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Purtle J, Rivera‐González AC, Mercado DL, Barajas CB, Chavez L, Canino G, Ortega AN. Growing inequities in mental health crisis services offered to indigent patients in Puerto Rico versus the US states before and after Hurricanes Maria and Irma. Health Serv Res 2023; 58:325-331. [PMID: 36310433 PMCID: PMC10012226 DOI: 10.1111/1475-6773.14092] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To assess changes in the availability of mental health crisis services in Puerto Rico relative to US states before and after Hurricanes Maria and Irma. DATA SOURCES/STUDY SETTING National Mental Health Services Surveys conducted in 2016 and 2020. STUDY DESIGN Repeated cross-sectional design. The independent variable was mental health facility location in Puerto Rico or a US state. Dependent variables were the availability of three mental health crisis services (psychiatric emergency walk-in services, suicide prevention services, and crisis intervention team services). DATA COLLECTION/EXTRACTION METHODS The proportion and per 100,000 population rate of facilities offering crisis services were calculated. PRINCIPAL FINDINGS The availability of crisis services at mental health facilities in Puerto Rico remained stable between 2016 and 2020. These services were offered less at indigent care facilities in Puerto Rico than US states (e.g., 38.2% vs. 49.5% for suicide prevention, p = 0.06) and the magnitude of difference increased following Hurricane Maria. CONCLUSIONS There are disparities between Puerto Rico and US states in the availability of mental health crisis services for indigent patients.
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Affiliation(s)
- Jonathan Purtle
- Department of Public Health Policy & Management, Director of Policy Research, Global Center for Implementation ScienceNew York University School of Global Public HealthNew York CityNew YorkUSA
| | - Alexandra C. Rivera‐González
- Drexel University Dornsife School of Public HealthDepartment of Health Management & PolicyPhiladelphiaPennsylvaniaUSA
| | - Damaris Lopez Mercado
- Drexel University Dornsife School of Public HealthDepartment of Health Management & PolicyPhiladelphiaPennsylvaniaUSA
| | - Clara B. Barajas
- Drexel University Dornsife School of Public HealthDepartment of Health Management & PolicyPhiladelphiaPennsylvaniaUSA
| | - Ligia Chavez
- Medical Sciences CampusBehavioral Sciences Research InstituteRio PiedrasPuerto Rico
| | - Glorisa Canino
- University of Puerto Rico, Medical Sciences CampusBehavioral Sciences Research InstituteRio PiedrasPuerto Rico
| | - Alexander N. Ortega
- Drexel University Dornsife School of Public HealthDepartment of Health Management & PolicyPhiladelphiaPennsylvaniaUSA
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Tran JT, Kosyluk KA, Dion C, Torres K, Jeffries V. A Qualitative Evaluation of an Adapted Assertive Community Treatment Program: Perspectives During COVID-19. J Behav Health Serv Res 2022; 50:301-314. [PMID: 36460895 PMCID: PMC9718462 DOI: 10.1007/s11414-022-09827-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2022] [Indexed: 12/04/2022]
Abstract
The Pinellas County Empowerment Team (PCET) was an adapted assertive community treatment (ACT) program created to meet the needs of Pinellas County residents with serious behavioral health concerns and high frequency of hospitalization (medical and psychiatric) and incarceration. Recent research demonstrates that individuals participating in ACT programs can transition to lower-intensity services. To understand the needs and barriers in transitioning PCET clients to lower-intensity services and the unique experiences during the coronavirus (COVID-19) pandemic, the researchers conducted a qualitative evaluation which includes a case record review and in-depth interviews with clients of PCET and staff members. Our findings indicated several barriers to transitioning PCET clients, including a lack of sufficient behavioral health support outside the ACT program and some clients' concerns regarding their abilities once out of the program.
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Affiliation(s)
- Jennifer T Tran
- Department of Mental Health Law & Policy, University of South Florida, 13301 Bruce B Downs Blvd, Tampa, FL, 33612, USA.
