Center for Mental Health Services Research
&
Research Network Development Core
Enola Proctor, Director, Curtis McMillen, Associate Director
RNDC: Wendy Auslander, Mike Nickel,
Nancy Morrow-Howell, Jim Washeck, RNDC
Sally Haywood, Director of Administration
P30 IR25 MH080916-A2
www.gwbweb.wustl.edu/cmhsr
314-935-5687
Center aims
Conduct practice-relevant
research
to improve quality of mental
health care
among clients in public social
services
What is the RNDC?
• “Supplement” to the CMHSR
– Four years of NIMH funding (09/05-07/09)
• Developed to:
– Build the research capacity of our partners
– Strengthen applicability of CMHSR’s
research
– Create sustainable agency/university
partnerships
.
3
Who are our partners?
• Missouri Department of Social
Services,
Children’s Division (CD)
• Missouri Department of Health and
Senior Services, Division of Senior and
Disability Services (DSDS), and State
Area Agencies on Aging (“Triple A’s”)
• Missouri Department of Mental Health
(DMH)
4
What do these partners have in
common?
 Common mission: public “safety net” settings
 Public health significance: Medicaid $, vulnerable
populations
 “Primary Care” functions:
 Comprehensive assessments, ongoing contact, gateway to
mental health specialists
 Client base with unmet mental health needs and high
rates of co-morbidity
 Mental health needs must be addressed to fulfill mandate
 Generalizability and “spread”: universal systems,
opportunity for replication, high public health impact
5
History and context: Core builds on
20+ year history of researcher-agency
collaboration
:•
•
•
•
•
Center: Agency engaged, service system research
IPA’s through other funding
– Agency staff placed at School
– School faculty/ researchers placed in agencies
Researchers deeply involved in agency
(committees, task forces
Researchers with practice experience
Agency staff deeply involved in School
– Adjunct faculty
– Advisory committees
Partnership goal:
 Improve quality of care
 Advance publish health mission
 Enhance impact of research
NIMH The Road Ahead: Research Partnerships to Transform Services
Guiding principles:
 Mutual benefit
 Defined by collaborative participation
throughout process of developing,
conducting, disseminating research and
information about evidence-based practice
Types of partnered activity
“Hanging out”
• Spending time together
Mutual assessment and goal setting around
practice concerns
• High MH service use among CD children
• Unmet need for depression care
• Concerns about quality of care
• Agency needs for information, infrastructure,
training
Types of partnered activity (cont’d)
Solution generation: each partner brings
expertise
– Researchers = source of “bench” knowledge
• Best practices in other states (assessment tools)
• EST’s
• Trainers
– Agency partners = source of “trench” knowledge
about implementation
• What “fits”?
• Acceptability, feasibility, sustainability
Types of partnered activity
Problem identification: agency partner
Explore options for problem response: mutual
 Find models, evidence-based practices:
researchers
 Assess appropriateness, acceptability,
feasibility: agency partner
Test new approach: mutual
Resource generation: mutual
Implement and Disseminate: mutual
Key Stakeholders
• CD and DSDS staff
• Mental Health providers
• Policy Makers
• Clients & Family members
• Academicians
• Broader Community
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Problem: concern about quality of
mental health care for children in
child welfare
• Center research: extremely high rates of
MH services among children in CD
• Agency partners concerned about quality
• New qualitative study found that MH
services provided by Medicaid MH providers
• Provider forum : expressed concerns about
practice infrastructure; requested University
help with ESTs
Led to PBRN practice leaders, rapid
response between policy and practice
Practice Based Research Network:
“MoNet”: 1200 + Medicaid providers
Gives:
• “Voice,” information, training to members
• Rapid feedback about implementation
challenges to researchers & policy makers
• Ready access to provider “real voice” to
researchers
Huge efficiency benefits
Other Accomplishments with CD
•
Psychotropic medications: Initiatives to help staff and clients better understand
psychotropic medications commonly prescribed to youth in child welfare
•
Data infrastructure:
–
–
•
Increase use of EST’s:
–
–
•
MH screening: Pilot implementation of a universal screener for new CD clients
Repeat maltreatment: Piloted tools to help workers ID families at risk
Integration language into CD service contracts that leverage evidence based practices
Medicaid Policies to utilize funding structures as a quality assurance approach to MH services
and incentives for payees to use EBPs-- implementation of prior authorization and documentation
requirements
EST training: pilot of Positive Parenting Program (Triple P), EB multi-layer
behavioral family intervention for child problem behaviors
Problem: Agency concern about untreated
depression among state served older
adults
• Center research: high rates of untreated/
poorly treated depression in DSDS clients
• Agency partners concerned about system
and client burden
– Clients unwilling to accept referrals to depression
care (stigma?)
