JBHSR Recent Issues

The Table of Contents and abstracts for recent issues of the JBHS&R are listed below.

Volume 37, 2010

Number 1 / January 2010

The Reality of Implementing Evidence-Based Practices...1-3
Linda Rosenberg

Development of a Model and Measure of Process-Oriented Quality of Care for Substance Abuse Treatment...4-24
Fred A. Mael, Patrick Gavan O’Shea, Mark Alan Smith, Andrea Seidner Burling, Kristin L. Carman, Amie Haas and Kelly S. Rogers
Abstract: The development of a detailed model of substance-abuse treatment (SAT) staff performance is described. The model describes the key behaviors of SAT staff. Specifically, researchers used the critical incident technique to develop the model, which includes a total of 15 dimensions, nested under four meta-dimensions: providing clinical services, employee citizenship behaviors, providing clinical support, and managerial behavior. Development and validation of a measure based on the model are also described. More than 600 SAT staff members in 51 SAT agencies completed the new measure. Factor analyses supported the measure's hypothesized dimensional structure; high internal consistency reliabilities were observed for all scales; and interrater agreement metrics indicated an acceptable level of within-agency agreement. Moreover, the measure correlated in expected and theoretically consistent ways with measures of job satisfaction and other job-related opinions.

Does Meeting the HEDIS Substance Abuse Treatment Engagement Criterion Predict Patient Outcomes?...25-39
Alex HS Harris, Keith Humphreys, Thomas Bowe, Quyen Tiet and John W. Finney
Abstract: This study examines the patient-level associations between the Health Plan Employer Data and Information Set (HEDIS) substance use disorder (SUD) treatment engagement quality indicator and improvements in clinical outcomes. Administrative and survey data from 2,789 US Department of Veterans Affairs SUD patients were used to estimate the effects of meeting the HEDIS engagement criterion on improvements in Addiction Severity Index Alcohol, Drug, and Legal composite scores. Patients meeting the engagement indicator improved significantly more in all domains than patients who did not engage, and the relationship was stronger for alcohol and legal outcomes for patients seen in outpatient settings. The benefit accrued by those who engaged was statistically significant but clinically modest. These results add to the literature documenting the clinical benefits of treatment entry and engagement. Although these findings only indirectly support the use of the HEDIS engagement measure for its intended purpose-discriminating quality at the facility or system level-they confirm that the processes of care captured by the measure are associated with important patient outcomes.

Assertive Outreach Strategies for Narrowing the Adolescent Substance Abuse Treatment Gap: Implications for Research, Practice, and Policy...40-63
Timothy J. Ozechowski and Holly Barrett Waldron
Abstract: In any given year, only about 10% of the nearly two million adolescents exhibiting substance abuse or dependence in the United States receive substance abuse treatment. Given this state of affairs, it is unlikely that the massive effort and expenditure of resources over the past decade on developing, testing, and disseminating effective treatments for adolescent substance abuse will have an appreciable impact on the prevalence of substance use disorders among the adolescent population. In order to substantially diminish the pervasive gap between levels of need for and utilization of adolescent substance abuse treatment, specialized assertive outreach strategies may be needed. This paper outlines a framework for assertive outreach for adolescents with substance use disorders and proposes specific types of strategies for identifying and enrolling such adolescents into treatment. Implications for practice and policy pertaining to adolescent substance abuse treatment service delivery are considered.

Substance Abuse Treatment Organizations as Mediators of Social Policy: Slowing the Adoption of a Congressionally Approved Medication...64-78
Stanley S. Wallack, Cindy Parks Thomas, Timothy C. Martin, Jon Chilingerian and Sharon Reif
Abstract: Most substance abuse treatment occurs in outpatient treatment centers, necessitating an understanding of what motivates organizations to adopt new treatment modalities. Tichy's framework of organizations as being comprised of three intertwined internal systems (technical, cultural, and political) was used to explain treatment organizations' slow adoption of buprenorphine, a new medication for opiate dependence. Primary data were collected from substance abuse treatment organizations in four of the ten metropolitan areas with the largest number of heroin users. Only about one fifth offered buprenorphine. All three internal systems were important determinants of buprenorphine adoption in our multivariate model. However, the cultural system, measured by attitude toward medications, was a necessary condition for adoption. Health policies designed to encourage adoption of evidence-based performance measures typically focus on the technical system of organizations. These findings suggest that such policies would be more effective if they incorporate an understanding of all three internal systems.

