Andrew Frank Cleek

Scaling Up Evidence-Based Practices for Children and Families in New York State: Toward Evidence-based Policies on Implementation for State Mental Health Systems

Dissemination of innovations is widely considered the sine qua non for system improvement. At least two dozen states are rolling out evidence-based mental health practices targeted at children and families using trainings, consultations, webinars, and learning collaboratives to improve quality and outcomes. In New York State (NYS) a group of researchers, policymakers, providers, and family support specialists have worked in partnership since 2002 to redesign and evaluate the childrens mental health system. Five system strategies driven by empirically based practices and organized within a state-supported infrastructure have been used in the child and family service system with more than 2,000 providers: (a) business practices, (b) use of health information technologies in quality improvement, (c) specific clinical interventions targeted at common childhood disorders, (d) parent activation, and (e) quality indicator development. The NYS system has provided a laboratory for naturalistic experiments. We describe these initiatives, key findings and challenges, lessons learned for scaling, and implications for creating evidence-based implementation policies in state systems.

Beyond Context to the Skyline: Thinking in 3D

Sweeping and profound structural, regulatory, and fiscal changes are rapidly reshaping the contours of health and mental health practice. The community-based practice contexts described in the excellent review by Garland and colleagues are being fundamentally altered with different business models, regional networks, accountability standards, and incentive structures. If community-based mental health services are to remain viable, the two-dimensional and flat research and practice paradigm has to be replaced with three-dimensional thinking. Failure to take seriously the changes that are happening to the larger healthcare context and respond actively through significant system redesign will lead to the demise of specialty mental health services.

Best Practices: Wellness Self-Management: An Adaptation of the Illness Management and Recovery Program in New York State

Wellness Self-Management (WSM) is a recovery-oriented, curriculum-based practice designed to help adults with serious mental health problems make informed decisions and take action to manage symptoms and improve their quality of life. WSM is an adaptation of the illness management and recovery program, a nationally recognized best practice. WSM uses comprehensive personal workbooks for group facilitators and consumers and employs a structured and easy-to-implement group facilitation framework. Currently, more than 100 adult mental health agencies are implementing WSM in New York State. The authors describe the development and key features of WSM and an initiative to promote widespread adoption and sustainability.

Motivation-based interventions for obesity in serious mental illness

People with serious mental illnesses die an average of 25 years earlier than people in the general population.1 An estimated 60% of this excess mortality is attributed to common preventable and treatable medical conditions, including heart disease, stroke, and diabetes. This has moved providers toward making the delivery of primary care an integral part of behavioral health services — treating people holistically rather than only “from the neck up.”2 People with serious mental illness (SMI) have a higher prevalence of cardiometabolic risk factors, including rates of obesity almost twice that of the general population3,4 The interactions between genotype and environment are complex and poorly understood. Dysfunctional mesolimbic reward patterns may lead to unhealthy food choices.5 These are often in tandem with financial constraints on patients, including living in neighborhoods where fresh fruits and vegetables are difficult to obtain. Symptoms of mental illness, including low energy and anhedonia, may lead to decreased physical activity. Lack of access to Jeanie Tse, MD, FRCPC, is Director of Integrated Health, Institute for Community Living (ICL); and Clinical Assistant Professor of Psychiatry, NYU School of Medicine. Elisa Chow, PhD, is Director of Outcomes Evaluation, ICL. Rosemarie SultanaCordero, MA, LMHC, is Clinical Coordinator, Integrated Health, ICL. Marcia Titus-Prescott, RN, is Associate Director of Integrated Health and Nursing, ICL. Ruth Chiles, RD, is Director of Nutrition, ICL. Andrew Cleek, PsyD, is Director, Urban Institute for Behavioral Health. Elizabeth Cleek, PsyD, is Vice President, Program Design, Evaluation and Systems Implementation, ICL. This work was supported by the New York State Health Foundation; the United Hospitals Fund; the New York Community Trust; and the Brooklyn Community Foundation. The authors acknowledge the contributions of Peter Campanelli, PsyD; Stella Pappas; Cynthia Williams; Shivonne Blake; Le-Nise Watson-Hudson; Drew LaStella, PhD; and Matt Wofsy, as well as numerous staff and consumers at ICL and multiple provider agencies, especially The Bridge; F.E.G.S.; and William F. Ryan Community Health Center. Address correspondence to: Jeanie Tse, MD, FRCPC, Institute for Community Living, Inc., 40 Rector St., New York, NY 10006; phone: 212-3853030; fax: 212-385-2380; email: jtse@iclinc.net. Dr. Tse, Dr. Chow, Ms. Sultana-Cordero, Ms. Titus-Prescott, Ms. Chiles, Mr. Cleek, and Ms. Cleek have disclosed no relevant fi nancial relationships. doi: 10.3928/00485713-20110921-05 Jeanie Tse, MD, FRCPC; Elisa Chow, PhD; Rosemarie Sultana-Cordero, MA, LMHC; Marcia Titus-Prescott, RN; Ruth Chiles, RD; Andrew Cleek, PsyD; and Elizabeth Cleek, PsyD

