Building trust: Leadership reflections on community empowerment and engagement in a large urban initiative.

BACKGROUND: Trust is essential for healthy, reciprocal relationships; creating safe environments; engaging in transparent interactions; successfully negotiating power differentials; supporting equity and putting trauma informed approaches into practice. Less is known, however, about the ways that trust-building may be at the forefront of consideration during community capacity building efforts, what trust-building elements are perceived as essential for optimally engaging communities, and what practices might support these efforts. METHODS: The present study examines an evolving understanding of trust-building over the course of 3 years, from qualitative data derived during interviews with nine agency leads from a large and diverse urban community, who are spearheading community-based partnerships to create more trauma-informed communities and foster resiliency. RESULTS: Data reflected fourteen trust-building elements, captured by three themes: 1) Building relationships and engagement (e.g., behavioral practices such as meeting people "where they are at" and creating safe spaces), 2) Embodying core values of trustworthiness (e.g., traits such as being transparent and embodying benevolence), and 3) Sharing decision-making, championing autonomy, and addressing barriers to trust (e.g., collaborative practices such as creating a shared vision and goals and addressing systemic inequities). These trust-building elements are presented in the Community Circle of Trust-Building, which provides an accessible, visual format that can facilitate capacity building efforts within organizations and with the broader community; guide the selection of training opportunities that support healthy interpersonal relationships; and aid in the identification of relevant, supporting frameworks (e.g., health equity, trauma-informed practices, inclusive leadership models). CONCLUSIONS: Community engagement and trust are essential for overall health and well-being, increasing equitable access to resources, and supporting an effective and connected citizenry. These data shed light on opportunities for trust-building and thoughtful engagement among agencies working directly with community members in large urban areas.

"Once a peer always a peer": A qualitative study of peer specialist experiences with employment following state certification.

OBJECTIVE: Peer specialists are people with lived experience of a mental health or substance use disorder who are certified to deliver peer support services under state training programs. This qualitative study explored recently certified peer specialist (CPS) experiences navigating the job market to find postcertification employment, experiences with employment once in the workforce, and reflections on CPS training. METHOD: Qualitative data were collected as part of a multistate, 3-year observational prospective cohort study of CPS graduate employment trajectories. We conducted 25 in-depth, semistructured interviews with a subsample of recent CPS graduates who indicated a range of employment experiences in a survey as part of the parent study. Interviews focused on their current employment and satisfaction with the position and experiences looking for work. Data were analyzed using constant comparative methods informed by grounded theory. RESULTS: Participants described factors that supported or undermined securing employment, which included a shortage of CPS positions, their professional networking skills, financial considerations, and a position's alignment with CPS values. Once employed, participants described how relationships with supervisors and coworkers, which ranged from supportive to confused about the value of the peer specialist role, impacted their work. In general, participants held their CPS training and certification in high regard. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Our findings highlight policy, employment, and practice opportunities to strengthen CPS training to improve their work readiness of graduates and expand their role, while preparing organizations and their staff to hire and work inclusively with CPSs. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Barriers to Accessing Mental Health Care Under the Mental Health Services Act: A Qualitative Case Study in Orange County, California.

Despite progress made under California's Mental Health Services Act, limited access to care for cultural and linguistic minority groups remains a serious issue in community mental health. In this qualitative study we report findings from a large-scale community-level assessment that explored barriers to accessing care from the perspectives of multiple stakeholders including county advisors, advocates, community members, and consumers representing a range of cultural and linguistic communities in Orange County, California. We conducted 14 focus groups with N = 112 participants. Qualitative analysis revealed that system fragmentation, limited availability of linguistically appropriate care, and stigma continue to undermine access to mental health care. Peer health navigation and culturally responsive peer support are potential ways to promote service engagement with persons from cultural and linguistic minority groups that encounter barriers when accessing mental health services.

Understanding discrimination towards persons experiencing homelessness: A scoping review protocol.

