Care integration goes Beyond Co-Location: Creating a Medical Home.

How to successfully integrate mental health and primary care remains a critically important question given the continued morbidity and early mortality of people with serious mental illness. This study investigated integration in a community mental health center (MHC) primarily treating people with SMI in a large, urban northeastern city where an on-site primary care center (PCC) was opened resulting in co-located mental health and primary care services being provided. Using focus groups and online surveys this study asked participants about their thoughts and interactions with the on-site PCC. Participants included staff from clinical, non-clinical, and leadership roles in the mental health center (MHC; PCC staff; and MHC clients who did not use the on-site PCC). MHC staff also offered their thoughts about and experiences with the on-site PCC one year and two years after the on-site PCC opened through an on-line survey. In both methods, staff reported limited awareness and expectations of the PCC in the first year. Staff indicated that successful care integration goes beyond co-location and peer health navigation can enhance integration. Finally, staff discussed desires for enhancing care integration and co-located services into a medical home that included communicating across medical records and providers at different agencies. Our results suggest that, in addition to the previously researched three C's of care integration (consultation, coordination, and collaboration), two more C's were essential to successful care integration: co-location and communication. Communication across medical records and providers at different agencies was an essential component of care integration, and co-location added increased ability to communicate across providers.

The Relationship between Substance Use Stigma and COVID-19 Vaccine Hesitancy.

Two parallel public health epidemics affecting the United States include the COVID-19 pandemic and a rise in substance use disorders (SUDs). Limited research has examined the potential relationship between these two epidemics. Our objective was therefore to perform an exploratory study in order to examine the association between public stigma toward people with a past history of opioid, methamphetamine, cocaine, and alcohol use disorder and COVID-19 vaccine hesitancy. A national sample of U.S. adults (N = 6515) completed a survey which assessed the degree of negative perceptions toward individuals with a past history of substance use disorders (referred to as substance use stigma) and COVID-19 vaccine hesitancy, along with variables such as racial prejudice, source of health news, and other demographics. We evaluated four multivariable logistic regression models to predict COVID-19 vaccine hesitancy, utilizing substance use stigma toward opioids, methamphetamine, cocaine, and alcohol use as independent variables. We found that COVID-19 vaccine hesitancy was positively associated with substance use stigma toward opioid (AOR = 1.34, p < 0.05), methamphetamine (AOR = 1.40, p < 0.01), and cocaine (AOR = 1.28, p < 0.05) use, but not alcohol use (AOR = 1.06, n.s.). Predictive models that incorporate substance use stigma may therefore improve our ability to identify individuals that may benefit from vaccine hesitancy interventions. Future research to understand the underlying reasons behind the association between substance use stigma and COVID-19 vaccine hesitancy may help us to construct combined interventions which address belief systems that promote both substance use stigma and vaccine hesitancy.

Primary Care's Challenges and Responses in the Face of the COVID-19 Pandemic: Insights From AHRQ's Learning Community.

The COVID-19 pandemic dramatically disrupted health care systems and delivery in the United States. Despite emotional, psychological, logistical, and financial stress, primary care clinicians responded to the challenges that COVID-19 presented and continued to provide essential health services to their communities. As the lead federal agency for primary care research, the Agency for Healthcare Research and Quality (AHRQ) identified a need to engage and support primary care in responding to COVID-19. AHRQ initiated a learning community from December 2020-November 2021 to connect professionals and organizations that support primary care practices and clinicians. The learning community provided a forum for participants to share learning and peer support, better understand the stressors and challenges confronting practices, ascertain needs, and identify promising solutions in response to the pandemic. We identified challenges, responses, and innovations that emerged through learning community engagement, information sharing, and dialog. We categorized these across 5 domains that reflect core areas integral to primary care delivery: patient-centeredness, clinician and practice, systems and infrastructure, and community and public health; health equity was crosscutting across all domains. The engagement of the community to identify real-time response and innovation in the context of a global pandemic has provided valuable insights to inform future research and policy, improve primary care delivery, and ensure that the community is better prepared to respond and contribute to ongoing and future health challenges.

Support for evidence-informed opioid policies and interventions: The role of racial attitudes, political affiliation, and opioid stigma.

