The Impact of the Massachusetts Behavioral Health Child Screening Policy on Service Utilization

OBJECTIVE

In 2008, Massachusetts Medicaid implemented a pediatric behavioral health (BH) screening mandate. This study conducted a population-level, longitudinal policy analysis to determine the impact of the policy on ambulatory, emergency, and inpatient BH care in comparison with use of these services in California, where no similar policy exists.

METHODS

With Medicaid Analytic Extract (MAX) data, an interrupted time-series analysis with control series design was performed to assess changes in service utilization in the 18 months (January 2008-June 2009) after a BH screening policy was implemented in Massachusetts and to compare service utilization with California's. Outcomes included population rates of BH screening, BH-related outpatient visits, BH-related emergency department visits, BH-related hospitalizations, and psychotropic drug use. Medicaid-eligible children from January 1, 2006, to December 31, 2009, with at least ten months of Medicaid eligibility who were older than 4.5 years and younger than 18 years were included.

RESULTS

Compared with rates in California, Massachusetts rates of BH screening and BH-related outpatient visits rose significantly after Massachusetts implemented its screening policy. BH screening rose about 13 per 1,000 youths per month during the first nine months, and BH-related outpatient visits rose to about 4.5 per 1,000 youths per month (p<.001). Although BH-related emergency department visits, hospitalization and psychotropic drug use increased, there was no difference between the states in rate of increase.

CONCLUSIONS

The goal of BH screening is to identify previously unidentified children with BH issues and provide earlier treatment options. The short-term outcomes of the Massachusetts policy suggest that screening at preventive care visits led to more BH-related outpatient visits among vulnerable children.

Effect of Pediatric Behavioral Health Screening and Colocated Services on Ambulatory and Inpatient Utilization

OBJECTIVE

The study sought to determine the impact of a pediatric behavioral health screening and colocation model on utilization of behavioral health care.

METHODS

In 2003, Cambridge Health Alliance, a Massachusetts public health system, introduced behavioral health screening and colocation of social workers sequentially within its pediatric practices. An interrupted time-series study was conducted to determine the impact on behavioral health care utilization in the 30 months after model implementation compared with the 18 months prior. Specifically, the change in trends of ambulatory, emergency, and inpatient behavioral health utilization was examined. Utilization data for 11,223 children ages ≥4 years 9 months to <18 years 3 months seen from 2003 to 2008 contributed to the study.

RESULTS

In the 30 months after implementation of pediatric behavioral health screening and colocation, there was a 20.4% cumulative increase in specialty behavioral health visit rates (trend of .013% per month, p=.049) and a 67.7% cumulative increase in behavioral health primary care visit rates (trend of .019% per month, p<.001) compared with the expected rates predicted by the 18-month preintervention trend. In addition, behavioral health emergency department visit rates increased 245% compared with the expected rate (trend .01% per month, p=.002).

CONCLUSIONS

After the implementation of a behavioral health screening and colocation model, more children received behavioral health treatment. Contrary to expectations, behavioral health emergency department visits also increased. Further study is needed to determine whether this is an effect of how care was organized for children newly engaged in behavioral health care or a reflection of secular trends in behavioral health utilization or both.

A planned care approach and patient registry to improve adherence to clinical guidelines for the diagnosis and management of attention-deficit/hyperactivity disorder

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) affects almost 2.4 million US children. Because American Academy of Pediatrics guidelines for ADHD recommend use of standardized diagnostic instruments, regular follow-up and the chronic care model, this pilot project sought to implement and assess an electronic registry of patients with ADHD combined with care coordination by a planned care team.

METHODS

This quality improvement project was structured with 2 intervention and 2 control clinics to facilitate evaluation of the use of a planned care system for management of ADHD. Care teams included a pediatrician, nurse, medical assistant, and care coordinator and tracked patients using an electronic registry with data drawn from the EMR. Clinical work flows were pilot tested to facilitate use of the Vanderbilt scales and their incorporation into the EMR at intervention sites. Outcome measures included 2 recommended clinical follow-ups based on HEDIS measures as well as use of the Vanderbilt rating scales. Initiation phase measure was for follow-up after initiating medication, while the continuation phase measure was for subsequent follow-up during the first year of treatment. Measures were monitored during the project year and then also in the ensuing period of spread of the intervention to other sites.

