An Investigation of Employment Hope as a Key Factor Influencing Perceptions of Subjective Recovery among Adults with Serious Mental Illness Seeking Community Work.

INTRODUCTION: Employment is an important contributor to recovery in people with serious mental illness (SMI), yet studies have not explored how subjective elements of employment hope contribute to perceptions of global recovery in this population. METHODS: The current study examined the relationship between employment hope and subjective recovery in 276 unemployed adults with SMI participating in a multi-site clinical trial of a cognitive behavioral group intervention tailored toward work and combined with vocational rehabilitation. Participants had diagnoses of schizophrenia spectrum, bipolar, depressive, and posttraumatic stress disorders, and were receiving services at three Veterans Affairs healthcare facilities in the United States. Data were collected at study baseline. Linear regression analysis examined the relationship between employment hope (Short Employment Hope Scale; EHS-14) and subjective recovery (Recovery Assessment Scale; RAS) after controlling for psychiatric symptom severity and mental-health-related burden on daily life. RESULTS: After accounting for covariates, employment hope significantly contributed to the regression model explaining subjective recovery. The overall model of predictor variables explained 52.5% of the variance in recovery. The results further explore the relationships between EHS-14 and RAS subscales. CONCLUSIONS: The findings suggest that employment hope is a key intervention target to bolster subjective recovery in this vulnerable population.

Results From the POINT Pragmatic Randomized Trial: An Emergency Department-Based Peer Support Specialist Intervention to Increase Opioid Use Disorder Treatment Linkage and Reduce Recurrent Overdose.

BACKGROUND: People with opioid use disorder (OUD) frequently present at the emergency department (ED), a potentially critical point for intervention and treatment linkage. Peer recovery support specialist (PRSS) interventions have expanded in US-based EDs, although evidence supporting such interventions has not been firmly established. METHODS: Researchers conducted a pragmatic trial of POINT (Project Planned Outreach, Intervention, Naloxone, and Treatment), an ED-initiated intervention for harm reduction and recovery coaching/treatment linkage in 2 Indiana EDs. Cluster randomization allocated patients to the POINT intervention (n = 157) versus a control condition (n = 86). Participants completed a structured interview, and all outcomes were assessed using administrative data from an extensive state health exchange and state systems. Target patients (n = 243) presented to the ED for a possible opioid-related reason. The primary outcome was overdose-related ED re-presentation. Key secondary outcomes included OUD medication treatment linkage, duration of medication in days, all-cause ED re-presentation, all-cause inpatient re-presentation, and Medicaid enrollment. All outcomes were assessed at 3-, 6-, and 12-months post-enrollment. Ad hoc analyses were performed to assess treatment motivation and readiness. RESULTS: POINT and standard care participants did not differ significantly on any outcomes measured. Participants who presented to the ED for overdose had significantly lower scores (3.5 vs 4.2, P < .01) regarding readiness to begin treatment compared to those presenting for other opioid-related issues. CONCLUSIONS: This is the first randomized trial investigating overdose outcomes for an ED peer recovery support specialist intervention. Though underpowered, results suggest no benefit of PRSS services over standard care. Given the scope of PRSS, future work in this area should assess more recovery- and harm reduction-oriented outcomes, as well as the potential benefits of integrating PRSS within multimodal ED-based interventions for OUD.

Latent class analysis of emergency department patients engaged in telehealth peer recovery support services and associations of identified classes with post-discharge outcomes.

