John S. Brekke, PhD

Frances Larson Professor of Social Work Research

School of Social Work

University of Southern California

Building quality into mental health services for the most vulnerable: The role of peers and of effective

psychosocial interventions.

Institute of Medicine Report

“Psychosocial Interventions for Mental andSubstance Use Disorders:

A Framework for Establishing Evidence-Based Standards”

(Report still in review)

• Mental health parity: Under ACA increased coverage for MH/SU treatment (psychosocial and pharmacologic)

• Increasing demand for effective treatments by multiple stakeholders, e.g., consumers, providers, payors, employers, regulatory bodies

• Consumer preference for psychosocial interventions over pharmacologic by 3 -1, especially by women and younger people (McHugh et al., 2013)

• But far more now receive pharmacologic treatment for mental health problems and this disconnect is increasing over time

• Mental health care costs for individuals ages 18 to 64 averaged more than $48 billion annually from 2009 to 2011, with 45 percent of the cost (about $22 billion) spent on prescription medicines (AHRQ, 2015).

• Expanding base of scientifically validated psychosocial interventions

Meta-analyses• In a recent meta-analysis of psychosocial

interventions the mean effect size across a broad range of mental disorders with 852 trials (137,000 participants) was higher than the corresponding effect size for pharmacotherapies (mean effect size = 0.58 vs 0.40) (Huhn et al., 2014).

Range of Evidence-Based Psychosocial Treatments

They include, but are not limited to:cognitive behavioral therapy, interpersonal psychotherapy, dialectal behavioral therapy, behavioral couple therapy, problem solving therapy, social skills training, family interventions for schizophrenia, family-focused therapy for bipolar disorder, motivational interviewing, contingency management, community reinforcement approach, exposure and response prevention, assertive community treatment, supported employment, psychodynamic therapy, and eye movement desensitization and reprocessing (IOM, 2010; World Health Organization Intervention Guide, 2010).

Quality chasm

(i) consumers are not receiving these psychosocial interventions in usual care settings

(ii) training programs not adequately preparing the professional workforce for delivering the interventions (social work, psychology, psychiatry, nursing)

• We have populations at risk for deleterious outcomes from MH conditions that can be effectively treated

• SAMHSA (2012) 20% of adults with MH disorders in past year (add 6.1% with substance use disorders)

• 39% of these received MH treatment in past year

Serious Mental illness5% of adult population had a diagnosable mental

disorder in past year (excluding developmental and substance use disorders) that has resulted in serious functional impairment which substantially limits one or more major life activities.

60% of these received MH treatment in past yearBut vast majority not receiving guideline care

(e.g., for schizophrenia less than 10%)

• We have an emerging crisis in population health with regard to MH/SU disorders and other treatable psychosocial problems.

• Multiple facets, causes, and levers of influence in this area

Two Places for Leverage

1. Peer-delivered services (“experts by experience”) 2. Closing the gap between research and practice using Practice-based Research Networks These are two places where social work and other professions have challenges and opportunities for building quality care

Typology of Peer-Delivered Services in Mental Health

Within existing Peer-run Outside the MH systemagency teams

Do what others do: publicly funded Icarus Project(e.g., case management) privately funded Painted BrainAdjunctive roleUnique role:e.g. health navigation,agency greeter

Tensions

• We want and need peers, but what can they do?

• How explicit is the peer identity?• What is lived experience?• How well are the explicit peer identity

strengths merged with the job?• When is this workforce exploitation?

The Bridge: A Peer Navigator Intervention for Improving the Health of

Adults With Serious Mental Illness

Dr. John S. Brekke

Dr. Erin Kelly

Peer Health Navigation• What it is• Look at the peer role: skills• Why peer providers?: previous models, work

that professionals are not often paid to do, the lived experience was beneficial in this complicated area, needed strong engagement and connection, chance for a unique role.

To deal with the health disparities in this population we need:

• Top-down: A healthcare system that is receptive and responsive

• Bottom up: Consumers that are ready to be active in the system and in their own health care.

Many types of Integration Models

• Single roof models• Collaborative care models: situated in primary

care with in-house or virtual mental health consultation

• Linkage models: Situated in mental health clinic and navigating to off-site healthcare services

Peer Health Navigation Intervention: “The Bridge”

A comprehensive health care engagement and

self-management interventiondelivered by peers

Comprehensive:

Connect consumers to primary care, specialty health care, and substance abuse services

Engagement:

Many individuals with serious mental illness are not successfully engaging a consistent primary health care provider (or a health home), or have given up trying to access and use outpatient primary care

Self-Management:

Train and empower consumers to be assertive self-managers of their health care so that their interactions with care providers can be more effective and consistent

In vivo approach

Develops self-management skills in real world health care settings

Intervention Mantra“For them” (modeling) Navigator performs task, Consumer observes

