Mary E. Evans

Family-centered intensive case management: A step toward understanding individualized care

New York States initial attempt at individualizing services occurred within the context of an experiment. We randomly assigned children 5–12 years old who were referred for out-of-home placement in treatment foster care to either treatment foster care, Family-Based Treatment (n=15), or to Family-Centered Intensive Case Management (FCICM) (n=27). FCICM used teams of case managers and parent advocates to provide in-home services. Flexible service dollars, respite care, and behavior management skills training were available to assist teams in individualizing care. Preliminary outcomes indicate that children in FCICM are doing as well or better than children assigned to FBT in their functioning and symptom reduction. Parents of children in FCICM have made gains, although not at a statistically significant level, in behavior management skills and family strengths that allow them to provide care for their children at home.

The effects of a tailored cardiac rehabilitation program on depressive symptoms in women: A randomized clinical trial

BACKGROUND Depression is known to co-occur with coronary heart disease (CHD). Depression may also inhibit the effectiveness of cardiac rehabilitation (CR) programs by decreasing adherence. Higher prevalence of depression in women may place them at increased risk for non-adherence. OBJECTIVE To assess the impact of a modified, stage-of-change-matched, gender-tailored CR program for reducing depressive symptoms among women with CHD. METHODS A two-group randomized clinical trial compared depressive symptoms of women in a traditional 12-week CR program to those completing a tailored program that included motivational interviewing guided by the Transtheoretical Model of behavior change. Women in the experimental group also participated in a gender-tailored exercise protocol that excluded men. The Center for Epidemiological Studies Depression (CES-D) Scale was administered to 225 women at baseline, post-intervention, and at 6-month follow-up. Analysis of Variance was used to compare changes in depression scores over time. RESULTS Baseline CES-D scores were 17.3 and 16.5 for the tailored and traditional groups, respectively. Post-intervention mean scores were 11.0 and 14.3; 6-month follow-up scores were 13.0 and 15.2, respectively. A significant group by time interaction was found for CES-D scores (F(2, 446)=4.42, p=.013). Follow-up tests revealed that the CES-D scores for the traditional group did not differ over time (F(2, 446)=2.00, p=.137). By contrast, the tailored group showed significantly decreased CES-D scores from baseline to post-test (F(1, 223)=50.34, p<.001); despite the slight rise from post-test to 6-month follow-up, CES-D scores remained lower than baseline (F(1, 223)=19.25, p<.001). CONCLUSION This study demonstrated that a modified, gender-tailored CR program reduced depressive symptoms in women when compared to a traditional program. To the extent that depression hinders CR adherence, such tailored programs have potential to improve outcomes for women by maximizing adherence. Future studies should explore the mechanism by which such programs produce benefits.

An experimental study of the effectiveness of intensive in-home crisis services for children and their families: Program outcomes.

In this article, we describe the outcomes associated with a 3-year research demonstration project. It is the second of a two-part article concerned with this research conducted in the Bronx, New York, to examine the efficacy of three models of intensive in-home services—Home-Based Crisis Intervention (HBCI), Enhanced Home-Based Crisis Intervention (HBCI+),and Crisis Case Management—as alternatives to hospitalization for children experiencing a psychiatric crisis. In Part I (Evans, Boothroyd, & Armstrong, 1997), we described the features of the three program models, the research design, data collection measures, and the presenting characteristics of the children and families. In Part 2, we describe the success of maintaining children at home (82%) and the increases in family adaptability, childrens self-concept, and parental self-efficacy both at discharge and at 6 months postdischarge. Enrollees in two of the models (HBCI and HBCI+) experienced a significant increase in family cohesion,although this was not maintained at 6 months postdischarge. While enrollees in the enhanced program showed significant increase in social support at discharge, all enrollees experienced this at 6 months postdischarge.