BACKGROUND: People with substance use disorders (SUDs) frequently use emergency department (ED) services. Despite evidence demonstrating that post-discharge SUD treatment linkage effectively reduces the number of ED re-presentations, relatively few hospitals have implemented interventions to identify and connect patients with SUDs to appropriate care. ED-based peer recovery support specialist (PRSS) interventions have emerged as a promising approach for hospitals, but more research is needed to understand the extent to which these interventions meet the needs of patients who present to the ED for different reasons and with various underlying concerns. METHOD: A retrospective cohort analysis used data from a telehealth PRSS program in 15 EDs within one Indiana hospital system. The study included 2950 ED patients who engaged with telehealth PRSS services between September 2018 and September 2021. Latent class analysis identified patterns of patient characteristics associated with post-discharge PRSS engagement and ED re-presentations. Covariate predictors and distal outcomes were assessed to examine the associations between class membership, demographic factors, and patient outcomes. RESULTS: The study team selected a six-class model as the best fit for the data. Class 1, representing patients with opioid use disorder and mental health diagnoses who presented to the ED for an opioid overdose, was used as the reference class for all other statistical tests. Multinomial logistic regression analysis demonstrated significant associations between covariate predictors, outcomes, and class membership. Regression results also demonstrate PRSSs had greater success contacting patients with prior year ED use and patients with a successful post-discharge PRSS contact were less likely to re-present to the ED. CONCLUSION: Results highlight the heterogeneity of patients with SUDs and emphasize the need for tailored interventions to address patient-specific needs more effectively. They also provide support for the perceived utility of PRSS engagement for ED patients.

Patterns of Opioid Prescriptions in the Veterans Health Administration for Patients With Chronic Low-Back Pain After the Onset of the COVID-19 Pandemic: A Retrospective Cohort Analysis.

The COVID-19 pandemic led to severe disruptions in health care and a relaxation of rules surrounding opioid prescribing-changes which led to concerns about increased reliance on opioids for chronic pain and a resurgence of opioid-related harms. Although some studies found that opioid prescriptions increased in the first 6 months of the pandemic, we know little about the longer-term effects of the pandemic on opioid prescriptions. Further, despite the prevalence of pain in veterans, we know little about patterns of opioid prescriptions in the Veterans Health Administration (VA) associated with the pandemic. Using a retrospective cohort of VA patients with chronic low-back pain, we examined the proportion of patients with an opioid prescription and mean morphine milligram equivalents over a 3-year period-1 year prior to and 2 years after the pandemic's onset. Analyses revealed that both measures fell during the entire observation period. The largest decrease in the odds of filling an opioid prescription occurred in the first quarter of the pandemic, but this downward trend continued throughout the observation period, albeit at a slower pace. Clinically meaningful differences in opioid prescriptions and dose over time did not emerge based on patient race or rurality; however, differences emerged between female and male veterans, with decreases in opioid prescriptions slowing more markedly for women after the pandemic onset. These findings suggest that the pandemic was not associated with short- or long-term increases in opioid prescriptions or doses in the VA. PERSPECTIVE: This article examines opioid prescribing over a 3-year period-1 year prior to and 2 years after the onset of the COVID-19 pandemic-for VA patients with chronic low-back pain. Results indicate that, despite disruptions to health care, opioid prescriptions and doses decreased over the entire observation period.

eHealth Use on Acute Inpatient Mental Health Units: Implementation Processes, Common Practices, and Barriers to Use.

Information technology to promote health (eHealth) is an important and growing area of mental healthcare, yet little is known about the use of patient-facing eHealth in psychiatric inpatient settings. This quality improvement project examined the current practices, barriers, implementation processes, and contextual factors affecting eHealth use across multiple Veteran Health Administration (VHA) acute mental health inpatient units. Staff from units serving both voluntary and involuntary patients (n = 49 from 37 unique sites) completed surveys regarding current, desired, and barriers to use of Veteran-facing eHealth technologies. Two subsets of respondents were then interviewed (high success sites in eHealth use, n = 6; low success sites, n = 4) to better understand the context of their eHealth use. Survey responses indicated that 20% or less of Veterans were using any type of eHealth technology while inpatient. Tablets and video chat were the most desired overall and most successfully used eHealth technologies. However, many sites noted difficulty implementing these technologies (e.g., limited Wi-Fi access). Qualitative analysis of interviews revealed differences in risk/benefit analysis and implementation support between high and low success eHealth sites. Despite desired use, patient-facing eHealth technology is not regularly implemented on inpatient units due to multiple barriers (e.g., limited staffing, infrastructure needs). Successful implementation of patient-facing eHealth may require an internal champion, guidance from external supports with experience in successful eHealth use, workload balance for staff, and an overall perspective shift in the benefits to eHealth technology versus the risks.

Exploring Factors Impacting the Implementation of Recovery-Oriented Treatment Planning on Acute Inpatient Mental Health Units.

