Peer navigators and integrated care to address ethnic health disparities of people with serious mental illness

Evaluating the tailored implementation of a multisite care navigation service for mental health in rural and remote Australia (The Bridging Study): protocol for a community-engaged hybrid effectiveness-implementation study

BACKGROUND

A dramatic decline in mental health of people worldwide in the early COVID-19 pandemic years has not recovered. In rural and remote Australia, access to appropriate and timely mental health services has been identified as a major barrier to people seeking help for mental ill-health. From 2020 to 2021 a care navigation model, Navicare, was co-designed with rural and remote communities in the Greater Whitsunday Region of Central Queensland in Australia. The Exploration, Preparation, Implementation and Sustainment (EPIS) framework was used to design and guide multiple aspects of a multisite study, The Bridging Study, to evaluate the implementation of Navicare in Australia.

METHODS

A community-engaged hybrid effectiveness-implementation study design will focus on the tailored implementation of Navicare at three new sites as well as monitoring implementation at an existing site established since 2021. Study outcomes assessed will include sustained access as the co-primary outcome (measured using access to Navicare mental health referral services) and Proctor's Implementation Outcomes of feasibility, acceptability, appropriateness, adoption, fidelity, implementation cost, and sustainability. Data collection for the implementation evaluation will include service usage data, community consultations, interviews, and workshops; analysed using mixed methods and guided by EPIS and other implementation frameworks. Pre-post effectiveness and cost-consequence study components are embedded in the implementation and sustainment phases, with comparison to pre-implementation data and value assessed for each EPIS phase using hospital, service, and resource allocation data. A scaling up strategy will be co-developed using a national roundtable forum in the final year of the study. Qualitative exploration of other aspects of the study (e.g., mechanisms of action and stakeholder engagement) will be conducted.

DISCUSSION

Our study will use tailoring to local sites and a community-engaged approach to drive implementation of a mental health care navigation service in rural and remote Australia, with expected benefits to mental healthcare access. This approach is consistent with policy recommendations nationally and internationally as building blocks for rural health including the World Health Organization Framework for Action on Strengthening Health Systems to Improve Health Outcomes.

TRIAL REGISTRATION

Prospectively registered on April 2, 2024, on the Australian New Zealand Clinical Trials Registry, no. ACTRN12624000382572. https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=386665&isReview=true .

Social-ecological barriers and facilitators to seeking inpatient psychiatric care among transgender and nonbinary people: A qualitative descriptive study

AIM(S)

To assess barriers and facilitators to seeking inpatient psychiatric treatment among transgender and nonbinary people.

DESIGN

Qualitative interview study.

METHODS

Semi-structured interviews were conducted from March 2019 to June 2022 with transgender and nonbinary people admitted to an inpatient psychiatric hospital in the United States during the past 5 years. Data were analysed using thematic analysis and constructed within a modified social-ecological model of stigma. Standards for Reporting Qualitative Research were used for this study.

RESULTS

Participants (N = 15) described barriers and facilitators across all three social-ecological levels. i) Individual themes included distrust of the mental healthcare system, feeling unsafe, loss of autonomy, minimizing one's own mental health needs, and feelings of accountability to others. ii) Interpersonal themes included: lack of support for transgender/nonbinary identity, limited transgender/nonbinary knowledge among mental healthcare professionals, and allyship. iii) Structural themes included: carceral setting, financial costs, and availability of non-profit treatment options.

CONCLUSION

Multi-level themes were identified as barriers and facilitators to seeking inpatient psychiatric care for transgender and nonbinary people, providing opportunities among inpatient settings to improve care delivery and engagement. Greater health equity can be achieved by addressing barriers to care.

IMPLICATIONS

Incorporating inclusive and affirming practices in inpatient psychiatric services presents an opportunity to reduce barriers to seeking care.

IMPACT

The present study describes the experiences of transgender and nonbinary people as they determine whether to voluntarily seek inpatient psychiatric treatment. This perspective allows nurses, health systems, and policymakers to integrate transgender and nonbinary people's needs to improve healthcare delivery.

PATIENT/PUBLIC CONTRIBUTION

Transgender and nonbinary participants were recruited in collaboration with community organizations. Members of the transgender and nonbinary community participated in study design development and analysis and were part of the study team.

WHO framework on meaningful engagement: A transformational approach to integrate lived experience in the noncommunicable disease and mental health agenda

As the global public health community continues to reflect and recover from the COVID-19 pandemic, noncommunicable diseases (NCDs), and mental health and neurological conditions remains one of the largest unmet gaps in progress towards meeting the Sustainable Development Goals (SDG). People living with these health conditions, particularly among those most marginalized, acutely understand the impact of these failures in global action and investment. Integrating lived experience into the NCD and mental health response can act as an accelerator for action. Through a participatory process to co-create the WHO Framework on Meaningful Engagement on NCDs, and Mental Health and Neurological Conditions, we conducted a mixed methods and semi-structured approach, including informal consultations, focus groups, in-depth interviews, online surveys, and a short film series, that captured the perspectives of 700 individuals from 111 countries, including 386 individuals with lived experience. Working alongside lived experience communities and other relevant stakeholders, we have established and co-created a set of principles, enablers and actions for operationalizing meaningful engagement, related to dignity and respect, power and equity, inclusivity and intersectionality, commitment and transparency, and institutionalization and contextualization. People with lived experience have a right to be equitably included in all levels of policy-setting, design and implementation of programs, and to have a central role in reforming and reorienting the structures and systems intended to address the complex multifactorial challenges that they face. WHO is committed to leveraging its role in global health to further operationalize meaningful engagement within WHO and its Member States.

Community engagement to inform development of strategies to improve referral for hypertension: perspectives of patients, providers and local community members in western Kenya

BACKGROUND

Hypertension is the leading cause of death and disability. Clinical care for patients with hypertension in Kenya leverages referral networks to provide basic and specialized healthcare services. However, referrals are characterized by non-adherence and delays in completion. An integrated health information technology (HIT) and peer-based support strategy to improve adherence to referrals and blood pressure control was proposed. A formative assessment gathered perspectives on barriers to referral completion and garnered thoughts on the proposed intervention.

METHODS

We conducted a qualitative study in Kitale, Webuye, Kocholya, Turbo, Mosoriot and Burnt Forest areas of Western Kenya. We utilized the PRECEDE-PROCEED framework to understand the behavioral, environmental and ecological factors that would influence uptake and success of our intervention. We conducted four mabaraza (customary heterogenous community assemblies), eighteen key informant interviews, and twelve focus group discussions among clinicians, patients and community members. The data obtained was audio recorded alongside field note taking. Audio recordings were transcribed and translated for onward coding and thematic analysis using NVivo 12.

RESULTS

Specific supply-side and demand-side barriers influenced completion of referral for hypertension. Key demand-side barriers included lack of money for care and inadequate referral knowledge. On the supply-side, long distance to health facilities, low availability of services, unaffordable services, and poor referral management were reported. All participants felt that the proposed strategies could improve delivery of care and expressed much enthusiasm for them. Participants appreciated benefits of the peer component, saying it would motivate positive patient behavior, and provide health education, psychosocial support, and assistance in navigating care. The HIT component was seen as reducing paper work, easing communication between providers, and facilitating tracking of patient information. Participants also shared concerns that could influence implementation of the two strategies including consent, confidentiality, and reduction in patient-provider interaction.