– Clients unwilling to accept SUA services
Problem: Agency concern about untreated
depression among state served older
adults (cont’d)
• Mutual selection of EST
– IMPACT, Pearls programs
• Shared concern: implementation success
– NIMH R34 grant
Results:
Priorities for Depression and Other
Problems
Frequency and Ranking of Problem Categories
% respondents
reporting problem
(N= 51)
Mean relative rank
of problem (SD)
(Larger # = Higher
Priority)
% respondents
ranking problem
MOST important
(of those reporting
problem)
% respondents
ranking problem
LEAST important
(of those reporting
problem)
Health
86.3%
.51 (.25)
38.6%
11.4%
Functioning
60.8%
.44 (.26)
19.4%
16.1%
Emotional Well-Being
41.2%
.47 (.32)
23.8%
19.0%
Money/Finances
29.5%
.48 (.25)
33.3%
13.3%
Family
25.5%
.52 (.22)
38.5%
0.0%
Frustrated with Medical
Care
23.4%
.31 (.25)
8.3%
33.3%
Getting Help
15.7%
.42 (.30)
37.5%
12.5%
Frustrated with Housing
9.8%
.43 (.31)
20.0%
20.0%
100.0%
.18 (.24)
5.9%
47.1%
PROBLEM CATEGORY
Depression
Relative Rank (RR) is reverse scored. RR = 1 – (Rank of Problem/Total Number of Problems Ranked)
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Implications
• Interventions should address depression in a broad
social context and practically link treatment with
other medical and social services.
• Motivational interviewing, health education, and
assessment of treatment preferences and priorities
should occur when initiating depression treatment
for older adults.
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Acceptability Outcomes of
Depression Screen by CLTC workers (n=94)
How well did the depression questions fit into your conversation? Mean = 1.89, S.D. = 1.03
How well did the client understand the depression questions? Mean = 1.37, S.D. = 0.66
80
70
60
50
40
30
20
10
0
1=Very Easy
2=Easy, Some Explanation
3=Moderate
4=Difficult
5= Very Difficult
Client Acceptability Outcomes
Per Well-Being Specialist rating of “Client acceptance of first-course
treatment” (n = 14 out of 15 who started treatment)
8
7
6
5
4
3
2
1
0
Readily Accepts
Accepts
Undecided
Some Resistance
Very Resistant
Where we are now?
• Depression management programs now in
DMH Transformation initiatives (SAMHSA)
• Researchers facilitating new partnerships:
–
–
–
–
–
Treatment developers
National advocates
Researchers
Local agencies
DMH
• Training for agencies
• New Implementation research
Other Accomplishments with DSDS:
Data infrastructure:
• Large pilot of a depression screener for all new intakes and
reassessments, with referral to a depression specialist
• “best practices” on SUA assessment tools
• Missouri “baby boomers” to inform long range planning and to help
set policy, with an emphasis on reforming state-supported long term
care
• Assisting state leadership to analyze their hotline data to better be
able to describe the nature of increased intensity of calls
• Older veterans: state-wide Veterans Services Summit (with DMH)
EST training:
• Suicidality – develop a protocol for case worker response to
suspicion of suicidality and integrate into standard worker training
• Hoarding
• Depression Care
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What’s needed in HSR for partnered
work?
•
•
•
•
•
•
Structures that span individual projects
Formal partnership structures
$ flow, flexible $
IRB flexibility
Focus on agency infrastructure
Focus on research incubation around
practice problems
• Designated liaisons
– Agency liaison
– Researcher liaison