COVID-19, Unemployment, and Behavioral Health Conditions: The Need for Supported Employment.

The COVID-19 pandemic has caused massive unemployment, exacerbated pre-existing behavioral health (mental health and substance use) disorders for many people, and created new disorders for others. Although policy changes have increased health care and unemployment benefits, most people want jobs and self-sufficiency rather than handouts. A robust evidence base shows that supported employment can enable unemployed people with behavioral health conditions to find competitive, integrated employment and behavioral health supports. Millions of U.S. citizens may need these services as the pandemic recedes and jobs become available. Government attention to supported employment is necessary now more than ever.

Cognitive remediation in large systems of psychiatric care.

IntroductionWith the increasing enthusiasm to provide cognitive remediation (CR) as an evidence-based practice, questions arise as to what is involved in implementing CR in a large system of care. This article describes the first statewide implementation of CR in the USA, with the goal of documenting the implementation issues that care providers are likely to face when bringing CR services to their patients. METHODS: In 2014, the New York State Office of Mental Health set up a Cognitive Health Service that could be implemented throughout the state-operated system of care. This service was intended to broadly address cognitive health, to assure that the cognitive deficits commonly associated with psychiatric illnesses are recognized and addressed, and that cognitive health is embedded in the vocabulary of wellness. It involved creating a mechanism to train staff to recognize how cognitive health could be prioritized in treatment planning as well as implementing CR in state-operated adult outpatient psychiatry clinics. RESULTS: By 2017, CR was available at clinics serving people with serious mental illness in 13 of 16 adult Psychiatric Centers, located in rural and urban settings throughout New York state. The embedded quality assurance program evaluation tools indicated that CR was acceptable, sustainable, and effective. CONCLUSIONS: Cognitive remediation can be feasibly implemented in large systems of care that provide a multilevel system of supports, a training program that educates broadly about cognitive health and specifically about the delivery of CR, and embedded, ongoing program evaluation that is linked to staff supervision.

Factors Influencing Buprenorphine Prescribing among Physicians in New York State.

BACKGROUND: Increasing access to buprenorphine is an important strategy for curtailing the opioid epidemic. Research is needed to understand what facilitates prescribing among waivered physicians and how to increase the willingness and capacity to prescribe. This study describes prescribing patterns in a sample of buprenorphine-waivered physicians in New York (NY) in 2016 and examines factors influencing prescribing capacity among waivered providers. METHODS: Surveys were mailed to a random sample of 300 physicians with DEA waivers to prescribe buprenorphine in NY which assessed demographics, practice characteristics, buprenorphine prescribing patterns, and barriers/facilitators to prescribing buprenorphine. Analyses include simple logistic regression to calculate the odds ratio, 95% confidence intervals, and p values, respectively, to examine differences in individual predictors among physicians that were actively prescribing buprenorphine and those that were not. RESULTS: 91 physicians responded to the survey, and 65% indicated they were currently prescribing buprenorphine. The mean patient census among physicians waivered to prescribe to 30 patients was 9.6 (SD = 9.7, median = 5), and to 100 patients, it was 60.5 (SD = 38.9, median = 72.5). Common facilitators included access to psychosocial referrals and better reimbursement, while inadequate resources, lack of time, and prior authorizations were the most common barriers. CONCLUSIONS: In addition to increasing the number of waivered physicians, policy-makers should provide enhanced training and implementation support for waivered physicians to start prescribing and facilitate continued and expanded prescribing among those already doing so.

Sustainability of collaborative care management for depression in primary care settings with academic affiliations across New York State.

BACKGROUND: In a large statewide initiative, New York State implemented collaborative care (CC) from 2012 to 2014 in 32 primary care settings where residents were trained and supported its sustainability through payment reforms implemented in 2015. Twenty-six clinics entered the sustainability phase and six opted out, providing an opportunity to examine factors predicting continued CC participation and fidelity. METHODS: We used descriptive statistics to assess implementation metrics in sustaining vs. opt-out clinics and trends in implementation fidelity 1 and 2 years into the sustainability phase among sustaining clinics. To characterize barriers and facilitators, we conducted 31 semi-structured interviews with psychiatrists, clinic administrators, primary care physicians, and depression care managers (24 at sustaining, 7 at opt-out clinics). RESULTS: At the end of the implementation phase, clinics opting to continue the program had significantly higher care manager full-time equivalents (FTEs) and achieved greater clinical improvement rates (46% vs. 7.5%, p = 0.004) than opt-out clinics. At 1 and 2 years into sustainability, the 26 sustaining clinics had steady rates of depression screening, staffing FTEs and treatment titration rates, significantly higher contacts/patient and improvement rates and fewer enrolled patients/FTE. During the sustainability phase, opt-out sites reported lower patient caseloads/FTE, psychiatry and care manager FTEs, and physician/psychiatrist CC involvement compared to sustaining clinics. Key barriers to sustainability noted by respondents included time/resources/personnel (71% of respondents from sustaining clinics vs. 86% from opt-out), patient engagement (67% vs. 43%), and staff/provider engagement (50% vs. 43%). Fewer respondents mentioned early implementation barriers such as leadership support, training, finance, and screening/referral logistics. Facilitators included engaging patients (e.g., warm handoffs) (79% vs. 86%) and staff/providers (71% vs. 100%), and hiring personnel (75% vs. 57%), particularly paraprofessionals for administrative tasks (67% vs. 0%). CONCLUSIONS: Clinics that saw early clinical improvement and who invested in staffing FTEs were more likely to elect to enter the sustainability phase. Structural rules (e.g., payment reform) both encouraged participation in the sustainability phase and boosted long-term outcomes. While limited to settings with academic affiliations, these results demonstrate that patient and provider engagement and care manager resources are critical factors to ensuring sustainability.

