Learning to be interprofessional advocates in the public sector

Engaging in advocacy is an ethical responsibility for behavioral health professionals, as reflected in professional competencies across disciplines and in personal accounts of wanting to affect change at various levels of patients'/clients' and communities' ecologies. However, the literature is replete with examples of barriers to routine advocacy engagement, including lack of an organized structure into which efforts can be embedded. There exists the desire among behavioral health professionals to engage in more advocacy work, yet a shared sense of not knowing how to incorporate this work into existing professional roles. One way to address these barriers is to establish more collaborative advocacy work environments within the public sector settings that employ behavioral health professionals. This article offers the first descriptive account of developing, implementing, and maintaining such a collaborative interprofessional advocacy workgroup. To that end, this case study is one example of such a group, the Atlanta Behavioral Health Advocates, based within the Emory University School of Medicine in the Department of Psychiatry and Behavioral Sciences and situated also within Grady Health System, a public health care system. This paper details our experiences forming and engaging in this group, which we believe can serve as a model for others developing similar advocacy workgroups in public sector settings. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Examining the role of funders in ensuring value and reducing waste in research: An organizational case-study of the Patient-Centered Outcomes Research Institute

International experts have recommended actions that funders can take to improve the value of research investments. They state that self-assessment and public sharing are the basis for accountability and improvement. We examined our policies and practice to determine the extent to which the Patient-Centered Outcomes Research Institute's (PCORI) policies and practices as a research funder align with international best practice recommendations. A self-audit of current policies and practice against 17 recommendations and 35 sub-recommendations representing five major stages of research production, based on adapted methods used for self-assessment by another funder, was performed.  Fit of existing PCORI policies and practices with 35 sub-recommendations, qualitative assessment of adequacy (area of strength; area of partial strength; area of growth; not applicable) for 17 recommendations for five stages of research production was assessed. Of the 17 recommendations, 15 were applicable to PCORI's research mission and focus.  PCORI has policies and practices in place for all elements of six recommendations ("area of strength") and policies that address each element but with some still in active development for three ("area of partial strength"). PCORI is partially addressing six of the 15 relevant recommendations ("area of growth"). Areas for growth include making study protocols publicly available, improving policies on data sharing, and enhancing collaboration with other funders to reduce redundant funding. A voluntary consortium of international funders is underway to encourage further progress, including additional self-assessment and public sharing for accountability. These findings indicate PCORI has undertaken efforts to align its funding practices with international recommendations to ensure the value of public dollars invested in research.  Further efforts will likely require additional coordination and collaboration between funders and stakeholders.

Examining the role of funders in ensuring value and reducing waste in research: An organizational case-study of the Patient-Centered Outcomes Research Institute

International experts have recommended actions that funders can take to improve the value of research investments. They state that self-assessment and public sharing are the basis for accountability and improvement. We examined our policies and practice to determine the extent to which the Patient-Centered Outcomes Research Institute's (PCORI) policies and practices as a research funder align with international best practice recommendations. A self-audit of current policies and practice against 17 recommendations and 35 sub-recommendations representing five major stages of research production, based on adapted methods used for self-assessment by another funder, was performed.  Fit of existing PCORI policies and practices with 35 sub-recommendations, qualitative assessment of adequacy (area of strength; area of partial strength; area of growth; not applicable) for 17 recommendations for five stages of research production was assessed. Of the 17 recommendations, 15 were applicable to PCORI's research mission and focus.  PCORI has policies and practices in place for all elements of six recommendations ("area of strength") and policies that address each element but with some still in active development for three ("area of partial strength"). PCORI is partially addressing six of the 15 relevant recommendations ("area of growth"). Areas for growth include making study protocols publicly available, improving policies on data sharing, and enhancing collaboration with other funders to reduce redundant funding. A voluntary consortium of international funders is underway to encourage further progress, including additional self-assessment and public sharing for accountability. These findings indicate PCORI has undertaken efforts to align its funding practices with international recommendations to ensure the value of public dollars invested in research.  Further efforts will likely require additional coordination and collaboration between funders and stakeholders.

A Window of Opportunity: Visions and Strategies for Behavioral Health Policy Innovation

Objective

The New York City's Thrive (ThriveNYC) and the Los Angeles County Health Neighborhood Initiative (HNI) are two local policies focused on addressing the social determinants of behavioral health as a preventive strategy for improving health service delivery. On January 29, 2016, leaders from both initiatives came together with a range of federal agencies in health care, public health, and policy research at the RAND Corporation in Arlington, Virginia. The goal of this advisory meeting was to share lessons learned, consider research and evaluation strategies, and create a dialogue between stakeholders and federal funders - all with the purpose to build momentum for policy innovation in behavioral health equity.

