DANIEL SICONOLFI, JULIA BANDINI, CRISTINA GLAVE, ALEJANDRO ROA CONTRERAS, SKYE A. MINER,
COURTNEY ANN KASE, JACOBO PEREIRA-PACHECO, NICOLE K. EBERHART
Evaluation of California’s
Multi-County Psychiatric
Advance Directives
Innovation Project
Early Implementation and Outcomes,
2024–2025
P
sychiatric advance directives (PADs) allow individuals with mental health conditions to
document preferences for care that they might not otherwise be able to communicate during
a crisis. For example, PADs may allow an individual to specify preferred treatments, pre-
ferred approaches to communication and deescalation, desired surrogate decisionmakers
or advocates, and other important health information (e.g., concurrent medications or allergies).
Despite their potential benefits, PADs have had relatively limited awareness and uptake (The Joint
Commission, 2020; Substance Abuse and Mental Health Services Administration [SAMHSA], 2019).
As a legal document, a PAD can be cumbersome to complete. Additionally, the preferences and
values captured by a PAD may draw from an individual’s past experiences with mental health treat-
ment and hypothetical future scenarios (e.g., significant symptoms that constitute a crisis). Reflect-
ing on these past experiences can be distressing, and envisioning future scenarios may be difficult.
Given the low levels of awareness and potential challenges in completing a PAD independently, PAD
initiatives have typically included outreach and facilitation—for example, by clinicians, advocates,
or peer workers (Swanson et al., 2006; Tinland et al., 2022). Peer workers (e.g., Peer Support Special-
ists) are individuals with lived experience related to mental health or substance use needs, or family
members of an individual with mental health or substance use needs, who provide a variety of sup-
ports within communities (California Mental Health Services Authority, undated). Prior research
and evaluation on the facilitation of PADs have focused less on peer workers than on other facilita-
tors (e.g., health care providers), with a few recent exceptions (e.g., Tinland et al., 2022).
Evaluation Report
