Erin Kelly
Thomas Jefferson University, Family and Community Medicine, Faculty Member
- University of California, Los Angeles, Semel Institute, Department MemberUniversity of Southern California, Social Work, Department Memberadd
- Serious Mental Illness (Neuropsych), Forensic Psychology, Peer Navigation, Psychiatric Hospitals, Institutional Change, Psychometrics, and 12 moreDevelopmental Psychopathology, Self-Injury, Psychology, Child Development, Physiological reactivity, Stress, Social Sciences, Psychiatric Services, Longitudinal data analysis, Multilevel modelling, Safety and Health in Workplace, and Psychometrics and Test Developmentedit
- Erin L. Kelly currently works at Thomas Jefferson University in the Department of Family and Community Medicine. Her ... moreErin L. Kelly currently works at Thomas Jefferson University in the Department of Family and Community Medicine. Her work primarily focuses on addressing health disparities for individuals with serious mental illnesses, such as schizophrenia, bipolar, and depression. Projects include integrated health care for individuals with serious mental illnesses, violence, substance use (particularly medical marijuana and opioids), stakeholder-driven research within practice-based research networks (www.roccpbrn.com), and evaluation of mental health policy.edit
Background Medication for opioid use disorder (MOUD) is the gold standard treatment for opioid use disorder. Traditionally, “success” in MOUD treatment is measured in terms of program retention, adherence to MOUD, and abstinence from... more
Background Medication for opioid use disorder (MOUD) is the gold standard treatment for opioid use disorder. Traditionally, “success” in MOUD treatment is measured in terms of program retention, adherence to MOUD, and abstinence from opioid and other drug use. While clinically meaningful, these metrics may overlook other aspects of the lives of people with opioid use disorder (OUD) and surprisingly do not reflect the diagnostic criteria for OUD. Methods Authors identified items for a pilesorting task to identify participant-driven measures of MOUD treatment success through semi-structured interviews. Interviews were transcribed verbatim and coded in Nvivo using directed and conventional content analysis to identify measures related to treatment success and quality of life goals. Participants of a low-threshold MOUD program were recruited and asked to rank identified measures in order of importance to their own lives. Multidimensional scaling (MDS) compared the similarity of items wh...
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Since 2020, people who use drugs (PWUD) experienced heightened risks related to drug supply disruptions, contamination, overdose, social isolation, and increased stress. This study explored how the lives of PWUD changed in Philadelphia... more
Since 2020, people who use drugs (PWUD) experienced heightened risks related to drug supply disruptions, contamination, overdose, social isolation, and increased stress. This study explored how the lives of PWUD changed in Philadelphia over a one-year period. Using semi-structured interviews with 20 participants in a Housing First, low-barrier medication for opioid use (MOUD) program in Philadelphia, the effects of the first year of the COVID-19 pandemic on the daily lives, resources, functioning, substance use, and treatment of PWUD were explored. Interviews were analyzed using a combination of directed and conventional content analysis. Six overarching themes emerged during data analysis: (1) response to the pandemic; (2) access to MOUD and support services; (3) substance use; (4) impacts on mental health, physical health, and daily functioning; (5) social network impacts; and (6) fulfillment of basic needs. Participants reported disruptions in every domain of life, challenges mee...
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Research Interests: Cognition, Attention, Neuropsychopharmacology, Experimental Design, Medicine, and 15 moreLinear models, Humans, Carbon Monoxide, Blood Pressure, Nicotine, Female, Male, Heart rate, Adult, Cognitive Function, Cotinine, Psychiatric Status Rating Scales, Antipsychotic agents, Medical and Health Sciences, and Cigarette Smoke
While recent work on community integration for individuals with serious mental illnesses (SMIs) has focused on the multi-dimensionality of community integration, it has not been fully rooted in how consumers define and experience... more
While recent work on community integration for individuals with serious mental illnesses (SMIs) has focused on the multi-dimensionality of community integration, it has not been fully rooted in how consumers define and experience communities for themselves . Guided by symbolic interactionism theory, the goal of the present study is to explore definitions of community as provided by individuals with SMIs, and to incorporate those definitions into a theoretical framework of community to inform community integration efforts in the context of mental health services and recovery. Semi-structured interviews were conducted between November 2017 and September 2018 with 90 racially/ethnically diverse participants who were 18 years and older with an SMI and receiving community mental health services. Interviews were audio-recorded, transcribed, and analyzed using ResearchTalk’s "Sort and Sift, Think and Shift" methodology. Themes derived from participants’ definitions of community included a structural aspect of people and places; a functional aspect of socializing, helping and receiving resources; and an experiential aspect of shared struggles and experiences, finding safety, and identifying with others. To this end, we propose a Structural, Functional and Experiential (SFE) model of community. The SFE model of community provides a conceptual framework and guidance for clinicians, researchers, policy makers and service stakeholders regarding the complexity and variability of community for their consumers, which is essential to their recovery. Application of the SFE framework for assessment and intervention is discussed.
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Background: Cannabis is increasingly used for symptom management, but its effects on health-related quality of life (QoL) have been inconclusive. Objectives: The goal of the present study was to characterize self-reported symptoms and QoL... more
Background: Cannabis is increasingly used for symptom management, but its effects on health-related quality of life (QoL) have been inconclusive. Objectives: The goal of the present study was to characterize self-reported symptoms and QoL among patients certified to use medical cannabis. Methods: These data are from the baseline assessment of a 12-month longitudinal study. The survey assessed certifying conditions, current medications, symptoms and symptom severity. QoL was assessed using the Functional Assessment of Chronic Illness Therapy-Palliative Care (FACIT-Pal) which includes Physical Well-Being (PWB), Social/Family Well-Being (SWB), Emotional Well-Being (EWB), Functional Well-Being (FWB), and the Palliative Care subscale. Higher scores indicated better QoL. Results: Overall, 210 patients (114 female, 92 male, 3 non-binary, 1 refused) completed the survey. The most common certifying conditions were pain (48.6%), anxiety (36.7%), and PTSD (15.7%) and the most common symptoms were anxiety (65.2%), pain (56.7%), sleep disturbance (38.6%), and depression (31.4%). Compared to normative data, this sample reported lower QoL, specifically EWB and SWB scores (i.e., T-Scores<45). Opioid/ benzodiazepine/sedative-hypnotic use was associated with lower QoL on all subscales (except SWB and FWB) (ps < 0.05). Greater number of self-reported symptoms and medical conditions were associated with lower QoL (ps < 0.01). Conclusion: Despite mixed evidence regarding cannabis' efficacy for anxiety, 36.7% of the current sample were certified by a physician for anxiety. Lower QoL was associated with more self-reported comorbid medical conditions, higher total symptom count, and reported use of an opioid and/or benzodiazepine. Future longitudinal data will provide critical information regarding the trajectory of these symptoms and QoL.