CONCLUSIONS

Appreciation of local realities and patients' experiences is critical to development and implementation of sustainable strategies to improve effectiveness of hypertension referral networks. Incorporating concerns from patients, health care workers, and local leaders facilitates adaptation of interventions to respond to real needs. This approach is ethical and also allows research teams to harness benefits of participatory community-involved research.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03543787, Registered June 1, 2018. https://clinicaltrials.gov/ct2/show/NCT03543787.

Effectiveness of system navigation programs linking primary care with community-based health and social services: a systematic review

BACKGROUND

Fragmented delivery of health and social services can impact access to high-quality, person-centred care. The goal of system navigation is to reduce barriers to healthcare access and improve the quality of care. However, the effectiveness of system navigation remains largely unknown. This systematic review aims to identify the effectiveness of system navigation programs linking primary care with community-based health and social services to improve patient, caregiver, and health system outcomes.

METHODS

Building on a previous scoping review, PsychInfo, EMBASE, CINAHL, MEDLINE, and Cochrane Clinical Trials Registry were searched for intervention studies published between January 2013 and August 2020. Eligible studies included system navigation or social prescription programs for adults, based in primary care settings. Two independent reviewers completed study selection, critical appraisal, and data extraction.

RESULTS

Twenty-one studies were included; studies had generally low to moderate risk of bias. System navigation models were lay person-led (n = 10), health professional-led (n = 4), team-based (n = 6), or self-navigation with lay support as needed (n = 1). Evidence from three studies (low risk of bias) suggests that team-based system navigation may result in slightly more appropriate health service utilization compared to baseline or usual care. Evidence from four studies (moderate risk of bias) suggests that either lay person-led or health professional-led system navigation models may improve patient experiences with quality of care compared to usual care. It is unclear whether system navigation models may improve patient-related outcomes (e.g., health-related quality of life, health behaviours). The evidence is very uncertain about the effect of system navigation programs on caregiver, cost-related, or social care outcomes.

CONCLUSIONS

There is variation in findings across system navigation models linking primary care with community-based health and social services. Team-based system navigation may result in slight improvements in health service utilization. Further research is needed to determine the effects on caregiver and cost-related outcomes.

Characterizing mobility patterns of forest goers in southern Lao PDR using GPS loggers

BACKGROUND

In the Greater Mekong Subregion (GMS), forest-going populations are considered high-risk populations for malaria and are increasingly targeted by national control programmes' elimination efforts. A better understanding of forest-going populations' mobility patterns and risk associated with specific types of forest-going trips is necessary for countries in the GMS to achieve their objective of eliminating malaria by 2030.

METHODS

Between March and November 2018, as part of a focal test and treat intervention (FTAT), 2,904 forest-goers were recruited in southern Lao PDR. A subset of forest-goers carried an "i-Got-U" GPS logger for roughly 2 months, configured to collect GPS coordinates every 15 to 30 min. The utilization distribution (UD) surface around each GPS trajectory was used to extract trips to the forest and forest-fringes. Trips with shared mobility characteristics in terms of duration, timing and forest penetration were identified by a hierarchical clustering algorithm. Then, clusters of trips with increased exposure to dominant malaria vectors in the region were further classified as high-risk. Finally, gradient boosting trees were used to assess which of the forest-goers' socio-demographic and behavioural characteristics best predicted their likelihood to engage in such high-risk trips.

RESULTS

A total of 122 forest-goers accepted carrying a GPS logger resulting in the collection of 803 trips to the forest or forest-fringes. Six clusters of trips emerged, helping to classify 385 (48%) trips with increased exposure to malaria vectors based on high forest penetration and whether the trip happened overnight. Age, outdoor sleeping structures and number of children were the best predictors of forest-goers' probability of engaging in high-risk trips. The probability of engaging in high-risk trips was high (~ 33%) in all strata of the forest-going population.

CONCLUSION

This study characterized the heterogeneity within the mobility patterns of forest-goers and attempted to further segment their role in malaria transmission in southern Lao People's Democratic Republic (PDR). National control programmes across the region can leverage these results to tailor their interventions and messaging to high-risk populations and accelerate malaria elimination.

Supporting Individuals with Mental Health and/or Addictions Issues Through Patient Navigation: A Scoping Review

Pathways through the mental health care system can be complex and laden with barriers that prevent individuals from finding the most appropriate care. Navigation has been proposed as a solution for improving access to and transition through complex health care systems. While several MHA navigation programs have emerged in the past decade, no study has explored the core themes of MHA navigation, which was the goal of the current review. A scoping review was conducted; the search yielded 11,525 unique results, of which 26 were entered into extraction and subsequent descriptive and thematic analysis. Barrier reduction, client-centered support, and integrated care emerged as the distinct themes underlying MHA services, and overall, navigation significantly improved outcomes for individuals experiencing MHA issues. These findings may support evidence-based implementation of navigation services and point to a need for increased exploration and reporting of MHA navigation outcomes in the literature.

Interventions to Promote the Utilization of Physical Health Care for People with Severe Mental Illness: A Scoping Review

BACKGROUND

The main contributor to excess mortality in severe mental illness (SMI) is poor physical health. Causes include unfavorable health behaviors among people with SMI, stigmatization phenomena, as well as limited access to and utilization of physical health care. Patient centered interventions to promote the utilization of and access to existing physical health care facilities may be a pragmatic and cost-effective approach to improve health equity in this vulnerable and often neglected patient population.

OBJECTIVE/METHODS

In this study, we systematically reviewed the international literature on such studies (sources: literature databases, trial-registries, grey literature). Empirical studies (quantitative, qualitative, and mixed methods) of interventions to improve the utilization of and access to medical health care for people with a SMI, were included.

RESULTS

We identified 38 studies, described in 51 study publications, and summarized them in terms of type, theoretical rationale, outcome measures, and study author's interpretation of the intervention success.

CONCLUSIONS

Useful interventions to promote the utilization of physical health care for people with a SMI exist, but still appear to be rare, or at least not supplemented by evaluation studies. The present review provides a map of the evidence and may serve as a starting point for further quantitative effectiveness evaluations of this promising type of behavioral intervention.

Engaging Same-Day Peer Ambassadors to Increase Coronavirus Disease 2019 Vaccination Among People Experiencing Unsheltered Homelessness in Los Angeles County: A Hybrid Feasibility-Evaluation Study

BACKGROUND

This study aimed to evaluate the feasibility and acceptability of engaging unhoused peer ambassadors (PAs) in coronavirus disease 2019 (COVID-19) vaccination efforts to reach people experiencing unsheltered homelessness in Los Angeles County.

METHODS

From August to December 2021, vaccinated PAs aged ≥18 years who could provide informed consent were recruited during vaccination events for same-day participation. Events were held at encampments, service providers (eg, housing agencies, food lines, and mobile showers), and roving locations around Los Angeles. PAs were asked to join outreach alongside community health workers and shared their experience getting vaccinated, receiving a $25 gift card for each hour they participated. Postevent surveys evaluated how many PAs enrolled and how long they participated. In October 2021, we added a preliminary effectiveness evaluation of how many additional vaccinations were attributable to PAs. Staff who enrolled the PAs estimated the number of additional people vaccinated because of talking with the PA.