Political affiliation, racial attitudes, and opioid stigma influence public support for public health responses to address opioid use disorders (OUD). Prior studies suggest public perceptions of the opioid epidemic are less racialized and less politically polarized than were public perceptions of the crack cocaine epidemic. Analyzing a cross-sectional, nationally representative sample (n = 1161 U.S. adults) from the October 2020 AmeriSpeak survey, we explored how political affiliation, racial attitudes (as captured in the Color-Blind Racial Attitudes Scale [CoBRAS]), and OUD stigma were associated with respondents' expressed views regarding four critical domains. Respondents with unfavorable attitudes towards Black Americans were less likely to support expanding Medicaid funding, increasing government spending to provide services for people living with OUD, and distributing naloxone for overdose prevention. Democratic Party affiliation was associated with greater support for all three of the above measures, and increased support for mandatory treatment, which may be seen as a substitute for more punitive interventions. Black respondents were also less likely to support expanding Medicaid funding, increasing government spending to provide services for people living with OUD, and of distributing naloxone. Our finding suggest that negative attitudes towards African-Americans and political differences remain important factors of public opinion on responding to the OUD epidemic, even after controlling for opioid stigma. Our findings also suggest that culturally-competent dialogue within politically conservative and Black communities may be important to engage public support for evidence-informed treatment and prevention.

National variability in Americans' COVID-19 protective behaviors: Implications for vaccine roll-out.

Protective behaviors such as mask wearing and physical distancing are critical to slow the spread of COVID-19, even in the context of vaccine scale-up. Understanding the variation in self-reported COVID-19 protective behaviors is critical to developing public health messaging. The purpose of the study is to provide nationally representative estimates of five self-reported COVID-19 protective behaviors and correlates of such behaviors. In this cross-sectional survey study of US adults, surveys were administered via internet and telephone. Adults were surveyed from April 30-May 4, 2020, a time of peaking COVID-19 incidence within the US. Participants were recruited from the probability-based AmeriSpeak® national panel. Brief surveys were completed by 994 adults, with 73.0% of respondents reported mask wearing, 82.7% reported physical distancing, 75.1% reported crowd avoidance, 89.8% reported increased hand-washing, and 7.7% reported having prior COVID-19 testing. Multivariate analysis (p critical value .05) indicates that women were more likely to report protective behaviors than men, as were those over age 60. Respondents who self-identified as having low incomes, histories of criminal justice involvement, and Republican Party affiliation, were less likely to report four protective behaviors, though Republicans and individuals with criminal justice histories were more likely to report having received COVID-19 testing. The majority of Americans engaged in COVID-19 protective behaviors, with low-income Americans, those with histories of criminal justice involvement, and self-identified Republicans less likely to engage in these preventive behaviors. Culturally competent public health messaging and interventions might focus on these latter groups to prevent future infections. These findings will remain highly relevant even with vaccines widely available, given the complementarities between vaccines and protective behaviors, as well as the many challenges in delivering vaccines.

Social Stigma toward Persons with Opioid Use Disorder: Results from a Nationally Representative Survey of U.S. Adults.

Background: This study seeks to understand the general adult population's knowledge, attitudes, and stigma towards opioid use disorder (OUD), people with histories of opioid misuse, and policies related to OUD. Methods: We conducted a cross-sectional national survey of the U.S. adult population, using AmeriSpeak's® web, probability-based panel. The number of participants were 947 (493 females and 454 males) general population adults ages 19 -89 years old who completed a self-report survey covering: social stigma of OUD, opioid policy attitudes, perceptions of OUD as a crime, knowledge and beliefs about opioids and treatment, personal experience with opioids and the criminal justice (CJ) system, and demographics. Results: Thirteen percent self-reported ever misusing opioids, 3% reported an opioid overdose, and 14% reported personal experience with the CJ system. On average, the general adult population moderately endorses stigmatizing behaviors, agrees that OUD is a medical condition, agrees with policies to increase access to OUD treatment, and is less likely to endorse OUD as a crime. Having a disregard for OUD as a medical condition was most associated with higher levels of stigma, endorsing OUD as a crime, and disagreeing with policies to help people access OUD treatment. Conclusions: Our data provide guidance to policymakers concerning individuals with certain characteristics to target for public education efforts to reduce stigma and draw more support for public heath interventions for OUD. Our data also suggest that the content of this education should include improving understanding of OUD as a medical condition.