Since 2020, people who use drugs (PWUD) experienced heightened risks related to drug supply disruptions, contamination, overdose, social isolation, and increased stress. This study explored how the lives of PWUD changed in Philadelphia... more
Since 2020, people who use drugs (PWUD) experienced heightened risks related to drug supply disruptions, contamination, overdose, social isolation, and increased stress. This study explored how the lives of PWUD changed in Philadelphia over a one-year period. Using semi-structured interviews with 20 participants in a Housing First, low-barrier medication for opioid use (MOUD) program in Philadelphia, the effects of the first year of the COVID-19 pandemic on the daily lives, resources, functioning, substance use, and treatment of PWUD were explored. Inter-views were analyzed using a combination of directed and conventional content analysis. Six overarching themes emerged during data analysis: (1) response to the pandemic; (2) access to MOUD and support services; (3) substance use; (4) impacts on mental health, physical health, and daily functioning; (5) social network impacts; and (6) fulfillment of basic needs. Participants reported disruptions in every domain of life, challenges meeting their basic needs, and elevated risk for adverse events. MOUD service providers offset some risks and provided material supports, treatment, social interaction, and emotional support. These results highlight how there were significant disruptions to the lives of PWUD during the first year of the COVID-19 pan-demic and identified critical areas for future intervention and policies.
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Introduction Medical providers' attitudes about caring for vulnerable populations have significant implications for persistent health disparities. Therefore, assessing medical students' self-perceived knowledge about... more
Introduction Medical providers' attitudes about caring for vulnerable populations have significant implications for persistent health disparities. Therefore, assessing medical students' self-perceived knowledge about community-based medicine and care for underserved populations can provide insights for improving health care delivery to achieve health equity. We evaluated third-year medical students' perceptions of their knowledge and attitudes about community medicine, and addressing health care needs of vulnerable populations. Methods From October 2, 2017 to July 12, 2019, third-year medical students at a private, urban medical school were asked to complete an assessment survey during their family medicine clerkship orientation. The anonymous survey assessed students' self-perceived knowledge and attitudes regarding community medicine and care of vulnerable populations. We examined differences in survey responses by student demographics. Results A total of 401 stude...
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Research objective The COVID-19 pandemic disrupted healthcare delivery worldwide with likely negative effects on people who use opioids (PWUO). This scoping review of the original research literature describes the impact of the COVID-19... more
Research objective The COVID-19 pandemic disrupted healthcare delivery worldwide with likely negative effects on people who use opioids (PWUO). This scoping review of the original research literature describes the impact of the COVID-19 pandemic on healthcare delivery for PWUO and identifies gaps in the literature. Methods This scoping review of the original research literature maps the available knowledge regarding the impact of the COVID-19 pandemic on healthcare delivery for PWUO. We utilized the methodology developed by the Joanna Briggs Institute for scoping reviews, and content analyses methodology to characterize the current state of the literature. Results Of the 14 included studies, administrative database (n = 11), cross-sectional (n = 1) or qualitative (n = 2) studies demonstrated service gaps (n = 7), patient/provider experiences (n = 3), and patient outcomes for PWUO (n = 4). In March 2020, healthcare utilization dropped quickly, sharply increasing only for reasons of o...
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Purpose: Assisted outpatient treatment (AOT) programs can compel treatment-refusing individuals to participate in mental health treatment via civil court order. In California’s AOT programs, individuals first must be offered 30 days of... more
Purpose: Assisted outpatient treatment (AOT) programs can compel treatment-refusing individuals to participate in mental health treatment via civil court order. In California’s AOT programs, individuals first must be offered 30 days of outreach services and can accept services voluntarily. This study examines the use of outreach strategies in an AOT program with the potential for voluntary or involuntary enrollment. Methods: Outreach staff completed a survey in which they reported and rated outreach strategies and barriers to treatment for 487 AOT-referred individuals. Results: Outreach staff reported using a broad array of strategies to persuade and engage clients. Supportive and persuasive strategies were most common. More coercive strategies, including court order, were used when needed. More clients enrolled voluntarily (39.4%) than involuntarily (7.2%). Conclusions: Outreach, coupled with the strategic use of potential court involvement, can lead to voluntary enrollment of trea...
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Patient assault is a serious issue for the well-being of staff in psychiatric hospitals. To guide workplace responses to patient assault, more information is needed about social support from different sources and whether those supports... more
Patient assault is a serious issue for the well-being of staff in psychiatric hospitals. To guide workplace responses to patient assault, more information is needed about social support from different sources and whether those supports are associated with staff well-being. The present study examines social support after patient assault from work-based and nonwork-based sources, and whether inpatient psychiatric staff desires support from them and perceive the support received as being effective. Received support across sources was examined in relations to staff well-being (physical health, mental health, anger, sleep quality) and perceptions of safety. Survey data was collected from 348 clinical staff in a large public forensic mental hospital. Among the 242 staff who reported an assault in the last year, 71% wanted support and 72% found effective support from at least one source. Generally, effective support from supervisors, coworkers, and their combination was associated with bet...
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Individuals with serious mental illness also have high rates of comorbid physical health issues. To address those issues, this population needs interventions that improve self-management of health and healthcare. In order to improve the... more
Individuals with serious mental illness also have high rates of comorbid physical health issues. To address those issues, this population needs interventions that improve self-management of health and healthcare. In order to improve the health and healthcare of individuals with serious mental illnesses, 151 consumers with serious mental illness were randomized to receive either usual mental healthcare plus the Bridge intervention (n=76) or usual mental healthcare while on a 6month waitlist (n=75). The waitlist group received the intervention after the waitlist period. Change score comparisons (difference of differences) of the treatment vs the waitlist groups revealed that the treated group showed significantly greater improvement in access and use of primary care health services, higher quality of the consumer-physician relationship, decreased preference for emergency, urgent care, or avoiding health services and increased preference for primary care clinics, improved detection of ...