RESULTS

A total of 117 PAs were enrolled at 103 events, participating for an average of 2 hours. At events with the effectiveness evaluation, 197 additional people were vaccinated over 167 PA hours ($21.19 gift card cost per additional person vaccinated), accounting for >25% of all vaccines given at these events.

DISCUSSION

Recruiting same-day unhoused PAs is a feasible, acceptable, and preliminarily effective technique to increase COVID-19 vaccination in unsheltered settings. The findings can inform delivery of other health services for people experiencing homelessness.

The lived experience of severe mental illness and long-term conditions: a qualitative exploration of service user, carer, and healthcare professional perspectives on self-managing co-existing mental and physical conditions

BACKGROUND

People with severe mental illness (SMI), such as schizophrenia, have higher rates of physical long-term conditions (LTCs), poorer health outcomes, and shorter life expectancy compared with the general population. Previous research exploring SMI and diabetes highlights that people with SMI experience barriers to self-management, a key component of care in long-term conditions; however, this has not been investigated in the context of other LTCs. The aim of this study was to explore the lived experience of co-existing SMI and LTCs for service users, carers, and healthcare professionals.

METHODS

A qualitative study with people with SMI and LTCs, their carers, and healthcare professionals, using semi-structured interviews, focused observations, and focus groups across the UK. Forty-one interviews and five focus groups were conducted between December 2018 and April 2019. Transcripts were coded by two authors and analysed thematically.

RESULTS

Three themes were identified, 1) the precarious nature of living with SMI, 2) the circularity of life with SMI and LTCs, and 3) the constellation of support for self-management. People with co-existing SMI and LTCs often experience substantial difficulties with self-management of their health due to the competing demands of their psychiatric symptoms and treatment, social circumstances, and access to support. Multiple long-term conditions add to the burden of self-management. Social support, alongside person-centred professional care, is a key facilitator for managing health. An integrated approach to both mental and physical healthcare was suggested to meet service user and carer needs.

CONCLUSION

The demands of living with SMI present a substantial barrier to self-management for multiple co-existing LTCs. It is important that people with SMI can access person-centred, tailored support for their LTCs that takes into consideration individual circumstances and priorities.

Implementing patient navigator programmes within a hospital setting in Toronto, Canada: A qualitative interview study

OBJECTIVES

This study sought to identify the organisation and system level barriers and facilitators influencing the implementation of patient navigator programmes in one acute care hospital system in Toronto, Canada.

METHODS

A qualitative descriptive approach informed by the Consolidated Framework for Implementation Research. Data were collected using in-depth interviews and analysed thematically.

RESULTS

Thirty-eight individuals participated in interviews (17 community, 21 acute care hospital), including 24 frontline clinicians and 14 programme directors, health care leaders and managers. Implementation of patient navigator programmes was dependent on: (1) a clear consensus on the unique need for patient navigators; (2) champions to promote patient navigation; (3) programme ownership and accountability; (4) external system and organisational landscape and (5) implementation climate. Appropriate mechanisms of communication were found to have impacted each factor as a barrier or facilitator to programme implementation.

CONCLUSION

Strategies for implementing patient navigator programmes into hospital clinical practice should include incorporating evidence to support the programme, considering mechanisms to enable collaborative communication, and the integration of frameworks to facilitate programme integration into the current practices within the organisation.

Linking criminal justice-involved individuals to HIV, Hepatitis C, and opioid use disorder prevention and treatment services upon release to the community: Progress, gaps, and future directions

Improving HIV and Hepatitis C Virus (HCV) management among people involved in the criminal justice (CJ) system who use drugs, in particular those with opioid use disorder (OUD), requires effective approaches to screening, linkage, and adherence to integrated prevention and treatment services across correctional and community agencies and providers. This manuscript reviews the literature to explore gaps in HIV, Hepatitis C, and OUD prevention, treatment, and delivery cascades of care for persons involved in the CJ system. Specifically, we compare two models of linkage to prevention and treatment services: Peer/Patient Navigation (PN) wherein the PN links CJ-involved individuals to community-based infectious disease (ID) and substance use prevention and treatment services, and Mobile Health Units (MHU) wherein individuals are linked to a MHU within their community that provides integrated ID and substance use prevention and treatment services. The most notable finding is a gap in the literature, with few to no comparisons of models linking individuals recently released from the CJ system to integrated HIV, Hepatitis C, and OUD prevention and treatment and other harm reduction services. Further, few published studies address the geographical distinctions that affect service implementation and their effects on these substance use, ID and harm reduction care cascades. This manuscript makes specific recommendations to fill this gap through a detailed evaluation of PN and MHU linkage models to co-located and integrated HIV, Hepatitis C, and OUD prevention and treatment services across different communities within the U.S.

The missing link-participants' perspectives on transfer from psychosocial interventional contexts to everyday community life: a qualitative synthesis of interventional studies

Background

The aim of this study was to illuminate participants’ experiences with transfer in (1) Illness Management and Recovery (IMR); and (2) two programs based on peer support: Turning Points, and Learn to Tackle Anxiety and Depression (LTAD); and whether peer support within these programs influenced the process of transfer beyond the interventional context. Furthermore, we investigated participants’ experiences with a community-based intervention [Individual Placement and Support (IPS)] to explore perspectives on mechanisms that may eliminate challenges in the transfer process.

Methods

The study was based on semi-structured interviews with participants with mental illness, from four different psychosocial interventions with and without peer support and across interventional settings. The material partly consists of secondary analyses of existing data sets of anonymised, transcribed interviews investigating participants' experience from two psychosocial interventions: Illness Management and Recovery (n = 15), and Individual Placement and Support (n = 12). Additionally, we conducted semi-structured interviews with persons who had participated in one of two peer-led programs: Turning Points and Learn How to Tackle Anxiety and Depression (n = 12). The analysis was guided by a hermeneutic-phenomenological approach to illuminate transfer processes and was based on the template method described by Nigel King.

Results

Applying a transfer perspective on rehabilitation interventions identified everyday life situations where capacities learned during the interventions were utilized and conditions were highlighted that promoted or hindered transfer. Experiential knowledge and peer-exchange made transferal pathways between the interventional context and everyday life. Illness intrusiveness and uncertainty, together with environmental obstacles, generated transferal gaps. Individualized support could partly address these gaps.

Conclusion

Findings from this qualitative study illuminate how peer-support in group-based rehabilitation interventions increased social functioning and developed better self-care strategies that can be transferred to daily life. Interventions situated in mental health settings, e.g. outpatient clinics, had limited impact on participation in broader community life. Advancing rehabilitation services in mental health may benefit from tailoring services to address illness fluctuation and combining group sessions with individualized support together with acknowledging and overcoming environmental obstacles.

Community voice in cross-sector alignment: concepts and strategies from a scoping review of the health collaboration literature

Background

Health care access is an important driver of population health, and factors beyond health care also drive health outcomes. Recognizing the importance of the social determinants of health (SDOH), different actors in the health care, public health, and social service sectors are increasingly collaborating to improve health outcomes in communities. To support such collaboration, the Robert Wood Johnson Foundation developed a cross-sector alignment theory of change. According to the cross-sector alignment theory of change, community voice is critical for helping collaboratives address community health needs. Yet research on health collaboratives offers mixed guidance on how community voice should be understood and which community voice strategies are most effective.

