Technology, data, people, and partnerships in addressing unmet social needs within Medicaid Managed Care

BACKGROUND

Individuals with unmet social needs experience adverse health outcomes and are subject to greater inequities in health and social outcomes. Given the high prevalence of unmet needs among Medicaid enrollees, many Medicaid managed care organizations (MCOs) are now screening enrollees for unmet social needs and connecting them to community-based organizations (CBOs) with knowledge and resources to address identified needs. The use of screening and referral technology and data sharing are often considered key components in programs integrating health and social services. Despite this emphasis on technology and data collection, research suggests substantial barriers exist in operationalizing effective systems.

METHODS

We used qualitative methods to examine cross-sector perspectives on the use of data and technology to facilitate MCO and CBO partnerships in Kentucky, a state with high Medicaid enrollment, to address enrollee social needs. We recruited participants through targeted sampling, and conducted 46 in-depth interviews with 26 representatives from all six Kentucky MCOs and 20 CBO leaders. Qualitative descriptive analysis, an inductive approach, was used to identify salient themes.

RESULTS

We found that MCOs and CBOs have differing levels of need for data, varying incentives for collecting and sharing data, and differing valuations of what data can or should do. Four themes emerged from interviewees' descriptions of how they use data, including 1) to screen for patient needs, 2) to case manage, 3) to evaluate the effectiveness of programs, and 4) to partner with each other. Underlying these data use themes were areas of alignment between MCOs/CBOs, areas of incongruence, and areas of tension (both practical and ideological). The inability to interface with community partners for data privacy and ownership concerns contributes to division. Our findings suggest a disconnect between MCOs and CBOs regarding terms of their technology interfacing despite their shared mission of meeting the unmet social needs of enrollees.

CONCLUSIONS

While data and technology can be used to identify enrollee needs and determine the most critical need, it is not sufficient in resolving challenges. People and relationships across sectors are vital in connecting enrollees with the community resources to resolve unmet needs.

Lower Emotional Exhaustion among Employees Is Associated with Intentional Incorporation of Animals into Residential Care Settings

Secondary effects of animal-integrated programming on residential care center (RCC) staff and organizational culture are not well understood. We explored emotional exhaustion among RCC employees both in facilities that incorporated animals and those that did not incorporate animals into the therapeutic environment. We conducted a survey throughout a large midwestern RCC system in the United States to determine relationships between organizational culture, emotional exhaustion, and the intentionality by which animals were incorporated into programming. Data were analyzed by examining associations between variables of interest using chi-square or t-tests, and linear mixed-effects modeling was used to identify potential confounding effects due to differences in children served within RCCs. Staff from RCCs that used animals intentionally reported lower emotional exhaustion (p = 0.006), and higher average workplace safety (p = 0.024) and psychological safety (p < 0.001). Integrating animals into RCC programming is associated with elements of a strong organizational culture. It is possible that animal-integrated programming has a positive impact on the facility culture and workforce, and/or that RCCs with strong pre-existing cultures are more likely to use animal-integrated programming.

Evaluation of Telehealth in Child Behavioral Health Services Delivery During the COVID-19 Pandemic

OBJECTIVE

The authors quantified the impact of the use of telehealth services on patient-level clinical outcomes among children with complex behavioral and emotional needs in Idaho during the COVID-19 pandemic by comparing data collected in 2020 with data for the same months in 2019.

METHODS

Longitudinal statewide data of Child and Adolescent Needs and Strengths (CANS) assessments were extracted from Idaho's mental and behavioral health system. Prepandemic assessments were matched to midpandemic assessments. A linear mixed-effect model was used to explore four child-level outcomes: psychosocial strengths-building rate, rate of need resolution within a life-functioning domain, rate of need resolution within a behavior-emotional domain, and rate of need resolution within a high-risk behaviors domain.

