Literature Collection

BACKGROUND: In Baltimore, MD, as in many cities throughout the USA, overdose rates are on the rise due to both the increase of prescription opioid abuse and that of fentanyl and other synthetic opioids in the drug market. Supervised injection facilities (SIFs) are a widely implemented public health intervention throughout the world, with 97 existing in 11 countries worldwide. Research has documented the public health, social, and economic benefits of SIFs, yet none exist in the USA. The purpose of this study is to model the health and financial costs and benefits of a hypothetical SIF in Baltimore. METHODS: We estimate the benefits by utilizing local health data and data on the impact of existing SIFs in models for six outcomes: prevented human immunodeficiency virus transmission, Hepatitis C virus transmission, skin and soft-tissue infection, overdose mortality, and overdose-related medical care and increased medication-assisted treatment for opioid dependence. RESULTS: We predict that for an annual cost of $1.8 million, a single SIF would generate $7.8 million in savings, preventing 3.7 HIV infections, 21 Hepatitis C infections, 374 days in the hospital for skin and soft-tissue infection, 5.9 overdose deaths, 108 overdose-related ambulance calls, 78 emergency room visits, and 27 hospitalizations, while bringing 121 additional people into treatment. CONCLUSIONS: We conclude that a SIF would be both extremely cost-effective and a significant public health and economic benefit to Baltimore City.

BACKGROUND: Patients with mental illness are frequently treated in primary care, where Primary Care Providers (PCPs) report feeling ill-equipped to manage their care. Team-based models of care improve outcomes for patients with mental illness, but multiple barriers limit adoption. Barriers include practical issues and psychosocial factors associated with the reorganization of care. Practice facilitation can improve implementation, but does not directly address the psychosocial factors or gaps in PCP skills in managing mental illness. To address these gaps, we developed Relational Team Development (RELATED). METHODS: RELATED is an implementation strategy combining practice facilitation and psychology clinical supervision methodologies to improve implementation of team-based care. It includes PCP-level clinical coaching and a team-level practice change activity. We performed a preliminary assessment of RELATED with a convergent parallel mixed method study in 2 primary care clinics in an urban Federally Qualified Health Center in Southwest, USA, 2017-2018. Study participants included PCPs, clinic staff, and patient representatives. Clinic staff and patients were recruited for the practice change activity only. Primary outcomes were feasibility and acceptability. Feasibility was assessed as ease of recruitment and implementation. Acceptability was measured in surveys of PCPs and staff and focus groups. We conducted semi-structured focus groups with 3 participant groups in each clinic: PCPs; staff and patients; and leadership. Secondary outcomes were change in pre- post- intervention PCP self-efficacy in mental illness management and team-based care. We conducted qualitative observations to better understand clinic climate. RESULTS: We recruited 18 PCPs, 17 staff members, and 3 patient representatives. We ended recruitment early due to over recruitment. Both clinics developed and implemented practice change activities. The mean acceptability score was 3.7 (SD=0.3) on a 4-point Likert scale. PCPs had a statistically significant increase in their mental illness management self-efficacy [change = 0.9, p-value= <.01]. Focus group comments were largely positive, with PCPs requesting additional coaching. CONCLUSIONS: RELATED was feasible and highly acceptable. It led to positive changes in PCP self-efficacy in Mental Illness Management. If confirmed as an effective implementation strategy, RELATED has the potential to significantly impact implementation of evidence-based interventions for patients with mental illness in primary care.

ATTAIN NAV (Access to Tailored Autism Integrated Care through Family Navigation) was delivered by family navigators to promote access to and engagement with mental health services for school-age autistic youth. This study used a mixed method, stepped wedge design to test the effects of family navigation on service and clinical outcomes while gathering information on implementation. Primary care providers from six clinics in California and 56 caregiver-child dyads enrolled in and completed the study. Clinics were randomized to either a technology-enhanced or standard family navigation condition. Caregivers completed assessments at baseline and post about child, family and services outcomes, and a subset participated in a post qualitative interview. Quantitative findings demonstrated improvements in child challenging behavior and parent activation across conditions although these improvements were more pronounced for families in the standard FN condition. At post-intervention, families in the standard FN condition reported higher levels of navigation satisfaction, a shorter time to attend their first mental health appointment, and higher engagement with their navigator. Qualitative findings complemented and expanded the quantitative survey findings. The ATTAIN NAV model of family navigation for autistic children with co-occurring mental health needs demonstrates promising implementation, service, and clinical benefits. Clinical Trials Registration. NCT05344378.