Methods

This study addresses a gap in the literature with a systematic scoping review of research on health-oriented cross-sector collaboration and community voice. By scanning key academic journals, searching three academic databases, and obtaining documents from across our professional networks, we identified 36 documents that address community voice in health collaboratives.

Results

The review reveals several conceptions of community voice and a range of community voice strategies. We find that community voice strategies fall on a spectrum between two broad types of approaches: active and passive. These vary not only in the level of power shared between communities and collaborators, but also in the level of involvement required from the community, and this in turn has important implications for community collaboration strategies. We also find that while most strategies are discussed in the context of short-term collaboration, many also lend themselves to adoption in the context of sustainable collaboration and, ultimately, cross-sector alignment.

Conclusion

This review provides a characterization and conceptualization of community voice in health-oriented collaborations that provides a new theoretical basis for future research. Passive and active community voice strategies can be studied in more detail for their expected impact on health outcomes and disparities. Increased attention to active community voice and the resources it requires can help practitioners achieve improved health outcomes and researchers understand the pathways to health improvement through collaboration.

Examining How Health Navigation Affects Mental Health Among Gay, Bisexual, and Other Men Who Have Sex with Men Living with Human Immunodeficiency Virus in Guatemala

Gay, bisexual, and other men who have sex with men (GBMSM) are disproportionately affected by mental health problems and human immunodeficiency virus (HIV). Health navigation has the potential to improve both HIV and mental health outcomes; however, few studies have measured the impact of navigation on mental health among people living with HIV. We analyzed longitudinal data from a sociobehavioral survey and navigation monitoring system with GBMSM living with HIV in Guatemala (n = 346) that participated in a 12-month differentiated care intervention. We examined relationships between navigation characteristics (frequency, duration, mode of interactions, and level of emotional, instrumental, and informational navigation support) and anxiety and depression using fixed-effects regression. We also examined if these relationships were moderated by baseline social support. We found that as navigation interactions increased, anxiety significantly improved [B = -0.03, standard error (SE) = 0.01 p = 0.05]. Participants who received high levels of informational navigator support also experienced a significant improvement in anxiety compared with those receiving low levels of informational support (B = -0.81, SE = 0.40, p = 0.04). Unexpectedly, we found that as the proportion of in-person navigation interactions increased, anxiety worsened (B = 1.12, SE = 0.54, p = 0.04). No aspects of navigation were significantly associated with depression and baseline social support did not moderate the relationship between navigation and anxiety and depression. To improve the mental health of key populations affected by HIV, health navigation programs should prioritize frequent interaction and informational navigation support for clients with anxiety while considering other strategies that specifically target reducing depressive symptoms, including other cost-effective modalities, such as mobile apps.

The Availability of Peer Support and Disparities in Outpatient Mental Health Service Use Among Minority Youth with Serious Mental Illness

We examine whether the availability of peer support reduces disparities in service use among minority youth ages 16-24 with serious mental illness in Los Angeles and San Diego Counties. Administrative data from 2015-2018 was used to summarize service use among 13,363 transition age youth age 16-24 with serious mental illness who received services from 183 outpatient public mental health programs; 17.2% were Black, 67.4% were Latinx, and 15.4% were non-Latinx white. The availability of peer support was assessed via a program survey. Generalized linear models were used to assess the relationship between availability of peer support, defined as having a peer specialist on staff, and the annual number of outpatient mental health visits. We also examined the relationship between racial/ethnic concordance of youth and peer specialists and use of outpatient services. Forty-six percent of youth received services from programs that employed peer specialists. Among youth in both counties, the availability of peer support was associated with an increase in annual outpatient visits (P ≤ .05 each). Peer support was associated with reductions in service use disparities among Black and Latinx youth in Los Angeles County (P < .001 each). Peer concordance was associated with an increase in outpatient service use among Latinx youth in both counties (P < .05 each). Peer support was associated with increases in use of outpatient mental health services. Detailed examination of the context for youth peer support implementation is merited to identify the specific pathways that improve outcomes.

The Affordable Care Act: policy predictors of integrated care between Hispanic-serving and mainstream mental health organizations

Background

The Patient Protection and Affordable Care Act increased funding for integrated care to improve access to quality health care among underserved populations. There is evidence that integrated care decreases inequities in access and quality of mental health care among Hispanic clients. Increasing integrated care at Hispanic-Serving Organizations may help to eliminate mental health service disparities among Hispanic clients.

Method

Using organizational responses from the 2014 and 2016 waves of the National Mental Health Service survey, this study conducted multivariate logistic analyses to assess whether the ACA policies related to integrated care increased the provision of integrated addictions treatment and primary care at mental health Hispanic-Serving Organizations, relative to Mainstream Organizations.

Results

Findings showed that Hispanic-Serving Organizations (54.4%) were less likely to provide integrated health services than Mainstream Organizations (59.1%) after the ACA. However, federal funding to help organizations transition into integrated care services (AOR = 1.74, p = 0.01) and accepting Medicaid payments (AOR = 1.59, p = 0.01) increased the provision of integrated care services at Hispanic-Serving Organizations over time.

Conclusions

Health care policies that increase funding to adopt integrated health services at community Hispanic-Serving Organizations may help decrease inequities in mental health access for Hispanics in the United States.

"Being There" vs "Being Direct:" Perspectives of Persons with Serious Mental Illness on Receiving Support with Physical Health from Peer and Non-Peer Providers

Individuals with serious mental illness (SMI) face significant health disparities and multiple barriers to engaging in health behavior change. To reduce these health disparities, it is necessary to enhance the support individuals with SMI receive through the collaboration of different healthcare providers. This study explored how people with SMI living in supportive housing perceived receiving support from peer and non-peer providers for their physical health. Qualitative interviews were conducted with 28 participants receiving a peer-led healthy lifestyle intervention in the context of a randomized trial in supportive housing agencies. Interviews explored participants' experiences working with the healthy lifestyle peer specialist and a non-peer provider who assisted them with health. Interviews were audio recorded, transcribed, and analyzed using strategies rooted in grounded theory. Participants viewed their relationships with peer and non-peer providers positively, but described differences in the approach to practice, power dynamics present, and how they identified with each provider. Participants described peers as process-oriented while non-peer staff as task-oriented, focusing on accomplishing concrete objectives. Each provider sought to boost participants' motivation, but peers built hope by emphasizing the possibility of change, while non-peer providers emphasized the consequences of inaction. Participants related to peer staff through shared experiences, while identifying the importance of having a shared treatment goal with their non-peer provider. Overall, participants appreciated the unique roles of both peer and non-peer staff in supporting their health. Study findings have implications for integrating the use of peer-based health interventions to improve the health of people with SMI.

