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Trauma-informed communities establish cross-sector coalitions that advocate for the use of trauma-informed practices. Whether and how communication occurs within newly established trauma-informed communities is unclear. We collected qualitative data and social network data from six trauma-informed community partnerships that received funding to build community capacity to address trauma across a range of special populations in Los Angeles county. We identified three communication network sub-types and highlight contributions of network leadership in setting the tone for cross-partnership communication. While partnership leaders shared the goal of strengthening cross-organizational communication, social network results illustrated a need to develop strategies that target these goals.

BackgroundBy 2034, the number of US individuals with diabetes is predicted to increase from 23.7 to 44.1 million, and annual diabetes-related spending is expected to grow from $113 to $336 billion. Up to 55% of US Hispanics born in the year 2000 are expected to develop diabetes during their lifetime. Poor healthcare access and cultural barriers prevent optimal care, adherence, and clinical benefit, placing Hispanics at disproportionate risk for costly diabetes complications. Mobile technology is increasingly prevalent in all populations and can circumvent such barriers. Our group developed Dulce Digital, an educational text messaging program that improved glycemic control relative to usual care. Dulce Digital-Me (DD-Me) has been tailored to a participant's individual needs with a greater focus on health behavior change.MethodsThis is a three-arm, parallel group, randomized trial with equal allocation ratio enrolling Hispanic adults with low income and poorly managed type 2 diabetes (N = 414) from a San Diego County Federally Qualified Health Center. Participants are randomized to receive Dulce Digital, Dulce Digital-Me-Automated, or Dulce Digital-Me-Telephonic. The DD-Me groups include Dulce Digital components plus personalized goal-setting and feedback delivered via algorithm-driven automated text messaging (DD-Me-Automated) or by the care team health coach (DD-Me-Telephonic) over a 12-month follow-up period. The study will examine the comparative effectiveness of the three groups in improving diabetes clinical control [HbA1c, primary outcome; low-density lipoprotein cholesterol (LDL-C), and systolic blood pressure (SBP)] and patient-provider communication and patient adherence (i.e., medication, self-management tasks) over 12 months and will examine cost-effectiveness of the three interventions.DiscussionOur comparative evaluation of three mHealth approaches will elucidate how technology can be integrated most effectively and efficiently within primary care-based

Bartolome R Celli,1 Maryam Navaie,2,3 Zhun Xu,4 Soojin Cho-Reyes,2 Carole Dembek,5 Todd P Gilmer41Chronic Obstructive Pulmonary Disease Center, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA, USA; 2Global Strategy, Advance Health Solutions, LLC, New York, NY, USA; 3School of Professional Studies, Columbia University, New York, NY, USA; 4Department of Family Medicine and Public Health, University of California San Diego, La Jolla, CA, USA; 5Global Health Economics and Outcomes Research, Sunovion Pharmaceuticals Inc, Marlborough, MA, USAPurpose: Global evidence-based treatment strategies for chronic obstructive pulmonary disease (COPD) recommend using long-acting bronchodilators (LABDs) as maintenance therapy. However, COPD patients are often undertreated. We examined COPD treatment patterns among Medicare beneficiaries who initiated arformoterol tartrate, a nebulized long-acting beta2 agonist (LABA), and identified the predictors of initiation.Methods: Using a 100% sample of Medicare administrative data, we identified beneficiaries with a COPD diagnosis (ICD-9 490–492.xx, 494.xx, 496.xx) between 2010 and 2014 who had ≥1 year of continuous enrollment in Parts A, B, and D, and ≥2 COPD-related outpatient visits within 30 days or ≥1 hospitalization(s). After applying inclusion/exclusion criteria, three cohorts were identified: (1) study group beneficiaries who received nebulized arformoterol (n=11,886), (2) a subset of the study group with no LABD use 90 days prior to initiating arformoterol (n=5,542), and (3) control group beneficiaries with no nebulized LABA use (n=220,429). Logistic regression was used to evaluate predictors of arformoterol initiation. Odds ratios (ORs), 95% confidence intervals (CIs), and p values were computed.Results: Among arformoterol users, 47% (n=5,542) had received no LABDs 90 days prior to initiating arformoterol. These beneficiaries were being treated with a nebulized (50%) or inhale