RESULTS

Although the modified HEDIS initiation phase measure for patients newly on medication remained static at approximately 50% throughout the project period, the continuation phase measure showed improvement from 35% at baseline to 45% at the end of the project assessment year, a 29% increase. Follow-up for patients stable on medications also remained unchanged during the project period, but during subsequent spreading of the intervention to nonproject sites, follow-up of these patients improved to over 90%. In adjusted analyses, patients with ADHD at intervention sites were over 2 times more likely than patients at control sites to have had a Vanderbilt score documented in their records.

CONCLUSIONS

The project achieved modest improvements in the diagnostic and treatment process for patients with ADHD. The use of a planned care system and electronic patient registry shows promise for improving the diagnosis and treatment process for patients with ADHD.

Behavioral health services following implementation of screening in Massachusetts Medicaid children

OBJECTIVES

To determine the relationship of child behavioral health (BH) screening results to receipt of BH services in Massachusetts Medicaid (MassHealth) children.

METHODS

After a court decision, Massachusetts primary care providers were mandated to conduct BH screening at well-child visits and use a Current Procedural Terminology code along with a modifier indicating whether a BH need was identified. Using MassHealth claims data, a cohort of continuously enrolled (July 2007-June 2010) children was constructed. The salient visit (first use of the modifier, screening code, or claim in fiscal year 2009) was considered a reference point to examine BH history and postscreening BH services. Bivariate and multivariate logistic regression analyses were performed to determine predictors of postscreening BH services.

RESULTS

Of 261,160 children in the cohort, 45% (118,464) were screened and 37% had modifiers. Fifty-seven percent of children screening positive received postscreening BH services compared with 22% of children screening negative. However, only 30% of newly identified children received BH services. The strongest predictors of postscreening BH services for children without a BH history were being in foster care (odds ratio, 10.38; 95% confidence interval, 9.22-11.68) and having a positive modifier (odds ratio, 3.79; 95% confidence interval, 3.53-4.06).

CONCLUSIONS

Previous BH history, a positive modifier, and foster care predicted postscreening BH services. Only one-third of newly identified children received services. Thus although screening is associated with an increase in BH recognition, it may be insufficient to improve care. Additional strategies may be needed to enhance engagement in BH services.

Parents' obesity-related behavior and confidence to support behavioral change in their obese child: data from the STAR study

OBJECTIVE

Successful childhood obesity interventions frequently focus on behavioral modification and involve parents or family members. Parental confidence in supporting behavior change may be an element of successful family-based prevention efforts. We aimed to determine whether parents' own obesity-related behaviors were related to their confidence in supporting their child's achievement of obesity-related behavioral goals.

METHODS

Cross-sectional analyses of data collected at baseline of a randomized control trial testing a treatment intervention for obese children (n = 787) in primary care settings (n = 14). Five obesity-related behaviors (physical activity, screen time, sugar-sweetened beverage, sleep duration, fast food) were self-reported by parents for themselves and their child. Behaviors were dichotomized on the basis of achievement of behavioral goals. Five confidence questions asked how confident the parent was in helping their child achieve each goal. Logistic regression modeling high confidence was conducted with goal achievement and demographics as independent variables.

RESULTS

Parents achieving physical activity or sleep duration goals were significantly more likely to be highly confident in supporting their child's achievement of those goals (physical activity, odds ratio 1.76; 95% confidence interval 1.19-2.60; sleep, odds ratio 1.74; 95% confidence interval 1.09-2.79) independent of sociodemographic variables and child's current behavior. Parental achievements of TV watching and fast food goals were also associated with confidence, but significance was attenuated after child's behavior was included in models.

CONCLUSIONS

Parents' own obesity-related behaviors are factors that may affect their confidence to support their child's behavior change. Providers seeking to prevent childhood obesity should address parent/family behaviors as part of their obesity prevention strategies.

