Using human-centered design to develop and implement a pediatric mental health care access program.

In 2019, the University of California at San Francisco (UCSF) launched the Child and Adolescent Psychiatry Portal (CAPP), a pediatric mental health care access (PMHCA) program providing remote mental health consultation services to pediatric primary care providers (PCPs) throughout Northern and Central California. The development and implementation of CAPP was guided by Human-Centered Design (HCD), an iterative, rapid-paced innovation process focusing on stakeholders' needs and experiences, which shaped the development of CAPP's programs. The resulting key programmatic elements are designed for pediatric workforce development: (1) PCP consultation with a child and adolescent psychiatrist via a telephone warmline; and (2) training and education for providers. CAPP has grown rapidly since its launch, having enrolled 1,714 providers from 257 practices spread across 36 counties and provided 3,288 consults on 2,703 unique lives as of August 2023. Preliminary evaluation findings indicate high PCP satisfaction with CAPP's services, despite continued challenges of integrating behavioral health into primary care. Throughout the HCD and implementation process, multidisciplinary partnerships have proven critical in providing end-user input to inform and improve program design. This growing network of partnerships, developed through the cultivation of personal relationships and trust over time, has also proven essential for CAPP's rapid growth and sustainability. Overall, this Community Case Study highlights the critical role of partnerships and the importance of taking a people-centered approach, as captured in CAPP's motto, "Connecting for Care."

Addressing adolescent substance use in an urban pediatric federally qualified health center.

OBJECTIVE: Screening, brief intervention, and referral to treatment (SBIRT) is a systematic approach to identification and intervention for individuals at risk for substance use disorders. Prior research indicates that SBIRT is underutilized in pediatric primary care. Yet few studies have examined procedures for identifying and addressing substance use in clinics that serve publicly insured adolescents (i.e., federally qualified health centers [FQHC]). This descriptive, multi-method study assessed adolescent substance use frequency and provider perspectives to inform SBIRT implementation in an urban pediatric FQHC in California. METHODS: A medical record review assessed substance use frequency and correlates among publicly insured adolescents aged 12-17 years who completed a well-child visit in pediatric primary care between 2014 and 2017 (N = 2252). Data on substance use (i.e., alcohol, illicit drugs, and tobacco) were from a health assessment tool mandated by Medicaid. Semi-structured interviews with 12 providers (i.e., pediatricians, nurse practitioners, behavioral health clinicians) elicited information about the current clinic workflow for adolescent substance use and barriers and facilitators to SBIRT implementation. RESULTS: Of 1588 adolescents who completed the assessment (70.5%), 6.8% reported current substance use. Self-reported use was highest among non-Hispanic Black (15.2%) adolescents and those with co-occurring depressive symptoms (14.4%). Provider-reported challenges to implementing SBIRT included a lack of space for confidential screening and a lack of referral options. Providers favored implementing technology-based tools such as tablets for adolescent pre-visit screening and electronic medical record-based decision support to facilitate brief intervention and treatment referrals. CONCLUSIONS: This study fills a substantial research gap by examining factors that impede and support SBIRT implementation in pediatric FQHC settings. Successful SBIRT implementation in these settings could significantly reduce the unmet need for substance use treatment among uninsured and publicly insured adolescents. Pediatric primary care and urgent care providers perceived SBIRT to be feasible, and health information and digital technologies may facilitate the integration of SBIRT into clinic workflows. Ensuring confidentiality for screening and expanding referral options for adolescents in need of community-based addiction treatment are also critical to increasing SBIRT uptake.

Smoking reduction is associated with lower alcohol consumption and depressive symptoms among young adults over one year.

