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Bilazarian A, McHugh J, Schlak AE, Liu J, Poghosyan L. Primary Care Practice Structural Capabilities and Emergency Department Utilization Among High-Need High-Cost Patients. J Gen Intern Med 2023; 38:74-80. [PMID: 35941491 PMCID: PMC9849605 DOI: 10.1007/s11606-022-07706-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 06/16/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND US primary care practices are actively identifying strategies to improve outcomes and reduce costs among high-need high-cost (HNHC) patients. HNHC patients are adults with high health care utilization who suffer from multiple chronic medical and behavioral health conditions such as depression or substance abuse. HNHC patients with behavioral health conditions face heightened challenges accessing timely primary care and managing their conditions, which is reflected by their high rates of emergency department (ED) utilization and preventable spending. Structural capabilities (i.e., care coordination, chronic disease registries, shared communication systems, and after-hours care) are key attributes of primary care practices which can enhance access and quality of chronic care delivery. OBJECTIVE The purpose of this study was to analyze the association between structural capabilities and ED utilization among HNHC patients with behavioral health conditions. DESIGN AND MEASURES We merged cross-sectional survey data on structural capabilities from 240 primary care practices in Arizona and Washington linked with Medicare claims data on 70,182 HNHC patients from 2019. KEY RESULTS Using multivariable Poisson models, we found shared communication systems were associated with lower rates of all-cause and preventable ED utilization among HNHC patients with alcohol use (all-cause: aRR 0.72, 95% CI: 0.62, 0.84; preventable: aRR 0.5, 95% CI: 0.40, 0.64) and HNHC patients with substance use disorders (all-cause: aRR 0.76, 95% CI: 0.68, 0.85; preventable: aRR 0.61, 95% CI: 0.52, 0.71). Care coordination was also associated with decreased rates of ED utilization among the overall HNHC population and those with alcohol use, but not among HNHC patients with depression or substance use disorders. CONCLUSION Shared communication systems and care coordination have the potential to increase the effectiveness of primary care delivery for specific HNHC patients.
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Affiliation(s)
- Ani Bilazarian
- School of Nursing, Columbia University, New York, NY, USA.
| | - John McHugh
- School of Nursing, Columbia University, New York, NY, USA
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | | | - Jianfang Liu
- School of Nursing, Columbia University, New York, NY, USA
| | - Lusine Poghosyan
- School of Nursing, Columbia University, New York, NY, USA
- Mailman School of Public Health, Columbia University, New York, NY, USA
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Weitzman ER, Kossowsky J, Blakemore LM, Cox R, Dowling DJ, Levy O, Needles EW, Levy S. Acceptability of a Fentanyl Vaccine to Prevent Opioid Overdose and Need for Personalized Decision-Making. Clin Infect Dis 2022; 75:S98-S109. [PMID: 35579508 PMCID: PMC9376272 DOI: 10.1093/cid/ciac344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The opioid epidemic worsened during the coronavirus disease 2019 (COVID-19) pandemic. Synthetic opioids (primarily fentanyl) comprise the most common drugs involved in overdose (OD) death. A vaccine that blocks fentanyl from reaching the brain to prevent OD is under development, and insight is needed into its acceptability. METHODS Using a semi-structured interview guide, persons with opioid use disorder (OUD), family, professionals, and the public were interviewed about attitudes and concerns regarding a fentanyl vaccine. Reactions to fictional clinical vignettes of persons at risk of OUD because of pain and/or substance use histories were collected, analyzed, and quantified for favorability. Interviews were transcribed, coded, and analyzed thematically. RESULTS Among N = 64 participants, (70.3% female, average age 32.4 years), attitudes were favorable toward a fentanyl vaccine, with preference for lifelong durability (76% of n = 55 asked). Perceived benefits centered on the potential for a life-saving intervention, suffering averted, healthcare dollars saved, and the utility of a passive harm reduction strategy. Concerns centered on uncertainty regarding vaccine safety, questions about efficacy, worry about implications for future pain management, stigma, and need for supportive counseling and guidance to personalize decision making. Reactions to vignettes revealed complex attitudes toward fentanyl vaccination when considering recipient age, health history, and future risks for addiction and pain. CONCLUSIONS Positive responses to a fentanyl vaccine were found along with appreciation for the complexity of a vaccine strategy to prevent OD in the setting of pain and uncertain durability. Further research is needed to elucidate operational, ethical, and communications strategies to advance the model.