Permanent supportive housing (PSH) programs are being implemented throughout the United States. This study examined the relationship between fidelity to the Housing First model and health service use among clients in PSH programs in California.Data from a survey of PSH program practices were merged with administrative data on service utilization to examine the association between fidelity to a benchmark program, the Housing First model, and health service use among 5,067 clients in 77 PSH programs. Regression analyses were used to compare inpatient, crisis and residential, and outpatient mental health service use between high-, mid-, and low-fidelity programs in a pre-post design.During the preenrollment period, clients in mid- and high-fidelity PSH programs, compared with low-fidelity programs, used inpatient and crisis and residential services more but used outpatient mental health services less. Postenrollment, patients in high-fidelity programs showed the largest increase in the number of outpatient visits, followed by clients in mid- and low-fidelity programs: 71.6 versus 48.2 and 29.0, respectively.Clients in housing programs with higher fidelity to the Housing First model had greater increases in outpatient visits. Compared with lower-fidelity programs, higher-fidelity programs also enrolled clients who used fewer mental health outpatient services in the year before enrollment. Higher-fidelity programs may be more effective than lower-fidelity programs in increasing outpatient service utilization and in their outreach to and engagement of clients who are not appropriately served by the public mental health system.

Permanent supportive housing (PSH) programs are being implemented throughout the United States. This study examined the relationship between fidelity to the Housing First model and health service use among clients in PSH programs in California.Data from a survey of PSH program practices were merged with administrative data on service utilization to examine the association between fidelity to a benchmark program, the Housing First model, and health service use among 5,067 clients in 77 PSH programs. Regression analyses were used to compare inpatient, crisis and residential, and outpatient mental health service use between high-, mid-, and low-fidelity programs in a pre-post design.During the preenrollment period, clients in mid- and high-fidelity PSH programs, compared with low-fidelity programs, used inpatient and crisis and residential services more but used outpatient mental health services less. Postenrollment, patients in high-fidelity programs showed the largest increase in the number of outpatient visits, followed by clients in mid- and low-fidelity programs: 71.6 versus 48.2 and 29.0, respectively.Clients in housing programs with higher fidelity to the Housing First model had greater increases in outpatient visits. Compared with lower-fidelity programs, higher-fidelity programs also enrolled clients who used fewer mental health outpatient services in the year before enrollment. Higher-fidelity programs may be more effective than lower-fidelity programs in increasing outpatient service utilization and in their outreach to and engagement of clients who are not appropriately served by the public mental health system.

ObjectiveCalifornia's full-service partnerships (FSPs) provide a combination of subsidized permanent housing and multidisciplinary team-based services with a focus on rehabilitation and recovery. The goal of the study was to examine whether participation in FSPs is associated with changes in health service use and costs compared with usual care.MethodsA quasi-experimental, pre-post, intent-to-treat design with a propensity score-matched contemporaneous control group was used to compare health service use and costs among 10,231 FSP clients and 10,231 matched clients with serious mental illness who were receiving public mental health services in California from January 1, 2004, through June 30, 2010.ResultsAmong FSP participants, the mean annual number of mental health outpatient visits increased by 55.5, and annual mental health costs increased by $11,725 relative to the matched control group. Total service costs increased by $12,056.ConclusionsParticipation in an FSP was associated with increases in outpatient visits and their associated costs. As supportive housing programs are implemented nationally and on a large scale, these programs will likely need to be more effectively designed and targeted in order to achieve reductions in costly inpatient services.

ObjectiveCalifornia's full-service partnerships (FSPs) provide a combination of subsidized permanent housing and multidisciplinary team-based services with a focus on rehabilitation and recovery. The goal of the study was to examine whether participation in FSPs is associated with changes in health service use and costs compared with usual care.MethodsA quasi-experimental, pre-post, intent-to-treat design with a propensity score-matched contemporaneous control group was used to compare health service use and costs among 10,231 FSP clients and 10,231 matched clients with serious mental illness who were receiving public mental health services in California from January 1, 2004, through June 30, 2010.ResultsAmong FSP participants, the mean annual number of mental health outpatient visits increased by 55.5, and annual mental health costs increased by $11,725 relative to the matched control group. Total service costs increased by $12,056.ConclusionsParticipation in an FSP was associated with increases in outpatient visits and their associated costs. As supportive housing programs are implemented nationally and on a large scale, these programs will likely need to be more effectively designed and targeted in order to achieve reductions in costly inpatient services.

