Implications of Telepsychiatry for Cost, Quality, and Equity of Mental Health Care.

This Viewpoint discusses overlapping challenges to multiple stakeholders as telepsychiatry continues to expand.

OnTrack Chile for people with early psychosis: a study protocol for a Hybrid Type 1 trial.

BACKGROUND: Substantial data from high-income countries support early interventions in the form of evidence-based Coordinated Specialty Care (CSC) for people experiencing First Episode Psychosis (FEP) to ameliorate symptoms and minimize disability. Chile is unique among Latin American countries in providing universal access to FEP services through a national FEP policy that mandates the identification of FEP individuals in primary care and guarantees delivery of community-based FEP treatments within a public health care system. Nonetheless, previous research has documented that FEP services currently provided at mental health clinics do not provide evidence-based approaches. This proposal aims to address this shortfall by first adapting OnTrackNY (OTNY), a CSC program currently being implemented across the USA, into OnTrackChile (OTCH), and then examine its effectiveness and implementation in Chile. METHODS: The Dynamic Adaptation Process will be used first to inform the adaptation and implementation of OTCH to the Chilean context. Then, a Hybrid Type 1 trial design will test its effectiveness and cost and evaluate its implementation using a cluster-randomized controlled trial (RCT) (N = 300 from 21 outpatient clinics). The OTCH program will be offered in half of these outpatient clinics to individuals ages 15-35. Usual care services will continue to be offered at the other clinics. Given the current COVID-19 pandemic, most research and intervention procedures will be conducted remotely. The study will engage participants over the course of 2 years, with assessments administered at enrollment, 12 months, and 24 months. Primary outcomes include implementation (fidelity, acceptability, and uptake) and service outcomes (person-centeredness, adherence, and retention). Secondary outcomes comprise participant-level outcomes such as symptoms, functioning, and recovery orientation. Over the course of the study, interviews and focus groups with stakeholders will be conducted to better understand the implementation of OTCH. DISCUSSION: Findings from this study will help determine the feasibility, effectiveness, and cost for delivering CSC services in Chile. Lessons learned about facilitators and barriers related to the implementation of the model could help inform the approach needed for these services to be further expanded throughout Latin America. TRIAL REGISTRATION: www. CLINICALTRIALS: gov NCT04247711 . Registered 30 January 2020. TRIAL STATUS: The OTCH trial is currently recruiting participants. Recruitment started on March 1, 2021, and is expected to be completed by December 1, 2022. This is the first version of this protocol (5/12/2021).

Substance use disorders and COVID-19: An analysis of nation-wide Veterans Health Administration electronic health records.

BACKGROUND: Substance use disorders (SUD) elevate the risk for COVID-19 hospitalization, but studies are inconsistent on the relationship of SUD to COVID-19 mortality. METHODS: Veterans Health Administration (VHA) patients treated in 2019 and evaluated in 2020 for COVID-19 (n=5,556,315), of whom 62,303 (1.1%) tested positive for COVID-19 (COVID-19+). Outcomes were COVID-19+ by 11/01/20, hospitalization, ICU admission, or death within 60 days of a positive test. Main predictors were any ICD-10-CM SUDs, with substance-specific SUDs (cannabis, cocaine, opioid, stimulant, sedative) explored individually. Logistic regression produced unadjusted and covariate-adjusted odds ratios (OR; aOR). RESULTS: Among COVID-19+ patients, 19.25% were hospitalized, 7.71% admitted to ICU, and 5.84% died. In unadjusted models, any SUD and all substance-specific SUDs except cannabis use disorder were associated with COVID-19+(ORs=1.06-1.85); adjusted models produced similar results. Any SUD and all substance-specific SUDs were associated with hospitalization (aORs: 1.24-1.91). Any SUD, cocaine and opioid disorder were associated with ICU admission in unadjusted but not adjusted models. Any SUD, cannabis, cocaine, and stimulant disorders were inversely associated with mortality in unadjusted models (OR=0.27-0.46). After adjustment, associations with mortality were no longer significant. In ad hoc analyses, adjusted odds of mortality were lower among the 49.9% of COVID-19+ patients with SUD who had SUD treatment in 2019, but not among those without such treatment. CONCLUSIONS: In VHA patients, SUDs are associated with COVID-19 hospitalization but not COVID-19 mortality. SUD treatment may provide closer monitoring of care, ensuring that these patients received needed medical attention, enabling them to ultimately survive serious illness.

COVID-19 Case Rates After Surveillance and Vaccinations in a Statewide Psychiatric Hospital System.

