workforce, particularly for interprofessional teams in rural and underserved areas.

Parent Intention to Participate in an Online Intervention to Enhance Health Behavior Change Among Youth Treated with Psychotropic Medication Who are Overweight or Obese: An Application of the Theory of Planned Behavior.

Youth with mental health disorders (MHD), particularly those who take psychotropic medications, are at increased risk of being overweight or obese (OW/OB) when compared to typical youth. Parents are important resources for interventions addressing OW/OB. However, parents of youth with MHD may face challenges that require interventions designed to address their needs. Prior to investing research funding in the development of interventions for this group, research is needed to understand factors associated with parents' decisions to enroll in these programs. The theory of planned behavior (TPB) provided a framework for examining parents' salient beliefs, direct attitudes, and intention to enroll in a hypothetical online healthy lifestyle intervention for their youth (ages 11-17) with OW/OB and treated with psychotropic medication. Parents who were enrolled in the study (n = 84) completed demographic questionnaires and a TPB questionnaire which was constructed for this study. A confirmatory factor analysis (CFA) of the direct attitude (i.e., attitude toward the behavior, subjective norm, perceived behavioral control) questions generally supported the three-factor model (i.e., RMSEA = .07, 90% CI .03-.11, p = .18; CFI = .96, SRMR = .06). Results from a multiple regression analysis demonstrated that direct attitudes predicted parent intention to participate in an online healthy lifestyle intervention for this sample of youth accounting for 84% of variance. In this preliminary study, the TPB appears to be a promising framework for understanding direct attitudes associated with parent intentions toward intervention participation in this population of youth. Interventions for parents of youth with OW/OB who are prescribed psychotropic medication should consider addressing these direct attitudes to improve intention.

Parent Intention to Enroll in an Online Intervention to Enhance Health Behavior Change among Youth Treated with Psychotropic Medication Who Are Overweight or Obese: An Elicitation Study.

Youth who are prescribed psychotropic medication are disproportionally affected by overweight/obesity (OW/OB), yet few interventions have been tailored to their needs. To develop new interventions, it is important to address the needs, preferences, and intentions of target users. Qualitative methods within the theory of planned behavior (TPB) framework were used in this study to identify salient beliefs which may influence attitudes associated with parents' intentions to participate in a future online intervention designed to develop behavioral health coaching skills among parents and guardians. Twenty parents and guardians of youth with OW/OB who were taking psychotropic medications, and were eligible for the study, were recruited through TurkPrime. Parents and guardians identified key salient beliefs consistent with the theory of planned behavior including behavioral beliefs (e.g., access and convenience), normative beliefs (e.g., family), and control beliefs (e.g., cost) that may influence their decision to enroll in a future, parent-oriented intervention. The results of this study suggest important salient beliefs which may be included in future research, as well as specific preferences which may be used to guide the development of a future intervention. Future work should focus on the creation of a salient belief quantitative measure and assess the relationships of these beliefs to attitudinal constructs and behaviors.

Barriers to Aging in Place for Rural, Institutionalized Older Adults: A Qualitative Exploration.

OBJECTIVES: Although the majority of older adults wish to "age in place" in their communities, rural contexts pose challenges to maintaining long-term independence. The purpose of this study was to develop an understanding of the experiences of rural older adults who live in Skilled Nursing Facilities (SNFs) and thus have not aged in place. By retrospectively analyzing their pre-institution care situation, we aim to generate foundational knowledge on the barriers to aging in place in rural settings. METHODS: A series of individual and group interviews was conducted in SNFs across seven rural communities. A grounded, thematic analysis was used to interpret interview findings, and coding was informed by the socio-ecological model (SEM). RESULTS: Participants were 32 adults with a mean age of 72 years (SD = 5.7 years) and an average SNF residence of 3.9 years. Two themes emerged as primary barriers to successful aging in place: (1) Caregiver-related support issues and (2) Present focus, or lack of advanced care-planning. CONCLUSIONS: Findings suggest the importance of specifically supporting caregivers, to ease burden and allow for increased agency for rural older adults. A lack of access to caregiver supports and other services limits the ability of community-dwelling rural older adults to age in place or plan for the future. CLINICAL IMPLICATIONS: Existing networks of rural community resources and innovative solutions should be leveraged to improve access to services for older adults and their informal caregivers.

Exploring Information and Referral Needs of Individuals with Dementias and Informal Caregivers in Rural and Remote Areas.