Implementation of Evidence-Based Practice and Organizational Performance...79-94
Peter S. Hovmand and David F. Gillespie
Abstract: Administrators of mental health services may expect evidence-based practice (EBP) to offer strategic benefits. Existing theory suggests that the benefits of implementing EBP vary by organizational characteristics. This paper presents a conceptual framework for considering how implementation impacts organizational performance. The framework is developed as a system dynamics simulation model based on existing literature, organizational theory, and key informant interviews with mental health services administrators and clinical directors. Results from the simulations show how gains in performance depended on organizations' initial inertia and initial efficiency and that only the most efficient organizations may see benefits in organizational performance from implementing EBP. Implications for administrators, policy makers, and services researchers are discussed.

Health and Mental Health Care Utilization by Clients of Resources for Homeless Persons in Quebec City and Montreal, Canada: A 5-year Follow-Up Study...95-110
Jean-Pierre Bonin, Louise Fournier, Régis Blais, Michel Perreault and Noé Djawn White
Abstract: The objective of this cohort study is to describe the service utilization by clients of homeless resources in Quebec and Montreal (Canada) over a 5-year period. Participants (N=426) were recruited from a survey conducted in 1999 about clients’ utilization of resources intended for homeless people in Montreal and Quebec. Data analyzed in this study were also drawn from three administrative databanks managed by the Quebec health care system. Results revealed that: (1) in general, mental health services are less used than physical health services; (2) generally, women, older persons, nonhomeless persons, and persons with mental health problems utilized proportionately more health services; and (3) participants involved in this study tend to continue using services over years in a system where health services are free. These findings are discussed in terms of long-term service utilization by clients of homeless resources.

Improving Practice-Research Connections through Technology Transfer Networks...111-123
Kimberley R. Isett and Susan D. Phillips
Abstract: This paper presents a first look at network and survey data collected to ascertain the salience and value-added of technology transfer networks in reducing the science-to-service gap in behavioral healthcare services. The National Child Traumatic Stress Network served as the case setting upon which administrative and survey data were analyzed. Results show a rich set of formal relationships within the National Child Traumatic Stress Network and suggest participants found these relationships and this medium useful in altering their day-to-day practices and increasing their professional knowledge. The implications of these findings are that technology transfer networks are useful mechanisms worthy of investment of scarce resources.

Psychometric Properties of the Spanish BASIS-24© Mental Health Survey...124-143
Susan V. Eisen, Pradipta Seal, Mark E. Glickman, Dharma E. Cortés, Mariana Gerena-Melia, Sergio Aguilar-Gaxiola, Vivian E. Febo San Miguel, Jesús Soto-Espinosa, Cristina Magaña and Glorisa Canino
Abstract: To assess mental health status among Latinos, culturally and linguistically appropriate instruments are needed. The purpose of this study was to assess psychometric properties and sensitivity of the Spanish revised Behavior and Symptom Identification Scale (BASIS-24©), a self-report mental health assessment instrument first developed and validated in English. The Spanish translation was field tested among Spanish-speaking recipients of inpatient (N?=?283) or outpatient (N?=?311) mental health services in Massachusetts, Puerto Rico, and California. BASIS-24© was completed within 72 h of admission and up to 48 h before discharge (for inpatients) or at intake and 30–60 days later for outpatients. Confirmatory factor analysis indicated adequate fit for the model obtained from the English instrument. Internal consistency reliability exceeded 0.70 for five of the six factors. Concurrent and discriminant validity were partially supported. Improvement following treatment was statistically significant, with small to moderate effect sizes.

Number 2 / January 2010

Hope for People with Mental Illness and Substance Use Disorders...145-146
Linda Rosenberg

Special Section: Collaborative Initiative to Help End Chronic Homelessness (CICH)
Special Section Editors: Sarah McGraw, PhD and James Herrell, PhD

Guest Editors’ Note...147-148
Sarah A. McGraw and James M. Herrell

Collaborative Initiative to Help End Chronic Homelessness: Introduction...149-166
Lawrence D. Rickards, Sarah A. McGraw, Lynnette Araki, Roger J. Casey, Cynthia W. High, Mary Ellen Hombs and Robyn S. Raysor
Abstract: The Collaborative Initiative to Help End Chronic Homelessness was a coordinated effort by the US Departments of Health and Human Services (HHS), Housing and Urban Development (HUD), and Veterans Affairs (VA), and the US Interagency Council on Homelessness to house and provide comprehensive supportive services to individuals with serious psychiatric, substance use, health, and related disabilities who were experiencing long-term chronic homelessness. Eleven communities received 3-year grants from HHS and VA (2003-2006) and up to 5-year grants from HUD (2003-2008) to implement the initiative. This article provides background on chronic homelessness, describes the federal collaboration to comprehensively address chronic homelessness, and introduces the seven articles in this special issue that describe the findings and lessons learned from the participating communities in addressing chronic homelessness. Collectively, these articles offer insight into the challenges and benefits of providing housing and services to individuals experiencing chronic homelessness.