Research Interests: Mental Health, Primary Health Care, Schizophrenia, Self Care, Medicine, and 14 moreSelf Help Groups, Humans, Female, Male, Psychological Intervention, Follow-up studies, Mental Disorders, Health Status, Middle Aged, Adult, Randomized Controlled Trial, Guidance and Counseling Intervention Programs, Psychology and Cognitive Sciences, and Medical and Health Sciences
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The authors' objective was to determine how assisted outpatient treatment (AOT) has been implemented in actual practice in the 45 states with AOT statutes. A national survey of AOT programs was conducted to examine the extent to which... more
The authors' objective was to determine how assisted outpatient treatment (AOT) has been implemented in actual practice in the 45 states with AOT statutes. A national survey of AOT programs was conducted to examine the extent to which AOT programs have been implemented and variations in implementation models. Although 45 states have current AOT statutes, the most active programs were identified in 20 states. These programs varied considerably in style of implementation, criteria applied, agency responsible, use of a treatment plan, monitoring procedures, and numbers of participants involved. Three implementation models were identified: community gateway, hospital transition, and surveillance (or safety net). Common problems included inadequate resources, lack of enforcement power, inconsistent monitoring, and weakness of interagency collaboration. AOT is a widely applied and much-discussed mechanism for providing treatment to individuals with serious mental illnesses nationally....
Research Interests: Business, Community-Based Mental Health Services, Family Medicine, Medicine, Humans, and 10 moreMental Health Services Research, United States, Mental Disorders, Implementation, Public health systems and services research, Psychiatric Services, Involuntary Treatment, Community Based Mental Health Services, Ambulatory Care, and Surveys and Questionnaires
Research Interests: Evidence Based Practice, Medicine, Humans, Female, Male, and 10 moreMental Disorders, Mental health services, Middle Aged, Adult, Public health systems and services research, Severe Persistent Mental Illness, Psychiatric Services, Cross Sectional Studies, Integrated health and mental health care, and Surveys and Questionnaires
Psychiatric staff are faced with multiple forms of hostility, aggression, and assault at work, collectively referred to as workplace violence, which typically is activated by patients but can also come from coworkers and supervisors.... more
Psychiatric staff are faced with multiple forms of hostility, aggression, and assault at work, collectively referred to as workplace violence, which typically is activated by patients but can also come from coworkers and supervisors. Whether workplace violence adversely affects staff well-being may be related not only to its presence, but also to an individual's stress reactivity. At a large public psychiatric hospital, an online survey was completed by 323 clinical care staff, of whom 69.5 % had experienced physical assault in the previous 12 months. Staff well-being (depression, anger, and physical health) and staff safety concerns were adversely affected by conflicts with other staff members and by individual reactivity to social conflict and to assault. To improve staff well-being, in addition to safety protocols, interventions should target staff relationships, personal health maintenance practices, and individual coping skills for dealing with adverse workplace experiences.
Research Interests: Psychology, Psychiatry, Anger, Mental Health, Occupational Health, and 15 moreDepression, Medicine, Humans, Safety and Health in Workplace, Aggression, Female, Workplace Violence, Male, Health Status, Clinical Sciences, Public health systems and services research, Occupational Stress, Psychiatric Hospitals, Inpatient Psychiatric Hospitals, and professional patient relations
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Practice-based research networks (PBRNs) create continuous collaborations among academic researchers and practitioners. Most PBRNs have operated in primary care, and less than 5% of federally registered PBRNs include mental health... more
Practice-based research networks (PBRNs) create continuous collaborations among academic researchers and practitioners. Most PBRNs have operated in primary care, and less than 5% of federally registered PBRNs include mental health practitioners. In 2012 the first PBRN in the nation focused on individuals with serious mental illnesses-the Recovery-Oriented Care Collaborative-was established in Los Angeles. This column describes the development of this innovative PBRN through four phases: building an infrastructure, developing a research study, executing the study, and consolidating the PBRN. Key lessons learned are also described, such as the importance of actively engaging direct service providers and clients.
Research Interests: Nursing, Evidence Based Practice, Medicine, Los Angeles, Community Based Participatory Research, and 10 moreHumans, Mental health services, Serious Mental Illness, Public health systems and services research, Community Networks, Psychiatric Services, Cooperative Behavior, Integrated Healthcare, Practice Based Research Networks, and Translational Medical Research
To understand staff factors associated with patient aggression towards the staff of an inpatient forensic psychiatric hospital. Violence by patients is a serious concern in psychiatric hospitals and staff are the most frequent targets of... more
To understand staff factors associated with patient aggression towards the staff of an inpatient forensic psychiatric hospital. Violence by patients is a serious concern in psychiatric hospitals and staff are the most frequent targets of physical and verbal assault. Assault and its consequences can severely disrupt the hospital environment and impair the functioning of staff members and patients. This study examined the interplay of staff dispositional and interpersonal factors associated with patient violence. This cross-sectional study surveyed the staff of a large public forensic hospital. A sample of 348 psychiatric staff participated in an online survey about their workplace experiences, psychosocial characteristics and well-being. Data were collected from November - December 2011. Nearly all staff reported verbal conflict with patients (99%) and 70% reported being assaulted during the previous 12 months. Verbal conflict with other staff (92%) was also high. Multiple regression...
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Objective: Integration of general medical care and mental health care is a high priority for individuals with serious mental illnesses because of their high risk of morbidity and early mortality. The Bridge is a peer-led, health navigator... more
Objective: Integration of general medical care and mental
health care is a high priority for individuals with serious
mental illnesses because of their high risk of morbidity and
early mortality. The Bridge is a peer-led, health navigator
intervention designed to improve access to and use of
health care and self-management of medical services by
individuals with serious mental illnesses. This study expands
on a previous study in which the authors examined participants’
self-reported outcomes from a 12-month randomized
controlled trial of the Bridge. In the study reported
here, Medicaid data were used to assess the impact of the
intervention on service use during that trial.
