Randomized Controlled Trial of Self-Directed Care for Medically Uninsured Adults With Serious Mental Illness.

OBJECTIVE: Self-directed care (SDC) is a treatment model in which recipients self-manage funds designated for provision of services. The model is designed to cost no more than traditional services while achieving superior participant outcomes. The authors examined the model's impact on outcomes, service costs, and user satisfaction among medically uninsured, low-income individuals with serious mental illness. METHODS: Adults in the public mental health system (N=42) were randomly assigned (1:1) to receive SDC or services as usual and were assessed at baseline and 6- and 12-month follow-ups. Outcomes included perceived competence for mental health self-management, met and unmet needs, degree of autonomy support, self-perceived recovery, and employment. Mixed-effects random regression analysis tested for differences in longitudinal changes in outcomes between the two study conditions. Differences in service costs were analyzed with negative binomial regression models. RESULTS: Compared with individuals in the control condition, SDC participants reported greater improvement in perceived competence, met and unmet needs, autonomy support, recovery from symptom domination, and employment. No differences were found between the two groups in total per-person service costs or costs for individual services. The most frequent nontraditional purchases were for medical, dental, and vision services (33%) and health and wellness supports (33%). Satisfaction with SDC services was high. CONCLUSIONS: Mental health SDC services achieved participant outcomes superior to treatment as usual, with equivalent service use and costs and high user satisfaction. This model may be well suited to the needs of uninsured adults with low income who receive public behavioral health care.

Nutrition and Exercise for Wellness and Recovery: A Randomized Controlled Trial of a Community-Based Health Intervention.

OBJECTIVE: The purpose of this study was to examine the efficacy of the Nutrition and Exercise for Wellness and Recovery (NEW-R) intervention for improving competency and behaviors related to diet, physical activity, and weight management. METHODS: Participants with psychiatric disabilities were recruited from four community mental health agencies and a hospital-based psychiatric outpatient clinic and randomly assigned to the NEW-R intervention (N=55) or control condition (N=58). Outcome measures included the Perceived Competence Scale, Health-Promoting Lifestyle Profile (HPLP), and weight change; random-effects regression models were used. A follow-up analysis examined the interactions of group, time, and site. RESULTS: Fifty of the 55 intervention participants and 57 of the 58 control participants completed the study. The two groups did not differ significantly on any measured baseline characteristic. The intervention group had statistically significant improvements, compared with the control group, in perceived competence for exercise and healthy eating, total HPLP score, and scores on two HPLP subscales (nutrition and spiritual growth). No significant difference between groups was found for weight loss. A study condition × time × site effect was observed: at the three sites where mean weight loss occurred, NEW-R participants lost significantly more weight than did control participants. CONCLUSIONS: NEW-R offers promise as an intervention that can initiate the change to healthy lifestyle behaviors and boost perceived competence in a healthy lifestyle. It may also be effective for weight loss when administered in supportive settings.

Whole Health Action Management: A Randomized Controlled Trial of a Peer-Led Health Promotion Intervention.

OBJECTIVE: Adults with serious mental illness have high rates of general medical comorbidity and encounter challenges in dealing with multiple health conditions. Chronic illness self-management programs may help them more effectively cope with comorbid illnesses, especially when instructors are certified peer specialists. This study assessed the longitudinal effectiveness of a peer-delivered health promotion program. METHODS: Community mental health program clients in Georgia and Illinois with serious mental illness and health impairments were randomly assigned to receive either Whole Health Action Management (WHAM), a medical illness self-management program led by peer specialists, or care as usual, resulting in a sample of N=139 (WHAM N=68, control N=71). Assessments were conducted at study baseline and at 3 and 6 months. Generalized estimating equations were used to examine change over time in the primary outcome of patient activation and secondary outcomes of general health, hope, and employment. RESULTS: Longitudinal analysis indicated that compared with control participants, WHAM participants demonstrated significantly greater improvement over time in patient activation for health care. Intervention participants also demonstrated greater improvement in their self-assessed general health, overall hopefulness, and paid employment. Reactions to the WHAM program were positive, with 97% reporting being very or somewhat satisfied, and almost two-thirds (63%) reporting that their health was better than before they joined the program. CONCLUSIONS: The WHAM program improved patient activation, perceived general medical health, hopefulness, and likelihood of paid employment among people with serious mental illness and co-occurring medical conditions. Results suggest that peer-delivered health self-management education is effective and well received by participants.

Key Drivers in Reducing Hospital-acquired Pressure Injury at a Quaternary Children's Hospital.