Examining the Challenges of Recruiting Women Into a Cardiac Rehabilitation Clinical Trial

PURPOSE To examine the challenges of recruiting women for a 5-year cardiac rehabilitation randomized clinical trial; the aims of the study were to describe the range of recruitment sources, examine the myriad of factors contributing to ineligibility and nonparticipation of women during protocol screening, and discuss the challenges of enrolling women in the trial. METHODS The Womens-Only Phase II Cardiac Rehabilitation program used an experimental design with 2 treatment groups. Eligible participants included women who were (1) diagnosed with a myocardial infarction or stable angina or had undergone coronary revascularization within the last 12 months; (2) able to read, write, and speak English; and (3) older than 21 years. Responses to multiple recruitment strategies including automatic hospital referrals, physician office referrals, mass mailings, media advertisements, and community outreach are described. Reasons for ineligibility and nonparticipation in the trial are explored. RESULTS Automatic hospital order was the largest source of referral (n = 1,367, 81%) accounting for the highest enrollment rate of women (n = 184, 73%). The barriers to enrollment into the cardiac rehabilitation clinical trial included patient-oriented, provider-oriented, and programmatic factors. Of the referral sources, 52% were screened ineligible for provider-oriented reasons, 31% were ineligible due to patient-oriented factors, and 17.4% were linked to the study protocol. Study nonparticipation of those eligible (73.8%) was largely associated with patient-oriented factors (65.2%), with far less due to provider-related factors (4%) or study-related factors (3.4%). CONCLUSION Standing hospital orders facilitated enrollment to the cardiac rehabilitation clinical trial, yet women failed to participate predominantly due to significant patient-oriented biopsychosocial barriers.

Workforce development and the organization of work: the science we need.

The industrialization of health care, underway for several decades, offers instructive guidance and models for speeding access of children and families to clinically and cost effective preventive, treatment, and palliative interventions. This industrialization—i.e., the systematized production of goods or services in large-scale enterprises—has the potential to increase the value and effects of care for consumers, providers, and payers (Hayes and Gregg in Integrated behavioral healthcare: Positioning mental health practice with medical/surgical practice. Academic Press, San Diego, 2001), and to generate efficiencies in care delivery, in part because workforce responsibilities become more functional and differentiated such that individuals with diverse educational and professional backgrounds can effectively execute substantive clinical roles (Rees in Clin Exp Dermatol, 33, 39–393, 2008). To date, however, the models suggested by this industrialization have not been applied to children’s mental health services. A combination of policy, regulatory, fiscal, systemic, and organizational changes will be needed to fully penetrate the mental health and substance abuse service sectors. In addition, problems with the availability, preparation, functioning, and status of the mental health workforce decried for over a decade will need to be addressed if consumers and payers are to gain access to effective interventions irrespective of geographic location, ethnic background, or financial status. This paper suggests that critical knowledge gaps exist regarding (a) the knowledge, skills, and competencies of a workforce prepared to deliver effective interventions; (b) the efficient and effective organization of work; and (c) the development and replication of effective workforce training and support strategies to sustain effective services. Three sets of questions are identified for which evidence-based answers are needed. Suggestions are provided to inform the development of a scientific agenda to answer these questions.

A public health approach to children's mental health services: possible solutions to current service inadequacies.

