Adoption of innovative and evidence-based practices for children and adolescents in state-supported mental health clinics: a qualitative study.

BACKGROUND: This study examined how mental health clinic administrators decided whether or not to adopt evidence-based and other innovative practices by exploring their views of implementation barriers and facilitators and operation of these views in assessment of implementation costs and benefits. METHODS: Semi-structured interviews were conducted with 75 agency chief executive officers and program directors of 34 New York State-licensed mental health clinics serving children and adolescents. RESULTS: Three interconnected themes relating to barriers and facilitators were identified, namely costs and benefits associated with adoption, capacity for adoption, and acceptability of new practices. The highest percentage of participants (86.7%) mentioned costs as a barrier, followed by limited capacity (55.9%) and lack of acceptability (52.9%). The highest percentage (82.3%) of participants identified available capacity as a facilitator, followed by acceptability (41.2%) and benefits or limited costs (24.0%). Assessment of costs and benefits exhibited several principles of behavioural economics, including loss aversion, temporal discounting use of heuristics, sensitivity to monetary incentives, decision fatigue, framing, and environmental influences. CONCLUSIONS: The results point to opportunities for using agency leader models to develop strategies to facilitate implementation of evidence-based and innovative practices for children and adolescents.

Implementing a Measurement Feedback System: A Tale of Two Sites.

A randomized experiment was conducted in two outpatient clinics evaluating a measurement feedback system called contextualized feedback systems. The clinicians of 257 Youth 11-18 received feedback on progress in mental health symptoms and functioning either every 6 months or as soon as the youth's, clinician's or caregiver's data were entered into the system. The ITT analysis showed that only one of the two participating clinics (Clinic R) had an enhanced outcome because of feedback, and only for the clinicians' ratings of youth symptom severity on the SFSS. A dose-response effect was found only for Clinic R for both the client and clinician ratings. Implementation analyses showed that Clinic R had better implementation of the feedback intervention. Clinicians' questionnaire completion rate and feedback viewing at Clinic R were 50 % higher than clinicians at Clinic U. The discussion focused on the differences in implementation at each site and how these differences may have contributed to the different outcomes of the experiment.

Implementing a Measurement Feedback System in Community Mental Health Clinics: A Case Study of Multilevel Barriers and Facilitators.

Measurement feedback systems (MFSs) have been proposed as a means of improving practice. The present study examined the implementation of a MFS, the Contextualized Feedback System (CFS), in two community-based clinic sites. Significant implementation differences across sites provided a basis for examining factors that influenced clinician uptake of CFS. Following the theoretical implementation framework of Aarons et al. (Adm Policy Mental Health Mental Health Serv Res 38(1):4-23, 2011), we coded qualitative data collected from eighteen clinicians (13 from Clinic U and 5 from Clinic R) who participated in semi-structured interviews about their experience with CFS implementation. Results suggest that clinicians at both clinics perceived more barriers than facilitators to CFS implementation. Interestingly, clinicians at the higher implementing clinic reported a higher proportion of barriers to facilitators (3:1 vs. 2:1); however, these clinicians also reported a significantly higher level of organizational and leadership supports for CFS implementation. Implications of these findings are discussed.

Beyond context to the skyline: thinking in 3D.

Sweeping and profound structural, regulatory, and fiscal changes are rapidly reshaping the contours of health and mental health practice. The community-based practice contexts described in the excellent review by Garland and colleagues are being fundamentally altered with different business models, regional networks, accountability standards, and incentive structures. If community-based mental health services are to remain viable, the two-dimensional and flat research and practice paradigm has to be replaced with three-dimensional thinking. Failure to take seriously the changes that are happening to the larger healthcare context and respond actively through significant system redesign will lead to the demise of specialty mental health services.

Engagement in Trauma-Specific CBT for Youth Post-9/11.

Treatment participation was examined among youth enrolled in an evaluation of cognitive behavioral therapy (CBT) for trauma following the 9/11 World Trade Center disaster. Staff at nine agencies serving a predominantly low-income ethnically diverse population were trained to deliver CBT and structured engagement strategies. Four hundred and forty-five youth ages 5-19 were eligible for CBT, and 417 (94%) received at least one treatment session. Pretreatment and treatment show rates and overall dose were examined. Treatment participation rates were higher than those typically reported in community studies of children's mental health services. Regression analyses indicated variability across sites in treatment show rates with the highest rates at where services were delivered in schools. However, sites, demographic factors and trauma symptoms accounted for a small amount of variance in treatment participation overall. The study suggests structured engagement strategies, linked to evidence-based treatments may improve treatment participation for youth.

Opioid Prescribing in the 2016 Medicare Fee-for-Service Population.

