Evaluation of California's Multi-County Psychiatric Advance Directives Innovation Project: Early Implementation and Outcomes, 2024–2025

Psychiatric advance directives (PADs) allow individuals with mental health conditions to document preferences for care that they might not otherwise be able to communicate during a crisis. For example, PADs may allow an individual to specify preferred treatments, preferred approaches to communication and deescalation, desired surrogate decisionmakers or advocates, and other important health information (e.g., concurrent medications or allergies). Despite their potential benefits, PADs have had relatively limited awareness and uptake (The Joint Commission, 2020; Substance Abuse and Mental Health Services Administration, 2019).

As a legal document, a PAD can be cumbersome to complete. Additionally, the preferences and values captured by a PAD may draw from an individual's past experiences with mental health treatment and hypothetical future scenarios (e.g., significant symptoms that constitute a crisis). Reflecting on these past experiences can be distressing, and envisioning future scenarios may be difficult. Given the low levels of awareness and potential challenges in completing a PAD independently, PAD initiatives have typically included outreach and facilitation—for example, by clinicians, advocates, or peer workers (Swanson et al., 2006; Tinland et al., 2022). Peer workers (e.g., Peer Support Specialists) are individuals with lived experience related to mental health or substance use needs, or family members of an individual with mental health or substance use needs, who provide a variety of supports within communities (California Mental Health Services Authority, undated). Prior research and evaluation on the facilitation of PADs have focused less on peer workers than on other facilitators (e.g., health care providers), with a few recent exceptions (e.g., Tinland et al., 2022).

In 2021 and 2022, seven California counties began collaborating on a Mental Health Services Act Innovation Project intended to increase the availability and uptake of PADs among individuals with mental health needs, supported by peer worker facilitation. The participating counties were Contra Costa, Fresno, Mariposa, Monterey, Orange, Shasta, and Tri-City.¹

The PADs Innovation Project developed a new, universal PAD template for Californians, drawing on extensive stakeholder input from individuals with lived experience and advocates. In tandem with the new template, the Innovation Project funded the creation of a web-based platform for individuals to create, store, update as desired, and potentially share their PAD. During this phase of the project, participating counties engaged in beta testing of the platform with small, defined groups of priority populations (e.g., individuals receiving services through a given program). The long-term goal is to facilitate access to this platform by first responders and staff in care settings (e.g., hospital emergency departments, inpatient units).

The PADs Innovation Project also developed a standardized curriculum to train peer workers as PAD facilitators. PAD facilitators conduct outreach and engagement with priority populations to promote the PAD opportunity, and they provide information and guidance to individuals as they complete their PAD.

Various contractors collaborated within the Innovation Project. Contractor roles included creating and implementing PAD facilitator trainings, working with counties to develop PAD content, building the electronic PAD platform, developing a PAD brand identity and PAD marketing materials, and evaluating PAD implementation and outcomes. Our task was to evaluate key aspects of PAD implementation and outcomes during this beta testing phase. We used a combination of interviews, surveys, and PAD completion metadata, which provided a variety of vantage points regarding PAD implementation and outcomes.

As an Innovation pilot spanning seven counties, the project had a fluid timeline and evolved over time. Most counties experienced longer-than-anticipated development and implementation runways. For example, the creation of the PAD template, design, and platform included intensive stakeholder engagement activities and a substantial technology development process. Several counties also had to navigate administrative requirements and legal agreements between implementation partners before launching PADs. These challenges are not uncommon to projects implementing novel tools in real-world settings, especially projects that are active across multiple heterogeneous contexts. However, these challenges significantly constrained the timeline and depth of our evaluation, which was originally planned to span one to two years and was based on plans for larger pilot populations and longer follow-up timelines. The longest beta testing span in a county was only seven months, and most counties had much shorter and finite beta testing (e.g., one to two months and limited to a set population of individuals served by a given program or agency). Additionally, one county ultimately did not implement PADs during this phase. We also note that one of the seven counties accounted for the vast majority of the PADs created (approximately two-thirds). Nevertheless, the findings and recommendations reported here can help inform future PAD development and implementation; we include a wide variety of perspectives from counties, staff, and individuals who created a PAD during the Innovation Project.

Key Findings

• Individuals who participated in a new training for implementing psychiatric advance directives (PADs) demonstrated high readiness for facilitating PADs, reporting significant improvements in PAD-specific skills and knowledge after the standardized training.
• Overall, feedback on the PAD training experience was positive regarding training delivery, the training team, and the achievement of the training's stated goals. However, some interviewees reported that the three-day training was too long and too focused on basic peer worker skills.
• PAD facilitators desired standardized guidance on the legal enforceability of PADs and how to communicate this information to individuals completing PADs.
• Individuals who created a PAD were satisfied with the experience. Most indicated that they felt in control of their PAD and that their privacy was respected. The benefits of completing a PAD include a sense of empowerment, improved trust and communication with health care providers, and peace of mind.
• County staff highlighted the pivotal role of peer workers in successful implementation. Beta testing provided opportunities to identify current limitations of the PAD platform and other barriers (e.g., integration, reimbursement models) to the successful rollout of PADs more broadly.
• Beta testing provided early evidence that peer worker–facilitated digital PADs are feasible and acceptable to facilitators and individuals served. More than 150 PADs were initiated during beta testing, and about half of participants fully completed at least the crisis directive section.
• Beta testing also points to barriers to real-world PAD utility that need to be addressed. These include a lack of awareness and understanding of PADs among first responders and care providers, the inability for first responders and hospitals to access PADs, and a lack of clear guidance on legal enforceability.