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Title: A Mixed Methods Approach to Assessing How System Change Impacts Clinics and Consumers in Public Ment


1
A Mixed Methods Approach to Assessing How
System Change Impacts Clinics and Consumers in
Public Mental Health
  • Joel T. Braslow, M.D., Ph.D.
  • Semel Neuropsychiatric Institute
  • UCLA
  • John S. Brekke, Ph.D.
  • Frances Larson Professor of Social Work Research
  • School of Social Work
  • University of Southern California
  • Kathleen Daly, M.D., MPH
  • Los Angeles County Department of Mental Health
  • Mapping Progress in Mental Health Disparities,
    May 20, 2009

2
The California MHS Act Impact on Practice
Organizational Culture in Public ClinicsNIMH
R-01 MH08067 (Joint PIs Braslow, Brekke Co-PI
Kathleen Daly)
3
Study Goals
  • What changes occur as a consequence of the MHSA?
  • Why does change occur (or not)?

4
MHSA in Historical Perspective
  • Apparent discontinuity with the past
  • Continuities with the past
  • Intended and unintended consequences

5
Psychiatric Interventions from the 1900s to 1954
Insulin Coma
6
Average Daily Antipsychotic Drug Dosage,
California State Hospitals, 1955-2001
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8
Continuities
"An alternative approach which would call for a
courageous scrapping of traditional concepts and
a gearing of our institutional program to the
concept of therapy rather than of
custody." California Department of Mental Health,
1949
9
Two Centuries of Recovery
10
UNINTENDED CONSEQUENCES OF POLICIES
11
California State Hospital Population, 1850-1995
12
  • Elpers JR (1989), Public Mental Health Funding in
    California, 1959 to 1989, Psychiatric Services

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  • Will the MHSA actually transform care in Los
    Angeles County?
  • How do we make sense of the continuities with the
    past?
  • How do we assess both intended and unintended
    consequences?

15
California and Los Angeles
  • California population of 36.8 million
  • 12 million live in households below 200 of the
    FPL
  • 8.8 of these low-income residents meet the MHSA
    funding allocation criteria of a serious
    emotional disturbance (SED) or serious mental
    illness (SMI)
  • Los Angeles County population of 10.25 million
  • 3.95 million individuals living in households
    below 200 of the FPL
  • 8.7 of these low-income residents meet the MHSA
    funding allocation criteria of a SED
  • LAC will receive 30 of MHSA funds

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The California MHS Act Impact on Practice
Organizational Culture in Public ClinicsNIMH
R-01 MH08067 (Joint PIs Braslow, Brekke Co-PI
Kathleen Daly)
18
Senior Study Team
  • Joel Braslow, MD/PhD Psychiatry/History
  • John Brekke, PhD Social Work
  • Kathleen Daly, MD/MPH Psychiatry
  • Beth Bromley, MD/PhD Psychiatry/ Anthropology
  • Project Director, Amanda Nelligan, MA Psychology

19
Research Staff
  • 4 PhD-level Ethnographers
  • 4 Consumer Specialists
  • 2 PhD Graduate Students

20
Collaborations
  • Public-Academic Partnership
  • LAC DMH
  • UCLA
  • USC
  • Interdisciplinary Collaborations
  • Health Services Research
  • Health economics
  • Biostatistics
  • Anthropology
  • Ethnocultural Mental Health

21
Specific Aims
  • Aim 1 County level Assess how LAC DMH develops
    and implements MHSA clinical policy over time
    examining fiscal, clinical, political, historical
    determinants.
  • Aim 2 Clinic Level Assess how clinics implement
    LAC DMHs interpretation of the MHSA, and how
    this transforms clinical culture, structure, and
    providers understandings of illness and
    treatment.
  • Aim 3 Client Level Assess the impact of local
    clinical transformations on clients objective
    outcomes and subjective experiences of their
    mental health treatment.