Methods

This article analyzes ethnographic notes taken during the meeting and in-depth interviews of 14 meeting participants through Kingdon's multiple streams theory of policy change.

Results

Results demonstrated that stakeholders shared a vision for behavioral health policy innovation focused on community engagement and social determinants of health. In addition, Kingdon's model highlighted that the problem, policy and politics streams needed to form a window of opportunity for policy change were coupled, enabling the possibility for behavioral health policy innovation.

Conclusions

The advisory meeting suggested that local policy makers, academics, and community members, together with federal agents, are working to implement behavioral health policy innovation.

Mental Health, Disabilities, and Women

Ongoing development and reform of health care systems worldwide are directing the attention of policymakers to the significance of mental disorders and ensuing disabilities. While this awareness has encouraged empirical work and scientific literature on disabilities associated with mental disorders, insufficient attention has been paid to issues of gender in the context of mental disorder and disability. This paper draws on four data sets-the 1994-96 Disability Survey; the 1992 National Health Interview Survey (NHIS); Social Security Disability Programs; and the recent international measure of Disability-Adjusted Life Years-to explore relationships among gender, mental disorders, and disability in the United States and to consider the special needs presented by women disabled by mental disorders for service development and service configuration. Generally younger than women disabled by physical disorders, women with mental disorders tend to be in their prime child-bearing years. While in the United States private sector managed care programs increasingly are perceived as the most reasonable way to provide health services in a fiscally responsible way, there appears to exist an implicit notion that managed care is intended exclusively for provision of acute care and preventive services. There is little discussion or exploration of the use of managed care systems for rehabilitation generally, or of the particular rehabilitation needs of young women. The implications for the additional “burden” of disabilities along with the potential risk factor of traditional female roles require serious consideration and enlightened policies. Mental

Guidance for New Motivational Interviewing Trainers When Training Addiction Professionals: Findings from a Survey of Experienced Trainers

Evidence-based practices, such as motivational interviewing (MI), are not widely used in community alcohol and drug treatment settings. Successfully broadening the dissemination of MI will require numerous trainers and supervisors who are equipped to manage common barriers to technology transfer. The aims of the our survey of 36 MI trainers were: 1) to gather opinions about the optimal format, duration, and content for beginning level addiction-focused MI training conducted by novice trainers and 2) to identify the challenges most likely to be encountered during provision of beginning-level MI training and supervision, as well as the most highly recommended strategies for managing those challenges in addiction treatment sites. It is hoped that the findings of this survey will help beginning trainers equip themselves for successful training experiences.

Promoting mental health recovery after hurricanes Katrina and Rita: what can be done at what cost

CONTEXT

Concerns about mental health recovery persist after the 2005 Gulf storms. We propose a recovery model and estimate costs and outcomes.

OBJECTIVE

To estimate the costs and outcomes of enhanced mental health response to large-scale disasters using the 2005 Gulf storms as a case study.

DESIGN

Decision analysis using state-transition Markov models for 6-month periods from 7 to 30 months after disasters. Simulated movements between health states were based on probabilities drawn from the clinical literature and expert input.

SETTING

A total of 117 counties/parishes across Louisiana, Mississippi, Alabama, and Texas that the Federal Emergency Management Agency designated as eligible for individual relief following hurricanes Katrina and Rita.

PARTICIPANTS

Hypothetical cohort, based on the size and characteristics of the population affected by the Gulf storms. Intervention Enhanced mental health care consisting of evidence-based screening, assessment, treatment, and care coordination.

MAIN OUTCOME MEASURES

Morbidity in 6-month episodes of mild/moderate or severe mental health problems through 30 months after the disasters; units of service (eg, office visits, prescriptions, hospital nights); intervention costs; and use of human resources.

RESULTS

Full implementation would cost $1133 per capita, or more than $12.5 billion for the affected population, and yield 94.8% to 96.1% recovered by 30 months, but exceed available provider capacity. Partial implementation would lower costs and recovery proportionately.

CONCLUSIONS

Evidence-based mental health response is feasible, but requires targeted resources, increased provider capacity, and advanced planning.

Cost shifting under managed behavioral health care

OBJECTIVE

The study examined whether a managed behavioral health care organization (MBHO) shifted treatment costs.