Objectives: The provision of information and referral (I&R) and connection to support services is crucial for individuals with Alzheimer's disease and related dementias (ADRD) and their informal caregivers, especially in rural and remote regions where care and support resources may be limited. The purpose of this study was to develop a deeper understanding of needs for I&R from community stakeholders across a rural and remote state.Methods: A series of town hall meetings were conducted across ten communities in a frontier state.Results: Participants were 175 adults with a mean age of approximately 60 years (SD = 15 years); a majority were non-Hispanic white, female, and self-identified as informal caregivers. Three themes emerged as primary areas of need: (1) to address stigma related to ADRD; (2) to improve the availability of dementia-related I&R; and (3) to efficiently disseminate dementia-related I&R.Conclusions: Findings suggest the importance of a single point of access for I&R with presence in local communities as well as initial and ongoing assessment and provision of appropriate I&R throughout the course of ADRDs.Clinical Implications: Existing community resources and funding support should be leveraged for multiple points and means of access to reliable I&R.

Examining community mental health providers' delivery of structured weight loss intervention to youth with serious emotional disturbance: An application of the theory of planned behaviour.

BACKGROUND: Rates of overweight and obesity are disproportionately high among youth with serious emotional disturbance (SED). Little is known about community mental health providers' delivery of weight loss interventions to this vulnerable population. OBJECTIVE: This study examined attitudinal predictors of their providers' intentions to deliver weight loss interventions to youth with SED using the theory of planned behaviour. DESIGN: This study used a cross-sectional, single-time-point design to examine the relationship of the theory of planned behaviour constructs with behavioural intention. SETTING AND PARTICIPANTS: Community mental health providers (n = 101) serving youth with SED in the United States completed online clinical practice and theory of planned behaviour surveys. MAIN VARIABLES STUDIED: We examined the relationship of direct attitude constructs (i.e., attitude towards the behaviour, social norms and perceived behavioural control), role beliefs and moral norms with behavioural intention. Analyses included a confirmatory factor analysis and two-step linear regression. RESULTS: The structure of the model and the reliability of the questionnaire were supported. Direct attitude constructs, role beliefs and moral norms predicted behavioural intention to deliver weight loss interventions. DISCUSSION: While there is debate about the usefulness of the theory of planned behaviour, our results showed that traditional and newer attitudinal constructs appear to influence provider intentions to deliver weight loss interventions to youth with SED. Findings suggest preliminary strategies to increase provider intentions. PUBLIC CONTRIBUTION: This study was designed and the results were interpreted as part of a larger, community-based participatory research effort that included input from youth, families, providers, administrators and researchers. Collaborative discussions with community mental health providers and administrators particularly contributed to the study question asked as well as interpretation of results.

Testing a self-determination theory perspective of informal caregiving: A preliminary study.

Informal caregivers provide valuable care for ill or disabled adults. Nevertheless, many caregivers experience negative consequences from caregiving such as reduced mental health. Balancing personal costs of caregiving with caregivers' desires or obligations to provide care, is necessary to promote the well-being of these individuals and their care recipients. Drawing on a self-determination theory (SDT) perspective, caregivers whose psychological needs for relatedness, autonomy, and competence are satisfied with their care recipient, and their care recipients' healthcare providers, should be more autonomously motivated to care. Greater autonomous motivation should promote better mental health. This study tested mediation models in a sample of 158 caregivers in the United States. Autonomous motivation was examined as a mediator of the (a) associations between caregivers' need satisfaction with their care recipient and caregiver burden and depressive symptoms, and (b) associations between caregivers' autonomy support received from their care recipients' healthcare providers and caregiver burden and depressive symptoms. Next, specific types of motivation that vary in their relative autonomy were examined as unique mediators. Support was found for models using autonomous motivation as the mediator. Additionally, caregivers' autonomy support and female caregivers' need satisfaction were positively associated with intrinsic motivation to care which was negatively associated with burden. Although much research suggests caregivers' outcomes stem from the care recipients' condition, such as their functional dependence on others, the present study focused on the caregivers' relationships and motivations. Results support an SDT perspective of caregiving. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Functional health status of adults with serious mental illness and diabetes mellitus: A latent profile analysis.

