Behavioral Health Care

Behavioral health care—which includes care for mental health and substance use problems—is critical to the health of the U.S. population. More than one in five U.S. adults live with a mental health or substance use condition. Effective treatments for these conditions exist, but about half of Americans with a mental illness and three-quarters of those in need of help for substance use do not get treatment. Treatment rates are also lower among Hispanic, Black, Asian-American, Native Hawaiian and Pacific Islander, and American Indian/Alaskan Native groups than among Non-Hispanic White populations. Mental health and substance use conditions also affect entire communities: More than more than 40% of Americans know someone who died of a drug overdose.

Researchers at RAND Health Care bring a multidisciplinary, systems-based approach to studying mental health and substance use treatment. Our teams integrate the expertise of mental health clinicians, policy researchers, economists, social scientists, statisticians, and other experts to address a broad range of critical policy issues. In particular, our research examines the many reasons why people might not be getting the care they need, including lack of access to providers, disparities in treatment, lack of insurance coverage, and lack of awareness of treatment options.

RAND research teams have offered recommendations for transforming the U.S. mental health care system and developed a web-based tool that allows users to uncover strategies, tactics, and examples of evidence-based solutions. Similarly, RAND’s opioid research center, OPTIC, advances innovative tools to tackle the opioid epidemic, including a framework that positions the issues surrounding opioids as an inter-related ecosystem and an interactive database of policy actions that could reduce addiction, overdose, suffering, and other harms. Our researchers also conduct tests, including clinical trials, of promising efforts to prevent mental health and substance use problems and to bring treatment to easy-to-access settings, including community-based organizations (CBOs) and primary care and behavioral health clinics.

Highlights

Delivering Care in Community-Based Settings

One way to improve access to care is by expanding the mental health care workforce to include non-clinicians trained to deliver initial care in community-based settings. For example, an innovative program in New York City trains and empowers lay people to use Mental Health First Aid (MHFA) to listen to those experiencing mental illness, reassure them, and encourage them to get help. Most of the more than 155,000 New Yorkers trained in city agency workplaces and community-based settings were still using what they had learned five years later.

RAND has also worked on similar efforts: The Connections to Care (C2C) collaborative in New York City delivered mental health screening and evidence-based interventions through staff at CBOs that already serve at-risk populations. RAND researchers worked with New York City government partners to evaluate the implementation, impact, and cost of the C2C program. In California, RAND evaluated a partnership between the National Alliance on Mental Illness and the Diocese of San Bernardino to deliver a parish-based intervention to reduce stigma, increase mental health literacy, and improve access to mental health services.

Treating Co-Occurring Disorders

Individuals with opioid use disorder (OUD) often have co-occurring mental health disorders, such as depression, bipolar disorders, or schizophrenia. The U.S. health care system, however, tends to treat substance use and mental health disorders separately. Building on a previous model of care called SUMMIT, RAND and the University of New Mexico have fielded an innovative clinical trial to test whether patients who have opioid use disorder and a mental health condition respond better to integrated treatment delivered in a primary care setting by a team of care professionals compared with patients receiving traditional care. The CLARO (Collaboration Leading to Addiction Treatment and Recovery from Other Stresses) study helps practitioners at 17 rural and urban primary care clinics in New Mexico and California form care teams and teaches them how to deliver effective collaborative care. Community health workers act as the hub of care delivery, coordinating care among primary care and behavioral health providers and making sure patients stay engaged. The five-year study is ongoing.

California's Statewide Initiatives

The state of California has been at the cutting edge of transforming mental health and substance use treatment systems to enhance community-based care, improve access and quality, and reduce disparities. RAND has been an evaluation partner with the state, working with the California Mental Health Services Authority (CalMHSA), a coalition of county-based behavioral health systems, since 2009. RAND assesses implementation and outcomes of a wide range of prevention and early intervention programs that aim to improve mental health outcomes for the state's individuals, families, and communities. For example, RAND researchers are helping program partners measure their progress toward meeting statewide objectives, assess the activities that they have implemented and the resources they have created, and evaluate overall program outcomes. A recent study developed a new framework to estimate psychiatric bed capacity in multiple California counties and statewide, which policymakers can use to inform resource allocation. RAND has also conducted evaluations for specific California counties. For instance, they have evaluated Los Angeles County’s mental health community engagement campaigns.

Other work for the California Department of Health Care Services, in partnership with the state’s Office of the Surgeon General, has been evaluating efforts to expand screening and response to adverse childhood experiences (ACEs), such as abuse and neglect, which can disrupt healthy development and lead to health conditions. For instance, RAND found that a program called Preventing and Responding to ACE-Associated Health Conditions and Toxic Stress in Clinics through Community Engagement (PRACTICE) transformed how vulnerable patients received supports by using a trauma-informed approach. RAND also evaluated implementation of ACE screening in terms of clinic readiness for trauma-informed care, actions clinicians take in response to the screenings, and perspectives on screening among clinicians and staff and patients and caregivers.

Evaluating Certified Community Behavioral Health Clinics

RAND, in collaboration with Mathematica Policy Research, is evaluating the Certified Community Mental Health Clinic (CCBHC) demonstration project, a national effort to address chronic fragmentation, underfunding, and inadequate capacity of behavioral health services in the United States. CCBHCs offer a “no-wrong-door” approach by serving anyone who requests care for mental health or substance use conditions, regardless of their ability to pay, place of residence, or age. Medicaid funded the first CCBHCs in 2017, with 67 clinics operating across eight states. Based in part on evaluation results, Congress has extended the demonstration, most recently expanding it to all states and territories. RAND continues to monitor its impact and shape its implementation.

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