INTRODUCTION: Despite being a participating Solutions for Patient Safety (SPS) children's hospital and having attempted implementation of the SPS hospital-acquired pressure injuries (HAPIs) prevention bundle, our hospital remained at a HAPI rate that was 3 times the mean for SPS participating children's hospitals. This performance led to the launch of an enterprise-wide HAPI reduction initiative in our organization. The purpose of this article is to describe the improvement initiative, the key drivers, and the resulting decrease in the SPS-reportable HAPI rate. METHODS: We designed a hospital-wide HAPI reduction initiative with actions grouped into 3 key driver areas: standardization, data transparency, and accountability. We paused all individual hospital unit-based HAPI reduction initiatives. We calculated the rate of SPS-reportable HAPIs per 1,000 patient days during both the pre- and postimplementation phases and compared mean rates using a 2-sided t test assuming unequal variances. RESULTS: The mean SPS-reportable HAPI rate for the preimplementation phase was 0.3489, and the postimplementation phase was 0.0609. The difference in rates was statistically significant (P < 0.00032). This result equates to an 82.5% reduction in HAPI rate. CONCLUSIONS: Having an institutional pause and retooled initiative to reduce HAPI with key drivers in the areas of standardization, data transparency, and accountability had a statistically significant reduction in our organization's SPS-reportable HAPI rate.

Mental Health Self-Directed Care Financing: Efficacy in Improving Outcomes and Controlling Costs for Adults With Serious Mental Illness.

OBJECTIVE: Self-directed care allows individuals with disabilities and elderly persons to control public funds to purchase goods and services that help them remain outside institutional settings. This study examined effects on outcomes, service costs, and user satisfaction among adults with serious mental illness. METHODS: Public mental health system clients were randomly assigned to self-directed care (N=114) versus services as usual (N=102) and assessed at baseline and 12 and 24 months. The primary outcome was self-perceived recovery. Secondary outcomes included psychosocial status, psychiatric symptom severity, and behavioral rehabilitation indicators. Mixed-effects random-regression analysis tested for longitudinal changes in outcomes between the two conditions. Differences in service costs were analyzed with negative binomial and zero-inflated negative binomial regression models. RESULTS: Compared with the control group, self-directed care participants had significantly greater improvement over time in recovery, self-esteem, coping mastery, autonomy support, somatic symptoms, employment, and education. No between-group differences were found in total per-person service costs in years 1 and 2 or both years combined. However, self-directed care participants were more likely than control group participants to have zero costs for six of 12 individual services and to have lower costs for four. The most frequent nontraditional purchases were for transportation (21%), communication (17%), medical care (15%), residential (14%), and health and wellness needs (11%). Client satisfaction with mental health services was significantly higher among intervention participants, compared with control participants, at both follow-ups. CONCLUSIONS: The budget-neutral self-directed care model achieved superior client outcomes and greater satisfaction with mental health care, compared with services as usual.

Correlates of Co-Occurring Diabetes and Obesity Among Community Mental Health Program Members With Serious Mental Illnesses.

OBJECTIVE: This study examined the prevalence and correlates of co-occurring obesity and diabetes among community mental health program members. METHODS: Medical screenings of 457 adults with serious mental illnesses were conducted by researchers and peer wellness specialists in four U.S. states. Body mass index was measured directly. Diabetes was assessed via glycosylated hemoglobin and interview self-report. Multivariable logistic regression analysis examined associations with known predictors. RESULTS: In the sample, 59% were obese, 25% had diabetes, and 19% had both conditions. When gender, diagnosis, and site were controlled, co-occurring diabetes and obesity was almost three times as likely among African Americans (OR=2.93) as among participants from other racial groups and half as likely among smokers as among nonsmokers (OR=.58). Older persons and those with poorer self-rated physical health also were more likely to have these co-occurring conditions. CONCLUSIONS: Results support the need for culturally competent treatment and for smoking cessation options with sensitivity to the potential for weight gain.

Associations Between Gender and Obesity Among Adults with Mental Illnesses in a Community Health Screening Study.

The prevalence of obesity and its associations with gender, clinical factors, and medical co-morbidities were examined among 457 adults attending public mental health programs in 4 U.S. states. BMI was measured directly and other information was gathered by interview. Over half (59%, n = 270) were obese including 18% (n = 83) who were morbidly obese. In hierarchical ordinary least squares regression analysis controlling for demographic, psychiatric, medical, smoking, and health insurance statuses, women were significantly more likely to be obese than men. Obesity also was more likely among those who were younger and not high school graduates, those with diabetes or hypertension, and those who did not smoke tobacco. Interaction effects were found between gender and diabetes, hypertension, tobacco smoking, education, race, and age. The high prevalence of obesity among women, coupled with interactions between gender and other factors, suggest that targeted approaches are needed to promote optimal physical health in this population.

Impact of Wellness Recovery Action Planning on service utilization and need in a randomized controlled trial.