Engaging a person with lived experience of mental illness in a collaborative care model feasibility study

Researchers have explored different types of treatment to help people with a mental illness with other problems they might be experiencing, such as their health condition and quality of life. Care models that involve many different health care providers working together to provide complete physical and mental health care are becoming popular. There has been a push from the research community to understand the value of including people with lived experience in such programs. While research suggests that people with lived experience may help a patient's treatment, there is little evidence on including them in a team based program. This paper describes how our research team included a person with lived experience of psychosis in both the research and care process. We list some guiding principles we used to work through some of the common challenges that are mentioned in research. Lastly, experiences from the research team, lessons learned, and a personal statement from the person with lived experience (AA) are provided to help future researchers and people with lived experience collaborate in research and healthcare. Background In our current healthcare system, people with a mental illness experience poorer physical health and early mortality in part due to the inconsistent collaboration between primary care and specialized mental health care. In efforts to bridge this gap, hospitals and primary care settings have begun to take an integrated approach to care by implementing collaborative care models to treat a variety of conditions in the past decade. The collaborative care model addresses common barriers to treatment, such as geographical distance and lack of individualized, evidence-based, measurement-based treatment. Person(s) with lived experience (PWLE) are regarded as 'experts by experience' in the scope of their first-hand experience with a diagnosis or health condition. Research suggests that including PWLE in a patient's care and treatment has significant contributions to the patient's treatment and overall outcome. However, there is minimal evidence of including PWLE in collaborative care models. This paper describes the inclusion of a PWLE in a research study and collaborative care team for youth with early psychosis. Aims To discuss the active involvement of a PWLE on the research and collaborative care team and to describe the research team's experiences and perspectives to facilitate future collaborations. Method This paper describes the inclusion of a PWLE on our research team. We provide a selective review of the literature on several global initiatives of including PWLE in different facets of the healthcare system. Additionally, we outline multiple challenges of involving PWLE in research and service delivery. Examples are provided on how recruitment and involvement was facilitated, with the guidance of several principles. Lastly, we have included a narrative note from the PWLE included in our study, who is also a contributing author to this paper (AA), where she comments on her experience in the research study. Conclusion Including PWLE in active roles in research studies and collaborative care teams can enhance the experience of the researchers, collaborative care team members, and PWLE. We showcase our method to empower other researchers and service providers to continue to seek guidance from PWLE to provide more comprehensive, collaborative care with better health outcomes for the patient, and a more satisfying care experience for the provider.

Re-engaging Dropouts of Prolonged Exposure for PTSD Delivered via Home-Based Telemedicine or In Person: Satisfaction with Veteran-to-Veteran Support

This paper describes feasibility of and patient and peer satisfaction with a Veteran-to-Veteran peer support program purposefully integrated into prolonged exposure (PE) for post-traumatic stress disorder (PTSD) to address barriers contributing to dropout from both in person and telemedicine delivered PE. Specifically, patients who had dropped out of PE were offered the opportunity to return to treatment, this time with a peer who themselves had completed PE, who would join them during a limited number of PE in vivo exposure homework trials. About half of the Veterans who dropped out indicated willingness to return to treatment, noting the peer as central to this decision, and about a third actually returned to treatment. Participants reported high satisfaction with the program, as did peers. Peers reported that their own symptoms were not exacerbated by engaging in exposure homework with the patients. While in the military, service members are trained to leverage the power of the group toward mission-specific tasks; and this training appears relevant to PTSD treatment in the present context.

The impact of patient navigation: a scoping review protocol

REVIEW OBJECTIVE/QUESTION

The objective of this review is to synthesize the evidence on the impact of patient navigation for all populations across all settings. The question of this review is: What is the existing evidence on the impact of patient navigation?

Peer navigation for individuals with serious mental illness leaving jail: a pilot randomized trial study protocol

Background

Serious mental illness (SMI) is a prevalent public health problem affecting 25% of individuals in jail. Re-entry to the community following incarceration is a vulnerable time for justice-involved individuals with SMI. SMI requires prompt and ongoing access to mental health and other healthcare services.

Methods

The study will (1) develop a Mentoring And Peer Support (MAPS) intervention for post-release mental health and other service connection among jailed individuals with SMI and (2) pilot test the MAPS intervention to determine its feasibility and acceptability. The primary outcomes will be to evaluate the feasibility and acceptability of the proposed recruitment methods and research design, of the intervention training methods, and of delivering the enhanced peer-navigator and control interventions. Study samples include focus groups (n=36), open trial (n=15), and a randomized pilot trial in a sample of 40 individuals with SMI re-entering the community after jail release. Secondary outcomes will include post-release enrollment in mental health, medical care, and substance use services. We will also evaluate reduction in psychiatric symptoms, improvements in functioning, adherence to psychiatric medications, fewer substance using days, fewer hospitalizations and suicide attempts, nights unstably housed, and time until rearrest.

Discussion

This pilot study will evaluate the feasibility and acceptability of a peer navigation intervention for individuals with serious mental illness leaving jails. The study will serve as a formative work for a larger randomized controlled trial assessing the effectiveness of peer navigator intervention for (include the primary outcome) in this population.

After the Affordable Care Act: the Effects of the Health Safety Net and the Medicaid Expansion on Latinxs' Use of Behavioral Healthcare in the US

This study investigated the association between the implementation of the Affordable Care Act (ACA) and Latinxs' use of behavioral health services in the US. Organizational responses from the 2010, 2014, and 2016 National Mental Health Service Survey were used to examine the number and proportion of outpatient Latinx admissions over time, as well as the role of Medicaid expansion and health safety net funding on Latinxs' admissions. Findings showed that there was an increase in Latinx admissions post-ACA (2014). However, 2 years post-implementation (2016), Latinx admissions were at levels lower than prior to the healthcare reform. Despite this overall decrease, behavioral health safety net organizations, particularly those located in states that adopted the expansion of Medicaid, served more Latinxs than behavioral health service organizations outside the safety net. Policy and practice implications to strengthen behavioral safety net organizations that serve Latinxs are discussed.

Exploring the role of lay and professional patient navigators in Canada

OBJECTIVES

To explore the roles of patient navigators in different settings and situations for various patient populations and to understand the rationale for implementing lay and professional models of patient navigation in a Canadian context.

METHODS

A qualitative descriptive design was applied, using interviews with 10 patient navigators from eight Canadian provinces, and Braun and Clarke's six phases of thematic analysis to guide the analysis of interview transcripts.

RESULTS

Findings indicate that a patient navigator's personality and experience (personal and work-related) may be more important than their specific designation (i.e. lay or professional).

CONCLUSIONS

Lay and professional navigators in Canada appear to be well suited to provide navigational services across populations. This study has the potential to inform future research, policy, and the delivery of navigation programmes in Canada.

Carers as System Navigators: Exploring Sources, Processes and Outcomes of Structural Burden

BACKGROUND AND OBJECTIVES

Structural features of formal care systems influence the amount, difficulty, and complexity of what carers do as they interface with those systems. In this study, we explored how carers navigate health and social care systems, and their experiences of structural burden related to features such as complexity and fragmentation.

RESEARCH DESIGN AND METHODS

This qualitative descriptive inquiry drew on data from in-person interviews with 32 carers of older adults, which were analyzed first using inductive thematic analysis and then using structural burden as a conceptual lens.

RESULTS

Participant accounts revealed how navigating formal systems on behalf of older adult family members can exact considerable demands on carers in terms of time investment and emotional energy. In this way, care systems exacerbate the stress and structural burden experienced by carers, even when formal services alleviate other forms of carer burden.

DISCUSSION AND IMPLICATIONS

Our findings contribute to knowledge of how the structural context of formal services shapes carer experiences and outcomes. To promote equity and prevent burden, system navigation work should be considered as a public, structural issue, rather than an individual-level problem of skills and learning.

Peer Support in Coordination of Physical Health and Mental Health Services for People With Lived Experience of a Serious Mental Illness

BACKGROUND

Engaging peer support to augment and enhance traditional mental health services presents novel opportunities to improve service engagement and delivery. However, there has not been an in-depth analysis of the processes and methods behind the coordination of physical health and mental health care by peer support specialists.