PURPOSE: The current literature on operationalizing and implementing recovery-oriented inpatient care in diverse settings remains limited. The present study systematically examined factors affecting the implementation of one aspect of recovery-oriented care in a large and diverse national sample of Veterans Health Administration (VHA) inpatient mental health units. METHOD: VHA inpatient mental health units were scored on the Recovery-Oriented Acute Inpatient scale (RAIN). Sites scoring either one standard deviation above (n = 8; i.e., high-scoring sites) or one standard deviation below (n = 5; i.e., low-scoring sites) the mean on the RAIN factor of inpatient treatment planning subscale were included for additional analyses (N = 13). We used a qualitative approach known as emergent thematic analysis to assess the implementation of inpatient treatment planning elements (e.g., goal setting, shared decision-making) from qualitative interviews, observation notes, and chart reviews collected for the 13 sites. The analysis was guided by Normalization Process Theory. RESULTS: The eleven themes that emerged across the elements of recovery-oriented inpatient treatment planning mostly represented commonalities across sites, such as a shared treatment philosophy of acute care. However, five themes emerged as "differentiators" that distinguished high- and low-scoring sites and included veteran input, elicitation of recovery goals, the value of group programming, and the purpose of family involvement. CONCLUSION: Findings provide insight into contextual factors and processes that impacted the implementation of recovery-oriented treatment planning at these VHA inpatient mental health units. To further facilitate the implementation of recovery-oriented inpatient treatment planning elements, future research should examine staff's collective understanding of recovery-oriented inpatient care.

Recovery-oriented inpatient mental health care and readmission.

OBJECTIVE: This article examines the relationship between inpatient mental health units' adherence to recovery-oriented care and 30-day patient readmission. METHOD: The sample included patients admitted to one of 34 Veterans Health Administration inpatient mental health units. Recovery-oriented care was assessed using interviews and site visits. Patient characteristics and readmission data were derived from administrative data. FINDINGS: Overall recovery orientation was not associated with readmission. Exploratory analyses found higher scores on a subsample of items pertaining to inpatient therapeutic programming were associated with lower patient readmissions. Additionally, patients with more prior service use and substance abuse or personality disorders were more likely to be readmitted. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: A growing body of literature supports the association between psychotherapeutic services in inpatient units and better patient outcomes. However, further research is needed to examine this association. More work is needed to develop appropriate psychotherapy services for the inpatient setting and support their implementation. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Introduction to the special section on recovery-oriented services in crisis settings.

While substantial progress has been made in integrating recovery-oriented services into traditional outpatient settings, similar progress has lacked in settings which commonly serve persons experiencing mental health crises. This special section includes three studies that highlight promising, recovery-oriented practices that divert persons in crisis from the criminal justice system and traditional emergency medical services, as well as improve the recovery orientation of inpatient services. These promising studies also highlight the substantial work still needed in this area. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Inpatient Mental Healthcare before and during the COVID-19 Pandemic.

Prior studies have demonstrated disruption to outpatient mental health services after the onset of the COVID-19 pandemic. Inpatient mental health services have received less attention. The current study utilized an existing cohort of 33 Veterans Health Affairs (VHA) acute inpatient mental health units to examine disruptions to inpatient services. It further explored the association between patient demographic, clinical, and services variables on relapse rates. Inpatient admissions and therapeutic services (group and individual therapy and peer support) were lower amongst the COVID-19 sample than prior to the onset of COVID-19 while lengths of stay were longer. Relapse rates did not differ between cohorts. Patients with prior emergent services use as well as substance abuse or personality disorder diagnoses were at higher risk for relapse. Receiving group therapy while admitted was associated with lower risk of relapse. Inpatient mental health services saw substantial disruptions across the cohort. Inpatient mental health services, including group therapy, may be an important tool to prevent subsequent relapse.

Recovery-oriented acute inpatient mental health care: Operationalization and measurement.