BACKGROUND AND OBJECTIVES: Opioid use and misuse are prevalent and remain a national crisis. This study identified beneficiary characteristics associated with filling opioid prescriptions, variation in opioid dosing, and opioid use with average daily doses (ADDs) equal to 120 morphine milligram equivalents (MMEs) or more in the 100% Medicare fee-for-service (FFS) population. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: In a cohort of FFS beneficiaries with 12 months of Medicare Part D coverage in 2016, we examined patient factors associated with filling an opioid prescription (n = 20,880,490) and variation in ADDs (n = 7,325,031) in a two-part model. Among those filling opioids, we also examined the probability of ADD equal to 120 MMEs or more via logistic regression. RESULTS: About 35% of FFS beneficiaries had one or more opioid prescription fills in 2016 and 1.5% had ADDs equal to 120 MMEs or more. Disability-eligible beneficiaries and beneficiaries with multiple chronic conditions were more likely to fill opioids, to have higher ADDs or were more likely to have ADD equal to 120 MMEs or more. Beneficiaries with chronic obstructive pulmonary disease (COPD) were more likely to fill opioids (odds ratio (OR) = 1.47, 95% confidence interval (CI) = 1.46-1.47), have higher ADDs (rate ratio = 1.06, 95% CI = 1.06-1.06) when filled and were more likely to have ADD equal to 120 MMEs or more (OR = 1.23, 95% CI = 1.21-1.24). Finally, black and Hispanic beneficiaries were less likely to fill opioids, had lower overall doses and were less likely to have ADDs equal to 120 MMEs or more compared to white beneficiaries. CONCLUSION: Several beneficiary subgroups have underappreciated risk of adverse events associated with ADD equal to 120 MMEs or more that may benefit from opioid optimization interventions that balance pain management and adverse event risk, especially beneficiaries with COPD who are at risk for respiratory depression.

Quality Measures for Managing Prescription of Antipsychotic Medication Among Youths: Factors Associated With Health Plan Performance.

OBJECTIVE: This study examined the performance of health plans on two HEDIS measures: metabolic monitoring of children and adolescents prescribed an antipsychotic and use of first-line psychosocial care for children and adolescents prescribed an antipsychotic for a nonindicated use. Plan characteristics and other contextual factors that may be associated with health plan performance were examined to identify potential strategies for improving care. METHODS: The study population included 279 commercial and 169 Medicaid health plans that voluntarily submitted data for care provided in 2016. Bivariate associations between performance on the two measures and each plan characteristic (eligible population size, region, profit status, model type, and operating in a state with legislation on prior authorization for antipsychotics) were examined. Main-effects multivariable linear regression models were used to examine the combined association of plan characteristics with each measure. RESULTS: Performance rates on both measures were comparable for commercial and Medicaid plans. Among commercial plans, not-for-profit plans outperformed for-profit plans on both measures. Commercial and Medicaid plans in the North performed significantly better on the metabolic monitoring measure. Commercial plans in the South and Medicaid plans in the West performed significantly worse on the first-line psychosocial care measure. Plans operating in states requiring prior authorization performed significantly better on the metabolic monitoring measure. CONCLUSIONS: This study identified key plan characteristics and other contextual factors associated with health plan performance on quality measures related to pediatric antipsychotic prescribing. Findings suggest that quality measures, in conjunction with policies such as prior authorization, can encourage better care delivery to vulnerable populations.

School mental health resources and adolescent mental health service use.

OBJECTIVE: Although schools are identified as critical for detecting youth mental disorders, little is known about whether the number of mental health providers and types of resources that they offer influence student mental health service use. Such information could inform the development and allocation of appropriate school-based resources to increase service use. This article examines associations of school resources with past-year mental health service use among students with 12-month DSM-IV mental disorders. METHOD: Data come from the U.S. National Comorbidity Survey Adolescent Supplement (NCS-A), a national survey of adolescent mental health that included 4,445 adolescent-parent pairs in 227 schools in which principals and mental health coordinators completed surveys about school resources and policies for addressing student emotional problems. Adolescents and parents completed the Composite International Diagnostic Interview and reported mental health service use across multiple sectors. Multilevel multivariate regression was used to examine associations of school mental health resources and individual-level service use. RESULTS: Nearly half (45.3%) of adolescents with a 12-month DSM-IV disorder received past-year mental health services. Substantial variation existed in school resources. Increased school engagement in early identification was significantly associated with mental health service use for adolescents with mild/moderate mental and behavior disorders. The ratio of students to mental health providers was not associated with overall service use, but was associated with sector of service use. CONCLUSIONS: School mental health resources, particularly those related to early identification, may facilitate mental health service use and may influence sector of service use for youths with DSM disorders.

Family Peer Advocates: A Pilot Study of the Content and Process of Service Provision.

Professional family peer advocates are increasingly employed by public mental health systems to deliver family-to-family support that reduces barriers families face in accessing children's mental health care. These services, however, are neither uniformly available nor standardized. This pilot study describes the process, content and context of family-to-family support services. Simulating a parent seeking services, a trained standardized parent participated as a client in meetings with advocates in four programs and collected data through structured observations, a structured survey, and session audiotapes. The "walk-through" process was determined to be feasible and acceptable to family peer advocates as a way of evaluating services. Four family peer advocates provided an average of 25 services during each 2-session simulation with the standardized parent, including the following: information and educational support, instruction and skills development, emotional and affirmational support, instrumental support, and advocacy. Findings also revealed variability in the range of services provided and identified challenges in aspects of service provision, such as boundaries of advocate roles, availability of confidential service environments, and addressing crises and parent concerns about child safety. This paper provides the first in-depth look at services provided by this emerging workforce.

Maximizing the Implementation Quality of Evidence-Based Preventive Interventions in Schools: A Conceptual Framework.

Increased availability of research-supported, school-based prevention programs, coupled with the growing national policy emphasis on use of evidence-based practices, has contributed to a shift in research priorities from efficacy to implementation and dissemination. A critical issue in moving research to practice is ensuring high-quality implementation of both the intervention model and the support system for sustaining it. The paper describes a three-level framework for considering the implementation quality of school-based interventions. Future directions for research on implementation are discussed.