INTRODUCTION: Given the increasing rates of homelessness in recent years, there is an urgent need to address the ongoing discrimination and societal disinterest in preventing, reducing and ending homelessness. There is no systematic review of experiences of stigma and discrimination among persons experiencing homelessness or interventions to combat this discrimination. The objective for the proposed study is to identify ways in which persons experiencing homelessness have been stigmatised and discriminated against, the results of these experiences, and interventions to reduce stigma and discrimination towards persons experiencing homelessness. METHODS AND ANALYSIS: We are conducting a scoping review with guidance from the JBI Manual for Evidence Synthesis and Arksey and O'Malley's framework. From 15 to 19 July 2022, we searched the following databases from our institutional licensed years of coverage: Medline, Embase, CINAHL Complete, Academic Search Ultimate, APA PsycINFO, Science Citation Index Expanded, Social Sciences Citation Index, Arts & Humanities Citation Index, Emerging Sources Citation Index, Left, PAIS International, PILOTS, Psychology & Behavioral Sciences Collection, Sociological Abstracts, and Dissertations and Theses Global. Two independent reviewers are screening study titles/abstracts and will independently screen the full texts. Study inclusion criteria include any study type reporting primary findings of English-language research on non-refugee persons experiencing homelessness in any type of setting or service worldwide. Three reviewers will then chart data of our included studies. Data will be extracted and organised into categories and subthemes in tabular form. To understand the validity of the scoping review findings in the local context and to gather additional perspectives on the topic, we will conduct an 'expert consultation' workshop. ETHICS AND DISSEMINATION: This study has ethics approval from the University of Utah Institutional Review Board. Review findings will be disseminated through a peer-reviewed journal and at conferences. We plan to preregister this protocol with Open Science Framework.

Behavioral Health Services use Among Racial and Ethnic Groups: Results from the California Health Interview Survey (CHIS).

Access and utilization of behavioral health services is a public health issue, yet disparities among racial/ethnic groups persist, resulting in fewer access points and lower utilization. Using pooled 2015 and 2016 California Health Interview Survey (N = 42,089) data of diverse adults, this study examines provider access points for behavioral health services use. Latinx (OR = 0.55, 95% CI, 0.38-0.80), Asian (OR = 0.32, 95% CI, 0.17-0.59), and first generation (OR = 0.56, 95% CI, .38-.83) individuals, reported lower odds of accessing specialty care behavioral health services, compared to no services. First generation adults reported lower odds accessing a primary care physician (OR = 0.66, 95% CI, 0.44-0.98), compared to none. Results advance knowledge of behavioral health services access points among racial, ethnic and immigrant groups, following passage of the California Mental Health Services Act. Findings suggest primary care may be an important entry point for behavioral health service use engagement among underserved populations.

A Mixed-method Evaluation of the Behavioral Health Integration and Complex Care Initiative Using the Consolidated Framework for Implementation Research.

BACKGROUND: Integrated behavioral health and primary care can improve the health of persons with complex chronic conditions. The Behavioral Health Integration and Complex Care Initiative (BHICCI) implemented integrated care across a large health system. Whether Behavioral Health Organizations (BHOs) and Federally Qualified Health Centers (FQHCs) implemented the BHICCI differently is unclear. OBJECTIVES: The objective of this study was to evaluate integration under the BHICCI and to understand implementation differences between BHOs and FQHCs. METHODS: We used a convergent parallel mixed-method design. Integration was measured quantitatively using the Maine Health Access Site Self-Assessment (SSA), which was completed by clinic teams at baseline and 24 months, and through n=70 qualitative interviews with initiative stakeholders, which were organized using the Consolidated Framework for Implementation Research. Results were compared to understand how qualitative findings explained quantitative results. RESULTS: Data were collected in 7 clinics (n=2 FQHC; n=5 BHOs). FQHCs reported greatest improvement in the client centered subscale, with a baseline score of 4.6 (SD=0.64) and 7.8 (SD=0.89) at 24 months. BHOs reported greatest improvement in the organizational supports for integration subscale, with a baseline score of 4.8 (SD=1.07) and 7.9 (SD=1.1) at 24 months. Our Consolidated Framework for Implementation Research analysis illustrates contextual factors, such as insurance plan supports and clinic-level challenges, that explain these scores. CONCLUSIONS: All clinical settings received support from the health plan, but differences between BHOs and FQHCs affected integration progress. Study results can help identify organizational practices that advance or undermine the delivery of integrated care across multiple clinical settings.