Twelve-Month Client Outcomes and Service Use in a Multisite Project for Chronically Homelessness Adults...167-183
Alvin S. Mares and Robert A. Rosenheck
Abstract: Collaborative Initiative to Help End Chronic Homelessness clients (N=734) were enrolled into an evaluation wherein assessments at program entry and quarterly thereafter addressed sociodemographic characteristics, health status, and a wide range of service use and outcomes data. Mixed linear regression analysis was used to test for significant changes over time. The average number of days housed during the previous 3 months increased dramatically from 18 at baseline to 83 by year’s end. Significant improvements of more modest magnitude were also observed in overall quality of life, mental health functioning, and reduced psychological distress. Alcohol and drug problems remained largely unchanged over time, among clients overall. However, among baseline drug users crack, cocaine, and marijuana use decreased by 28–50% over the follow-up period. Total quarterly health cost estimates declined by 50%, as well, from $6,832 to $3,376. These findings suggest that adults who have experienced chronic homelessness may be successfully housed and can maintain their housing, when provided with comprehensive services.

An Evaluation of an Initiative to Improve Coordination and Service Delivery of Homeless Services Networks...184-196
Greg A. Greenberg and Robert A. Rosenheck
Abstract: This study examines system changes associated with the implementation of the Collaborative Initiative to Help End Chronic Homelessness, an 11-site multi-agency intervention for chronically homeless adults. Data obtained from key informants on community-level interventions and interorganizational relationships were gathered from an average of 6.6 agencies at each site in four yearly waves. Hierarchical linear modeling was used to examine time trends and bivariate relationships between measures. There were significant increases over the full study period in the use of practices designed to encourage system integration, as well as in interorganizational measures of joint planning and coordination, and of trust and respect, although in later waves of the study these measures leveled off. There were also highly significant and positive cross-sectional associations between the use of practices designed to encourage system integration and direct measures of service system integration as well as between measures of change in these system characteristics.

Adopting Best Practices: Lessons Learned in the Collaborative Initiative to Help End Chronic Homelessness (CICH)...197-212
Sarah A. McGraw, Mary Jo Larson, Susan E. Foster, Marilyn Kresky-Wolff, Elizabeth M. Botelho, Emily A. Elstad, Ana Stefancic and Sam Tsemberis
Abstract: The Collaborative Initiative to Help End Chronic Homelessness (CICH) was established to provide housing and supportive services for individuals experiencing chronic homelessness. As part of this initiative, 11 projects across the country received funding to apply models of best practices to support their clients in housing. This paper reports on the experiences of the CICH projects in their use of Assertive Community Treatment (ACT) and Motivational Interviewing (MI), clinical practice models commonly used by CICH projects. A qualitative analysis identified five areas of challenge for the projects: (1) Incomplete and underdeveloped staff teams; (2) Incomplete understanding of the practice models; (3) Using the elements of the practice models; (4) Interagency teaming; and (5) Competing expectations of multiple federal agencies. The paper describes the specific challenges in each of the five areas as well as training approaches and gaps in training and the perceived benefits of the practice models as reported by project staff.

Supportive Housing Approaches in the Collaborative Initiative to Help End Chronic Homelessness (CICH)...213-225
Marilyn Kresky-Wolff, Mary Jo Larson, Robert W. O’Brien and Sarah A. McGraw
Abstract: The Federal Collaborative Initiative to Help End Chronic Homelessness funded 11 sites to expand permanent housing and offer supportive services to persons experiencing chronic homelessness and suffering from mental and substance use disorders. This study examines qualitative data on how the projects used US Department of Housing and Urban Development funding and three housing approaches (scattered units, congregate/clustered, or a combination) for rapid placement of clients. Each housing approach called for adaptations by the services teams and property personnel in order to support clients with independent living skills, prevent housing loss, and promote their overall health in line with Initiative goals. Property personnel reported taking on new roles with clients and forming new collaborative arrangements with services teams. The authors discuss the lessons reported by sites that were associated with housing configuration, type of lease, and role of property personnel.