The Organizational Multicultural Competence Assessment (OMCA): A tool to assess an organization's multicultural competence and adherence to the National Standards for Culturally and Linguistically Appropriate Services in Health and Healthcare (the National CLAS Standards).

Objective: Behavioral health organizations must respond to the needs of increasing numbers of multicultural populations, as the world population continues to diversify. The goal of this research was to develop a measure to assess the multicultural competence of a behavioral health agency using a quick and efficient but comprehensive strategy that utilizes input from multiple staff members. Method: The Organizational Multicultural Competence Assessment (OMCA) was developed through a review of existing cultural competence assessment measures and item generation from researchers and policy makers. 469 staff from all departments of a U.S. state-operated and funded behavioral health facilities were asked by the CEO of their agency to complete the 45-item survey. Findings: Principal components analysis revealed seven factors that accounted for 64% of the variance in item responses: Governance, Policies, and Procedures; Staff Training and Service Delivery; Addressing Stigma and Discrimination; Accessibility of Services; Community Relationships; Quality, Monitoring, and Evaluation; and Human Resource Development. Items within factors showed high internal reliability. Conclusions and Implications for Practice: This measure may be used on an ongoing basis as a quality improvement tool to assess an agency or system's multicultural competence and adherence to the CLAS standards. Future research can investigate the relationship between scores on this measure and organization-level recovery oriented, client health, and person-centered outcomes. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

An "oasis within a desert," but the desert remains: Clubhouse members' experiences of social belonging and societal oppression.

Persons living with mental health challenges are at increased risk of stigma, social isolation, and social exclusion. Due to its emphasis on member participation and community, the clubhouse model of mental health may help address these issues. In this study, we examined experiences of social belonging and of various social determinants of mental health among members attending a psychosocial clubhouse. Twelve members of a large psychosocial clubhouse were interviewed regarding their experiences of community life and belonging. Phenomenological qualitative methods were utilized to examine the meaning and structure of these experiences. Members overwhelmingly experienced the clubhouse as a central site of belonging ("an oasis"), but members also recounted devastating portraits of life in the outside world ("a desert"). This world presented fundamental restrictions on their movement and speech and held deeply sedimented norms pertaining to who is considered valuable, productive, and even human, which they were reminded of through an endless tyranny of questions ("what do you do," "where do you live," etc.). Life in the clubhouse presented an alternative world for members to experience nourishment, dignity, reaffirmed personhood, and a sense of beauty. And yet, the desert outside remained. Implications of these findings for clubhouses, mental health practice, and sociopolitical and community engagement are discussed, including the need to address profound deprivations and power imbalances within the wider world, beyond the walls of humane spaces such as these. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Opioid Use Disorder Stigma, Discrimination, and Policy Attitudes in a National Sample of U.S. Young Adults.

PURPOSE: A small fraction of people with opioid use disorder (OUD) receives appropriate care. Public opinion about addiction contributes to the availability and accessibility of effective treatment services. Little is known about such attitudes toward OUD among young adults, a population at heightened risk for OUD onset. The current study examined endorsement of social stigma, discrimination, and policy attitudes about OUD and hypothesized correlates of such attitudes (familiarity with OUD, criminal justice involvement, respondent demographic characteristics). METHODS: A national sample of 190 young adults (weighted n = 408; 69% female, 42% White, non-Hispanic) aged 19-29 years completed web and telephone surveys covering opioid social stigma, discrimination, policy attitudes, personal experience with opioids, and criminal justice, and participant characteristics (age, sex, race, education, employment, income). Linear regressions were performed to examine associations between respondent characteristics and attitudes. RESULTS: Young adults, on average, endorsed moderate levels of stigma and discrimination toward people with OUD and support for treatment-oriented policies. Stigma was positively associated with discrimination and negatively associated with support for policies favorable to people with OUD. Regression results revealed that more negative attitudes toward OUD were endorsed as a function of older age and less personal experience or familiarity with OUD. CONCLUSIONS: Heterogeneity in young adults' attitudes about OUD may be explained, in part, by personal characteristics and familiarity with OUD. Adolescence may be an opportune developmental period to prevent or reduce public stigma related to OUD and MOUD and increase public attitudes in support of expanded access to effective OUD treatments.