| | - Kristin A Kosyluk
- Department of Mental Health Law & Policy, University of South Florida, 13301 Bruce B Downs Blvd, Tampa, FL, 33612, USA
| | - Charles Dion
- Department of Mental Health Law & Policy, University of South Florida, 13301 Bruce B Downs Blvd, Tampa, FL, 33612, USA
| | - Katie Torres
- University of South Florida, 13301 Bruce B Downs Blvd, Tampa, FL, 33612, USA
| | - Victoria Jeffries
- Institute of Best Practices, UNC Center for Excellence in Community Mental Health, 101 Manning Drive First Floor, Chapel Hill, NC, 27514, USA
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Law S, Guan I, Beder M, Ritts M, Sediqzadah S, Levy M, Kirwan N. Further Adaptations and Reflections by an Assertive Community Treatment Team to Serve Clients with Severe Mental Illness during COVID-19. Community Ment Health J 2021; 57:1227-9. [PMID: 34109512 DOI: 10.1007/s10597-021-00855-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 05/26/2021] [Indexed: 11/04/2022]
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Couser GP, Taylor-Desir M, Lewis S, Griesbach TJ. Further Adaptations and Reflections by an Assertive Community Treatment Team to Serve Clients with Severe Mental Illness During COVID-19. Community Ment Health J 2021; 57:1217-26. [PMID: 34146189 DOI: 10.1007/s10597-021-00860-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 06/10/2021] [Indexed: 11/25/2022]
Abstract
In September of 2020, Guan and colleagues wrote about their experience of an Assertive Community Psychiatry Program responding to the COVID-19 pandemic. We describe our own experience as an Assertive Community Treatment team in Minnesota responding to challenges of effectively and safely delivering service to clients. As the pandemic has progressed since last year, so has the literature, and updated references are highlighted. Common threads are woven between our experience, the experience of Guan and colleagues, and others to suggest the beginnings of a template to adapt services to a new post-pandemic world.
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Abstract
Psychiatric crisis care in the U.S. exemplifies the "more is less paradox" of U.S. health care. We spend more for health care than any other high-income country, yet our outcomes are typically poor compared to these other countries (OECD in OECD health statistics. Retrieved from https://www.oced.org/health/health-data.html , 2020). We do this, in part, by emphasizing medical treatments for problems that are inherently social, rather than addressing social determinants of health. Medical interventions for socio-economic problems are usually expensive and ineffective. For mental health crisis care, adding unfunded, untested, medical interventions to the current mélange of poorly funded, disorganized arrangements will not help. Instead, the U.S. should address social determinants, emphasize research-based interventions, and emphasize prevention-proven strategies that decrease costs and improve outcomes.
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Affiliation(s)
- Robert E Drake
- Westat, IPS Employment Center, 85 Mechanic Street, Lebanon, NH, 03766, USA.
| | - Gary R Bond
- Westat, IPS Employment Center, 85 Mechanic Street, Lebanon, NH, 03766, USA
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Cummings JR, Smith JL, Cullen SW, Marcus SC. The Changing Landscape of Community Mental Health Care: Availability of Treatment Services in National Data, 2010-2017. Psychiatr Serv 2021; 72:204-208. [PMID: 33334150 DOI: 10.1176/appi.ps.201900546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The authors sought to describe changes in availability of crisis and substance use treatment services in U.S. mental health facilities (including outpatient and inpatient facilities) from 2010 to 2017. METHODS Using National Mental Health Services Survey data, the authors of this descriptive study examined changes in the proportion of facilities providing crisis and substance use treatment services during the 2010-2017 period. RESULTS Although the proportion of outpatient facilities offering treatment for substance use increased significantly during the period studied (adjusted relative risk [ARR]=1.05, 95% confidence interval [CI]=1.01-1.10), the proportion of outpatient facilities offering crisis services significantly decreased, including emergency psychiatric walk-in services (ARR=0.81, 95% CI=0.75-0.88) and crisis intervention (ARR=0.88, 95% CI=0.83-0.93). CONCLUSIONS Mental health facilities are an integral piece of the behavioral health safety net and need to respond to changes in service needs. Findings suggest that mental health facilities have not shifted their services mix to address the ongoing suicide epidemic.
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Affiliation(s)
- Janet R Cummings
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (Cummings); Center for Mental Health, Department of Psychiatry, Perelman School of Medicine (Smith, Marcus), Leonard Davis Institute of Health Economics (Smith), and School of Social Policy and Practice (Cullen, Marcus), University of Pennsylvania, Philadelphia
| | - Joseph L Smith
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (Cummings); Center for Mental Health, Department of Psychiatry, Perelman School of Medicine (Smith, Marcus), Leonard Davis Institute of Health Economics (Smith), and School of Social Policy and Practice (Cullen, Marcus), University of Pennsylvania, Philadelphia
| | - Sara W Cullen
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (Cummings); Center for Mental Health, Department of Psychiatry, Perelman School of Medicine (Smith, Marcus), Leonard Davis Institute of Health Economics (Smith), and School of Social Policy and Practice (Cullen, Marcus), University of Pennsylvania, Philadelphia
| | - Steven C Marcus
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (Cummings); Center for Mental Health, Department of Psychiatry, Perelman School of Medicine (Smith, Marcus), Leonard Davis Institute of Health Economics (Smith), and School of Social Policy and Practice (Cullen, Marcus), University of Pennsylvania, Philadelphia
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Talley RM, Brunette MF, Adler DA, Dixon LB, Berlant J, Erlich MD, Goldman B, First MB, Koh S, Oslin DW, Siris SG. Telehealth and the Community SMI Population: Reflections on the Disrupter Experience of COVID-19. J Nerv Ment Dis 2021; 209:49-53. [PMID: 33003053 DOI: 10.1097/nmd.0000000000001254] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The novel coronavirus pandemic and the resulting expanded use of telemedicine have temporarily transformed community-based care for individuals with serious mental illness (SMI), challenging traditional treatment paradigms. We review the rapid regulatory and practice shifts that facilitated broad use of telemedicine, the literature on the use of telehealth and telemedicine for individuals with SMI supporting the feasibility/acceptability of mobile interventions, and the more limited evidence-based telemedicine practices for this population. We provide anecdotal reflections on the opportunities and challenges for telemedicine drawn from our daily experiences providing services and overseeing systems for this population during the pandemic. We conclude by proposing that a continued, more prominent role for telemedicine in the care of individuals with SMI be sustained in the post-coronavirus landscape, offering future directions for policy, technical assistance, training, and research to bring about this change.