RESULTS

The number of new patients admitted to Idaho's state-funded mental and behavioral health program decreased almost twofold from April-December 2019 to April-December 2020 (N=4,458 vs. 2,794). For most children with complex needs, the use of telehealth was as effective in terms of strengths building and needs resolution as in-person services; for children whose caregivers had issues with access to transportation, availability of telehealth services improved outcomes for the children.

CONCLUSIONS

The COVID-19 pandemic in 2020 was associated with a dramatic drop in the number of children served by Idaho's mental health program. Telehealth may effectively bridge mental health service delivery while patients and providers work toward the resolution of transportation issues or may serve as a more acceptable permanent format of service delivery for some populations.

The interaction between affective lability and eating expectancies predicts binge eating

Both affective lability and eating expectancies have been found to predict binge eating. There is the additional possibility that the joint effect of affective lability and eating expectancies incurs further risk: perhaps expectancies for affective relief from eating operate more strongly in those experiencing frequent, rapid shifts in emotion. In the current study, we tested whether such a joint effect predicts binge eating prospectively in college students. We assessed affective lability, eating expectancies, and binge eating in 358 college students at two time points during the first year of college (e.g., December and April). The interaction of affective lability and eating expectancies in December predicted binge eating 4 months later in April. The influence of eating expectancies on binge eating was stronger at higher levels of affective lability. Findings offer support to the hypothesis that risk factors may transact to further elevate risk for eating disorder behaviors.Clinical implicationsThe interaction of affective lability and eating expectancies predicts binge eatingRisk factors may interact to further increase binge eatingIdentification of co-occurring risk factors may have vital treatment implications.

How people experience and respond to their distress predicts problem drinking more than does the amount of distress

Although broad dispositional negative affect predicts problematic alcohol use, emerging evidence suggests that individual differences in how people experience and respond to negative affect may play an important role in risk. In a sample of 358 college students assessed twice across their first year of college, the current study investigated the predictive roles of trait negative affect, affective lability (the tendency to experience rapid and intense shifts in mood), negative urgency (the tendency to act rashly when highly emotional), and problem drinking via self-report measures completed online. Data were analyzed using structural equation modeling (SEM). Individual differences in how negative affect is experienced and responded to, represented by affective lability and negative urgency, predicted problem drinking above and beyond trait negative affect, and trait negative affect had no incremental predictive power. Additionally, affective lability predicted increases in negative urgency, but the opposite was not true. A focus on characteristic ways in which individuals experience and respond to negative affect, rather than negative affect itself, may improve risk assessment and clarify the etiology of problem drinking. Continued work toward the development of comprehensive affect-based risk models for problem drinking is needed.

Affect-Based Problem Drinking Risk: The Reciprocal Relationship between Affective Lability and Problem Drinking

AIMS

Negative affect has been implicated in risk for the development of problematic drinking behavior. Furthermore, there is evidence for reciprocal relationships between negative affect and problem drinking, such that engagement in problem drinking also predicts increases in negative affect. However, affective models of risk often fail to consider affective lability-the experience of rapidly changing mood. Although affective lability appears to increase risk for problem drinking, it is unknown if this relationship persists above and beyond other affect-related constructs (e.g. depression, anxiety) and if it is reciprocal in nature. Accordingly, we used a longitudinal survey design to examine (a) if affective lability predicts problem drinking above and beyond depression and anxiety and (b) if affective lability and problem drinking demonstrate a reciprocal relationship.

METHODS

First-year college students (n = 358) participated in a three wave longitudinal study. We constructed a structural equation model (SEM) of a random intercept cross-lagged panel model to test our hypotheses.

RESULTS

Consistent with our hypotheses, affective lability predicted increases in problem drinking while anxiety and depression did not. Problem drinking and affective lability demonstrated a reciprocal relationship in which increases in one predicted increases in the other at subsequent time points. This relationship was present beyond the predictive effects of anxiety or depression.