Individuals with serious mental illness are particularly vulnerable to COVID-19. The New York State (NYS) Office of Mental Health implemented patient and staff rapid testing, quarantining, and vaccination to limit COVID-19 spread in 23 state-operated psychiatric hospitals between November 2020 and February 2021. COVID-19 infection rates in inpatients and staff decreased by 96% and 71%, respectively, and the NYS population case rate decreased by 6%. Repeated COVID-19 testing and vaccination should be priority interventions for state-operated psychiatric hospitals. (Am J Public Health. 2021;111(10):1780-1783. https://doi.org/10.2105/AJPH.2021.306444).

Adapting coordinated specialty care in the post-COVID-19 era: study protocol for an integrative mixed-methods study.

BACKGROUND: Coordinated Specialty Care (CSC) programs provide evidence-based services for young people with a recent onset of a psychotic disorder. OnTrackNY is a nationally recognized model of CSC treatment in New York state. In 2019, OnTrackNY was awarded a hub within the Early Psychosis Intervention Network (EPINET) to advance its learning health care system (LHS). The OnTrackNY network is comprised of 23 CSC teams across New York state. OnTrack Central, an intermediary organization, provides training and implementation support to OnTrackNY teams. OnTrack Central coordinates a centralized data collection protocol for quality improvement and evaluation of program fidelity and a mechanism to support practice based-research. OnTrackNY sites' breadth coupled with OnTrack Central oversight provides an opportunity to examine the impacts of the COVID-19 crisis in New York State, and supplementary funding was awarded to the OnTrackNY EPINET hub in 2021 for that purpose. METHODS: This project will examine the implications of modifications to service delivery within the OnTrackNY LHS during and after the COVID-19 crisis. We will use the Framework for Reporting Adaptations and Modification-Enhanced (FRAME) to classify systematically, code, and analyze modifications to CSC services and ascertain their impact. We will utilize integrative mixed methods. Qualitative interviews with multi-level stakeholders (program participants, families, providers, team leaders, agency leaders, trainers (OnTrack Central), and decision-makers at the state and local levels) will be used to understand the process of making decisions, information about modifications to CSC services, and their impact. Analysis of OnTrackNY program data will facilitate examining trends in team staffing and functioning, and participant service utilization and outcomes. Study findings will be summarized in a CSC Model Adaptation Guide, which will identify modifications as fidelity consistent or not, and their impact on service utilization and care outcomes. DISCUSSION: A CSC Model Adaptation Guide will inform CSC programs, and the state and local mental health authorities to which they are accountable, regarding modifications to CSC services and the impact of these changes on care process, and participant service utilization and outcomes. The guide will also inform the development of tailored technical assistance that CSC programs may need within OnTrackNY, the EPINET network, and CSC programs nationally. TRIAL REGISTRATION: NCT04021719 , July 16th, 2019.

Adapting Coordinated Specialty Care in the Post-COVID-19 Era: Study Protocol for an Integrative Mixed-methods Study.

Background : Coordinated Specialty Care (CSC) programs provide evidence-based services for young people with a recent onset of a psychotic disorder. OnTrackNY is a nationally recognized model of CSC treatment in New York state. In 2019, OnTrackNY was awarded a hub within the Early Psychosis Intervention Network (EPINET) to advance its learning health care system (LHS). The OnTrackNY network is comprised of 23 CSC teams across New York state. OnTrack Central, an intermediary organization, provides training and implementation support to OnTrackNY teams. OnTrack Central coordinates a centralized data collection protocol for quality improvement and evaluation of program fidelity and a mechanism to support practice based-research. OnTrackNY sites’ breadth coupled with OnTrack Central oversight provides an opportunity to examine the impacts of the COVID-19 crisis in New York State. Methods : This project will examine the implications of modifications to service delivery within the OnTrackNY LHS during and after the COVID-19 crisis. We will use the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) to classify systematically, code, and analyze modifications to CSC services and ascertain their impact. We will utilize integrative mixed methods. Qualitative interviews with multi-level stakeholders (program participants, families, providers, team leaders, agency leaders, trainers (OnTrack Central), and decision-makers at the state and local levels) will be used to understand the process making decisions, information about modifications to CSC services, and their impact. Analysis of OnTrackNY program data will facilitate examining trends in team staffing and functioning, and participant service utilization and outcomes. Study findings will be summarized in a CSC Model Adaptation Guide , which will identify modifications as fidelity consistent or not, and their impact on service utilization and care outcomes. Discussion : A CSC Model Adaptation Guide will inform CSC programs, and the state and local mental health authorities to which they are accountable, regarding modifications to CSC services and the impact of these changes on care process, and participant service utilization and outcomes. The guide will also inform the development of tailored technical assistance that CSC programs may need within OnTrackNY, the EPINET network, and CSC programs nationally. Trial Registration : NCT04021719, July 16 th , 2019.