BACKGROUND: This secondary analysis examined whether smoking reduction among young adults participating in a Facebook-based smoking cessation intervention study was associated with corresponding reductions in alcohol consumption and depressive symptoms. METHODS: Participants were young adults who smoked and engaged in heavy episodic drinking (HED). Alcohol consumption (AUDIT-C, days of HED), depressive symptoms (PHQ-2), and past-month cigarettes per day (CPD) were self-reported at baseline and 12 months (N = 150). Linear regression estimated the relationship between the mean change in CPD and mean changes in alcohol consumption and depressive symptoms. RESULTS: CPD, alcohol consumption, and depressive symptoms decreased significantly between baseline and 12 months. The adjusted mean reduction in CPD was significantly associated with mean reductions in AUDIT-C (Beta [ß] = 0.09, 95 % confidence interval [CI] = 0.04-0.14), days of HED (ß = 0.17, 95 % CI = 0.04-0.29) and PHQ-2 (ß = 0.05, 95 % CI = 0.01-0.08). Smoking abstinence (n = 48) was associated with a significantly larger mean reduction in AUDIT-C compared to a ≥50 % reduction (n = 45) (-2.9 vs -1.7 points, p = 0.03) or <50 % reduction in CPD (n = 57) (-2.9 vs -1.1 points, p < 0.01). The mean reduction in AUDIT-C did not differ between a ≥50 % reduction and <50 % reduction in CPD (-1.7 vs.-1.1 points, p = 0.18). Mean reductions in days of HED and the PHQ-2 did not differ according to the level of reduction in CPD. CONCLUSION: Smoking reduction was associated with reductions in alcohol consumption and depressive symptoms. Reductions appeared to be greater for those who achieved abstinence compared to a reduction in smoking.

The Relationship of E-Cigarette Use to Tobacco Use Outcomes Among Young Adults Who Smoke and Use Alcohol.

OBJECTIVES: E-cigarette use is increasing among young adults in the U.S. However, longitudinal research studies examining associations between e-cigarette use and combustible cigarette use among young adults are limited. This study assessed the relationship of e-cigarette use to smoking reduction and cessation among young adults. METHODS: This is a secondary analysis of a randomized controlled social media-based smoking cessation trial comprising adults ages 18 to 25 who smoked cigarettes and engaged in heavy episodic drinking (N = 179). Over 12 months, participants reported past month e-cigarette use with nicotine or tetrahydrocannabinol, cigarette quantity in the past week, quit attempts, and cessation strategies including nicotine e-cigarettes. Longitudinal regression models estimated associations between e-cigarette use, smoking reduction, and 7-day abstinence. RESULTS: Past-month nicotine e-cigarette use prevalence ranged from 53.1% at baseline to 50.3% at 12 months. Over 70% of participants who reported past month nicotine e-cigarette use also smoked cigarettes (ie, dual use). Neither past month nicotine nor tetrahydrocannabinol e-cigarette use was associated with smoking reduction or cessation. However, use of nicotine e-cigarettes as a cessation strategy among participants attempting to quit (N = 137) was positively associated with abstinence (adjusted odds ratio = 2.47, 95% CI = 1.20-5.09) and ≥50% reduction in cigarettes per week from baseline (aOR = 2.36,95% CI = 1.08-5.18), relative to other strategies. CONCLUSIONS: Nicotine e-cigarettes were significantly associated with improved tobacco use outcomes when used as a cessation strategy, but not when used apart from trying to quit smoking. Dual use may not be an effective path to achieve smoking cessation.

Factors Associated With Use of Mental Health and Substance Use Treatment Services by Justice-Involved Youths.

OBJECTIVE: Nonincarcerated (community-supervised) youths who are first-time offenders have high rates of mental and substance use disorders. However, little is known about their use of psychiatric services (mental health and substance use) or factors associated with service use. This study examined the prevalence, determinants, and barriers to service use among community-supervised youths. METHODS: Data were from a longitudinal study of mental health and substance use outcomes among adolescents ages 12-18 from a northeastern family court in which caregivers and youths completed assessments (N=423 dyads). The Behavior Assessment System for Children, Second Edition, assessed youths' psychiatric symptoms. The Child and Adolescent Services Assessment assessed service use and barriers. Family functioning and caregiver-adolescent communication were assessed with the McMaster Family Assessment Device and the Parent-Adolescent General Communication Scale, respectively. Multivariable regression analyses examined the cross-sectional relationship between youths' service use and determinants of use at baseline. RESULTS: Of the 423 youths, 49% experienced psychiatric symptoms and 36% used psychiatric services in the past 4 months. The highest adjusted odds of service use were associated with youths' psychiatric symptoms and caregivers' history of a psychiatric diagnosis. The lowest odds were associated with caregivers' identifying as being from racial and ethnic minority groups. Caregiver-reported barriers to service use differed according to prior service use and by caregiver race-ethnicity. CONCLUSIONS: Results suggest a need for interventions to increase access to and engagement in psychiatric services for community-supervised youths and the importance of caregiver factors in designing such interventions.