CONCLUSIONS

Affective lability appears to be an important affect-based predictor of problem drinking, and there may be a reciprocal, risk-enhancing relationship between affective lability and problem drinking.Components of negative affect, such as depression or anxiety, have been shown to predict risk for problem drinking, and vice versa. A less considered construct, affective lability, predicted problem drinking while anxiety and depression did not add any predictive power. Problem drinking and affective lability also appeared to demonstrate a reciprocal relationship.

The General Factor of Psychopathology

An important advance in understanding and defining mental disorders has been the development of empirical approaches to mapping dimensions of dysfunction and their interrelatedness. Such empirical approaches have consistently observed intercorrelations among the many forms of psychopathology, leading to the identification of a general factor of psychopathology (the p factor). In this article, we review empirical support for p, including evidence for the stability and criterion validity of p. Further, we discuss the strong relationship between p and both the general factor of personality and the general factor of personality disorder, substantive interpretations of p, and the potential clinical utility of p. We posit that proposed substantive interpretations of p do not explain the full range of symptomatology typically included in p. The most plausible explanation is that p represents an index of impairment that has the potential to inform the duration and intensity of a client's mental health treatment.

Heavy, Problematic College Drinking Predicts Increases in Impulsivity

OBJECTIVE

Impulsigenic personality traits are among the many factors demonstrated to predict drinking behavior among late adolescents. The current study tested the opposite possibility, that during the emerging adulthood developmental period, problematic drinking behavior predicts increases in impulsigenic traits. This possibility is important because such traits increase risk for multiple forms of dysfunction.

METHOD

Using a prospective design, we studied the personality traits and drinking behavior of 458 traditional college freshmen over one year.

RESULTS

We found that drinking problems predicted increases in urgency (the tendency to act rashly when highly emotional), lack of planning (the tendency to act without forethought), and lack of perseverance (difficulty maintaining focus on a task).

CONCLUSIONS

Maladaptive personality change may be one mechanism that increases risk transdiagnostically for some individuals who drink problematically during college. Increases in impulsigenic traits predictable from problem drinking put individuals at risk for not only more drinking, but a host of other negative outcomes.

Problematic alcohol use and sexting as risk factors for sexual assault among college women

Sexual assault is a major public health concern and college women are four times more likely to experience sexual assault than any other group. We investigated whether sexting is a mechanism by which alcohol use increases risk for college women to be targeted for sexual assault. We hypothesized that sexting would mediate the relationship between problem drinking and sexual assault, such that drinking (T1 = beginning fall semester) would contribute to increased sexting (T2 = end fall semester), and in turn increase the risk of being targeted for sexual assault (T3 = end spring semester). Results: Among 332 undergraduate women (M(SD)age = 19.15(1.69), 76.9% Caucasian), sexting (T2) predicted sexual assault (T3; b = 3.98, p = .05), controlling for baseline sexual assault (b = 0.82, p < .01). Further, sexting (T2) mediated the relationship between problem drinking (T1) and sexual assault (T3) (b = 0.04, CI[.004,.12]). Conclusion: Findings suggest that sexting is one mechanism through which drinking increases the risk of college women being targeted for sexual assault.

Heavy, Problematic College Drinking Predicts Increases in Impulsivity

OBJECTIVE

Impulsigenic personality traits are among the many factors demonstrated to predict drinking behavior among late adolescents. The current study tested the opposite possibility, that during the emerging adulthood developmental period, problematic drinking behavior predicts increases in impulsigenic traits. This possibility is important because such traits increase risk for multiple forms of dysfunction.

METHOD

Using a prospective design, we studied the personality traits and drinking behavior of 458 traditional college freshmen over one year.

RESULTS

We found that drinking problems predicted increases in urgency (the tendency to act rashly when highly emotional), lack of planning (the tendency to act without forethought), and lack of perseverance (difficulty maintaining focus on a task).

CONCLUSIONS

Maladaptive personality change may be one mechanism that increases risk transdiagnostically for some individuals who drink problematically during college. Increases in impulsigenic traits predictable from problem drinking put individuals at risk for not only more drinking, but a host of other negative outcomes.