Staffing Challenges and Strategies for Organizations Serving Individuals who have Experienced Chronic Homelessness...226-238
Jeffrey Olivet, Sarah McGraw, Megan Grandin and Ellen Bassuk
Abstract: Hiring and retaining appropriate staff is essential for programs serving those who have experienced chronic homelessness. This paper describes specific staffing challenges and strategies from the Collaborative Initiative to Help End Chronic Homelessness (CICH), an 11-site, multi-agency Federal program designed to serve people experiencing chronic homelessness who also have a disabling condition such as substance use or mental health problems. This paper addresses approaches to staffing including team structures, staff supervision, and training. Challenges identified include low pay, high rates of burnout and turnover, limited time for supervision, and multiple staff training needs. This paper also explores specific staffing strategies based on the experience of the CICH sites, and concludes with implications for practice, research, and policy, including recommendations for ongoing staff training, suggestions for future mixed-methods research, and a call for an enhanced focus on strengthening the homeless services workforce.

Services and Supports for Individuals with Co-occurring Disorders and Long-Term Homelessness...239-251
Susan Foster, Charlene LeFauve, Marilyn Kresky-Wolff and Lawrence D. Rickards
Abstract: Co-occurring mental health and substance use disorders are highly prevalent among individuals experiencing long-term homelessness. This paper describes strategies used by 11 projects funded by the Federal Collaborative Initiative to Help End Chronic Homelessness (CICH) to serve individuals with co-occurring disorders (COD) as they transition from homelessness to permanent-supported housing. Findings are based on the observations of clients, program team members, and administrators. This paper presents findings organized around three themes: characteristics and needs of CICH clients with COD, strategies employed to respond to those needs, and challenges associated with implementing an integrated approach to COD. Client characteristics include histories of untreated or intermittently treated mental health and substance use disorders, often further complicated by trauma and chronic illness. Project teams endorsed a variety of services and supports such as engagement, stabilization, motivational techniques, groups, and trauma-informed interventions as useful for their clients with COD. Challenges identified include difficult client behavior, the extended time required for change to occur within this population, inadequate staffing and community resources, and system barriers. The paper concludes with recommendations for further research into the effectiveness of various combinations of service strategies for this population in non-traditional settings during the earliest stage of recovery, along with a call for overcoming workforce and system-level barriers to providing integrated care.

Regular Articles

Using Administrative Data for Longitudinal Substance Abuse Research...252-271
Elizabeth Evans, Christine E. Grella, Debra A. Murphy and Yih-Ing Hser
Abstract: The utilization of administrative data in substance abuse research has become more widespread than ever. This selective review synthesizes recent extant research from 31 articles to consider what has been learned from using administrative data to conduct longitudinal substance abuse research in four overlapping areas: (1) service access and utilization, (2) underrepresented populations, (3) treatment outcomes, and (4) cost analysis. Despite several notable limitations, administrative data contribute valuable information, particularly in the investigation of service system interactions and outcomes among substance abusers as they unfold and influence each other over the long term. This critical assessment of the advantages and disadvantages of using existing administrative data within a longitudinal framework should stimulate innovative thinking regarding future applications of administrative data for longitudinal substance abuse research purposes.

The Distribution and Frequency of Seclusion and/or Restraint among Psychiatric Inpatients...272-281
Michael Hendryx, Yaroslav Trusevich, Frank Coyle, Robert Short and John Roll
Abstract: This paper reports on the frequency and distribution of seclusion or restraint (SR) episodes among 1,266 adult inpatients at a state psychiatric hospital during the 2004 calendar year. Data on the concentration of SR episodes over patients and time can assist in planning alternative, recovery-oriented treatment models. Fifteen percent (N?=?194) of patients experienced seclusion or restraint. Sixty-three percent of all seclusion hours were concentrated among only ten patients. Likewise, the ten patients with the most restraint hours constituted nearly 65% of total restraint hours for the year and 48% of all restraint episodes. Variables accessible through administrative data accounted for modest seclusion and restraint variance. A comprehensive strategy to prevent SR episodes requires tailored interventions targeted to known high-risk individuals and development of general hospital-wide alternatives to SR. General alternatives require greater attention to staff education, administrative oversight, de-escalation and debriefing practices, patient involvement, and other recovery-oriented practices to reduce or eliminate use of seclusion and restraint.

Number 3 / January 2010

Medicare Parity: We’re Not Done Yet!...283-284
Linda Rosenberg
Abstract: While Medicare’s discriminatory copayments for mental and physical health care are being eliminated, much remains to be done to achieve true parity within Medicare. Medicare needs to recognize and pay for such critical mental health services as case management, psychiatric rehabilitation, and assertive community treatment. Medicare must cover payments for all behavioral health professionals. Also the 190-day lifetime limit on inpatient psychiatric hospital days under Medicare must be removed. We envision a time—in the not too distant future—when Medicare provides a mental health benefit that includes vital community services.