People with serious mental illness, such as schizophrenia and bipolar disorder, experience premature mortality, often from cardiovascular disease (CVD). Unfortunately, people with serious mental illness typically are not screened or treated for CVD risk factors despite national guideline recommendations. Access to primary preventive care in community mental health settings has the potential to reduce early mortality rates in this population. The authors review best practices for developing an integrated care model for people with serious mental illness by considering economic feasibility and sustainability from the perspective of a community mental health clinic (CMHC). A process-mapping approach was used to gather information on clinic costs (staff roles, responsibilities, time, and salary) of serving 544 patients at one CMHC. The estimated annual cost of the model was measurable and modest, at $74 per person, suggesting that this model may be financially feasible.

People with serious mental illness, such as schizophrenia and bipolar disorder, experience premature mortality, often from cardiovascular disease (CVD). Unfortunately, people with serious mental illness typically are not screened or treated for CVD risk factors despite national guideline recommendations. Access to primary preventive care in community mental health settings has the potential to reduce early mortality rates in this population. The authors review best practices for developing an integrated care model for people with serious mental illness by considering economic feasibility and sustainability from the perspective of a community mental health clinic (CMHC). A process-mapping approach was used to gather information on clinic costs (staff roles, responsibilities, time, and salary) of serving 544 patients at one CMHC. The estimated annual cost of the model was measurable and modest, at $74 per person, suggesting that this model may be financially feasible.

People with serious mental illness, such as schizophrenia and bipolar disorder, experience premature mortality, often from cardiovascular disease (CVD). Unfortunately, people with serious mental illness typically are not screened or treated for CVD risk factors despite national guideline recommendations. Access to primary preventive care in community mental health settings has the potential to reduce early mortality rates in this population. The authors review best practices for developing an integrated care model for people with serious mental illness by considering economic feasibility and sustainability from the perspective of a community mental health clinic (CMHC). A process-mapping approach was used to gather information on clinic costs (staff roles, responsibilities, time, and salary) of serving 544 patients at one CMHC. The estimated annual cost of the model was measurable and modest, at $74 per person, suggesting that this model may be financially feasible.

ObjectiveTo characterize the health risk of enrollees in California's state-based insurance marketplace (Covered California) by metal tier, region, month of enrollment, and plan.Data source/study setting2014 Open-enrollment data from Covered California linked with 2012 hospitalization and emergency department (ED) visit records from statewide all-payer administrative databases.Data collection/extraction methodsChronic Illness and Disability Payment System (CDPS) health risk scores derived from an individual's age and sex from the enrollment file and the diagnoses captured in the hospitalization and ED records. CDPS scores were standardized by setting the average to 1.00.Principal findingsAmong the 1,286,089 enrollees, 120,573 (9.4 percent) had at least one ED visit and/or a hospitalization in 2012. Higher risk enrollees chose plans with greater actuarial value. The standardized CDPS health risk score was 11 percent higher in the first month of enrollment (1.08; 99 percent CI: 1.07-1.09) than the last month (0.97; 99 percent CI: 0.97-0.97). Four of the 12 plans enrolled 91 percent of individuals; their average health risk scores were each within 3 percent of the marketplace's statewide average.ConclusionsProviding health plans with a means to assess the health risk of their year 1 enrollees allowed them to anticipate whether they would receive or contribute payments to a risk-adjustment pool. After receiving these findings as a part of their negotiations with Covered California, health plans covering the majority of enrollees decreased their initially proposed 2015 rates, saving consumers tens of millions of dollars in potential premiums.