Methods: Medicaid data on use of general medical services
(emergency room, outpatient, and inpatient) for 6
months were compared for 144 individuals with serious
mental illnesses—Bridge participants (N572) and a waitlist
control group (N572). An intent-to-treat approach was
used, with regression models controlling for general medical
services in the 6 months before baseline.
Results: Zero-inflated negative binomial analyses, controlling
for service use 6 months before baseline, found that
the intervention group used the emergency room significantly
less frequently, compared with the control group
(adjusted mean6SD number of visits, 0.7260.19 versus
1.5960.42). No between-group differences were found in
use of general medical inpatient or outpatient services.
Conclusions: The Bridge was effective in decreasing
emergency room use among individuals with serious
mental illnesses.
health care is a high priority for individuals with serious
mental illnesses because of their high risk of morbidity and
early mortality. The Bridge is a peer-led, health navigator
intervention designed to improve access to and use of
health care and self-management of medical services by
individuals with serious mental illnesses. This study expands
on a previous study in which the authors examined participants’
self-reported outcomes from a 12-month randomized
controlled trial of the Bridge. In the study reported
here, Medicaid data were used to assess the impact of the
intervention on service use during that trial.
Methods: Medicaid data on use of general medical services
(emergency room, outpatient, and inpatient) for 6
months were compared for 144 individuals with serious
mental illnesses—Bridge participants (N572) and a waitlist
control group (N572). An intent-to-treat approach was
used, with regression models controlling for general medical
services in the 6 months before baseline.
Results: Zero-inflated negative binomial analyses, controlling
for service use 6 months before baseline, found that
the intervention group used the emergency room significantly
less frequently, compared with the control group
(adjusted mean6SD number of visits, 0.7260.19 versus
1.5960.42). No between-group differences were found in
use of general medical inpatient or outpatient services.
Conclusions: The Bridge was effective in decreasing
emergency room use among individuals with serious
mental illnesses.
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Purpose. The COVID-19 pandemic dramatically affected all areas of healthcare. Primary care practices are on the front lines for patients seeking healthcare during this period. Understanding clinical and administrative staff members’... more
Purpose. The COVID-19 pandemic dramatically affected all areas of healthcare. Primary care practices are on the front lines for patients seeking healthcare during this period. Understanding clinical and administrative staff members’ strategies for managing the wide-ranging changes to primary care service delivery is important to support workforce well-being, burnout and commitment to primary care. Methods. Thirty-three staff members from eight practices within a single healthcare system completed short semi-structured interviews from May 11, 2020 to July 20, 2020. Interviews were coded using a combination of conventional and directed content analysis. Results: Themes that emerged from the data mapped onto the Job-Demands-Control-Support model. Participants reported that every aspect of primary care service delivery needed to be adapted for COVID-19, which increased their job demands significantly. Several also described pride in their development of their new skills and, in most interviews, that this experience brought staff together. Staff engaged in active cognitive reframing of these events during the interviews as they coped with their increased workplace stress. However, over time, as the pandemic changed from an acute stress event to chronic stressors, staff were more likely to indicate signs of burnout. Conclusions: Primary care teams absorbed tremendous burdens during COVID-19 but also found that some stress was offset by the increased support from management and their colleagues, belief in their necessity, and new development opportunities. Considering high pre-pandemic strain levels, long-term the ability of primary care teams to persist in these new conditions may erode, as the crisis becomes an enduring challenge.
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Background: The COVID-19 pandemic fundamentally changed every aspect of healthcare delivery and training. Few studies have reported on the impact of these changes on the experiences, skill development, and career expectations of medical... more
Background: The COVID-19 pandemic fundamentally changed every aspect of healthcare delivery and training. Few studies have reported on the impact of these changes on the experiences, skill development, and career expectations of medical students. Method: Using 59 responses to a short reflection essay prompt, 3rd year medical students in Philadelphia described how the COVID-19 pandemic affected their education in mid-2020. Using conventional content analysis, six main themes were identified across 14 codes. Results: Students reported concerns regarding their decreased clinical skill training and specialty exposure on their career development due to the loss of in-person experience during their family medicine clerkship. A small number felt very let down and exploited by the continued high cost of tuition while missing clinical interactions. However, many students also expressed professional pride and derived meaning from limited patient and mentorship opportunities. Many students developed a new sense of purpose and a call to become stronger public health and patient advocates. Conclusions: The medical field will need to adapt to support medical students adversely impacted by the COVID-19 pandemic, from an educational and mental health standpoint. However, there are encouraging signs that this may also galvanize many students to engage in leadership roles in their communities, to become more empathetic and thoughtful physicians, and to redesign healthcare in the future to better meet the needs of their most vulnerable patients.
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Research objective: The COVID-19 pandemic disrupted healthcare delivery worldwide with likely negative effects on people who use opioids (PWUO). This scoping review of the original research literature describes the impact of the COVID-19... more
Research objective: The COVID-19 pandemic disrupted healthcare delivery worldwide with likely negative effects on people who use opioids (PWUO). This scoping review of the original research literature describes the impact of the COVID-19 pandemic on healthcare delivery for PWUO and identifies gaps in the literature. Methods: This scoping review of the original research literature maps the available knowledge regarding the impact of the COVID-19 pandemic on healthcare delivery for PWUO. We utilized the methodology developed by the Joanna Briggs Institute for scoping reviews, and content analyses methodology to characterize the current state of the literature. Results: Of the 14 included studies, administrative database (n = 11), cross-sectional (n = 1) or qualitative (n = 2) studies demonstrated service gaps (n = 7), patient/provider experiences (n = 3), and patient outcomes for PWUO (n = 4). In March 2020, healthcare utilization dropped quickly, sharply increasing only for reasons of opioid overdose by May 2020. Service gaps existed in accessing treatment for new patients during the pandemic due to capacity and infrastructure limits. Physicians reported difficulty referring patients to begin an outpatient opioid treatment program due to increased restrictions in capacity and infrastructure. Patients also reported uncertainty about accessing outpatient treatment, but that telehealth initiation of buprenorphine increased access to treatment from home. Disproportionate increases in overdose rates among African Americans were reported in two studies, with differences by race and gender not examined in most studies. Fatal overdoses increased 60% in African Americans during the pandemic, while fatal overdoses in Non-Hispanic White individuals decreased. Conclusions: In summary, this beginning evidence demonstrates that despite early reluctance to use the healthcare system, opioid overdose-related use of healthcare increased throughout the pandemic. Service delivery for medications to treat OUD remained at or above pre-pandemic levels, indicating the ability of telehealth to meet demand. Yet, racial disparities that existed pre-pandemic for PWUO are intensifying, and targeted intervention for high-risk groups is warranted to prevent further mortality. As the pandemic progresses, future research must focus on identifying and supporting subgroups of PWUO who are at heightened risk for experiencing negative outcomes and lack of access to care.