Using mobile health technology to improve behavioral skill implementation through homework in evidence-based parenting intervention for disruptive behavior disorders in youth: Study protocol for intervention development and evaluation

BackgroundDisruptive behavior disorders (DBDs) (oppositional defiant disorder (ODD) and conduct disorder (CD)) are prevalent, costly, and oftentimes chronic psychiatric disorders of childhood. Evidence-based interventions that focus on assisting parents to utilize effective skills to modify children’s problematic behaviors are first-line interventions for the treatment of DBDs. Although efficacious, the effects of these interventions are often attenuated by poor implementation of the skills learned during treatment by parents, often referred to as between-session homework. The multiple family group (MFG) model is an evidence-based, skills-based intervention model for the treatment of DBDs in school-age youth residing in urban, socio-economically disadvantaged communities. While data suggest benefits of MFG on DBD behaviors, similar to other skill-based interventions, the effects of MFG are mitigated by the poor homework implementation, despite considerable efforts to support parents in homework implementation. This paper focuses on the study protocol for the development and preliminary evaluation of a theory-based, smartphone mobile health (mHealth) application (My MFG) to support homework implementation by parents participating in MFG.Methods/designThis paper describes a study design proposal that begins with a theoretical model, uses iterative design processes to develop My MFG to support homework implementation in MFG through a series of pilot studies, and a small-scale pilot randomised controlled trial to determine if the intervention can demonstrate change (preliminary efficacy) of My MFG in outpatient mental health settings in socioeconomically disadvantaged communities.DiscussionThis preliminary study aims to understand the implementation of mHealth methods to improve the effectiveness of evidence-based interventions in routine outpatient mental health care settings for youth with disruptive behavior and their families. Developing methods to augment the benefits of evidence-based interventions, such as MFG, where homework implementation is an essential mediator of treatment benefits is critical to full adoption/implementation of these intervention in routine practice settings and maximizing benefits for youth with DBDs and their families.Trial registrationClinicalTrials.gov NCT01917838

Generalizability of the NAMI Family-to-Family Education Program: Evidence From an Efficacy Study

Previous studies conducted in Maryland of the Family-to-Family (FTF) education program of the National Alliance on Mental Illness (NAMI) found that FTF reduced subjective burden and distress and improved empowerment, mental health knowledge, self-care, and family functioning, establishing it as an evidence-based practice. In the study reported here, the FTF program of NAMI-NYC Metro was evaluated. Participants (N=83) completed assessments at baseline and at completion of FTF. Participants had improved family empowerment, family functioning, engagement in self-care activities, self-perception of mental health knowledge, and emotional acceptance as a form of coping. Scores for emotional support and positive reframing also improved significantly. Displeasure in caring for the family member, a measure of subjective burden, significantly declined. Despite the lack of a control group and the limited sample size, this study further supports the efficacy of FTF with a diverse urban population.

A model of integrated health care in a poverty-impacted community in New York City: Importance of early detection and addressing potential barriers to intervention implementation

ABSTRACT Disruptive behavior disorders (DBDs) are chronic, impairing, and costly behavioral health conditions that are four times more prevalent among children of color living in impoverished communities as compared to the general population. This disparity is largely due to the increased exposure to stressors related to low socioeconomic status including community violence, unstable housing, under supported schools, substance abuse, and limited support systems. However, despite high rates and greater need, there is a considerably lower rate of mental health service utilization among these youth. Accordingly, the current study aims to describe a unique model of integrated health care for ethnically diverse youth living in a New York City borough. With an emphasis on addressing possible barriers to implementation, integrated models for children have the potential to prevent ongoing mental health problems through early detection and intervention.

Barriers and facilitators to mental health screening efforts for families in pediatric primary care.

ABSTRACT The purpose of this commentary was to describe the barriers and facilitators to mental health screening efforts for children between age 5 and 18 years within three primary care clinics in poverty-impacted communities as part of an integrated care model. Three screeners, two women and one male, participated in a screening effort between September and December 2015. Screeners were interviewed about their perceptions of barriers and facilitators to screening. Organizational, family, and screener-level factors were found to influence delivery of screenings to children. Given the benefits of screening in primary care settings, identifying barriers to these initiatives and ways to address them pre-emptively could potentially alter the developmental trajectory and outcomes of children at risk for serious mental health conditions.