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Affiliation(s)
| | | | | | | | | | | | - Beth Goldman
- Group for Advancement of Psychiatry, New York, New York
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Bhalla IP, Stefanovics EA, Rosenheck RA. Social determinants of mental health care systems: intensive community based Care in the Veterans Health Administration. BMC Public Health 2020; 20:1311. [PMID: 32859202 PMCID: PMC7456068 DOI: 10.1186/s12889-020-09402-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 08/18/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Since deinstitutionalization in the 1950s-1970s, public mental health care has changed its focus from asylums to general hospitals, outpatient clinics and specialized community-based programs addressing both clinical and social determinants of mental health. Analysis of the place of community-based programs within a comprehensive health system such as the Veterans Health Administration (VHA) may illuminate the role of social forces in shaping contemporary public mental health systems. METHODS National VHA administrative data were used to compare veterans who exclusively received outpatient clinic care to those receiving four types of specialized community-based services, addressing: 1) functional disabilities from severe mental illness (SMI), 2) justice system involvement, 3) homelessness, and 4) vocational rehabilitation. Bivariate comparisons and multinomial logistic regression analyses compared groups on demographics, diagnoses, service use, and psychiatric prescription fills. RESULTS An hierarchical classification of 1,386,487 Veterans who received specialty mental health services from VHA in Fiscal Year 2012, showed 1,134,977 (81.8%) were seen exclusively in outpatient clinics; 27,931 (2.0%) received intensive SMI-related services; 42,985 (3.1%) criminal justice services; 160,273 (11.6%) specialized homelessness services; and 20,921 (1.5%) vocational services. Compared to those seen only in clinics, veterans in the four community treatment groups were more likely to be black, diagnosed with HIV and hepatitis, had more numerous substance use diagnoses and made far more extensive use of mental health outpatient and inpatient care. CONCLUSIONS Almost one-fifth of VHA mental health patients receive community-based services prominently addressing major social determinants of health and multimorbid substance use disorders.
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Affiliation(s)
- Ish P Bhalla
- Yale University Department of Psychiatry, 950 Campbell Ave, Building 35, West Haven, CT, 06516, USA.
- University of California, Los Angeles National Clinician Scholars Program, 1100 Glendon Ave, Suite 900, Los Angeles, CA, 90024, USA.
| | - Elina A Stefanovics
- Yale University Department of Psychiatry, 950 Campbell Ave, Building 35, West Haven, CT, 06516, USA
- Veterans Affairs New England Mental Illness Research Education, and Clinical Center, West Haven, USA
| | - Robert A Rosenheck
- Yale University Department of Psychiatry, 950 Campbell Ave, Building 35, West Haven, CT, 06516, USA
- Veterans Affairs New England Mental Illness Research Education, and Clinical Center, West Haven, USA
- Yale University School of Public Health, 950 Campbell Ave, Building 35, West Haven, CT, 06516, USA
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Abstract
PURPOSE OF REVIEW Assertive Community Treatment is an established evidenced based practice that provides intensive community treatment for individuals with severe mental illness with recurrent hospitalizations and/or homelessness. Emerging evidence indicates limitations in its implementation in terms of to the original ACT model and its current relevance. RECENT FINDINGS Findings from recent studies (2018-2020) reveals challenges with implementation centered around basic implementation activities, such as changes in the psychosocial context of individuals with SMI, clinicians' abilities to demonstrate competencies with new practices, and ongoing evolution of mental health systems of care worldwide. Intermediary and purveyor organizations (IPO) can provide the infrastructure to support the spread of EBPs while addressing challenges and opportunities. Thus, implementation of ACT can be accomplished when employing a rigorous framework and infrastructure that can synthesize and translate science relevant for practice. SUMMARY The relevance of ACT depends on its implementation that is responsive to change. An implementation science-informed approach is key to providing ACT to individuals in the critical space between the hospital and community. With this approach, we can optimize ACT as a service delivery vehicle by careful analysis of how best to furnish and evaluate the latest, most effective and efficient treatments, rehabilitation and support services.
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