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Purpose: Individuals with serious mental illness have high rates of substance use. The most commonly used substances among this population are alcohol and cannabis, and whether clinical providers delivering mental health services feel... more
Purpose: Individuals with serious mental illness have high rates of substance use. The most commonly used substances among this population are alcohol and cannabis, and whether clinical providers delivering mental health services feel adequately prepared to address substance use is unclear. While information about the effects of alcohol are well established, the effects of cannabis are less well known and staff may feel less confident in their abilities to assess its use and may rely on more informal sources to learn about it. Methods: Mental health agencies in three states (California, Ohio, and New York) surveyed their staff (n =717) to explore their knowledge, training, and expertise in assessment of substance use generally as well as cannabis and alcohol specifically. Results: Overall, providers felt more prepared to address their clients’ alcohol use than cannabis use. In between-state comparisons, California providers felt significantly less well prepared to assess, discuss, and refer their clients to treatment compared to Ohio and New York providers. Using a series of multi-categorical mediation models, we confirmed that deficits in training for these specific substances largely accounted for between-state differences in assessment, capacity, and treatment. Conclusions: Substance use training to address the service needs of individuals with co-occurring disorders is insufficient and a significant need exists for systemic changes to workforce training of community mental health providers.
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Research Interests: Metabolism, Insulin Resistance, Humans, Blood Glucose, Insulin, and 15 moreGlucose Metabolism, Chronic Disease, Female, Male, Benzodiazepines, Body Mass Index, Aged, Middle Aged, Longitudinal Studies, Adult, Clinical Psychiatry, Glucose Tolerance Test, Long Term, Antipsychotic agents, and Medical and Health Sciences
Diabetes mellitus has been reported to increase whole-body protein breakdown and thus loss of lean body mass. Cystic fibrosis-related diabetes (CFRD) is associated with undernutrition and increased mortality. We hypothesized that CFRD is... more
Diabetes mellitus has been reported to increase whole-body protein breakdown and thus loss of lean body mass. Cystic fibrosis-related diabetes (CFRD) is associated with undernutrition and increased mortality. We hypothesized that CFRD is associated with increased whole-body protein breakdown, which results in negative protein balance, and that correction of the glucose intolerance with insulin therapy would normalize whole-body protein metabolism. Rates of whole-body protein turnover and protein balance were measured in 28 adults with cystic fibrosis (17 M, 11 F). Subjects were assessed with a modified oral-glucose-tolerance test and categorized as having normal glucose tolerance, impaired glucose tolerance, or CFRD with and without fasting hyperglycemia; then they were compared with previously diagnosed CFRD adults already receiving insulin therapy. Indexes of protein turnover were calculated from [15N]glycine and 15N in urinary urea. Analysis of variance for the 28 subjects showed...
Research Interests: Engineering, Cystic Fibrosis, Energy Metabolism, Humans, Blood Glucose, and 15 moreInsulin, Diabetes mellitus, Female, Male, American, Homeostasis, Adult, Analysis of Variance, Group, Glucose Tolerance Test, Glucose Intolerance, Area Under Curve, Lean Body Mass, Impaired Glucose Tolerance, and Glucose tolerance
Research Interests: Metabolism, Insulin Resistance, Humans, Blood Glucose, Insulin, and 15 moreGlucose Metabolism, Chronic Disease, Female, Male, Benzodiazepines, Body Mass Index, Aged, Middle Aged, Longitudinal Studies, Adult, Clinical Psychiatry, Glucose Tolerance Test, Long Term, Antipsychotic agents, and Medical and Health Sciences
The study evaluated the effect of California's Mental Health Services Act (MHSA) on the structure, volume, location, and patient centeredness of Los Angeles County public mental health services. This prospective mixed-methods study... more
The study evaluated the effect of California's Mental Health Services Act (MHSA) on the structure, volume, location, and patient centeredness of Los Angeles County public mental health services. This prospective mixed-methods study (2006-2013) was based in five Los Angeles County public mental health clinics, all with usual care and three with full-service partnerships (FSPs). FSPs are MHSA-funded programs designed to "do whatever it takes" to provide intensive, recovery-oriented, team-based, integrated services for clients with severe mental illness. FSPs were compared with usual care on outpatient services received (claims data) and on organizational climate, recovery orientation, and provider-client working alliance (surveys and semistructured interviews), with regression adjustment for client and provider characteristics. In the first year after admission, FSP clients (N=174) received significantly more outpatient services than did usual care clients (N=298) (5,238...