Patient-Centered Medical Home Care for Adolescents in Need of Mental Health Treatment.

PURPOSE: The patient-centered medical home (PCMH) has emerged as an optimal primary care model for all youth; however, little is known about the extent to which adolescents in need of mental health (MH) treatment receive care consistent with the PCMH. This study assessed (1) 10-year trends in PCMH care among U.S. adolescents according to MH need and (2) variations in PCMH care and its subcomponents among adolescents with MH need, by individual and family characteristics. METHODS: This was a secondary analysis of Medical Expenditure Panel Survey data (2004-2013). The sample included adolescents aged 12-17 years with ≥1 office-based visits in the past year (N = 18,717). Questions assessing a usual source of care and care that is accessible, comprehensive, family-centered, and compassionate were used to define PCMH care. For adolescents with MH needs, multivariable logistic regression was used to describe the association between PCMH care and sample characteristics. RESULTS: Fifty percent of adolescents experienced PCMH care, with little change between 2004 and 2013. Adolescents with MH need (N = 3,794) had significantly lower odds of experiencing PCMH care compared with those without MH need (odds ratio, .78; 95% confidence interval, .69-.87). Among adolescents with MH needs, being uninsured and living with a parent who did not graduate high school were negatively associated with PCMH care, whereas parental usual source of care was positively associated (odds ratio, 1.69; 95% confidence interval, 1.28-2.22). CONCLUSIONS: Increasing care accessibility, integrating MH services into primary care settings, and targeting socioeconomically disadvantaged subgroups could improve rates of PCMH care among adolescents with MH needs.

Lessons learned about advancing healthcare equity from the Aligning Forces for Quality initiative.

OBJECTIVE: The Robert Wood Johnson Foundation's (RWJF's) Aligning Forces for Quality (AF4Q) initiative aimed to advance healthcare quality and equity in 16 communities across the United States through multi-stakeholder alliances of healthcare payers, providers, and consumers. Our objectives are (1) to summarize the major approaches and activities undertaken by the AF4Q alliances that were most successful in tracking and implementing programs that aimed to reduce local healthcare disparities by race, ethnicity, and primary language spoken (REL), and socioeconomic status (SES); and (2) to identify the major lessons learned from the successes and failures of the AF4Q alliances to inform other equity-focused initiatives. METHODS: We analyzed data from 6 rounds of key informant interviews conducted between 2010 and 2015, and triannual progress reports submitted by the alliances to RWJF between 2008 and 2015. RESULTS: Of the 16 AF4Q alliances, 2 succeeded in developing community wide systems to track local healthcare disparities, 5 alliances implemented substantive programs that aimed to reduce local disparities, and 3 alliances were successful in disparity measurement and program implementation. The alliances that were most active in addressing disparities tended to have long-established relationships with relevant community organizations, focused on improving the quality of care provided by safety-net providers, and shifted quickly toward working to address disparities even if their initial efforts to stratify performance measures by REL failed. CONCLUSION: Few alliances were able to develop community wide systems to track local healthcare disparities or implement large-scale initiatives to reduce disparities during the 7 years that these objectives were advanced by the AF4Q initiative. Establishing robust local disparity-tracking systems and establishing productive relationships with key community stakeholders took substantial time. The AF4Q experience suggests that efforts to reduce disparities should not be held up by disparity measurement challenges.

Why and how six aligning forces for quality communities have focused on reducing disparities.

Public reports on provider performance can help guide consumers' health care decisions, yet consumer awareness and use of public reports is low and may be even lower among racial/ethnic minorities. In this qualitative research article, we describe activities implemented by multi-stakeholder alliances in six U.S. communities to increase minorities' awareness of public reports. We also describe alliances' motivation for deliberately targeting greater awareness among minorities. We found that alliances' decision was influenced by the proportion of minorities and perceptions of race-based disparities in care in the community. To raise awareness, alliances collaborated with minority-serving organizations to (a) advertise their web-based public report using ethnic media outlets, (b) present their public reporting website during health education outreach events held in minority communities, and (c) translate their public report into multiple languages. We conclude that community partnerships are a promising mechanism for targeting efforts to increase awareness of public reports in minority communities.