Seven California counties collaborated on a Mental Health Services Act Innovation Project intended to develop and implement psychiatric advance directives (PADs), facilitated by trained peer workers. RAND researchers evaluated several aspects of the Innovation Project, including PAD facilitation training outcomes, PAD user experiences and outcomes, and county implementation perspectives. This report summarizes the evaluation findings.

Evaluation of California's Multi-County Psychiatric Advance Directives Innovation Project

Early Implementation and Outcomes, 2024–2025

Daniel Siconolfi, Julia Bandini, Cristina Glave, Alejandro Roa Contreras, Skye A. Miner, Courtney Ann Kase, Jacobo Pereira-Pacheco, Nicole K. Eberhart

ResearchPublished Jun 24, 2025

Psychiatric 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. Over the past several years, seven California counties have been collaborating on a Mental Health Services Act Innovation Project intended to increase the availability and uptake of PADs among persons with mental health needs, supported by peer worker outreach and facilitation.

In this report, RAND researchers evaluate three aspects of the PADs Innovation Project pilot. First, they present findings from an assessment of post-training outcomes and experiences with real-world PAD facilitation, using surveys and interviews with peer workers. Second, they describe PAD creation rates and outcomes across the participating counties, using a combination of administrative metadata from the PAD platform, a brief user survey contained within the PAD platform, and a follow-up interview and survey with a subset of individuals who created a PAD. Third, they report the perspectives of county implementation staff, who provided overall reflections on the implementation of beta testing through interviews. Finally, the authors summarize their findings and provide a set of recommendations for future PAD implementation.

Key Findings

  • Individuals who participated in a new training for implementing PADs demonstrated high readiness for facilitating PADs, reporting significant improvements in PAD-specific skills and knowledge after the training.
  • Overall, feedback on the PAD training experience was positive regarding training delivery, the training team, and the achievement of the training's stated goals. However, some interviewees reported that the three-day training was too long and too focused on basic peer worker skills.
  • PAD facilitators desired standardized guidance on the legal enforceability of PADs and how to communicate this information to individuals completing PADs.
  • Individuals who created a PAD were satisfied with the experience. Most indicated that they felt in control of their PAD and that their privacy was respected. The benefits of completing a PAD include a sense of empowerment, improved trust and communication with health care providers, and peace of mind.
  • County staff highlighted the pivotal role of peer workers in successful implementation. Beta testing provided opportunities to identify current limitations of the PAD platform and other barriers (e.g., integration, reimbursement models) to the successful rollout of PADs more broadly.
  • Beta testing provided early evidence that peer worker–facilitated digital PADs are feasible and acceptable to facilitators and individuals served.
  • Beta testing also points to barriers to real-world PAD utility that need to be addressed. These include a lack of awareness and understanding of PADs among first responders and care providers, the inability for first responders and hospitals to access PADs, and a lack of clear guidance on legal enforceability.

Recommendations

  • Offer a streamlined or modular version of the PAD facilitator training to decrease training burden and increase usefulness.
  • Evaluate future iterations of the training program, with continued attention to facilitator readiness and feedback on the training experience.
  • Continue implementing the peer worker model for PAD facilitation, involve peer workers in implementation design, and consider increasing leadership opportunities for peer workers.
  • Provide clear, ongoing guidance to facilitators and individuals served on the legal enforceability of PADs and timelines for first responder and hospital system integration as these systems evolve.

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Siconolfi, Daniel, Julia Bandini, Cristina Glave, Alejandro Roa Contreras, Skye A. Miner, Courtney Ann Kase, Jacobo Pereira-Pacheco, and Nicole K. Eberhart, Evaluation of California's Multi-County Psychiatric Advance Directives Innovation Project: Early Implementation and Outcomes, 2024–2025. Santa Monica, CA: RAND Corporation, 2025. https://www.rand.org/pubs/research_reports/RRA3464-1.html.
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This research was funded by California counties under the Mental Health Services Act and carried out within the Access and Delivery Program in RAND Health Care.

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