# Facilitators of and barriers to County Behavioral Health System Transformation and Innovation: an interview study

## TL;DR

This study explores what helps or hinders changes in county mental health systems, focusing on Orange County's efforts to improve access through contracts and digital tools.

## Contribution

The study identifies specific facilitators and barriers to behavioral health system transformation using stakeholder interviews and an implementation framework.

## Key findings

- Five key themes emerged: aligning goals, addressing fit, fostering engagement, understanding contexts, and promoting communication.
- Barriers included misalignment with incentive structures and changing state guidelines.
- Involving diverse communities improved digital tool development.

## Abstract

Inadequate and inequitable access to quality behavioral health services and high costs within the mental health systems are long-standing problems. System-level (e.g., fee-for-service payment model, lack of a universal payor) and individual factors (e.g., lack of knowledge of existing resources) contribute to difficulties in accessing resources and services. Patients are underserved in County behavioral health systems in the United States. Orange County’s (California) Behavioral Health System Transformation project sought to improve access by addressing two parts of their system: developing a template for value-based contracts that promote payor-agnostic care (Part 1); developing a digital platform to support resource navigation (Part 2). Our aim was to evaluate facilitators of and barriers to each of these system changes.

We collected interview data from County or health care agency leaders, contracted partners, and community stakeholders. Themes were informed by the Consolidated Framework for Implementation Research.

Five themes were identified related to behavioral health system transformation, including 1) aligning goals and values, 2) addressing fit, 3) fostering engagement and partnership, 4) being aware of implementation contexts, and 5) promoting communication. A lack of fit into incentive structures and changing state guidelines and priorities were barriers to contract development. Involving diverse communities to inform design and content facilitated the process of developing digital tools.

The study highlights the multifaceted factors that help facilitate or hinder behavioral health system transformation, such as the need for addressing systematic and process behaviors, leveraging the knowledge of leadership and community stakeholders, fostering collaboration, and adapting to implementation contexts.

The online version contains supplementary material available at 10.1186/s12913-024-11041-9.