Exploring State and Facility Characteristics of the Implementation of Evidence-Based Treatments for People Living with Schizophrenia

Background and Purpose: Providing care for persons with serious mental illness (SMI), such as schizophrenia, includes comprehensive wrap-around services.  The Schizophrenia Patient Outcome Research Team Recommendations are a package of nine EBTs (PORT EBTs) delivered in outpatient mental health settings. These interventions have primarily been tested in academic medical centers and there is a little known about the widespread implementation of the PORT EBTs. Further gaps in knowledge include the facility infrastructure and the policy environment which encourages implementation of the PORT EBTs. Therefore, this study aims to address these gaps by exploring the relationship between facility and state-level characteristics and the implementation of PORT EBTs.

Methods: This study is a secondary analysis of the National Mental Health Services Survey (2015) (N-MHSS), a yearly survey collects data on all known mental health service treatment facilities in all 50 states, the District of Colombia, and US territories. Included in the sample were only outpatient mental health centers, community mental health services, and mixed inpatient/outpatient facilities which self-reported providing treatment for people living with SMI (n=4209).

A cross-sectional generalized mixed effects logistic regression with two levels, state and facility, was fit. Model fit was determined by examining AIC values (AIC= 1978.36) and conditional R² value (R2=0.24).  The outcome variable was whether a facility had implemented all of the PORT EBTs. The following facility-level independent variables were included in the model: # of grants, receipt of Mental Health Block Grants or Community Service Block Grants or both; public insurance, accepted Medicare, Medicaid, neither, or both; and facility type. The state-level independent variable was Medicaid expansion passage as of 2015.

Results: Preliminary results indicated only 7% of facilities implemented the full PORT. The average number of PORT EBTs implemented was 4.36 (SD= 1.99).  Location of the facility explained approximately 17% of the variance in whether a facility has implemented the total PORT EBTs or not (ICC=0.17). Mixed inpatient and outpatient facilities were more likely to have implemented the full recommendations compared to community mental health and outpatient facilities (OR=1.51, z=2.22, p ≤0.05). Facility-level characteristics explained little of the variances in the implementation of the PORT EBTs (marginalized R²=0.08). A significant interaction between the number of grants and public insurance, specifically being a Medicare Expansion State, was found (OR=0.41, p≤ 0.05). In states which did not have Medicaid Expansion, the number of grants only increased the likelihood of the implementation of PORT EBTs if the facility accepted both Medicaid and Medicare. 

Conclusions and Implications: The relationship between the implementation of the PORT EBTs and the facility characteristics, number of grants and public insurance acceptance, varied by Medicaid Expansion and non-Expansion states. Results need to be interpreted with caution as facility and state-level characteristics described small amount of the variance whether a facility implemented the PORT EBTs. However, these results do indicate the need for a better understanding of the structural conditions encouraging the dissemination and implementation of EBTs  for schizophrenia.