OBJECTIVE: Adults with serious mental illness are at increased risk for diabetes mellitus and diabetes-related complications. This article classifies subgroups among people with serious mental illness and comorbid diabetes with respect to functional status and examines differences among those groups. METHODS: This analysis used a baseline sample of 157 adults with serious mental illness and diabetes mellitus enrolled in a National Institute of Health-funded research study. Latent profile analysis was used to distinguish health status profiles and investigate how these subgroups differed across assessment domains. RESULTS: Participants with depression, schizophrenia, and bipolar disorder (n = 157) were included in the study. Mean age was 52.9 years (standard deviation = 9.8), and 62 (40%) were African American. From the latent profile analysis, a three-class model appeared to provide the best fit. Class 1 (34.9%) had a very low functional health status approximately two standard deviations below the general population mean. Class 2 (43.7%) had a low functional status approximately one standard deviation below the general mean. Class 3 (21.4%) had moderate functional status with scores near population mean. Groups differed on measures of personal characteristics, clinical status and symptom severity, self-care behaviors, and environmental characteristics. CONCLUSIONS: Although individuals with schizophrenia generally have poor prognosis once they develop diabetes, latent profile analysis identified distinct health status subgroups. Although all three groups demonstrated illness burden, the pattern of differences between these groups across measures may suggest the need for different interventions for highly diverse adults who received care within safety-net primary care.

Community Mental Health Providers' Beliefs About Addressing Weight Loss Among Youth Clients with Serious Emotional Disturbance and Overweight/Obesity: An Elicitation Study.

Youth with Serious Emotional Disturbance (SED) have high rates of overweight/obesity. Factors influencing mental health provider intentions to deliver weight-related advice are unclear. This study used qualitative methodology and Theory of Planned Behavior (TPB) constructs to examine these factors. Community mental health providers serving youth with SED were recruited via convenience sampling and an online provider list. Participants completed an open-ended TPB-based questionnaire online. Content analysis identified thematic beliefs. Twenty-one providers completed the questionnaire. Providers identified behavioral beliefs (e.g., client defensiveness), normative beliefs (e.g., medical professionals), and control beliefs (e.g., limited resources) that impact decisions to provide weight-related advice. Knowledge of factors that may influence providers' delivery of weight-related advice may lead to more effective healthy lifestyle programming for youth with SED.

Diabetes Knowledge Among Adults with Serious Mental Illness and Comorbid Diabetes Mellitus.

This study examined the association between psychiatric symptoms and diabetes knowledge (DK) among 90 adults with serious mental illness (SMI) and type 2 diabetes. The relationship between DK and glucose control (i.e., A1C) was also examined. In a hierarchical linear regression, greater negative symptom severity and lower cognitive functioning both predicted lower DK, though cognitive functioning superseded negative symptom severity when analyzed simultaneously. A Pearson correlation showed no significant relationship between DK and A1C. Although symptom severity and cognitive functioning are both related to DK among this population, cognitive functioning maybe particularly important.

Barriers and facilitators of obesity management in families of youth with emotional and behavioral disorders.

While youth with emotional and behavioral disorders experience increased rates of obesity, few obesity interventions exist that are tailored to their needs. Qualitative methods were employed to elucidate obesity management practices in this population. In all, 56 participants (i.e. 21 youths with emotional and behavioral disorders, 20 caregivers of youth with emotional and behavioral disorders, and 15 mental health providers) were recruited from community mental health centers. Participants completed a demographic form and semi-structured interview regarding obesity-related behaviors. Barriers (e.g. psychiatric symptoms) and facilitators (e.g. social support) to obesity management were identified. These results highlight preferred intervention components for this unique population.

Health Status and Social Networks as Predictors of Resilience in Older Adults Residing in Rural and Remote Environments.

Purpose. Health status and social networks are associated with resilience among older adults. Each of these factors may be important to the ability of adults to remain in rural and remote communities as they age. We examined the association of health status and social networks and resilience among older adults dwelling in a rural and remote county in the Western United States. Methods. We selected a random sample of 198 registered voters aged 65 years or older from a frontier Wyoming county. Hierarchical linear regression was used to examine the association of health status as well as social networks and resilience. We also examined health status as a moderator of the relationship between social networks and resilience. Results. Family networks (p = 0.024) and mental health status (p < 0.001) significantly predicted resilience. Mental health status moderated the relationship of family (p = 0.004) and friend (p = 0.021) networks with resilience. Smaller family and friend networks were associated with greater resilience when mental health status was low, but not when it was high. Conclusion. Efforts to increase mental health status may improve resilience among older adults in rural environments, particularly for those with smaller family and friends networks.

Self-Efficacy and Hemoglobin A1C Among Adults With Serious Mental Illness and Type 2 Diabetes: The Roles of Cognitive Functioning and Psychiatric Symptom Severity.