Squalene Emulsion Manufacturing Process Scale-Up for Enhanced Global Pandemic Response.

Squalene emulsions are among the most widely employed vaccine adjuvant formulations. Among the demonstrated benefits of squalene emulsions is the ability to enable vaccine antigen dose sparing, an important consideration for pandemic response. In order to increase pandemic response capabilities, it is desirable to scale up adjuvant manufacturing processes. We describe innovative process enhancements that enabled the scale-up of bulk stable squalene emulsion (SE) manufacturing capacity from a 3000- to 5,000,000-dose batch size. Manufacture of concentrated bulk along with the accompanying viscosity change in the continuous phase resulted in a ≥25-fold process efficiency enhancement. Process streamlining and implementation of single-use biocontainers resulted in reduced space requirements, fewer unit operations, and minimization of cleaning requirements. Emulsion physicochemical characteristics were measured by dynamic light scattering, laser diffraction, and HPLC with charged aerosol detection. The newly developed full-scale process was demonstrated by producing two 5,000,000-dose batches of bulk concentrated SE. A scale-up of adjuvant manufacturing capacity through process innovation enables more efficient production capabilities for pandemic response.

Enhancing outcomes for persons with co-occurring disorders through skills training and peer recovery support.

Background: "Recovery supports", often provided by persons in recovery themselves, have emerged over the last decade as important components of recovery-oriented systems of care for persons with substance use disorders.Aims: This study assesses the benefit of adding peer recovery supports to the care of adults with co-occurring psychosis and substance use.Method: 137 adults with both disorders who had at least one prior admission within the past year were recruited during an index hospitalization into a randomized trial of standard care vs skills training with and without a peer-led social engagement program. Participants were assessed at admission and at three and nine months post-discharge on symptoms, functioning, substance use, and other factors.Results: At three months, skills training was effective in reducing alcohol use and symptoms, with the addition of peer-led support resulting in higher levels of relatedness, self-criticism, and outpatient service use. At nine months, skills training was effective in decreasing symptoms and inpatient readmissions and increasing functioning, with the addition of peer support resulting in reduced alcohol use.Conclusions: Adding peer-led support may increase engagement in care over the short term and reduce substance use over the longer-term for adults with co-occurring disorders.

A Pilot Study of Motive Control to Reduce Vengeance Cravings.

Violence is a serious public health problem in the United States, and a common risk factor for many forms of violence is the perpetrator's motivation to achieve personal justice for past wrongs and injustices. Using a fictional transgression scenario to stimulate revenge feelings, we studied the preliminary efficacy of an intervention designed to mitigate revenge desires among victims of perceived injustice. The intervention consisted of a guided role-play of key figures in the justice system (e.g., victim, prosecutor, defendant, judge, etc.) in an imaginary mock trial of the offender. Study participants' revenge desires toward the perpetrator decreased significantly immediately after the intervention and at a 2-week follow-up interview. Benevolence toward the offender increased immediately postintervention and at a 2-week follow-up interview. These results suggest that the intervention has promise to decrease revenge desires in people who have been victimized, and it potentially opens the door to behavioral health motive control approaches to violence prevention. Findings on the roles of vengeance and the desire for retaliation in relation to violent acts, as well as neuroscience research that suggests a connection between retaliatory aggression and the neural circuitry of anticipated reward and cravings, are discussed. Limitations of this pilot study are also discussed, and recommendations for future research are provided.

Racial and Ethnic Differences in Use of State-Operated Inpatient Substance Abuse Services, 2004-2005 Versus 2010-2011.

