Close the Health Gap

Dr. Perez Jolles seeks to close the health gap by engaging in team-based science to examine the effects and implementation of complex health interventions in under-resources health and human service settings.

Parents advise investigators on mental health treatment in children

USC News  online

2017-01-13

Monica Perez Jolles, an assistant professor at the USC Suzanne Dworak-Peck School of Social Work, created and led a parent mentor group as part of a randomized pragmatic trial called “Padres Efectivos: Skills Latina Mothers Use to Get Healthcare for Their Children” ...

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Supporting the implementation of a state policy on screening for Adverse Childhood Experiences (ACEs) in Federally Qualified Health Centers

NIMH 

PROJECT SUMMARY Adverse Childhood Experiences (ACEs) are defined as traumatic events occurring before age 18, such as maltreatment, life-threatening accident, harsh migration experiences or exposure to violence. ACEs are pervasive, with 45% experiencing at least one ACE and 10% experiencing three or more ACEs, placing them at high risk for negative life outcomes. ACEs are more prevalent among minority and immigrant communities due to exposure to poverty, discrimination, community violence, national disasters, and refugee experiences. ACEs screenings have potential value in identifying children experiencing toxic stress and the physical and mental health conditions associated with it such as asthma, ADHD and anxiety. Yet, they are seldom used in primary care during well-child visits. The Surgeon General of the state of California has addressed this care gap by issuing an ACEs screening policy. Starting January 2020, MediCal, California's Medicaid health care program, will reimburse primary care settings ($29) for using the Pediatric ACEs and Related Life-events Screener (PEARLS) tool to screen children for ACEs during wellness visits. Despite significant investment in California and nationwide, evidence of the public health value of universal child screening policies is unclear. Increased screening efforts often do not translate into higher access to care for children and may even exacerbate disparities by increasing stigma and reinforcing a deficit view of marginalized groups. These results have been attributed to a lack of rigorous studies testing implementation strategies suited for pediatric screening policies. This mixed-method study will fill this gap by refining and testing an implementation strategy using a multi-site control trial with a Federally Qualified Health Center in Southern California. Using the EPIS framework, we will employ a hybrid (type 2), randomized controlled trial using a stepped-wedge design (n=5 clinics) to test a central hypothesis that clinics employing a multifaceted implementation strategy will have higher fidelity and reach of the ACEs screening policy. A secondary hypothesis will examine the public health impact of the ACEs policy on child patient-level mental health service and symptom outcomes. This project capitalizes on a rare opportunity to pilot test an implementation strategy to maximize the impact of a state-wide policy intended to improve child health in under-resourced settings.

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Views on health activation and support services among formerly homeless adults living in Permanent Supportive Housing in the United States

Monica Perez Jolles PhD | Dean Rivera MSW | Gabrielle Jacobs MSW | Kathleen C. Thomas PhD | Janet U. Schneiderman PhD, MN, RN | Suzanne Wenzel PhD

2021-11-04

Individuals who have experienced chronic homelessness often have unmet physical and mental health needs and experiences of trauma and stigma. This study aimed to measure, for the first time, health activation (self-advocacy and empowerment) levels among formerly homeless adults living in Permanent Supportive Housing or PSH (referred to hereafter as residents). In addition, residents' experiences accessing health services, and their sense of health activation and efforts to manage their health within PSH settings, were explored. A mixed-methods study was conducted in Southern California (October 2018–June 2019) using a validated survey and interviews with a randomly selected group of residents (n = 61) from three PSH agencies. Activation levels were measured using the Patient Activation Measure. Descriptive and univariate survey analyses were conducted. Interview data was analysed using NVivo. Two coders coded all transcripts, and team meetings were held to reach consensus. Results showed most residents were female (64%), racial and ethnic minorities (66%), on average 54-year-olds, with 37 months of PSH residency, and 43% were taking some action to manage their health (intermediate activation level). Challenges accessing care were due to breakdowns in care, unpleasant experiences with providers, low health literacy and feeling overwhelmed by co-occurring chronic conditions. Health activation related to knowing when to take care of their health on their own and when to seek care. Unique challenges emerged related to PSH, such as lack of resident control within the housing setting and limited personnel responding to health emergencies. These challenges were magnified because residents live alone, per PSH requirements.

