OnTrackNY: The Development of a Coordinated Specialty Care Program for Individuals Experiencing Early Psychosis.

OnTrackNY is a coordinated specialty care program that delivers early intervention services to youths experiencing a first episode of nonaffective psychosis. Treatment aims to help individuals improve their mental health and achieve personal goals related to work, school, and social relationships. This column describes OnTrackNY's progression from a research project to real-world implementation. The authors describe the treatment model, approach to training and dissemination, and procedures for collecting and sharing data with OnTrackNY teams and provide data on client characteristics and selected outcomes.

Using incentives for training participation.

TOPIC: This column describes how public partners can help incentivize participation in training. Specifically, a state mental health agency and its implementation center applied financial and nonfinancial incentives to encourage participation in training and implementation supports. PURPOSE: Although training is not sufficient to change practice, it is a necessary first step in implementing evidence-based treatments. Finding ways to incentivize participation, particularly strategies with minimal resource involvement, is important for the psychiatric rehabilitation workforce and cash-strapped public systems. SOURCES USED: This description draws from published material and experiences from New York State. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Engaging public partners to incentivize training can significantly increase participation in training. Incentive programs exist that do not require additional funding-an important consideration, given the fiscal climate for most public payers.

Scaling up evidence-based behavioral health care practices in New York state.

This column describes the Center for Practice Innovations (CPI), which was created in 2007 by the New York State Office of Mental Health and the Department of Psychiatry at Columbia University. CPI uses innovative approaches to build stakeholder collaborations, develop and maintain practitioners' expertise, and build agency infrastructures that support implementing and sustaining evidence-based practices. CPI's five core initiatives provide training in co-occurring mental and substance use disorders, assertive community treatment, supported employment and education, wellness self-management, and treatment of first-episode psychosis. Central to CPI's activities are award-winning training modules, statewide learning collaboratives, and use of a learning management system.

The rational choice model in family decision making at the end of life.

BACKGROUND: Most end-of-life decisions are made by family members. Current ethical guidelines for family decision making are based on a hierarchical model that emphasizes the patient's wishes over his or her best interests. Evidence suggests that the model poorly reflects the strategies and priorities of many families. METHODS: Researchers observed and recorded 26 decision-making meetings between hospital staff and family members. Semi-structured follow-up interviews were conducted. Transcriptions were analyzed using qualitative techniques. RESULTS: For both staff and families, consideration of a patient's best interests generally took priority over the patient's wishes. Staff generally introduced discussion of the patient's wishes for rhetorical purposes, such as persuasion. Competing moral frameworks, which de-emphasized the salience of patients' autonomy and "right to choose," played a role in family decision making. CONCLUSIONS: The priority given to the patients' wishes in the hierarchical model does not reflect the priorities of staff and families in making decisions about end-of-life care.

The role of the bioethicist in family meetings about end of life care.

There has been little study of the content of bioethicists' communication during family meeting consultations about end of life care. In the literature, two roles for bioethicists are usually described: the "consultant" role, in which bioethicists define and support ethical principles such as those enshrined in the "rational choice" model; and the "mediator" role, which focuses on the enhancement of communication in order to reduce conflict. In this study, we use observational data to explore how bioethicists support the practice of decision making during family meetings about end of life care. In a study conducted in the Bronx, New York, USA, researchers observed and recorded 24 decision-making meetings between hospital staff and family members of elderly patients identified as being in the last stages of illness, who were unable or unwilling to make the decision for themselves. Bioethics consultants were present during five of those meetings. Although bioethicists referred to the "rational choice" decision-making hierarchy, we did not see the systematic exploration described in the literature. Rather, our data show that bioethicists tended to employ elements of the rational model at particular turning points in the decision-making process in order to achieve pragmatic goals. As mediators, bioethicists worked to create consensus between family and staff and provided invaluable sympathy and comfort to distressed family members. We also found evidence of a context-dependent approach to mediation, with bioethicists' contributions generally supporting staff views about end of life care. Bioethicists' called to consult on family meetings about end of life care do not appear to adhere to a strict interpretation of the official guidelines. In order to negotiate the difficult terrain of end of life decision making, our data show that bioethicists often add a third role, "persuader", to official roles of "consultant" and "mediator".

Safe play spaces to promote physical activity in inner-city children: results from a pilot study of an environmental intervention.

OBJECTIVES: We evaluated the effect of providing a safe play space on the physical activity level of inner-city schoolchildren. METHODS: In 1 of 2 matched neighborhoods, we opened a schoolyard and provided attendants to ensure children's safety. Over the next 2 years we directly observed the number of children and their physical activity levels in the school-yard, as well as in the surrounding intervention and comparison neighborhoods. We also surveyed children in the schools in the intervention and comparison neighborhoods regarding sedentary activities. RESULTS: After the schoolyard was opened, a mean of 71.4 children used it on weekdays and 25.8 used it on weekends during the school year. When observed, 66% of these children were physically active. The number of children who were outdoors and physically active was 84% higher in the intervention neighborhood than the comparison neighborhood. Survey results showed that children in the intervention school reported declines relative to the children in the comparison school in watching television, watching movies and DVDs, and playing video games on weekdays. CONCLUSION: When children were provided with a safe play space, we observed a relative increase in their physical activity. Provision of safe play spaces holds promise as a simple replicable intervention.

Conceptual models of treatment in depressed Hispanic patients.

PURPOSE: Though patient variables are likely to play an important role in the undertreatment of depression, little is known of patients' perceptions of standard depression treatments. In an effort to understand their perspective, we investigated depressed Hispanic patients' perceptions of primary care treatments and the specific benefits associated with them. METHODS: We undertook semistructured interviews with 121 depressed Hispanic medical patients waiting for their appointments. We developed and implemented a coding scheme using standard iterative procedures. RESULTS: More than one half of the patients viewed physician consultation and medication as helpful. Almost all patients considered psychotherapy to be helpful. Supportive talk was the most commonly mentioned specific benefit of physician consultation. The most common benefit of medication was its anxiolytic, sedative effect; energizing effects were less common. The most common benefits associated with psychotherapy included support, advice, and catharsis. Patients currently taking medication for depression had a more favorable view of pharmacological treatment; differences by language of interview were noted. CONCLUSIONS: Patients' perceptions of the specific efficacies of depression treatment did not match priorities implicit in current treatment guidelines. Such perceptions may play a key role in shaping patients' decisions to initiate and maintain treatment.