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Affiliation(s)
- Elissa R Weitzman
- Correspondence: E. R. Weitzman, 1 Autumn Street, Boston, MA 02215 ()
| | - Joe Kossowsky
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Laura M Blakemore
- Division of Adolescent/Young Adult Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Rachele Cox
- Division of Adolescent/Young Adult Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - David J Dowling
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Precision Vaccines Program, Boston Children’s Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Ofer Levy
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Precision Vaccines Program, Boston Children’s Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Boston Children’s Hospital, Boston, Massachusetts, USA
- Broad Institute of MIT & Harvard, Cambridge, Massachusetts, USA
| | - Emma W Needles
- Adolescent Substance Use and Addiction Program, Division of Developmental Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Sharon Levy
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Adolescent Substance Use and Addiction Program, Division of Developmental Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
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O'Reilly LM, Froberg BA, Gian CT, D'Onofrio BM, Simon KI. The Affordable Care Act Young Adult Mandate and Suicidal Behavior. Med Care Res Rev 2020; 79:17-27. [PMID: 33213274 DOI: 10.1177/1077558720974144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article aimed to determine the association between the Affordable Care Act young adult mandate and suicidal behavior. From 2007 to 2013, we used the Nationwide/National Inpatient Sample and National Poison Data System to examine suicide attempt, and Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research to examine suicide. We aggregated each outcome by quarter/year and conducted a difference-in-differences linear regression to compare young adults aged 19 to 25 years with those 27 to 29 years before and after implementation. There were not statistically significant associations between the mandate and suicide attempt inpatient hospitalizations (unstandardized beta coefficient [b] = -0.72, p = .12, standard error [SE] = 0.42) and percentage of poisoning cases due to suspected suicidal intent (b = 0.23, p = .19, SE = 0.16). There was a statistically significant association when examining suicide prevalence (b = -0.03, p = .01, SE = 0.001). The results suggest that health insurance may buffer against but is unlikely to reverse the increasing suicide rate.
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Affiliation(s)
| | - Blake A Froberg
- Indiana University School of Medicine, Indianapolis, IN, USA
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Shalev D, Docherty M, Spaeth-Rublee B, Khauli N, Cheung S, Levenson J, Pincus HA. Bridging the Behavioral Health Gap in Serious Illness Care: Challenges and Strategies for Workforce Development. Am J Geriatr Psychiatry 2020; 28:448-462. [PMID: 31611044 DOI: 10.1016/j.jagp.2019.09.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/31/2019] [Accepted: 09/03/2019] [Indexed: 11/30/2022]
Abstract
Comorbidity with behavioral health conditions is highly prevalent among those experiencing serious medical illnesses and is associated with poor outcomes. Siloed provision of behavioral and physical healthcare has contributed to a workforce ill-equipped to address the often complex needs of these clinical populations. Trained specialist behavioral health providers are scarce and there are gaps in core behavioral health competencies among serious illness care providers. Core competency frameworks to close behavioral health training gaps in primary care exist, but these have not extended to some of the distinct skills and roles required in serious illness care settings. This paper seeks to address this issue by describing a common framework of training competencies across the full spectrum of clinical responsibility and behavioral health expertise for those working at the interface of behavioral health and serious illness care. The authors used a mixed-method approach to develop a model of behavioral health and serious illness care and to delineate seven core skill domains necessary for practitioners working at this interface. Existing opportunities for scaling-up the workforce as well as priority policy recommendation to address barriers to implementation are discussed.
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Affiliation(s)
- Daniel Shalev
- Columbia University Medical Center (DS, SC, JL, HAP), New York, NY; New York State Psychiatric Institute (DS, MD, BS-R, NK, HAP), New York, NY
| | - Mary Docherty
- New York State Psychiatric Institute (DS, MD, BS-R, NK, HAP), New York, NY
| | | | - Nicole Khauli
- New York State Psychiatric Institute (DS, MD, BS-R, NK, HAP), New York, NY
| | - Stephanie Cheung
- Columbia University Medical Center (DS, SC, JL, HAP), New York, NY
| | - Jon Levenson
- Columbia University Medical Center (DS, SC, JL, HAP), New York, NY
| | - Harold Alan Pincus
- Columbia University Medical Center (DS, SC, JL, HAP), New York, NY; New York State Psychiatric Institute (DS, MD, BS-R, NK, HAP), New York, NY.
