Primary outcomes
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Activation in care | Service user | Baseline and every 6 mo during intervention phase | PAM68 |
Health statusa | Service user | Baseline and every 6 mo during intervention phase | SF-12v269 |
Engagement in primary/specialty care | PA DHS claims data | Updated every 6 mo | Frequency of visits in 12-mo periods |
Secondary outcomes
| | | |
Hope | Service user | Baseline and every 6 mo during intervention phase | Single-item hope measure70 |
Quality of life | Service user | Baseline and every 6 mo during intervention phase | Q-LES-Q-SF71 |
Functional status | Service user | Baseline and every 6 mo during intervention phase | Sheehan Disability Index72 |
Satisfaction with care | Service user | Baseline and every 6 mo during intervention phase | PACIC73 |
Medication adherence | Community Care and PA DHS claims data | Updated every 6 mo | Medication possession ratio in 6-mo periods74 |
Emergent care | Community Care and PA DHS claims data | Updated every 6 mo | Frequency of inpatient or emergency department claims in 12-mo periods |
Laboratory monitoring | PA DHS claims data | Updated every 6 mo | Frequency of laboratory monitoring: lipids, glucose, and HgbA1c in 12-mo periods |
Covariates
| | | |
Engagement in interventions | Community Care claims data | Updated every 6 mo | Low, medium, or high intervention engagement based on behavioral health service user as a proxy |
Social support | Service user | Baseline and every 6 mo during intervention phase | ISEL75 |
Severity of mental illness | Community Care claims data | Baseline | Inpatient behavioral health service use in the past 6 mo |
Medical stability | PA DHS claims data | Baseline | CCI76 |
Demographic characteristics | Community Care administrative/claims data | Baseline | Age, gender, race, SMI diagnosis, anxiety diagnosis, or substance use diagnosis |
Process
| | | |
Implementation facilitators and barriers | Service users; CMHC providers | Baseline; 12 mo and 24 mo during intervention phase | Qualitative interviews |