The Child-Adolescent Mental Health Services (CAMHS) system confronts clinically complex youth with high rates of behavior problems, diverse mental health disorders, substance abuse, criminal behavior, and other “at risk” behaviors (e.g. school truancy, family conflict, etc.). Because of the complexity of the youth, the system has serious difficulties helping them to successfully overcome the myriad of problems they confront. This group proposes that a public health approach would help solve many of the inadequacies of the current system. Public health has been variously defined; however, all definitions recognize it as the art and science of dealing with the protection and improvement of community health by organized community efforts. As such, it includes prevention, screening, and treatment, as well as environmental and social interventions. We propose that a public health approach should be taken on behalf of child mental health. Although public health is often conceptualized as focusing on physical health, we take the holistic position that “there is no health without mental health.” A public health approach is appropriate because the strengths and problems of children and adolescents are based upon interactions between their internal genetic/biological predispositions, as well as their family, community, school, and societal environments. Through research, we are uncovering more and more evidence that all aspects of environment (intra-person, family, peer, community, and even society) are important: We can document the importance of the social and physical environment as a determinant of behavior and mental illnesses (Rutter 2006; McDonald and Murray 2000); The link between environment and human development is well-known (Leventhal and Brooks-Gunn 2003; Stiffman et al. 1999; Sampson et al. 1997); We have evidence that when a child or adolescent’s environment is improved, some mental health problems decline (Costello et al. 2003; McKay 2005; Stiffman et al. 2007); and There is evidence that even the most resilient of children will succumb to a chronically stressful environment (Vanderbilt-Adriance and Shaw 2006). A public health approach would provide an over-arching framework to integrate all arenas (health, education, social services, child welfare, juvenile justice, mental health) for interventions and services. First, it should be comprehensive in involving and integrating the arenas where the children are, rather than being confined to only the mental health arena. Second, the public health approach should be comprehensive in its scope and ideally range from health promotion through disease prevention to disease treatment. Third, the approach should be comprehensive in terms of the population and diseases targeted, including universal as well as intensive foci. A public health approach requires an ecological understanding of mental health and mental illness. Thus, potential targets for such an approach range from the most proximal issues concerning the individual, to the more distal, starting with the family, moving outward to the community (neighborhood, housing, etc.), and finally to the sociopolitical environment which includes public policy and economics. Each of these layers of ecological features suggests different forms of interventions, and each layer confronts the reality of finite resources, opportunity costs, and social processes. At the same time each of these ecological layers suggest potential leverage points for solving issues concerning child and adolescent mental health services. The potential of the public health approach to address the limitations of the mental health model for children and adolescents has been recognized by others. In 1961, the Joint Commission on Mental Illness and Health issued its call for mental health system transformation (Joint Commission on Mental Illness and Health 1961). This commission noted the rising demand for mental health services and recommended that public health professionals become more knowledgeable about the prevalence and spread of mental health disorders. The Surgeon General in 1999 also called for a public health approach to the outreach, prevention, screening and treatment of mental health disorders for all, and especially for populations of color. More recently, Kathryn Power, in her capacity as director of the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration (SAMHSA), advocated for the development of a public health model of mental health that takes a community approach to prevention, treatment, and promotion of well-being. Two states that are recipients of Mental Health Transformation Grants from SAMHSA (Texas and Washington) have made the public health approach a core feature in their transformation (Crump 2007; Ganju 2008). Similar support for this integrative approach is also seen in the advocacy community (Blueprint for a Healthier America: Modernizing the Federal Public Health System to Focus on Prevention and Preparedness 2008; Guiding Principles for Collaboration between Mental Health and Public Health 2005; Bazelon Center for Mental Health Law 2005). Clearly, there is a widespread recognition of the importance of a public health model as a solution to the limitations of the current CAMHS. The remainder of this paper details potential barriers to optimal child and adolescent mental health services, and suggests potential public health oriented solutions to those barriers. The primary barriers in mental health services are finite resources, limited policy perspectives, disjointed systems, a lack of a comprehensive multi-tiered approach, inequity in access, and failure to adopt effective interventions.

Development and Implementation of an Experimental Study of the Effectiveness of Intensive In-Home Crisis Services for Children and Their Families.