METHODS

Four years of claims data (1991-1995) from an insurer that introduced an MBHO in 1992 to control treatment costs were analyzed. Although the MBHO was not at direct financial risk for specialty mental health treatment, it faced incentives related to reputation and contract renewal to shift costs to primary care treatment or prescription drugs. It was hypothesized that if cost shifting occurred, an increase would be noted in the use of psychotropic medications without concurrent use of specialty mental health treatment. Simple t tests and a generalized estimating equations probit specification were used to test this hypothesis. Separate tests were performed for use of any psychotropic medication, any newer antidepressant, and any stimulant in a large employer group that simultaneously implemented parity coverage (75,360 enrollees) and a group of smaller employers that did not (9,228 enrollees).

RESULTS

The use of any psychotropic medication rose 64% in relative terms (p<.001) over the four-year period among enrollees of the large employer group and by 87% in the smaller groups (p<.001). In general, there were downward secular trends in the use of psychotropic medications without specialty care. Introduction of the MBHO was not significantly associated with the use of psychotropic medication alone. For newer antidepressants, introduction of the MBHO was associated in the large group with a 2.4 (p=.003) absolute percentage point decrease in medication use alone.

CONCLUSIONS

No evidence was found to suggest that the MBHO shifted treatment costs.

Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D: implications for clinical practice

OBJECTIVE

Selective serotonin reuptake inhibitors (SSRIs) are widely used to treat depression, but the rates, timing, and baseline predictors of remission in "real world" patients are not established. The authors' primary objectives in this study were to evaluate the effectiveness of citalopram, an SSRI, using measurement-based care in actual practice, and to identify predictors of symptom remission in outpatients with major depressive disorder.

METHOD

This clinical study included outpatients with major depressive disorder who were treated in 23 psychiatric and 18 primary care "real world" settings. The patients received flexible doses of citalopram prescribed by clinicians for up to 14 weeks. The clinicians were assisted by a clinical research coordinator in the application of measurement-based care, which included the routine measurement of symptoms and side effects at each treatment visit and the use of a treatment manual that described when and how to modify medication doses based on these measures. Remission was defined as an exit score of <or=7 on the 17-item Hamilton Depression Rating Scale (HAM-D) (primary outcome) or a score of <or=5 on the 16-item Quick Inventory of Depressive Symptomatology, Self-Report (QIDS-SR) (secondary outcome). Response was defined as a reduction of >or=50% in baseline QIDS-SR score.

RESULTS

Nearly 80% of the 2,876 outpatients in the analyzed sample had chronic or recurrent major depression; most also had a number of comorbid general medical and psychiatric conditions. The mean exit citalopram dose was 41.8 mg/day. Remission rates were 28% (HAM-D) and 33% (QIDS-SR). The response rate was 47% (QIDS-SR). Patients in primary and psychiatric care settings did not differ in remission or response rates. A substantial portion of participants who achieved either response or remission at study exit did so at or after 8 weeks of treatment. Participants who were Caucasian, female, employed, or had higher levels of education or income had higher HAM-D remission rates; longer index episodes, more concurrent psychiatric disorders (especially anxiety disorders or drug abuse), more general medical disorders, and lower baseline function and quality of life were associated with lower HAM-D remission rates.

CONCLUSIONS

The response and remission rates in this highly generalizable sample with substantial axis I and axis III comorbidity closely resemble those seen in 8-week efficacy trials. The systematic use of easily implemented measurement-based care procedures may have assisted in achieving these results.

Reliability of the services assessment for children and adolescents

OBJECTIVE

This study examined the test-retest reliability of a new instrument, the Services Assessment for Children and Adolescents (SACA), for children's use of mental health services.

METHODS

A cross-sectional survey was undertaken at two sites. The St. Louis site used a volunteer sample recruited from mental health clinics and local schools. The Ventura County, California, site used a double-blind, community-based sample seeded with cases of service-using children. Participating families completed the SACA and were retested within four to 14 days. The reliability of service use items was calculated with use of the kappa statistic.

RESULTS

The SACA- Parent Version had excellent test-retest reliability for both lifetime service use and previous 12-month use. The SACA also had good to excellent reliability when administered to children aged 11 and older for lifetime and 12-month use. Reliability figures for children aged nine and ten years were considerably lower for lifetime and 12-month use. The younger children's responses suggested that they were confused about some questions.

CONCLUSIONS

This study demonstrates that parents and older children can reliably report use of mental health services by using the SACA. The SACA can be used to collect currently unavailable information about use of mental health services.