“With them” (coaching) Consumer performs task, Navigator coaches

“By them” (fading) Consumer self-manages healthcare, Navigator supports as needed

Critical Elements of Health Navigation

• Consumer Screening & Engagement

• Assessment

• Goal setting (Healthcare, Wellness/Lifestyle)

• Preparing for the Medical Appointment

• Navigating the Medical Appointment

• Reviewing the Appointment

• Follow up Care Plan

• Self Management of Health Care

Peer Health Navigator Skills• Engaging and connecting with consumers

• Assessment and building commitment for self management

• Making a collaborative plan for the consumer’s health care based on the consumer’s goals

• Accessing and utilizing health care

• Teaching coping skills

• Modeling, coaching, fading

Skills Consumers Develop

1. Accessing Medical Services– Find medical services– Access transportation– Make and keep appointments

2. Utilizing Medical Services– Prepare for the medical visit– Communicate with medical staff– Follow treatment plan

3. Maintaining health– Be organized about their health care– Achieve Health and Wellness Goals– Prioritize health needs

4. Asking for support to overcome roadblocks

5. Managing emotions and symptoms during medical activities

Interviews with Peer Health Navigators

• People who provide critical services receive benefits themselves (the “helper principle”)• Increased self-esteem• Newfound confidence• High job satisfaction

• Peer Health Navigators were more likely to obtain medical care for their own health care needs after navigating consumers

Summary of Pilot FindingsThe Peer Health Navigation Intervention (“Bridge”) shows impact and promise for:

Reducing health problems

Reducing bodily pain related to health problems

Impacting the use of medications

Shifting the locus of health care from ER and UC to outpatient primary care

Bridge TeamJohn Brekke, PhD, PI; USCLou Mallory, Peer Health Navigator Supervisor; Pacific ClinicsErin Kelly, PhD, Co-I; USCHeather Cohen, MPP, Project Director; USCLaura Pancake, MSW, Corporate Director; Pacific ClinicsHolly Kiger, RN, MSN; USCToni Rainey, Francisco Espinoza, Tamara Ra: Peer Health Navigators; Pacific ClinicsCrystal Stewart, Jorge Avila, Research Assistants; USC

Publications• Kelly E, Fulginiti A, Pahwa R, Tallen L, Duan L, Brekke JS (in press). A pilot

test of a peer navigator intervention for improving the health of individuals with serious mental illness. Community Mental Health Journal 50 4: 435-446.

• Brekke JS, Siantz E, Kelly E, Pahwa R, Tallen L, Fulginiti A (2013). Reducing health disparities for people with serious mental illness: Development and feasibility of a peer health navigation intervention. Best Practices in Mental Health 9 1: 62-81.

• Kelly E, Fenwick K, Barr N, Cohen H, Brekke JS (2014). A systematic review of self-management health care models for individuals with severe mental illness. Psychiatric Services 65: 1300–1310.

• On April 29, 2015 the House and Senate had briefings on Peer Support Services in mental health, substance use, and traumatic brain injury services

Two Places for Leverage

1. Peer-delivered services (“experts by experience”)

2. Closing the gap between research and practice using Practice-based Research Networks

Practice-Research Gap• There is a 15 year gap between the

publication of scientific findings and their impact on usual care practice in mental health in the U.S.

• This gap is a problem for practitioners and researchers

• Practice-based research networks (PBRNs) offer one solution to closing this gap.

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• Also a notable tension in mental health between evidence-based practice and practice-based evidence

• PBRNs are built and thrive at this interface

The Recovery Oriented Care Collaborative:

A Practice Based Research Network

Funded by the USC Clinical Translational Science Institute

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What is a PBRN?• A practice-based research network (PBRN) is a group of care providers that considers issues and questions that impact their practice, partners with researchers to answer the questions, and then improves service delivery. Providers generate and vet study ideas and academic researchers assist in study logistics over multiple projects.

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• PBRNs were established in the 1970s within primary care, and by 2014 there were 154 registered PBRNs across 44 states in the U.S.

• Few of these PBRNs consider mental health issues. Less than 5% include mental health providers.

The Recovery-Oriented Care Collaborative:

The goals of ROCC are to:• identify questions that center on practitioner’s

experience, • actively include practitioners in developing a

research protocol, collecting and analyzing data, and disseminating and implementing research findings

• have the expectation of continued collaboration, rather than a single project

• implement findings immediately into usual care

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Current Context1. Leader created a steering committee from four agencies2. The four agencies serve over 100,000 consumers with

SMI3. All four agencies had worked together on LA County

funded innovative projects on integrated care4. All of agencies believed in using empirical information to guide their decision making were willing to deal with disconfirming findings 5. Received mentoring from primary care PBRN in LA6. All agencies dedicated staff and clients to work on the

PBRN, and gave some relief from billing requirements

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7. There was mutual respect among the agencies and the original leader of the PBRN was a respected agency leader8. Convened three day-long meetings (30+ staff and clients) to introduce the PBRN and to generate and vet practitioner and client ideas9. Worked with academic team to create research questions and the measures 10. Implemented card study method with practitioners as recruiters and data gatherers

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STEP 6: FOLLOW-UP

Research team analyzed data and presented findings to ROCC, locally, and nationally.

