Experts from the Quad-State Mental and Behavioral Health Capacity Project, an important component of the Gulf Region Health Outreach Program (GRHOP), describe the impact of the Quad-State MBHCP.

JPHMP Direct: What makes the Quad-State MBHCP component of the GRHOP unique and why was this collaborative effort important?

Quad-State Mental and Behavioral Health Capacity Projects: The Quad-State MBHCP component of the GRHOP is unique because we were designed to work collaboratively but in a localized/state-specific way (each of the four MBHCP projects had a designated leader located in within a state-specific university) while the other GRHOP projects were centralized in one state while working across the other four. As a result, the overall MBHCP project had a shared multi-state mission but flexibility in implementation which led to culturally-sensitive, location-specific initiatives. Being localized in each state also allowed each MBHCP project to tailor its initiatives and responses to the particular challenges encountered in the individual states. A second unique feature of the MBHCP projects was that our work supported change at three distinct ecological levels (ie, client, clinic, and community); other GRHOP projects tended to focus on one or two of these levels rather than all three.

JPHMP Direct: What did each of the four state-specific MBHCPs bring to the table that benefited the shared mission of the multistate collaborative?

Quad-State MBHCP: Each state has a different culture, political climate, and existing resource base with varying impacts from this disaster (the Deepwater Horizon oil spill) versus previous disasters. Within each state, efforts also reflected the previous experiences and assets of the named investigators and the team they assembled including but not limited to the location of the university, mental health discipline of project leader(s), and the developmental status of the primary care locations that were targeted for integrated behavioral health efforts. Some states had more of a child/school focus than others; some targeted particular chronic diseases more than others; some had particular sub-populations that were focused on such as infants, elderly patients, first responders. This enhanced our ability to learn from one another and to work more closely with a particular partner when there was a shared focus (eg, the Generational Resiliency Conference co-hosted by the University of West Florida – MBHCP-FL and the University of South Alabama – MBHCP-AL).

JPHMP Direct: How difficult was it to integrate strategies? What role did GRHOP play in facilitating collective success?

Quad-State MBHCP: Integration of strategies naturally evolved on the basis of shared interests and shared challenges. In-person GRHOP quarterly meetings every three months provided the opportunity to meet and discuss details of the programs and share implementation experiences. On-going GRHOP-wide conversations about sustainability also reinforced the shared MBHCP goal of fuller integration and long-lasting mental and behavioral health capacity building. As the backbone organization, GRHOP was supportive of the integration of strategies across MBHCP sites. However, the leadership of each program welcomed collaboration, so sharing strategies, resources, information, and effort was not difficult. At the same time, full integration of the different strategies chosen by each state was never the mission. Instead, the four state-specific MBHCP projects looked for common ground and promoted synergistic activities, coming together on those points instead of every point of work (some work remained located in only one state; some efforts were shared across two, three, or all four states).

JPHMP Direct: Were there other challenges the group faced?

Quad-State MBHCP: In each state, the policies and laws related to clinic structure and reimbursement differed. These challenges deferentially impacted the sustainability of particular efforts. Similarly, each primary care site had its own challenges, so the work had to proceed in concert with the capacity of each site to make changes or focus on integrating behavioral health. In addition, each state used different models of integration so that complete alignment of integration strategies was not possible.

JPHMP Direct: In what way was the Collective Impact Model so beneficial to your mission?

Quad-State MBHCP: The GRHOP Coordinating Committee (CC), with each project having a voting member and representative, was the “backbone organization” that fostered and promoted collective impact. The CC explicitly promoted whole group conversations that were designed to foster collaboration, enhance synergistic efforts, and prepare for sustainability after the GRHOP funds were exhausted. The CC required the development of logic models, for each MBHCP project, for the Quad state group, and for GRHOP as a whole. Logic models require explicit short, mid-term, and long-term outcomes. While these were evolving naturally, the structured interactions that occurred at face-to-face CC meetings made underlying shared goals explicit. For example, conversations about billing success as a potential long-term outcome for the MBHCP Quad-State project helped each state identify similarities and differences in existing regulations. These conversations included exchanging possible solutions to mutual challenges. The CC provided a forum for information exchange, which is not common among funded independent grants, and served as a place to grow trusting relationships while fostering a balance between MBHCP state-specific competition and cooperation.

JPHMP Direct: What lessons did the group learn and how can those serve as guideposts for others?

