In 2016, New York City policymakers came together with federal and private funders to support a program, Connections to Care (C2C), intended to provide quality mental health support within high-risk communities. RAND researchers conducted an evaluation of C2C, examining its implementation across 15 community-based organizations, its impact on access and utilization of mental health care, mental health symptoms, and other outcomes, and its costs.
Mental Health Task-Shifting in Community-Based Organizations
Implementation, Impact, and Cost — Evaluation of the Connections to Care Program
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Research Questions
- How were C2C program strategies implemented?
- What are the key facilitators of and barriers to effective implementation of C2C program strategies within and across CBO and mental health provider (MHP) partnerships?
- Do C2C participants have greater reductions in barriers to mental health care and greater increases in utilization of mental health services relative to comparison group participants?
- Do C2C participants show greater positive improvement in mental health symptoms and employment, housing, education, and incarceration relative to comparison group participants?
- What are the costs to CBOs associated with implementation of the C2C program?
Mental health problems, such as depression and anxiety, affect a substantial portion of the U.S. population. About 20 percent of Americans deal with these problems, and, among young adults, that figure is even higher, at just above 25 percent. Mental health problems disproportionately affect low-income individuals, racial and ethnic minorities, and those with low English proficiency. Left unaddressed, these problems can profoundly affect people's lives and their ability to care for themselves physically and emotionally.
Easy-to-administer screening can detect mental health problems, and early intervention can stop or slow the progression of mild symptoms to more severe illness. But obtaining early intervention can be difficult because of a nationwide shortage of mental health care professionals. In both rural and urban areas, mental health professionals — particularly those who can deliver evidence-based treatments — are in short supply.
To fill gaps in the mental health care workforce and lower barriers to accessing mental health care, regional governments and coalitions have been exploring new strategies to address mental health care delivery. One such effort, begun in 2016, is the Connections to Care (C2C) Collaborative in New York City, which has built an innovative model of delivering mental health screening and evidence-based interventions through staff at community-based organizations (CBOs) that already serve at-risk populations. RAND researchers describe the C2C model and their evaluation of its implementation; whether it had the intended effects on access and utilization of mental health care, mental health symptoms, and related outcomes (such as employment); and how much it costs CBOs.
Key Findings
- Overall, the results of the impact evaluation did not provide evidence of the effectiveness of the C2C model of task-shifting. Although C2C participants as a whole improved in most of the outcome domains investigated in the impact study, the comparison group as a whole improved by a similar amount.
- Although the impact evaluation results do not support broad scale-up of the C2C model of task-shifting, there are some key insights about the task-shifting approach that should be considered by practitioners, policymakers, and researchers interested in further exploring how to design, implement, and evaluate task-shifting interventions.
- Reaching full implementation of a complex task-shifting model requires significant investment of time and resources, but it is feasible.
- Although C2C was well received by clients and providers, such barriers as stigma and access challenges were hard to overcome.
- There were some benefits of C2C for certain subpopulations and in certain settings.
Recommendations
- Design the mental health task-shifting model with evidence-based content and alternative delivery modes (e.g., telehealth) to reduce barriers to mental health care.
- Consider replacing or augmenting the four skills that made up the original C2C model (screening, mental health first aid, motivational interviewing, and psychoeducation) with other evidence-based strategies.
- Examine the role of systemic barriers to implementation and sustainment of the model and other nontraditional mental health delivery models.
- Invest resources in reducing barriers to care among youth and young adults.
- To implement mental health task-shifting, plan for at least an initial one-year ramp-up period and prepare for increasing costs over time until the program gets to scale.
- Consider the population, setting, and outcomes when determining whether and how to implement the model.
- Design future evaluations of the effectiveness of task-shifting to account for individual and site-level heterogeneity, and to examine mechanisms of change.
Table of Contents
Part I
Introduction
Chapter One
Introduction
Chapter Two
Background and Rationale for C2C
Chapter Three
C2C Program and Logic Model
Part II
Implementation
Chapter Four
Adaptation of C2C at Community-Based Organizations in Early-Stage Implementation
Chapter Five
Evolution of C2C Implementation
Chapter Six
How C2C Transformed Organizational Culture and Approaches to Client Care Coordination
Part III
Impact
Chapter Seven
Impact of C2C on Mental Health Care Access and Utilization
Chapter Eight
Impact of C2C on Mental Health Symptoms
Chapter Nine
Impact of C2C on Employment, Education, Housing, and Incarceration
Part IV
Cost
Chapter Ten
Resources Required to Implement and Maintain the C2C Program
Part V
Conclusions and Recommendations
Chapter Eleven
Conclusions and Recommendations
Appendix A
C2C Program Summaries
Appendix B
Implementation Evaluation Methods
Appendix C
Impact Evaluation Methods
Appendix D
Cost Evaluation and Sensitivity Analyses
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This research was sponsored by the Mayor’s Fund to Advance NYC and conducted by the Access and Delivery Program within RAND Health Care.
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