Pre-Assault Personality Predicts the Nature of Adverse Outcomes Among Sexual Assault Victims

OBJECTIVE

Exposure to sexual assault results in ongoing harms for women. After an assault, some women engage in higher levels of externalizing behaviors, such as problem drinking, and others experience higher levels of internalizing dysfunction, such as symptoms of anxiety and depression. We sought to understand the role of premorbid factors on the different post-assault experiences of women.

METHOD

We studied 1,929 women prospectively during a period of high risk for sexual assault (the first year of college): women were assessed in July before arriving at college and in April near the end of the school year.

RESULTS

A premorbid personality disposition to act impulsively when distressed (negative urgency) interacted positively with sexual assault experience to predict subsequent increases in drinking behavior; a premorbid personality disposition toward internalizing dysfunction positively interacted with sexual assault experience to predict increased symptoms of anxiety and depression.

CONCLUSIONS

Women with different personalities tend to experience different forms of post-assault consequences.

Towards a Developmentally Integrative Model of Personality Change: A Focus on Three Potential Mechanisms

While the overall stability of personality across the lifespan has been well-documented, one does see incremental changes in a number of personality traits, changes that may impact overall life trajectories in both positive and negative ways. In this chapter, we present a new, developmentally-oriented and integrative model of the factors that might lead to personality change, drawing from the theoretical and empirical work of prior models (e.g. Caspi & Roberts, 2001; Roberts et al., 2005) as well as from our own longitudinal studies of personality change and risky behavior engagement in children, adolescents, and young adults (Boyle et al., 2016; Riley & Smith, 2016; Riley et al., 2016). We focus on change in the trait of urgency, which is a high-risk personality trait that represents the tendency to act rashly when highly emotional. We explore processes of both biologically-based personality change in adolescence, integrating neurocognitive and puberty-based models, as well as behavior-based personality change, in which behaviors and the personality traits underlying those behaviors are incrementally reinforced and shaped over time. One implication of our model for clinical psychology is the apparent presence of a positive feedback loop of risk, in which maladaptive behaviors increase high-risk personality traits, which in turn further increase the likelihood of maladaptive behaviors, a process that continues far beyond the initial experiences of maladaptive behavior engagement. Finally, we examine important future directions for continuing work on personality change, including trauma-based personality change and more directive (e.g., therapeutic) approaches aimed at shaping personality.

The reciprocal predictive relationship between high-risk personality and drinking: An 8-wave longitudinal study in early adolescents

In youth, maladaptive personality traits such as urgency (the tendency to act rashly when highly emotional) predict early onset alcohol consumption. In adults, maladaptive behaviors, including substance use, predict negative personality change. This article reports on a test of hypothesized maladaptive, reciprocal prediction between youth drinking and the trait of urgency. In a sample of 1,906 youth assessed every 6 months from the spring of 5th grade through the spring of 8th grade, and again in the spring of 9th grade, the authors found such reciprocal prediction. Over each 6 month and then 12 month time lag, urgency predicted increased subsequent drinking. In addition, over 6 of the 7 time lags, drinking behavior predicted subsequent increases in urgency. During early adolescence, maladaptive personality and dysfunctional behavior each led to increases in the other. The results of this process include cyclically increasing risk for youth drinking and may include increasing risk for the multiple maladaptive behaviors predicted by the trait of urgency. (PsycINFO Database Record

Childhood drinking and depressive symptom level predict harmful personality change

Personality traits in children predict numerous life outcomes. Although traits are generally stable, if there is personality change in youth, it could affect subsequent behavior in important ways. We found that the trait of urgency, the tendency to act impulsively when highly emotional, increases for some youth in early adolescence. This increase can be predicted from the behavior of young children: alcohol consumption and depressive symptom level in elementary school children (5th grade) predicted increases in urgency 18 months later. Urgency, in turn, predicted increases in a wide range of maladaptive behaviors another 30 months later, at the end of the first year of high school. The mechanism by which early drinking behavior and depressive symptoms predict personality is not yet clear and merits future research; notably, the findings are consistent with mechanisms proposed by personality change theory and urgency theory.

