Mental health services utilization in a children's mental health managed care demonstration

Factors associated with the use of intrusive measures at a tertiary care facility for children and youth with mental health and developmental disabilities

This study seeks to identify some of the explanatory factors associated with the use of intrusive measures among children with mental health and developmental disabilities in psychiatric facilities. Intrusive intervention data were collected using an organizational database that was developed internally at a tertiary care facility. The sample was composed of 338 children/youth aged between 6 and 18 years (mean = 12.33, standard deviation = 2.70) admitted within a 2-year period. Logistic regression was used to examine the relationship between chemical restraint, physical restraint and secure isolation, and programme type after controlling for demographic and other relevant client characteristics. The study found that the number of chemical restraints and secure isolations was higher for clients with developmental disabilities than for clients with mental health, whereas the number of physical restraints was lower for clients with developmental disabilities than clients with mental health issues. Demographic variables also predicted specific types of intrusive measures. The results of this study outline the differential factors associated with specific types of intrusive measures to control aggressive and self-harm behaviours. The paper also outlines cultural change initiatives, organizational interventions, and policy implications for best practice services for children/youth in psychiatric facilities to further reduce intrusive measures.

An episode-based framework for analyzing health care expenditures: an application of reward renewal models

OBJECTIVE

To illustrate an episode-based framework for analyzing health care expenditures based on reward renewal models, a stochastic process used in engineering for describing processes that cycle on and off with "rewards" (or costs) occurring at the end of each cycle.

DATA SOURCES/STUDY SETTING

Data used in the illustration were collected as part of an evaluation of a national initiative to improve mental health services for children and youth. Participants were enrolled in a longitudinal study at a demonstration site and in a comparison community between 1997 and 1999. The illustration involves analyses of mental health expenditures at the two sites and of the dynamics of service use behind those expenditures.

DATA COLLECTION/EXTRACTION METHODS

Services data were derived from management information systems as well as patient records at inpatient facilities in the two communities. These data cover services received between 1997 and 2003. The analysis focuses on the year following study entry.

PRINCIPAL FINDINGS

Between-site differences in expenditures reflect complex between-site differences in the timing of service use. In particular, children at the demonstration stayed in treatment longer but were less likely to return for treatment later. In contrast, children at the comparison site experienced substantially less continuity of care. Costs per day of treatment within an episode were comparable at the two sites.

CONCLUSIONS

Reward renewal models offer a promising means for integrating research on service episodes and the dynamics of service use with that on health care expenditures.

Chemical dependency and psychiatric services for adolescents in private managed care: implications for outcomes

BACKGROUND

Many adolescents with alcohol and drug problems have mental health comorbidities. The literature suggests that patients entering chemical dependency (CD) treatment with co-occurring problems have less successful outcomes, including treatment dropout and relapse. We examined the impact of psychiatric services on treatment initiation, retention, and alcohol and drug abstinence outcomes for adolescents in CD treatment.

METHODS

Participants were 419 adolescents aged 12-18 years who were seeking treatment at four CD programs of a nonprofit, managed care, group model health system and a parent or guardian for each adolescent. We surveyed participants at intake and 6 months and examined clinical and administrative data on diagnoses and CD and psychiatric utilization. Six-month response rates were 91% for adolescents and 93% for parents.

RESULTS

Fifty-five percent of the patients with treatment intakes had at least one psychiatric diagnosis in addition to a substance use disorder. Compared with matched controls, patients with CD intakes had higher rates of depression, anxiety, eating disorders, attention deficit hyperactivity disorder, conduct disorder, and conduct disorder including oppositional defiant disorder. Thirty-one percent of the full sample had psychiatric visits in the 6 months after intake; among those with a psychiatric diagnosis, 54% had a psychiatric visit. Girls and those with higher Youth Self-Report internalizing scores were more likely to have a psychiatric visit (OR = 2.27, p < 0.001 and OR = 1.05, p < 0.0001, respectively). Adolescents receiving psychiatric services were more likely to be abstinent from both alcohol and drugs than those not receiving these services (OR = 1.57, 95% CI = 0.98-2.5) and more likely to be alcohol abstinent (OR = 1.68, 95% CI = 1.00-2.85). Those adolescents at colocated clinics had higher odds of abstinence from both alcohol and drugs (OR = 1.57, 95% CI = 1.03-2.39) and drugs (OR = 1.84, 95% CI = 1.87-2.85) and of returning after intake to initiate CD treatment (OR = 2.28, 95% CI = 1.44-3.61, p < 0.001) than others.