Practice Facilitation in Integrated Behavioral Health and Primary Care Settings: a Scoping Review.

Little is known about the contributions of practice facilitators in settings aiming to deliver integrated behavioral health and primary care. This scoping review identifies peer-reviewed articles that describe efforts to deliver integrated behavioral health care with the support of practice facilitators. Five databases were systematically searched to identify empirical and conceptual papers. Fourteen articles met the following inclusion criteria: (1) empirical studies evaluating the effectiveness of practice facilitation (n = 4), (2) study protocols that will test the effectiveness of practice facilitation (n = 2), (3) studies that included practice facilitators as part of a larger intervention without evaluating their effectiveness (n = 5), and (4) conceptual manuscripts endorsing practice facilitation for integrated care (n = 3). Practice facilitators can potentially support health systems in delivering integrated behavioral health care, but future research is needed to understand their necessary qualifications, the effectiveness of practice facilitation these efforts, and what study outcomes are appropriate for evaluating whether practice facilitation has been effective.

Patient experience with a large-scale integrated behavioral health and primary care initiative: A qualitative study.

Introduction: Patient engagement in research can improve a health system's responsiveness to patient need, but patient experience with integrated care is not well understood. This qualitative study explores patient experience and provider perceptions of patient experience with the Behavioral Health Integration and Complex Care Initiative (BHICCI), which is a large-scale system redesign that delivers integrated care to persons with complex needs. Methods: We conducted 8 patient focus groups (n = 54 patients) and n = 32 interviews with BHICCI providers at five community health settings participating in the BHICCI during which patients and providers described how patient experience with care had changed under the initiative. Results: Patient experience and provider perception of patient experience aligned under 2 themes: (a) care coordination is essential for positive patient experience; and (b) the BHICCI strengthened patient provider relationships. Perspectives diverged under theme (c) patient experience with programmatic "growing pains." Discussion: This study highlights the importance of seeking outpatient feedback and incorporating these experiences into the redesign of integrated care systems. Formal mechanisms, such as patient advisory boards, are needed to ensure that health care quality improvement initiatives are patient centered. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Advancing Integrated Care through Practice Coaching.

INTRODUCTION: Practice coaches are skilled consultants who work in health care service delivery systems to make changes designed to improve patient outcomes, yet research is limited regarding their use to support integrated health care. This article describes the use of practice coaches in a large-scale effort to implement integrated care in the United States for patients with complex care needs. THEORY AND METHODS: This immersive, qualitative project involved five implementation team members; eight practice coaches; and 77 staff members from 12 health care organizations. Semistructured interviews were recorded and transcribed verbatim. Thematic and content analyses were applied in multiple stages to understand the use of practice coaches. RESULTS: Qualitative themes about the use of practice coaching in this initiative were: (a) development of "a very rich coaching model"; (b) moving from an organic to standardized coaching approach; and (c) coaches representing the "face of the initiative." DISCUSSION: A rich coaching model that includes an interdisciplinary coaching team can support integrated care transformation but challenges including finding highly qualified coaches and sustaining and disseminating the coaching model exist. Standardization was seen as a way to address such challenges. CONCLUSION: Practice coaches can provide individualized, hands-on guidance to support successful implementation of integrated care.

Attitudes of Mental Health Peer-Run Organizations Towards Health Homes: Recommendations for Policy and Practice.

This study examined peer-run organizations' attitudes towards collaborating in health homes. Data were drawn from the 2012 National Survey of Peer-Run Organizations. Multinomial logistic regression modeled the association between organizational willingness to participate in a health home and salient factors. Current efforts (OR = 5.05; p < 0.05), planned efforts (OR = 4.27; p < 0.05) to encourage physical healthcare, and staff size (OR = 1.09; p < 0.05) were associated with willingness to collaborate in health homes. Some organizations were concerned about power dynamics with potential medical collaborators. Relationships with medical providers, staffing capacity, and concerns about coercion should be considered when integrating peer-run organizations and health homes.

