Reduction of Mental Health-Related Emergency Department Admissions for Youth and Young Adults Following a Remote Intensive Outpatient Program: Quality Improvement Analysis

BACKGROUND

Pediatric mental health emergency department (ED) visits are increasing at 6% to 10% per year, at substantial cost, while 13% of youth with psychiatric hospitalizations are readmitted in the following weeks. Hospitals do not have the resources to meet escalating youth's mental health needs. Intensive outpatient (IOP) programs, which provide multiple hours of care each week, have the power to reduce the number of patients in need of hospitalized care and provide a step-down option for patients discharging from ED's in order to prevent readmissions.

OBJECTIVE

The purpose of this program evaluation was to assess (1) whether youth and young adult ED admission rates decreased following participation in a remote IOP program and (2) whether there were differences in readmission rates between youth and young adults by gender identity, sexual orientation, race, or ethnicity.

METHODS

Data were collected from intake and 3-month postdischarge surveys for 735 clients who attended at least 6 sessions of a remote IOP program for youth and young adults. Patients reported if they had been admitted to an ED within the previous 30 days and the admission reason. Over half (407/707, 57.6%) of clients were adolescents and the rest were young adults (300/707, 42.4%; mean age 18.25, SD 4.94 years). The sample was diverse in gender identity (329/687, 47.9% female; 196/687, 28.5% male; and 65/669, 9.7% nonbinary) and sexual orientation (248/635, 39.1% heterosexual; 137/635, 21.6% bisexual; 80/635, 10.9% pansexual; and 170/635, 26.8% other sexual orientation) and represented several racial (9/481, 1.9% Asian; 48/481, 10% Black; 9/481, 1.9% Indigenous; 380/481, 79% White; and 35/481, 7.2% other) and ethnic identities (112/455, 24.6% Hispanic and 28/455, 6.2% other ethnic identity).

RESULTS

Mental health-related ED admissions significantly decreased between intake and 3 months after discharge, such that 94% (65/69) of clients with a recent history of mental health-related ED admissions at IOP intake reported no mental health-related ED admissions at 3 months after discharge from treatment (χ21=38.8, P<.001). There were no differences in ED admissions at intake or in improvement at 3 months after discharge by age, gender, sexuality, race, or ethnicity.

CONCLUSIONS

This study documents a decrease in ED admissions between intake and 3 months after discharge among both youth and young adults who engage in IOP care following ED visits. The similar outcomes across demographic groups indicate that youth and young adults experience similar decreases after the current tracks of programming. Future research could conduct a full return-on-investment analysis for intensive mental health services for youth and young adults.

Predicting Youth and Young Adult Treatment Engagement in a Transdiagnostic Remote Intensive Outpatient Program: Latent Profile Analysis

BACKGROUND

The youth mental health crisis in the United States continues to worsen, and research has shown poor mental health treatment engagement. Despite the need for personalized engagement strategies, there is a lack of research involving youth. Due to complex youth developmental milestones, there is a need to better understand clinical presentation and factors associated with treatment engagement to effectively identify and tailor beneficial treatments.

OBJECTIVE

This quality improvement investigation sought to identify subgroups of clients attending a remote intensive outpatient program (IOP) based on clinical acuity data at intake, to determine the factors associated with engagement outcomes for clients who present in complex developmental periods and with cooccurring conditions. The identification of these subgroups was used to inform programmatic decisions within this remote IOP system.

METHODS

Data were collected as part of ongoing quality improvement initiatives at a remote IOP for youth and young adults. Participants included clients (N=2924) discharged between July 2021 and February 2023. A latent profile analysis was conducted using 5 indicators of clinical acuity at treatment entry, and the resulting profiles were assessed for associations with demographic factors and treatment engagement outcomes.