BackgroundThe Centers for Medicare & Medicaid Services (CMS) Medicare Health Plan Quality and Performance Ratings program, or Star Ratings program, includes 3 medication adherence outcome measures (Medication Adherence for Diabetes Medications, Medication Adherence for Hypertension, and Medication Adherence for Cholesterol), which contribute to approximately 31% of a Medicare Advantage prescription drug (MA-PD) plan's Part D summary rating and 12% of its overall star rating (a weighted summary of a plan's Part C and Part D ratings). MA-PD plans have been increasing their adherence intervention efforts as an approach to improving beneficiaries' medication adherence and the plan's quality performance ratings. However, few evaluations have examined the effects of these interventions on medication adherence and performance ratings.ObjectiveTo assess the impact of a quasi-experimental multichannel adherence intervention on beneficiaries' medication adherence and health plan quality performance measures for 2 MA-PD plans. The intervention included a daily prescriber-directed 90-day retail refill component and a weekly member-directed refill reminder component.MethodsMembers filling 1 or more medications assessed by the 3 CMS star ratings adherence measures (oral antidiabetics [DM], antihypertensives [HTN], and statins [CHOL]) were identified for a 2-component intervention starting in April 2013. The retail-based 90-day refill component sent populated 90-day prescription letters via fax to prescribers of members who had filled a 30-day prescription. One fax per member-medication instance was sent and included the option to fax approval of a new 90-day prescription. For prescribers who approved, members were notified that a 90-day refill was available at their retail pharmacies. The refill reminder component used weekly scans of pharmacy claims to identify members' refill patterns. Reminder letters were sent to members 7 days late to refill. An intent-to-treat approach

BackgroundThe Centers for Medicare & Medicaid Services (CMS) Medicare Health Plan Quality and Performance Ratings program, or Star Ratings program, includes 3 medication adherence outcome measures (Medication Adherence for Diabetes Medications, Medication Adherence for Hypertension, and Medication Adherence for Cholesterol), which contribute to approximately 31% of a Medicare Advantage prescription drug (MA-PD) plan's Part D summary rating and 12% of its overall star rating (a weighted summary of a plan's Part C and Part D ratings). MA-PD plans have been increasing their adherence intervention efforts as an approach to improving beneficiaries' medication adherence and the plan's quality performance ratings. However, few evaluations have examined the effects of these interventions on medication adherence and performance ratings.ObjectiveTo assess the impact of a quasi-experimental multichannel adherence intervention on beneficiaries' medication adherence and health plan quality performance measures for 2 MA-PD plans. The intervention included a daily prescriber-directed 90-day retail refill component and a weekly member-directed refill reminder component.MethodsMembers filling 1 or more medications assessed by the 3 CMS star ratings adherence measures (oral antidiabetics [DM], antihypertensives [HTN], and statins [CHOL]) were identified for a 2-component intervention starting in April 2013. The retail-based 90-day refill component sent populated 90-day prescription letters via fax to prescribers of members who had filled a 30-day prescription. One fax per member-medication instance was sent and included the option to fax approval of a new 90-day prescription. For prescribers who approved, members were notified that a 90-day refill was available at their retail pharmacies. The refill reminder component used weekly scans of pharmacy claims to identify members' refill patterns. Reminder letters were sent to members 7 days late to refill. An intent-to-treat approach

ObjectiveTo characterize the health risk of enrollees in California's state-based insurance marketplace (Covered California) by metal tier, region, month of enrollment, and plan.Data source/study setting2014 Open-enrollment data from Covered California linked with 2012 hospitalization and emergency department (ED) visit records from statewide all-payer administrative databases.Data collection/extraction methodsChronic Illness and Disability Payment System (CDPS) health risk scores derived from an individual's age and sex from the enrollment file and the diagnoses captured in the hospitalization and ED records. CDPS scores were standardized by setting the average to 1.00.Principal findingsAmong the 1,286,089 enrollees, 120,573 (9.4 percent) had at least one ED visit and/or a hospitalization in 2012. Higher risk enrollees chose plans with greater actuarial value. The standardized CDPS health risk score was 11 percent higher in the first month of enrollment (1.08; 99 percent CI: 1.07-1.09) than the last month (0.97; 99 percent CI: 0.97-0.97). Four of the 12 plans enrolled 91 percent of individuals; their average health risk scores were each within 3 percent of the marketplace's statewide average.ConclusionsProviding health plans with a means to assess the health risk of their year 1 enrollees allowed them to anticipate whether they would receive or contribute payments to a risk-adjustment pool. After receiving these findings as a part of their negotiations with Covered California, health plans covering the majority of enrollees decreased their initially proposed 2015 rates, saving consumers tens of millions of dollars in potential premiums.