STUDY AIM

To explore the potential of peer support specialists in community mental health centers and as a means to improve coordination of physical health and mental health services for people with a serious mental illness.

METHODS

We conducted 28 semi-structured qualitative interviews with peer support specialists and mental healthcare professionals in community mental health centers in two states (blinded for review) in the United States. Data were triangulated to explore peer support specialists and mental health professionals' perspectives.

RESULTS

We found five themes characterizing the role of peer support services in the coordination of physical health and mental health services for individuals with serious mental illness: (1) Advocacy in interprofessional meetings, clinical teams, and advisory councils; (2) Sharing lived experiences and connecting with available resources and services; (3) Preparing for mental health and physical health care visits; (4) Mutuality; and (5) Affiliations, funding, and sustainability of peer support services.

CONCLUSION

This study suggests that peer support specialists can uniquely contribute to the coordination of physical health and mental health services for individuals with serious mental illness.

Study protocol for a cluster-randomized split-plot design trial to assess the effectiveness of targeted active malaria case detection among high-risk populations in Southern Lao PDR (the AcME-Lao study)

Introduction: Novel interventions are needed to accelerate malaria elimination, especially in areas where asymptomatic parasitemia is common, and where transmission generally occurs outside of village-based settings. Testing of community members linked to a person with clinical illness (reactive case detection, RACD) has not shown effectiveness in prior studies due to the limited sensitivity of current point-of-care tests. This study aims to assess the effectiveness of active case finding in village-based and forested-based settings using novel high-sensitivity rapid diagnostic tests in Lao People’s Democratic Republic (Lao PDR).

Methods and analysis: This study is a cluster-randomized split-plot design trial. The interventions include village-based mass test and treat (MTAT), focal test and treat in high-risk populations (FTAT), and the combination of these approaches, using high-sensitivity rapid diagnostic tests (HS-RDTs) to asses P. falciparum infection status. Within four districts in Champasak province, Lao PDR fourteen health center-catchment areas will be randomized to either FTAT or control; and within these HCCAs, 56 villages will be randomized to either MTAT or control. In intervention areas, FTAT will be conducted by community-based peer navigators on a routine basis, and three separate rounds of MTAT are planned. The primary study outcome will be PCR-based Plasmodium falciparum prevalence after one year of implementation. Secondary outcomes include malaria incidence; interventional coverage; operational feasibility and acceptability; and cost and cost- effectiveness.

Ethics and dissemination: Findings will be reported on clinicaltrials.gov, in peer-reviewed publications and through stakeholder meetings with Ministry of Health and community leaders in Lao PDR and throughout the Greater Mekong Subregion.

Trial registration: clinicaltrials.gov NCT03783299 (21/12/2018)

Mental health disparities, mechanisms, and intervention strategies: perspective from Hawai'i

PURPOSE OF REVIEW

Although there is a growing body of literature describing the scope and impact of mental health disparities, there is relatively less literature focused on youth and on interventions that are grounded in the cultures of youth most significantly affected by disparities. From the perspective of Hawai'i, one of the world's most diverse communities where disparities nonetheless exist, the authors review the varieties of diversity encountered in psychiatry and healthcare, specific youth mental health disparities, and examples of locally tailored solutions.

RECENT FINDINGS

Mental health disparities are born from the differential exposures to poverty, trauma, discrimination, and barriers to accessing care, especially mental healthcare, which is nationally in short supply. They exist even in supposedly high-resource settings and significantly impact indigenous populations, including in terms of risk for incarceration and risk for suicidal behavior.

SUMMARY

Addressing disparities involves insuring access to preventive and treatment-focused mental healthcare and applying cultural humility in clinical and community settings. The authors add to the reviewed literature by highlighting interventions that are population-based, culturally grounded, and focused on indigenous youth.

Qualitative Evaluation of a Peer Navigator Program for Latinos with Serious Mental Illness

Peer navigator programs (PNP) may help reduce physical health disparities for ethnic minorities with serious mental illness (SMI). However, specific aspects of PNP that are important to peer navigators and their clients are under-researched. A qualitative study explored the perspectives of service users (n = 15) and peer navigators (n = 5) participating in a randomized controlled trial of a PNP for Latinos with SMI. Results show PN engagement with service users spans diverse areas and that interactions with peers, trust, and accessibility are important from a service user perspective. PNs discussed needs for high-quality supervision, organizational support, and additional resources for undocumented Latinos.

Perspectives on diet and physical activity among urban African Americans with serious mental illness

African Americans are burdened by high rates of obesity that contribute to chronic disease and early mortality. To tailor a weight loss intervention to meet the needs of African Americans with serious mental illness, a community-based participatory research (CBPR) team comprised primarily of African Americans with serious mental illness guided qualitative research to understand factors that affect weight and interventions that may diminish obesity. Data from five focus groups (n = 55) were analyzed to better understand this group's needs. Participants voiced individual, social, and structural barriers to maintaining and achieving a healthy weight and provided perspectives on potential solutions.

Our Peers-Empowerment and Navigational Support (OP-ENS): Development of a Peer Health Navigator Intervention to Support Medicaid Beneficiaries With Physical Disabilities

People with disabilities (PWD) are a health disparities population who experience well-documented physical, structural, attitudinal, and financial barriers to health care. The disability rights community is deeply engaged in advocacy to promote health care justice for all PWD. As the community continues to work toward systems change, there is a critical need for community-directed interventions that ensure individuals with disabilities are able to access the health care services they need and are entitled to. Peer health navigator (PHN) programs have been shown to help people from diverse underserved communities break down barriers to health care. The PHN model has not been systematically adapted to meet the needs of PWD. In this article, we describe the collaborative process of developing Our Peers—Empowerment and Navigational Supports (OP-ENS), an evidence-informed PHN intervention for Medicaid beneficiaries with physical disabilities in Chicago, IL, USA. Our Peers—Empowerment and Navigational Supports is a 12-month community-based PHN intervention that pairs Medicaid beneficiaries with physical disabilities (peers) with disability PHNs who use a structured recursive process of barrier identification and asset mapping, goal setting, and action planning to help peers meet their health care needs. Our Peers—Empowerment and Navigational Supports was developed by a collaborative team that included disability rights leaders, representatives from a Medicaid managed care organization, and academic disability health care justice researchers. We highlight both the conceptual and empirical evidence that informed OP-ENS as well as the lessons learned that can assist future developers.

How formal navigators interpret their roles supporting families

Purpose

The purpose of this paper is to examine how formal navigators interpret their roles supporting families of older adults.

Design/methodology/approach

This study was an interpretive inquiry informed by critical gerontology and discourse analytic methods. Interview data were collected and analyzed from 22 formal service providers who helped older adults and their families navigate health and social care resources in one Western Canadian city.

Findings

Although acknowledging structural barriers to service access, participants emphasized individual empowerment as their dominant strategy, interpreting their roles as providing information and education about services. In part, these interpretations may reflect the limited nature of their ability to help broker access or advocate; in part, they may also reflect the broader political and economic discourses surrounding care in Canada.

Research limitations/implications

When providers position navigation and access to care as individual problems, this can obscure structural burden as well as potential inequities among older adults. Future research should examine whether navigational role interpretations are similar or different to those of navigators in other regions. Navigators in other health and social care contexts may enact differing meanings in their work.