Medicare Mental Health Parity: A High Potential Change that is Long Overdue...285-290
Laysha Ostrow and Ronald Manderscheid
Abstract: Recent changes in legislation regarding mental health parity in Medicare will revolutionize payment for mental health care and delivery systems. This commentary discusses why this policy change was essential to promote adequate care for populations served by Medicare and to address expected changes in beneficiary, provider, and plan behavior as more equitable payments by Medicare are implemented.

Improving Risk Adjustment of Self-Reported Mental Health Outcomes...291-306
Amy K. Rosen, Sharmila Chatterjee, Mark E. Glickman, Avron Spiro, Pradipta Seal, and Susan V. Eisen
Abstract: Risk adjustment for mental health care is important for making meaningful comparisons of provider, program, and system performance. The purpose of this study was to compare the predictive value of three diagnosis-based risk-adjustment models for predicting self-reported mental health outcomes. Baseline and 3-month follow-up mental health assessments were obtained on 1,023 veterans in Veterans Health Administration mental health programs between 2004 and 2006. Least-squares regression models predicting mental health outcomes used the Behavior and Symptom Identification Scale-24, Veterans RAND-36, and Brief Symptom Inventory. Sequential models began with sociodemographics, added baseline self-reported mental health, and compared three psychiatric case mix schemes: two using six diagnostic categories and the other (psychiatric case mix system [PsyCMS]) using 46 categories. R 2 were lowest for sociodemographic models (0.010–0.074) and highest for models with the PsyCMS (0.187–0.425). The best predictive ability was obtained when baseline mental health and 1 year of psychiatric diagnoses were added to sociodemographic models; however, the “best” risk-adjustment model differed between inpatients and outpatients.

Service System Involvement and Delinquent Offending at System of Care Entry...307-321
Leyla F. Stambaugh, Dannia Southerland, Sarah A. Mustillo and Barbara J. Burns
Abstract: This study examines correlates of delinquent offending among 2,554 youths presenting to community-based treatment in Center for Mental Health Services-funded systems of care. Variables in five key domains, including demographics, family risk, child clinical risk, school, and service system involvement, were examined in relation to severity of offending at treatment entry for early/middle (11–15 years) versus late (16–18 years) adolescents. Significant correlates of offending severity were identified in all domains except family risk for the 11 to 15 year olds and in demographics and child clinical risk for the 16 to 18 year olds. Service system involvement was a unique correlate of delinquency in the younger group. Findings add to other studies showing that correlates of offending appear to differ across stages of adolescence; specifically, school and service system involvement may be less important for older adolescents than for younger adolescents. Service system involvement should be included in longitudinal studies of risk for adolescent offending.

Top Manager Effects on Buprenorphine Adoption in Outpatient Substance Abuse Treatment Programs...322-337
Peter D. Friedmann, Lan Jiang and Jeffrey A. Alexander
Abstract: To examine the influence of top managers’ characteristics on the adoption of buprenorphine for opioid dependence among U.S. outpatient substance abuse treatment units, this investigation analyzed a cross-sectional national study of 547 such units in the 2004–2005 wave of the Drug Abuse Treatment System Survey. Administrators reported their demographics, training, and treatment orientation, as well as features of the unit and its pattern of use of buprenorphine. Nationally, 15.8% of programs offered any buprenorphine services. Greater adoption of buprenorphine correlated with directors’ younger age, longer tenure, male gender, and weaker endorsement of abstinence as the most important treatment goal. Availability of naltrexone and medical services also correlated positively with buprenorphine adoption. The authors conclude that leaders’ characteristics are related to the adoption of innovative practices in addiction treatment programs. Future work should examine whether leadership development for community addiction programs might speed up the diffusion of buprenorphine and other innovative, evidence-based practices.

School Personnel Perspectives on their School’s Implementation of a School-Based Suicide Prevention Program...338-349
Bradley D. Stein1, Sheryl H. Kataoka, Alison B. Hamilton, Dana Schultz, Gery Ryan, Pamela Vona, and Marleen Wong
Abstract: Youth suicide is a national public health priority, with policymakers highlighting schools as an ideal setting in which to deliver suicide prevention programs. Over the past decade, the number of schools implementing such programs has grown substantially, yet little is known about how successfully such programs are being implemented. This study examines the implementation of a district-wide suicide prevention program through key informant interviews with school personnel. Schools with higher rates of implementing district protocols for at-risk students had an organized system to respond to at-risk students, a process for effectively responding to students who were at-risk for suicide, and strong administrative support. In contrast, schools that had lower rates of implementing district protocols relied on a handful of individuals for suicide prevention activities and had limited administrative support. Attention to organizational factors leading to successful implementation of school-based suicide prevention programs may enhance the role of schools in national adolescent suicide prevention efforts.