BACKGROUND: Self-efficacy is a core element of diabetes self-care and a primary target of diabetes interventions. Adults with serious mental illness (SMI) are twice as likely as adults among the general population to have Type 2 diabetes. This population faces substantial barriers (i.e., cognitive impairment, psychiatric symptoms) to optimal diabetes self-care, but the relationship of these barriers to both self-efficacy and glycemic control (hemoglobin A1C [A1C]) is not clearly understood. METHODS: Data collected from adult participants with SMI (i.e., schizophrenia, schizoaffective disorder, bipolar disorder) and Type 2 diabetes (n = 92) were used to examine the moderating effects of cognitive functioning and psychiatric symptoms (i.e., positive and negative symptoms) on the association between self-efficacy and A1C. RESULTS: The relationship between self-efficacy and A1C was moderated by cognitive functioning (B = -4.03, standard error = 1.54, p = .011). Greater self-efficacy was associated with better glycemic control when cognitive functioning was high, but worse control when functioning was low. The relationship between self-efficacy and A1C was moderated by negative symptom severity (B = 6.88, standard error = 3.34, p = .043). Higher self-efficacy was associated with poorer glycemic control only when negative symptom severity was high. Positive symptoms did not interact with self-efficacy to predict A1C. CONCLUSIONS: These results suggest that adults with SMI and low cognitive function or high negative symptom severity may misperceive their ability to manage their diabetes. They may benefit from efforts, including care management and monitoring, cognitive remediation, and skill training, to identify and correct inaccurate diabetes self-efficacy.

Clinical management of comorbid diabetes and psychotic disorders.

Individuals with psychotic disorders experience substantial health disparities with respect to diabetes, including increased risk of incident diabetes and of poor diabetes outcomes (eg, diabetes complications and mortality). Low-quality medical care for diabetes is a significant contributor to these poor health outcomes. A thoughtful approach to both diabetes pharmacotherapy and drug management for psychotic disorders is essential, irrespective of whether treatment is given by a psychiatrist, a primary care provider, or an endocrinologist. Exposure to drugs with high metabolic liability should be minimised, and both psychiatric providers and medical providers need to monitor patients to ensure that medical care for diabetes is adequate. Promising models of care management and team approaches to coordination and integration of care highlight the crucial need for communication and cooperation among medical and psychiatric providers to improve outcomes in these patients. Evidence-based programmes that promote weight loss or smoking cessation need to be more accessible for these patients, and should be available in all the settings where they access care.

Oral health in adults with serious mental illness: needs for and perspectives on care.

This study used qualitative methods to investigate barriers to and facilitators of oral health care among 25 adult community mental health outpatients with serious mental illness (SMI). Participants completed 30- to 60-min, semi-structured interviews that were recorded and transcribed. Qualitative analysis was used to characterize common themes. Results showed that lack of awareness of dental problems, poverty, and dental care access were key barriers to oral health care. When oral health care was accessed, fear of stigma was associated with missed opportunities to educate about the intersection of mental and oral health. Community mental health providers were viewed as trusted and important sources of advocacy and support for obtaining oral health care when needed. Oral health may be improved for persons with SMI by implementing education in points of frequent service contact, such as community mental health.

Depression, diabetic complications and disability among persons with comorbid schizophrenia and type 2 diabetes.

BACKGROUND: People with schizophrenia are at increased risk for type 2 diabetes, its complications, depression, and disability. However, little is known about the interrelationships of these 3 factors in adults with schizophrenia and type 2 diabetes. OBJECTIVE: We sought to assess the number of diabetic complications and depressive symptom severity as predictors of disability and evaluate depressive symptom severity as a mediator of the relationship between diabetic complications and disability in a sample of 62 adults with schizophrenia and type 2 diabetes. METHODS: Two- and 3-step sequential regression models were used to evaluate the relationship of depression and number of diabetic complications with disability. Path analysis with bootstrapping was used to evaluate depressive symptom severity as a mediator of the relationship between complications and disability. RESULTS: Diabetic complications significantly predicted disability scores when controlling for age, gender, socioeconomic status, hemoglobin A1C, positive symptom severity, and negative symptom severity. The addition of depression severity scores resulted in a significant increase in explained variance in disability scores. In the final model, only depression severity scores were significantly associated with disability scores. The full model accounted for 56.2% of the variance in disability scores. Path analysis revealed a significant indirect association of diabetic complications to disability through depression severity scores while controlling for all covariates. The association between complications and disability was nonsignificant when depressive symptom severity was included in the model. CONCLUSIONS: Depressive symptoms may present an important and tractable target for interventions aimed at reducing disability in people with schizophrenia and type 2 diabetes.

Genetic attributions and mental illness diagnosis: effects on perceptions of danger, social distance, and real helping decisions.