OBJECTIVE: The purpose of this study was to assess the impact of a mental illness self-management intervention, called Wellness Recovery Action Planning (WRAP), on the use of and need for mental health services over time compared with nutrition and wellness education. METHOD: Participants were recruited from outpatient community mental health settings in Chicago, Illinois. Using a single-blind, randomized controlled trial design, 143 individuals were assigned to WRAP or to a nutrition education course and assessed at baseline and at 2-month and 8-month follow-up. The WRAP intervention was delivered by peers in recovery from serious mental illness who were certified WRAP educators over nine weekly sessions lasting 2.5 hrs. The nutrition education curriculum was taught by trained non-peer educators using the same schedule. Mixed-effects random regression analysis tested for differences between the two interventions in (a) self-reported use of 19 clinical, rehabilitation, peer, emergent, and ancillary services; and (b) self-reported need for these services. RESULTS: Results of mixed-effects random regression analysis indicated that, compared with controls, WRAP participants reported significantly greater reduction over time in service utilization (total, individual, and group), and service need (total and group services). Participants in both interventions improved significantly over time in symptoms and recovery outcomes. DISCUSSION: Training in mental illness self-management reduced the self-reported need for and use of formal mental health services over time. This confirms the importance of WRAP in an era of dwindling behavioral health service availability and access.

Improving propensity for patient self-advocacy through wellness recovery action planning: results of a randomized controlled trial.

A fundamental aspect of successful illness self-management for people with serious mental illnesses is the ability to advocate for themselves in health and rehabilitation settings. This study reports findings from a randomized controlled trial comparing propensity for patient self-advocacy among those who received a peer-led mental illness self-management intervention called Wellness Recovery Action Planning (WRAP) and those who received usual care. Outcomes were self-reported engagement in self-advocacy with service providers, and the relationship between patient self-advocacy and other key recovery outcomes. In a multivariable analysis, at immediate post-intervention and 6-month follow-up, WRAP participants were significantly more likely than controls to report engaging in self-advocacy with their service providers. Higher self-advocacy also was associated with greater hopefulness, better environmental quality of life, and fewer psychiatric symptoms among the intervention group. These findings provide additional support for the positive impact of peer-led illness self-management on mental health recovery.

A randomized controlled trial of effects of Wellness Recovery Action Planning on depression, anxiety, and recovery.

OBJECTIVE: The purpose of this study was to test the effectiveness of the Wellness Recovery Action Planning (WRAP) self-management intervention in reducing depression and anxiety and in increasing self-perceived recovery among individuals with a serious mental illness. METHODS: Participants were recruited from outpatient community mental health settings in six Ohio communities: Canton, Cleveland, Columbus, Dayton, Lorain, and Toledo. With a single-blind, randomized controlled trial design, 519 individuals were assigned to WRAP or to services as usual and assessed at baseline and at two- and eight-month follow-ups. The intervention consisted of eight weekly 2.5-hour sessions delivered by peers in recovery from serious mental illness who were certified WRAP educators. RESULTS: The mean number of WRAP sessions attended was five, and fidelity ranged from 90% to 92%. Analysis using mixed-effects random regression revealed interactions of study condition by time in each outcome area. Compared with the control group, intervention participants reported significantly greater reduction over time in Brief Symptom Inventory depression and anxiety subscales and significantly greater improvement in total Recovery Assessment Scale scores as well as the subscales measuring personal confidence and goal orientation. CONCLUSIONS: Training in mental illness self-management reduced depression and anxiety and improved participants' self-perceived recovery over time. Results confirmed the importance of WRAP as part of a group of evidence-based, recovery-oriented interventions.

Results of a randomized controlled trial of mental illness self-management using Wellness Recovery Action Planning.

The purpose of this study was to determine the efficacy of a peer-led illness self-management intervention called Wellness Recovery Action Planning (WRAP) by comparing it with usual care. The primary outcome was reduction of psychiatric symptoms, with secondary outcomes of increased hopefulness, and enhanced quality of life (QOL). A total of 519 adults with severe and persistent mental illness were recruited from outpatient community mental health settings in 6 Ohio communities and randomly assigned to the 8-week intervention or a wait-list control condition. Outcomes were assessed at end of treatment and at 6-month follow-up using an intent-to-treat mixed-effects random regression analysis. Compared to controls, at immediate postintervention and at 6-month follow-up, WRAP participants reported: (1) significantly greater reduction over time in Brief Symptom Inventory Global Symptom Severity and Positive Symptom Total, (2) significantly greater improvement over time in hopefulness as assessed by the Hope Scale total score and subscale for goal directed hopefulness, and (3) enhanced improvement over time in QOL as assessed by the World Health Organization Quality of Life-BREF environment subscale. These results indicate that peer-delivered mental illness self-management training reduces psychiatric symptoms, enhances participants' hopefulness, and improves their QOL over time. This confirms the importance of peer-led wellness management interventions, such as WRAP, as part of a group of evidence-based recovery-oriented services.