Mental health service use by Americans with severe mental illnesses

BACKGROUND

The aim of this study was to determine the patterns and determinants of service use in severely mentally ill persons drawn from the National Institute of Mental Health Epidemiological Catchment Area (ECA) program, a community-based epidemiologic survey. This information provides a baseline against which to track ongoing changes in the US mental health service system.

METHODS

Severe mental illness (SMI) was defined according to US Senate Appropriations Committee guidelines. Comparisons were made with persons who had a mental disorder that did not meet these criteria (non-SMI). Sociodemographic factors, and 1-year volume and intensity of mental or addictive services use were determined. Differences between those who used services and those who did not were examined using logistic regression.

RESULTS

Persons with SMI differed from persons with non-SMI in most sociodemographic characteristics. A higher proportion of persons with SMI used ambulatory services, but the mean number of visits per person did not differ from the non-SMI population. Persons with SMI comprised the bulk of hospital inpatients admitted during a 1-year period. Several significant sociodemographic determinants of service use were found, with different patterns for general medical and specialty service use, pointing out potential barriers to care.

CONCLUSIONS

As health care reform measures continue to be debated, attention to the service needs of the severely mentally ill is of crucial importance. Pre-managed care (pre-1993) baseline service use benchmarks will be essential to assess the impact of managed care on access to care, particularly for the severely mentally ill. Periodic collection of epidemiologic data on prevalence and service use would thus greatly facilitate service planning and addressing barriers to receiving mental health services in this population.

Advances in understanding and treating mental illness: implications for policy

Mental illnesses have a significant impact on public health and contribute to a substantial part of the disability of the general population. Recent research on understanding and treating such illnesses has produced data that can inform policymakers about how to improve the condition of persons who suffer from these illnesses. This paper discusses how this research can be used to inform policy decisions regarding the allocation of community treatment resources and what research is still needed.

Effects of Medicare's prospective payment system on service use by depressed elderly inpatients

OBJECTIVE

To determine the effects of Medicare's prospective payment system (PPS) on hospital care, changes in length of stay and intensity of clinical services received by 2,746 depressed elderly patients in 297 acute care general medical hospitals were studied.

METHODS

A pre-post design was used, and differences in sickness at admission were controlled for. Data on length of stay and use of specific clinical services were obtained from the medical record using a medical record abstraction form. Care provided on units exempt from PPS was compared with care provided in nonexempt units.

RESULTS

After implementation of PPS, the average length of stay fell by up to three days within the different types of acute care settings studied, but this decline was partially offset by proportionately more admissions to psychiatric units, which had longer lengths of stay. Intensity of clinical services increased after PPS implementation, especially in nonexempt psychiatric units.

CONCLUSION

Despite financial incentives for hospitals to reduce clinical services under PPS, its implementation was not associated with a marked decline in length of stay, when averaged across all treatment settings, and was associated with an increase in the intensity of many clinical services used by depressed elderly patients in general hospitals.

Quality of care for depressed elderly patients hospitalized in the specialty psychiatric units or general medical wards

BACKGROUND

Studies to assess quality of care have become increasingly important for research and policy purposes.

OBJECTIVE

To evaluate the difference in quality of care between elderly depressed patients hospitalized in specialty psychiatric units and those hospitalized in general medical wards.

METHODS

We reviewed retrospectively the medical charts of 2746 patients with depression hospitalized in 297 general medical hospitals in five different states. Quality of care was assessed by clinical review of explicit and implicit information contained in the medical records of patients in specialty psychiatric units (n = 1295) and general medical wards (n = 1451). We also used other secondary data sources to determine postdischarge outcomes.

RESULTS

We found that (1) a higher percentage of admissions on the psychiatric units were considered appropriate, (2) overall psychological assessment was better on the psychiatric unit, (3) patients were more likely to receive psychological services on the psychiatric wards but more likely to receive traditional general medical services on medical wards, (4) there were more inpatient general medical complications on the psychiatric wards, and (5) implicit measures of clinical status at discharge were better for those on the psychiatric unit.

CONCLUSIONS

Although limited by reliance on medical record abstraction and a retrospective study design, our data indicate that the quality of care for the psychological aspects of the treatment of depression may be better on psychiatric units, while the quality of general medical components of care may be better on general medical wards.