RESULTS

Among the 2924 participants, 4 profiles of clinical acuity were identified: a low-acuity profile (n=943, 32.25%), characterized by minimal anxiety, depression, and self-harm, and 3 high-acuity profiles defined by moderately severe depression and anxiety but differentiated by rates of self-harm (high acuity+low self-harm: n=1452, 49.66%; high acuity+moderate self-harm: n=203, 6.94%; high acuity+high self-harm: n=326, 11.15%). Age, gender, transgender identity, and sexual orientation were significantly associated with profile membership. Clients identified as sexually and gender-marginalized populations were more likely to be classified into high-acuity profiles than into the low-acuity profile (eg, for clients who identified as transgender, high acuity+low self-harm: odds ratio [OR] 2.07, 95% CI 1.35-3.18; P<.001; high acuity+moderate self-harm: OR 2.85, 95% CI 1.66-4.90; P<.001; high acuity+high self-harm: OR 3.67, 95% CI 2.45-5.51; P<.001). Race was unrelated to the profile membership. Profile membership was significantly associated with treatment engagement: youth and young adults in the low-acuity and high-acuity+low-self-harm profiles attended an average of 4 fewer treatment sessions compared with youth in the high-acuity+moderate-self-harm and high-acuity+high-self-harm profiles (ꭓ23=27.6, P<.001). Individuals in the high-acuity+low-self-harm profile completed treatment at a significantly lower rate relative to the other 2 high-acuity profiles (ꭓ23=13.4, P=.004). Finally, those in the high-acuity+high-self-harm profile were significantly less likely to disengage early relative to youth in all other profiles (ꭓ23=71.12, P<.001).

CONCLUSIONS

This investigation represents a novel application for identifying subgroups of adolescents and young adults based on clinical acuity data at intake to identify patterns in treatment engagement outcomes. Identifying subgroups that differentially engage in treatment is a critical first step toward targeting engagement strategies for complex populations.

Treating Depression in Adolescents and Young Adults Using Remote Intensive Outpatient Programs: Quality Improvement Assessment

BACKGROUND

Youth and young adults face barriers to mental health care, including a shortage of programs that accept youth and a lack of developmentally sensitive programming among those that do. This shortage, along with the associated geographically limited options, has contributed to the health disparities experienced by youth in general and by those with higher acuity mental health needs in particular. Although intensive outpatient programs can be an effective option for youth with more complex mental health needs, place-based intensive outpatient programming locations are still limited to clients who have the ability to travel to the clinical setting several days per week.

OBJECTIVE

The objective of the analysis reported here was to assess changes in depression between intake and discharge among youth and young adults diagnosed with depression attending remote intensive outpatient programming treatment. Analysis of outcomes and the application of findings to programmatic decisions are regular parts of ongoing quality improvement efforts of the program whose results are reported here.

METHODS

Outcomes data are collected for all clients at intake and discharge. The Patient Health Questionnaire (PHQ) adapted for adolescents is used to measure depression, with changes between intake and discharge regularly assessed for quality improvement purposes using repeated measures t tests. Changes in clinical symptoms are assessed using McNamar chi-square analyses. One-way ANOVA is used to test for differences among age, gender, and sexual orientation groups. For this analysis, 1062 cases were selected using criteria that included a diagnosis of depression and a minimum of 18 hours of treatment over a minimum of 2 weeks of care.

RESULTS

Clients ranged in age from 11 to 25 years, with an average of 16 years. Almost one-quarter (23%) identified as nongender binary and 60% identified as members of the lesbian, gay, bisexual, transgender, queer (LGBTQ+) community. Significant decreases (mean difference -6.06) were seen in depression between intake and discharge (t₉₆₇=-24.68; P<.001), with the symptoms of a significant number of clients (P<.001) crossing below the clinical cutoff for major depressive disorder between intake and discharge (388/732, 53%). No significant differences were found across subgroups defined by age (F_2,958=0.47; P=.63), gender identity (F_7,886=1.20; P=.30), or sexual orientation (F_7,872=0.47; P=.86).

CONCLUSIONS

Findings support the use of remote intensive outpatient programming to treat depression among youth and young adults, suggesting that it may be a modality that is an effective alternative to place-based mental health treatment. Additionally, findings suggest that the remote intensive outpatient program model may be an effective treatment approach for youth from marginalized groups defined by gender and sexual orientation. This is important given that youth from these groups tend to have poorer outcomes and greater barriers to treatment compared to cisgender, heterosexual youth.