OBJECTIVE: This study examined ethnic-racial differences in referral source, length of stay, legal status, and diagnosis in state-operated substance abuse inpatient treatment in Connecticut. METHODS: Data from 2004-2005 (N=1,484) and from 2010-2011 (N=4,529) were investigated with regression analyses. RESULTS: At both time points, African Americans were more likely than other groups to be referred by criminal justice sources, Hispanics were more likely than whites to be referred by other sources, and whites were more likely than African Americans to have emergency-crisis admissions; length of stay was shorter for Hispanics than for whites and longer for African Americans than for whites and Hispanics; and Hispanics were less likely than other groups to have an alcohol use disorder, more likely than other groups to have a drug use disorder, and more likely than whites to receive a discharge diagnosis of a personality disorder from cluster B. CONCLUSIONS: Targeted interventions to address racial-ethnic differences in inpatient addiction treatment are needed.

An Efficient Model for Designing Medical Countermeasure Just-in-Time Training During Public Health Emergencies.

Rapidly training numerous staff and volunteers to distribute and dispense medical countermeasures is challenging because of limited resources and evolving information during public health emergencies. The Applied Learning and Development Team within the Division of State and Local Readiness at the Centers for Disease Control and Prevention (CDC) proposes just-in-time training (JITT) templates that can be rapidly customized and implemented early in any public health emergency. The proposed template model aligns with modular training design research to increase relevance and rapid deployment of training. Two case studies are described to demonstrate the potential for training templates to support medical countermeasure responses: (1) customization and implementation of a JITT to prepare staff to work on a CDC task force during the 2016-2017 Zika virus response and (2) a new modular, customizable course to teach the basics about working at a point-of-dispensing site. Flexible JITT templates in these cases reduce the burden on emergency planners and trainers, allowing for rapidly developed, customized training viable for all emergency responses.

Perceived provider stigma as a predictor of mental health service users' internalized stigma and disempowerment.

Despite increasing awareness of stigma from mental health service providers as a barrier to recovery, little research has directly examined how it might influence the service users' self-perceptions and treatment experience. The present study examined the association of service users' perceived provider stigma with their experience of internalized stigma and disempowerment, two psychosocial constructs known to hinder recovery. Mental health service users (N = 350) completed questionnaires assessing perceived stigma from mental health service providers, including perceptions of negative affective reactions towards individual users and desired social distance towards people with mental illnesses across various life domains, internalized stigma, and disempowerment (i.e., diminished self-efficacy and mastery) in mental health treatment settings. Structural equation modeling showed that both perceived negative affective reactions and perceived social distance were positively associated with disempowerment. Furthermore, these associations were significantly mediated by internalized stigma. These findings illuminate how perceived stigma from providers can "get under the skin" of mental health service users and contribute to their overall sense of disempowerment in mental health settings. They also highlight the need for future stigma reduction interventions to specifically target the attitudes and beliefs held by mental health professionals.

An Evaluation of Racial and Ethnic Health Differences in State Mental Health Inpatient Services: 2002-2005 Versus 2010-2011.

This study analyzed racial-ethnic differences previously documented in the Connecticut Department of Mental Health and Addiction Services mental health inpatient system across two time periods (2002-2005 and 2010-2011). Comparisons of logistic regression analyses from the two time periods showed that, at time 1, significant racial-ethnic differences were found for referral by other sources (e.g., outpatient), length of stay, discharge against medical advice, and some diagnostic differences (e.g., schizophrenia, other psychotic disorders, cluster B discharge diagnosis), but these differences were not significant at time 2. Other diagnostic differences remained significant at time 2 (e.g., mood disorders, substance use disorders, other axis I disorders, mental retardation) as well as racial-ethnic differences in self-referral. These results suggest that the multiple national and state cultural competence initiatives between time 1 and time 2 could have resulted in decreases in racial-ethnic differences. Targeted interventions to alleviate the remaining differences are needed.

Development of a Response Inconsistency Scale for the Personality Inventory for DSM-5.

The advent of a dimensional model of personality disorder included in DSM-5 has necessitated the development of a new measurement scheme, specifically a self-report questionnaire termed the Personality Inventory for DSM-5 (PID-5; Krueger, Derringer, Markon, Watson, & Skodol, 2012 ). However, there are many threats to the validity of a self-report measure, including response inconsistency. This study outlines the development of an inconsistency scale for the PID-5. Across both college student and clinical samples, the inconsistency scale was able to reliably differentiate real from random responding. Random responses led to increased scores on the PID-5 facets, indicating the importance of detecting inconsistent responding prior to test interpretation. Thus, this inconsistency scale could be of use to researchers and clinicians in detecting inconsistent responses to this new personality disorder measure.