Quality of care for depressed elderly pre-post prospective payment system: differences in response across treatment settings

We evaluated the quality of care for depressed elderly patients (n = 2,746) hospitalized in general medical hospitals (n = 297) before or after implementation of Medicare's Prospective Payment System, focusing on whether the response to time period differed for hospitals that in the post-PPS period had no psychiatric unit, an exempt psychiatric unit, or a nonexempt unit, and by ward placement within hospitals with psychiatric units. Quality of care increased over time, and for most measures of quality of care the level of improvement did not differ significantly across different types of hospitals or by ward placement. The intensity of use of therapeutic services, such as rehabilitation, occupation, or recreation therapy, increased over time, particularly in nonexempt psychiatric units and hospitals without psychiatric units, such that these locations caught up some over time in the level of use of these services to the level for exempt psychiatric units. Several outcomes of care improved over time, and the degree of improvement in the rate of inpatient medical and psychiatric complications and other outcomes was significantly greater for psychiatric units that were exempt post-PPS than for nonexempt treatment locations.

Quality of antidepressant medications prescribed at discharge to depressed elderly patients in general medical hospitals before and after prospective payment system

This study describes the quality of antidepressant medication use at hospital discharge for depressed elderly inpatients and compares quality of care before and after implementation of Medicare's Prospective Payment System (PPS). The study reviewed data from medical records of 2746 depressed, elderly, hospitalized patients in acute-care general medical hospitals in five U.S. states (pre-PPS period 1981-82; post-PPS period 1985-86). The majority were discharged on antidepressant medication both pre-PPS and post-PPS. After PPS' implementation, sedating medications were used less often in all treatment settings. In general medical wards, a higher percentage post-PPS (24%) than pre-PPS (14%) were discharged 48 hours or less after first starting an antidepressant medication. In both time periods, one-third of patients receiving antidepressant medications were prescribed daily dosages at discharge below recommended, minimum, therapeutic levels, whether treated in general medical wards or psychiatric units. Otherwise, patients previously treated in psychiatric units received higher quality of medication management than those treated in general medical wards. Over time, patients discharged on antidepressant medication were less likely to use sedating medication, suggesting improved quality of care. In general medical wards, however, patients were discharged more rapidly after starting medication, possibly suggesting lower quality of care. A substantial percentage of patients received subtherapeutic dosages of medication or sedating medications, suggesting that improved management of discharge antidepressant medication in the elderly is needed in general medical hospitals.

Quality of care for hospitalized depressed elderly patients before and after implementation of the Medicare Prospective Payment System

OBJECTIVE

The authors evaluated the impact of Medicare's Prospective Payment System on aspects of quality of care and outcomes for depressed elderly inpatients in acute-care general medical hospitals.

METHOD

The depressed elderly inpatients (N = 2,746) were hospitalized in 297 acute-care general medical hospitals. The authors used a retrospective before-and-after design, controlling for differences over time in sickness at admission. Quality of care and outcomes were assessed through clinical review of explicit and implicit information in the medical records; secondary data sources provided information on postdischarge outcomes.

RESULTS

After implementation of the prospective payment system 1) a higher percentage of patients had clinically appropriate acute-care admissions; 2) the initial assessment of psychological status by the treating provider was more complete; 3) the quality of psychotropic medication management, as rated by the study psychiatrists, improved; 4) the rates of any inpatient medical or psychiatric complication, of discharge to another hospital or a nursing home, and of inpatient readmission declined; and 5) there was no marked change in the percentage of patients rated by study clinicians as having acceptable overall clinical status at discharge or the rate of mortality 1 year after admission.

CONCLUSIONS

After the implementation of the Medicare Prospective Payment System, the quality of care for depressed elderly inpatients improved and there was no marked increase in adverse clinical outcomes. Despite these gains, after implementation the quality of care was moderate at best and over one-third of the patients had unacceptable clinical status at discharge.

Mental health needs of the uninsured

As many as 37 million Americans have no medical insurance, but no data exist on the mental health needs of community samples of the uninsured. Using interview data from a household sample in Los Angeles, we found that the uninsured had a higher prevalence of serious psychiatric disorder (16%) than those with private health insurance (12%), but had a prevalence similar to those with Medicaid (18%). Access to mental health services among those with a psychiatric disorder was similar in the uninsured (14.5%) and those with private insurance (18%) but was less than those with Medicaid coverage (42%). These results indicate that the uninsured have a great potential need for mental health services and that access might be improved through insurance plans such as Medicaid. However, further study is needed to determine the adequacy and quality of services provided under Medicaid and whether such a plan would improve access for an uninsured population such as the one studied here.