PURPOSE: Practice transformation initiatives have the potential to promote collaborations between public health, primary care, and behavioral health, but limited empirical evidence is available on how these programs affect participating clinical practices. OBJECTIVE: To report the findings from a mixed-methods program evaluation of the Washington Practice Transformation Support Hub (Hub), a publicly funded, multicomponent practice transformation initiative in Washington State. DESIGN: We used quantitative and qualitative methods to evaluate the impact of Hub activities on participating primary care and behavioral health practices. Pre- and posttest survey data were combined with administrative program data to understand the effect of program components. Qualitative interviews contextualized findings. SETTING: Urban and rural primary care and behavioral health practices in Washington State. PARTICIPANTS: One hundred seventy-five practices that were recruited to receive Hub coaching and facilitation from 8 coaches; of these, 13 practices and all coaches participated in key informant interviews. INTERVENTION: Practice coaching and facilitation supported by an online resource portal, from January 2017 through January 2019. MAIN OUTCOME MEASURES: Self-reported progress in specific activities in 3 practice-level domains: bidirectional integration of physical and behavioral health care (care integration); alignment with community-based services for whole-person care (clinical-community linkages); and value-based payment. RESULTS: Participation in Hub activities was associated with improvements in care integration and clinical-community linkages but not with progress toward value-based payment. Qualitative results indicated that practice progress was influenced by communication with practices, the culture of the practice, resource constraints (particularly in rural areas), and perceptions about sustainability. CONCLUSIONS: This statewide practice transformation initiative was successful in strengthening primary care and behavioral health integration and clinical-community linkages among participating practices but not value-based payment. Future practice transformation efforts may benefit from addressing barriers posed by communication, limited application of value-based payment, culture change, competing priorities, and resource limitations, particularly for rural communities.

OBJECTIVE: This systematic review and meta-analysis evaluated the effectiveness of mobile app-based psychological interventions in reducing distress (depressive and anxiety symptoms) and improving quality of life among adults in primary care (PC). METHODS: We included randomized controlled trials (RCTs) involving adults with depression and/or anxiety identified through searches of PsycINFO, PubMed, Embase, and the Cochrane Library from database inception to April 11, 2025. Standardized mean differences (SMDs) and relative risks (RRs) were pooled using fixed- and random-effects models. Study quality was assessed using the Cochrane Risk-of-Bias 2 tool. RESULTS: Eleven RCTs (N = 2915) met inclusion criteria, contributing 15 comparisons to the meta-analysis (N = 2588; intervention vs. treatment as usual). Pooled analyses showed a significant reduction in overall distress (SMD = -0.44; 95% CI -0.68 to -0.21, p < 0.001) and a moderate decrease in depressive symptoms (SMD = -0.53, 95% CI -0.81 to -0.24, p < 0.001). Limited evidence from four comparisons showed no significant effect on anxiety (SMD = -0.25, 95% CI -0.68 to 0.18, p = 0.26). A small but significant improvement in quality of life was found (SMD = 0.16, 95% CI 0.06 to 0.25, p = 0.001). Participants using apps were more likely to drop out at post-treatment than controls (RR = 1.45, 95% CI 1.18 to 1.79, p < 0.001). CONCLUSIONS: Mobile app-based interventions appear to reduce distress and depressive symptoms and modestly improve quality of life in PC, although no significant effects were observed for anxiety. These findings support the potential role of app-based interventions as accessible tools within primary care. However, the limited and heterogeneous reporting of follow-up assessments restricts conclusions about the durability of these effects over time. Higher dropout rates also highlight the need to improve adherence strategies.

Emergency medical services (EMS) are integral to public health and safety and provide health care to both individuals and communities. Community paramedicine (CP) and mobile integrated health care (MIH) programs are expanded models of EMS that provide needs-based, patient-centered care in the community. Successful implementation requires a community health needs assessment, engaged EMS medical directors, multidisciplinary collaboration, and sustainable reimbursement that recognizes prehospital care delivery beyond traditional payment for transport.; Engaged and knowledgeable EMS physician medical directors, preferably with EMS board certification, must guide CP and MIH programs.CP and MIH programs should be tailored to meet local community needs based on a community health needs assessment and designed to bridge local gaps in access or care without duplication of services. The role of EMS clinicians should be clearly defined by the physician medical director and reflect the boundaries of collaborative practice.Physician medical directors may seek additional guidance on CP and MIH practice from state regulatory bodies, though practice regulations and standards should not stifle innovation and be established upon available data and outcome measures. Any state training or certification regulations should be dependent upon the expanded services provided and made with input from physician EMS medical directors.Clinician training programs intending to be comprehensive in approach should use standardized curricula. In programs with a limited expanded scope of practice, modularized training specific to the targeted disease processes may be appropriate. In both cases, CP and MIH clinicians should undergo regular competency evaluation supported by the physician medical director.State and federal agencies should establish reimbursement systems under Medicare and Medicaid, and EMS agencies should work with private payors to ensure reimbursement for the provision of community paramedicine and mobile integrated health care, decoupled from reimbursement for transportation.Data collection and analysis using standardized tools, methods, and reporting structures are essential for the evaluation and growth of CP and MIH programs. CP and MIH research should develop a standard taxonomy for describing programs, identify common data definitions and outcomes measures, collaboratively aggregate data, and advocate for development of data reporting standards.; eng