Peer Respites: A Qualitative Assessment of Consumer Experience.

This qualitative study explored the experiences of persons staying at two peer respites through interviews with 27 respite guests near the end of their stay and at 2-6 months following their stay. Trained peer interviewers conducted baseline and follow-up interviews. Peer respites can be beneficial spaces within the mental health system for guests to temporarily escape stressful situations while building relationships with other persons with mental illness, though some respondents were uncomfortable receiving services from peers, and several guests did not want to leave after their stay. Ongoing training of peers and orientations for respite guests can help ensure optimal respite experiences.

Evaluation Of The Behavioral Health Integration And Complex Care Initiative In Medi-Cal.

This article reports how a large Medi-Cal managed care plan addressed challenges in accessing health care for approximately 7,000 enrollees with multiple chronic conditions through a project known as the Behavioral Health Integration and Complex Care Initiative. The initiative increased staffing for care management, care coordination, and behavioral health integration. In our evaluation of the initiative, we demonstrated that participation in it was associated with improved clinical indicators for common chronic conditions, reduced inpatient costs in some sites, and improved patient experience in all sites. The initiative may be best understood as a new type of ongoing strategic partnership among the health plan, its providers, and their patients. Changes in funding to support models of value-based care are needed to sustain these efforts in the long term.

From Physical Wellness to Cultural Brokering: Unpacking the Roles of Peer Providers in Integrated Health Care Settings.

This qualitative study explored peer provider experiences working in newly integrated mental health and primary care pilot programs within a large public mental health system. Nineteen peer providers participated in semistructured interviews that focused on experiences delivering care within integrated teams. Interviews were analyzed using constant comparative methods informed by grounded theory. Findings were organized into three themes that speak to variation in the definition and function of peers; lack of clarity in the peer role; and relating to other providers. Integrated settings need ongoing support to ensure clarity in the peer role and an inclusive work environment.

Integrated Primary Care in Assertive Community Treatment.

Assertive community treatment (ACT) has the potential to serve as a medical home for adults with serious mental illness, a population that experiences some of the most significant health disparities in the United States. Using site visit methodology, the authors describe partnerships that were created between five ACT programs and federally qualified health centers (FQHCs) to provide integrated behavioral health and primary care. The authors examined rates of screening for common chronic conditions. The programs used three distinct approaches: two programs colocated ACT teams at an FQHC, two programs employed primary care providers who split their time between the FQHC and the ACT program, and one program embedded a primary care provider within the ACT team. Effective communication between staffs may be more important than type of partnership in determining integration success.

Where do Peer Providers Fit into Newly Integrated Mental Health and Primary Care Teams? A Mixed Method Study.

Little is known about the involvement of peer providers in integrated behavioral health teams. This study asks where peer providers fit within integrated care teams in Los Angeles County. Social network analysis combined with qualitative fieldwork was used to understand the network positions of peer providers in 14 integrated pilot programs. Four programs' peer providers were highly central, while 3 programs' were on the network's periphery. Positional variation appeared to be related to the peers' mental health status. Targeted efforts are needed to support the implementation of peer providers on integrated teams at the program and system levels.

Health Care Decisions among Mental Health Services Consumers in San Diego County: Implications for Integrated Care.

People living with serious mental illness are at elevated risk for chronic diseases compared with those in the general population. Whether integrated care for this population would be most accessible in primary care or mental health settings is unclear. The cross-sectional study described in this article used descriptive analyses and multinomial logistic regression to assess factors associated with using physical health services from primary or mental health providers. Data were drawn from a large-scale assessment of client-reported use of primary care services in a large and ethnically diverse public mental health system. Most people (80.4 percent) reported accessing primary care services from one or more service settings. Having chronic conditions was associated with accessing physical health care from multiple service settings, whereas having poor self-rated emotional health decreased health services use from any setting. It was concluded that mental health services consumers access health care from various service settings. Social workers can play a critical role in enhancing care coordination across the mental health and primary care systems.

Peer Support in Full-Service Partnerships: A Multiple Case Study Analysis.