STEP 1: GENERATION

ROCC members (providers and consumers) from 4 participating agencies were at an all day forum. We identified 99 potential research questions that were then categorized into 23 domains by post doctoral fellows. After polling, the 10 domains with the most perceived interest were presented to the full ROCC membership.

STEP 2: SELECTION

At a second all day forum, 10 domains were discussed and refined into researchable questions. Identified questions were evaluated based on criteria developed by Knox and Lomonaco*. A score was given for each criterion. These scores were tallied for a composite score for each question. The four highest scoring questions advanced to the next step.

Criteria*1) Will it change my practice?2) Will it change my colleagues’ practice? 3) Is it feasible? 4) Is it publishable? 5) Is it fundable? 6) Is there a provider champion? * Knox & Lomonaco, 2005

STEP 3: EVALUATION

Following the forum, the fellows performed literature reviews for the 4 highest scoring questions. They wrote background summaries and sample card studies for each research question. These were sent out to all the members.

STEP 4:VOTE

Members voted electronically for their preferred research question.

STEP 5:STUDY

The selected card study was pilot tested and refined by the research team. After obtaining IRB approval data collection occurred at member sites.

Steps of Reflective Practitioner Process Model for Study Topic Selection and Study Design

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Sample: N = 237 participants from 4 clinics: Didi Hirsch (n = 52), Exodus (n = 99), Mental Health America (n = 48), and Pacific Clinics (n= 38).

Gender: 138 identified as Male, 90 as Female, and 8 were missing and 1 identified as Other.

Mean Age = 47.4 (SD = 11.5), ranging from ages 20-65

Current research question:

What is the impact of integrated mental health and healthcare services on access to health care, utilization of health care, and health and mental health outcomes?

Card Study Methodology

• Single card or sheet of paper contains the entire data gathering instrument. Goal is 10 minutes or less of administration time.

Change in Emergency Room Use

Less than Before Same as Before More than Before0

20406080

100120140160180 166

3828

Change in Emergency Room Use

Change in Primary Care Service Use

Less than Before Same as Before More than Before0

102030405060708090

100

6776

90

Change in Health Care Access

It is worse It is the same It is better0

20406080

100120140160180

9

64

162

Physical Health Change

It is worse It is the same It is better0

20

40

60

80

100

120

140

18

76

132

Change in Mental Health

020406080

100120140160180

12

43

171

Changes in Lifestyle

0

40

80

120

160

1243

171

Challenges• Time. Developing the research question and refining the card study took

several months. Frequent delays in the process, such as waiting for regulatory approvals. Revising the study instrument and pilot testing are familiar to academic researchers; however, this can be frustrating to community providers. Conversely, the time required to involve agency members in the development of a research question can be challenging to researchers. Rigor of methodology will develop over time.

• Using agency providers to administer surveys had benefits and challenges. Providers had to complete responsible conduct training, taking time away from practice hours. On the other hand, the response rate was exceptionally high likely because the staff were well known to the subjects and they were highly motivated to facilitate participation in the study.

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Dissemination of the findings and sustainabilityTo the participants: staff and clientsTo the agencies and their stakeholdersTo the local Department of Mental HealthNational PBRN ConferenceWhite PaperScholarly Publications (2 in press)Preparing a funding requestNew ROCC member agency (now up to 150,000 consumers)

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Next PBRN Project

• What are the critical components of our services from the perspectives of consumers and practitioners?

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Publications• Kelly E, Brekke JS et al. (in press). The Recovery-

Oriented Care Collaborative: A Practice-based research network to improve care for people with serious mental illness. Psychiatric Services.

• Kelly E, Davis L, Brekke JS (in press). Mental health Practice-based Research Network findings: Integrated care for individuals with serious mental illnesses. Psychiatric Services.

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PBRNs for Social Work• Social work has huge workforce and enormous

agency representation across sectors• PBRNs could be fruitful partnerships between

university and agency settings• Implications and opportunities for BSW, MSW

and PhD training and education• In primary care they are engines for research

and training at some universities

Institute on Agency-based Practice and Science in Integrated Health Services

• Using the ROCC as a primary collaborator, create a USC SSW-based institute to train and mentor MSW, PhD, and Post-doctoral scientists in policy-relevant observational studies, intervention development, and intervention testing.