OBJECTIVE: The current article describes efforts to develop and test a measure of recovery-oriented inpatient care. METHOD: The Recovery-oriented Acute INpatient (RAIN) scale was based on prior literature and current Veterans Health Administration (VHA) policy and resources and further revised based on data collection from 34 VHA acute inpatient units. RESULTS: A final scale of 23, behaviorally anchored items demonstrated a four-factor structure including the following factors: inpatient treatment planning, outpatient treatment planning, group programming, and milieu. While several items require additional revision to address psychometric concerns, the scale demonstrated adequate model fit and was consistent with prior literature on recovery-oriented inpatient care. Conclusions and Implementations for Practice: The RAIN scale represents an important tool for future implementation and empirical study of recovery-oriented inpatient care. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Peer Support for Self-Management of Chronic Pain: the Evaluation of a Peer Coach-Led Intervention to Improve Pain Symptoms (ECLIPSE) Trial.

BACKGROUND: Pain self-management is an effective, evidence-based treatment for chronic pain. Peer support, in which patients serve as coaches for other patients, has been effective in other chronic conditions and is a potentially promising approach to implementing pain self-management programs using fewer clinical resources. OBJECTIVE: To test a peer coach-delivered pain self-management program for chronic pain. DESIGN: Randomized controlled trial. PARTICIPANTS: Veterans with chronic musculoskeletal pain. INTERVENTION: Intervention patients were assigned a trained peer coach for 6 months. Coaches, who were volunteers, were asked to contact their assigned patients, either by phone or in person, twice per month. Coaches and patients were given an intervention manual to guide sessions. The control group was offered a 2-hour pain self-management class. MAIN MEASURES: The primary outcome was total pain, assessed by the Brief Pain Inventory (BPI). Secondary outcomes were anxiety, depression, pain catastrophizing, self-efficacy, social support, patient activation, health-related quality of life, and healthcare utilization. Outcomes were measured at baseline, 6 months, and 9 months. KEY RESULTS: Two hundred fifteen patients enrolled (120 intervention, 95 control). Adherence to intervention protocol was low, with only 13% of patients reporting having at least the recommended 12 peer coach meetings over the 6-month intervention. BPI total decreased from baseline to 6 months and baseline to 9 months in both groups. At 9 months, this change was statistically significant (intervention, - 0.40, p = 0.018; control, - 0.47, p = 0.006). There was not a statistically significant difference between groups on BPI at either time point. No secondary outcomes improved significantly in either group after adjusting for multiple comparisons. CONCLUSIONS: Patients randomized to peer support did not differ from control patients on primary and secondary outcomes. Other peer support models that do not rely on volunteers might be more effective. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02380690.

Exploring peer coaches' outcomes: Findings from a clinical trial of patients with chronic pain.

OBJECTIVE: Although peer coaching can help patients manage chronic conditions, few studies have evaluated the effects of peer coaching on coaches, and no studies have systematically examined these effects in the context of chronic pain coaching. METHODS: Peer coach outcomes were assessed as part of a randomized trial of peer coaching for chronic pain. In this exploratory analysis, linear mixed models were used to evaluate changes in peer coaches' pain and related outcomes from baseline to 6 and 9 months. The Sidák method was used to account for multiple comparisons. RESULTS: Peer coaches (N = 55) experienced statistically significant increases in anxiety and pain catastrophizing from baseline to 6 months, which were no longer significant after adjustment. All other changes were not statistically significant. CONCLUSIONS: Despite prior studies suggesting that peer coaches benefit from serving as a coach, the current study failed to support that conclusion. PRACTICE IMPLICATIONS: Peer coaching remains a promising model, with high potential for implementation, for a number of chronic conditions requiring self-management. However, to maximize the benefits of such interventions, it is essential to monitor both those being coached and the coaches themselves, and not to assume that serving as a coach is inherently beneficial.

Emergency department-based peer support for opioid use disorder: Emergent functions and forms.

Emergency department (ED)-based peer support programs aimed at linking persons with opioid use disorder (OUD) to medication for addiction treatment and other recovery services are a promising approach to addressing the opioid crisis. This brief report draws on experiences from three states' experience with such programs funded by the SAMHSA Opioid State Targeted Repose (STR) grants. Core functions of such programs include: Integration of peer supports in EDs; Alerting peers of eligible patients and making the patient aware of peer services; and connecting patients with recovery services. Qualitative data were analyzed using a general inductive approach conducted in 3 steps in order to identify forms utilized to fulfill these functions. Peer integration differed in terms of peer's physical location and who hired and supervised peers. Peers often depend on ED staff to alert them to potential patients while people other than the peers often first introduce potential patients to programming. Programs generally schedule initial appointments for recovery services for patients, but some programs provide a range of other services aimed at supporting participation in recovery services. Future effectiveness evaluations of ED-based peer support programs for OUD should consistently report on forms used to fulfill core functions.