Peer providers are integral to Full Service Partnerships (FSPs), which are team-based mental health service models. Peer providers use principles of recovery to engage clients, but FSPs can vary in their recovery orientation. Whether and how peer recovery orientation reflects the organizational environments of FSPs is unclear. This qualitative study explored peer provider attitudes towards recovery within the organizational contexts of FSPs where they are employed. Case study analysis was conducted on eight purposively sampled FSPs using qualitative interviews with peer providers and program directors. In two cases, peer recovery attitudes diverged from those of their organizational context. In these cases, peer providers were champions for recovery, and used practice-based strategies to promote client autonomy despite working in settings with lower recovery orientation. Peer providers could be uniquely positioned to promote client autonomy in settings where organizational factors limit consumer choice.

Mental Illness Is Not Associated with Adherence to Colorectal Cancer Screening: Results from the California Health Interview Survey.

BACKGROUND: Colorectal cancer is the second leading cause of cancer-specific death in the USA. Evidence suggests people with mental illness are less likely to receive preventive health services, including cancer screening. We hypothesized that mental illness is a risk factor for non-adherence to colorectal cancer-screening guidelines. METHODS: We analyzed results of the 2007 California Health Interview Survey to test whether mental illness is a risk factor for non-adherence to colorectal cancer-screening recommendations among individuals age 50 or older (N = 15,535). This cross-sectional dataset is representative of California. Screening was defined as either fecal occult blood testing during the preceding year, sigmoidoscopy, or colonoscopy during the preceding 5 years. Mental illness was identified using the Kessler K6 screening tool. Associations were evaluated using weighted multivariate logistic regressions. RESULTS: Mental illness was not associated with colorectal cancer-screening adherence (OR 0.89; 95% CI 0.63-1.25). Risk factors for non-adherence included being female (OR 1.25; 95% CI 1.09-1.44), delaying accessing health care during the previous year (OR 1.89; 95% CI 1.56-2.29). CONCLUSION: Unlike previous studies, this study did not find a relationship between mental illness and colorectal cancer-screening adherence. This could be due to differences in study populations. State-specific healthcare policies involving care coordination for individuals with mental illness could also influence colorectal cancer-screening adherence in California.

The use of inhaled antibiotic therapy in the treatment of ventilator-associated pneumonia and tracheobronchitis: a systematic review.

BACKGROUND: Ventilator-associated respiratory infections (tracheobronchitis, pneumonia) contribute significant morbidity and mortality to adults receiving care in intensive care units (ICU). Administration of broad-spectrum intravenous antibiotics, the current standard of care, may have systemic adverse effects. The efficacy of aerosolized antibiotics for treatment of ventilator-associated respiratory infections remains unclear. Our objective was to conduct a systematic review of the efficacy of aerosolized antibiotics in the treatment of ventilator-associated pneumonia (VAP) and tracheobronchitis (VAT), using the Cochrane Collaboration guidelines. METHODS: We conducted a search of three databases (PubMed, Web of Knowledge and the Cochrane Collaboration) for randomized, controlled trials studying the use of nebulized antibiotics in VAP and VAT that measured clinical cure (e.g., change in Clinical Pulmonary Infection Score) as an outcome measurement. We augmented the electronic searches with hand searches of the references for any narrative review articles as well as any article included in the systematic review. Included studies were examined for risk of bias using the Cochrane Handbook's "Risk of Bias" assessment tool. RESULTS: Six studies met full inclusion criteria. For the systemic review's primary outcome (clinical cure), two studies found clinically and statistically significant improvements in measures of VAP cure while four found no statistically significant difference in measurements of cure. No studies found inferiority of aerosolized antibiotics. The included studies had various degrees of biases, particularly in the performance and detection bias domains. Given that outcome measures of clinical cure were not uniform, we were unable to conduct a meta-analysis. CONCLUSIONS: There is insufficient evidence for the use of inhaled antibiotic therapy as primary or adjuvant treatment of VAP or VAT. Additional, better-powered randomized-controlled trials are needed to assess the efficacy of inhaled antibiotic therapy for VAP and VAT.