22
Mixed-Methods Approach
  • Goal
  • What effects the MHSA has on clients
  • Why the observed effects occurred
  • Quantitative methods using
  • Provider questionnaires
  • Client questionnaires
  • LAC DMH IS Database
  • Qualitative methods using
  • Semi-structured interviews
  • Ethnographic observations
  • Focus groups

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Summary
  • The four studies targeted system factors and then
    examined their impact on client-level outcomes.
  • None of them examined clinic level factors, yet
    all involved a clinic level context of service
    delivery.
  • The clinic and its context was a black box in
    these studies, despite being critical in
    mediating between system-level and client level
    outcomes.

27
Aim 1 Research Questions(Assess how the LAC DMH
develops and implements MHSA clinical policy over
time.)
  • What clinical, fiscal, and political concerns
    enter into LAC DMH MHSA policy implementation and
    policy change over time?
  • What ways in which past policy decisions (e.g.,
    AB 2034) shape current policy decisions?

28
Aim 1 Design
  • Administrative/historical documents
  • Semi-structured interviews (n18)
  • three levels (executive management, district
    chiefs and staff)
  • baseline and at the end of years 1, 2, 3
  • Five focus groups
  • (1) Union of American Physicians and Dentists
  • (2) Services Employee International Union (SEIU
    local 660)
  • (3) National Alliance for the Mentally Ill (Los
    Angeles Chapter)
  • (4) Los Angeles County Client Coalition and
  • (5) California Mental Health Directors Association

29
Remember Aim 2 concerns the clinic Aim 3
concerns the client
30
Aim 2
  • Clinic Level Assess how clinics implement LAC
    DMHs interpretation of the MHSA, and how this
    transforms clinical culture, structure, and
    providers understandings of illness and
    treatment.

31
Aim 2 Research Questions
  • How and why do providers beliefs, attitudes and
    practices change over time?
  • Do FSP (MHSA) providers differ in their recovery
    orientation and competencies relative to non-FSP
    providers?
  • Does MHSA clinic funding affect recovery
    competencies/orientation for providers not in
    FSPs?

32
Los Angeles County
  • 469.1 square miles
  • 8 Service Planning Areas
  • 321 clinics
  • 33 directly operated by DMH and treat
    approximately 60 of unique DMH adult
    outpatients
  • 288 contract clinics

33
Design For Aims 2 3
  • Intensive Case Study with Quasi-Experimental
    Cross-site Comparisons
  • 3 MHSA Clinics (2 DO, 1 Contact)
  • 2 Non-MHSA Clinics (1 DO, 1 Contract)

34
Clinic Site Selection
35
Collaborative Sites
  • 2 Contract Clinics
  • 1 with MHSA funding with Full Service Partnership
  • 1 with no MHSA Funding
  • 3 Directly-Operated Clinics
  • 2 with MHSA funding with Full Service Partnership
  • 1 with no MHSA Funding

36
Aim 2 Methods
  • Ethnographic observation
  • Semi-structured provider interviews (n50 6
    waves)
  • Observation of clinician-client visits
  • Provider self-administered surveys (n377 3
    waves)
  • Administrative data from LAC DMH IS database

37
Provider Assessments
  • Survey
  • Universal Sample of All clinicians
  • Frequency every 12 months
  • Semi-structured interviews
  • Sample based on purposive criteria
  • Frequency 6 months

38
Provider Survey
  • Recovery Self-Assessment (RSA)-Provider Version
  • Gauges providers perceptions of how well
    programs implement practices consistent with
    principles of recovery.
  • Attitudes Towards Illness
  • Beliefs about A) impact of illness, B)
    chronicity, C) client understanding and control
    of illness, D) causes of illness, E) impact of
    treatment
  • Clinic Culture
  • Clinic culture, structure, climate, work
    attitudes (Glisson)

39
Provider Semi-Structured Interviews
  • Open-ended interviews focusing on beliefs about
    recovery, illness and therapeutics
  • Frequency 6 months

40
Provider snapshots of clinic life
  • 15 minute face-to-face or phone interactions
    every two weeks. Cohort followed over time.