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Disparities in Shared Decision Making and Service Receipt Among Children With Special Health Care Needs and Developmental Delay: A National Survey Analysis

Monica Perez Jolles , Leah L. Zullig, Pey-Jiuan Lee, and Gauri Kolhatkar

2020-10-25

Abstract Shared decision making (SDM) is associated with increased service satisfaction among pediatric patients. Our objective was to examine the association between SDM and service use experiences across racial/ethnic child groups. This secondary data analysis used the 2009-2010 National Survey of Children with Special Health Care Needs (CSHCN) and 2011 Pathways to Diagnosis and Services Survey. We used a rank-and-replace matching approach consistent with Institute of Medicine recommendations for health disparities research. We included CSHCN aged 6 to 17 years. The exposure of interest was parents of CSHCN reporting engagement in SDM with clinicians. There were 4032 CSHCN included in analysis. CSHCNs experiencing SDM had a 16% higher probability of reporting service use compared to those not experiencing it (95% CI, 14.24-19.42). Black children experiencing SDM reported seeing all needed care providers at a lower rate than whites (79% and 87.6% respectively; 95% CI, -14.05-3.27). The benefit of SDM over not experiencing it for blacks was 12.2% less than for whites for the outcome of seeing all needed care providers. For the outcome of receiving all needed treatments and services, the SDM benefit was 9.1% lower for Hispanics compared with whites. SDM can improve service experiences but implementation flexibility may be needed.

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Methods to identify and prioritize research projects and perform embedded research in learning healthcare systems

Thearis A. Osuji, Julie Frantsve-Hawley, Monica Perez Jolles, Heather Kitzman, Carly Parry, Michael K. Gould, For the Embedded Research Conference Priorities and Methods Workgroup

2020-10-25

Background: The Embedded Healthcare Research Conference aimed to promote and enhance research-operations partnerships in diverse health care settings. Within this conference, the Priorities and Methods Workgroup set out to define a vision of embedded research that leverages diverse methods to address clearly articulated research questions of importance to health systems. Methods: The Workgroup session involved a combination of small and large group discussions around three broadly focused topics: the integration of embedded research within the existing quality improvement (QI) ecosystem; the identification, prioritization and formulation of embedded research questions; the creation of an embedded research “tool kit.” Results: Workgroup participants envisioned a future for embedded research that is characterized by authentic engagement between researchers and health system leaders; seamless integration between research, QI and clinical operations; clear and explicit articulation of research questions; an appropriate balance between rigor and relevance in applied methodology; alignment between study design, available resources and the importance of the knowledge to be gained; efficient processes; and bi-directional communication. Important barriers to achieving this vision include limited access to executive leaders, silos that discourage integration of research and QI, generally low tolerance for disruption in high-risk clinical settings, limited access to data, and limited availability of researchers with requisite skills and training. Conclusions: Embedded research holds potential to enhance the relevance, value and use of research, while also creating generalizable knowledge. Key recommendations include building authentic relationships, discouraging silos, encouraging innovation and experimentation, and expanding opportunities for funding research in delivery systems.

Core Functions and Forms of Complex Health Interventions: A Patient-Centered Medical Home Illustration

Perez Jolles, M., Lengnick-Hall, R., Mittman, B.

2019-01-08

Abstract Despite policy and practice support to develop and test interventions designed to increase access to quality care among high-need patients, many of these interventions fail to meet expectations once deployed in real-life clinical settings. One example is the Patient-Centered Medical Home (PCMH) model, designed to deliver coordinated care. A meta-analysis of PCMH initiatives found mixed evidence of impacts on service access, quality, and costs. Conceptualizing PCMH as a complex health intervention can generate insights into the mechanisms by which this model achieves its effects. It can also address heterogeneity by distinguishing PCMH core functions (the intervention’s basic purposes) from forms (the strategies used to meet each function). We conducted a scoping review to identify core functions and forms documented in published PCMH models from 2007 to 2017. We analyzed and summarized the data to develop a PCMH Function and Form Matrix. The matrix contributes to the development of an explicit theory-based depiction of how an intervention achieves its effects, and can guide decision support tools in the field. This innovative approach can support transformations of clinical settings and implementation efforts by building on a clear understanding of the intervention’s standard core functions and the forms adapted to local contexts’ characteristics.

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Involving Latina/o parents in patient-centered outcomes research: Contributions to research study design, implementation and outcomes.

Pérez Jolles, M., Martinez, M., Garcia, SJ, Stein, G., MPG, Mentor Parent Group., Thomas, K.