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The application of continuous systems improvement in medical education can provide ac-tionable information for curriculum development, improvement, and future planning (as reported by Bowe and Armstrong, Acad Med 92:585-92, 2017). After... more
The application of continuous systems improvement in medical education can provide ac-tionable information for curriculum development, improvement, and future planning (as reported by Bowe and Armstrong, Acad Med 92:585-92, 2017). After receiving a medical education grant, we developed a curriculum to teach medical students how to use quality improvement (QI) to address health disparities in vulnerable populations. During the process of developing and implementing this curriculum, we learned several lessons. One of the major surprises was that our proposed project work took much longer to complete than anticipated. This was mainly because we did not have the right team assembled from the beginning. Specifically , we were missing a team member with evaluation expertise, and therefore we did not devise a systematic process for evaluation and assessment. Without periodic checks or timely assessments built into our curriculum design, we received feedback from students after it was too late to implement changes. We realized that our initial research design had some methodolog-ical flaws, which we later rectified. We encountered additional technical challenges during the curriculum implementation. We struggled with various online learning platforms. Through this, we learned the importance of being knowledgeable upfront about the features of learning platforms and adaptable to changing educational technologies. We also learned our curriculum could and should evolve to meet the needs of our learners and faculty. Moving forward, we realize the benefit of applying a quality improvement process to our curriculum development and implementation, which will help us to continuously transform medical education for future health care needs. The story To meet the growing needs of the American population , the National Academy of Science includes teaching quality improvement (QI) and population health as core competencies in medical school training [1]. This training can help students learn how to address health disparities (HD) and eliminate gaps in care to achieve health equity [2, 3]. Our department at an urban , private medical school received educational support to develop a population health curriculum-to teach medical students how to use QI methods to improve care for vulnerable populations. The three objectives of the novel, multifaceted curricula were for students to learn about: (1) QI foundational principles , (2) HD in certain communities and vulnerable populations, and (3) to apply QI processes to improve the care of a vulnerable population. What we learned in the development of a third-year medical student curricular project
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Introduction: Medical providers' attitudes about caring for vulnerable populations have signiRcant implications for persistent health disparities. Therefore, assessing medical students' self-perceived knowledge about community-based... more
Introduction: Medical providers' attitudes about caring for vulnerable populations have signiRcant implications for persistent health disparities. Therefore, assessing medical students' self-perceived knowledge about community-based medicine and care for underserved populations can provide insights for improving health care delivery to achieve health equity. We evaluated third-year medical students' perceptions of their knowledge and attitudes about community medicine, and addressing health care needs of vulnerable populations.
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Background: Medication for opioid use disorder (MOUD) with buprenorphine is effective in treating opioid use disorder yet remains underutilized. Scant research has examined the experience of patients, clinic staff, and providers in a... more
Background: Medication for opioid use disorder (MOUD) with buprenorphine is effective in treating opioid use disorder yet remains underutilized. Scant research has examined the experience of patients, clinic staff, and providers in a “low-threshold” group-based MOUD program. This study evaluates a “low-threshold” MOUD program at a federally qualified health center (FQHC) in Philadelphia, Pennsylvania through the perspectives of its key stakeholders. Methods: This qualitative study involved focus groups of patients, providers, and clinic staff. Focus groups were conducted between October 2017 and June 2018. Grounded theory was used for analysis. Results: There were a total of 10 focus groups, including 20 patient participants and 26 staff members. Program participants noted that a strength of the program is its person-centered harm reduction approach, which is reflected in the program’s policies and design. Program participants discussed the programmatic design choices that facilitated their participation and engagement in the program: ease of access, integration into primary care, and group-based visit model. Challenges in program implementation included varying acceptance and understanding of harm reduction among staff, the unpredictability of clinic volume and workflow, and the need to balance access to primary care and MOUD. Conclusion: This group-based MOUD program’s philosophy of person-centered harm reduction, low-barrier approach, the structure of group-based visits, and integrated care contributes to increased patient access and retention. Understanding the strengths and challenges of the program may be useful for other safety-net clinics considering a MOUD program.
Research Interests:
Purpose: Community integration is a key component of recovery for individuals with serious mental illnesses (SMIs). The goal of the current study is to explore the nature and impact of safety concerns for experiences of communities for... more
Purpose: Community integration is a key component of recovery for individuals with serious mental illnesses (SMIs). The goal of the current study is to explore the nature and impact of safety concerns for experiences of communities for individuals with SMIs. Method: Using constructivist grounded theory, 30 semistructured interviews were analyzed to explore the depth and breadth of individuals' safety concerns, how individuals manage these concerns, and how these concerns shape their community experiences. Findings: Participants described various unsafe encounters related to neighborhood disorder, homelessness, traumatic experiences, substance use, stigma, and loss of relationships and multiple strategies to manage their safety. Many saw mental health services as a sanctuary from the dangers of their environment, providing support, resources, and coping skills. For many, future communities were envisioned within the context of safety. Conclusions: Service providers should consider safety as a critical issue that impacts how individuals experience their current and future communities.
Research Interests:
Purpose: Assisted outpatient treatment (AOT) programs can compel treatment-refusing individuals to participate in mental health treatment via civil court order. In California’s AOT programs, individuals first must be offered 30 days of... more
Purpose: Assisted outpatient treatment (AOT) programs can compel treatment-refusing individuals to participate in mental
health treatment via civil court order. In California’s AOT programs, individuals first must be offered 30 days of outreach services
and can accept services voluntarily. This study examines the use of outreach strategies in an AOT program with the potential for
voluntary or involuntary enrollment. Methods: Outreach staff completed a survey in which they reported and rated outreach
strategies and barriers to treatment for 487 AOT-referred individuals. Results: Outreach staff reported using a broad array of
strategies to persuade and engage clients. Supportive and persuasive strategies were most common. More coercive strategies,
including court order, were used when needed. More clients enrolled voluntarily (39.4%) than involuntarily (7.2%). Conclusions:
Outreach, coupled with the strategic use of potential court involvement, can lead to voluntary enrollment of treatment-refusing
individuals with many, often severe, barriers to engaging in outpatient treatment.
health treatment via civil court order. In California’s AOT programs, individuals first must be offered 30 days of outreach services
and can accept services voluntarily. This study examines the use of outreach strategies in an AOT program with the potential for
voluntary or involuntary enrollment. Methods: Outreach staff completed a survey in which they reported and rated outreach
strategies and barriers to treatment for 487 AOT-referred individuals. Results: Outreach staff reported using a broad array of
strategies to persuade and engage clients. Supportive and persuasive strategies were most common. More coercive strategies,
including court order, were used when needed. More clients enrolled voluntarily (39.4%) than involuntarily (7.2%). Conclusions:
Outreach, coupled with the strategic use of potential court involvement, can lead to voluntary enrollment of treatment-refusing
individuals with many, often severe, barriers to engaging in outpatient treatment.
Research Interests:
Purpose: The field of social work is evolving toward community-engaged, stakeholder-driven research in the context of evidence-based practice (EBP) and practice-based evidence (PBE). Methods: We propose that practice-based research... more
Purpose:
The field of social work is evolving toward community-engaged, stakeholder-driven research in the context of evidence-based practice (EBP) and practice-based evidence (PBE).
Methods:
We propose that practice-based research networks (PBRNs) are an approach to conducting stakeholder-driven research that can be uniquely valuable for the field of social work.