Ending the Opioid Epidemic by Changing the Culture.

The opioid epidemic continues to take thousands of lives each year in the United States, more than motor vehicle accidents and suicides combined. Real solutions, based on science, will require a culture shift in the way that we think about and respond to substance use disorders, in the healthcare system and in our communities. Just more of the same approach will not turn the tide. This article discusses how to better understand the use of psychoactive drugs and how prevention, treatment and policy change can disseminate evidence-based practices, fight stigma, and advance harm reduction; not only as strategies to improve outcomes, but as a social justice movement as well.

Results of a Coordinated Specialty Care Program for Early Psychosis and Predictors of Outcomes.

OBJECTIVE: This study prospectively evaluated outcomes of OnTrackNY, a statewide coordinated specialty care (CSC) program for treatment of early psychosis in community settings, as well as predictors of outcomes. METHODS: The sample included 325 individuals ages 16-30 with recent-onset nonaffective psychosis who were enrolled in OnTrackNY and who had at least one three-month follow-up. Clinicians provided data at baseline and quarterly up to one year. Domains assessed included demographic and clinical characteristics, social and occupational functioning, medications, suicidality and violence, hospitalization, and time to intervention. Primary outcomes included the symptoms, occupational functioning, and social functioning scales of the Global Assessment of Functioning (GAF), as adapted by the U.S. Department of Veterans Affairs Mental Illness Research, Education and Clinical Center; education and employment status; and psychiatric hospitalization rate. RESULTS: Education and employment rates increased from 40% to 80% by six months, hospitalization rates decreased from 70% to 10% by three months, and improvement in GAF scores continued for 12 months. Female gender, non-Hispanic white race-ethnicity, and more education at baseline predicted better education and employment status at follow-up. CONCLUSIONS: Individuals with early psychosis receiving CSC achieved significant improvements in education and employment and experienced a decrease in hospitalization rate. Demographic variables and baseline education predicted education and employment outcomes. CSC teams should make particular effort to support the occupational goals of individuals at increased risk of not engaging in work or school, including male participants and participants from racial and ethnic minority groups.

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.

Achieving Wellness: Monitoring the Success and Challenges of the Youth Health Indicator Program for Youth Treated in Outpatient Psychiatric Settings.

The youth health indicator (YHI) program was developed to improve health and reduce risk behaviors for youth treated in clinic and day treatment psychiatric settings. This study examined implementation of the YHI program and factors associated with BMI % change for youth participating in the program. Outpatient facilities which implemented the YHI program were surveyed (N = 10) and lessons learned were summarized. Mixed random effects repeated measures analysis was used to examine BMI % trajectory for youth admitted during 2010-2014 with BMI % measured (N = 6403). Treatment settings indicated a variety of strategies to undertake and sustain the YHI program. Factors associated with BMI % change over time were identified. The YHI program resulted in the development of a wide variety of programmatic innovations targeted at improving youth health. Continued work needs to be done to improve the health outcomes for youth in these treatment settings.

Implementing Cognitive Remediation Programs in France: The "Secret Sauce".

Cognitive remediation (CR) is a psychosocial therapy that seeks to restore patients' cognitive abilities by providing strategies to improve functioning in cognitive domains and helping them transfer acquired capabilities to everyday life. Since 2008, CR programs have been introduced in several regional health ministry areas in France. This column describes that implementation initiative, which includes creation of a network of the most active CR programs to conduct multicenter trials; establishment of a university degree in CR, awarded after completion of a one-year clinical training program; and implementation activities of regional health agencies. The authors describe three core elements of a "secret sauce"-a common language, timing, and leadership-that has helped ensure the success of the implementation efforts and that may be useful in other countries.

An Initiative to Improve Clozapine Prescribing in New York State.

Clozapine remains the only medication approved for treatment-resistant schizophrenia. But underuse is the norm. In 2010, the New York State Office of Mental Health began a multifaceted initiative to promote the evidence-based use of clozapine. From 2009 to 2013, in the absence of a well-funded pharmaceutical marketing campaign, the proportion of new clozapine trials among all new outpatient antipsychotic trials increased 40% among adult New York Medicaid recipients with a diagnosis of schizophrenia. The largest gains occurred in state-operated clinics. New York's experience demonstrates the feasibility of making clozapine more accessible to patients who stand to benefit most.