This article describes a 3-year research demonstration project originally funded by the National Institute of Mental Health and now funded in part by the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration. This project, which was conducted in the Bronx, New York, examined the efficacy of 3 models of intensive in-home services as alternatives to hospitalization for children experiencing serious psychiatric crises. All programs were 4- to 6-week interventions. The first, Home-Based Crisis Intervention (HBCI), was modeled on the Homebuilders model of family preservation; the second, Enhanced HBCI (HBCI+), added respite care, flexible service money, parent advocate and support services, and additional staff training in cultural competence and violence management. Crisis Case Management, the third model, used case managers to assess child and family needs and link them to services, as well as respite care and flexible money. The specific features of the 3 program models, the research design, and data collection measures are described. The intake data on the children and families are presented, and implications for providing services and for future research are discussed.

Support, Empowerment, and Education A Study of Multiple Family Group Psychoeducation

n this article we describe the results of a randomized trial (N = 94) that developed and evaluated a multiple family group psychoeducation interIvention (MFGPI) for parents/primary caregivers of children with serious emotional disturbance (SED) enrolled in community-based child and youth intensive case management programs. Through group problem-solving and interactive knowledge development activities, the MFGPI addressed the key components of social support, parent education,and parental empowerment. The structured group sessions used a professional/parent leadership model. Parents/primary caregivers were randomly assigned to one of two treatment conditions (intensive case management plus adjunctive MFGPI or “treatment as usual” intensive case management). Parent problem-solving skills, parental coping skills, perceived social support resources,and child behavior were measured at three points in time (baseline, 9 months, and 18 months). No statistically significant difference occurred by group condition for the key variables of social support versus problem-solving/coping measures; parents in both intervention conditions had significantly more individuals to help them out over time.Youth behavior in both conditions improved significantly over time as measured by the overall child behavior scores.Analysis of the time by intervention interaction suggested that parents in the group condition also reported significant improvements on child externalizing and internalizing behavior scores and several subscale behavior scores.

Initial hospitalization and community tenure outcomes of intensive case management for children and youth with serious emotional disturbance

Since 1988 New York States Children and Youth Intensive Camse Management (CYICM) program has enrolled more than 1,700 children. The program goal is to maintain children in the least restrictive environment approriate to their needs. This linkagke and advocacy focussed program uses a small caseload and flexible service money to meet its goal. We review the program model, describe the enrolled children, highlight some of the problems associated with determining program outcomes, and present the outcomes related to hospitalization and community tenure. Using two analytic techniques, CYICM was shown to be associated with fewer hospital admissions and fewer days in the hospital over a two-year period following the intervention of CYICM than prior to enrollment.

Adverse baseline physiological and psychosocial profiles of women enrolled in a cardiac rehabilitation clinical trial.

PURPOSE Coronary heart disease (CHD) remains the leading cause of death in women. Despite positive outcomes associated with cardiac rehabilitation (CR), investigations of women are sparse. This article presents the baseline physiological and psychosocial profiles of 182 women in the Womens-Only Cardiac Rehabilitation study. METHOD Women were randomized to a womens-only motivational interviewing or traditional CR group. Physiological measures included lipid profiles, body mass index, functional capacity, and anthropomorphic measures. Psychosocial measures included optimism, hope, social support, anxiety, depression, quality of life, and health perceptions. The median age was used to split the sample to examine data on 92 younger (≤64 years) and 90 older (>64 years) women. RESULTS With a mean age of 63 years, 66.5% were white, 47% were retired, and 54% were married. Most women were physically inactive (83%), hypertensive (76%), and overweight (56%). Most women (71.4%) met the criteria for metabolic syndrome. Younger women demonstrated significantly worse psychosocial profiles than older women. More of the younger women (64%) had depressive symptoms than older women (37%). Younger women demonstrated a mean Center for Epidemiological Studies Depression Scale score of 20.8 ± 12.4, whereas older women had a substantially lower mean score of 14.9 ± 9.5 (P < .001). Younger participants also reported significantly more anxiety than older participants (38.8 ± 13.4 vs 32.8 ± 10.6, P < .001). CONCLUSION Younger women enrolled in a CR clinical trial had adverse baseline risk factor profiles placing them at high risk for disease progression.