41
Aim 3
  • Client Level Assess the impact of local
    clinical transformations on clients objective
    outcomes and subjective experiences of their
    mental health treatment.

42
Aim 3 Research Questions
  • How and why do clients experiences of care
    change?
  • How effective are FSPs relative to usual care in
    MHSA-funded clinics?
  • Does MHSA funding result in worse outcomes for
    usual-care clients in MHSA- funded clinics?

43
Aim 3 Methods
  • Ethnographic observation
  • Semi-structured client interviews (n50 6 waves)
  • Client self-administered surveys (n616 every
    six months over 3 years)
  • Administrative data from LAC DMH IS system

44
Client Sampling Design
45
Matching Criteria
  • high service utilization or homeless or jail
  • diagnosis
  • age
  • gender
  • ethnicity

46
Client Assessment
  • Client assessment surveys
  • Semi-structured interviews
  • Observation of client-provider interactions

47
Client Assessment Continued
  • The BASIS-32 is a brief, widely-used behavioral
    health assessment instrument that provides a
    comprehensive measure of functioning.
  • Recovery Self-Assessment Person in Recovery
    version gauges perceptions of how well programs
    implement practices consistent with principles of
    recovery
  • Working Alliance Inventory Attitudes Towards
    Illness Living situation and work functioning
  • Quality of life measures SWL, AQOL,
    Acculturation and Ethnic identity
  • Frequency 6 months

48
Semi-Structured Interviews
  • 5 Clients per cell (10-15/clinic)
  • Frequency 6 months
  • Aim probe clients subjective experiences of
    treatment (its process and impact on them) and of
    the clinic.

49
Overview of Conceptual Domains in Quantitative (
Qualitative) Measures for MHSA Study1.
Organizational and Social Context (staff only)
A). structure is the distribution of
power and formalization of roles (i)
centralization of authority and decision making
in a few people (ii) formalization is the extent
to which rules and regulations guide all work
activities B). culture is the values and
norms that drive behavior (i) constructive,
(ii) passive defensive, (iii) active defensive
C). climate is the psychological impact of the
work environment on the individual (i)
engagement, (ii) stress, (iii) psychological
safety D). work attitudes are the
individuals morale (i) job satisfaction, (ii)
commitment to organization
50
2. Recovery Assessment (staff and client)
A). Life goals extent to which staff help
with pursuit of life goals B). Involvement
consumer involvement with services and
administrative aspects of clinic C).
Diversity of treatment options linkages to peer
providers, variety of treatment options and
non-mental health activities D). Choice
consumer choice is respected, access to treatment
records, non-coercive treatment methods used
E). Individually-tailored services services
tailored to consumer needs, interests and
ethnicity 3. Attitudes Towards Illness
(staff and client) Beliefs about A) impact
of illness, B) chronicity, C) client
understanding and control of illness, D) causes
of illness, E) impact of treatment
51
4. Client Functioning (client only) Assesses
client difficulty with A) daily living/role
functioning B) relationship to self and others
C) depression/anxiety D) impulsive/addictive
behavior E) psychosis. 5. Satisfaction with
Life (client only) A) work B) social
relationships C) living situation D)
psychological condition E) self and present
life 6. Alliance with Service Provider (client
only) A) emotional alliance with provider B)
task and goal alliance with provider
52
How are we mixing our methods?
  • By type quantitative measures, focus groups,
    ethnographic observation, semi-structured
    interviews
  • By utilization a) quantitative results are used
    to select Ss for qualitative interviews b)
    qualitative data will be used to interpret pooled
    and site-specific findings (confirmations and
    disconfirmations) c) qualitative data will be
    used to set context for quantitative findings
    (e.g., leadership, relationship with County)
  • By linking constructs especially around a)
    beliefs and behaviors concerning illness and
    treatment b)

53
Data collection
  • Clients enrolled 454
  • Providers enrolled 293
  • All surveyed
  • 99 semi-structured interviews
  • Clients enrolled 454
  • All surveyed
  • 68 semi-structured interviews

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Preliminary data on usual care clients living
situation (site a)
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