Evaluation of a peer coach-led intervention to improve pain symptoms (ECLIPSE): Rationale, study design, methods, and sample characteristics.

Chronic pain is prevalent, costly, and a leading cause of disability. Pain self-management (i.e., employing self-management strategies including behavioral modifications) is an effective, evidence-based treatment. However, implementation and delivery of a pain self-management model is challenging because of time and resources. Peer supported pain self-management offers a promising approach to implementing pain self-management programs using fewer clinical resources. Evaluation of a Peer Coach-Led Intervention for the Improvement of Pain Symptoms (ECLIPSE) is a randomized controlled trial testing effectiveness of peer coach-delivered pain self-management intervention versus controls receiving a class on pain and pain self-management. ECLIPSE is a Hybrid Type 1 study testing effectiveness while examining implementation factors. ECLIPSE enrolled 215 veterans randomly assigned to the peer coaching (N = 120) or control (N = 95) arm. The peer coaching intervention lasts 6 months, with patient-peer coach pairs instructed to talk twice per month. Coaches attend initial training, are provided a detailed training manual, and attend monthly booster sessions. Outcomes are assessed at baseline, 6 months, and 9 months. The primary outcome is overall pain (intensity and interference), measured by the Brief Pain Inventory (BPI). Secondary outcomes are self-efficacy, social support, pain catastrophizing, patient activation, health-related quality of life, and health care utilization. To maximize implementation potential of pain self-management, innovative delivery methods are needed that do not require additional resources from healthcare teams. A novel and promising approach is a peer-coaching model, in which patients who are successfully managing their pain offer information, ongoing support, and advice to other patients with pain. Clinical Trials Registration: NCT02380690.

Facilitators and Barriers to Implementation of a Peer Support Intervention for Patients with Chronic Pain: A Qualitative Study.

OBJECTIVE: Pain self-management information and support, delivered by peers, are a potentially useful approach to help patients who are struggling to manage their chronic pain. Before implementation into clinical settings, it is important to understand factors that may influence the success of implementation. The purpose of this study was to explore facilitators and barriers to implementation of peer support for chronic pain. DESIGN: Semistructured interviews were conducted with clinicians who provide care to patients with chronic pain, regarding their perceptions of the proposed peer support intervention. SETTING: A single US Veterans Affairs Medical Center. SUBJECTS: Using maximum variation sampling, 15 providers were interviewed (11 women, four men). Clinicians' disciplines included primary care, physical therapy, nursing, clinical psychology, social work, and pharmacy. RESULTS: Findings indicated that clinicians 1) had an overall positive perception of the intervention; 2) had specific intervention outcomes they wanted for patients; 3) anticipated that the intervention could positively influence their role; 4) anticipated barriers to intervention participation and maintenance; and 5) had concerns regarding peer coach selection. Findings are discussed in the context of the Consolidated Framework for Implementation Research. CONCLUSIONS: Understanding clinician perceptions of a peer support intervention is critical for successful implementation. The feedback collected in this study will facilitate implementation of the intervention on a broader scale, allowing more patients to benefit.

Helping veterans achieve work: A Veterans Health Administration nationwide survey examining effective job development practices in the community.