ObjectiveThis study examined whether receipt of outpatient psychiatric services after hospital discharge was associated with reduced risk of readmission.MethodsTreatment records from patients admitted to San Diego County psychiatric hospitals over a one-year period were obtained from the San Diego County Behavioral Health Services electronic health record system. A discrete-time proportional hazards model was used to examine the association of receipt of outpatient psychiatric services with readmission within 30 days of discharge from the index hospitalization.ResultsOf the 4,663 patients, 16% were readmitted within 30 days. In an adjusted model, receipt of outpatient therapy after discharge was associated with a greater likelihood of being readmitted (hazard ratio=1.36, 95% confidence interval=1.14-1.67), whereas receipt of case management or medication management was not associated with readmission.ConclusionsThe differential risk of readmission by service type suggests a need for studies that explore reasons for an increased risk of readmission with certain types of services.

BackgroundPhysical inactivity is high in Latinas, as are chronic health conditions. There is a need for physical activity (PA) interventions that are not only effective but have potential for cost-effective widespread dissemination. The purpose of this paper was to assess the costs and cost effectiveness of a Spanish-language print-based mail-delivered PA intervention that was linguistically and culturally adapted for Latinas.MethodsAdult Latinas (N = 266) were randomly assigned to receive mail-delivered individually tailored intervention materials or wellness information mailed on the same schedule (control). PA was assessed at baseline, six months (post-intervention) and 12 months (maintenance phase) using the 7-Day Physical Activity Recall Interview. Costs were calculated from a payer perspective, and included personnel time (wage, fringe, and overhead), materials, equipment, software, and postage costs.ResultsAt six months, the PA intervention cost $29/person/month, compared to $15/person/month for wellness control. These costs fell to $17 and $9 at 12 months, respectively. Intervention participants increased their PA by an average of 72 min/week at six months and 94 min/week at 12 months, while wellness control participants increased their PA by an average of 30 min/week and 40 min/week, respectively. At six months, each minute increase in PA cost $0.18 in the intervention group compared to $0.23 in wellness control, which fell to $0.07 and $0.08 at 12 months, respectively. The incremental cost per increase in physical activity associated with the intervention was $0.15 at 6 months and $0.05 at 12 months.ConclusionsWhile the intervention was more costly than the wellness control, costs per minute of increase in PA were lower in the intervention. The print-based mail-delivered format has potential for broad, cost-effective dissemination, which could help address disparities in this at-risk population.Trial registrationNCT01583140; Date of Registration: 03/06/201

BackgroundPhysical inactivity is high in Latinas, as are chronic health conditions. There is a need for physical activity (PA) interventions that are not only effective but have potential for cost-effective widespread dissemination. The purpose of this paper was to assess the costs and cost effectiveness of a Spanish-language print-based mail-delivered PA intervention that was linguistically and culturally adapted for Latinas.MethodsAdult Latinas (N = 266) were randomly assigned to receive mail-delivered individually tailored intervention materials or wellness information mailed on the same schedule (control). PA was assessed at baseline, six months (post-intervention) and 12 months (maintenance phase) using the 7-Day Physical Activity Recall Interview. Costs were calculated from a payer perspective, and included personnel time (wage, fringe, and overhead), materials, equipment, software, and postage costs.ResultsAt six months, the PA intervention cost $29/person/month, compared to $15/person/month for wellness control. These costs fell to $17 and $9 at 12 months, respectively. Intervention participants increased their PA by an average of 72 min/week at six months and 94 min/week at 12 months, while wellness control participants increased their PA by an average of 30 min/week and 40 min/week, respectively. At six months, each minute increase in PA cost $0.18 in the intervention group compared to $0.23 in wellness control, which fell to $0.07 and $0.08 at 12 months, respectively. The incremental cost per increase in physical activity associated with the intervention was $0.15 at 6 months and $0.05 at 12 months.ConclusionsWhile the intervention was more costly than the wellness control, costs per minute of increase in PA were lower in the intervention. The print-based mail-delivered format has potential for broad, cost-effective dissemination, which could help address disparities in this at-risk population.Trial registrationNCT01583140; Date of Registration: 03/06/201

ObjectiveThis study examined whether receipt of outpatient psychiatric services after hospital discharge was associated with reduced risk of readmission.MethodsTreatment records from patients admitted to San Diego County psychiatric hospitals over a one-year period were obtained from the San Diego County Behavioral Health Services electronic health record system. A discrete-time proportional hazards model was used to examine the association of receipt of outpatient psychiatric services with readmission within 30 days of discharge from the index hospitalization.ResultsOf the 4,663 patients, 16% were readmitted within 30 days. In an adjusted model, receipt of outpatient therapy after discharge was associated with a greater likelihood of being readmitted (hazard ratio=1.36, 95% confidence interval=1.14-1.67), whereas receipt of case management or medication management was not associated with readmission.ConclusionsThe differential risk of readmission by service type suggests a need for studies that explore reasons for an increased risk of readmission with certain types of services.