Practical implications

Although formal public navigators can play an important role, approaches that go beyond providing information may better meet families’ needs for support.

Originality/value

This is one of the first studies focused specifically on providers’ interpretations of the meaning of navigational work in health and social care for older adults, and to extend a critical gerontological gaze toward the issue of system navigation.

A Qualitative Study on Primary Care Integration into an Asian Immigrant-specific Behavioural Health Setting in the United States

Introduction

Integrating primary care and behavioural health services improves access to services and health outcomes among individuals with serious mental illness. Integrated care is particularly promising for racial and ethnic minority individuals given higher rates of chronic illnesses and poorer access to and quality of care compared to Whites. However, little is known about integrated care implementation in non-White populations. The aim of this study is to identify facilitators and barriers to successful implementation of primary care-behavioural health integration in a multilingual behavioural healthcare setting.

Methods

Seven focus groups and five semi-structured interviews were conducted with 41 patients and 5 providers participating in integrated care in a community mental health clinic in California serving Asian immigrants.

Results

Themes generated from constant comparative analysis suggest limited system-level preconditions and cross-organisational dynamics challenged integrated care. At the same time, changing organisational culture and practice, improving patient-provider and provider-provider communication, and increasing patient involvement enhanced clinical outcomes and facilitated successful implementation.

Discussion and conclusions

Findings highlight the importance of patient involvement, peer services and interdisciplinary communication to successfully implement integrated care in the face of linguistic and operational challenges in settings serving multilingual and multicultural patients.

Peer Workers in the Behavioral and Integrated Health Workforce: Opportunities and Future Directions

The growth of the peer workforce in behavioral health services is bringing opportunities to organizations and institutions that serve people living with mental and substance use disorders and their families. Peer workers are defined as people in recovery from mental illness or substance use disorders or both that possess specific peer support competencies. Similar roles are identified for families of people in recovery. Peer support has been implemented in a vast range of behavioral health services, including in the relatively new use of peer support in criminal justice and emergency service environments. Behavioral health services are striving to integrate peer workers into their workforce to augment existing service delivery, in part because peer support has demonstrated effectiveness in helping people with behavioral health conditions to connect to, engage in, and be active participants in treatment and recovery support services across all levels of care. This article describes the experiences that organizations and their workforce, including peer workers, encounter as they integrate peer support services into the array of behavioral health services. Specific attention is given to the similarities and differences of services provided by peers in mental health settings and substance use settings, and implications for future directions. The article also addresses the role of peer workers in integrated behavioral and physical healthcare services.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration of the U.S. Department of Health and Human Services.

Effectiveness of a patient navigator on patient satisfaction in adult patients in an ambulatory care setting: a systematic review

BACKGROUND

One approach to overcoming healthcare system barriers and facilitating timely access to quality care and patient satisfaction is with a patient navigator. A patient navigator is a trained person who individually assists patients, families and caregivers navigate the healthcare system barriers efficiently and effectively at any point along the care continuum, improving patient care at all levels of an organization.

OBJECTIVES

To synthesize the best available evidence on the effectiveness of a patient navigator on patient satisfaction in adult patients 18 years and older in ambulatory care settings.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

This review considered studies that involved adults of any ethnicity, race or gender, aged 18 years or older, regardless of diagnoses, stage of illness, whether the illness is acute or chronic or previous treatment, who had been receiving care in an ambulatory care setting.

TYPES OF INTERVENTION(S)/PHENOMENA OF INTEREST

This review considered studies on the use of a patient navigator as an additional intervention to usual care for promoting patient satisfaction for adult patients in an ambulatory care setting. Usual care without a patient navigator was considered as a comparator.

TYPES OF STUDIES

This review considered experimental and observational studies.

OUTCOMES

The outcome considered was patient satisfaction.

SEARCH STRATEGY

The literature search included published and unpublished studies in the English Language from 1990 through July 2015. A search of PubMed, CINAHL, Excerpta Medica Database (EMBASE), Academic Search Premier, Cochrane Library, PsycINFO and Health Source: Nursing/Academic Edition, Social Work Abstracts and Web of Science was conducted. A search for gray literature and electronic hand searching of relevant journals was also performed.

METHODOLOGICAL QUALITY

Two reviewers independently evaluated the included studies for methodological quality utilizing standardized critical appraisal instruments from the Joanna Briggs Institute.

DATA EXTRACTION

Standardized data extraction tools from Joanna Briggs Institute were used by two independent reviewers for data extraction.

DATA SYNTHESIS

A statistical meta-analysis was not possible due to heterogeneity between the included studies. Results are presented in a narrative form.

RESULTS

Four studies were included in this review, two were randomized controlled trials (RCTs), one was a quasi-experimental pre-post-test design study and one was a cohort study. The four studies showed that a patient navigator had clinical benefit for patient satisfaction, care coordination and patient access to timely healthcare services. One RCT reported a mean satisfaction score of 4.3 for navigated patients and 2.9 for non-navigated patients; P < 0.001. A second RCT showed an odds ratio 1.29; 95% confidence interval 0.92-1.82 for navigated versus non-navigated patients. The quasi-experimental pre-test-post-test study showed navigated patient satisfaction with a mean = 11.45 (standard deviation [SD], 3.69) in comparison with the non-navigated patient (mean, 14.95; SD, 1.69) (F = 11.85; P = 0.000). The cohort study demonstrated a mean satisfaction score of 90.7 for navigated patients and 85.5 for non-navigated patients; P = 0.03. The four studies showed no clinically significant results; however, the patient navigator role may promote relationships among the healthcare team, reducing barriers for patient-centered care and enhanced patient satisfaction.

CONCLUSION

There is a paucity of evidence on the effectiveness of a patient navigator on patient satisfaction. In the four studies selected for inclusion, a patient navigator had a positive effect on patient satisfaction, although none of the studies demonstrated statistical significance with a patient navigator on patient satisfaction. The effect of a patient navigator remains questionable with differences in perceptions on the best individual for the role and the expected role perception and performance. A standardized approach to the role of the patient navigator may maximize health outcomes and positively affect the quality of life for all patients.

The Healthcare Needs of Latinos with Serious Mental Illness and the Potential of Peer Navigators

Latinos with serious mental illness get sick and die much younger than other adults. In this paper, we review findings of a community based participatory research project meant to identify important healthcare needs, barriers to these needs, solutions to the barriers, and the promise of peer navigators as a solution. Findings from focus groups reflected general concerns of people with mental illness (e.g., insurance, engagement, accessibility) and Latinos with serious mental illness (e.g., immigration, language, and family). Feedback and analyses especially focused on the potential of peer navigators. Implications of these findings for integrated care of Latinos with serious mental illness are discussed.

Development, Implementation, and Evaluation of a Curriculum to Prepare Volunteer Navigators to Support Older Persons Living With Serious Illness

The purpose of this article is to report the development, implementation, and evaluation of a curriculum designed to prepare volunteer navigators to support community-dwelling older persons with serious chronic illness. The role of the volunteer navigator was to facilitate independence and quality of life through building social connections, improving access to resources, and fostering engagement. A curriculum was constructed from evidence-based competencies, piloted and revised, and then implemented in 7 subsequent workshops. Workshop participants were 51 volunteers and health-care providers recruited through local hospice societies and health regions. Curriculum was evaluated through satisfaction and self-efficacy questionnaires completed at workshop conclusion. Postworkshop evaluation indicated a high degree of satisfaction with the training. One workshop cohort of 7 participants was followed for 1 year to provide longitudinal evaluation data. Participants followed longitudinally reported improved self-efficacy over 12 months and some challenges with role transition. Future improvements will include further structured learning opportunities offered by telephone postworkshop, focusing on advocacy, communication, and conflict management. Overall, volunteers were satisfied with the curriculum and reported good self-perceived efficacy in their new role as navigators.