2020-10-25

Abstract Background: Comparative effectiveness research (CER) is supported by policymakers as a way to provide service providers and patients with evidence-based information to make better health-care decisions and ultimately improve services for patients. However, Latina/o patients are rarely involved as study advisors, and there is a lack of documentation on how their voices contribute to the research process when they are included as collaborators. Objectives: The purpose of this article was to contribute to the literature by presenting concrete contributions of Latina/o parent involvement to study design, implementation and outcomes in the context of a CER study called Padres Efectivos (Parent Activation). Methods: Researchers facilitated a collaborative relationship with parents by establishing a mentor parent group. The contributions of parent involvement in the following stages of the research process are described: (i) proposal development, (ii) implementation of protocols, (iii) analysis plan and (iv) dissemination of results. Results: Mentor parents’ contributions helped tailor the content of the intervention to their needs during proposal, increased recruitment, validated the main outcome measure and added two important outcome measures, emphasized the importance of controlling for novice treatment status and developed innovative dissemination strategies. Conclusions: Mentor parents’ guidance to the researchers has contributed to reaching recruitment goals, strengthened the study protocol, expanded findings, supported broad ownership of study implications and enriched the overall study data collection efforts. These findings can inform future research efforts seeking an active Latino parent collaboration and the timely incorporation of parent voices in each phase of the research process.

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Managerial Strategies to Influence Frontline Worker Understanding of Performance Measures in Nonprofit Child Welfare Agencies.

Pérez Jolles, M., Collins-Camargo, C., McBeath B., Bunger, A., Chuang E.

2017 6(46):1166-1188.

Levels and Consequences of Embeddedness among Nonprofit Human Service Organizations: National Survey Evidence from Child Welfare.

Bunger, A., McBeath, B., Collins-Camargo, C., Chuang, E., Perez Jolles.

(In press)

Does caregiver participation in decision making within child welfare agencies influence children’s primary and mental health service use?

Pérez Jolles, M., Wells, R.

2017 DOI: 10.1111/cch.12384.

Fostering Activation Among Latino Parents of Children With Mental Health Needs

Thomas, KC., Livas Stein, G., Williams, C.S., Perez Jolles, M., Sleath, B.L., Prandoni, J., Martinez, M., Garcia, S.J., Guzman, L., Williams, C.E, Morrissey, J.

2017 DOI: 10.1176/appi.ps.201600366.

Caregiver involvement in behavioural health services in the context of child welfare service referrals: a qualitative study

2016 Human service agencies serve a growing number of adults with behavioural health needs. Despite these agencies' key role in identifying need and facilitating services, many individuals do not receive care or end services prematurely. Few studies have explored the experiences of families referred to behavioural health services by such agencies or the extent to which families' perceptions of service need align with those of treatment providers and frontline workers. This study presents findings from a qualitative study of caregivers involved with child welfare agencies who were referred to behavioural health services. Researchers reviewed agencies' case records and conducted in-depth interviews with 16 caregivers, 9 child welfare caseworkers and 12 behavioural health treatment counsellors. Findings suggest that when deciding to engage in services, caregivers weigh not only their individual and family behavioural health needs but also potential agency intervention, including loss of child custody. Many professionals reported that involvement with a child welfare agency hindered the caregiver's disclosure of behavioural healthcare needs. Implications for managers and practitioners are discussed.

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Cultural and Linguistic Adaptation of a Multimedia Colorectal Cancer Screening Decision Aid for Spanish-Speaking Latinos

2013 As the United States becomes more linguistically and culturally diverse, there is a need for effective health communication interventions that target diverse, vulnerable populations, including Latinos. To address such disparities, health communication interventionists often face the challenge to adapt existing interventions from English into Spanish in a way that retains essential elements of the original intervention while also addressing the linguistic needs and cultural perspectives of the target population. The authors describe the conceptual framework, context, rationale, methods, and findings of a formative research process used in creating a Spanish-language version of an evidence-based (English language) multimedia colorectal cancer screening decision aid. The multistep process included identification of essential elements of the existing intervention, literature review, assessment of the regional context and engagement of key stakeholders, and solicitation of direct input from target population. The authors integrated these findings in the creation of the new adapted intervention. They describe how they used this process to identify and integrate sociocultural themes such as personalism (personalismo), familism (familismo), fear (miedo), embarrassment (verguenza), power distance (respeto), machismo, and trust (confianza) into the Spanish-language decision aid.

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