UNLABELLED: Genetic essentialism suggests that beliefs in genetic causes of mental illness will inflate a desire for social distance from affected individuals, regardless of specific disorder. However, genetic contingency theory predicts that genetic attributions will lead to an increased desire for social distance only from persons with disorders who are perceived as dangerous. PURPOSE: To assess the interactive effect of diagnosis and attribution on social distance and actual helping decisions across disorders. METHODS: Undergraduate students (n = 149) were randomly assigned to read one of the six vignettes depicting a person affected by one of the three disorders (i.e., schizophrenia, bipolar disorder, or major depression) with either a genetic or environmental causal attribution for disorder. Participants completed measures of perceived dangerousness, social distance, empathic concern, familiarity with mental illness, and actual helping decisions. RESULTS: When provided with genetic attributions, participants' desire for social distance was greater for targets with schizophrenia relative to targets with depression or bipolar disorder. This effect was mediated by perceived dangerousness. The indirect effect of diagnosis on helping decisions, through social distance, was significant within the genetic attribution condition. CONCLUSION: Consistent with genetic contingency theory, genetic attributions for schizophrenia, but not affective disorders, lead to greater desire for social distance via greater perceived dangerousness. Further, results suggest that genetic attributions decrease the likelihood of helping people with schizophrenia, but have no effect on the likelihood of helping people with affective disorders. These effects are partially accounted for by desired social distance from people with schizophrenia.

Barriers and facilitators of a healthy lifestyle among persons with serious and persistent mental illness: perspectives of community mental health providers.

The investigators used qualitative methods to examine perspectives of community mental health professionals on obesity management in adults with serious mental illness (SMI). Data from 5 focus groups were subjected to constant comparison analysis and grounded theory. Results showed that influences at individual, social, community, and societal levels impact development and maintenance of obesity. Mental health providers desired a collaborative relationship with health promotion program staff. They also believed that frequent, group-based health promotion should include participation incentives for adults with SMI and should occur over durations of at least 6-months to achieve improved health outcomes for this population.

The effect of serious mental illness on the risk of rehospitalization among patients with diabetes.

BACKGROUND: Medical-surgical rehospitalizations within a month after discharge among patients with diabetes result in tremendous costs to the US health care system. OBJECTIVE: The study's aim was to examine whether co-morbid serious mental illness diagnoses (bipolar disorder, schizophrenia, or other psychotic disorders) among patients with diabetes are independently associated with medical-surgical rehospitalization within a month of discharge after an initial hospitalization. METHODS: This cohort study of all community hospitals in Washington state evaluated data from 82,060 adults discharged in the state of Washington with any International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis indicating diabetes mellitus between 2010 and 2011. Data on medical-surgical hospitalizations were obtained from the Washington State Comprehensive Hospital Abstract Reporting System. Co-morbid serious mental illness diagnoses were identified based on International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes indicating bipolar disorder, schizophrenia, or other psychotic disorders. Logistic regression analyses identified factors independently associated with rehospitalization within a month of discharge. Cox proportional hazard analyses estimated time to rehospitalization for the entire study period. RESULTS: After adjusting for demographics, medical co-morbidity, and characteristics of the index hospitalization, co-morbid serious mental illness diagnosis was independently associated with increased odds of rehospitalization within 1 month among patients with diabetes who had a medical-surgical hospitalization (odds ratio: 1.24, 95% confidence interval: 1.07, 1.44). This increased risk of rehospitalization persisted throughout the study period (up to 24 mo). CONCLUSIONS: Co-morbid serious mental illness in patients with diabetes is independently associated with greater risk of early medical-surgical rehospitalization. Future research is needed to define and specify targets for interventions at points of care transition for this vulnerable patient population.

Depression Treatment Among Rural Older Adults: Preferences and Factors Influencing Future Service Use.

The purpose of this study was to investigate depression treatment preferences and anticipated service use in a sample of adults aged 55 years or older who reside in rural Wyoming. Sixteen participants (mean age = 59) completed 30- to 60-minute, semi-structured interviews. Qualitative methods were used to characterize common themes. Social/provider support and community gatekeepers were perceived by participants as important potential facilitators for seeking depression treatment. In contrast, perceived stigma and the value placed on self-sufficiency emerged as key barriers to seeking treatment for depression in this rural, young-old sample. Participants anticipated presenting for treatment in the primary care sector and preferred a combination of medication and psychotherapy for treatment. Participants were, however, more willing to see mental health professionals if they were first referred by a clergy member or primary care physician.