Results:
We define the concept of a PBRN and demonstrate how it can address the development of complementary agendas for service improvement, social work science, policy development and advocacy, as well as highlight the challenges and benefits of participating in a PBRN. We provide details of our experiences with a mental health–based PBRN in Los Angeles County, the Recovery-Oriented Care Collaborative, to illustrate the processes outlined and inform our recommendations.
Conclusions:
PBRNs are an important form of community-based participatory research, which can help the field of social work with reconciling EBPs and PBE to improve service delivery.
The field of social work is evolving toward community-engaged, stakeholder-driven research in the context of evidence-based practice (EBP) and practice-based evidence (PBE).
Methods:
We propose that practice-based research networks (PBRNs) are an approach to conducting stakeholder-driven research that can be uniquely valuable for the field of social work.
Results:
We define the concept of a PBRN and demonstrate how it can address the development of complementary agendas for service improvement, social work science, policy development and advocacy, as well as highlight the challenges and benefits of participating in a PBRN. We provide details of our experiences with a mental health–based PBRN in Los Angeles County, the Recovery-Oriented Care Collaborative, to illustrate the processes outlined and inform our recommendations.
Conclusions:
PBRNs are an important form of community-based participatory research, which can help the field of social work with reconciling EBPs and PBE to improve service delivery.
Research Interests:
Research Interests:
Objective: Anger and depression are associated with a number of psychosocial problems, and their comorbidity may exacerbate maladjustment among incarcerated youth. The present study aims to identify whether anger and its different facets... more
Objective: Anger and depression are associated with a number of psychosocial problems, and their comorbidity may exacerbate maladjustment among incarcerated youth. The present study aims to identify whether anger and its different facets (cognitive, arousal, and behavioral), either independently or when conjoined with depressed mood, affects violent and non-violent institutional infractions. Method: Males (14-17 years of age) were recruited within 48 hours of arrival at a juvenile detention facility and were administered psychometric measures of anger (NAS) and depression (CES-D) at baseline, 1 month, and 2 months. Offending within the facility was assessed via self-report and institutional records. Results: Controlling for prior offending and other background factors, individuals having high anger scores were more likely to offend over the 2-month period, compared to those with lower levels of anger. NAS scores, especially its Behavioral facet, predicted both official- and self-reported (violent and non-violent) institutional offending. There was evidence for the interaction of depression and anger at baseline predicting self-reported offending at 1 month only. Conclusions: Given that juveniles’ self-report of emotional distress, particularly anger, is predictive of their violent and non-violent infractions, focused intervention programs could reduce behavior problems during incarceration that add to juveniles’ maladjustment and continued exposure to adversities.
Research Interests:
Individuals with serious mental illnesses have high rates of comorbid physical health issues and have numerous barriers to addressing their health and health care needs. The present pilot study tested the feasibility of a modified form of... more
Individuals with serious mental illnesses have high rates of comorbid physical health issues and have numerous barriers to addressing their health and health care needs. The present pilot study tested the feasibility of a modified form of the " Bridge " peer-health navigator intervention delivered in a usual care setting by agency personnel. The modifications concerned the use of an electronic personal health record with individuals experiencing with housing instability. Twenty participants were randomized to receive the intervention immediately or after 6 months. Health navigator contacts and use of personal health records were associated with improvements in health care and self-management. This pilot study demonstrated promising evidence for the feasibility of adding personal health record use to a peer-led intervention. Keywords Peer-delivered · Personal health record · Serious mental illness · Integrated health care · Homelessness
Research Interests:
Patient assault is a serious issue for the well-being of staff in psychiatric hospitals. To guide workplace responses to patient assault, more information is needed about social support from different sources and whether those supports... more
Patient assault is a serious issue for the well-being of staff in psychiatric hospitals. To guide workplace responses to patient assault, more information is needed about social support from different sources and whether those supports are associated with staff well-being. The present study examines social support after patient assault from work-based and nonwork-based sources, and whether inpatient psychiatric staff desires support from them and perceive the support received as being effective. Received support across sources was examined in relations to staff well-being (physical health, mental health, anger, sleep quality) and perceptions of safety. Survey data was collected from 348 clinical staff in a large public forensic mental hospital. Among the 242 staff who reported an assault in the last year, 71% wanted support and 72% found effective support from at least one source. Generally, effective support from supervisors, coworkers, and their combination was associated with better well-being. Support from nonwork sources was related to less concerns about safety, but not to other well-being measures. However, 28% of staff did not receive effective support from any source post-assault. Gaps in support as reported in this study and as found by other investigators call for systematic programming by hospital organizations to enhance the well-being of clinical staff, which in turn has implications for patient care.
Research Interests:
Objective: Individuals with serious mental illness also have high rates of comorbid physical health issues. To address those issues, this population needs interventions that improve self-management of health and healthcare. Methods: In... more
Objective: Individuals with serious mental illness also have high rates of comorbid physical health issues. To address those issues, this population needs interventions that improve self-management of health and healthcare.
Methods: In order to improve the health and healthcare of individuals with serious mental illnesses, 151 consumers with serious mental illness were randomized to receive either usual mental healthcare plus the Bridge intervention (n =76) or usual mental healthcare while on a 6 month waitlist (n = 75). The waitlist group received the intervention after the waitlist period.
Results: Change score comparisons (difference of differences) of the treatment vs the waitlist groups revealed that the treated group showed significantly greater improvement in access and use of primary care health services, higher quality of the consumer-physician relationship, decreased preference for emergency, urgent care, or avoiding health services and increased preference for primary care clinics, improved detection of chronic health conditions, reductions in pain, and increased confidence in consumer self-management of healthcare.
Conclusions: Peer providers using a manualized intervention can be an important part of the efforts to address the general medical care of individuals with serious mental illnesses.
Methods: In order to improve the health and healthcare of individuals with serious mental illnesses, 151 consumers with serious mental illness were randomized to receive either usual mental healthcare plus the Bridge intervention (n =76) or usual mental healthcare while on a 6 month waitlist (n = 75). The waitlist group received the intervention after the waitlist period.
Results: Change score comparisons (difference of differences) of the treatment vs the waitlist groups revealed that the treated group showed significantly greater improvement in access and use of primary care health services, higher quality of the consumer-physician relationship, decreased preference for emergency, urgent care, or avoiding health services and increased preference for primary care clinics, improved detection of chronic health conditions, reductions in pain, and increased confidence in consumer self-management of healthcare.