CONCLUSIONS

Our results demonstrate the need for psychiatric treatment of adolescents in CD treatment and highlight the importance of their receiving such services.

Pathways to chemical dependency treatment for adolescents in an HMO

This study examines pathways to chemical dependency (CD) treatment for adolescents in a prepaid health plan, including factors influencing treatment referral and access. Data were collected from 419 adolescent CD treatment intakes ages 13 to 18 in a large, private health plan. The study examines predictors of referral from different sources and of mental health treatment prior to CD treatment. Referral patterns, problem severity, and psychiatric comorbidity differed by gender. Being male (p < .05) and higher scores on the Youth Self-Report (YSR) externalizing scale (p < .01) predicted a justice system referral. Using more types of substances predicted referral by medical and mental health providers (p < .05) and self-referral (p < .01). Higher YSR internalizing scores predicted referral from mental health (p < .01) and self-referral (p <.01). Being White versus African American (p < .05) or Latino (p < .01), older (p < .05), and having higher YSR internalizing scores (p < .05), a conduct disorder (p < .01), or a family member with a substance use problem (p < .01) predicted a mental health visit prior to CD intake. The findings raise questions regarding the role of health plans, clinicians, families, schools, and community agencies in referring and treating adolescents with substance use problems. They suggest that improved coordination of care may promote more integrated treatment practices, which could decrease substance use, mental health, and medical problem severity.

Looking for the disorder in conduct disorder

Besides their well-known externalizing behavior, children with conduct disorder (CD) often have additional impairments outside the criteria for the CD diagnosis. In a 5-year study of 984 treated children (ages 5-17 years), those with CD had an average of 2.2 primary diagnoses. Children with CD showed the worst problem and impairment scores in comparison with 11 common diagnoses. Compared with other treated children, children with CD achieved worse scores on 14 of 15 syndromes, including internalizing problems such as withdrawal and major depression. The average child with CD had larger relapse scores in the 1.5- to 3-year period after admission to treatment. This pattern, pervasive at intake and chronic in course, resembles a global disability more than a circumscribed problem managed with a narrow range of treatments specific to it.

Rejoinder to Mordock's critique of the Fort Bragg Evaluation Project: the sample is generalizable and the outcomes are clear

The Fort Bragg Evaluation Project (FBEP) showed that children in a well implemented and expensive continuum of care had no better clinical outcomes than those experiencing more traditional and fragmented services. In an article published in this journal that was critical of the evaluation, Mordock argued that the FBEP results be viewed with skepticism because of what he perceived to be methodological, design, measurement, and analytic failures of this study. We think it is important to respond to Mordock's critique since it contributes to the great reluctance to seriously consider the study's findings and their implications.

Use of the Child and Adolescent Functional Assessment Scale to predict service utilization and cost

The Child and Adolescent Functional Assessment Scale (CAFAS) is a multidimensional measure of impairment that assesses the extent of interference in day-to-day functioning secondary to emotional, behavioral, or substance use problems. Respondents were 984 youths, aged 5 to 17, who were referred for mental health services. They were assessed at intake and at 6 and 12 months postintake with a battery of measures administered by evaluation staff who were independent of treatment. Utilization indicators included restrictiveness of care, total cost, number of bed days, and total number of days of service received. The CAFAS total score at intake was a significant predictor of service utilization and cost determined at 6 and 12 months postintake. The CAFAS score was also the best predictor when compared with other measures of psychopathology. Only the CAFAS and presence of conduct disorder contributed to the prediction of service utilization and cost at 12 months.