ObjectiveTo characterize the 20 most common prescription medications and the 10 most common prescription medications classified in the former U.S. Food and Drug Administration categories D or X dispensed to pregnant women enrolled in the U.S. Medicaid program.MethodsWe conducted a cohort study of 1,106,757 pregnant women with live births using 2000-2007 Medicaid Analytic eXtract data. We used outpatient pharmacy records to identify medication dispensings and reported the proportion of pregnancies that were dispensed at least one prescription medication. Maternal age and race and ethnicity-stratified estimates were compared using prevalence ratios and 95% confidence intervals (CIs).ResultsDuring pregnancy, 82.5% of the cohort had a dispensing for one or more prescription medication. The most commonly dispensed medications during pregnancy included nitrofurantoin (21.6%), metronidazole (19.4%), amoxicillin (18.0%), azithromycin (16.9%), and promethazine (13.5%). Proportions were highest among younger women for several medications; eg, nitrofurantoin (23.9% compared with 15.4%; prevalence ratio 1.55, CI 1.52-1.58), metronidazole (20.7% compared with 12.0%; prevalence ratio 1.73, CI 1.69-1.77), and azithromycin (21.1% compared with 11.0%; prevalence ratio 1.93, CI 1.89-1.97) were more common among women younger than 20 years than among women aged 35 years or older. Proportions were highest among white women with some exceptions; eg, compared with white women, metronidazole was more common among black women (29.8% compared with 14.4%; prevalence ratio 2.07, CI 2.05-2.09). Excluding fertility treatments, 42.0% had at least one dispensing for a D or X medication during pregnancy. Codeine (11.9%) and hydrocodone (10.2%) were the most common D medications.ConclusionMedications used to treat infections were the most commonly dispensed prescription medications. Dispensing of commonly used prescription medications during pregnancy varied by maternal age and race-ethnicity.Level

Adjustments for the underlying differences in risks among patients in payment approaches has been widely used and accepted; yet current risk adjustment approaches are limited because they do not account for the various social determinants of health (SDH) that can also influence health outcomes. This can have implications for providers serving disadvantaged populations. This article discusses why the inclusion of SDH in the formulas for risk adjustment is important for federally qualified health centers (FQHCs) under the Patient Protection and Affordable Care Act (ACA) and recommends ways in which FQHCs can be leaders in informing payment reform policies.

Social health is important to measure when assessing outcomes in community mental health. Our objective was to validate social health scales using items from two broader commonly used measures that assess mental health outcomes. Participants were 609 adults receiving psychological treatment services. Items were identified from the California Quality of Life (CA-QOL) and Mental Health Statistics Improvement Program (MHSIP) outcome measures by their conceptual correspondence with social health and compared to the Social Functioning Questionnaire (SFQ) using correlational analyses. Pearson correlations for the identified CA-QOL and MSHIP items with the SFQ ranged from .42 to .62, and the identified scale scores produced Pearson correlation coefficients of .56, .70, and, .70 with the SFQ. Concurrent validity with social health was supported for the identified scales. The current inclusion of these assessment tools allows community mental health programs to include social health in their assessments.

Social health is important to measure when assessing outcomes in community mental health. Our objective was to validate social health scales using items from two broader commonly used measures that assess mental health outcomes. Participants were 609 adults receiving psychological treatment services. Items were identified from the California Quality of Life (CA-QOL) and Mental Health Statistics Improvement Program (MHSIP) outcome measures by their conceptual correspondence with social health and compared to the Social Functioning Questionnaire (SFQ) using correlational analyses. Pearson correlations for the identified CA-QOL and MSHIP items with the SFQ ranged from .42 to .62, and the identified scale scores produced Pearson correlation coefficients of .56, .70, and, .70 with the SFQ. Concurrent validity with social health was supported for the identified scales. The current inclusion of these assessment tools allows community mental health programs to include social health in their assessments.