LGBTQIA+ Adapted Telehealth Intensive Outpatient Program for Youth and Young Adults: Subgroup Analysis of Acuity and Improvement Following Treatment (Preprint)

BACKGROUND

Lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other minoritized gender and sexual identities (LGBTQIA+) youth have disproportionately high levels of depression, self-harm, and suicidal thoughts and behaviors. In addition, LGBTQIA+ youth frequently report lower levels of satisfaction or comfort with their health care providers because of stigmatization, which may prevent continuation of care, yet there is a lack of mental health treatment and outcome research addressing these disparities. However, there is some indication that LGBTQIA+ individuals feel more comfortable with web-based formats, indicating that telehealth services may be beneficial for this population.

OBJECTIVE

This program evaluation explored the effectiveness of a remote intensive outpatient program with a curriculum tailored specifically to LGBTQIA+ youth with high-acuity depression, anxiety, and suicidality. This study sought to understand baseline acuity differences between LGBTQIA+ and non-LGBTQIA+ youth and young adult patients and to determine if there were differences in clinically significant improvement by subtypes within the LGBTQIA+ population following participation in LGBTQIA+-specific programming.

METHODS

Data were collected from intake and discharge outcome surveys measuring depression, suicidality, and nonsuicidal self-injury (NSSI) in 878 patients who attended at least six sessions of a remote intensive outpatient program for youth and young adults. Of these 878 clients, 551 (62.8%) were identified as having at least one LGBTQIA+ identity; they participated in an LGBTQIA+-adapted program of the general curriculum.

RESULTS

LGBTQIA+ patients had more clinically severe intake for depression, NSSI, and suicidal ideation. Nonbinary clients had greater NSSI within the LGBTQIA+ sample at intake than their binary counterparts, and transgender clients had significantly higher depressive scores at intake than their nontransgender counterparts. LGBTQIA+ patients demonstrated improvements in all outcomes from intake to discharge. The Patient Health Questionnaire for Adolescents depression scores improved from 18.15 at intake to 10.83 at discharge, representing a 41.5% reduction in depressive symptoms. Overall, 50.5% (149/295) of the LGBTQIA+ youth who endorsed passive suicidal ideation at intake no longer reported it at discharge, 72.1% (160/222) who endorsed active suicidal ideation at intake no longer reported it at discharge, and 55.1% (109/198) of patients who met the criteria for clinical NSSI no longer met the criteria at discharge. In the subgroup analysis, transgender patients were still 2 times more likely to report clinical NSSI at discharge.

CONCLUSIONS

This program evaluation found substantial differences in rates of depression, NSSI, and suicidal ideation between LGBTQIA+ clients compared with their non-LGBTQIA+ counterparts. In addition, this evaluation showed a considerable decrease in symptoms when clients attended LGBTQIA+-affirming care. The findings provide support for the role of LGBTQIA+-specific programming to meet the elevated mental health needs of these youth and that more research is needed to understand barriers that may negatively affect transgender clients, specifically.

The title has been changed to: Understanding Treatment Needs of Youth in a Remote IOP: A Quality Improvement Analysis of Solicited Journals (Preprint)

BACKGROUND

Youth experiencing high-acuity mental health symptoms often require highly restrictive levels of care (ie, inpatient care) that removes them from the relationships and activities essential for healthy development. An alternative treatment gaining evidence in its ability to support this population is the intensive outpatient programming (IOP) model. Understanding the experiences of adolescents and young adults during IOP treatment episodes may enhance clinical responsiveness to changing needs and protect against transfer to inpatient care.

OBJECTIVE

The objective of the analysis reported here was to identify heretofore unrecognized treatment needs of adolescents and young adults attending a remote IOP to help the program make clinical and programmatic decisions that increase its ability to support the recovery of program participants.