The Social Determinants of Mental Health.

Ninety percent of the determinants of our health derive from our lifetime social and physical environment-not from the provision of health care. The author describes behaviors, such as poor eating, excessive drinking and abuse of drugs, smoking, and physical inactivity, and social factors, such as adverse childhood experiences, poor education, food insecurity, poor housing quality, unemployment, and discrimination, that contribute to ill health and early demise. Better health and mental health can be achieved by understanding and responding to these determinants of health.

Sustaining Screening of Key Health Risk Factors in New York State Mental Health Clinics After Implementation of the Health Indicator Initiative.

OBJECTIVE: Screening data on obesity and smoking among adult outpatients in state-operated clinics were collected and analyzed by the New York State Office of Mental Health to determine relationships between demographic and clinical risk factors and obesity and smoking. Predictors of weight loss and smoking cessation were examined. METHODS: Individuals enrolled in 2010-2012 with two or more valid body mass index measures and two or more valid smoking measures (N=22,574) were selected. Chi square tests examined associations between demographic and clinical risk factors and obesity and smoking. Multivariable logistic regression identified predictors of weight loss and smoking cessation. RESULTS: The prevalence of obesity and smoking was 45% and 50%, respectively. The odds of losing weight or remaining at a stable weight were higher among males (versus females), individuals ages ≤49 (versus ≥50), smokers (versus nonsmokers) at baseline, and individuals with diabetes (versus without diabetes). The odds of gaining weight were higher among individuals prescribed psychotropic medications compared with those who were not prescribed psychotropic medications. Individuals ages ≤49 and those with a pulmonary condition or psychotic or substance use disorders (versus without these conditions) were less likely to quit smoking. Individuals who were obese (versus not obese) at baseline and those with an endocrine condition (versus without this condition) were more likely to quit smoking. CONCLUSIONS: Significant associations were found between demographic and clinical risk factors and obesity, smoking, and improvements in smoking and obesity outcomes. Continued work is needed to identify critical points of intervention to prevent weight gain and promote weight loss and smoking cessation in this population.

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.

The New York State Collaborative Care Initiative: 2012-2014.

We report on a partnership between the NYS Department of Health and Office of Mental Health that delivered the full integration of depression care into primary medical care. Called the NYS Collaborative Care Initiative (NYS-CCI), nineteen NYS academic medical centers participated. Based on principles of chronic illness care, Collaborative Care detects and manages depression in primary care using a highly prescriptive protocol (University of Washington AIMS Center website: http://uwaims.org/ ). Fidelity was ensured by measuring screening rates, diagnosis, enrollment, and improvement among those in treatment for 16 weeks. There was significant, progressive performance improvement in sites that served over 1 million patients over the course of the two and a half year grant. Clinics also reported satisfaction with the CC model. Based on the experience gained, we recommend a number of critical actions necessary for the successful implementation and scaling-up of CC throughout any state undertaking this endeavor.

The New York State Office of Mental Health Positive Alternatives to Restraint and Seclusion (PARS) Project.

OBJECTIVE: The Positive Alternatives to Restraint and Seclusion (PARS) project of the New York State Office of Mental Health (OMH) was designed to build capacity to use alternatives to restraint and seclusion within state-operated and licensed inpatient and residential treatment programs serving children with severe emotional disturbances. Its long-term goal was to eliminate the use of these restrictive interventions throughout the state's mental health system of care by creating coercion- and violence-free treatment environments governed by a philosophy of recovery, resiliency, and wellness. METHODS: The central feature of the PARS project was training in, implementation of, and engagement with the Six Core Strategies to Reduce the Use of Seclusion and Restraint, a comprehensive approach developed by the National Association of State Mental Health Program Directors. This report provides an overview of the project, results from January 2007 through December 2011, and lessons learned by OMH. RESULTS: The three participating mental health treatment facilities demonstrated significant decreases in restraint and seclusion episodes per 1,000 client-days. Each identified specific activities that contributed to success, including ways to facilitate open, respectful two-way communication between management and staff and between staff and youths and greater involvement of youths in program decision making. CONCLUSIONS: All three facilities continued to implement key components of the PARS initiative after termination of grant-funded activities, and OMH initiated multiple activities to disseminate lessons learned during the project to all inpatient and residential treatment programs throughout the state mental health system.

State Partnerships for First-Episode Psychosis Services.

The RAISE (Recovery After an Initial Schizophrenia Episode) Connection Program was a partnership that involved state mental health authorities (SMHAs) in Maryland and New York with research funding from the National Institute of Mental Health. The SMHAs collaborated with researchers to implement a team-based approach designed to serve people with newly emerged schizophrenia to maximize recovery and minimize disability. This column explains why states are interested in first-episode psychosis services and describes the development of the successful partnership, financing mechanisms, and plans to add teams in both states.