Alcohol use and strenuous physical activity in college students: A longitudinal test of 2 explanatory models of health behavior

OBJECTIVE

To help clarify the effect of gender on the bidirectional relationship between alcohol use and strenuous physical activity in college students.

PARTICIPANTS

Five hundred twenty-four (52% female) college students recruited in August 2008 and 2009 and followed up in April 2009 and April 2011, respectively.

METHODS

Participants reported their alcohol use and strenuous physical activity on 2 occasions (baseline and follow-up) spaced approximately 1 or 2 years apart.

RESULTS

For females, alcohol use quantity at baseline was associated with increased strenuous physical activity at 1- and 2-year follow-ups, and alcohol use frequency at baseline was associated with decreased strenuous physical activity at 2-year follow-up. For males, alcohol use frequency at baseline predicted decreased strenuous physical activity at 1-year follow-up.

CONCLUSIONS

Gender differences may be explained from an eating disorders perspective such that women use physical activity as a compensatory strategy to combat potential weight gain from calories consumed during alcohol use.

Nonsuicidal Self-injury as a Risk Factor for Purging Onset: Negatively Reinforced Behaviours that Reduce Emotional Distress

Both nonsuicidal self-injury (NSSI) and purging behaviour are thought to involve harm to the self. The acquired capability for self-harm model holds that engaging in one self-harming behaviour increases the capability to tolerate harm to the self, thus increasing risk for engaging on other such behaviours. In addition, both behaviours are thought to serve the similar function of relief from distress. We thus tested whether engagement in one of these behaviours predicts the subsequent onset of the other. In a longitudinal design, 1158 first-year college women were assessed for purging and NSSI at two time points. Engagement in NSSI at time 1 predicted the college onset of purging behaviour 9 months later (OR = 2.20, p < .04, CI = 1.07-4.19) beyond prediction from time 1 binge behaviour, and purging behaviour at time 1 predicted the subsequent onset of NSSI (OR = 6.54, p < .01, CI = 1.71-25.04). These findings are consistent with the acquired capability for harm model and with the possibility that the two behaviours serve a similar function.

Negative Urgency and Lack of Perseverance: Identification of Differential Pathways of Onset and Maintenance Risk in the Longitudinal Prediction of Nonsuicidal Self-Injury

Many researchers have identified impulsivity-related personality traits as correlates of and risk factors for nonsuicidal self-injury (NSSI). Using a longitudinal design, we tested the hypothesis that one such trait, negative urgency (the tendency to act rashly when distressed), predicts the onset of NSSI during the first year of college and a different trait, lack of perseverance (the disposition to fail to maintain focus on tasks that are difficult or boring), predicts the maintenance of NSSI during the first year of college. In a sample of n=1,158 college women (mean age=18.04, 95% of participants were 18 at Time 1), we found support for these hypotheses. Negative urgency, measured prior to college entry, predicted the onset of NSSI behavior across the first year of college (odds ratio=1.58). Lack of perseverance predicted the maintenance of NSSI status across the first year of college, controlling for prior NSSI behavior (odds ratio=1.73). These findings indicate that different impulsivity-related personality traits may play different roles in the risk process for NSSI.

D-Cycloserine facilitation of exposure therapy improves weight regain in patients with anorexia nervosa: a pilot randomized controlled trial

OBJECTIVE

Exposure therapy in anorexia nervosa has preliminarily been shown to be effective for increasing food intake. D-Cycloserine is a glutamatergic N-methyl-d-aspartate receptor agonist that has been shown to facilitate the benefits of exposure therapy for anxiety disorders by enhancing the emotional learning in the exposures; therefore, we examined D-cycloserine-facilitation of exposure therapy to increase body mass index (BMI) in patients with anorexia nervosa.