METHODS

Treatment experiences are collected weekly via electronic journals as part of ongoing quality improvement efforts. The journals are used by clinicians proximally to help them identify youth in crisis and distally to help them better understand and respond to the needs and experiences of program participants. Journal entries are downloaded each week, reviewed by program staff for evidence of the need for immediate intervention, and later deidentified and shared with quality improvement partners via monthly uploads to a secure folder. A total of 200 entries were chosen based on inclusion criteria that focused primarily on having at least one entry at 3 specified time points across the treatment episode. Overall, 3 coders analyzed the data using open-coding thematic analysis from an essentialist perspective such that the coders sought to represent the data and thus the essential experience of the youth as closely as possible.

RESULTS

Three themes emerged: mental health symptoms, peer relations, and recovery. The mental health symptoms theme was not surprising, given the context within which the journals were completed and the journal instructions asking that they write about how they are feeling. The peer relations and recovery themes provided novel insight, with entries included in the peer relations theme demonstrating the central importance of peer relationships, both within and outside of the therapeutic setting. The entries contained under the recovery theme described experience of recovery in terms of increases in function and self-acceptance versus reductions in clinical symptoms.

CONCLUSIONS

These findings support the conceptualization of this population as youth with both mental health and developmental needs. In addition, these findings suggest that current definitions of recovery may inadvertently miss supporting and documenting treatment gains considered most important to the youth and young adults receiving care. Taken together, youth-serving IOPs may be better positioned to treat youth and assess program impact through the inclusion of functional measures and attention to fundamental tasks of the adolescent and young adult developmental periods.

The Impact of Family Therapy Participation on Youth and Young Adult Engagement and Retention in a Telehealth Intensive Outpatient Program: Quality Improvement Analysis (Preprint)

BACKGROUND

 Early treatment dropout among youths and young adults (28%-75%) puts them at risk for poorer outcomes. Family engagement in treatment is linked to lower dropout and better attendance in outpatient, in-person treatment. However, this has not been studied in intensive or telehealth settings.

OBJECTIVE

 We aimed to examine whether family members' participation in telehealth intensive outpatient (IOP) therapy for mental health disorders in youths and young adults is associated with patient's treatment engagement. A secondary aim was to assess demographic factors associated with family engagement in treatment.

METHODS

 Data were collected from intake surveys, discharge outcome surveys, and administrative data for patients who attended a remote IOP for youths and young adults, nationwide. Data included 1487 patients who completed both intake and discharge surveys and either completed or disengaged from treatment between December 2020 and September 2022. Descriptive statistics were used to characterize the sample's baseline differences in demographics, engagement, and participation in family therapy. Mann-Whitney U and chi-square tests were used to explore differences in engagement and treatment completion between patients with and those without family therapy. Binomial regression was used to explore significant demographic predictors of family therapy participation and treatment completion.

RESULTS

 Patients with family therapy had significantly better engagement and treatment completion outcomes than clients with no family therapy. Youths and young adults with ≥1 family therapy session were significantly more likely to stay in treatment an average of 2 weeks longer (median 11 weeks vs 9 weeks) and to attend a higher percentage of IOP sessions (median 84.38% vs 75.00%). Patients with family therapy were more likely to complete treatment than clients with no family therapy (608/731, 83.2% vs 445/752, 59.2%; P<.001). Different demographic variables were associated with an increased likelihood of participating in family therapy, including younger age (odds ratio 1.3) and identifying as heterosexual (odds ratio 1.4). After controlling for demographic factors, family therapy remained a significant predictor of treatment completion, such that each family therapy session attended was associated with a 1.4-fold increase in the odds of completing treatment (95% CI 1.3-1.4).

CONCLUSIONS

 Youths and young adults whose families participate in any family therapy have lower dropout, greater length of stay, and higher treatment completion than those whose families do not participate in services in a remote IOP program. The findings of this quality improvement analysis are the first to establish a relationship between participation in family therapy and an increased engagement and retention in remote treatment for youths and young patients in IOP programing. Given the established importance of obtaining an adequate dosage of treatment, bolstering family therapy offerings is another tool that could contribute to the provision of care that better meets the needs of youths, young adults, and their families.