Longitudinal Predictors of Youth Functional Improvement in a Public Mental Health System...350-362
Charles W. Mueller, Ryan Tolman, Charmaine K. Higa-McMillan and Eric L. Daleiden
Abstract: The present study examined youth characteristics that predict level of impairment at entry into a system of care and rate of improvement over the course of service provision. Youth characteristics studied included gender, age, specific diagnostic categories, and comorbidity. A total of 2,171 youth served in a state-wide public mental health system were included in the study. Hierarchical linear modeling was used to analyze longitudinal data derived from quarterly ratings of functional status. Gender had no relationship to initial level of impairment or rate of improvement. Older youth, those with disruptive behavior disorders, and those with more than one DSM diagnosis were more impaired at system entry. Those with attentional disorders began services less impaired. Older youth improved at faster rates. Youth with a disruptive behavior disorder diagnosis improved at slower rates. Neither comorbidity nor the presence of a mood or attentional disorder affected the rate of improvement. Both researchers and systems of care developers should consider these patterns in their future work.

Regular Article Differences in Mental Health Service Sector Utilization among African American and Caucasian Youth Entering Systems of Care Programs...363-373
Crystal L. Barksdale, Melissa Azur and Philip J. Leaf
Abstract: Differences in unmet need and access to services between African American and Caucasian youth have been established; less is known about differences in specific mental health service sectors. This study examined differences in past year outpatient, school-based, day treatment and residential/inpatient service utilization among African American and Caucasian youth (n = 3,649) entering a federally funded system of care program. Random effect logistic regression models were implemented to examine the relationship between race and past year service utilization. Analyses revealed that African American youth were less likely than Caucasian youth to have utilized school-based and residential/inpatient mental health services in the past year. Findings suggest that racial disparities exist in service use for certain types of service sectors and highlight the importance of understanding and identifying individual, family, and community factors that contribute to disparities in service utilization.

Special Issue
Exploring the Utility of an Estimation Procedure to Reveal Drug Use among Arrestees: Implications for Service Delivery...374-384

Shayne Jones, Christopher Sullivan, Michael Caudy and Thomas Mieczkowski
Abstract: One of the most persistent questions plaguing researchers and service providers is how to best estimate the extent of targeted behaviors in relevant populations. One problem of particular importance is the prevalence of drug use in justice-involved populations. Data have been collected through such methods as self-report and analysis of biological specimens, although both have notable limitations when used alone. As a means of drawing on the strengths of both methods, such data can be used in a confirmatory manner or, alternatively, may be summed to estimate prevalence. However, this latter approach is not without difficulty as different sources lack substantial agreement. The focus of this study is to employ a methodology that utilizes multiple data sources and adjusts for nonreporting from either source. Compared to more commonly employed techniques, the results indicate that the alternative method yields higher estimates of marijuana and cocaine use among a sample of arrestees. These findings, in turn, suggest that current behavioral health interventions and policies may be based on underestimates of drug use.

Regular Article
Recovery Orientation in Hospital and Community Settings...385-399
Jack Tsai and Michelle P. Salyers
Abstract: There has been an increasing emphasis on community integration, consumer involvement, and recovery-focused treatment; but the extent to which these recovery-oriented principles have been adopted in state hospitals is unknown. This study surveyed 1,150 staff at three state hospitals and 230 staff at four community mental health centers on personal optimism, consumer optimism, and agency recovery orientation. Responses were obtained from 729 (63.4%) hospital staff and 181 (78.7%) community staff. Staff at state hospitals scored significantly lower on all three recovery measures even after controlling for background differences. Treatment setting may be an important factor in the dissemination of recovery-oriented care principles.

Case Study
Use of Performance-Based Contracting to Improve Effective Use of Resources for Publicly Funded Residential Services...400-408
Joseph Faith, Catherine Panzarella, Robert C. Spencer, Catherine Williams and James Brewer, et al.
Abstract: This article details the process that was undertaken to convert the financing mechanism for publicly funded mental health residential programs in a large urban setting from nonincentivized agreements to performance-based contracts. The initial target for change was improving occupancy rates for residential services targeted to persons with serious and persistent mental illness. Improving occupancy rates enhanced efficiency such that 25 additional cents for every dollar spent on mental health residential services went to direct care. Challenges met in the process of effecting the contracting conversion of this expansive system are addressed. The importance of centralized gatekeeping, stakeholder involvement, and setting modest expectations are emphasized as keys to success. Although the system still has less capacity than client demand warrants, existing beds are no longer underutilized. Recent efforts to expand contracting targets beyond efficiency goals to include improved quality and effectiveness are also discussed.

