Impacts of the Certified Community Behavioral Health Clinic Demonstration on Emergency Department Visits and Hospitalizations

OBJECTIVE

The Certified Community Behavioral Health Clinic (CCBHC) demonstration is designed to increase access to comprehensive ambulatory care and crisis services, which may reduce emergency department (ED) visits and hospitalizations. This study examined whether the demonstration had an impact on ED visits and hospitalizations in Missouri, Oklahoma, and Pennsylvania.

METHODS

This difference-in-differences analysis used Medicaid claims data from 2015 to 2019 to examine service use during a 12-month baseline period and the first 24 months of the demonstration for beneficiaries who received care from CCBHCs and beneficiaries who received care from other behavioral health clinics in the same state, representing care as usual. Propensity score methods were used to develop treatment and comparison groups with similar characteristics.

RESULTS

In Pennsylvania and Oklahoma, beneficiaries who received care from CCBHCs had a statistically significant reduction in the average number of behavioral health ED visits, relative to the comparison group (13% and 11% reductions, respectively); no impact on ED visits in Missouri was observed. The demonstration was associated with a statistically significant reduction in all-cause hospitalizations in Oklahoma, when the analysis used a 2-year rather than a 1-year baseline period, and also in Pennsylvania, when hospitalizations were truncated at the 98th percentile to exclude beneficiaries with outlier hospitalization rates.

CONCLUSIONS

The CCBHC demonstration reduced behavioral health ED visits in two states, and the study also revealed some evidence of reductions in hospitalizations.

Therapist Financial Strain and Turnover: Interactions with System-Level Implementation of Evidence-Based Practices

Therapist turnover is a major problem in community mental health. Financial strain, which is composed of cognitive, emotional, and behavioral responses to the experience of economic hardship, is an understudied antecedent of therapist turnover given the tumultuous financial environment in community mental health. We prospectively examined the relationship between therapist financial strain and turnover in 247 therapists in 28 community mental health agencies. We expected greater therapist financial strain to predict higher turnover and participation in a system-funded evidence-based practice (EBP) training initiative to alleviate this effect. Controlling for covariates, financial strain predicted therapist turnover (OR 1.12, p = .045), but not for therapists who participated in an EBP training initiative. Reducing financial strain and/or promoting EBP implementation may be levers to reduce turnover.

Homolactate fermentation by metabolically engineered Escherichia coli strains

We report the homofermentative production of lactate in Escherichia coli strains containing mutations in the aceEF, pfl, poxB, and pps genes, which encode the pyruvate dehydrogenase complex, pyruvate formate lyase, pyruvate oxidase, and phosphoenolpyruvate synthase, respectively. The process uses a defined medium and two distinct fermentation phases: aerobic growth to an optical density of about 30, followed by nongrowth, anaerobic production. Strain YYC202 (aceEF pfl poxB pps) generated 90 g/liter lactate in 16 h during the anaerobic phase (with a yield of 0.95 g/g and a productivity of 5.6 g/liter . h). Ca(OH)(2) was found to be superior to NaOH for pH control, and interestingly, significant succinate also accumulated (over 7 g/liter) despite the use of N(2) for maintaining anaerobic conditions. Strain ALS961 (YYC202 ppc) prevented succinate accumulation, but growth was very poor. Strain ALS974 (YYC202 frdABCD) reduced succinate formation by 70% to less than 3 g/liter. (13)C nuclear magnetic resonance analysis using uniformly labeled acetate demonstrated that succinate formation by ALS974 was biochemically derived from acetate in the medium. The absence of uniformly labeled succinate, however, demonstrated that glyoxylate did not reenter the tricarboxylic acid cycle via oxaloacetate. By minimizing the residual acetate at the time that the production phase commenced, the process with ALS974 achieved 138 g/liter lactate (1.55 M, 97% of the carbon products), with a yield of 0.99 g/g and a productivity of 6.3 g/liter . h during the anaerobic phase.

Sample size: an important parameter in flash-cooling macromolecular crystallization solutions

The effect of sample size on flash-cooling was assessed using an assortment of Hampton Screen I solutions (Hampton Research). These were cryogenically cooled to ascertain the minimum glycerol concentration needed for vitrification of solutions. Solutions were `flash-cooled' in 1.0, 0.5 and 0.1 mm commercial cryoloops, using a 100 K nitrogen stream generated by an Oxford 600 Cryostream. The loops were visually examined and then X-ray diffraction data were collected and evaluated for ice formation. The glycerol concentration needed for vitrification was found to decrease significantly as sample size decreased; detailed key data are presented in tabular form. Glass transition temperatures, T g, were measured for solutions leading to successful vitrification in the 1 mm cryoloop. The trends in the required concentration of glycerol and resultant T g can be understood through a simplified heat-transfer analysis. This analysis points to a critical cooling time period for successful vitrification.

Reactions to the death of a parent. Results from patients and field subjects

The authors studied two groups of persons who had experienced either the death of a mother or father. One group consisted of patients who had sought treatment because of pathological aspects of bereavement. The other group consisted of volunteers selected from a review of hospital death records, which indicated the recent death of their parent. The study used a nonequivalent groups design, where both groups were followed over time. The field subjects were initially seen much sooner after the death than the patients. The patient group received a time-limited dynamic therapy focused on the stress response syndrome induced by the death. At the pretherapy evaluation point, the patient sample had significantly higher levels of symptomatic distress than did the nonpatient sample. The distress declined over a 13-month period, so that patients had comparable levels of distress to that of the field subjects. After adjusting for initial values, the main difference was that patients reduced their avoidant operations more than did the field subjects. Intervening variables were assessed for the prediction of change in symptoms over time as related to the parental death. The variables that showed significant correlations to symptomatic change were cumulative negative life events from varied sources, occupation, social class, developmental level of the self-concept, identity of the deceased parent, and attribution of blame for the death. Social support did not relate to change in symptoms over time.