Incorporating peer support during in vivo exposure to reverse dropout from prolonged exposure therapy for posttraumatic stress disorder: Clinical outcomes

Objective Prolonged exposure is characterized by reported dropout rates ranging from 25% to 40%. This premature attrition is also observed in other evidence-based treatments for posttraumatic stress disorder. While home-based telehealth delivery of prolonged exposure resolves logistical barriers to care such as travel time and cost, dropout appears unaffected. A previous study on dropouts from prolonged exposure delivered via telehealth found that Veterans, particularly those receiving care via telehealth, reported problems with in vivo exposure and that having a peer to offer support during in vivo exposure assignments might have prevented their attrition from treatment. Methods The present pilot study treatment was designed in a manner consistent with the aforementioned Veteran suggestions, specifically to involve peers offering verbal support and encouragement during in vivo exposure homework. Such a treatment modification might be particularly useful for those receiving care via telehealth, given increased difficulties with exposure reported when this treatment delivery modality is used. It was hypothesized that dropouts would agree to reengage in treatment with a peer and would subsequently evince improvement in posttraumatic stress disorder and depression scores as a result of this treatment reengagement. Results Of 82 dropouts from prolonged exposure, 29 reentered treatment when offered peer support during exposure (12 in telehealth and 17 in person). Conclusion Treatment reentry was effective insofar as indices of both posttraumatic stress disorder and depression were significantly reduced in both telehealth and in person groups, indicating that using peers in this way may be an effective means by which to return Veterans to care, and ultimately reduce symptomatology.

Using Peer Navigators to Address the Integrated Health Care Needs of Homeless African Americans With Serious Mental Illness

OBJECTIVE

The study examined the impact of a peer navigator program (PNP) developed by a community-based participatory research team and used with a group of African Americans with serious mental illness who were homeless.

METHODS

Sixty-seven research participants were randomly assigned to receive PNP or treatment as usual (control) for one year. Data on general health and mental health, recovery, and quality of life were collected at baseline and at four, eight, and 12 months.

RESULTS

Findings from group × trial analyses of variance of omnibus measures of the four constructs showed significant impact over the year for participants in PNP compared with those in the control group, with analyses showing small to moderate effect sizes: general health status (η²=.24), psychological experience of physical health (η²=.42), recovery (η²=.36), and quality of life (η²=.14). These differences emerged even though both groups showed significant reductions in homelessness and increases in insurance coverage.

CONCLUSIONS

Implications for improving in-the-field health care for this population are discussed. Whether these results occurred because navigators were peers per se needs to be examined in future research.

Patient and Practitioner Perspectives on Culturally Centered Integrated Care to Address Health Disparities in Primary Care

INTRODUCTION

Addressing the multifaceted health and mental health needs of ethnically and culturally diverse individuals is a challenge within the current health care system. Integrated care provides a promising approach to improve mental health treatment-seeking disparities; however, adaptation of care models to impact African Americans is lacking. Although resources to support engagement of diverse populations in depression care exist, little has been developed to tailor patient preferences in accessing and engaging mental health services that are integrated into primary care.

OBJECTIVE

Our research seeks to add a cultural focus to the existing literature concerning integrated health care models to help address depression and selected co-occurring chronic health conditions in primary care settings.

METHODS

Thirty-two adult patients of an integrated primary care clinic participated in focus groups discussing their individual health experiences. Nine health care practitioners/administrators from five different integrated practice settings in the Atlanta, GA, area participated in key informant interviews.

MAIN OUTCOME MEASURES

Transcripts were analyzed for key themes related to depression care, perceived unmet cultural needs, and desired adaptations.

RESULTS

Common themes emerged such as the importance of peer-support and community engagement as areas of patient interest. Participants had good knowledge in recognizing depressive symptoms but were less knowledgeable about treatment options and expectations of treatment. The administrative and practitioner perspective suggests that patient preferences are valued and perceived as valid.

CONCLUSION

It is critical that strategies and models are developed to improve health care among underserved minorities because current models offer variable efficacy among this population.

Prioritizing the healthcare needs of Latinos with mental illness

Latinos with serious mental illness have higher morbidity and mortality rates than same age peers. In this paper, we review findings of a community based participatory research project meant to identify important health needs of this group, barriers to these needs, solutions to the barriers and the promise of peer navigators as a solution. Findings from a prior qualitative study yielded 84 themes related to needs, barriers and solutions. These findings were transposed into individual items, to which 122 Latino participants with mental illness responded using a 7-point importance scale. Results showed item importance means ranging from 4.34 to 5.47, with counseling/therapy services and mental health treatment topping the list for healthcare needs. Analyses also examined differences between those born in the USA versus those born elsewhere. Latinos who were native to the USA differed significantly from those born abroad in over one quarter of importance ratings. Implications of these findings for integrated care of Latinos with serious mental illness are discussed.

Community-based participatory research examining the health care needs of African Americans who are homeless with mental illness

African Americans with mental illness who are homeless experience significant health risks and illnesses leading to high mortality and morbidity rates. A community-based participatory research (CBPR) team conducted a qualitative study to begin to describe these problems. Results from focus groups and key informant interviews of 42 individuals yielded 98 themes which were sorted into three categories: problems, solutions, and peer navigators. Results included a review of the problems and solutions which the community or people might adopt. An additional goal was to understand and develop impact of peer navigators for addressing health problems in this group. Results yielded a list of values in hiring peer navigators as well as skills and resources they might need to successfully do their job. Findings from the study are currently being used by the CBPR team to develop a peer navigator program for this community.

The Family Value of Information, Community Support, and Experience Study: Rationale, Design, and Methods of a "Family-Centered" Research Study

The Patient Protection and Affordable Care Act focuses on improving consumer engagement and patient-centered care. This article describes the design and rationale of a study targeting family engagement in pediatric mental health services. The study is a 90-day randomized trial of a telephone-delivered Family Navigator services versus usual care for parents of Medicaid-insured youth younger than 13 years with serious mental illness. Youth are identified through a pediatric antipsychotic medication preauthorization program. Family Navigators offer peer support to empower and engage parents in their child's recovery. Outcomes include parent report of empowerment, social support, satisfaction with child mental health services, and child functioning as well as claims-based measures of psychotherapy service utilization and antipsychotic medication dosage. The focus on "family-centered" care in this study is strongly supported by the active role of consumers in study design and implementation.

Mental disabilities in an Aboriginal context

Aboriginal (meaning original peoples) North American mental health is acknowledged to be in a more precarious state than that of the dominant cultures. Disability arises from the conditions of poverty, homelessness, and lack of resources that are compounded for North American aboriginal people by the historical trauma of conquest, being placed on reservations, residential schools, and continued discrimination. We present culturally sensitive and syntonic intervention programs that can reduce the impact of Aboriginal mental disabilities and discuss the commonality among these programs of celebrating culture, language, and tradition.