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Ford JH, Osborne EL, Assefa MT, McIlvaine AM, King AM, Campbell K, McGovern MP. Using NIATx strategies to implement integrated services in routine care: a study protocol. BMC Health Serv Res 2018; 18:431. [PMID: 29884164 PMCID: PMC5994046 DOI: 10.1186/s12913-018-3241-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 05/27/2018] [Indexed: 01/06/2023] Open
Abstract
Background Access to integrated services for individuals with co-occurring substance use and mental health disorders is a long-standing public health issue. Receiving integrated treatment services are both more effective and preferred by patients and families versus parallel or fragmented care. National policy statements and expert consensus guidelines underscore the benefits of integrated treatment. Despite decades of awareness, adequate treatment for individuals with co-occurring substance use and mental health disorders occurs infrequently. The underlying disease burden associated with alcohol, illicit and prescription drug problems, as well as mental health disorders, such as depression, posttraumatic stress disorder and schizophrenia, is substantial. Methods This cluster randomized controlled trial (RCT) is designed to determine if the multi-component Network for the Improvement of Addiction Treatment (NIATx) strategies are effective in implementing integrated services for persons with co-occurring substance use and mental health disorders. In this study, 50 behavioral health programs in Washington State will be recruited and then randomized into one of two intervention arms: 1) NIATx implementation strategies, including coaching and learning sessions over a 12-month intervention period to implement changes targeting integrated treatment services; or 2) wait-list control. Primary outcome measures include: 1) fidelity - a standardized organizational assessment of integrated services (Dual Diagnosis in Addiction Treatment [DDCAT] Index); and 2) penetration - proportion of patients screened and diagnosed with co-occurring disorders, proportion of eligible patients receiving substance use and mental health services, and psychotropic or substance use disorder medications. Barriers and facilitators, as determinants of implementation outcomes, will be assessed using the Consolidated Framework for Implementation Research (CFIR) Index. Fidelity to and participation in NIATx strategies will be assessed utilizing the NIATx Fidelity Scale and Stages of Implementation Completion (SIC). Discussion This study addresses an issue of substantial public health significance: the gap in access to an evidence-based practice for integrated treatment for individuals with co-occurring mental health and substance use disorders. The study utilizes rigorous and reproducible quantitative approaches to measuring implementation determinants and strategies, and may address a longstanding gap in the quality of care for persons with co-occurring disorders. Trial registration ClinicalTrials.gov NCT03007940. Registered 02 January 2017 – Retrospectively Registered Electronic supplementary material The online version of this article (10.1186/s12913-018-3241-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- James H Ford
- School of Pharmacy - Social and Administrative Sciences Division, University of Wisconsin - Madison, 777 University Ave, Madison, WI, 53705, USA.
| | - Eric L Osborne
- Office of Behavioral Health and Managed Care, Division of Behavioral Health and Recovery, Washington State Department of Social and Health Services, Olympia, WA, 98504, USA
| | - Mehret T Assefa
- Center for Behavioral Health Services and Implementation Research, Division of Public Health & Population Sciences, Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, 1520 Page Mill Road, Palo Alto, CA, 94304, USA
| | - Amy M McIlvaine
- School of Pharmacy - Social and Administrative Sciences Division, University of Wisconsin - Madison, 777 University Ave, Madison, WI, 53705, USA
| | - Ahney M King
- Office of Behavioral Health and Prevention, Division of Behavioral Health and Recovery, Washington State Department of Social and Health Services, Olympia, WA, 98504, USA
| | - Kevin Campbell
- Washington State Health Care Authority, Olympia, WA, 98501, USA
| | - Mark P McGovern
- Division of Public Mental Health & Population Sciences, Department of Psychiatry & Behavioral Sciences, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, 1520 Page Mill Road MC5265, Palo Alto, CA, 94304, USA
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