J ohn S. Brekke, PhD Frances Larson Professor of Social Work Research School of Social Work

1. Building quality into mental health services for the most vulnerable: The role of peers and of effective psychosocial interventions. ​ John S. Brekke, PhD Frances Larson Professor of Social Work Research School of Social Work University of Southern California

2. Institute of Medicine Report “Psychosocial Interventions for Mental and Substance Use Disorders: A Framework for Establishing Evidence-Based Standards” (Report still in review)

3. 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

4. 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

5. 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

6. 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).

7. 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).

8. 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)

9. 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

10. Serious Mental illness 5% 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 year But vast majority not receiving guideline care (e.g., for schizophrenia less than 10%)

11. 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

12. Two Places for Leverage • 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

13. Typology of Peer-Delivered Services in Mental Health Within existing Peer-run Outside the MH system agency teams Do what others do: publicly funded Icarus Project (e.g., case management) privately funded Painted Brain Adjunctive role Unique role: e.g. health navigation, agency greeter

14. 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?

15. The Bridge: A Peer Navigator Intervention for Improving the Health of Adults With Serious Mental Illness Dr. John S. Brekke Dr. Erin Kelly

16. 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.

17. 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.

18. 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

19. Peer Health Navigation Intervention: “The Bridge” A comprehensive health care engagement and self-managementintervention delivered by peers

20. Comprehensive: Connect consumers to primary care, specialty health care, and substance abuse services

21. 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

22. 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

23. In vivo approach Develops self-management skills in real world health care settings

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. Summary of Pilot Findings The Peer Health Navigation Intervention (“Bridge”) shows impact and promise for:

31. Bridge Team John Brekke, PhD, PI; USC Lou Mallory, Peer Health Navigator Supervisor; Pacific Clinics Erin Kelly, PhD, Co-I; USC Heather Cohen, MPP, Project Director; USC Laura Pancake, MSW, Corporate Director; Pacific Clinics Holly Kiger, RN, MSN; USC Toni Rainey, Francisco Espinoza, Tamara Ra: Peer Health Navigators; Pacific Clinics Crystal Stewart, Jorge Avila, Research Assistants; USC

32. 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.

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

34. Two Places for Leverage • Peer-delivered services (“experts by experience”) 2. Closing the gap between research and practice using Practice-based Research Networks

35. 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.

36. Also a notable tension in mental health between evidence-based practice and practice-based evidence • PBRNs are built and thrive at this interface

37. The Recovery Oriented Care Collaborative: A Practice Based Research Network Funded by the USC Clinical Translational Science Institute

38. 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.

39. 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.

40. 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

41. Current Context Leader created a steering committee from four agencies The four agencies serve over 100,000 consumers with SMI All four agencies had worked together on LA County funded innovative projects on integrated care 4. 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 LA All agencies dedicated staff and clients to work on the PBRN, and gave some relief from billing requirements

42. 7. There was mutual respect among the agencies and the original leader of the PBRN was a respected agency leader 8. Convened three day-long meetings (30+ staff and clients) to introduce the PBRN and to generate and vet practitioner and client ideas 9. Worked with academic team to create research questions and the measures 10. Implemented card study method with practitioners as recruiters and data gatherers

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

44. 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?

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

46. Change in Emergency Room Use

47. Change in Primary Care Service Use

48. Change in Health Care Access

49. Physical Health Change

50. Change in Mental Health