Conclusions: Peer providers using a manualized intervention can be an important part of the efforts to address the general medical care of individuals with serious mental illnesses.
Research Interests:
Research Interests:
Allocating limited mental health resources is a challenge for juvenile justice facilities. We evaluated the clinical utility of the Massachusetts Youth Screening Instrument, Version 2 (MAYSI-2)—an instrument designed to aid in this... more
Allocating limited mental health resources is a challenge for juvenile justice facilities. We evaluated the clinical utility of the Massachusetts Youth Screening Instrument, Version 2 (MAYSI-2)—an instrument designed to aid in this process—in three subsamples of justice-involved youth (ages 14-17): detained girls (n = 69), detained boys (n = 130), and incarcerated boys (n = 373). For perspective, we compared its performance (in the incarcerated subsample) to that of the Youth Self-Report (YSR), a more widely-used screen. The MAYSI-2 subscales were moderately useful for detecting relevant diagnoses, and differences were observed across samples. However, as a general mental health screen, the MAYSI-2 performed well (and comparably to the YSR), correctly classifying 66% to 75% of youth. When used to differentiate youth with any and without any disorder, both instruments were effective. Given the MAYSI-2’s practical advantages over the YSR (lower cost, easier administration), it may be a better option for juvenile facilities.
Research Interests:
Background: Psychiatric staff are at high risk for victimization at work. For example, approximately 30% of 586 nurses in 7 states reported being assaulted in the prior year (Carroll & Morin, 1998) and in multinational samples career... more
Background: Psychiatric staff are at high risk for victimization at work. For example, approximately 30% of 586 nurses in 7 states reported being assaulted in the prior year (Carroll & Morin, 1998) and in multinational samples career assault rates of approximately 75% have been found (Dehn, 1999; Quintal, 2005). Patients, supervisors, coworkers, and visitors are all potential sources of aggression and assault for staff. Identifying the risk factors for assault and aggression are critical to designing interventions to prevent their occurrence. Previous research has fairly consistently identified males, less experienced staff, having high patient contact, and using patient containment procedures, as associated with risk for patient assault but other risk factors such as reactivity to conflict, anger, and aggression from other staff are less well established. The goal of this study is to examine existing and novel risk factors for patient-on-staff aggression and assault. Methods: Clini...
Background: Workplace violence (WPV) in psychiatric settings has widespread implications for patients, staff, and institutions. WPV may be perpetrated by patients, visitors, or staff and encompasses assault and aggression. Assault... more
Background: Workplace violence (WPV) in psychiatric settings has widespread implications for patients, staff, and institutions. WPV may be perpetrated by patients, visitors, or staff and encompasses assault and aggression. Assault incorporates a range of physically violent acts while aggression consists of verbal threats, insults, and criticism. Prior research has focused on risk factors for patient violence or staff conflict. The current study tests a more comprehensive model of WPV by (a) examining the relationships between different facets of WPV and staff's well-being, and (b) determining whether staff reactivity to social conflict (aggression) or distress over assault moderates those relationships. Methods: The sample included 328 staff at a large public mental hospital who completed a one-hour online survey about their occupational stressors and strains (26% response rate). WPV was estimated using measures of staff relationships (conflict and criticism from other staff), f...
Research Interests:
Objective: The authors’ objective was to determine how assisted outpatient treatment (AOT) has been implemented in actual practice in the 45 states with AOT statutes. Methods: A national survey of AOT programs was conducted to examine... more
Objective:
The authors’ objective was to determine how assisted outpatient treatment (AOT) has been implemented in actual practice in the 45 states with AOT statutes.
Methods:
A national survey of AOT programs was conducted to examine the extent to which AOT programs have been implemented and variations in implementation models.
Results:
Although 45 states have current AOT statutes, the most active programs were identified in 20 states. These programs varied considerably in style of implementation, criteria applied, agency responsible, use of a treatment plan, monitoring procedures, and numbers of participants involved. Three implementation models were identified: community gateway, hospital transition, and surveillance (or safety net). Common problems included inadequate resources, lack of enforcement power, inconsistent monitoring, and weakness of interagency collaboration.
Conclusions:
AOT is a widely applied and much-discussed mechanism for providing treatment to individuals with serious mental illnesses nationally. The uneven implementation of AOT programs within and across states highlights the ambivalence in the community, by judicial officials, and by mental health clinicians about the role and scope of AOT and the difficulties of implementation under existing funding constraints and statutory limitations.
The authors’ objective was to determine how assisted outpatient treatment (AOT) has been implemented in actual practice in the 45 states with AOT statutes.
Methods:
A national survey of AOT programs was conducted to examine the extent to which AOT programs have been implemented and variations in implementation models.
Results:
Although 45 states have current AOT statutes, the most active programs were identified in 20 states. These programs varied considerably in style of implementation, criteria applied, agency responsible, use of a treatment plan, monitoring procedures, and numbers of participants involved. Three implementation models were identified: community gateway, hospital transition, and surveillance (or safety net). Common problems included inadequate resources, lack of enforcement power, inconsistent monitoring, and weakness of interagency collaboration.
Conclusions:
AOT is a widely applied and much-discussed mechanism for providing treatment to individuals with serious mental illnesses nationally. The uneven implementation of AOT programs within and across states highlights the ambivalence in the community, by judicial officials, and by mental health clinicians about the role and scope of AOT and the difficulties of implementation under existing funding constraints and statutory limitations.
Research Interests:
TO THE EDITOR: In our column in this issue (1), we discuss the formation of a practice-based research network (PBRN) by mental health providers and how a card study was used to generate R3 rapid-learning research designs (2). Here, we... more
TO THE EDITOR: In our column in this issue (1), we discuss the formation of a practice-based research network (PBRN) by mental health providers and how a card study was used to generate R3 rapid-learning research designs (2). Here, we briefly report the findings of that initial study, which focused on integrated general medical and mental health care services directed by mental health providers. We chose this topic because most service-level intervention strategies targeting this health disparity for individuals with serious mental illnesses have focused on how general medical providers can direct and improve health care for this population. Mental health providers can also effectively lead these efforts, but more research is needed on integrated services that are organized or provided by mental health agencies (3).