METHOD

Participants (N = 36) with anorexia nervosa (diagnosed via DSM-IV) were recruited from a partial hospitalization eating disorder clinic between February 2013 and November 2013. Participants were randomly assigned to receive exposure therapy plus D-cycloserine (n = 20) or placebo (n = 16). Participants completed psychoeducation and 4 sessions of exposure therapy, with medication (D-cycloserine vs placebo) given prior to the first 3 exposure sessions. They also completed a 1-month follow-up.

RESULTS

As hypothesized, participants in the D-cycloserine group showed a significantly greater increase in BMI than those in the placebo group (Wilk Λ = 0.86, F3,32 = 2.20, P = .043, ηp(2) = 0.12). D-Cycloserine participants gained 3 pounds relative to 0.5 pounds in the placebo group. Both groups experienced significantly decreased anxiety over the course of therapy (Wilk Λ = 0.80, F3,32 = 3.32, P = .023, ηp(2) = 0.20).

CONCLUSIONS

This study preliminarily demonstrates that D-cycloserine facilitates exposure therapy for anorexia nervosa, leading to increased weight gain. A potential mechanism is that participants who receive D-cycloserine may generalize learning from within-session exposures to food intake during other similar meals, resulting in sustained increases in BMI. Further research is needed to confirm these findings and test the putative mechanism that generalized learning from exposure therapy can increase BMI and stabilize a healthy weight.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01996644.

Two pathways toward impulsive action: an integrative risk model for bulimic behavior in youth

BACKGROUND

This study provides an integrative review of existing risk factors and models for bulimia nervosa (BN) in young girls. We offer a new model for BN that describes two pathways of risk that may lead to the initial impulsive act of binge eating and purging in children and adolescents.

SCOPE

We conducted a selective literature review, focusing on existing and new risk processes for BN in this select population.

FINDINGS

We identify two ways in which girls increase their risk to begin engaging in the impulsive behavior of binge eating and purging. The first is state-based: the experience of negative mood, in girls attempting to restrain eating, leads to the depletion of self-control and thus increased risk for loss of control eating. The second is personality-based: elevations on the trait of negative urgency, or the tendency to act rashly when distressed, increase risk, particularly in conjunction with high-risk psychosocial learning. We then briefly discuss how these behaviors are reinforced, putting girls at further risk for developing BN.

CONCLUSIONS

We highlight several areas in which further inquiry is necessary, and we discuss the clinical implications of the new risk model we described.

Catheter-related colonization associated with percutaneous inserted central catheters

The intravenous therapy team at Massachusetts General Hospital studied the potential infectious risks of maintaining percutaneous inserted central catheters (PICC) for prolonged periods. Cultures of 100 PICC sites and catheters were performed on removal of the catheters, which had remained in place for 2 to 43 days. The insertion sites and/or proximal or distal segments of the catheters were found to be colonized in 11% of the patients, with distal catheter tips significantly colonized in only four patients. Nine of the patients were colonized at the insertion site. Bacteremia did not occur as a result of the extended dwell time of the catheters.

Protecting the intravenous nurse from blood-borne pathogens

Intravenous nurses are at risk for infection with blood-borne pathogens to the extent that they are directly exposed to blood. By classifying work-related tasks according to potential for exposure and by implementing appropriate precautions for each task, the I.V. nurse's risk of infection can be minimized.

Ear asymmetry in recognition of unfamiliar voices

Female right-handed subjects were presented with a memory set consisting of five unfamiliar female voices. They were then tested with a recognition procedure in which samples of voice, memory set or novel, 2 or 4 sec in duration, were heard in one ear and a competing noise stimulus was heard in the other ear. There was an overall left-ear advantage in accuracy of recognition. This advantage held particularly for identifications of memory-set voices in the second half of trials. Internal analyses indicated that the left-ear advantage could not be attributed to greater retroactive interference during right-ear presentation. Congruent with studies of recognition of unfamiliar faces, the findings suggested right-hemisphere superiority in the recognition of unfamiliar voices.