Evaluation results from an active living intervention in Somerville, Massachusetts

BACKGROUND

Community policies and programs can encourage active living and promote physical activity among residents. Somerville MA implemented an Active Living by Design project in 2003-2008 that promoted partnerships and advocacy to encourage physical activity.

PURPOSE

To evaluate the Active Living by Design project implemented in Somerville.

METHODS

A retrospective design assessed relative differences in the rates of meeting moderate or vigorous physical activity recommendations among middle- and high-school students and adults at baseline and follow-up within Somerville and at follow-up only in Everett MA, a comparison community. The middle- and high-school Youth Risk Behavior Surveys and the adult Behavioral Risk Factor Surveillance Survey were supplemented with Active Living by Design evaluation-specific questions at follow-up. Analyses included chi-square and logistic regression modeling to assess relationships.

RESULTS

Approximately 1000 youth completed surveys at baseline and follow-up in Somerville and at follow-up in Everett. Similarly, adult residents completed surveys at baseline (n=1081) and follow-up in Somerville (n=644) and follow-up in Everett (n=608). Within Somerville, high school-aged students and adults were more likely to meet physical activity recommendations at follow-up after adjusting for demographic, health, and behavioral variables (OR=1.6 [95% CI=1.34, 1.92] and 2.36 [95% CI=2.29, 2.43], respectively). Between cities, Somerville adults were 1.47 (95% CI=1.37, 1.56) times more likely than Everett adults to meet physical activity recommendations.

CONCLUSIONS

Community-based active living interventions may help residents meet physical activity recommendations. To improve community health, public health surveillance data can identify predictors of meeting physical activity recommendations that can be used to inform city policy and planning.

Predicting maintenance or achievement of healthy weight in children: the impact of changes in physical fitness

Physical fitness is often inversely associated with adiposity in children cross-sectionally, but the effect of becoming fit or maintaining fitness over time on changes in weight status has not been well studied in children. We investigated the impact of changes in fitness over 1-4 years of follow-up on the maintenance or achievement of healthy weight among 2,793 schoolchildren who were first measured as 1st to 7th graders. Students were classified as "fit" or "underfit" according to age- and gender-specific norms in five fitness domains: endurance, agility, flexibility, upper body strength, and abdominal strength. Weight status was dichotomized by BMI percentile: "healthy weight" (<85th percentile) or "overweight/obese" (≥85th percentile). At baseline, of the 38.3% overweight/obese children, 81.9% (N = 875) were underfit. Underfit overweight students were more likely to achieve healthy weight if they achieved fitness (boys: odds ratio (OR) = 2.68, 95% confidence interval (CI) = 1.24-5.77; girls: OR = 4.67, 95%CI = 2.09-10.45). Initially fit overweight children (N = 194) were more likely to achieve healthy weight if they maintained fitness (boys: OR = 11.99, 95%CI = 2.18-65.89; girls: OR = 2.46, 95%CI = 1.04-5.83). Similarly, initially fit healthy-weight children (N = 717) were more likely to maintain healthy weight if they maintained fitness (boys: OR 3.70, 95%CI = 1.40-9.78; girls: OR = 4.14, 95%CI = 1.95-8.78). Overweight schoolchildren who achieve or maintain physical fitness are more likely to achieve healthy weight, and healthy-weight children who maintain fitness are more likely to maintain healthy weight. School-based policies/practices that support physical fitness may contribute to obesity reduction and maintenance of healthy weight among schoolchildren.

Mental and behavioral health screening at preventive visits: opportunities for follow-up of patients who are nonadherent with the next preventive visit

OBJECTIVES

To determine the type of subsequent care received by children nonadherent with their next preventive visit and whether behavioral factors predict use of emergency or acute care in this population.