Number 4 / January 2010

Time to Take a Breath...409-411
Linda Rosenberg
Abstract: With health care reform the law of the land, we must be ready to compete on a new playing field where increasing numbers of individuals will have healthcare insurance benefits. Our job is to ensure that their new benefits result in access to effective behavioral health services. The National Council for Community Behavioral Healthcare has led breathtaking initiatives to make access to care more timely, to create structures for collaborative care for shared patients, to enhance the knowledge, skills, and abilities of psychiatrists who are medical directors in community behavioral health centers, and to combat stigma, educate key audiences, and improve awareness of treatment options for individuals with mental illnesses.

An Examination of Emergency Department Pediatric Psychiatric Services...412-426
Jennifer Field Brown and Christine M. Schubert
Abstract: The purpose of this study was to explore the structure, process, and outcomes of emergency department (ED) psychiatric services that are available to children who present with behavioral health problems. The author designed and employed a 33-item survey for data collection. All nonfederal EDs in one southeastern state (N = 68) were solicited to participate. Descriptive analyses including ANOVAs, t tests, and chi-squares summarized sample characteristics and group differences by ED pediatric psychiatric service (EDPPS) arrangement. Thirty-four hospitals participated, sharing similar organizational characteristics with nonresponders except that participating hospitals were significantly more likely to have inpatient psychiatric services. The survey successfully captured data confirming that EDs use a range of strategies to manage children with behavioral health problems, raising concerns about the suitability of such service variation. These results highlight the need for further research that examines the association of EDPPS structure and process with patient and organizational outcomes to inform quality improvements in pediatric behavioral healthcare.

Implementing the Essential Elements of a Mental Health Court: The Experiences of a Large Multijurisdictional Suburban County...427-442
Donald M. Linhorst, P. Ann Dirks-Linhorst, Steve Stiffelman, Janet Gianino Herbert L. Bernsen,and B. Joyce Kelley
Abstract: Mental health courts developed in the USA in the late 1990s as one means to reduce the involvement of people with mental illness in the criminal justice system. In response to the growth in number of mental health courts, the Council of State Governments led an initiative to identify essential elements of mental health courts to guide their development and implementation. This paper applies these essential elements to a municipal mental health court in a multijurisdictional, suburban county. While this court met most essential elements, they faced a number of challenges. The primary ones included not being able to advance from hearing municipal cases only to state misdemeanor and felonies, not having the resources to expand program capacity for municipal cases, and participants not being able to always access needed mental health treatment, rehabilitation, and support services. The paper concludes with implications for behavioral health administrators and direct service staff in implementing the essential elements of mental health courts.

Maternal Mental Health and Pediatric Health Care Use Among a National Sample of Medicaid- and SCHIP-Insured Children...443-460
Sara Wiesel Cullen, Jason C. Matejkowski, Steven C. Marcus and Phyllis L. Solomon
Abstract: While the literature has shown that health care use is associated with mental health status, little is known about the relationship between a mother’s mental health status and her children’s health care use. This study examined the association of maternal mental health status and pediatric health care for their children in a nationally representative sample of 17,830 women parenting children ages 0–17 insured through Medicaid or a State Children’s Health Insurance Program (SCHIP). Mothers with a mental health problem were significantly more likely to be poorer, single parents, with lower levels of education, fewer parenting supports, and greater difficulty coping with parenting than mothers without a mental health problem; however, they reported comparable receipt of pediatric health care for their children, indicating their resilience as caretakers. The findings also suggest that all Medicaid- or SCHIP-eligible families could benefit from targeted engagement strategies linking them with consistent and appropriate sources of pediatric health care.

Employment Services Utilization and Outcomes among Substance Abusing Offenders Participating in California’s Proposition 36 Drug Treatment Initiative...461-476
Elizabeth Evans, Yih-Ing Hser and David Huang
Abstract: California drug treatment programs may use funds to address barriers to work faced by Proposition 36 offenders, most of whom are not working at treatment entry, but employment services utilization and related behavioral outcomes have never been studied. This study examined primary data collected on 1,453 offenders by 30 programs during 2004 to explore the characteristics, employment services utilization, and outcomes of those who did and did not receive employment services while in drug treatment. One-year outcomes were mostly similar across groups, however, increases in the proportion of offenders employed, receiving income from employment and family or friends, and being paid for work were significantly greater among the received-employment-services group, and a greater proportion of this group also completed drug treatment. Employment services utilization was less likely for persons recruited from outpatient settings and more likely with greater severity of family/social problems and desire for services. Odds of employment one-year post-treatment entry were higher for those of Hispanic race/ethnicity (vs. White) and for those with treatment completion/longer retention but lower for those who were older, lived in specific counties, had greater employment problem severity at intake, and received other income-related services. Strategies for improving employment services utilization and outcomes among Proposition 36 offenders are discussed.