Barriers and Facilitators of Healthcare for People with Mental Illness: Why Integrated Patient Centered Healthcare Is Necessary.

Understanding barriers and facilitators of healthcare for people with mental illness is essential for healthcare and mental healthcare organizations moving towards patient centered care. This paper presents findings of a measure on barriers and facilitators of healthcare completed by 204 patients being served at a co-located wellness center (primary healthcare clinic) located in an urban mental health center. The top 10 results show important findings for planning healthcare services that are responsive to the needs of people with mental illness. Basic structural issues as a result of poverty are extremely important (transportation, housing, payment) as well as difficulty with public healthcare that often involves long wait-times for appointments and at the doctor's office and hours that might not be convenient. Healthcare services that want to meet the needs of people with mental illness need to address these issues. What facilitates healthcare is not just removing the barriers to receiving healthcare services but instead involves more interpersonal aspects of healthcare such as liking your provider, being able to talk with your provider, feeling your provider cares about you and listens to you. Structural supports such as also being in mental health services, having systems for remembering appointments, and/or having appointment times that are convenient also facilitate seeking healthcare. Facilitating healthcare seeking also seems to involve a sense of agency-looking forward to taking charge of your health and feeling capable of following healthcare provider instructions. Healthcare systems for people with mental illness need to support these facilitators to give care-seekers the support they need. Key points are provided on how organizations and staff can work more effectively in implementing patient centered care.

"Recovery Speaks": A Photovoice Intervention to Reduce Stigma Among Primary Care Providers.

OBJECTIVE: Preliminary findings are reported from a photovoice intervention, "Recovery Speaks," to reduce primary care provider stigma in regard to people with mental illness and addiction. METHODS: Twenty-seven primary care providers were recruited through a practice-based research network. Participants were randomly assigned to the intervention-attending a one-hour performance followed by discussion-or to no intervention. Provider stigma was evaluated by using established measures of stigma and recovery and qualitative responses. Linear mixed models controlling for baseline differences compared changes in provider stigma across time and groups. RESULTS: Providers who attended Recovery Speaks demonstrated significantly decreased negative stereotypes, attribution of dangerousness, fear, desire to coerce people into treatment, desire to segregate people from the community, and desire for avoidance. More desire to help and more hope for recovery were also found. CONCLUSIONS: Witnessing people's unique recovery stories and how they contribute to their communities may reduce provider stigma.

Learning from those we serve: Piloting a culture competence intervention co-developed by university faculty and persons in recovery.

OBJECTIVE: This article describes the development and piloting of a bilevel intervention codeveloped by persons in recovery from mental illness and addiction and university faculty with expertise in cultural competence to improve the cultural competence of a community mental health center in the northeastern United States. METHOD: Two faculty and 5 persons in recovery met for 6 months to develop the bilevel training intervention. They discussed experiences of culturally responsive care and developed experiential activities and case examples for the 2-day training. Forty-five community mental health service providers attended the 2-day training. Trainees' self-reported awareness, knowledge, and skills in cultural competence were measured pre and post training and analyzed with repeated measure t tests. Next, faculty and persons in recovery provided follow-up training and helped to establish an infrastructure supported to support the agency cultural competence plan. One hundred twenty-five providers completed the Organizational Multicultural Competence Survey and between-subjects t tests measured increases in organizational cultural competence. RESULTS: Significant increases were found in providers' multicultural knowledge, awareness, and skills. Qualitative responses demonstrated the contribution of the experiences of persons in recovery to the training. Ratings of the organizational-level cultural competence intervention showed significant improvements in the agency's cultural competence policies (e.g., implementation of strategies to hire and retain a diverse workforce). CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: These data suggest that bilevel interventions codeveloped by persons in recovery and researchers may be effective in increasing provider and organizational-level cultural competence. Future research should evaluate the effect of these interventions on consumers and health outcomes.