STUDY DESIGN

Data on 1703 children (4-16 years) screened at a preventive visit with the Pediatric Symptom Checklist (PSC)/Youth-PSC were examined to determine subsequent preventive care adherence (10-18 months later). Then, nonadherent children were monitored to determine whether they returned to their medical home for acute care, delayed preventive care, or visited the emergency department (ED). Multivariate analyses were conducted to determine whether demographic and behavioral factors predicted return to either acute care or ED care site.

RESULTS

Of the 461 children who were nonadherent with a second preventive care visit, most (85%) subsequently returned for acute, emergency, or delayed preventive care in the same medical system. Predictors of acute care or ED use included behavioral health risk characteristics (positive PSC, counseling, referral, parental concern), as well as adolescent age, self-pay and public insurance status, and living in lower socioeconomic communities.

CONCLUSIONS

Pediatricians should consider acute care or ED visits as opportunities for mental health screening follow-up, and intervention in populations at high risk who miss preventive care.

Validity of estimated dietary eicosapentaenoic acid and docosahexaenoic acid intakes determined by interviewer-administered food frequency questionnaire among older adults with mild-to-moderate cognitive impairment or dementia

Epidemiologic research is increasingly being focused on elderly persons, many of whom exhibit mild-to-moderate cognitive impairment. This presents a challenge for collection and interpretation of self-reported dietary data. There are few reports on the impact of cognitive function and dementia on the validity of self-reported dietary intakes. Using plasma phospholipid fatty acid profiles as a biomarker of intake, the authors assessed the validity of an interviewer-administered food frequency questionnaire (FFQ) to estimate intakes of 2 marine-based omega-3 fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), among 273 community-dwelling adults aged > or =60 years participating in the Nutrition, Aging, and Memory in Elders Study (Boston, Massachusetts, 2002-2008). Age- and energy-adjusted Pearson correlation coefficients for correlations between dietary intakes and plasma phospholipids were consistent across categories of high and low cognitive function (r = 0.48), based on Mini-Mental State Examination score, and were similar across clinically diagnosed categories of normal functioning (r = 0.49), mild cognitive impairment (r = 0.45), and dementia (r = 0.52). The FFQ ranked 78% of subjects to within 1 quartile of their plasma phospholipid EPA + DHA quartile. This frequency was consistently high across all cognitive categories. With interviewer administration, this FFQ seems to be a valid method of assessing dietary EPA + DHA intake in older adults with mild-to-moderate cognitive impairment.

Multivitamin use and B vitamin status in a homebound elderly population

OBJECTIVE

Homebound elderly are at increased risk for micronutrient deficiencies and nutritional status in this population has not been adequately described. There is evidence for beneficial effects of multivitamin use and a greater understanding of their nutritional contribution could identify behaviors that may help alleviate excess chronic disease. The purpose of this analysis is to investigate, in a racially diverse group of homebound elders, the association of multivitamin use with measures of plasma B vitamin concentrations.

DESIGN

We examined the cross-sectional association between multivitamin use and plasma concentrations of B vitamins and homocysteine in 236 white and 182 black homebound elders (65-99y). Dietary intake was assessed and demographic and health information was ascertained.

RESULTS

White and black elders had a high prevalence of dietary intakes below the Estimated Average Requirement for folate (38.1 and 40.7%), vitamin B6 (16.9 and 19.2%.), and vitamin B12 (3 and 3.9%) respectively. Multivitamin use was associated with higher mean plasma B vitamin concentrations in each group. In whites, multivitamin users had higher concentrations of vitamin B6 (64.6 vs. 32.4 nmol/L; p < 0.001), vitamin B12 (398 vs. 324 pmol/L;p < 0.001) and folate (39.4 vs. 30.4 nmol/L;p < 0.001). Black multivitamin users had higher concentrations of vitamin B6 (53.7 vs. 29.5 nmol/L; p < 0.001), B12 (427 vs. 372 pmol/L; p < 0.05) and folate (35.7 vs. 25.4 nmol/L; < 0.001) than non-users.

CONCLUSIONS

Multivitamin supplementation was associated with higher mean plasma concentrations of vitamins B6, B12, and folate and lower prevalence of low plasma B vitamin status in a biracial homebound elderly.