Categorizing Temporal Patterns of Arrest in a Cohort of Adults with Serious Mental Illness...477-490
William H. Fisher, Steven M. Banks, Kristen Roy-Bujnowski, Albert J. Grudzinskas, Lorna J. Simon, and Nancy Wolff
Abstract: Temporal patterns of arrest among mental health systems' clientele have not been well explored. This study uses “trajectory analysis,” a methodology widely employed by criminologists exploring patterns of desistence in offending, to examine patterns of criminal justice involvement in a cohort of mental health service recipients. Data for this study are from a statewide cohort of individuals who received services from the Massachusetts Department of Mental Health in 1991 (N = 13,876) and whose arrests were followed for roughly 10 years. Zero-inflated Poisson trajectory analysis applied to cohort members having two or more arrests identified five trajectories with widely varying arrest patterns. Analysis of differences in the composition of the five trajectory-based groups revealed few between-group differences in members' demographic and service use characteristics, while certain offense types were disproportionately prevalent among particular trajectory-based groups. The implications of these findings for understanding criminal justice involvement in this population and the utility of the trajectory model for system planning are discussed.

Patterns of Functional Impairment and Their Change among Youth Served in Systems of Care: An Application of Latent Transition Analysis...491-507
Robert L. Stephens, Hanno Petras, Anupa Fabian and Christine M. Walrath
Abstract: This study describes patterns of youth functioning at intake and 6 months into services in systems of care and change in functioning profiles. Participants included 2,826 males and 1,335 females aged 5 to 18 at intake. Functional impairment was assessed at intake and 6 months. Latent class analysis was used to classify youth based on their functional impairment profiles, and latent class transition analysis was used to examine the conditional probabilities of transitions in class membership between intake and 6 months. Males and females enter services with distinct patterns of functional impairment. The majority of youth remained in their respective profiles. Transitions tended to be from a higher to a lower impairment class. Importantly, a small group of males and females transitioned from a low to a higher impairment class. Providers should note that gender differences existed in the nature of change in class membership over time.

US Hospitalizations and Costs for Illicit Drug Users with Soft Tissue Infections...508-518
Traci A. Takahashi, Matthew L. Maciejewski and Katharine Bradley
Abstract: Skin and soft tissue infections (SSTIs) are common complications of illicit drug use. Studies at single, urban hospitals demonstrate high rates of emergency department visits and hospitalizations for these infections. This study sought to estimate nationwide and regional incidence and costs of hospitalizations for illicit drug users with SSTIs in the US. AHRQ’s Nationwide Inpatient Sample was used to conduct a retrospective cross-sectional, time-series study. Hospitalizations of illicit drug users with SSTIs were identified using International Classification of Diseases, 9th Revision Clinical Modification codes. An estimated 106,126 hospitalizations for illicit drug users with SSTIs represented 0.07% of all US non-Federal hospitalizations from 1998 to 2001 and cost over 193 million dollars in 2001. Higher rates of hospitalization were found in the West, Northeast, and urban teaching hospitals. Hospitalization rates for illicit drug users with SSTIs vary significantly according to US region. Resources to reduce the incidence and severity of these infections should be targeted accordingly.

Burnout in the Mental Health Workforce: A Review...519-528
Manuel Paris and Michael A. Hoge
Abstract: There are enormous concerns regarding the recruitment, retention, training, and performance of the behavioral health workforce. Paramount among these concerns is turnover, which causes disruption in continuity of care, diminishes access to care while a position remains vacant, and poses financial hardship on the provider organization through costs related to recruitment, orientation, and training of a new hire. There is frequent mention of burnout within the literature and among behavioral health managers as a potential cause of turnover. However, there is no recent or comprehensive review of burnout that examines the evidence surrounding its validity, utility, and potential relationship to turnover. The purpose of this paper is to provide such a review by examining the construct of burnout, methodological and measurement issues, its prevalence in the mental health workforce, correlates of burnout, and interventions to decrease it. The implications for provider organizations and recommendations for future research are identified.

Mind and Body Reunited: Improving Care at the Behavioral and Primary Healthcare Interface...529-542
Barbara J. Mauer and Benjamin G. Druss
Abstract: This paper reviews current models, research, and approaches to improving care on the primary care/behavioral health interface in the USA. We focus on care in the public sector where high rates of comorbidity, regulatory burdens, and lack of resources create particular challenges to collaboration and coordination. To achieve the goals of improved coordination and collaboration, it will be critical to address key financing, workforce, information technology, performance assessment, and research issues. It will also be critical to engage multiple stakeholders including