Quad-State MBHCP: We learned that it is important to understand the impact of multiple traumatic experiences on children and families post-disaster; we believe that public health projects post-disaster that focus on mental health outcomes are essential. We also learned and demonstrated multiple innovative ways to increase access to mental and behavioral healthcare. As a group, we are unified in our goal of integrating and embedding mental health services in clinics and Federally Qualified Health Centers (FQHCs); these sites are accessible to individual clients and receiving mental health care in these locations is less stigmatizing. We believe many of the approaches taken across states to help individuals in clinics and schools following disasters will serve as important guideposts for others who are looking to assist in the wake of a wide-spread catastrophe. Other lessons included the importance of garnering clinic-based buy-in and maintaining long-term community relationships, as these are the bedrocks of sustainable change. We also endorse the importance of working across disciplines; multi-disciplinary, system-wide changes are essential if we are going to improve population health outcomes. Finally, all four projects recognized the important role of graduate students in capacity-building and workforce development; including community sites in their training experiences can be cost-effective and may be a pathway to sustainable services in under-resourced areas. Locating each MBHCP project in a university that was engaged in training MBH professionals was extremely beneficial to the collective impact.

Many lessons were learned during this project. Some lessons learned related to the process of working together while others related to the importance of the mission and how to move forward independently, yet collaboratively, to promote integrated health.

JPHMP Direct: What are the implications for policymakers and practitioners?

Quad-State MBHCP: It is important to recognize mental health as a public health imperative and as one of the main negative impacts post-disaster. Our work supports the inclusion of a mental and behavioral component to a medical settlement; as a whole, the structure of GRHOP provides a model for how to improve the likelihood of sustainable capacity-building when settling a class action lawsuit focused on compromised health and/or disaster. In particular, inclusion of the Quad-State MBHCP recognizes the importance of a mental health focus while highlighting that mental health initiatives need to be sensitive to culture and state context. Policies need to address issues surrounding integrating services following disasters while recognizing that mental and behavioral health concerns play an important role in disaster recovery.

For practitioners, the idea of integrating on-site services with telemedicine (telepsychiatry) allows the opportunity to provide consultation and supportive services to those impacted in rural areas that also address the issues of disparities in care. Furthermore, helping children and families following a technological disaster requires careful preparation that should occur for any disaster and recovery; our work indicates that this preparation should include thinking “outside the box” to find non-traditional ways and settings that will enhance our ability to reach these impacted and often under-served populations.

We found that the longer-than-usual timeframe of GRHOP (5 years) allowed for the transition from disparate to collaborative projects. The collective impact of the MBHCP projects was possible because of each state project’s ability to assess needs, engage with the existing clinic and sites, establish initiatives, and then have time to work on embedding the changes in a sustainable fashion. The longevity of GRHOP also allowed each project to develop a structure and hire and train staff to accomplish the initiatives.

JPHMP Direct: Why is it important to solidify the connection between behavioral and mental health and the broader public health community?

Quad-State MBHCP: Mental and behavioral health issues have shown a significant role in the onset, maintenance, and outcomes of physical health concerns. By addressing the whole patient, health outcomes are improved, which leads to a reduction of health care costs through the reduction of health care utilization. As communities’ overall health outcomes improve, there can be an improvement in the social determinants of health, including employment, housing, and education (particularly when the mental/behavioral health of children is included).

Restoring mental health post-disaster requires deploying short-term and long-term or system-wide assets. Most existing mental health resources that are deployed post-disaster are short-term and target individuals rather than system-level change. Pairing traditional mental health strategies, focused on individual level change, with population health interventions is particularly important post-disaster when health disparities are intensified.

Read the full issue of our special supplement highlighting the work of the Gulf Region Health Outreach Program (GRHOP).

• Four States, Four Projects, One Mission: Collectively Enhancing Mental and Behavioral Health Capacity Throughout the Gulf Coast
• Integration of Mental and Behavioral Health in Pediatric Health Care Clinics
• The Louisiana Mental and Behavioral Health Capacity Project Trauma-Informed Integrated Care Model and Improved Posttraumatic Stress Outcomes
• The Prevalence and Mental and Physical Health Correlates of Posttraumatic Stress Disorder Symptoms in Vulnerable and Underresourced Primary Care Patients Referred to a Behavioral Health Provider
• Embedding a Social Work–Led Behavioral Health Program in a Primary Care System: A 2012-2018 Case Study
• Infographic: Collectively Enhancing Mental and Behavioral Health Capacity Throughout the Gulf Coast