Cultural competency in peer-run programs: results of a web survey and implications for future practice.

OBJECTIVE: The study explored perceptions of adults with psychiatric disabilities regarding cultural competency of peer-run mental health support groups and programs. METHODS: Web survey respondents were recruited via mental health list-servs, web sites, newsletters, emails, and word of mouth. A total of 527 peers were surveyed about cultural competency barriers facing peer-run programs; common reasons for not using peer services; and strategies to engage diverse communities. RESULTS: Both multicultural and Caucasian respondents agreed that lack of funding and staff education about diversity were barriers to cultural competency in peer programs. Multicultural respondents were more likely than whites to feel that both the recognition of the need for and interest in attending cultural competency training is lacking in peer programs, as well as information about the diverse composition of peer program memberships. Among those who had never participated in peer support, people of color were more likely than whites to endorse feeling they would not belong and believing their languages would not be spoken in peer programs. Whites, on the other hand, were more likely to cite a preference for professional over peer support, while nearly half of both groups indicated that the main reason for non-attendance is a lack of knowledge about peer programs. Qualitative results highlighted successful outreach and engagement strategies. CONCLUSIONS: Study findings informed development of a cultural competency tool that was pilot-tested among peer-run programs. Given the importance of peer support in recovery, these findings suggest the need for additional research on cultural competency in peer programs.

The recovery education in the academy program: transforming academic curricula with the principles of recovery and self-determination.

TOPIC: This article describes a curricular transformation initiative, the Recovery Education in the Academy Program (REAP), spearheaded by the University of Illinois at Chicago's National Research and Training Center on Psychiatric Disability. PURPOSE: REAP is designed to integrate principles of recovery, self-determination, and other evidence-based practices for people with psychiatric disabilities into medical, social, and behavioral sciences curricula. The principles on which the curricula transformation efforts are based, the instructional activities employed, early outcomes of the endeavor, and future plans for replication are delineated. SOURCES USED: As described in this paper, REAP builds on a theoretical framework derived from the evidence-based literature, multiple technical reports, and curricular initiatives, including the Institute of Medicine, the Annapolis Coalition for Behavioral Workforce Development, and the Final Report of President's New Freedom Commission on Mental Health. CONCLUSIONS: REAP has delivered state-of-the-science education to over 1,000 trainees, including medical students, psychiatry residents, psychology and social work interns, and rehabilitation counselors, pre/post-doctoral students and professionals within a variety of academic settings. REAP serves as a replicable structure to successfully integrate recovery education into existing, accredited academic programs and curricula using the parameters outlined by multiple experts and stakeholders. Barriers to curricular transformation and strategies to overcome these barriers are highlighted.

Initial outcomes of a mental illness self-management program based on wellness recovery action planning.

OBJECTIVE: This study examined changes in psychosocial outcomes among participants in an eight-week, peer-led, mental illness self-management intervention called Wellness Recovery Action Planning (WRAP). METHODS: Eighty individuals with serious mental illness at five Ohio sites completed telephone interviews at baseline and one month after the intervention. RESULTS: Paired t tests of pre- and postintervention scores revealed significant improvement in self-reported symptoms, recovery, hopefulness, self-advocacy, and physical health; empowerment decreased significantly and no significant changes were observed in social support. Those attending six or more sessions showed greater improvement than those attending fewer sessions. CONCLUSIONS: These promising early results suggest that further research on this intervention is warranted. Confirmation of the efficacy and effectiveness of peer-led self-management has the potential to enhance self-determination and promote recovery for people with psychiatric disabilities.

Work status, benefits, and financial resources among people with HIV/AIDS.

With the advent of more advanced treatments and therapies, people with HIV/AIDS are experiencing significant improvements in their health, making many of their ongoing employment and career goals more realistic. However, people with HIV/AIDS continue to have major concerns regarding the impact of working on their benefits and entitlements, including apprehensions about potential economic hardships related to loss of financial supports and health insurance coverage. This article focuses on factors related to employment status, sources of health benefits, and entitlements among people with HIV/AIDS. In addition, results of the study demonstrate differences in employment status, benefit types, and the amount of financial support individuals receive based on gender.

Predictors of mental health services use among lesbian and heterosexual women.

Studies examining mental health services have identified a series of indicators with demonstrated effects on services access, barriers, and utilization, including gender, race/ethnicity, and socioeconomic status, as well as indicators such as type of insurance, client attitudes toward mental health, and diagnosis. This study identifies predictors of mental health services utilization in a diverse community sample of lesbians and heterosexual women (N=120). Outcomes for study participants are compared to those found in the services utilization literature, and similarities and differences among lesbians and heterosexual women are examined. Suggestions are offered for identifying new factors in mental health service utilization among groups with diverse sexual orientations.