OBJECTIVE: Veterans Health Administration vocational services assist veterans with mental illness to acquire jobs; one major component of these services is job development. The purpose of this study was to characterize the nature of effective job development practices and to examine perceptions and intensity of job development services. METHOD: A national mixed-methods online survey of 233 Veterans Health Administration vocational providers collected data regarding frequency of employer contacts, perceptions of job development ease/difficulty, and effective job development practices when dealing with employers. Qualitative responses elucidating effective practices were analyzed using content analysis. RESULTS: Vocational providers had a modest number of job development employer contacts across 2 weeks (M = 11.0, SD = 10.6) and fewer were face-to-face (M = 7.6, SD = 8.4). Over 70% of participants perceived job development to be difficult. Six major themes emerged regarding effective job development practices with employers: using an employer-focused approach; utilizing a targeted marketing strategy; engaging in preparation and follow-up; going about the employer interaction with genuineness, resilience, and a strong interpersonal orientation; serving as an advocate for veterans and educator of employers; utilizing specific employer-tailored strategies, such as arranging a one-on-one meeting with a decision maker and touring the business, individualizing a prescripted sales pitch, connecting on a personal level, and engaging in ongoing communication to solidify the working relationship. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Respondents highlight several potentially effective job development strategies; tools and resources may be developed around these strategies to bolster job development implementation and allow opportunities for fruitful employer interactions. (PsycINFO Database Record

Integrating Self-Determination and Job Demands-Resources Theory in Predicting Mental Health Provider Burnout.

Limited progress has been made in reducing burnout in mental health professionals. Accordingly, we identified factors that might protect against burnout and could be productive focal areas for future interventions. Guided by self-determination theory, we examined whether supervisor autonomy support, self-efficacy, and staff cohesion predict provider burnout. 358 staff from 13 agencies completed surveys. Higher levels of supervisor autonomy support, self-efficacy, and staff cohesion were predictive of lower burnout, even after accounting for job demands. Although administrators may be limited in their ability to reduce job demands, our findings suggest that increasing core job resources may be a viable alternative.

Consumer factors predicting level of treatment response to illness management and recovery.

OBJECTIVE: This study aims to identify consumer-level predictors of level of treatment response to illness management and recovery (IMR) to target the appropriate consumers and aid psychiatric rehabilitation settings in developing intervention adaptations. METHOD: Secondary analyses from a multisite study of IMR were conducted. Self-report data from consumer participants of the parent study (n = 236) were analyzed for the current study. Consumers completed prepost surveys assessing illness management, coping, goal-related hope, social support, medication adherence, and working alliance. Correlations and multiple regression analyses were run to identify self-report variables that predicted level of treatment response to IMR. RESULTS: Analyses revealed that goal-related hope significantly predicted level of improved illness self-management, F(1, 164) = 10.93, p < .001, R2 = .248, R2 change = .05. Additionally, we found that higher levels of maladaptive coping at baseline were predictive of higher levels of adaptive coping at follow-up, F(2, 180) = 5.29, p < .02, R2 = .38, R2 change = .02. Evidence did not support additional predictors. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Previously, consumer-level predictors of level of treatment response have not been explored for IMR. Although 2 significant predictors were identified, study findings suggest more work is needed. Future research is needed to identify additional consumer-level factors predictive of IMR treatment response in order to identify who would benefit most from this treatment program. (PsycINFO Database Record

Comparing the Costs and Acceptability of Three Fidelity Assessment Methods for Assertive Community Treatment.

Successful implementation of evidence-based practices requires valid, yet practical fidelity monitoring. This study compared the costs and acceptability of three fidelity assessment methods: on-site, phone, and expert-scored self-report. Thirty-two randomly selected VA mental health intensive case management teams completed all fidelity assessments using a standardized scale and provided feedback on each. Personnel and travel costs across the three methods were compared for statistical differences. Both phone and expert-scored self-report methods demonstrated significantly lower costs than on-site assessments, even when excluding travel costs. However, participants preferred on-site assessments. Remote fidelity assessments hold promise in monitoring large scale program fidelity with limited resources.

The Relationship Between Provider Competence, Content Exposure, and Consumer Outcomes in Illness Management and Recovery Programs.

Provider competence may affect the impact of a practice. The current study examined this relationship in sixty-three providers engaging in Illness Management and Recovery with 236 consumers. Improving upon previous research, the present study utilized a psychometrically validated competence measure in the ratings of multiple Illness Management and Recovery sessions from community providers, and mapped outcomes onto the theory underlying the practice. Provider competence was positively associated with illness self-management and adaptive coping. Results also indicated baseline self-management skills and working alliance may affect the relationship between competence and outcomes.